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Background Workflow interruptions are common in modern work systems. Electronic health record (EHR) tasks are typical tasks involving human–machine interactions in nursing care, but few studies have examined interruptions and nurses’ mental workload in the tasks. Therefore, this study aims to investigate how frequent interruptions and multilevel factors affect nurses’ mental workload and performance in EHR tasks. Methods A prospective observational study was conducted in a tertiary hospital providing specialist and sub-specialist care from June 1 st to October 31 st , 2021. An observer documented nurses’ EHR task interruptions, reactions and performance (errors and near errors) during one-shift observation sessions. Questionnaires were administered at the end of the electronic health record task observation to measure nurses’ mental workload for the electronic health record tasks, task difficulty, system usability, professional experience, professional competency, and self-efficacy. Path analysis was used to test a hypothetical model. Results In 145 shift observations, 2871 interruptions occurred, and the mean task duration was 84.69 (SD 56.68) minutes per shift. The incidence of error or near error was 158, while 68.35% of errors were self-corrected. The total mean mental workload level was 44.57 (SD 14.08). A path analysis model with adequate fit indices is presented. There was a relationship among concurrent multitasking, task switching and task time. Task time, task difficulty and system usability had direct effects on mental workload. Task performance was influenced by mental workload and professional title. Negative affect mediated the path from task performance to mental workload. Conclusions Nursing interruptions occur frequently in EHR tasks, come from different sources and may lead to elevated mental workload and negative outcomes. By exploring the variables related to mental workload and performance, we offer a new perspective on quality improvement strategies. Reducing harmful interruptions to decrease task time can avoid negative outcomes. Training nurses to cope with interruptions and improve competency in EHR implementation and task operation has the potential to decrease nurses’ mental workload and improve task performance. Moreover, improving system usability is beneficial to nurses to mitigate mental workload.

Background The transition from paper‐based documentation to electronic nursing records (ENRs) is a critical component of digital transformation in healthcare. In intensive care units (ICUs), where timely and accurate documentation is essential, nurses’ readiness plays a pivotal role in determining the success of ENR implementation. However, readiness remains uneven across healthcare settings, particularly in resource‐constrained context. This study aimed to explore ICU nurses’ readiness to adopt ENRs within a hospital setting in Indonesia where nursing documentation remains predominantly manual. Methods A qualitative descriptive design using thematic analysis was employed. In‐depth interviews were conducted with 15 ICU nurses. The study was conducted in the ICU of a hospital in Indonesia. ICU nurses were recruited using purposive sampling based on their direct involvement in patient care and nursing documentation. Semistructured interviews were conducted, with data collection and analysis occurring concurrently. Participant recruitment continued until data saturation was achieved, which occurred after 15 interviews. Interview transcripts were analyzed using thematic analysis. Results Five interrelated themes emerged: (1) the current state of ENR implementation characterized by limited digital integration and ongoing reliance on manual documentation, (2) perceived benefit of ENRs including improved efficiency, accuracy, and accessibility of patient data, (3) readiness for ENR implementation required leadership, infrastructure supports, and human resources capacity, (4) anticipated challenges and barriers to implement comprises resistance to change and limited digital literacy, and (5) expectations for ENRs implementation highlighting the need for training, policy development, and system integration. Readiness was found to be conditional and context‐dependent rather than solely individual. Conclusions ICU nurses demonstrated cautious yet positive readiness toward ENR adoption. Successful implementation requires coordinated sociotechnical strategies that address organizational, technological, and human factors simultaneously. These findings provide context‐specific and transferable insights for similar critical care settings undergoing digital transition.

Introduction: The advancement of nursing science and practice necessitates the documentation of information, which is increasingly being recorded in electronic mediums due to the progress of information technology. Various countries around the world have implemented electronic nursing records (ENRs) or are in the process of implementing them. This study aims to ascertain the significance of electronic nursing records and consolidate their primary benefits for nursing. Methods: The study utilized an established scoping review methodology (Arksey and O‘Malley protocol; JBI method; PRISMA ScR (2018)). Results: Out of 6970 initial articles extracted from four databases, 36 were included in the study. Several essential elements for structuring, introducing, and emphasizing the importance of ENRs have been recognized, including the availability of standardized terminology, enhancement of nursing care quality, advancement of research activity, integration with electronic systems, optimization of healthcare, and conditions for ENR integration. Conclusions: Electronic nursing records are indispensable and beneficial for enhancing care quality, improving patient safety, and affirming the autonomy of the nursing profession.

Background: The purpose of using an electronic nursing record system (ENRS) is to support comprehensive and accurate nursing documentation and ensure safe and high-quality patient care. This qualitative study aimed to gain an in-depth understanding of nurses’ perceptions and the interrelationships between the effectiveness of ENRS, caring behaviour, and technological competency in nursing practice. Methods: Corbin’s and Strauss’s grounded theory approach was employed. Data were collected through semi-structured interviews with eleven nurses from four Slovenian hospitals, recruited using theoretical sampling between July 2021 and July 2023. Open, axial, and selective coding were conducted using MAXQDA 2020. Results: The core category “Losing caring in technology-focused documentation” was developed, including seven categories and seventeen subcategories. The paradigmatic model identified causal conditions (inadequate ENRS effectiveness), contextual conditions (poor ENRS integration into hospital environments), and intervening conditions (patient care) that contributed to insufficient documentation of individualised and holistic care. Two action–interaction strategies were identified: developing technological competency and integrating caring into documentation practices. Consequences manifested at individual, organisational, and national levels. Conclusions: Nurses’ caring behaviour, effective ENRS, and technologically competent use of the ENRS are essential for documenting and ensuring individualised and holistic patient care.

Introduction. The most important application of information technology in nursing is generating and maintaining patient’s electronic records. Implementing ICNP® to this can guarantee the continuity and high quality of evidence-based care.Aim. Obtaining information on nurses’ opinions on the implementation of ICNP® in clinical practice.Material and methods. The study was conducted in late 2018 and early 2019 in a group of 104 nurses of the University Clinical Centre in Gdańsk. It involved conducting a diagnostic survey.Results. Prior to the survey, 77.9% of the respondents were aware of ICNP®. The respondents who did not provide the correct answer to question about the essence of the ICNP® were mostly over 45 years of age. When it comes to 25% of subjects, they declared they were willing to use ICNP®. The vast majority considered it more convenient to maintain care records in the traditional way than with the use of ICNP®. The respondents with a master’s degree showed a higher level of acceptance for the implementation of the ICNP® to clinical practice than respondents with secondary and tertiary education.Conclusions. The nursing staff over 45 years old presented a lower level of knowledge related to the ICNP® as compared to other respondents. The reasons behind the conviction that applying ICNP® would be difficult included understaffing and lack of mobile devices such as tablets or laptops in hospital wards. It is, therefore, necessary to launch a nursing terminology training programme, equip branches with the necessary devices and comply with minimum employment standards.

背景：完整的透析電子護理記錄是呈現護理照護過程與品質重要的依據，更是醫療團隊間重要的溝通橋樑。經現況分析，發現護理人員對透析電子護理記錄系統操作介面不熟悉、缺乏系統操作教育訓練、透析電子護理記錄系統設計不佳、缺乏透析電子護理記錄書寫指引，及缺乏透析電子護理記錄書寫稽核制度，導致透析電子護理記錄書寫之完整性僅58.2%。目的：提升透析電子護理記錄完整性大於90%。解決方案：修改透析電子護理記錄系統、建置透析電子護理記錄片語範例、製作透析電子護理記錄操作手冊、進行系統操作在職教育、執行記錄書寫臨床情境模擬演練與透析資訊護理師制度，及落實透析電子護理記錄稽核制度。結果：透析電子護理記錄完整性提升為96.0%；護理師書寫記錄時間由平均21分35秒縮短至8分15秒。結論：良好的資訊系統確實有效提升透析電子護理記錄完整性，也縮短記錄時間，有助於確保透析病人之照護品質。

As computerization in the nursing field has been recently progressing, an electronic nursing record system is gradually introduced in the medical institution in Japan. Although it is expected for the electronic nursing record system to reduce the load of nursing work, the conventional keyboard operation is used for information input of the present electronic nursing record system and it has some problems concerning the input time and the operationability for common nurses who are unfamiliar with the computer operation. In the present study, we conducted a basic study on application of voice recognition input to an electronic nursing record system. The voice input is recently introduced to an electronic medical record system in a few clinics. However, so far the entered information cannot be processed because the information of the medical record must be entered as a free sentence. Therefore, we contrived a template for an electronic nursing record system and introduced it to the system for simple information entry and easy processing of the entered information in this study. Furthermore, an input experiment for evaluation of the voice input with the template was carried out by voluntary subjects for evaluation of the function as an input interface of an electronic nursing record system. The results of the experiment revealed that the input time by the voice input is obviously fast compared with that by the keyboard input and operationability of the voice input was superior to the keyboard input although all subjects had inexperience of the voice input. As a result, it was suggested our method, the voice input using the template made by us, might be useful for an input interface of an electronic nursing record system.

Background The time that nurses spent on documentation can be substantial and burdensome. To date it was unknown if documentation activities are related to the workload that nurses perceive. A distinction between clinical documentation and organizational documentation seems relevant. This study aims to gain insight into community nurses’ views on a potential relationship between their clinical and organizational documentation activities and their perceived nursing workload. Methods A convergent mixed-methods design was used. A quantitative survey was completed by 195 Dutch community nurses and a further 28 community nurses participated in qualitative focus groups. For the survey an online questionnaire was used. Descriptive statistics, Wilcoxon signed-ranked tests, Spearman’s rank correlations and Wilcoxon rank-sum tests were used to analyse the survey data. Next, four qualitative focus groups were conducted in an iterative process of data collection - data analysis - more data collection, until data saturation was reached. In the qualitative analysis, the six steps of thematic analysis were followed. Results The majority of the community nurses perceived a high workload due to documentation activities. Although survey data showed that nurses estimated that they spent twice as much time on clinical documentation as on organizational documentation, the workload they perceived from these two types of documentation was comparable. Focus-group participants found organizational documentation particularly redundant. Furthermore, the survey indicated that a perceived high workload was not related to actual time spent on clinical documentation, while actual time spent on organizational documentation was related to the perceived workload. In addition, the survey showed no associations between community nurses’ perceived workload and the user-friendliness of electronic health records. Yet focus-group participants did point towards the impact of limited user-friendliness on their perceived workload. Lastly, there was no association between the perceived workload and whether the nursing process was central in the electronic health records. Conclusions Community nurses often perceive a high workload due to clinical and organizational documentation activities. Decreasing the time nurses have to spend specifically on organizational documentation and improving the user-friendliness and intercommunicability of electronic health records appear to be important ways of reducing the workload that community nurses perceive.

Background Errors in medication administration by qualified nursing staff in hospitals are a significant risk factor for patient safety. In recent decades, electronic medical records (EMR) systems have been implemented in hospitals, and it has been claimed that they contribute to reducing such errors. However, systematic research on the subject in Israel is scarce. This study examines the position of the qualified nursing staff regarding the impact of electronic medical records systems on factors related to patient safety, including errors in medication administration, workload, and availability of medical information. Methods This cross-sectional study examines three main variables: Medication errors, workload, and medical information availability, comparing two periods– before and after EMR implementation based on self-reports. A final sample of 591 Israeli nurses was recruited using online private social media groups to complete an online structured questionnaire. The questionnaires included items assessing workload (using the Expanding Nursing Stress Scale), medical information availability (the Carrington-Gephart Unintended Consequences of Electronic Health Record Questionnaire), and medical errors (the Medical Error Checklists). Items were assessed twice, once for the period before the introduction of electronic records and once after. In addition, participants answered open-ended questions that were qualitatively analyzed. Results Nurses perceive the EMR as reducing the extent of errors in drug administration (mean difference = -0.92 ± 0.90SD, p  < 0.001), as well as the workload (mean difference = -0.83 ± 1.03SD, p  < 0.001) by ∼ 30% on average, each. Concurrently, the systems are perceived to require a longer documentation time at the expense of patients’ treatment time, and they may impair the availability of medical information by about 10% on average. Conclusion The results point to nurses’ perceived importance of EMR systems in reducing medication errors and relieving the workload. Despite the overall positive attitudes toward EMR systems, nurses also report that they reduce information availability compared to the previous pen-and-paper approach. A need arises to improve the systems in terms of planning and adaptation to the field and provide appropriate technical and educational support to nurses using them.

Background Nursing documentation is a critical aspect of the nursing care workflow. There is a varying degree in how detailed nursing reports are described in scientific literature and care practice, and no uniform structured documentation is provided. This study aimed to describe the process of designing and evaluating the content of an electronic clinical nursing documentation system (ECNDS) to provide consistent and unified reporting in this context. Methods A four-step sequential methodological approach was utilized. The Minimum Data Set (MDS) development process consisted of two phases, as follows: First, a literature review was performed to attain an exhaustive overview of the relevant elements of nursing and map the available evidence underpinning the development of the MDS. Then, the data included from the literature review were analyzed using a two-round Delphi study with content validation by an expert panel. Afterward, the ECNDS was developed according to the finalized MDS, and eventually, its performance was evaluated by involving the end-users. Results The proposed MDS was divided into administrative and clinical sections; including nursing assessment and the nursing diagnosis process. Then, a web-based system with modular and layered architecture was developed based on the derived MDS. Finally, to evaluate the developed system, a survey of 150 registered nurses (RNs) was conducted to identify the positive and negative impacts of the system. Conclusions The developed system is suitable for the documentation of patient care in nursing care plans within a legal, ethical, and professional framework. However, nurses need further training in documenting patient care according to the nursing process, and in using the standard reporting templates to increase patient safety and improve documentation.