Utilizing nursing standards in electronic health records: A descriptive qualitative study
Lene Baagøe Laukvik1, Merete Lyngstad2, Ann Kristin Rotegård2
1Department of Health and Nursing Science, Faculty of Health and Sport Sciences, University of Agder, PO Box 509, NO-4898 Grimstad, Norway.
International Journal of Medical Informatics
|February 2, 2024
Summary
Registered nurses
Area of Science:
- Nursing Informatics
- Health Services Research
- Geriatric Care
Background:
- Electronic health records (EHRs) are vital for nursing situational awareness.
- Nurses' use of standardized nursing language and care plans in EHRs is under-researched.
- Understanding documentation practices in dementia care is crucial.
Purpose of the Study:
- To explore Norwegian nurses' experiences with EHR documentation using standardized nursing care plans and language.
- Focus on nurses in specialized dementia care units within nursing homes.
- Describe perceptions of daily documentation practices.
Main Methods:
- Descriptive qualitative study design.
- Conducted in Norwegian nursing homes (April-November 2021).
- In-depth interviews with registered nurses analyzed using reflexive thematic analysis.
Main Results:
- User knowledge, skills, and attitudes impact documentation.
- Management and organizational factors influence engagement.
- EHR usability issues hinder workflow and information access.
- Nursing standards in EHRs promote ethical awareness and knowledge development.
Conclusions:
- Continuous nurse and leadership involvement is essential for EHR development.
- Active engagement ensures the implementation of relevant nursing standards.
- This supports improved documentation and patient care.
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