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Charting the path forward: Nursing perspectives on documentation and change
Lisa G Johnson1, Tamara G R Macieira1, Olatunde O Madandola1
1College of Nursing, University of Florida College of Nursing, Gainesville, FL.
Background:
Legislation and research have not sufficiently considered the unique electronic health record (EHR) documentation burdens faced by nurses.
Purpose:
Explore documentation burden by identifying the EHR changes hospital-based nurses find most critical, serving as a foundational step in enhancing EHR usability and functionality for nurses.
Methods:
An electronic survey, developed and pre-tested, was emailed and texted to 38,000 randomly selected registered nurses (RNs) across five U.S. states (June-July 2024); 146 inpatient respondents provided demographics mirroring national RN statistics and open-ended feedback.
Discussion:
Four themes emerged from open-ended responses to this rapid, cost-effective survey. The most frequently cited priority was improving human-computer interaction, particularly user interface features (56%) and reducing redundant documentation (17%). These insights can support nurse-centered design and AI-enhanced strategies to streamline documentation.
Conclusion:
Nurses' recommendations provide a foundation for developing EHR systems that reduce excessive documentation burden while improving quality, accuracy, and effectiveness of nursing care.
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