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Use of electronic health records and standardized terminologies: A nationwide survey of nursing staff experiences.

Authors
  • De Groot, Kim1
  • De Veer, Anke J E2
  • Paans, Wolter3
  • Francke, Anneke L4
  • 1 Netherlands Institute for Health Services Research (Nivel), PO Box 1568, 3513 CR Utrecht, The Netherlands; Thebe Wijkverpleging [Home care organisation], Lage Witsiebaan 2a, 5042 DA Tilburg, The Netherlands. Electronic address: [email protected] , (Netherlands)
  • 2 Netherlands Institute for Health Services Research (Nivel), PO Box 1568, 3513 CR Utrecht, The Netherlands. , (Netherlands)
  • 3 Research Group Nursing Diagnostics, School of Nursing, Hanze University of Applied Sciences, Petrus Driessenstraat 3, 9714 CA Groningen, The Netherlands. , (Netherlands)
  • 4 Netherlands Institute for Health Services Research (Nivel), PO Box 1568, 3513 CR Utrecht, The Netherlands; Department of Public and Occupational Health, Amsterdam Public Health Research Institute (APH), Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands. , (Netherlands)
Type
Published Article
Journal
International journal of nursing studies
Publication Date
Jan 07, 2020
Volume
104
Pages
103523–103523
Identifiers
DOI: 10.1016/j.ijnurstu.2020.103523
PMID: 32086028
Source
Medline
Keywords
Language
English
License
Unknown

Abstract

Nursing documentation could improve the quality of nursing care by being an important source of information about patients' needs and nursing interventions. Standardized terminologies (e.g. NANDA International and the Omaha System) are expected to enhance the accuracy of nursing documentation. However, it remains unclear whether nursing staff actually feel supported in providing nursing care by the use of electronic health records that include standardized terminologies. a. To explore which standardized terminologies are being used by nursing staff in electronic health records. b. To explore to what extent they feel supported by the use of electronic health records. c. To examine whether the extent to which nursing staff feel supported is associated with the standardized terminologies that they use in electronic health records. Cross-sectional survey design. A representative sample of 667 Dutch registered nurses and certified nursing assistants working with electronic health records. The respondents were working in hospitals, mental health care, home care or nursing homes. A web-based questionnaire was used. Descriptive statistics were performed to explore which standardized terminologies were used by nursing staff, and to explore the extent to which nursing staff felt supported by the use of electronic health records. Multiple linear regression analyses examined the association between the extent of the perceived support provided by electronic health records and the use of specific standardized terminologies. Only half of the respondents used standardized terminologies in their electronic health records. In general, nursing staff felt most supported by the use of electronic health records in their nursing activities during the provision of care. Nursing staff were often not positive about whether the nursing information in the electronic health records was complete, relevant and accurate, and whether the electronic health records were user-friendly. No association was found between the extent to which nursing staff felt supported by the electronic health records and the use of specific standardized terminologies. More user-friendly designs for electronic health records should be developed. The poor user-friendliness of electronic health records and the variety of ways in which software developers have integrated standardized terminologies might explain why these terminologies had less of an impact on the extent to which nursing staff felt supported by the use of electronic health records. Copyright © 2020. Published by Elsevier Ltd.

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