The factors influencing community nurses' usage of electronic health records: findings from focus groups

The ‘Understanding quality in district nursing services’ report (King's Fund, 2016) highlighted significant issues in service provision facing community services and argued that mobile electronic health record (EHR) access, shared records and linked IT systems are crucial in joining up services and addressing the problems of fragmented and poorly coordinated community care (Gov.UK, 2013; King's Fund, 2018).

EHRs have been found to enable and support evidence-based clinical decision-making (Mangalampalli et al, 2006). Trust in the effectiveness of available technology, delivered performance and efficiency improvements were primary factors in clinician engagement (Kim et al, 2016) with EHRs. The importance of EHRs to the future of community healthcare is not in doubt.

Internationally, there has been movement toward the increased use of EHRs, and a growing evidence base of their benefits. However, little of the current body of research relates to community nursing and to the lived experiences of nurses using these systems. Themes that emerge from the literature are of nurses seeing the potential benefits of increased engagement with technology being stymied by slow IT systems, poor design and badly supported implementation (Huryk, 2010; Ward et al, 2011; Kuek and Hakkennes, 2020). Where there is good engagement, it is characterised by nurses seeing benefits to patients, sharing positive peer-to-peer experience and receiving support from their organisation (Kaye, 2017; King's Fund, 2020).

Previous research has not explored the community nurse's experience of using EHRs in patients' homes. This study explores the influences at play and how this knowledge could increase engagement, leading to improved service delivery.

Project design

A qualitative research design using focus groups for data collection was used to enable participants to explore their lived experience (Creswell, 2009; Braun and Clarke, 2013).

Ethics

Ethics approval was sought and gained from both University of the West of England (UWE) and from the employing organisation of the participants and researcher. Data collection and storage was carried out as per the UK General Data Protection Regulation (GDPR) (Gov.UK, 2018). An information sheet was provided, written consent gained and participants informed about their right to withdraw at any time.

Sample, setting and data collection

Invitations to participate were emailed to the 220 community nurses working for one community trust in south west England. The invitation was sent as a poster to bases and added to the organisation's intranet newsletter to encourage engagement. Using employees of a single organisation ensured consistency of hardware/software and organisational directives to focus discussion on experiential, rather than technical, issues.

Online focus groups were used in response to COVID-19 protocols. Flynn et al (2018) have outlined the benefits of online focus groups as the following: time savings; increased attendance; removal of geographical constraints. This work provided the researcher with some insights into running sessions online. There were 20 initial respondents who were invited to attend an hour-long focus group via Microsoft Teams, a videoconferencing platform that was familiar to respondents and easy to access (Daniels et al, 2019). The focus groups were self-selecting, as respondents opted for a time and date of their choice. The resulting demographic, split into job roles, was a random and not deliberate occurrence. From 20 respondents, 15 accepted the invitation to one of two scheduled focus groups; three respondents did not attend on the day and did not offer a reason for this (Table 1).

A focus group guide was designed and adhered to in order to lead the discussion. Sessions were recorded with consent of participants, providing an audio-visual record that was later transcribed verbatim by the researcher.

Data analysis

The researcher works as a community nurse, and recognises the impact of their insider knowledge (Johnston et al, 2017). Reflexive thematic analysis, as developed by Braun, Clarke and Hayfield (Clarke, 2019a; 2019b; 2019c), was applied to the data (Table 2).

This process generated the following themes:

• Perceptions of practicality
• Time wasted/time saved
• Technology for knowing and caring
• Team talk.

To anonymise data, each participant was assigned a number. Auotations used in the findings section are identified as: P = participant number and FG = focus group.

Findings

Perceptions of practicality

During discussions, concern was expressed around practicalities of confidentiality when using a digital screen in patients' homes:

‘You might have people wandering around, you know, and looking at your screen.’

(P2FG2)

Participants described social awkwardness around producing EHRs during visits:

‘Patients and their families don't necessarily expect us to set up a laptop in their home.’

(P1FG2)

There was agreement on this, with one participant expressing that:

‘I am here to give them all my attention and don't get out the iPad’.

(P3FG1)

Some participants saw IT equipment as a burden, as keeping it charged and ready to use felt like another task in their busy day. However, one team leader had little patience for staff who were not IT-ready at the start of the day:

‘You don't come to work in your underwear because you can't find your uniform, you know—it's got to be like part of your uniform. Come on—charge your phone, charge your iPad!’

(P4FG1)

The group broadly agreed that it is a professional responsibility to come to work with IT equipment in good order so you can provide the best service.

An aspect that had not been identified by previous studies was that clutter, dirt, smoking, unhygienic conditions and a lack of space impacts on nurses feeling comfortable prolonging a visit and were valid concerns raised by participants as to why they may not wish to access EHRs in a patient's home.

Time wasted/time saved

Limited trust in the reliability of the IT systems led to some staff disengaging with EHR while mobile and in the community. Lack of Wi-Fi or slow connection speeds that hampered EHR access were a common reason for returning to base to complete notes:

‘It's not consistently good enough and, therefore, you just go to an environment where you know it will perform.’

(P2FG2)

Of her team, one leader said:

‘With COVID-19, and staying out of the office, they have completely embraced the remote way of working.’

(P4FG1)

EHR template completion was discussed as a time-consuming task that had little perceived patient benefit:

‘What worries and bothers me is: is this really benefitting the patient? … [or just] using my time to just be going through the motions and ticking boxes unnecessarily?’

(P4FG2)

The completion of notes during or immediately after a visit gave some a feeling of liberation, and the patient-centric nature of this was acknowledged:

‘When you have done a visit, and you have done the notes, and you've emailed from the car to get a prescription, then you can just sort of put that visit to bed and it's satisfying and you can move on then to the next one and it gives you more headspace then.’

(P4FG2)

‘Doing my notes as I go it seems more patient-orientated … I have given the time to the patient at that time.’

(P5FG2)

Participants reflected that recording in real-time improved communication and patient safety:

‘Once you write your notes on [EHR] and then synch it, it can't be lost.’

(P4FG1)

‘What you are writing on [EHR] is what people see, and it is more important as it is what the GP and other professionals can see.’

(P4FG1)

‘Leaving your notes until the end of the day … there are things that you might have thought of during your visit that might have completely slipped your mind.’

(P3FG2)

The importance of timely sharing of information was acknowledged:

‘I can see that services are probably linked together better if you are acting on it in the moment.’

(P3FG2)

The benefit of real-time recording to gauge service capacity was discussed. One team leader wittily observed:

‘You can't hand your notes over to the lovely extended care team, but you could hand a visit over, couldn't you? …’

(P4FG1)

In contrast, those leaving documentation to the end of the day reported finding it disproportionately time-consuming and a chore rather than central to the act of caring. Those not recording in real-time expressed an interest in changing practice to reap the benefits others were experiencing.

Technology for knowing and caring

Focus group discussions acknowledged that EHRs improved clinicians' ability to deliver safe and effective holistic care:

‘I really value being able to access patient information when I am out and about. That makes me feel much more confident and kind of secure that I am not going in blind.’

(P5FG1)

Access assured staff of up-to-date information, conferring ability to clarify queries and ensure patient safety:

‘If they say “oh well this happened and the GP said this” and then I get it up and say actually, “no, this is what the GP said” or the letter said … that's just really useful.’

(P3FG1)

Stories of the innovative use of IT generated a sharing of experiences. Participants discussed videocalling GPs or colleagues to show a wound, ask an opinion or facilitate an out-of-hours video consultation. They described using IT to show a patient an item of equipment and its usage, to facilitate acceptance through informed choice:

‘[I was] doing a capacity assessment on someone about having a peg feed put in and I was able to show him, on the iPad, the procedure, what would happen, how he could be fed … and from that he made a decision.’

(P2FG1)

Team talk

Within this theme, participants identified how team ethos was a major factor in how EHR was used:

‘It comes from leadership and how important the leadership thinks it is, because you are sort of directly guided by their thoughts. I've especially seen that in the teams that I have worked with.’

(P1FG1)

This strong influence of team leaders and their individual approaches led to inconsistency in uptake of EHR access from team to team. Participants felt that the organisational expectations of EHR use were not clearly defined, which could lead to disparity:

‘You set this example of “this is what is (the company) culture and this is the way that we do things” and if people are like, well why are you doing it that way? …. you can explain the good benefits.’

(P2FG1)

Returning to base to write notes was established practice, and wishing to continue this was a barrier to some nurses using EHRs in patients' homes.

Since infection control and social distancing measures were implemented because of COVID-19, and instructions issued to minimise office use, participants stated:

‘We miss that team spirit of all getting together and thrashing it all out.’

(P3FG2)

Therefore, team communication via other mediums became significant:

‘Making sure … by whatever means you do—whether that is regular texts or regular calls or handover in Teams—that you are still a part of a team, even though you are virtually meeting and not physically.’

(P4FG1)

Embracing remote use of EHRs helps nurses become more confident with the use of IT and led to greater engagement with clinical and social support when lone working.

Discussion

Confidentiality concerns arise from the perspective that notes belong to clinicians and patients need permission to view these. The Patient's Association (2021) states that patients are entitled to view their notes; indeed, the NHS app is configured to allow 24/7 patient access to GP records, including requesting extended access to test results and so on. If other people are present during a patient visit, nurses should gain consent from the patient for their presence (Nursing and Midwifery Council (NMC), 2018); their involvement in EHR recording/sharing is an extension of consent. The King's Fund (2020) called for digital technology to bring more balance to the patient-clinician relationship, moving power to the patient; Meinert et al (2018) agree that use of EHR during consultation facilitates this shift. For community nurses to embrace this idea, the patient benefit from use of technology needs to be highlighted, as a means of moving away from Farrellys' idea (2014) that nurses could see technology as optional and not integral to caring. This finding is borne out by previous studies (Huryk, 2010; Kim, 2016; Kaye, 2017), all of which concluded that recognising patient benefit was a prime motivator in clinicians' use of and engagement with new technologies.

Technology was seen as a barrier between clinician and patient by some participants, and their statements described a social awkwardness around accessing notes, as well as a feeling of excluding, rather than including, the patient in the consultation. The King's Fund (2020) discussed patients' negative perception of clinicians hiding behind screens; however, it provided exemplar studies where collaborative use of IT increased patient participation in care and condition management. In the first focus group of this study, the matrons and team leaders did not report feeling social awkwardness; their longer-term relationships with patients may have influenced this experience. This suggests that a coaching approach, where benefits are demonstrated in practice, may be beneficial.

Discomfort in the patient's home—whether from smoking, dirt, clutter, etc—may be reasonable grounds for not wishing to prolong a visit. However, there should an expectation that access to the EHR is made immediately before and after the visit, to ensure knowledge is current and updates recorded in a timely manner (NMC, 2018). At present, this is not common practice in the researcher's organisation, but referral to the NMC's professional guidelines (2018) could be used to encourage this practice.

Poor engagement with EHR while mobile working has been found to relate to nurses' expectations not being met by what systems deliver (Ward et al, 2011). A lack of trust in a system that does not work well when introduced is difficult to reverse; initial enthusiastic engagement with IT quickly dwindles when a user is disappointed by lived experience. Better introduction and training with new systems (Royal College of Nursing, 2017), along with recognising patient benefit as clinicians' prime motivator for using IT, as borne out by Huryk (2010), Kim (2016) and Kaye (2017), could combat this problem and should be central to any introductory strategy.

General negativity around templates suggests that service improvements developed from template data are not communicated to nurses, leading to disengagement with the data collection process. Recognising beneficence as nurses' major motivating factor, it would seem sensible to clearly flag this link and ensure that nurses in patient-facing roles can clearly see why they are asked to use a template-based system to record patient data.

Locsin (2017) establishes that knowing is caring, and data generated and held electronically is knowledge; therefore, interaction with EHR can be perceived as an act of caring. When sharing EHRs, a co-authored plan of care can be developed. Community nurses embracing EHR access this complete knowledge, work collaboratively and see the resultant patient benefits. Focus group discussion led some participants to reflect on their current practice and suggest they would try to change their ways of working. This change in opinion emerged from experiential sharing, which suggests coaching may be effective in spreading new ways of working across an organisation.

The King's Fund (2016) stated that community nurses coordinate and provide continuity of care based on holistic knowledge. This study's findings suggest that using EHRs to fully ‘know’ the patient and their situation facilitates an effective and safe service; clinicians using EHR before, during and after visits were fully informed of current patient status and were able to make contributions to the real-time patient record. Participants in this study expressed feelings of job satisfaction, improved efficiency and better patient safety from engaging with EHRs in real time, and those not presently working in this way commented on the real benefits that they felt could be achieved if they were able to change their own approach. Feeling overworked and under constant pressure were recurring themes in discussions and were pinpointed as reasons why practice remained unchanged. However, change theory (Nursing Theory, 2020) proposes that it can require a seismic event to unfreeze a way of working, as a means of effecting change. The events of 2020 and 2021, with the COVID-19 pandemic, have provided such an event, and an unexpected benefit of COVID-19 has been to challenge some established ways of working.

Increased mobile working has been perceived by some as a threat to the security and camaraderie of being with colleagues, and the fears and anxieties this has raised across teams should not be dismissed. Regular meeting to discuss patient care, caseload management and receive collegiate support are vitally important for team cohesion and morale. Merchant (2021) highlighted the importance of leaders in supporting team wellbeing and retaining team cohesion and support while working remotely.

Across all themes, a lack of clear messaging around EHR use at team and organisational level was apparent. Both focus groups felt that more direction from a senior organisational level was required to standardise and develop EHR use in the mobile workforce, to achieve equity for both patients and staff.

Conclusion

Awareness of the benefit that accessing EHRs in the home can bring to a patient is a major factor in community nurses' engagement with EHRs. This small-scale study found that those working at a higher clinical grade were more likely to access EHRs with the patient as a means of making collaborative, informed clinical decisions. Regularly accessing EHR in the patients' home was shown to translate into an increase in innovative thinking regarding the use of IT for improving care. Staff working at lower grades felt they were operating under greater time pressures and were more likely to view engaging with EHR as a separate activity to the giving of care. Coaching or modelling strategies that demonstrate the benefits of EHR use in a patient's home could be a useful strategy for more widespread engagement.

Real-time recording improves workflow and informs capacity management. It helps the nurse feel more in control of their time, reduces errors of omission and improves safety by providing an up-to-date picture for other clinicians. It allows dynamic management of caseload by co-ordinators, who can see the whole team's progress and, therefore, allocate call-outs or reallocate visits in a way that balances team members' workloads.

There is opportunity to improve efficiency and capacity by increasing the use of EHRs in real time. To achieve this, organisations need to acknowledge that many nurses' primary driver is a wish to be beneficent. Demonstrating how changing practice improves patient care should be central to introduction or promotion of any new working practice. Without consistent messaging and clear organisational expectation around EHR and real-time recording, the uptake is likely to remain dependent on individual leaders providing inspiration for their teams.

Key points

• Accessing records at time of patient contact can improve clinical outcomes
• Real-time recording improves workflow and informs capacity management
• An overuse of templates for data collection is a barrier to positive engagement with health records
• Having access to mobile electronic health records via a mobile device is a gateway for further innovative use of IT within the patient's home
• Nurses are more likely to access records at time of patient contact if they can see the benefit to the patient
• Organisations need clearer mobile working/real-time recording objectives to ensure clarity and parity of service delivery.

CPD reflective questions

• Consider your own practice. How do you use electronic health records during your working day?
• Do the experiences of the nurses in the article reflect your own experience?
• Can you think of any changes you may make to your practice as a result of reading this article?