The Implication of an IEHRA on the Quality of Nursing Care Delivered
The past few decades have witnessed many changes concerning increasing demand for health care services across the globe. The increasing demand poses many challenges to health care providers since health systems can hardly meet the rising demands. Among the challenges that are experienced in health care delivery are increased public expectations, unsuitable health conditions, increasing costs of health care, unlimited financial resource availability, and socio-demographic changes among others.
The emergence of a complex health care environment has prompted leaders in the industry to seek solutions that can facilitate the provision of better health care. To this effect, the use of modern technologies in health care provision has been identified as one of the sure ways of boosting the efficiency in nursing care provision. Specifically, the use of a computerized health record system is believed to be one of the most effective ways to enhance health care delivery. Applying a computerized record system mainly focuses on ensuring seamless collection, storage, retrieval, and dissemination of patients’ health records to facilitate the provision of quality health care. Although technology applies to all players in the health industry, its nerve center is seen in the functions of nurse informatics. Adoption of electronic health records (EHR) improved nursing care delivery in terms of reduced costs, improved patients’ satisfaction, and decreased burnout by nurse practitioners.
Background and Significance of the Problem
The subject of computerization of nursing documentation started back with the increase in the number of health care seekers. Early in the 1980s, a proposal was made that computerized nursing documentation should be adopted to facilitate the attainment of medical orders, enable capturing of patients’ responses to health care provisions, and facilitate nursing interventions (Jha et al., 2011). Although electronic health documentation is an old concept, a lot still needs to be studied on the effects of such interventions and the perceptions that society has on computer documentation.
A rapid increase has been realized in the application of computerized health records. The Institute of Medicine (OIM) targeted that in the 21st century, the health care system would facilitate effectiveness, security, timeliness, equitability, and provision of patient-centered health care (Carlson et al., 2010). EHR application in health care provision is believed to have the capacity to facilitate the acquisition of real-time patient health records, reduce unnecessary workflow, standardize care, enhance productivity, limit cases of medical errors, and facilitate communication among healthcare providers. Different suggestions for the application of electronic documentation in health care were anchored on the belief that such a move would help in showing health care as provided to patients while also enhancing workflow.
Despite the existence of research findings on the prevailing assumptions around the clinical documentation programs, very little has been done about studying the types of workflow designs that can most effectively promote the implementation of computerized documentation. Besides, there is a lot of interest in understanding the level of accuracy that is achieved concerning nursing documentation after the adoption of EHR systems.
It is essential to understand that rapid changes in care delivery activities can have adverse implications on the quality of performance particularly in areas that need critical thinking. Access to computers that are not made to appear as part of an ongoing workflow can play a role in activity change hence affecting the safety of patient care and effective health care provision by nurses (Ankner, Coughlin, & Holman, 2010). To this effect, there is a need for further research aimed at examining the nurse workflow after the introduction of modern technology like the application of electronic documentation systems. As Cornel et al. (2010) state, failing to conduct more research to investigate the application of modern technology in the health care environment can result in inefficiencies, reduced productivity levels, increased cases of medical errors, and frustrations. For this reason, the current study is believed to be significant today as technology takes a center stage in health care activities. The study will enable deductions to be made on how the adoption of integrated EHR affects the efficiency of nursing care provision.
Statement of the Problem and Purpose of the Study
With the introduction of technology in health care provision, it is important to evaluate the nursing environment since the results of the study will help when assessing the level of effectiveness of care, and performance levels and aid in planning and resource allocation. Health care facilities should be capable of understanding the way the effectiveness of nursing care delivery is affected by the use of a comprehensive integrated EHR (American Nurses Association, 2013). For purposes of enhancing easy accessibility of information so that nurses get adequate time for analysis, synthesis, decision, and provision of patient care, the adoption of a computerized system is a viable move (Cornell, Riordan, et al., 2010).
This proposed research will serve the purpose of measuring the impacts of Integrated EHR adoption in the health care environment with particular attention to the quality of nursing care delivery. The study will be conducted with an assumption that EHR innovations adoption impacts positively on the time that a nurse gets to officer care and enhances effectiveness in nursing care delivery through a decrease in cases of hospital-acquired conditions and nurse turnover.
Literature Review Introduction
A literature review has been conducted to help in examining the available empirical research that focuses on the implications of integrated EHR application in nursing care. Several databases including Pub Med and Cumulative Index of Nursing, Allied Health Literature (CINAHL), Medline, and Google Scholar have been used among others. The parameter that was used in arriving at the study items included a look into peer-reviewed articles that were published between 2003 and 2016. Among the keywords that were used are EHRs, adoption of innovation, and quality nursing care among others. The choice of articles for inclusion was mainly narrowed down to research articles that did not directly study the adoption of innovation and the implications of such adoptions in patients’ outcomes. As such, the literature review looks at areas like the adoption of innovation in health care organizations, the factors that affect the environment of nursing practice, nurses, and decision-making practices, and the implications of EHR adoption on quality outcomes.
- Innovation Adoption
The application of computers in the health care environment is an innovative shift in the nursing practice. With the increasing trends of EHR implementation, nurses have largely adopted the use of computers in data analysis like in analysis laboratory tests and in completing laboratory studies. However, van Bogaert, Clarke, Roelant, Meulemans, and van de Heyning (2010) state that new technological advancements in the healthcare industry have resulted in the integration of computerized documentation in health care, which did not exist in the early days. Out of the overall population of health professionals, a higher percentage is composed of nurses. The perception that nurses have of the application of computers in health care providers has a lot of implications on the level of success in the implementation of technological changes (Jha et al., 2011).
An exploration of the factors that contribute to the trends that were witnessed in acceptance and rejection of innovation by groups of individuals can be done by the use of the Rogers Diffusion of Innovation (DOI) model. Jha et al. (2011) studied the perception that 12 nurses had on the adoption of integrated health care systems in the intensive care unit. By using a constant comparative analysis, the researchers obtained central themes that were in support of nurses’ behavior concerning the adoption of computerized health systems that are aligned to five components of the model proposed by Rogers. The study findings revealed that computerized documentation facilitated orderliness but resulted to stress among nurses in cases where the chatting process experienced delays. In the study, the nurses applied the computerized systems as learning tools for enhanced patient care, as a memory aid, and a system that facilitated modification of ongoing patients’ care plans.
Recently, a debate emerged on whether or not EHR adoption influences the diffusion of innovation. According to Di Pietro et al. (2008), an increase in the sale of personal digital assistants was realized to about 13.1 million worldwide due to the multifunctionality of the devices. Going by the findings of the study, it was established that PDAs can help in time-saving, error prevention, and enhance the mobility of devices that can safeguard against potentially harmful events. However, the researcher recommended that a further study should be conducted to investigate the challenges that nurses have in ensuring the accuracy and reliability of the information at the point of care.
- Nurse Practice Environment
Hospitals primarily focus on providing health care services for the sick, those with injuries, and patients with general needs. The outcomes of patient care are largely determined by the staff that attends to patients. For nurses to be able to function and provide quality health care, their work environment must be improved so that they get satisfied with the conditions under which they provide their services. Among the main factors that affect the health care environment are turnover rates, job satisfaction, as well as the ability to function in a safe work environment. According to Rathert, Ishqadief, and May (2009), there has been an increase in the demand for nurse practitioners because of the increase in demand for health care. The disparity in terms of the ratio of nurse practitioners to that of patients poses a big challenge to the available nurses as they strive to attend to all patients. In turn, nurses end up suffering burnout and stress that largely impact on their performance.
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Rathert et al. (2009) state that the provision of high-quality care calls for the ability of nurses to develop the intimate relationship between them and their patients. The researchers examined the implication of the work environment on the staff's psychological safety. Rathert et al. (2009) conclude that the nature of the work environment in terms of workload, social relationships, and safety of the work environment largely influences the quality of work as demonstrated by nurses. To this point, the researchers suggested the application of integrated computerized documentation systems to boost efficiency in health care and enhance the authorized accessibility of health information.
Eaton-Spiva et al. (2010) state that changes in the demographics of nurses and patients imply the nursing environment. The researchers noted that nurses who operate in a favorable environment show high levels of satisfaction with their work and that they record low turnover. Therefore, the researchers suggest that leaders of health care should seek to improve the working conditions of nurses to rip the benefits of nurse retention in hospitals. One of the ways of improving nurses’ job satisfaction is by facilitating them by way of initiating the use of effective technology in the healthcare setting for ease of information sharing among healthcare providers (Jha et al., 2011).
- Nurse Decision-Making
Several studies have been done to understand the implications of the nursing work environment on nurse decision-making. Eaton-Spiva et al. (2010) studied factors influencing the level of involvement of registered nurses in decision-making. The study findings indicate that nurses are likely to express moderate or low autonomy concerning decision-making in their line of duty when they work under unsuitable working conditions. The changes that nurses have to deal with in terms of the influx of innovations in their practice can cause nurses a strain in the short run, but after such technologies have been fully integrated into the system, they start displaying positive results as evidenced by increased efficiency of nurses in decision-making. Besides, the study indicated that integrated electronic systems documentation assists ensure accuracy in decision-making by nurses as they rely on viable data.
A qualitative study that was conducted by Rathert et al. (2009) to understand the clinical decision making for nurses gave five themes namely self-confidence, a feeling of competence, level of nursing education, availability of support, and organizational structure. All these elements were identified as vital aspects that determine effectiveness in clinical decision-making.
Computerized Documentation and Quality Outcomes
The attitude towards the implementation of EHR tools varies among nurses depending on their expertise in the use of computers. Rathert et al. (2009) studied the functionality of EHR and the extent to which nurses preferred them. The study is important in understanding the perception that nurses have towards the implementation of EHR tools. The study also highlights the strengths and weaknesses of the application of EHR tools. Based on their findings, the researchers argue that implementation of the innovative tools leads to cases of duplicate documentation and instances of interruption in nurse workflow. The researchers suggest that more studies should be done to determine necessary changes that can be made to EHR systems in a manner that can boost their efficiency.
Carlson et al. (2010) state that EHR implementation can affect the amount of time that nurses have for health care delivery. In their study, the researchers focused their attention on the implication of online documentation on the attitudes of staff members, the completeness of data, and the time that was needed for documentation. The study findings indicated an increase in the level of staff motivation with the implementation of EHR and improved accuracy of documentation. The study also showed that the time that was required for documentation using EHR tools was relatively shorter in comparison to manual documentation.
Research Questions, Hypothesis, and Variables
This research will use the following questions:
1) How does the adoption of EHR affect nursing care delivery concerning acquired falls, nurse turnover, and working hours?
2) Which behavior changes do nurses show in the initial stages of adoption and implementation of EHR in the medical and critical care units?
3) To what extent does the adoption of EHR in the nursing practice improve the quality of nursing care, aid in reducing the cost of care, improve job satisfaction for nurses, and reduce turnover?
This study is based on the hypothesis that the cost of nursing health care, quality of nursing delivery, and the level of job satisfaction for nurses improve following the use of Integrated EHR in the nurse workflow. The hypothesis is anchored on the perception that the adoption of innovation in nursing care helps to improve efficiency in health care provision and reduce the burden of manual documentation. It is also based on an assumption that all nurses have a similar attitude towards EHR application hence the adoption of the electronic systems is positively received in all nursing care settings.
The study will help in the identification of the implication of several variables of the quality of nursing care delivery. The variables include the rate of nurse turnover and job satisfaction, the actual nursing care worked hours, cases of hospital patient fall developed while in the hospital environment, and the hospital-acquired pressure ulcers.
- Overview and Guiding Propositions
This research will be conducted with close reference to the Diffusion and Innovation (DOI) theory. The theory presents summary characteristics that are common in all cases of innovation adoption. DOI theory has been successfully used in several health care advances and it has proved effective in explaining the reason why some evidence-based practices are welcomed as others face resistance. The theory refers to the process through which a practice that one regards as new can be applied and disseminated via given channels for a given time (Carlson et al., 2010). The dependent variable in the DOI theory is innovativeness. The extent to which one can respond to the adoption of innovations is mostly viewed in different levels known as adopter categories.
The theory has four elements namely time, communication channels, innovation, and the level of innovation adoption. The last component of the theory is the social system. It refers to a series of interrelated units that are actively involved in collective problem solving to accomplish a common goal (Carlson et al., 2010).
The DOI theory has two processes namely adoption and decision. Adoption denotes the progressions that take place in an individual’s mind from the time when the individual first hears of a change to the time when the change is adopted. According to Carlson et al. (2010), the theory asserts that the adoption process has five stages that involve knowledge, interest development, evaluation, the trial stage, and adoption. The process of innovation-decision refers to the way an individual goes from transformation to innovation to decision. One first acquires knowledge of the existence of the innovation and then develops an opinion regarding the innovation. In the third stage, one decides to take in or resist the innovation. Implementation takes place in the fourth stage and the fifth stage, people confirm their decision to innovate.
- Application of Theory to Study Focus
The Diffusion and Innovation (DOI) theory applies to this research study since it highlights the factors that have implications on people’s decisions to innovate. The factors that are addressed by the theory can be used to understand the reasons behind the diverse perception that nurses have over the decisions by their organizations to innovate. Besides, the theory can be used to explain varied tendencies and levels of implementation of innovation in different health care settings. DOI is effective in explaining the process of innovation hence its application in this study will help in explaining the relationship between the variables.
- Sample Setting
This research study will be set in a large community hospital system that is located in New York. The central New York hospital is identified as a viable setting for the study due to its comprehensive health care services. The hospital was founded by the St. Francis sisters several years ago. A faith-based institution always ensures resource allocation to facilitate the provision of health care to patients. The choice of the hospital is also made due to the high number of employees in the organization. The hospital has more than 4,000 employees of which 1737 are nurses. The number of registered professional nurses in the hospital is 1,437 with at least 300 licensed practical nurses. Approximately 27,500 patients are served by the hospital annually with the hospital’s yearly emergency department patients visit of over 70,000.
- Sample Strategy
This research targets the nurse population in the surgical and critical care specialties. The target population that will be included will be summarized by demographic variables like the type of EHR tools that are used, the populations of patients, patients’ length of stay, and the extent of the illness. In particular, the study will rely on data from the National Database of Nursing Quality Indicators (NDNQI) between the years 2011 and 2016. Other data will be obtained from the organization as obtained from the human resource performance improvement departments. For over 10 years, the hospital has been reporting cost outcome strategies and nursing-sensitive indicators to the NDNQI database. Other sources of data that will be used in this study are information obtained from the human resource files that relate to aspects of turnover rate and the outcomes of the hospital’s annual satisfaction survey. The study targets to use seven surgical units and five critical care unit data sets that will be arrived at through random sampling.
- Research Design
This will be a quantitative descriptive study that will assist in establishing relationships between variables. The use of a quantitative descriptive study design is believed to be appropriate in investigating the relationship between the study variables by looking at the measure of performance before the adoption of EHR and after the adoption. The research study will use the available retrospective data that will be obtained from the hospital’s acute care system.
- Extraneous Variables
Apart from the main study variables, other extraneous variables are expected in the study that if left uncontrolled, may have implications for the findings of the study. The extraneous variables include the motivation of nurse care providers, the financial capacity of the organization, and the technical competence of the nurses.
Before the start of the study, a receipt of approval will be obtained from the hospital’s Institutional Review Board (IRB). With that approval, there will be an authorization to use data that will be obtained from the NDNQI and the information that will be obtained from the archives of the human resource besides using performance improvement records over the years starting from 2010 to 2016. The research instrument in which the data will be entered is the R statistical package together with Interrupted Time Series (ITS) regression for measuring the implication of the EHR tools on the dependent variables. The ITS approach will be applied in establishing relationships to form the foundation upon which predictions can be made as is always necessary for clinical decision making and in setting goals.
- Description of the Intervention
This intervention is intended to add worth to earlier studies by other researchers in that it will seal the gaps identified in the prior studies. Application of the DOI theory in the study will facilitate the derivation of relationships hence enabling a clear understanding of how the variables relate. To that effect, this intervention will aid in providing an extra layer of proving whether or not, the application of an Integrated Electronic Health Information Systems impacts positively on the quality of nurse service delivery.
- Data Collection Procedures
In most cases, studies that aim to find hospital-based outcomes use a combination of private and public data (Eaton-Spiva et al., 2010). For this study, data will be obtained from administrative sources within the organization. The data that will be collected will be handled with great confidentiality in that they will be locked in an assigned location within the hospital. The study will not use the hospital’s names. Besides, the study will avoid keeping any employee-specific information. Among the administrative data and data verification benchmark that will be consistent with the IRB requirements of the hospital. The elements of data obtained will be put into categories by the variable.
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- Data Analysis Plans
Data analysis will be done by the use of R Statistical Package 0.2, and the variable relationship will be examined like the adoption of EHR and the implications of such adoption on nursing. The response will be analyzed sequentially over a period. ITS methodology will also be applied to facilitate the analysis of data to explain the nature of the relationship of the outcome of nursing with the adoption of EHR technology as applied in the direct care environment. Time series models will also be constructed to enable the analysis of data over time. The methods that will be used will facilitate the derivation of results that will be analyzed in the subsequent section of the study.
- Ethical Issues
The first ethical consideration that will be made is to ensure that a formal written approval is obtained from the institution’s administration and the IRB to authorize the study of the hospital administration’s data.
Second, necessary measures will be put in place to safeguard sensitive and private information regarding the hospital and its employees. No record that can lead to the personal identification of employees will be stored for whatever reason. Storage of such information goes against the rights of individuals who are involved in a study as participants whose identity should always be protected.
The principle of informed consent will also be applied to ensure that all participants included in the study are fully informed of the purpose of the study before they either accept or decline to participate in the study.
- Limitation of Proposed Study
This study will have a limitation since it seeks to use administrative data that can face challenges in case of failure to control the collection method. It is also projected that there may be a minimal concurrent validation of the findings of the study. The challenges will be mitigated by the choice of an appropriate research methodology.
Another limitation relates to the period that is allowed for this study. The topic under study is relatively wide and a long time would be necessary to enable extensive research into the subject. With adequate time, it would be possible to dig deeper into the matter and read more on the topic for a better understanding that would facilitate better deductions. Besides, resource availability is a factor that will also limit the extent to which the study will be conducted.
- Implications for Practice
This study will have many implications for the practice of nurse informatics. It will help in identifying how the adoption of innovations like the EHR tools in nursing impacts the quality of nursing. As such, the study findings will be highly applicable to organizations that seek to make informed judgments on the choice to use innovative technologies. To nurse informatics, the findings of this study will serve as a motivating factor and a revelation that will guide them on how to benefit from Integrated EHR as they strive to provide quality services to patients.
Based on the success that is associated with the use of innovation in nursing care (as evident in the literature review), this study will serve as one of the justifications to be used in support of nurses’ inclusion in the innovation adoption. The study will also serve as a pointer towards the necessary adjustments to be made in the health care setting concerning staff models to enable retention of nurse practitioners, as innovation is implemented. The literature review has unearthed several advantages associated with the application of evidence-based computerized tools in improving nursing care. To that effect, this study will be a viable reference resource for health care leaders in their effort to improve the quality of nursing care.
Application of innovation in health care started as a novelty level and developed to become a basic requirement in the health care environment that promotes organizational effectiveness. Currently, health care facilities are perceived to be among the main consumers of a variety of innovations. Adopting new clinical behaviors in the health care systems should be regarded as a multifaceted process hence necessitating its consideration as a process. Due to the recent trends that have been observed in technological adoption in health care, it is necessary to explore the implications that computerized documentation has on nurse workflow. It is believed that the increased application of an integrated EHR will help in improving the overall quality of nursing care provision besides facilitating cost management in hospitals. In this preliminary stage, this study has involved a comprehensive literature review that has pointed out that the use of EHR in the hospital setting can give positive safety outcomes and increase nurses’ satisfaction level with their work hence resulting in quality care. The literature had gaps concerning highlights on the application of EHR in nurses’ direct care practices. As such, further research should be conducted on the concept.