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Could you please read and write the key takeaways of each of the video and articles below:International Journal of Nursing Studies 94 (2019) 74–84
Contents lists available at ScienceDirect
International Journal of Nursing Studies
journal homepage: www.elsevier.com/ijns
The electronic health record’s impact on nurses’ cognitive work: An
integrative review
Kirsten Wisner* , Audrey Lyndon1, Catherine A. Chesla
Department of Family Health Care Nursing, University of California, San Francisco, United States
A R T I C L E I N F O
A B S T R A C T
Article history:
Received 16 June 2018
Received in revised form 14 February 2019
Accepted 6 March 2019
Background: Technology use can impact human performance and cognitive function, but few studies have
sought to understand the electronic health record’s impact on these dimensions of nurses’ work.
Objective: The purpose of this review was to synthesize the literature on the electronic health record’s
impact on nurses’ cognitive work.
Design: Integrative review.
Data sources: MEDLINE/PubMed, CINAHL, Embase, Web of Science, and PsycINFO.
Review methods: The literature search focused on 3 concepts: the electronic health record, cognition, and
nursing practice, and yielded 4910 articles. Following a stepwise process of duplicate removal, title and abstract
review, full text review, and reference list searches, a total of 18 studies were included: 12 qualitative, 4 mixedmethods, and 2 quantitative studies from the United States (13), Scandinavia (2), Australia (1), Austria (1), and
Canada (1). The Mixed Methods Appraisal Tool was used to assess the quality of eligible studies.
Results: Five themes identiﬁed how nurses and other clinicians used the electronic health record and
perceived its impact: 1) forming and maintaining an overview of the patient, 2) cognitive work of
navigating the electronic health record, 3) use of cognitive tools, 4) forming and maintaining a shared
understanding of the patient, and 5) loss of information and professional domain knowledge. Most studies
indicated that forming and maintaining an overview of the patient at both the individual and team level
were difﬁcult when using the electronic health record. Navigating the volumes of information was
challenging and increased clinicians’ cognitive work. Information was perceived to be scattered and
fragmented, making it difﬁcult to see the chronology of events and to situate and understand the clinical
implications of various data. The template-driven nature of documentation and limitations on narrative
notes restricted clinicians’ ability to express their clinical reasoning and decipher the reasoning of
colleagues. Summary reports and handoff tools in the electronic health record proved insufﬁcient as standalone tools to support nurses’ work throughout the shift and during handoff, causing them to rely on selfmade paper forms. Nurses needed tools that facilitated their ability to individualize and contextualize
information in order to make it clinically meaningful.
Conclusion: The electronic health record was perceived by nurses as an impediment to contextualizing
and synthesizing information, communicating with other professionals, and structuring patient care.
Synthesizing and communicating information at the individual and team levels are known drivers of
patient safety. The ﬁndings from this review have implications for electronic health record design.
© 2019 Elsevier Ltd. All rights reserved.
Keywords:
Clinical grasp
Cognitive work
Communication
Computerized documentation
Electronic health record
Integrative review
Perception
Situation awareness
Unintended consequences
What is already known about the topic?
There has been widespread implementation of electronic
health records in developed countries in the past decade.
Electronic health records were expected to enhance patient safety
by increasing access to information and preventing clinical errors.
A growing body of literature suggests that electronic health
records have introduced some unintended, negative consequences to cognitive processing and communication.
* Corresponding author.
E-mail address: Kirsten.wisner@ucsf.edu (K. Wisner).
Audrey Lyndon is now at New York University, Rory Myers College of Nursing, New York, NY, United States.
1
https://doi.org/10.1016/j.ijnurstu.2019.03.003
0020-7489/© 2019 Elsevier Ltd. All rights reserved.
K. Wisner et al. / International Journal of Nursing Studies 94 (2019) 74–84
What this paper adds
The electronic health records’ focus on data aggregation and
completeness has introduced cognitive challenges for users as
they compile and synthesize information from throughout the
medical record.
Navigating the structure of the electronic health record may not
always match how nurses think and work, generating additional
work to integrate it into their complex, dynamic workﬂow.
Clinicians reported difﬁculty formulating and maintaining an
overview of the patient when using the electronic health record.
Limited narrative notes in the electronic health record hindered
clinicians’ ability to communicate and understand others’
clinical reasoning regarding care decisions.
1. Background and signiﬁcance
The implementation of electronic health records (EHRs) was
conceived as a system-level safety intervention aimed at improving communication and access to information, reducing medication-related errors, supporting decision-making, improving
clinical guideline adherence, and assisting with data analysis
(Aspden et al., 2004; Page, 2004). Since the widespread
implementation of EHRs in the last decade, a growing body of
research suggests that their use has introduced unintended
consequences related to usability, alterations in communication
or information exchange, and system complexity (Bristol et al.,
2018; Campbell et al., 2006; Cresswell et al., 2012; Harrington
et al., 2011; Koppel et al., 2005).
Achieving many of the quality, safety, and efﬁciency outcomes
related to meaningful use of EHRs (HealthIT.gov, 2014) has
necessitated EHR infrastructures to support the aggregation,
storage, and visibility of data, as well as the creation of automated
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or built-in functions designed to remind and aid clinicians to
compile and record information. Human factors and sociotechnical
systems frameworks suggest that this focus on data completeness,
aggregation and storage, and the associated work processes create
challenges for end-users. Users encounter difﬁculties when they
try to compile and synthesize information from the EHR, and
integrate cumbersome EHR-related workﬂows with the dynamic
and demanding nature of clinical work (Holden, 2011).
Despite recognition that new technologies can impact human
performance and cognitive function (Dekker, 2015; Perrow, 1999),
few studies have sought to understand the EHR’s impact on
clinicians’ cognitive work. The frameworks of clinical grasp
(Benner et al., 1999,2009) and situation awareness (Endsley,
1995) conceptualize cognitive work as a higher order, dynamic,
and evolving understanding of the patient’s status, situated in a
particular clinical context, and dependent on the clinician’s ability
to continually contextualize and synthesize data over time across
information sources. Information retrieved from the EHR represents one of many important data sources used by clinicians to
continually update their individual and shared perceptual
understanding of clinical situations. This ability to perceive,
understand, and anticipate information about a patient in evolving
clinical situations is seen as a vital contributor to patient safety
(McComb and Simpson, 2014). The purpose of this review was to
summarize the literature about the EHR’s impact on nurses’
cognitive work.
2. Methods
An integrative review methodology was used since it allows for
the synthesis of experimental, non-experimental, and theoretical
data, and is particularly useful for exploring complex phenomena
(Whittemore and Knaﬂ, 2005). The steps in this method include
problem identiﬁcation, literature search, data evaluation, data
Table 1
Search Terms Used.
Search Terms Used for Each Concept
Electronic Health Record
Nursing
Mental Processes/Cognition
Electronic health record/s
Electronic medical record/s
Electronic documentation
Computerized documentation
Electronic charting
Computerized medical records systems
Primary nursing
Nursing
Nursing care
Nurse’s role
Nursing staff
Nursing process
Nurse(s)
Nurs*
Mental Processes
Cognition
Workload
Mental workload
Workﬂow
Work routines
Clinical reasoning
Clinical decision making
Decision making
Situation awareness
Clinical overview
Patient story/ies
Clinical summary/ies
Distraction/s
Perception/s
Perspective/s
Thinking
Cognitive function
Human performance
Information seeking behavior
Critical thinking
Mental performance
Narratives
Problem solving
Psychology
Unintended consequence/s
Attitude to computers
Computerized patient documentation
EMR
EHR
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K. Wisner et al. / International Journal of Nursing Studies 94 (2019) 74–84
analysis, and presentation. Problem identiﬁcation is addressed in
the background section.
science (PubMed, CINAHL, Embase, Web of Science, PsycINFO).
No limiters were applied in order to capture literature not yet
indexed.
2.1. Literature search
2.2. Data evaluation
The search focused on three main concepts: the EHR,
cognition, and nursing practice. See Table 1 for a list of all
search terms used. Search terms related to cognition were
challenging to deﬁne since there is no single deﬁnition of
cognitive work in the healthcare literature, and there are
numerous clinically relevant mental processes that may be
impacted by EHR use. These include concepts and terms such
as situation awareness, clinical grasp, decision-making, critical
thinking, and clinical overview but also encompass mental
processes such as perception, thinking, or problem solving.
Some of these concepts have been identiﬁed as secondary or
incidental ﬁndings in studies focused on the EHR’s impact on
workﬂow, communication, or collaboration. Hence, search
terms such as workload, workﬂow, work routines, and
attitudes were added to capture the breadth of literature on
the EHR’s impact on nurses’ work. This ensured that studies
with incidental cognitive ﬁndings were identiﬁed. Research
came from literature in three main ﬁelds: healthcare,
psychology, and information science.
With assistance from a medical librarian with extensive
experience searching healthcare literature, ﬁve databases were
chosen based on their likelihood of containing literature
related to clinical care (MEDLINE/PubMed, Cumulative Index to
Nursing and Allied Health Literature (CINAHL), and Embase),
psychology (Web of Science and PsycINFO), and information
A total of 4910 articles were retrieved. Duplicates were removed
by a reference manager software and by hand. The titles and/or
abstracts of the remaining 3821 records were screened according
to inclusion and exclusion criteria, and 3801 were excluded,
leaving 20 articles to assess for eligibility. During full text review, 6
articles were excluded based on inclusion criteria. The reference
lists of eligible records were reviewed and work by prominent EHR
researchers was searched to ensure data completeness (Whittemore and Knaﬂ, 2005), adding 4 additional records. A total of 18
records met eligibility criteria for this review. See Fig. 1 for the
stepwise process used for study selection.
2.2.1. Inclusion criteria
Studies had to meet the following inclusion criteria: a) written in
English; b) be original qualitative, quantitative, or mixed methods
research published in a peer-reviewed journal; c) sample included
direct-care nurses in hospital settings; and either d) the study
reported ﬁndings related to the EHR’s (or synonym) effect on nurses’
cognitive work as deﬁned in the mental processes/cognition search
terms; or, e) the study outcomes included concepts related to
collaborative decision-making or team situation awareness.
Fig. 1. Study Selection Process.
K. Wisner et al. / International Journal of Nursing Studies 94 (2019) 74–84
2.2.2. Exclusion criteria
Studies were excluded if they met any of the following criteria: a)
focused on technology or computers generally instead of the EHR (or
synonym); b) EHR use was secondary to EHR-related features or
processes such as displays, software, checklists, care plans, or
decision support; d) focused on EHR implementation strategies, or
user adoption, satisfaction, acceptance or perceptions, where
cognition was not part of the ﬁndings; e) focused on workﬂow,
productivity, or documentation time with ﬁndings unrelated to
cognition; or f) the study focused on computerized physician order
entry without evaluating other elements of the EHR.
2.2.3. Quality appraisal
The Mixed Methods Appraisal Tool ([MMAT], Pluye et al.,
2011) was used to appraise the quality of eligible studies. The
MMAT is designed to evaluate the methodology of quantitative, qualitative, and mixed-methods research studies. Each
study was assessed according to MMAT criteria based on the
study methodology, which included qualitative, quantitative
(further delineated by type: randomized controlled trial, nonrandomized, and descriptive), and mixed methods. The
appraisal process involved scoring 4 quality questions for
each study type, and another 3 questions for mixed-methods
studies. Examples of criteria addressed in the scored
questions for qualitative studies included data quality and
sources, analytic processes, and researcher positionality. The
quantitative questions varied according to study type, but in
general addressed sampling strategy and/or representativeness, measurement processes, and response rates. Mixed
methods questions addressed research design and appropriate integration of methods (Pluye et al., 2011). One point was
assigned for each of the 4 questions meeting deﬁned criteria,
yielding an overall score of 0–4. When scoring mixedmethods studies, the lowest of the quantitative and qualitative scores was assigned according to the scoring guidelines,
since the overall quality of a study is reﬂected by its weakest
element (Pluye et al., 2011).
All studies were ﬁrst screened using two questions about the
clarity of the research questions or objectives and if appropriate
data were collected to address these. Pluye et al. (2011) caution
that if the answer to either screening question is no or
unknown, further appraisal may not be appropriate. Because
the body of literature for this integrative review was limited,
certain studies were included when the response to one of the
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screening questions was unknown. If the answer to both
screening questions was no or unknown, the study was
excluded. See Table 3 for a summary of MMAT scores assigned
to each study.
3. Results
3.1. Data analysis
Eighteen studies met eligibility criteria. See Table 3 for a
summary of included studies. Twelve studies were qualitative
(grounded theory, interpretive phenomenology, ethnography,
content analysis, thematic analysis, network analysis, interpretive
descriptive). Four were mixed-methods, and two were quantitative
descriptive. Publication dates ranged from 2004 to 2016. Studies
were from the United States (13), Scandinavia (2), Australia (1),
Austria (1), and Canada (1).
Instruments used in the quantitative and mixed-methods
studies included the NASA-TLX: Task Load Index (1), an amended
Health Information Systems (HIS)-monitor instrument (1), the
Information Systems Expectations and Experiences (ISEE) survey
(1), an adapted Masrom’s Technology Acceptance Model and Elearning survey (1), and researcher-developed surveys (2). Interviews (8), focus groups (5), observations (8), think-aloud and
think-after sessions (1) and artifacts analysis (7) were used alone
or in combination in the mixed-methods and qualitative studies.
One study used network analysis.
The quality of the studies evaluated using the MMAT ranged
from 1 to 3 (0–4 scale), with 9 studies considered moderate quality
(MMAT score 3), and 9 as low quality. One point was deducted for
half of the qualitative studies because researcher positionality was
not addressed (Pluye et al., 2011). These six studies would have
been judged high quality (4 on a scale of 0–4) had that been
included (Collins et al., 2011; Embi et al., 2013; Keenan et al., 2013;
Staggers et al., 2011, 2012; Varpio et al., 2015). See Table 2 for an
overview of methods, instruments, and MMAT scores for all
studies.
Twelve of the studies focused on RNs only. The other six studies
focused on physicians and RNs (3); midwives and RNs (1), and
multiple stakeholders including RNs (2). Most studies were
conducted in inpatient acute care units within community or
tertiary hospitals. Inpatient units included pediatrics, neonatal
intensive care, perinatal, medical surgical, oncology, orthopedic,
and critical care settings. One study was conducted in 25 different
practice settings across Australia. Another study took place in 4 U.S.
Table 2
Summary of Themes.
Forming and Maintaining an Overview of the Patient
The Cognitive Work of Navigating the EHR
The Use of Cognitive Tools
Forming and Maintaining Common Ground and a
Shared Understanding of the Patient
The Loss of Information and Professional Domain
Knowledge
Studies suggested that clinicians found the process of forming and maintaining an overview of the patient
challenging when using the EHR. Overview has been deﬁned as a dynamic clinical skill that resulted in a
cumulative and comprehensive understanding of the patient’s history, current status, data patterns and
future plan (Varpio et al., 2015).
In most studies, clinicians found that entering, retrieving, understanding, and synthesizing information was
difﬁcult in the EHR and either increased clinicians’ cognitive workload or failed to provide necessary
cognitive support.
The available EHR-generated summary reports and screens were insufﬁcient as stand-alone tools to support
nurses’ information management during their shift and/or at handoff. These tools often did not match how
nurses thought or worked, resulting in reliance on paper notes and verbal exchanges.
Findings indicated that the increased volume and electronic exchange of information did not enhance
communication in a way that facilitated arriving at common ground and shared situation awareness.
Common ground refers to having a mutual understanding of a situation, and shared situation awareness (or
understanding) refers to having a mutual understanding of its meaning.
Nurses relied heavily on paper notes and other disposable forms of documentation, which may have
implications for loss of information when this is not recorded in the EHR. Representations of nurses’ work
and knowledge were not captured in the EHR, or nurses’ notes and documentation were not read by others,
suggesting that in certain settings, nurses’ work and professional knowledge are not integrated into team
processes.
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Table 3
Overview of Studies.
MMAT
Score
Methods
Study Focus
Contribution to
Themesa
Ammenwerth et al. (2011)
MM-1
Information processing
A, B
Chao (2016)
MM-3
Collaborative work routines, interdisciplinary communication
A, B, C, D, E
Kossman et al. (2013)
MM-2
MM-1
Cognitive artifacts support of clinical judgment and team
communication
RN perceptions, ease of use, usefulness, attitudes
C
Schenk et al. (2016)
Health Information Systems (HIS)-monitor instrument; content
analysis of open-ended questions.
Case study, thematic analysis, network analysis, researcherdeveloped survey, interviews, observations, artifact analysis.
Mixed methods convergent, descriptive. Researcher-developed
survey, content analysis of open-ended questions, focus groups.
Mixed methods; pre- post-survey and interviews. Adapted survey.
Qualitative method not stated but consistent with content or
thematic analysis.
A, B, C, E
Quant
Colligan et al. (2015)
Ward et al. (2011)
Quan-3
Quan-2
Quantitative descriptive, NASA-TLX.
Quantitative; descriptive. Information Systems Expectations and
Experiences (ISEE) Survey.
Cognitive workload, computer attitudes, EHR implementation
Implementation, RN perceptions
B
B
Qual
Collins et al. (2011)
Qual-3
Types of communication and information activities during
interdisciplinary rounds
B, C, D, E
Darbyshire (2004)
Embi et al. (2013)
Keenan et al. (2013)
Qual-2
Qual-3
Qual-3
Qual-2
Perspectives and understandings of EHR
Computerized documentation effect on clinician’s work
Information management and ﬂow, communication patterns, use
of artifacts
EHR use during care, RN practice patterns, problems with EHR use,
patient outcomes
B
A, B, C, D, E
A, C, D, E
Kossman and
Scheidenhelm (2008)
Staggers et al. (2012)
Qual-3
Handoff, use of cognitive artifacts
A, B, C
Staggers et al. (2011)
Qual-3
Handoff, electronic summary reports
A, C
Stevenson and Nilsson
(2012)
Varpio et al. (2015)
Qual-2
Clinical communication space and distributed cognition
frameworks used to analyze and map data. Ethnographic
observations, interviews, focus groups.
Qualitative, Interpretive Phenomenology. Focus groups.
Qualitative, cross-sectional. Thematic analysis. Focus groups.
Qualitative, content analysis. Ethnographic observations, artifact
analysis.
Researcher-developed survey w/open ended questions to explore
boundaries of phenomena, interviews, observations. Analysis not
clear, consistent with thematic analysis.
Qualitative; interpretive, descriptive. Audiotaped handoffs,
interviews, observations, ﬁeld notes, artifact review.
Qualitative; interpretive, descriptive. Audiotaped handoffs,
interviews, observations, ﬁeld notes, artifact review.
Qualitative; content analysis. Focus groups.
Use of EHR, overview, medication module
A, B, D, E
Building the patient’s story when using the EHR
A, B, D
Vikkelsø (2005)
Qual-2
Practice, workﬂows, interaction
A, D, E
Weir et al. (2011)
Qual-3
User experiences, collaboration, coordination
A, B, D, E
Zadvinskis et al. (2014)
Qual-2
Mixed Methods
Qual-3
Qualitative; constructivist grounded theory. Observations,
interviews, artifact analysis, think-aloud and think-after sessions.
Qualitative, grounded theory, actor-network theory. Observation,
ﬁeld notes, artifacts analysis, photos, interviews.
Qualitative; used Clark’s theory of communication to focus on one
theme (communication and coordination) from prior study. Focus
groups.
Qualitative, phenomenology. Interviews.
B, C, E
Nurses’ perceptions of EHR and barcode medication administration B, C
Note. EHR = electronic health record; MM = mixed-methods; MMAT = Mixed-Methods Appraisal Tool; NASA-TLX = NASA Task Load Index; Qual = qualitative; Quan = quantitative; RN = registered nurse; VS = vital signs.
a
A = forming and maintaining an overview of the patient; B = the cognitive work of navigating the EHR; C = the use of cognitive tools; D = forming and maintaining common ground and a shared understanding of the patient; E = the
loss of information and professional domain knowledge.
K. Wisner et al. / International Journal of Nursing Studies 94 (2019) 74–84
Citation
K. Wisner et al. / International Journal of Nursing Studies 94 (2019) 74–84
Veterans Administration sites. The focus of the studies included
clinician perceptions of the EHR; its impact on collaboration,
communication, practice and workﬂows, care coordination or
information processing; overall effect on work, use of the EHR
during handoff, evaluation of cognitive artifacts in the EHR, and
measurement of cognitive workload.
Five themes were identiﬁed: 1) forming and maintaining an
overview of the patient, 2) the cognitive work of navigating the
EHR, 3) the use of cognitive tools, 4) forming and maintaining
common ground and a shared understanding of the patient, and 5)
the loss of information and professional domain knowledge. In the
following sections, we use the term nurses for results from studies
with nurses only and when distinct ﬁndings for nurses were
reported. In studies with nurses and other clinicians, and when
ﬁndings were not delineated by provider group, we use the term
clinicians.
3.2. Data presentation
3.2.1. Forming and maintaining overview of the patient
Eleven of the studies reported on clinicians’ ability to obtain or
maintain an overview of the patient. Most ﬁndings indicated that
forming and maintaining an overview of the patient’s status is
complex and difﬁcult when using the EHR. While the EHR has
facilitated the ability to collect and store vast amounts of
information, ﬁndings suggested that this information often lacked
clinical utility.
Overview was described as a vital and dynamic clinical skill that
resulted in a cumulative and comprehensive understanding of the
patient’s history, current status, data patterns and future plan of
care (Varpio et al., 2015). Clinicians assembled an overview by
consolidating, analyzing, interpreting and contextualizing various
data derived from their own and others’ assessments and
communications, the medical record, patient history, and interactions with patients and colleagues. Overview represented a
synthesis of information and a cognitive framework that clinicians
used to guide their thinking, interpret and respond to clinical
ﬁndings and data, and to anticipate the patient’s clinical trajectory
(Varpio et al., 2015). While the process of assembling and
synthesizing information across data sources, and contextualizing
and synthesizing information was described differently in various
studies, it was seen as fundamental to the process of forming the
big picture or overview of the patient and supporting clinical work
(Embi et al., 2013; Keenan et al., 2013; Staggers et al., 2011, 2012;
Stevenson and Nilsson, 2012; Varpio et al., 2015; Weir et al., 2011).
While template-driven documentation facilitated data entry,
the information generated was less informative than free text
documentation (Embi et al., 2013). The emphasis on documentation completeness and increased volume of information in the
record made it difﬁcult to readily locate and process desired
content, thus diminishing its clinical usefulness and failing to offer
a concise summary of the patient’s status (Embi et al., 2013). The
EHR facilitated the collection and storage of more information;
however, it scattered and fragmented parts of the patient’s story,
distributing pieces throughout the record (Chao, 2016; Schenk
et al., 2016; Varpio et al., 2015; Vikkelsø, 2005). This made the
process of consolidation, interpretation, and synthesis more
difﬁcult to achieve, complicating clinicians’ ability to acquire a
summative understanding of the patient’s status (Varpio et al.,
2015), and did little to facilitate the understanding and synthesis
needed by clinicians to support their cognitive work (Weir et al.,
2011). Vikkelsø (2005) reported that an overview was particularly
difﬁcult to obtain surrounding the patient’s medications, and that
the work of assembling an overview for the care team was taken up
informally by nurses.
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Findings from studies examining nurses’ handoff processes and
information management and ﬂow reported lack of a standardized
overview in the EHR, causing nurses to rely on paper forms
containing their personal notes (Keenan et al., 2013; Staggers et al.,
2011, 2012). Chao (2016) also reported this in a study examining
collaborative work routines. These paper forms contained synthesized, dynamic information derived from various sources, tailored
by nurses to both align with and support their work throughout the
shift and during handoff (Chao, 2016; Staggers et al., 2012, 2011).
These synthesized data provided the cognitive support needed for
nurses to prioritize and organize their work and were not available
in the EHR despite it containing an electronic summary intended
for this purpose (Chao, 2016; Staggers et al., 2012, 2011). In
particular, the electronic summary lacked contextual information
necessary to formulate an overview such as vital sign trends, or the
integration of information such as seeing medications in the
context of vital signs or with pertinent laboratory data (Staggers
et al., 2011).
Clinicians found the narrative note features and processes in the
EHR problematic. Across several studies, the visibility of colleagues’ thought processes (including their intentions, clinical
interpretations, and reasoning) was fundamental to achieving an
overview the of patient’s clinical status (Embi et al., 2013; Varpio
et al., 2015; Weir et al., 2011). The EHR restricted the amount and
quality of narrative notes which hindered clinicians’ ability to both
share and decipher the intentions and clinical reasoning behind
care decisions and activities (Embi et al., 2013; Varpio et al., 2015;
Weir et al., 2011). Like other information in the EHR, narrative
notes were fragmented and scattered across the medical record,
making it difﬁcult to formulate a chronological narrative (Varpio
et al., 2015). Clinicians described the process of sorting and
interpreting information in narrative notes to reconstruct the
chronology of events as cumbersome and difﬁcult (Weir et al.,
2011). They had difﬁculty reconstructing details about the patient’s
course of care across various problems and encounters, which
hindered their ability to decipher symptom patterns and the
course of disease (Embi et al., 2013), and created undue cognitive
work as they compiled data from across the record to build the
patient’s story (Varpio et al., 2015).
One mixed-methods study reported improved overview when
using the EHR; however, this was based on favorable responses to
several survey questions that evaluated perceptions about access
to information and visibility of open tasks, supported by content
analysis of open-ended responses (Ammenwerth et al., 2011).
Other studies using immersive data collection methods such as
interviews, observations and artifact analysis suggested that access
to and visibility of information in the medical record did not
enhance an overview, and in many cases rendered information
opaque and more difﬁcult to interpret. Stevenson and Nilsson
(2012) and Schenk et al. (2016) reported mixed ﬁndings about
overview. In both studies, nurses felt that access by multiple users
to the medical record was advantageous, and that information in
the EHR was more comprehensive; however, this information was
fragmented (Schenk et al., 2016), difﬁcult to retrieve and
synthesize, and challenged users’ ability to track the patient’s
progress (Stevenson and Nilsson, 2012), making the increased
volume of information less useful.
3.2.2. The cognitive work of navigating the EHR
Fourteen studies reported ﬁndings related to navigation in the
EHR and its effect on cognitive workload or cognitive support. Most
ﬁndings indicated that entering, retrieving, understanding, and
synthesizing information was difﬁcult in the EHR and increased
clinicians’ cognitive work or failed to provide necessary cognitive
support. These issues were related to the scattering or fragmenting
of information, information overload or complexity, poor quality of
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K. Wisner et al. / International Journal of Nursing Studies 94 (2019) 74–84
information, inability to decipher intent and clinical reasoning, and
lack of chronology.
Findings related to access to and usefulness of information
needed for certain aspects of cognitive work were mixed. Kossman
and Scheidenhelm (2008) reported improved access to information needed for decision-making, and better organization of
information and tasks within the EHR, thus enhancing nursing
work. A study using the Health Information Systems (HIS)-monitor
instrument reported improved information processing, including
support for compiling the patient’s medical history and other
information for the admission process and for creating and
updating the care plan (Ammenwerth et al., 2011). On the other
hand, a study using the Information Systems Expectations and
Experiences Survey (ISEE) reported that nurses felt less conﬁdent
that they had access to the right information for patient care and
reported poorer access to information that improved their ability
to make good patient care decisions (Ward et al., 2011).
Other investigators suggested that clinically relevant information retrieval from the EHR was difﬁcult and cumbersome (Collins
et al., 2011; Darbyshire, 2004; Weir et al., 2011; Zadvinskis et al.,
2014). Processes such as inputting and locating vital signs during
care were perceived as problematic (Stevenson and Nilsson, 2012).
Clinicians found it hard to search across documents located
throughout the medical record to ﬁnd relevant information. The
EHR scattered and fragmented information, making its retrieval
and synthesis challenging. This created more cognitive work for
clinicians and did not provide the cognitive support needed to
synthesize and understand the information (Chao, 2016; Embi
et al., 2013; Schenk et al., 2016; Varpio et al., 2015; Zadvinskis et al.,
2014).
Finding relevant, clinically meaningful information from
lengthy printouts or screens containing irrelevant, truncated, or
outdated information increased clinicians’ cognitive work (Chao,
2016; Embi et al., 2013; Staggers et al., 2012; Varpio et al., 2015;
Weir et al., 2011), and impeded the interpretive process central to
synthesizing and comprehending information (Varpio et al., 2015).
When clinicians detected that the copy and paste function was
used for narrative notes, they mistrusted the currency and
accuracy of information, and engaged in more cognitive work to
validate and cross-check such data (Weir et al., 2011).
One study used the NASA-TLX to assess cognitive workload
during data entry and retrieval tasks in a matched sample of 74
nurses. The survey was administered prior to EHR implementation,
at the end of each nurse’s 1st, 5th, and 10th work shifts postimplementation, and again at 4 months post-implementation
(Colligan et al., 2015). Cognitive workload was statistically
signiﬁcantly higher for nurses after their 1st and 5th work shifts,
returning to baseline for most participants by their 10th shift,
suggesting that cognitive challenges were limited to the early
implementation period.
3.2.3. The use of cognitive tools
Ten of the studies focused on or reported incidental ﬁndings
about the cognitive tools available in the EHR. In all these studies,
available EHR-generated summary reports and screens were seen
as insufﬁcient as stand-alone tools to support nurses’ information
management throughout the shift or surrounding handoff. Nurses
reported that these EHR summary report tools and templates did
not match how they thought and worked, resulting in the
persistence of paper forms or reliance on verbal exchanges.
Across several studies, nurses did not use available EHRgenerated summary reports during the shift or for handoff. When
used, nurses augmented and tailored them to provide missing
information (Chao, 2016; Staggers et al., 2011, 2012). Some nurses
found printouts such as medication administration records,
ﬂowsheets, orders and care plans helpful, but still relied heavily
on personal notes and scraps of paper that they continually
updated and revised throughout the shift to support handoff
(Keenan et al., 2013). Most EHR-generated summary tools were too
long and contained truncated or extraneous information and did
not meet nurses’ needs for a concise (Chao, 2016), contextualized,
synthesized summary (Staggers et al., 2011, 2012). Nurses tailored
their paper forms to contain the signiﬁcant information they
needed to know, using these forms to plan and organize activities
individually and collectively for assigned patients, as well as to
collect and synthesize information throughout the shift (Keenan
et al., 2013; Staggers et al., 2011, 2012). This recorded content
helped nurses to structure clinical judgments and prioritize and
plan actions for the day. Writing on the forms was not just about
collecting information; nurses reported that it supported how they
remembered and processed their thoughts, and helped them verify
that they had pertinent information to structure their work for the
shift (Staggers et al., 2011, 2012). Nurses wanted to tailor self-made
or EHR-generated tools to each patient; for example, they may
forgo certain demographic data on patients who were familiar to
them, or add highlighted information that required special
attention or vigilance such as a high-risk medication that required
speciﬁc timing (Staggers et al., 2011).
Nurses used their paper forms more often after EHR implementation for handoff and throughout the shift to mitigate new
documentation issues encountered with the EHR. They found they
were using these self-made forms to track information and
document later, resulting in duplicate documentation (Chao,
2016). The EHR’s focus on the aggregation and storage of
information was at odds with clinical work (Chao, 2016) and
yielded electronic tools that were too generic and cluttered with
immaterial information to be useful to nurses as they planned and
performed their work (Staggers et al., 2011, 2012).
Clinicians found information retrieval from their personal notes
or verbal communication easier than from the EHR, causing an
increased reliance on verbal exchanges (Collins et al., 2011). They
wanted succinct and up-to-date summaries of the patient’s status
and overall goals of care, and found the templated and exhaustive
information in the EHR confusing, limiting their ability to
understand the course of care (Embi et al., 2013). Nurses reported
that documentation in the EHR did not match the fast-paced,
mobile and team-based nature of their work. Tools and structures
in the EHR were difﬁcult to access and use, forcing duplicative
documentation, ﬁrst on paper notes and later in the EHR (Embi
et al., 2013). Nurses reported frustration that support for patient
care was not built into the EHR (Schenk et al., 2016). The physical
assessment templates did not correspond to how nurses
performed and thought about their assessment, resulting in
inefﬁciency and frustration (Zadvinskis et al., 2014), and the
mandate to document a care summary in shift notes was at odds
with their continuous data collection and entry (Embi et al., 2013).
Kossman et al. (2013) evaluated seven cognitive artifacts for
their support of nurses’ clinical judgment and communication.
These included six EHR-generated tools and the nurses’ self-made
worklists. Nurses rated their self-made worklists as more useful
overall for clinical judgment and communication than any of the
EHR-generated tools except for the medication administration
record. The EHR-generated templates, problem lists and summary
reports failed to organize and display information in ways that
aligned with and supported important aspects of nursing work
(Kossman et al., 2013; Staggers et al., 2011), such as how they were
accustomed to ﬁnding information and thinking about their
patients (Staggers et al., 2011). The self-made tools organized and
displayed information in a way that supported their workﬂow and
style by making information portable, easily accessible and
prompting memory (Kossman et al., 2013; Staggers et al., 2011).
While work lists and automated alerts in the EHR enhanced
K. Wisner et al. / International Journal of Nursing Studies 94 (2019) 74–84
efﬁciency and aided memory, and information for clinical decisionmaking was more accessible, nurses expressed concern that heavy
reliance on drop-down menus, cut and paste features, and
checkboxes could impair their critical thinking and documentation
accuracy (Kossman and Scheidenhelm, 2008).
Simply having information in a printout or screen was
insufﬁcient, since individualizing and contextualizing information
was integral to synthesizing the information in a clinical context.
For example, nurses wanted to see vital sign trends, view the
patient’s apical pulse when giving a cardiac medication, or evaluate
clotting factors when giving a blood thinner (Staggers et al., 2011).
Findings suggested that nurses engaged more readily in this
process of contextualizing and individualizing information when
using their self-made tools, as opposed to the EHR-generated tools
that did not provide sufﬁcient support (Staggers et al., 2011, 2012).
3.2.4. Forming and maintaining common ground and a shared
understanding of the patient
Eight studies reported ﬁndings related to some aspect of
clinician/team communication or the EHR’s effect on care
coordination, collaborative decision-making, and achieving common ground and a shared understanding of the patient’s status.
Common ground refers to individuals having a mutual understanding of a situation, and shared situation awareness (or
understanding) refers to having a mutual understanding of its
meaning (Weir et al., 2011). The ﬁndings indicated that communication—the fundamental element required for clinicians to
organize and advance a shared understanding of the patient’s
status—was not enhanced by the increased volume and exchange
of information and data. Instead, clinicians needed access to
contextualized information that helped them form and maintain
common ground and to expedite a shared situation awareness
(Weir et al., 2011), especially in uncertain and dynamic clinical
situations.
The EHR provided limited support for interprofessional
communication and care coordination (Chao, 2016; Keenan
et al., 2013), and nurses’ use of verbal communication with
physicians increased after EHR implementation, presumably
because computer-mediated communication was insufﬁcient for
understanding physicians’ intentions (Chao, 2016). The EHR
contained a structure for orders and shared goals (such as
documenting the plan of care in a physician’s note), and alerting
functions regarding abnormal ﬁndings, such as laboratory values.
However, the EHR provided insufﬁcient support for activities like
collaborative decision-making, conveying updates aimed at
establishing a shared understanding of the clinical situation, or
contextualizing certain clinical ﬁndings relative to a patient’s case
(Collins et al., 2011). The EHR did not facilitate deciphering and
prioritizing goals and understanding the clinical reasoning behind
orders, and did not facilitate communication of information
needed to establish common ground during uncertain or evolving
clinical situations, as with unstable patients (Collins et al., 2011).
Clinicians felt the EHR was inadequate as a single information
source, and multiple modes of communication were required to
support effective clinical communication and care coordination
(Embi et al., 2013). This was especially problematic since clinicians
reported that the EHR changed work routines in a way that reduced
their direct communication with each other (Embi et al., 2013).
Nurses reported continued reliance on verbal report to ensure an
understanding of the patient and care priorities (Stevenson and
Nilsson, 2012).
As noted in other themes in this review, narrative notes were
appreciably limited in EHR documentation, which emphasized
capturing objective information via drop-down features, check
boxes, and other preconﬁgured templates. Features and structures
in the EHR impeded clinicians’ ability to decipher colleagues’
81
interpretations and subjective impressions of the patient’s status
(Varpio et al., 2015; Weir et al., 2011), resulting in loss of shared
situation awareness. Clinicians identiﬁed the process of reading
colleagues’ notes and their interpretations, intentions, and clinical
reasoning as central to how they formed and maintained an
individual and shared understanding of the patient’s status and
clinical trajectory. Loss of access to others’ reasoning impeded the
team’s collective work of developing this shared understanding
(Varpio et al., 2015). Deciphering the meaning of the situation
relied on being able to see the chronology of events and linkages
between certain data and points in time, as well as being able to
extract and synthesize relevant and temporal information from the
vast stores of information in the medical record (Weir et al., 2011).
The copy and paste functions in the EHR were frequently used and
produced narrative notes that were cluttered and missing a sense
of dialogue and interpretation (Weir et al., 2011).
Some ﬁndings were mixed. While there was better coordination
of certain aspects of the patient’s case—in particular the medical
aspects of care (medications, diagnosis), the EHR led to a
diminished focus on nurses’ perspectives and care activities. Ways
to represent psychosocial aspects of care and the patient’s
perspective were reduced and thus there were fewer opportunities
for this information to be shared among the team (Vikkelsø, 2005).
3.2.5. The loss of information and professional domain knowledge
Nine studies reported ﬁndings related to lost or missing
information. A subtheme was the continued reliance on personal
notes, scraps of paper, or other disposable forms of documentation,
which may have implications related to information loss if such
information is not recorded in the EHR. In numerous studies,
representations of nurses’ work and knowledge were not captured
in the EHR, or nurses’ notes were not read, which suggests that in
certain settings the work and knowledge of nursing are not
integrated into team processes.
Several studies reported increased variability and inconsistency
in where data were documented (Chao, 2016; Kossman and
Scheidenhelm, 2008; Stevenson and Nilsson, 2012), leading to
frustration and possibly overlooked information (Kossman and
Scheidenhelm, 2008). Input ﬁelds that were grouped in related
sections in the paper chart were missing in certain EHR-generated
forms or were difﬁcult to ﬁnd. This caused nurses to document in
text boxes, often in different places throughout the record (Chao,
2016). Nurses avoided the use of templates because they were
difﬁcult to use, leading to inconsistency in where certain data were
charted. Nurses were concerned about missing or overlooking
important information because it was complex to input and locate
(Stevenson and Nilsson, 2012). Preconﬁgured checklists or
templates did not always contain details that matched the clinical
situation; for example, a screen may have a drop down for staples,
when the patient instead had sutures (Kossman and Scheidenhelm, 2008). In such cases, nurses had to decide whether to chart
inaccurately, take time to navigate to another part of the record to
enter a note, or not to document the ﬁnding (Kossman and
Scheidenhelm, 2008).
Clinicians found it difﬁcult to navigate the EHR and to locate
relevant information in cluttered screens (Embi et al., 2013). They
coped with this by selectively reading narrative notes which left
them concerned that they had missed or overlooked important
information (Embi et al., 2013). Nurses’ notes were not read by
other disciplines (Kossman and Scheidenhelm, 2008), because
their formats required too much work to navigate and understand
(Weir et al., 2011). This led to increased verbal exchanges or loss of
information (Kossman and Scheidenhelm, 2008; Weir et al., 2011).
Nurses reported a delay in being able to access and read physician
notes from the emergency department and notes from morning
82
K. Wisner et al. / International Journal of Nursing Studies 94 (2019) 74–84
rounds reﬂecting team decisions made during that time (Embi
et al., 2013).
Certain care activities were not found in the EHR, such as
patient safety double-checks and the evaluation of goals (Collins
et al., 2011). Alerts and notiﬁcations about laboratory ﬁndings
changed from a linear process managed by ward clerks to a
continuous notiﬁcation process embedded in the EHR. While
critical laboratory results were more readily ﬂagged, other results
were overlooked or lost in the record (Vikkelsø, 2005). When a
patient had numerous abnormal ﬁndings, nurses found it difﬁcult
to navigate the medical record to ﬁnd where to document various
ﬁndings, potentially leading to lost or overlooked information
(Schenk et al., 2016).
There was no centralized overview function accessible by all
clinical team members. Given the rarity of interdisciplinary communication and very limited time spent on the units by non-nursing
members of the team, it was unlikely that nursing knowledge was
accessed and used by other disciplines (Keenan et al., 2013). While
nurses’ autonomous actions and decision-making were apparent
during observations, these were not represented in the EHR (Collins
et al., 2011). Another study reported a shift in focus to the medical
versus nursing or patient-centered aspects of care when using the EHR,
leading to loss of nurses’ and patients’ perspectives (Vikkelsø, 2005).
4. Discussion
This review summarized the literature on the EHR’s impact on
nurses’ cognitive work. Five themes were identiﬁed that described
how nurses and other clinicians perceived and used the EHR. These
were 1) forming and maintaining an overview of the patient, 2) the
cognitive work of navigating the EHR, 3) the use of cognitive tools,
4) forming and maintaining common ground and a shared
understanding of the patient, and 5) loss of information and
professional domain knowledge.
Most ﬁndings indicated that forming and maintaining an
overview of the patient at both the individual and team level were
difﬁcult when using the EHR. The work of navigating the vast
volumes of information in the EHR to locate, contextualize, and
synthesize relevant clinical information was challenging and
increased clinicians’ cognitive work. The EHR scattered and
fragmented information, making it difﬁcult for clinicians to see
the chronology of events and to situate and understand the clinical
implications of various data. The template-driven nature of
documentation and limited narrative note functions in the EHR
created difﬁculties and increased cognitive work for clinicians as
they attempted to express their clinical thinking and reasoning,
and decipher that of colleagues. The EHR-generated cognitive tools
such as summary reports and handoff tools were insufﬁcient as
stand-alone tools to support nurses’ work throughout the shift and
during handoff, resulting in reliance on self-made paper forms or
augmented or tailored EHR-generated tools. Nurses needed tools
that helped them individualize and contextualize information to
make it clinically meaningful. These were dynamic tools used
throughout the shift, representing synthesized information across
data sources. Information overload caused clinicians to selectively
read narrative notes, usually bypassing those written by nurses,
suggesting that certain professional domain knowledge and
perspective may be lost or buried in the medical record. In
addition, nurses’ reliance on paper forms or scraps of paper may
lead to clinically important information not being transferred into
the record.
These ﬁndings suggest that the increased collection, aggregation and storage of information in the EHR have not led to
increased access to clinically meaningful information. The
challenges that nurses and other clinicians encounter when
attempting to contextualize and synthesize information have
important implications for the ability to achieve and maintain
clinical grasp and situation awareness, which are clearly deﬁned
cognitive processes that affect how clinicians maintain safety
(Benner et al., 1999, 2009; Endsley, 1995). Information retrieved
from the EHR represents one of many important data sources used
by clinicians to continually update their individual and shared
perceptual and mental models of the clinical situation. Mental
models represent rich, dynamic knowledge structures that
clinicians use to understand and anticipate evolving clinical
situations and are a vital driver of patient safety (McComb and
Simpson, 2014). A novel ﬁnding in this review is that clinicians
relied on seeing and understanding others’ clinical reasoning,
interpretations, and intentions as part of their understanding of a
patient’s clinical status—a process they found more challenging
when using the EHR. The EHR’s focus on template-driven
documentation, data completeness, and serving as an information
repository does not provide the types of information exchanges
that support effective communication. Coiera (2000) posited that
information access and communication are different processes,
and certain communication cannot be executed using information
technology. Clinicians look to each other when working through
their interpretations and deciding on a course of action and this
interaction is part of an ongoing and iterative process of updating a
dynamic understanding of the situation at hand (Coiera, 2000).
Studies of physicians’ perceptions of the EHR and computerized
physician order entry have reported ﬁndings that align with the
main themes in this review including loss of overview, fragmentation of data, increased cognitive work when navigating the EHR,
and difﬁculty deciphering colleagues’ clinical reasoning or intent
(Ash et al., 2004; Ash et al., 2009; Holden, 2011). Workﬂows in the
clinical environment and EHR use in real life are rarely linear and
predictable (Hazlehurst et al., 2003); therefore, effectively
evaluating EHR impact requires consideration of the interactions
between clinician, technology, the environment, and the social
system (Harrison et al., 2007; Karsh et al., 2006).
Some ﬁndings in this review suggest that the EHR enhances or
improves some aspects of cognitive work. In most cases, the
conclusion is based on the assumption that increased visibility of or
access to information, having information available to multiple
users, data completeness, readability or legibility, or automated data
entry enhanced cognition (Ammenwerth et al., 2011; Chao, 2016;
Embi et al., 2013; Kossman and Scheidenhelm, 2008; Staggers et al.,
2012; Stevenson and Nilsson, 2012; Ward et al., 2011). In most cases
these were a small part of overall ﬁndings suggesting that use of the
EHR creates cognitive challenges (Chao, 2016; Embi et al., 2013;
Kossman and Scheidenhelm, 2008; Staggers et al., 2012; Stevenson
and Nilsson, 2012). Studies that use immersive data collection
methods such as interviews, observations and artifact analysis
suggest that access to and visibility of information in the medical
record do not enhance an overview or ready access to the information
needed to support clinicians’ cognitive work (Chao, 2016; Collins
et al., 2011; Embi et al., 2013; Keenan et al., 2013; Staggers et al., 2011,
2012; Varpio et al., 2015; Vikkelsø, 2005; Weir et al., 2011).
One study sought to evaluate mental workload directly using
the NASA-TLX: Task Load Index (Colligan et al., 2015), a tool that
measures the operator’s subjective assessments of workload using
six questions focused on the mental, physical and temporal
demand of a task, how much effort was required, its perceived
effect on performance, and the level of frustration experienced
(Hart and Staveland, 1988). This tool was used to measure narrowly
deﬁned aspects of cognitive work during and shortly after the EHR
implementation period. When viewing cognitive work through the
lenses of clinical grasp and situation awareness (Benner et al., 1999,
2009; Endsley, 1995), a tool such as the NASA-TLX as a stand-alone
measure is likely incapable of capturing the complexity of
cognitive work.
K. Wisner et al. / International Journal of Nursing Studies 94 (2019) 74–84
4.1. Limitations
Most of the studies in this review sought to evaluate nurses’ or
clinicians’ overall perspectives about the EHR or its effect on work,
communication, or collaboration. Aside from the study using the
NASA-TLX to measure cognitive/mental workload (Colligan et al.,
2015), and a mixed-methods study that measured the quality of
information processing using an unvalidated HIS-monitor instrument (Ammenwerth et al., 2011), few studies set out to explore the
impact of the EHR on a clearly deﬁned aspect of clinicians’ cognitive
work (Kossman et al., 2013; Staggers et al., 2011, 2012; Varpio et al.,
2015). Several studies using immersive qualitative methods reported
incidental ﬁndings related to cognition supported by rich and
substantive data elements (Chao, 2016; Embi et al., 2013; Keenan
et al., 2013; Weir et al., 2011). In the remaining studies, cognitive
work was reported as an incidental ﬁnding, and in some cases the
report lacked substantive data elements to support such conclusions
(Collins et al., 2011; Darbyshire, 2004; Kossman and Scheidenhelm,
2008; Schenk et al., 2016; Stevenson and Nilsson, 2012; Vikkelsø,
2005; Zadvinskis et al., 2014). While rigor was enhanced by a
comprehensive search of the literature in ﬁve databases, all phases of
data evaluation, extraction and analysis were conducted by one
researcher, which may have led to bias.
4.2. Strengths
This comprehensive review of the literature is the ﬁrst to
attempt to summarize and evaluate how EHR use affects nurses’
cognitive work. Concepts from clinical grasp (Benner et al., 1999,
2009) and situation awareness (Endsley, 1995) were used to
conceptualize cognitive work as a higher order, dynamic, and
evolving understanding of the patient’s status, situated in a
particular clinical context, and dependent on the clinician’s ability
to continually contextualize and synthesize data across information sources. This review identiﬁed only a few studies that have
focused on clearly deﬁned aspects of cognitive work using
immersive qualitative methods, representing a gap in the
literature.
5. Implications for future research
Using a human factors and sociotechnical systems framework,
future research should focus on understanding how nurses
retrieve, organize, synthesize, and communicate information;
how they achieve and maintain clinical grasp and situation
awareness when using the EHR; and exploring information
technology design that supports cognitive work. Practical research
applications might include how to effectively integrate narrative
notes in the EHR as an organizing aspect of clinical practice;
evaluate handoff and tracking tools and align them with how
nurses think and work; and focus on best practices for clinician
input on information technology design to ensure content in
preconﬁgured templates is clinically meaningful and organized in
ways that support clinical work.
6. Conclusion
Findings from this review challenge the assumption that EHRs
have improved communication, access to information, and assisted
with clinical decision-making (Aspden et al., 2004; Page, 2004).
Instead, ﬁndings suggest that EHR use has generated numerous
cognitive challenges for clinicians that may have important safety
implications. The EHR’s focus on data completeness, aggregation,
and storage has produced vast volumes of information that
clinicians ﬁnd difﬁcult to navigate and synthesize, making
clinically meaningful information less accessible and available.
83
Nurses found that the structure of the EHR did not always match
how they thought and worked, which generated additional work to
integrate EHR use into their complex and dynamic workﬂows. The
EHR’s focus on data completeness needs to be balanced with
design features and structures that make relevant clinical
information readily accessible for clinicians without creating
undue cognitive burden.
Author contributions
Study design: KW, AL, CC.
Data collection: KW.
Data analysis: KW.
Study supervision: KW, AL, CC.
Manuscript writing: KW.
Critical revisions for important intellectual content: KW, AL, CC.
We would like to thank Evans Whitaker, MD, MLIS, Research
Librarian at UCSF Health Sciences Library, for his extensive
guidance during the literature search phase of this project.
Appendix A. Supplementary data
Supplementary material related to this article can be found, in
the online version, at doi:https://doi.org/10.1016/j.ijnurstu.2019.03.003.
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Crit Care Nurs Q
Vol. 44, No. 3, pp. 309–315
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
Benefits and Challenges of
Social Media in Health Care
Kathleen Hale, MHSA, BSN, RN
Benefits of the use of social media platforms in health care are significant and far-reaching. There
are also times when these platforms place health care professionals at risk. This article assists
health care professionals to understand the overall uses of social media while providing descriptions of events that result in unplanned consequences. Simple tips are provided that all health
care professionals should consider to ensure their privacy and that of their patients. Key words:
benefits, challenges, health care environment, social media
WHAT IS SOCIAL MEDIA AND HOW
DOES IT IMPACT THE HEALTH CARE
ENVIRONMENT?
According to the 2019 Merriam-Webster
dictionary, “social media” is a noun defined
as “forms of electronic communication (such
as Web sites for social networking and microblogging) through which users creates
online communities to share information,
ideas, personal messages, and other content
(such as videos).”1 The first known use of this
definition was in 2004.
One search on Google for more information about social media resulted in more than
of 9 billion hits. This information included
the history of social media, current use, most
frequently used sites and examples, individual perspectives, benefits, risks, dedicated
publications, and editorials.
The variety of evolving stand-alone and
built-in social media services makes it chal-
Author Affiliation: Allegheny General Hospital,
Pittsburgh, Pennsylvania.
The author has disclosed that she has no significant relationships with, or financial interest in, any
commercial companies pertaining to this article.
Correspondence: Kathleen Hale, MHSA, BSN, RN,
Allegheny General Hospital, 320 East North Ave,
Pittsburgh, PA 15212 (Kathleen.hale@ahn.org).
DOI: 10.1097/CNQ.0000000000000366
lenging to define them. However, marketing
and social media experts broadly agree that
social media includes the following 13 types
of social media2 :
• Blogs,
• Business networks,
• Collaborative projects,
• Enterprise social networks,
• Forums,
• Microblogs,
• Photo sharing,
• Products/services review,
• Social bookmarking,
• Social gaming,
• Social networks,
• Video sharing, and
• Virtual worlds.
The most popular social networks are listed
in the Table.3
Most people use social media daily to get
news, find services, stay in contact with
friends/family, and network for social and/or
business reasons. For most people, a day does
not go by without hearing something about
how social media has been used by a politician, a movie star, law enforcement, or even a
local church or school.
A survey of colleagues, friends, and family,
aged 18 to 60+ years, asked for a list of all the
social media platforms that they used or were
familiar with. Everyone knew of and/or used
Facebook, Instagram, Twitter, and YouTube
and most also knew Snapchat and TikTok.
309
Copyright © 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
310
CRITICAL CARE NURSING QUARTERLY/JULY–SEPTEMBER 2021
Table. The Most Popular Social Networks
Network Name
Number of Users
(in Millions)
Facebook
YouTube
WhatsApp
Facebook Messenger
WeChat
Instagram
TikTok
QQ
Douyin’
Sina Weibo
2701
2000
2000
1300
1206
1158
689
648
600
523
Ranking
1
2
3
4
5
6
7
8
9
10
Surprisingly, the collective list from 18- to 29year-olds was rather small, with an average of
only 5 platforms listed. The list from 30- to
45-year-olds was the largest and most broad
reaching.
In health care, social media can be used
for a variety of reasons including patient education, helping patients stay in contact with
their health care team, and marketing. These
are all positive uses; however, when personal
use of social media meets health care, there
are both benefits and challenges. The purpose of this article is to outline the benefits
and challenges of social media use and to
specify situations in which the social media
use can be damaging to a nurse’s career and
therefore avoided.
BENEFITS OF SOCIAL MEDIA USE
The benefits of social media in general are
almost too numerous to describe. The benefits in health care can be readily seen in
recruitment, connecting or networking with
colleagues, collaboration with law enforcement, education, and advocacy.
Hospital and health system recruiters use
social media to connect with top talent
locally, regionally, and nationally. Everyone
knows someone who found the perfect job
on a social media site, whether it was the
Facebook page of a hospital or health care
system, a recruiter on LinkedIn, or a referral
from a colleague applying for a job. Nurses
and other health care providers can keep in
touch with classmates and mentors as they
enter the workforce and begin their careers,
leaning on those individuals for guidance and
support or even using them as a sounding
board during times of stress or change.
Hospitals have used social media in cooperation with law enforcement to help
identify unconscious or seriously injured patients whose identities were unknown at the
time of admission.
Heartwarming tales have been told of
long-lost friends and estranged families reconnecting through the magic of social media.
Patient families use social media to keep their
networks informed about the progress of a
friend or loved one who is in the hospital
or undergoing outpatient treatment of some
sort.
Hospitals, health systems, physician practices, urgent care centers, and advocacy
organizations have all taken advantage of
the reach that social media has today. From
large organizations such as Mayo Clinic, Massachusetts General, and Johns Hopkins to
small, rural hospitals such as Penobscot Bay
Medical Center in Rockport, Maine, and Sheridan Memorial Hospital in Sheridan, Wyoming,
more and more organizations are reaching out
with social media. One study showed that
almost 95% of hospitals had a Facebook page
and more than half had a Twitter account.4
Copyright © 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Benefits and Challenges of Social Media in Health Care
Health care organizations whose role is education and advocacy have capitalized on
the ease of use associated with social media.
The American Heart Association, the American Cancer Society, the American Lung
Association, the Alzheimer’s Association, and
other disease- or condition-specific advocacy
groups make available education, training,
and support through a variety of social media
platforms, all of which can be found by visiting their Web sites. Then there are sites such
as “Patients Like Me” (www.PatientsLikeMe.
com), where patients and families can go to
learn more or find support for a disease or
condition.
Social media can be used in a variety of
ways to help patients who could not otherwise attend support groups or meetings.
Doctors can hold a live Twitter chat instead
or read comments from patients on their
own blogs or Facebook pages to learn more
about the patient experience. “Seventy-five
percent of people who access Twitter access
it daily on their phone. Mobile is where it
is at for communication, and it will soon be
the same in health care.”5 Over the past year,
the COVID-19 pandemic has expedited both
the use and payment of “video visits” with
providers.
A Hootsuite blog from February 2019 provided insight into other reasons for using
social media6 : Nearly 40 percent of young
people (ages 14 to 22) have used online
tools to try to connect with other people
who have similar health challenges. That
includes social media groups.
That connection can have real benefits
for patients. Researchers who published
their work in the journal Surgery created
a Facebook group for 350 liver transplant patients, caregivers, and health care
providers. A full 95% of survey respondents said that joining the group had been
positive for their care.
Facebook groups are also a great place for
health care professionals and patients to
interact. Those interactions can include patient support and education. One study is
311
evaluating whether a Facebook group for
patients with coronary heart disease can
increase participation in cardiac rehabilitation.
Of course, here are privacy concerns when
discussing health online. This is a great use
of Facebook secret groups, which do not
show up in search results. Users have to be
invited to join.
Australian nurses who work in rural areas can use social media Web sites to access
online courses for continuous education requirements to ensure their registration are
up to date despite significant geographical
distance. Also noted was how social media
platforms have an influence on educating
nursing students. In one example, tutors used
media sharing Web sites such as YouTube in
the class to illustrate a concept or to stimulate students to discuss. Students watched the
video and responded to activities that eventually improved their clinical practice.7 Over
the last year, many professional organizations
have moved planned in-person education
offerings to an online format as well.
These are just a few examples of the benefits of social media in health care. They
are positive in terms of both intent and impact, can help an individual either personally
or professionally, and, importantly, cause no
harm.
CHALLENGES OF SOCIAL MEDIA USE
It is no surprise that there are also challenges with the use of social media. Some
of those challenges, such as maintaining patient privacy, are unique to health care.
Other challenges such as complying with
employer rules, using good judgment when
posting information, and protecting oneself
from unwanted attention are general risks or
challenges when using social media.
In terms of rules and regulations, health
care organizations and all of their employees
are obligated to comply with patient privacy laws (Health Insurance Portability and
Accountability Act—HIPAA)8 as well as
Copyright © 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
312
CRITICAL CARE NURSING QUARTERLY/JULY–SEPTEMBER 2021
unique laws in their state and organizational
policies. For example, in Pennsylvania, an
individual can capture images in public
places without consent but it is also a 2-party
consent state, meaning that both parties to
an audio recording must consent to being
recorded. In addition, organizations usually
have policies around use of social media
at work that all employees are obligated to
follow.
In the following situations, health care
team members (nurses and other health care
providers) or the patients/families they serve
have exercised poor judgment or blatantly ignored policies and regulations and have been
held accountable for their actions.
• A patient arrived at the emergency department (ED) at a hospital in California
mortally wounded. The 60-year-old had
been stabbed more than a dozen times by
a fellow nursing home resident; his throat
was slashed so savagely that he was almost
decapitated. Instead of focusing on treating him, nurses and other hospital staff
did the unthinkable: They snapped photographs of the dying man and posted them
on Facebook.
Four staff members were fired and
3 disciplined, according to a hospital
spokeswoman. At least 2 nurses were involved, but none were fired, a union
spokesman said. Hospital officials in California and elsewhere have faced an uneasy
relationship with Facebook and other forms
of social networking. Managers, struggling
to prevent staff members from posting
patient information on the sites, have developed no-tolerance policies and blocked
employees from using Facebook and similar Web sites at work. The restrictions are
being enforced even as hospitals tout such
sites as a way to boost their images and
reach more patients.9
• An RN staff member posted to her Facebook page while at work how she felt about
caring for a particular terminally ill patient.
There was enough information posted that
others might have been able to identify the
patient. In addition, the staff member’s ID
could be seen in photographs that were
posted and her profile listed her employer
and her profession.
The staff member was counseled by
her manager about posting during her
shift, about maintaining patient privacy, and
about organizational policies on use of personal devices and social media. The RN also
completed additional privacy training and
recognized that what she had done was inappropriate. Unfortunately, the story does
not end there. The RN did the same thing 2
months later and was terminated.10
• RN staff members posed photographs of
themselves at a local bar, beers in hand,
in their work uniforms (hospital logo distinctive and apparent), complete with ID
badges. While many may relate to a photograph like that one, the organization for
which the RNs work had a strict policy that
stated:
“While (hospital name) recognizes the right of
employees to engage in dialogue and provide
information on social media Web sites about
day-to-day issues they face and other personal
information that might relate to their jobs and
job responsibilities, all employees must refrain
from posting information about (hospital name)
or their jobs that could detrimentally affect
(hospital name) reputation, violate its policies,
or might embarrass or offend coworkers, patients, or other constituents of (hospital name).
Employees must use common sense and good
judgment, recognizing information they publish online becomes immediately searchable, can
be immediately shared, and will have a long
presence on the Internet.”11
The post was seen by staff from several
other units who told their managers because they were upset by the photographs.
Imagine how families of the patients they
cared for would feel if they saw the post.
• A staff member of an assisted living home
in Red Wing, Minnesota, was dismissed this
year after taking a photograph of an elderly resident on the toilet and posting it
on Instagram, according to a local CBS affiliate. The photograph was taken without the
resident’s permission and showed bare skin
Copyright © 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Benefits and Challenges of Social Media in Health Care
just up to the upper hip area. The facility’s
handbook prohibited any photography of
home residents. But the employee clearly
took it a step further by posting a distasteful
photograph of a resident on her social media account without permission to do so.12
• An RN was caring for a young patient who
has just returned from a long surgery. The
patient was sleepy, confused, and demanding water. The RN soothed the patient
and did a bedside swallow test and determined that the patient was not yet able to
protect their airway, so used oral swabs
to moisten the patient’s mouth. The RN
explained to the patient and family the reason for the swabs rather than water. They
indicate understanding and the patient
went back to sleep. The patient awakened
a short time later, had more oral swabs,
and went back to sleep again. This pattern
was repeated several more times before the
patient was able to protect their airway and
safely drink. Each time the patient awakened, they had no recall of the reason they
could not have water. Sometime during this
pattern, another family member arrived.
The patient tells the “new” family member
that the nurse would not give them water.
That night the RN started getting threats on
her Facebook page. The threats were nasty
and accompanied by hurtful, bigoted comments. She was frightened and stunned.
The nurse did not know the people who
were threatening her. She let her manager
know and an investigation was started.
What the investigation revealed in short
order was that the “new” family member of
the nurse’s patient had taken to heart what
the patient said about the nurse denying
the patient water and went to social media with her concerns/beliefs. The family
member posted on Facebook that the nurse
(listed by name) had denied the patient
water and basic care. The nurse also had a
Facebook page using her full name which
the family member found and shared with
all their Facebook friends. That was where
all the threats were coming from. The nurse
blocked all the unknowns on her Facebook
313
page. All involved were concerned for her
safety, so a guard was posted on her unit
and she was escorted to her car for a period
of time.13
• An ED got a call that the victim of a shooting was en route via ambulance. One of the
senior RNs was assigned care of the patient
and met the ambulance at the door to the
ED. The RN noticed that the patient was
awake and appeared to be having a FaceTime conversation with someone. She was
concerned about the stability of the patient
and moved to the head of the bed and noticed that her face appeared in the screen.
Concerned, she asked “Are you recording
this”? She then asked one of the Emergency
Medicine Technicians (EMTs) to secure the
patient’s phone. Later that day after finishing her shift she got a call from an EMT
friend who said ‘You’re all over Facebook
and so am I!’ Confused, she went online to
find out what had happened. She learned
that the patient was not on FaceTime but
on Facebook Live and had uploaded her
face, her ID badge, the EMT’s face, and a
video of the entire situation was recorded
from getting in the ambulance until the
care team at the hospital took the phone
from the patient. The patient decompensated shortly after arrival in the ED and was
intubated and aggressively resuscitated.
That was not captured on Facebook Live.
The patient’s page was public, so anyone on Facebook could see the post/live
stream. It is not surprising that there were
comments posted. What was surprising was
the number of comments along the lines of
“Those people should be saving his life, not
taking his phone.”
There were significant safety concerns
for the patient and the staff after that event.
The circumstances of the patient’s injuries
were concerning for continued violence
and the patient’s whereabouts were known
as were the identities of some of the team
members who cared for him.
With support from the hospital, the
nurse contacted Facebook to ask if they
would remove the post because of safety
Copyright © 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
314
CRITICAL CARE NURSING QUARTERLY/JULY–SEPTEMBER 2021
concerns. Facebook said they would not
take the posts down; only the owner of
the page could do that. As a result, hospital leadership and the local police went to
speak with the patient and asked that he remove the post. He agreed to do so and was
witnessed removing it.13
A FEW SIMPLE STEPS
Nurses come to work each day to do their
work with compassion and good intent. They
want to do what is best for patients and families and help them through whatever their
health care issues may be. Social media can
be an important tool in the care of those
patients. It can be a way for patients to network and for the health care team to educate
patients and families as well as a way for
patients to stay connected with friends and
family. With all the good that can come with
using social media, how can a nurse use it
effectively?
First, never post information about patients. Next, nurses should know exactly
what their employer’s policies are about use
of social media in general. The policies/rules
are usually quite rigid and the penalties
that come with violating those policies are
significant. If nurses absolutely MUST use
social media while at work, they should use
break time to do it and their own electronics
(not those of their employer) to access it.
That way nurses will not run afoul of their
employer’s policies.
Everyone wants family and friends to be
able to find them on social media, but having
good control over being found by people
outside a chosen social network is equally important. When creating or updating a profile
on any social media platform, nurses should
consider whether their page names/online
presence would be easy to find for someone
outside of their chosen network. They may
want to consider a moniker that makes sense
to them but would be difficult for someone
outside their social circle to find. Nurses are
generally proud of their profession and the
jobs they hold so having that kind of information in a profile is understandable but putting
“health care” as an occupation would make
a nurse more difficult to find. Nurses should
also consider not listing the specific hospital,
clinic, school, or other setting where they
work.
There is no doubt about the benefits of
strong passwords. That holds true for any social media platform as well as on the devices
used to access the social media. Each device
and application should have a different password. Finally, put every possible protection
on every social media platform used.
Social media can be a wonderful tool in
health care. It can be used to educate, to connect, and to help patients in a wide variety
of ways. It can also lead to problems if a patient’s privacy is not maintained and if staff
do not know or follow organizational rules regarding the use of social media and that can
lead to consequences that the user did not
anticipate.
Please understand this—social media is just
that: social. It is meant as a public forum, and
it needs to be treated like one. Workers in the
medical industry need to be especially careful
about how they discuss work-related issues
online and should be aware of how their actions might reflect their ability to inspire trust
in a general public that requires dependable,
quality care.
REFERENCES
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June 11, 2020.
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3. Most popular social networks worldwide as of July,
2019, ranked by number of active users (in millions).
Statista. https://www.statista.com/statistics/274773/
global-penetration-of-selected-social-media-sites. Accessed August 13, 2019.
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Benefits and Challenges of Social Media in Health Care
4. Griffis HM, Kilaru AS, Werner RM, et al. Use of social media across US hospitals: descriptive analysis of
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Copyright © 2021 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

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Unlimited Amendments upon request
Satisfaction guarantee

How it Works

Click on the “Place Order” tab at the top menu or “Order Now” icon at the bottom and a new page will appear with an order form to be filled.
Fill in your paper’s requirements in the "PAPER DETAILS" section.
Fill in your paper’s academic level, deadline, and the required number of pages from the drop-down menus.
Click “CREATE ACCOUNT & SIGN IN” to enter your registration details and get an account with us for record-keeping and then, click on “PROCEED TO CHECKOUT” at the bottom of the page.
From there, the payment sections will show, follow the guided payment process and your order will be available for our writing team to work on it.