International Journal of Medical Informatics 184 (2024) 105350

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International Journal of Medical Informatics

journal homepage: www.elsevier.com/locate/ijmedinf

Utilizing nursing standards in electronic health records: A descriptive

qualitative study
Lene Baagøe Laukvik a, *, Merete Lyngstad b, Ann Kristin Rotegård b, Mariann Fossum c
a
Department of Health and Nursing Science, Faculty of Health and Sport Sciences, University of Agder, PO Box 509, NO-4898 Grimstad, Norway
b
VAR Healthcare, Cappelen Damm, Oslo, Norway
c
University of Agder, Department of Health and Nursing Science, Faculty of Health and Sport Sciences, Grimstad, Norway

A R T I C L E I N F O A B S T R A C T

Keywords: Background: The electronic health record (EHR), including standardized structures and languages, represents an
Care planning important data source for nurses, to continually update their individual and shared perceptual understanding of
Documentation clinical situations. Registered nurses’ utilization of nursing standards, such as standardized nursing care plans
Electronic health records
and language in EHRs, has received little attention in the literature. Further research is needed to understand
Nursing homes
Nursing standards
nurses’ care planning and documentation practice.
Aims: This study aimed to describe the experiences and perceptions of nurses’ EHR documentation practices
utilizing standardized nursing care plans including standardized nursing language, in the daily documentation of
nursing care for patients living in special dementia-care units in nursing homes in Norway.
Methods: A descriptive qualitative study was conducted between April and November 2021 among registered
nurses working in special dementia care units in Norwegian nursing homes. In-depth interviews were conducted,
and data was analyzed utilizing reflexive thematic analysis with a deductive orientation.
Findings
Four themes were generated from the analysis. First, the knowledge, skills, and attitude of system users were
perceived to influence daily documentation practice. Second, management and organization of documentation
work, internally and externally, influenced motivation and engagement in daily documentation processes. Third,
usability issues of the EHR were perceived to limit the daily workflow and the nurses’ information-needs. Last,
nursing standards in the EHR were perceived to contribute to the development of documentation practices,
supporting and stimulating ethical awareness, cognitive processes, and knowledge development.
Conclusion: Nurses and nursing leaders need to be continuously involved and engaged in EHR documentation to
safeguard development and implementation of relevant nursing standards.

1. Introduction implemented in clinical practice [3]. International research shows that

the implementation and utilization of nursing standards in EHR can
Initiatives of nursing standards such as standardized nursing care increase the possibility of distinguishing, extracting, and analyzing
plans (SNCPs) and standardized nursing languages (SNL) have been nursing care for quality and safety improvements, including improve­
developed to support nursing documentation processes in EHR [1]. ments of nurses’ knowledge of evidence-based clinical guidelines [1,3].
SNCPs are evidence-based, pre-prepared documents structured accord­ Other potential benefits include reductions in administrative burdens,
ing to the nursing process [2], while SNL is an established set of terms improved quality of documentation, and enabling identification of pa­
that systematically groups, defines, and encodes nursing care as nursing tient care needs and more effective management of long-term conditions
diagnoses, nursing interventions and/or nursing outcomes [3]. The In­ [4,5]. However, achieving these benefits is challenging, and
ternational Classification for Nursing Practice (ICNP), the Omaha Sys­ organization-wide adoption and utilization of nursing standards in EHR
tem, and NANDA are examples of SNLs that have been accepted and in clinical practice are not optimal [6,7]. Outcomes concerning the

* Corresponding author.
E-mail addresses: lene.laukvik@uia.no (L.B. Laukvik), merete.lyngstad@nsf.no (M. Lyngstad), ann.kristin.rotegaard@cappelendamm.no (A.K. Rotegård),
mariann.fossum@uia.no (M. Fossum).

https://doi.org/10.1016/j.ijmedinf.2024.105350
Received 21 September 2023; Received in revised form 15 January 2024; Accepted 24 January 2024
Available online 30 January 2024
1386-5056/© 2024 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
L.B. Laukvik et al. International Journal of Medical Informatics 184 (2024) 105350

patient’s experiences and preferences and high-quality care delivery are interview guide. The questions were open-ended to facilitate a broader
lacking in EHRs [8,9]. Moreover, biomedical values dominate EHR- data collection and richer discussion. The interview guide was piloted
related ethical concerns [10]. Additionally, inaccurate, and non- with one participant and included in the final analysis without changes.
comprehensive recording of information [11], mismatch with nurses’ A deductive orientation towards the data was performed during anal­
workflow, increased documentation load, and cognitive overload, have ysis. The consolidated criteria for reporting qualitative research
been reported [12,13]. The European Union (2021) report highlights the (COREQ) checklist [25] were utilized to ensure quality reporting (Sup­
need for knowledge about the actual utilization of EHR and standards in plementary File 1). The Norwegian Centre for Research Data (NSD) and
clinical practice, to understand how to overcome barriers to adoption local ethics committee X University approved the study (approval
and use in specific clinical contexts [14]. Investigations of nurses’ ex­ number blinded). Information about the study was provided, and writ­
periences and perceptions on utilizing nursing standards in daily EHR ten consent was obtained from the participants. The information letter
documentation are lacking [15,16]. Exploring and describing the ex­ followed the standards of the NSD and General Data Protection Regu­
periences and perceptions of such, could increase our understanding of lations [26]. Confidentiality was ensured by removing all personal
how to generate valuable nursing knowledge and high-quality care from identification information and assuring participants that their informa­
EHR documentation [4]. Additionally, it could improve the custom­ tion would only be utilized for research purposes.
izability of EHR to enhance documentation processes and communica­
tion of patient information [17]. Lastly, such EHR documentation focus 2.2. Sample and setting
could improve our understanding of nurses’ digital competence and how
evidence-based knowledge can be transferred into everyday clinical A purposeful sampling method was utilized to recruit nurses within
practice [18]. This study is underpinned by the socio-technical-system three large municipalities (populations of 50,000–130,000) and one
(STS) theory, emphasizing interactions between the human, technical, medium-sized municipality (population of 19,000) in southern Norway.
and environmental levels to understand an organizational or work sys­ We were granted access to the field through healthcare service leaders,
tem [19]. The socio-technical view allowed us to understand the who helped identify appropriate nurses for participation. Eighteen
contribution of phenomena at the human social level (nurses in de­ nurses who met the following inclusion criteria were identified: a) a
mentia care) to the performance of technical systems (nursing standards bachelor’s degree in nursing, b) currently working in a special dementia
in EHRs) [20], and has previously been utilized in development, care unit, c) over two years of experience working with patients living
implementation, and evaluation of safe and effective EHR systems in with dementia, d) over two years of experience documenting nursing
healthcare services [21,22]. care in EHR of patients living with dementia, and e) access to EHR,
This study aims to describe nurses’ experiences and perceptions of including nursing standards. Fifteen nurses agreed to participate; how­
utilizing nursing standards, including SNCPs with SNL, in daily EHR ever, one participant withdrew on the day of data collection. Five of the
documentation of nursing care for patients living in special dementia- respondents had special education in dementia care, and 11 had over
care units in nursing homes. five years of clinical experience in dementia care. Ten participants rated
their experience documenting nursing care for patients living with de­
2. Material and methods mentia in the EHR at an expert level (over five years). Demographics are
summarized in Table 2.
2.1. Study design At all study sites, nurses were responsible for initiating and devel­
oping nursing care plans. Nursing aides or registered nurses were the
A qualitative descriptive (QD) design based on data from individual primary contacts of the patients and responsible for updating the nursing
interviews was utilized in this study to elicit shared meaning among care plans. All staff members, regardless of whether they had received
nurses related to experiences and perceptions of daily EHR utilization, professional education, had access to the EHR and were responsible for
including nursing standards, in documenting nursing in a dementia authoring daily reports in the progress notes per Norwegian health
long-term care setting [23]. Semi-structured interviews were conducted, legislation [27]. The EHR utilized at all study sites were structured ac­
and the interview guide was inspired by the Health Information Tech­ cording to the nursing process model. The basic needs categories, such as
nology Reference-based Evaluation Framework (HITREF) [24] and the “Circulation,” “Respiration,” “Nutrition,” “Personal Hygiene,” and
clinical expertise of all authors. The semi-structured interview guide’s “Mental Health”, were defined as areas to enter for free text writing of
questions covered experiences and perceptions regarding the nurses’ nursing diagnoses, patient outcomes, and interventions. The EHR uti­
daily documentation practice in the EHR in general and when utilizing lized at all sites contained SNCPs with ICNP terminology, which were
SNCPs and SNL. Table 1 presents the questions in the semi-structured optional to use.

2.3. Data collection and analysis

Table 1
The semi-structured interview guide questions.
The data were collected between April and November 2021 by the
Number Questions first author (XX), who was a female PhD candidate with prior experience
1. What are your experiences with the documentation of nursing care? as a nurse in dementia care. Each interview took place at the nursing
2. What are your experiences with standardized terminology or language? home during the day shift. The participant and interviewer had not
3. To what extent do you experience the care plan as updated?
interacted before the interview. The primary researcher listened
4. To what extent do you experience that the care plan is followed-up?
5. In which contexts do you use free text rather than standardized language actively, took notes on issues to explore further, and asked follow-up
when developing a care plan? questions to deepen participants’ responses. No repeat interviews were
6. How do you structure the documentation of nursing care? carried out. The interviews were conducted in Norwegian, audiotaped
7. Which areas are most important to document for patients with dementia?
8. How can you ensure completeness and comprehensiveness in the
planning of nursing care for patients with dementia? Table 2
9. How can completeness and comprehensiveness be expressed in the care Characteristics of participants (N = 14).
plan of patients with dementia?
Median Range
10. How can patients with dementia be ensured person-centered care in the
planning of nursing care? Age (years) 46 23–59
11. How can person-centered care be expressed in the care plan of patients Experience from clinical practice as a registered nurse 16 2–35
with dementia? Experience working with persons living with dementia 17 2–34

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L.B. Laukvik et al. International Journal of Medical Informatics 184 (2024) 105350

with a digital recorder, and transcribed verbatim by the first author. a need to receive pertinent data relevant to the surgical patient in
Eight hours of individual interviews were transcribed into approxi­ handoff situations to “make sense” of the patient’s situation [29]. Kemp
mately 50 pages. The interviews lasted around 34 min (range: 23–42 et al. found that participants viewed general health literacy as a pre­
min). ceding need to implement digital health approaches in cancer care [30].
The data analysis was performed manually following the principles Nevertheless, several of our participants experienced a need to be
of reflexive thematic analysis by Braun and Clark [28]. The analysis adequately prepared with education and training regarding EHR.
included (1) familiarizing, (2) production of initial codes, (3) exploring
“I think it is the computer that makes it difficult for many, the fear of
potential themes utilizing thematic maps, including central organizing
deleting the whole care plan if they push the wrong button.” (P9).
concepts, (4) reviewing themes, (5) defining, refining, and naming
themes, and (6) finalizing the findings. Each theme and sub-theme were Arikan et al. and Jedwab et al. both found that the lack of knowledge
initially discussed by two members of the research team (XX and XX) and skills for effective EHR utilization is a major barrier to adoption and
and further with all the members of the research team for consensus. utilization of EHR in clinical practice, and must be considered [16,31]. If
nurses’ clinical knowledge and skills relating to dementia care and their
3. Results and discussions digital competence is strengthened with proper and continuous educa­
tion it might increase nurses’ adoption and utilization of EHR, which in
STS-theory was an appropriate framework for this study as it allowed turn could enhance nurses’ workflow and patient care in the dementia
us to be specific about the technology (EHR, including standards), while care setting [16,31,32].
simultaneously incorporate actors such as the participants, and
contextual and cultural elements, and how relationships between these 3.1.2. Skills in expressing content
elements lead to action possibilities (care planning and documentation Expressing content was highlighted by most participants as chal­
practices). The semi-structured interview guide stimulated rich discus­ lenging, often related to provision of understanding of meaning (se­
sions about the topics, and about the attitudes and feelings of the person mantics). Expressions concerning the psychosocial aspects of care were
utilizing the EHR, including nursing standards. Several themes and sub- often viewed as especially difficult.
themes were generated from the analysis (see Table 3 below). “It is difficult to write in a way that everyone understands. I think a lot
about how to formulate the content simple and reasonable [sic]” (P13).
3.1. Theme: Knowledge, skills, and attitude of the system-user Some of the participants highlighted careful word choice concerning
the patients’ behaviors or feelings. As stated by P9: “…you need to find
Most participants expressed that the knowledge, skills, and attitude words that preserve the patient and the situation, it is not my own feelings that
of the person utilizing the EHR matter for quality and safety of the should be in the center”. Such findings correspond to previous research
documentation and communication of patient information in everyday showing that nurses have concerns and dilemmas relating to the pa­
work. This theme was supported by three sub-themes. tient’s dignity and well-being, when choosing words and content during
documentation in the EHR [33,34]. Balancing ethical principles relating
3.1.1. Education and training in nursing and about computers to benefit/risk for the patient is important for nurses. Leveraging nurses’
Professional education in nursing, and education and training concerns regarding respectful documentation of patient information
regarding documenting nursing in the EHR were important factors in the could be a way to optimize EHR utilization among nurses in the de­
production of high-quality EHR documentation and in securing appro­ mentia care setting, possibly thus supporting the well-being of the pa­
priate follow-up of the patients, according to study participants. tient [35]. Increased focus within the EHR system on content relating to
Knowing how to document nursing in the EHR were viewed as crucial to psychosocial aspects of care might enable a more informative and
secure the well-being of the patients. meaningful recording of nursing care, which could promote the nurse’s
“Nurses have education that enables them to document better, they see skills in expressing high-quality care in the EHR [9].
things that needs [sic] to be documented. When we have few nurses not
everything with the patients is done properly…we need to use our 3.1.3. Attitude towards documentation work
knowledge from nursing school relating to what is relevant” (P2). Several participants talked about a personal responsibility towards
documentation work as crucial to secure information flow and proper
These findings correspond to previous research showing that strong follow–up of documentation.
professional knowledge and skills are necessary for nurses to adopt and
utilize EHR in clinical practice. Staggers et al. found that nurses reported “It is completely necessary in relation to the patients, that it is well
documented both from nurses and other staff. It is necessary that you read
Table 3 what the nurses have been writing when you come to work…we are totally
Summary of findings. dependent on that” (P3).
Themes Sub-themes Such responsibility was commonly assigned to those who had pri­
Knowledge, skills, and attitude of the Education and training in nursing and mary responsibility for the patients. However, there was a general
system-user about computers concern among the participants that the feeling of responsibility towards
Skills in expressing content documentation work is not something everyone involved with the daily
Attitude towards documentation patient care possessed. As P6 noted: “My experience is that those who are
Management and organization of Provision of significant time and place to
documentation work document
here now and then do not care very much about documentation, I often write
Frequent decisions concerning structure information that is not picked up by everyone…”. This often led to a general
and content affect motivation to engage in concern that the necessary information was not regularly read or utilized
EHR by everyone involved in the daily planning and caring of the patients,
Usability issues of the EHR* Entry and navigation within the EHR
which could potentially harm the patient.
system
Fragmentation of information These findings could be explained by a general lack of focus
Nursing standards contributes to Support of ethical awareness regarding the value of documentation in the working environment,
development of documentation Stimulation of cognitive processes potentially affecting the attitude of all staff regarding involvement and
practices Transfer of different types of knowledge engagement in EHR documentation work [36]. Jedwab et al. [31] found
*
EHR = Electronic healthcare records. that motivation was the most perceived barrier and enabler among

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nurses for utilizing the EHR system in a hospital setting. If nurses (and 3.3.1. Navigation and fragmentation of information within the EHR system
other staff) in the dementia care setting are supported with proper ed­ Several participants experienced challenges navigating within the
ucation and training regarding care planning and documentation in the system to find relevant information. Not finding relevant information
EHR, it may stimulate the feeling of responsibility to read, write, and within the system, such as the nursing notes or the data collection, was
follow–up documentation work in the EHR. perceived as a major challenge, potentially leading to information loss
and interruptions in workflow.
“Finding the nursing-notes is challenging because you must look through
3.2. Theme: Management and organization of documentation work
the whole system to find them; some information clearly gets lost on the
way.” (P10).
Most participants experienced local and external management and
organization of documentation work as highly influential on their The systems’ requirements of information fragmentation especially
documentation practices. This theme is supported by two sub-themes. caused frustrations regarding time spent on double documentation and
division of holistic information, which was perceived as inefficient for
3.2.1. Provision of significant time and place to document optimizing the care plans.
Several participants expressed that lacking sufficient time and a
“The care plan is what we are supposed to use, but sometimes it is chal­
designated place for EHR documentation work as a stressful and dis­
lenging and time-consuming because we must split the information into
tracting factor causing concerns regarding the quality of the documen­
several boxes. I mean the information you collect should be reflected in the
tation, such as regular updates of the care plans.
care plan. We need to start with their story and current needs.” (P12).
“We do not get the care plans updated regularly; we have too little time for
Similar results are reported in the review of Tsai et al. [40], who
such tasks. If we had better time, I think the care plans would be better”
found that inefficiencies of EHR often are experienced by functionality
(P12).
problems not compatible with the nurses’ workflow. A breakdown in the
Such findings correspond with previous research showing that suf­ nurses’ workflow caused by usability and functionality challenges,
ficient time and a designated place for completing EHR documentation leading to insufficient transfer of important information and documen­
are important for efficient documentation and secure patient care. tation putting the patients’ security at risk [12,40].
Varpio et al. [37] showed that lack of accommodated time to perform
documentation work in the nurses’ time schedules leads to an insuffi­ 3.4. Theme: Nursing standards in EHR contributes to development of
cient patient overview for the nurses. Furthermore, negative responses documentation practices
concerning overall workflow are reported in literature if documentation
work is interrupted or exposed to noise [12]. If nurses in dementia care According to our participants, nursing standards included in the EHR
settings are provided with both appropriate time and a designated place have the potential to support and develop daily documentation prac­
to perform EHR documentation work, it may increase their concentra­ tices. This theme is supported by three sub-themes.
tion during documentation. However, there are inconsistencies in the
literature regarding the time required by nurses to utilize the EHR 3.4.1. Support of ethical awareness
effectively, which could be related to different EHRs or versions [12]. Nursing standards were perceived as more professional and objective
by the participants, and they could be helpful in avoiding subjectivity
3.2.2. Frequent decisions concerning documentation structure and content and promote a more respectful documentation, which in turn could
affects motivation to engage in EHRs stimulate their ethical awareness when free text was required.
Participants experienced constant changes in documentation rou­
“It saves the pondering on how to formulate problems or interventions, it
tines as negatively affecting the daily documentation work. Frequent
is very good that it is already formulated.” (P4).
changes in decisions relating to structure and content, (i.e., how and
what to document) were viewed as confusing, often resulting in low Few studies exist regarding the ethical issues of utilizing nursing
engagement in documentation work and nothing (relevant) recorded. standards in EHR in a single healthcare practice. Ethical principles are
important in clinical practice and these findings could indicate that
“It has been a lot of back and forth, people cannot land on anything, as
nursing standards represent one solution to the negative experiences of
soon as you have become accustomed to writing in one way, everything is
nurses regarding ethical issues when utilizing EHR [10]. If nurses have
turned upside down” (P3).
access to nursing standards in their daily documentation practices, it
Internal and external decisions concerning daily EHR documentation may enhance their ability to make morally correct decisions when
practice should involve nurses and be consistent over time to facilitate a planning care and documenting nursing in EHR. This could support the
sustainable adoption and utilization of the EHR. Raddaha et al. identi­ patients’ best interests, potentially safeguarding the wellbeing and
fied a significant correlation between nurses’ positive attitudes towards dignity of patients.
EHR and leader-initiated involvement of nurses in questions related to
customization of the system [38]. Furthermore, nurses that are provided 3.4.2. Stimulation of cognitive processes
with time to familiarize themselves with the EHR system might be Our participants perceived nursing standards as helpful in support­
quicker at non-documentation administrative tasks, increasing time ing cognitive processes such as memory and creativity during care
spent on direct care in the dementia care setting [4,39]. planning and documentation. Several mentioned them as particularly
supportive in development of the care plan content, making it easier to
identify and document nursing diagnosis, especially related to the pa­
3.3. Theme: Usability issues of the EHR tient’s psychosocial needs.
“It is super-important, without it we are almost nothing; it brainstorms
Generally, storing the recorded information in the electronic system
you, helps you to think more…without SNL it would be hard to write
was viewed positively by all the participants, making retrieving histor­
nursing diagnosis, goals, and interventions. Everyone should use it.” (P5).
ical information and continuity of care easier. However, the EHR system
was experienced as challenging, especially concerning entry, naviga­ Similar findings were shown in a study from an acute hospital setting
tion, and fragmentation of information. This theme is supported by two reporting that the utilization of SNCPs simplified nurses’ work regarding
sub-themes. easier decision-making processes concerning choices of diagnosis or

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interventions in care plans [41]. If nurses have access to nursing stan­ problematic regarding nursing visibility and in achieving a compre­
dards relevant for patients in the dementia care setting, it may facilitate hensive view of the patient’s clinical status [46].
clinical reasoning and decision making in documentation practice,
potentially decrease the diversity in nursing diagnosis and interventions 3.5. Limitations, strengths, and implications for future recommendations
and making the patient care plan more meaningful [5]. However,
several participating nurses emphasized that activating critical thinking Regarding limitations, our study has a relatively small sample size,
is crucial when utilizing nursing standards. It was a general concern that which could have affected the sufficiency of the data collected. More­
by using such standards uncritically it may result in an impersonalized over, our study did not include the experiences of other significant
care plan. stakeholders (e.g., nurse aides or other care givers), and hence, future
research is needed to explore the experiences of these stakeholders.
“I like to use my brain and I think that if everything gets automized,
However, the participants had a wide range of experiences relevant to
maybe people think less logically” (P2).
this study, implying information power [47]. Furthermore, our findings
“The care plan might not be so individual in a way and that is negative, it
may have been influenced by the interview guide, potentially causing
will not be special for each patient, they become very alike” (P8).
significant data to be overlooked in the data collection and analysis
A good practice approach in planning care for patients living with process. Conversely, the interview guide may have minimized subjec­
dementia is to tailor the individual needs and preferences of the patient, tivity, as our interpretation of the findings may be one of many possible
and critical thinking is an essential and active part of nursing practice to [48].
safeguard the patient [42,43]. Previous research show that if nurses From our findings, we have three recommendations. First, nurses’
experience becoming passive users (i.e., simply following an automated professional, digital, and ethical knowledge, skills, and attitude is not
system), it leads to inappropriate nursing statements in the descriptions only necessary for safeguarding quality of documentation work, but also
of patient situations [4]. suggested for the continuity and safe delivery of care when utilizing EHR
in clinical practice. Second, EHR utilization, including nursing stan­
3.4.3. Transfer of different types of knowledge dards, is an effective strategy to improve understanding and knowledge
Personal information, such as the life story of the patient or every- regarding dementia care. Third, to further develop knowledge for
day events (“the little things”), were viewed as particularly important enhancing care planning and nursing documentation in the dementia
to incorporate into the care plan for making sense of changes in the care setting, this study suggests implementing relevant nursing stan­
patient’s situation. dards into the EHR.
“The care plan must represent what is special about this person, the little
4. Conclusions
things must appear there. This is completely crucial information which we
have no opportunity to get, especially from those who lack language.”
Although EHR utilization in Norway is common in clinical practice,
(P11).
the utilization of nursing standards is novel, and research is limited. Our
This need for personalized and individualized information might be findings suggests that nurses and nursing leaders must be continuously
an explanation to the nurses’ concerns related to thinking critically involved and engaged in EHR documentation to safeguard development
when utilizing nursing standards for documentation purposes. For the and implementation of relevant nursing standards. Further qualitative
nurses to become active users of nursing standards included in the EHR research is needed to get a better understanding of how nurses in
of patients living with dementia, there should be possibilities to add data different clinical settings experience and perceive adoption and utili­
or information that facilitate an individualized and personalized zation of EHRs, including nursing standards.
approach to care. Being able to add such information may enhance
nurses’ EHR adoption and utilization, including enhancing patient care 5. Author’s contributions
[32,44].
Several participants mentioned that nursing standards could clarify All authors participated in designing the study. Lene Baagøe Laukvik
dementia care and be helpful in guiding and improving their care was responsible for data collection, writing the main manuscript and
planning and delivery. preparing the tables. All authors participated in analysis and discus­
sions, in addition to preparing the manuscript. All authors reviewed the
“I think it would be helpful, especially for me since I have little experience
manuscript and read and approved the final manuscript
in dementia care and there are lots of things that I don’t know regarding
Summary table
what affects the patients, even though I have been a nurse for several
years.” (P12).
• This study aimed to describe the experiences and perceptions of
However, thorough descriptions in the documentation were high­ nurses’ electronic health record (EHR) documentation practices
lighted for understanding the patient’s needs and knowing how to meet utilizing standardized nursing care plans, including standardized
them. nursing language, in the daily documentation of nursing care for
These findings correspond to previous research showing that nursing patients living in special dementia-care units in nursing homes in
standards facilitating the generation of accurate and timely knowledge Norway.
aids high-quality care planning and documentation [3]. However, in­ • International research shows that the implementation and utilization
dividual and personalized information require more text, often written of nursing standards in EHR can increase the possibility of dis­
in a more narrative way [45]. Castellà-Creus et al. [41] reports that tinguishing, extracting, and analyzing nursing care for quality and
nurses in acute care hospitalization wards preferred to record in a safety improvements, including improvements of nurses’ knowledge
narrative way to individualize the planning and delivery of care. Lack of of evidence-based clinical guidelines. Other potential benefits
possibilities for free text writing may make nursing standards inflexible include reductions in administrative burdens, improved quality of
and inadequate to follow, especially regarding psychosocial aspects of documentation, and enabling identification of patient care needs and
care. A possible solution may be to grant nurses in the dementia care more effective management of long-term conditions.
setting access to nursing standards containing free text possibilities on • Exploring and describing the experiences and perceptions of such,
specific keywords regarding the psychosocial needs and wellbeing of the could increase our understanding of how to generate valuable
patient. However, the quality of natural language notes should be nursing knowledge and high-quality care from EHR documentation.
considered as features and processes of such notes in EHR could be Additionally, it could improve the customizability of EHR to enhance

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