Nurses Perceptions of an Electronic Patient Record

SHORT REPORT

Nurses’ perceptions of an electronic patient record from a patient safety

perspective: a qualitative study

Jean E. Stevenson & Gunilla Nilsson

Accepted for publication 11 June 2011

Correspondence to J.E. Stevenson:

e-mail: [email protected]

Jean E. Stevenson BA MSc RN

Lecturer

School of Language and Literature, Linnaeus

University, Kalmar, Sweden

Gunilla Nilsson PhD RN

Associate Professor of Nursing and Health

Informatics

School of Health and Nursing, Linnaeus

University, Kalmar, Sweden

STEVENSON J.E. & NILSSON G. (2012)STEVENSON J.E. & NILSSON G. (2012) Nurses’ perceptions of an electronic

patient record from a patient safety perspective: a qualitative study. Journal of

Advanced Nursing 68(3), 667–676. doi: 10.1111/j.1365-2648.2011.05786.x

AbstractAims. The overall aim of this study was to explore nurses’ perceptions of using an

electronic patient record in everyday practice, in general ward settings. This paper

reports on the patient safety aspects revealed in the study.

Background. Electronic patient records are widely used and becoming the main

method of nursing documentation. Emerging evidence suggests that they fail to

capture the essence of clinical practice and support the most frequent end-users:

nurses. The impact of using electronic patient records in general ward settings is

under-explored.

Method. In 2008, focus group interviews were conducted with 21 Registered

Nurses. This was a qualitative study and the data were analysed by content analysis.

At the time of data collection, the electronic patient record system had been in use

for approximately 1 year.

Findings. The findings related to patient safety were clustered in one main category:

‘documentation in everyday practise’. There were three sub-categories: vital signs,

overview and medication module. Nurses reported that the electronic patient record

did not support nursing practice when documenting crucial patient information,

such as vital signs.

Conclusions. Efforts should be made to include the views of nurses when designing

an electronic patient record to ensure it suits the needs of nursing practice and

supports patient safety. Essential patient information needs to be easily accessible

and give support for decision-making.

Keywords: acute hospital settings, documentation, electronic patient records, focus

group interviews, patient safety, record keeping, supporting nursing practice

Introduction

Patient safety and nursing documentation are internationally

important aspects of patient care. Patients admitted to

hospital have the right to expect optimal care (Department

of Health 2008). In the event that a patient’s condition

should deteriorate, it is assumed that timely and appropriate

action will be taken. However, according to the National

Institute of Clinical Excellence NHS UK, sometimes deteri-

oration in patients’ clinical status is not detected or acted

upon in time, leading to potentially fatal outcomes (NICE

2007). In addition, it is possible that complex documentation

� 2011 The Authors

Journal of Advanced Nursing � 2011 Blackwell Publishing Ltd 667

J A N JOURNAL OF ADVANCED NURSING

in electronic patient records may be compounding this

problem, although we have been unable to find such evidence

in the literature. Patient safety is a primary concern for nurses

(Feng et al. 2008) and their perceptions of patient safety in

electronic patient records (EPR) are important as they are the

largest group of healthcare workers and the professionals

who are with patients round the clock (Clark 2007).

Although this study represents only one EPR system in one

hospital, we believe there are important universal lessons

about system design, patient vigilance and patient safety,

which can be applied to any EPR system. Our main study

highlighted several aspects of nurses’ experiences of the EPR

in general ward settings. In this article we only present the

patient safety issues which emerged.

Background

Healthcare information systems have evolved to play a

major role in health care in modern society and the EPR

aims to improve patient safety and documentation quality

(Granlien et al. 2008). Nurses play a pivotal role in patient

safety and studies from across the world confirm that the

quality of the nursing environment has a direct impact on

patient outcomes (Clarke & Aiken 2005). Nurses are hands-

on carers so their contribution to health care clearly affects

patient safety (Burhans & Alligood 2010). Also, according

to the Institute of Medicine, nursing vigilance protects

patients from errors (IOM 2004). Finally, on-going vigilance

is vital for the early detection and prevention of potential

problems (Despins et al. 2009).

The need for excellent patient vigilance is currently

emphasized. To begin with, there is an increasingly complex

group of older patients with multiple diagnoses, routinely

treated in acute care settings (Armitage et al. 2007, James

et al. 2010). Moreover, acute hospitals tend to manage only

the seriously ill, because length of stay has greatly decreased

(Hillman et al. 2001). Therefore, good-quality routines for

documenting physiological status in adult patients are essen-

tial, as patients are at risk of becoming acutely ill due to their

underlying diagnoses or previous medical condition. Further-

more, many studies have shown that careful monitoring of a

patient’s physiological status, early recognition of deteriora-

tion and timely management can greatly reduce the incidence

of cardiac arrest and unplanned admission to critical care

units (Buist et al. 2002, Andrews & Waterman 2005,

McBride et al. 2005, Gardner-Thorpe et al. 2006, Armitage

et al. 2007, NICE 2007).

Criteria for detecting patient deterioration include respi-

ratory rate, systolic blood pressure, heart rate, conscious

level and temperature. According to NICE (2007), these

parameters need to be ‘done well and recorded well’.

In addition, these should be easily viewed so that changes

in trends can be instantly identified by all clinicians (Hutson

& Millar 2009). Traditional visual views of vital signs in

graphical form on paper charts are being replaced by

electronic formats in the EPR, so it is important that this

clinical documentation is comprehensively presented.

However, previous studies have shown that, despite some

positive views, for example, improved legibility, nurses were

predominantly dissatisfied with EPR systems (Stevenson

et al. 2010). This was largely due to lack of an efficient

way to view an overall picture of patient progress and care,

and poor navigability (Darbyshire 2000, 2003, Timmons

2003, Moody et al. 2004, Smith et al. 2005, Lind 2007).

Although technophobia and resistance to technology have

been blamed, nurses have had minimal influence in the

design of systems (Clark 2007) and therefore, some claim

that perceived resistance to EPR is more accurately explained

by nurses defying poorly designed systems that fail to meet

the needs of documentation in nursing practice (Timmons

2003). As there is a dearth of studies on nurses’ experience of

EPR in general wards, this study was designed to increase

knowledge of nurses’ experiences by investigating their

perceptions of using the EPR for documentation in everyday

practice.

The study

Aim

This study aims to explore nurses’ perceptions of using

electronic patient records in everyday practice, in general

ward settings.

Design

A qualitative design was selected, where data were collected

through focus group interviews and analysed by means of

content analysis. This article forms part of a larger study on

nurses’ perceptions of using EPR.

Participants

The participants were Registered Nurses (RNs), (hereinafter,

referred to as nurses) who worked in a district general

hospital in the southeast of Sweden. A letter explaining the

purpose of the study was sent to six acute wards and nurses

who wanted to participate could volunteer. The inclusion

criteria were that participants were RNs, from acute clinical

areas (medical/surgical wards) where an EPR was used for

J.E. Stevenson and G. Nilsson


668 Journal of Advanced Nursing � 2011 Blackwell Publishing Ltd

clinical documentation. Nurses (n = 21) responded voluntar-

ily from six wards; two medical (n = 5), two surgical (n = 6),

one orthopaedic (n = 4) and a stroke unit (n = 6). At the time

of data collection, the EPR system had been in place for

approximately 1 year in all the wards.

Data collection

The data were collected within a 2-week period in Novem-

ber and December 2008. A total of four focus group

interviews was conducted, each lasting between 50 and

80 minutes with a mean of 65 minutes. Two researchers, the

authors, carried out the interviews in quiet conference rooms

adjacent to the wards in which the nurses worked. The

researchers were university lecturers and, apart from recog-

nizing one previous student in one of the groups, the

researchers were not acquainted with any of the nurses. The

nurses and researchers sat round a table in a circle. Each

interview was audio-recorded digitally. There was no specific

interview guide, as we wanted the nurses to speak freely

about their perceptions of the EPR. A general question was

asked at the beginning which covered the broad aim of the

study. The question was: What are your experiences of

using electronic patient record systems in your everyday

work?

Although an unstructured approach was taken, when

necessary, probing questions were added by the researchers

to gain more information, for example, to describe something

in more detail, such as ‘describe what you mean by journal’.

In each interview, the introductory question initiated an

immediate response and a free flow of dialogue. Towards the

end of each interview, when the researchers considered that

saturation point had been reached, a so-called ‘round robin’

was initiated, whereby each respondent was asked to state

something they found positive and something they found

negative about the EPR system. It was clear that focus group

interviews provided a good climate for discussion and gave

the nurses an opportunity to reflect on their experiences

as a group; hence, enriching the information they shared

(McLafferty 2004). Citations from all interviewees were

included to validate the findings.

Ethical considerations

The study was approved by the appropriate university and the

Ethics Committee of Southeast Sweden. Permission to perform

the focus group interviews was obtained from the managers of

the three hospital departments involved in the study; surgical,

medical and orthopaedics. Information about the study was

given to potential participants. The nurses who volunteered

(n = 21) gave their consent to participate in the study and were

informed that they could withdraw from the study at any time.

Confidentiality of the participants was guaranteed by remov-

ing any identifying features from the transcripts.

Data analysis

The digital audio-recordings of the interviews were tran-

scribed verbatim and content analysis was carried out as

proposed by Graneheim and Lundman (2004). The process

began by reading through the interview transcripts several

times and sometimes returning to interview recordings to

become completely familiar with the data and to comprehend

its essential features. The raw data were processed by open-

coding (JS): writing notes and headings in the margins while

reading, to include all aspects of the content which related to

the aim of the study. Meaning units were identified and

colour-highlighted on a word-processor. Subsequently, these

were transferred to a coding sheet. The meaning units were

condensed to give a manifest description of the content and

then coded according to content. Sub-categories were iden-

tified according to similar codes. Finally, main categories

(of which only one is included in this report) were established

where similar elements of the sub-categories could be

combined. Both authors discussed the categories until

consensus was reached. Checking and rechecking the cate-

gories led to total immersion and interaction with the data in

the spirit of insightful interpretation (Polit & Beck 2008).

Examples of the process of content analysis of small pieces of

text are illustrated in Table 1.

The authors discussed and revised coding until general

agreement concerning categories and sub-categories was

reached (Table 2). Herein we present only one of the

Table 1 Example of the analysis process: from meaning units to category

Meaning unit Condensed meaning unit Code Sub-category Category

‘It takes a long time before you

can even begin to understand a

little and even then I might have

missed something’

Understanding

patient history

and status

Patient safety Difficult to see

vital signs

Documentation in

everyday practice

JAN: SHORT REPORT Patient safety in an electronic patient record



categories from our larger study; the one we report in this

article.

Trustworthiness

Trustworthy is the term applied in qualitative studies to

describe reliability (Polit & Beck 2008). To ensure trustwor-

thiness, two researchers performed the interviews and anal-

ysed the data ensuring investigator triangulation (Polit &

Beck 2008). In addition, authentic citations have been

included to increase trustworthiness (Elo & Kyngas 2008).

By this, we believe that a high degree of trustworthiness was

maintained throughout the study. Furthermore, member

checking was carried out by three randomly selected mem-

bers of the focus groups. They were asked to review and react

to the interview data, emerging categories and results. They

acknowledged that our report gave a true account of what

they perceived. In addition, in October 2009, we presented

our study to a group of 15 nurses, currently using the Cambio

Cosmic EPR in various hospitals in the same region. They

unanimously agreed that what we reported was applicable to

their own experiences.

Findings

Documentation in everyday practice

The evidence for this work comes from the opinions of nurses

using the EPR on a daily basis. The primary focus of this

paper was to describe nurses’ opinions, directly or indirectly

linked to patient safety aspects of documentation in the EPR

in general wards (Table 2). In the larger study, ‘Documen-

tation in everyday practice’ emerged as a main category.

There are three sub-categories into which we have grouped

the nurses’ opinions. The first sub-category is vital signs, and

given priority position as it is generally accepted by nurses as

being vitally important to patient safety. Another sub-

category, which emerged from the evidence, was overview.

The third important feature which arose was the medication

module.

The participants were all women and the following

represents age and nursing experience. Age: 20–29 years

(n = 4), 30–44 years (n = 11), >45 years (n = 6); years in

nursing: <2 years (n = 1), 2–5 years (n = 5), 5–15 years

(n = 10), >15 years (n = 5). All had been using the current

integrated EPR for 12–18 months.

The EPR was used by the entire healthcare team for

documentation. Other professionals such as doctors, physio-

therapists and occupational therapists, had one point of

information entry referred to as the ‘journal’. Nurses had

three possible locations for documentation; the ‘journal’, care

templates and report sheets (Table 3).

Vital signs

As the focus group interviews progressed, it became evident

that there were some issues in determining where various

types of information should be documented. There was no

consensus between different wards, and sometimes within the

same ward, about which part of the EPR was the correct

place for various aspects of nursing documentation.

And it’s difficult to know whereabouts to write, as there is so much

everywhere. The system allows you to use several different places to

document the same thing, and this is a problem I’d say - it’s not clear

where what should be documented.

There’s 17 places to document everything... where should I write

what I have found?

The participants indicated that this could lead to uncertainty

for personnel from another ward.

It’s different from ward to ward. If a doctor from a medical ward

comes here on a consultation, they are used to going in to another

part of the EPR to see the blood pressure (BP) and when there is

nothing there, they think we haven’t taken the patient’s blood

pressure. But it’s in the template instead.

Participants reported that they used all three possible

locations for documenting physiological observations. Some

had chosen not to use templates.

There are templates which we should use. Those templates are not so

good as we would like them to be. Therefore, we have chosen not to

use them and write in the report sheet instead.

About half of the nurses (n = 10) indicated that they

thought the ‘correct’ place to document vital signs such as

Table 2 Findings: category, sub-categories and codes

Category Sub-category Code

Documentation

in everyday practice

Vital signs Patient safety

Overview Patient safety

Medication module Patient safety

Table 3 Organization of documentation in the EPR

Journal

Used by all members of the multi-disciplinary team

Care template

Used by nurses only

Report sheet

Used by nurses only




temperature, pulse and respiration (TPR) and blood pressure

(BP), was in a care template. Participants described how

creating templates was time-consuming and difficult to learn

with multiple steps and clicks required in the process. A

separate template was required for each observation; one

template for blood pressure, another for pulse, another for

respiratory rate and so on.

Some of us have problems to make these templates- it takes a while,

so if you don’t have time, you write in the BP under the heading

circulation [in the report sheet] so you don’t forget it. There are

templates which we should use. There are separate templates for

pulse and blood pressure.

A template entails that you first make an indication and then an

action, so there are many parts, often 3 things must be written before

you can sign it and have your template. And then you write in the BP.

You have to give the reason for taking the blood pressure in the first

place, when you plan to take it and how frequently and how long you

want to do this. And it takes rather many clicks in order to make a

template, it certainly takes 10.

It was also possible to produce a visual graph but this

required further steps and the majority of the participants did

not know how to do this.

Participants described documenting other physiological

values.

Just to record a blood sugar takes a long time. Before, you could add

it to the same chart used for TPR and BP. How many clicks is it? At

least six and probably takes about five minutes.

Nurses reported that this type of patient information had

been charted at the bedside when they had paper charts, but

now they often scrawled information into pocket notebooks

or paper towels until they had time to enter it into the EPR.

Overview

There were both positive and negative opinions reported by

the nurses concerning overview.

It was considered an advantage that nurses could access the

EPR simultaneously allowing many users access at the same

time. Also, time was no longer wasted trying to trace paper

records. This is shown in the following extracts.

With the computer system, everyone has access – the occupational

therapist, physiotherapist, nurses and doctors so it’s more accessible

in that way.

Everything’s there, everyone can read at the same time, and everyone

can read what everyone has written; there is not that eternal fight

over charts.

And the journals are available in every unit, that’s really good too.

This describes how all departments had access to the same

information.

A second advantage was that patient safety was enhanced

because once something was written in the record it was

always there. One example of this is patient allergies.

It’s actually safer. If something’s written down once then it’s there

forever, such things and warnings and stuff. And it comes up

no matter what department the patient is in, and those things are

safe.

A third advantage was having less paper to work with.

Everyone was in agreement that they would not like to go

back to paper records; less paper was better.

However, nurses were also anxious to point out disadvan-

tages of the EPR because, they said, no one had given them

the opportunity to air their views before. They reported that

it was difficult to get an overview of patients in the EPR

because of a number of factors and also stated strategies

which they used to ameliorate the problem.

One negative aspect was the time taken in complex

processes thereby taking too much time to find out about

their patients.

The whole process takes longer now; all the clicks to come in and

then you have to choose where to write. We just can’t get a picture of

the patient’s progress.

They described how they searched through many different

sections of the EPR; they scrolled backwards in the report

sheet to read many written notes and those notes made by

doctors on completion of their rounds.

Another difficulty was in finding information, expressed in

the following extract:

An overview is very difficult to get as it takes something like 15 clicks

before you can even begin to understand a little and even then you

may have missed something.

Generally, they said that accessing the information they

needed about their patients at their fingertips was an

unnecessarily complex process consuming much time and

risking patient safety if overlooked.

The participants indicated that they had adopted several

strategies to overcome poor accessibility to vital information

in the EPR. Firstly, they reported that they preferred to have a

verbal report to make sure they knew what was important

about their patients.

We just can’t get an overview of the patient; therefore, we have gone

back to verbal reports. I feel safer when I have had a verbal report.

Secondly, nurses said they wrote a lot of information in

pocket notebooks. Thirdly, they described the importance of




using their experience and clinical judgment when meeting

their patients at the beginning of a shift.

We thank our experience for every year that goes... you know what

to focus on.

We depend on our clinical judgment.

A general negative comment was that it was not easy to

change things as they were not involved in the decision-

making process.

Yes, we all experience that it’s hard to change things as it’s so far

away from us – the decision-making. And I don’t know if they really

perceive just how much of a problem it is for us, if they really

understand.

It’s even more annoying to feel that we can’t be involved in the

process and develop this because it is supposed to benefit the patient.

You are the first who have asked us what we think.

Medication module

There were mainly positive views from the nurses on the

medication module about patient safety. They reported that

the computer-written text meant that they no longer had

problems with illegible handwriting and could be sure that

they were giving the right medicine in the right dose and this

led to fewer errors. The following opinion from one partici-

pant was generally expressed by the group.

You can see which drugs are prescribed and also what colleagues

have written. I think it’s safer for the patient, much fewer errors.

They get the right medicine in the right dose today.

Another positive view was the advantage of quicker routines

and access to relevant information. It was now possible to

sign for all the medicines at one time when dispensing, which

they valued as it was quicker. They appreciated that it was

very easy to read information about medications because of

the direct link to the Swedish National Formulary (http://

www.fass.se/LIF/home/index.jsp). This led to nurses reading

more about the medicines they administered and improving

knowledge. Some nurses said they felt more secure in that the

medication lists had a direct link to the pharmacy so there

was a degree of internal control.

However, nurses also reported some disadvantages with

the medication module. There were two aspects which they

felt could jeopardize patient safety. Firstly, it was possible to

sign for medications on the wrong day or the wrong time and

nurses said that it was wrong that the system allowed this to

happen.

It’s easy to sign something on the wrong day, or the time may not be

correct.

Therefore, nurses were concerned that patients could

inadvertently receive a double dose of a medicine or miss a

dose altogether.

Secondly, adjustments were not accounted for in the

system.

It’s not very clear when an adjustment is made in a dose. You can’t

see if it’s newly prescribed.

Thus, it was difficult to see when medications had been

commenced or when doses had been changed.

To sum up, there was general consensus in most of the

views reported. The ‘round robin’ at the end of each focus

group interview confirmed that none of the nurses wanted to

return to paper records but strongly verified that they wanted

a much improved system.

Discussion

Study limitations

We do not claim to make generalizations from the findings in

this study. We have examined the views of a limited number

of nurses (n = 21) and only one electronic record system in

one medium-sized hospital in southeast Sweden. Further-

more, the nurses may have been excessively negative in their

perceptions, as they seemed to need to tell us their concerns

about the system: they reported that no one else had asked

them what they thought about using the EPR. They did not

seem to have any route for their concerns to be taken

seriously and acted upon. Despite these limitations, we feel

that this study adds to research in this field by obtaining

detailed accounts of how these nurses experienced documen-

tation in the EPR. Qualitative design allowed us to probe

deeply into the experience of nurses, obtaining rigorous data

from the ‘sharp end’ of patient care.

The findings give a deeper insight into nurses’ perceptions

of using the EPR in general wards. The evidence presented

supports the international literature which suggests problems

with poor navigability and in obtaining an overview of the

patient (Darbyshire 2000, 2003, Timmons 2003, Moody

et al. 2004, Smith et al. 2005). Furthermore, the evidence

suggests that these issues could have a bearing on patient

safety, in line with Stevenson et al. (2010).

It is apparent from the findings presented that there were

difficulties encountered in documenting vital signs, also

recognized by Moody et al. (2004). The importance of easy

access to vital signs is underlined by current trends for

hospitals in the UK to use ‘track and trigger’ systems such as

Early Warning Scores (EWS) systems (Department of Health

2007). These systems were created to detect early signs and




secure timely rescue of the deteriorating patient. Further, they

facilitate the early recognition of deteriorating patients at the

earliest possible stage, thereby reducing the incidence of

cardiac arrest and unplanned admission to intensive care

units (Buist et al. 2002, Andrews & Waterman 2005,

McBride et al. 2005, Gardner-Thorpe et al. 2006).

In line with other international studies (Darbyshire 2000,

2003, Timmons 2003, Moody et al. 2004, Smith et al.

2005), vital information was difficult to enter and difficult to

view in the EPR, because the system was cumbersome and

complicated to navigate, Moreover, it was not easy to enter

or find patient information because there was not a desig-

nated area for documenting various patient data, for

example, vital signs. This could mean that the nurses’ role

in maintaining high-quality patient vigilance may be difficult

to realize in this EPR; clinicians may need to view several

locations to find vital sign recordings; trends deviating from

the norm could be overlooked and signs of patient deteri-

oration missed. To be effective, this essential information

ought to be grouped in a way that allows trends to be easily

viewed, giving accurate indication of patient status (Hutson

& Millar 2009). Information that is hard to locate could be

especially problematic for nurses at the beginning of a new

shift. Despins et al. (2009) recognized that procedures which

fully communicate patient status will more easily distinguish

patients who are at risk. In light of age-old practice, and in

current trends to try to ensure early detection of patient

deterioration, EPRs which support good documentation

routines are essential.

The findings support the literature which suggests that a

problem of EPR is lack of overview (Darbyshire 2000, Rose

et al. 2005, Smith et al. 2005). The participants experienced

that this had two main effects. Firstly, excessive time spent

trying to find information could imply less time for hands-on

patient care and thereby, patient safety could be put at risk.

Even if each piece of data retrieval only takes some minutes

longer than previously, the accumulative result could have an

important impact on time available for hands-on patient care.

Secondly, difficulty in identifying the most important infor-

mation, left nurses feeling insecure as they were afraid they

might miss something. To ‘feel unsafe’ could suggest that the

patient’s safety was threatened because nurses did not have

relevant information at their fingertips. In this context, it is

logical to believe that less time spent with the patient could

incur additional strain on clinicians which could increase the

risk of dangerous errors (Peute et al. 2008). Poor design can

even put heavy demands on users’ mental energy (Rose et al.

2005) and this overload in turn may lead to an adverse effect

on performance and judgment, according to high reliability

theory (Despins et al. 2009).

Nurses appreciated the benefits of the medication module,

but also suggested there could be problems. Improved

legibility of text rather than handwriting was an advantage

consistent with the literature (Smith et al. 2005). However,

being able to sign for medicines on the wrong date or time

during administration, raised concerns for patient safety as

this meant that it could look as though a patient had not had

their medication when in fact they had. One possible

outcome of this is therefore the risk of a patient receiving a

double dose or missing a dose. As medication errors are a

major cause of medical error (IOM 2000, Nielsen 2005), the

threat to patient safety is evident. According to the IOM

(2000), to prevent error and improve safety for patients,

conditions that contribute to errors should be modified,

indicating the need for modification here. Further, other

studies underline the importance of safety in design, as poorly

designed systems may have the unintentional potential of

What is already known about this topic

• Nurses play a pivotal role in patient safety.

• Although nurses recognize benefits with electronic

patient records, there is general dissatisfaction with the

systems.

• Electronic patient records take more time for

documentation.

What this paper adds

• Essential information such as vital sign recordings of

temperature, pulse and respiratory rate, and blood

pressure is difficult to enter and locate in the electronic

patient record.

• Nursing documentation is disseminated throughout the

electronic patient record; it is unclear where specific

information should be documented.

• Nurses adapt their routines to maintain patient safety

by working around the system.

Implications for practice and/or policy

• Patient safety could be threatened if vital information

on physiological status is not easily accessible.

• Careful monitoring of documentation should be

maintained during the implementation of electronic

patient record systems.

• The opinions of end-users need to be taken into account

in system design so that systems meet the demands of

working practice and patient safety.




increasing medical errors (Kushniruk et al. 2004, Wong et al.

2008).

Previous studies emphasize the important role nurses

perform in maintaining patient safety; vigilance is high on

the priority list. In its landmark report ‘To err is human’, the

Institute of Medicine commented that nursing vigilance

protects patients against error (IOM 2000). In addition,

quality of nursing has an important impact on patient safety

(Burhans 2010). The evidence in our study suggests that

nurses strove to maintain a culture of patient safety. As

described by Feng et al. (2008), ‘patient safety culture’ is ‘the

observable degree of effort with which all members in the

organization direct their attention and actions towards

improving patient safety on a daily basis’. These nurses

seemed to make a considerable effort to find ways to ensure

patient safety. For example, they had more verbal reports and

wrote notes to keep in their pockets. Another strategy was

that the nurses used their clinical judgment and experience to

get a picture of their patients, for instance, at the beginning of

a shift as they went round and met their patients. It is

unfortunate that nurses felt obliged to work around the EPR

system but this finding is also supported in other studies

(Timmons 2003, Rose et al. 2005).

Conclusion

The accounts presented in this paper make an important

contribution to knowledge about nurses’ perceptions of EPR.

Although this study may appear, superficially, as a list of

complaints by discontented end-users, it does identify what

works well and not so well in the EPR. Most importantly, it

identifies factors in the system which enhance patient safety,

and the factors which put patient safety at risk, an aspect we

have not found in other studies. For this reason, our study

emphasizes the need for systems to support documentation

related to patient vigilance and, thus, patient safety. In a

climate of rising awareness of hospital-induced patient safety

incidents, the need for accurate record keeping has never been

greater (EU 2005, RCN 2008). As proposed by other studies

(Goorman & Berg 2000, Berg 2001, Nemeth et al. 2005,

Rose et al. 2005, Clark 2007), we also recommend that

designers listen to the views of end-users to understand work

routines and workflow, and subsequently design optimal

systems. More research is required in this field, especially

qualitative studies as indicated by Berg (2001).

Moreover, close monitoring of systems during implemen-

tation could enhance usability (Berg 2001, Kushniruk 2002).

This might avoid convoluted decision-making procedures

when modification is required. Finally, we recommend that

organizations have a policy for reviewing EPR systems prior

to implementation to ensure they facilitate patient safety and

meet the needs of the end-users (Carrajo et al. 2008, Peute

et al. 2008).

Acknowledgements

The authors offer their sincere thanks to the nurses who

kindly shared their experiences and made this study possible.

We are also grateful to those who helped to arrange time and

place for the interviews and to the hospital managers who

allowed us to conduct the study. Further, we extend our

gratitude to Professor Catherine Legrand and Dr Rowena

Jansson for reviewing the manuscript. This study was

supported by Linnaeus University, Kalmar, Sweden.

Funding

This research received no specific grant from any funding

agency in the public, commercial, or not-for-profit sectors.

Author contributions

JS was responsible for the study conception and design. JS

and GN performed the data collection. JS and GN performed

the data analysis. JS was responsible for the drafting of the

manuscript. JS and GN made critical revisions to the paper

for important intellectual content. GN supervised the study.

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Nurses Perceptions of an Electronic Patient Record