Background
Working life trends such as increased use of information and communication technology (ICT), constant learning of new skills, and time pressure place increasingly high demands on personnel [
1]. Digitalization re-engineers organizational processes and routines, both encouraging and pressuring individuals to learn new skills and get accustomed to change [
2]. Healthcare has not been isolated from the digitalization. In the field of healthcare, organizations, as well as individuals, need new skills and competence to cope with changing and increasingly digital work [
3‐
6]. However, information technology competence or training to use new information technologies will not solve the dysfunction of information technology unless the technology itself functions well [
7].
Research in the field of ICT functionalities and wellbeing in work in healthcare has focused on two main areas. First, several studies have focused on experiences and satisfaction with electronic health record (EHR) systems [
8‐
10]. For example, in Texas and Norway, nurses’ satisfaction with their EHRs has been found to be low [
3,
11,
12]. Among Canadian physicians, the ease of use of the patient information systems influenced their satisfaction and easy-to-use patient information systems were found to be more acceptable [
13]. Among Canadian nurses, the most important determinant of their satisfaction was the compatibility of the EHR with the nurses’ preferred working style, existing practices, and values [
14]. In Finland, physicians expressed more critical attitudes towards EHR systems when poor design, system slow-down and system downtime were common [
15]. Second, many researchers have focused on work stressors in healthcare and studies indicate that nursing is a high-stress occupation and nurses are at risk of suffering from psychological distress [
16,
17]. Time pressure among healthcare personnel has been recognized in many studies in Finland [
18‐
21]. Time pressure has been found to decrease the quality of long-term care [
16]. Quality deviations and insufficient time for completing required tasks (in other words, high time pressure) are related to elevated levels of stress of personnel. Recent studies suggest that time pressure and information systems related stress are crucial sources of stress also among Finnish physicians [
20]. On the other hand, improved usability and technical stability of EHR systems lead to better work-related well-being, including lower time pressure [
17].
Consequently, the interactive relationship between EHR usability factors and the well-being of nurses at work is interesting. For years information technology has been an elementary part of work in the healthcare, creating conductivity to the quality of healthcare [
22]. Documentation using EHR systems comprises an integral part of the everyday work of nurses [
3,
8,
23‐
25] and the use of information technology influences several elements of nursing care [
9]. The advantages and problems related to specified EHRs have been described recently [
10]. In some studies, nurses report that time needed for documentation has increased, although their ability to use templates for documentation reduced the time needed [
26]. In the Finnish context, patterns of providing health services are changing. This change influences nurses’ work and the required competence in electronic recording within digital health services in many ways. Furthermore, the information technology that nurses use is under pressure for change. Currently, nurses have identified EHR systems’ poor stability and poor information system integration which leads to navigation between multiple screens as common problems [
10]. In another study, navigating between multiple screens was identified as a usability barrier of EHR [
27]. Difficulties in using the EHR system along with time pressure may increase psychological distress among nurses.
Furthermore, interplay between EHR usability factors and RNs’ informatics competence factors for both time pressure and psychological distress, is an area with little research and also national overviews of the issue are seldom available. Obviously, findings from observational studies with a wide range of EHR systems [
3,
8‐
15] introduce variations regarding experiences related to EHR systems. In Finland, the largest professional group in health care is registered nurses and therefore it is interesting to find out their experiences of EHR systems. In this study, we do not limit on satisfaction with EHR systems, but consider the more important step, namely the RNs’ self-reported informatics competence.
Aims of the study
The present survey study explores the associations of EHR usability factors and nurses’ informatics competence factors with self-reported time pressure and psychological distress among registered nurses.
Discussion
For this study, it was of interest to investigate both EHRs usability factors and nurses’ informatics competence factors associations to self-reported time pressure and psychological distress. The results of the present study revealed that low reliability and poor user-friendliness of EHRs were associated with time pressure among RNs in Finland. Moreover, low reliability and low support for cooperation and information flow were associated with high levels of psychological distress. Additionally, low competence in using eHealth tools in tailoring patient care and working in primary care were associated with high time pressure as well as high levels of psychological distress. The age of RNs was associated with high levels of psychological distress but not with time pressure. Similar results suggesting improving competency in the use of information and communication technologies in the delivery of patient care has been reported among practicing nurses in Canada [
40], the Netherlands [
7] and Finland [
6]. Furthermore, training needs are widely discussed as part of age-related management [
41].
Rapid technological progress puts nurses on a continuous learning track. Digital competence comprises not only IT skills but also the ability to meet complex demands using psychosocial resources (including skills and attitudes) in a particular circumstance [
5]. For patients with multiple care needs, nurses should tailor care between social care and healthcare [
42,
43]. In these situations, a fluent exchange of information between professionals and organizations is important for care continuity. It is estimated that one in 10 healthcare patients needs help for a range of problems, but most working-age people need services only occasionally [
44]. Working-age people are also more likely to master the use of digital services [
45]. In everyday work, healthcare professionals need training and coaching in adopting new digital services for patient work [
6]. It is important to note that teaching patients to use digital services is a new task for healthcare professionals.
Our results related to high time pressure among RNs’ work echoes the general trend of increasing time pressure in working life [
46]. Specifically in RNs’ work, the technical problems of EHRs were associated with higher time pressure, as was the situation among Finnish physicians [
17]. To summarize, both poorly functioning electronic health records and information technology competence play a role in high time pressure and high levels of psychological distress among RNs. Therefore, strategies for improving both challenges are needed. Firstly, healthcare professionals’ experiences with EHR systems should be taken into account in the development of these systems. Secondly, the organizations should invest in informatics education for RNs. Involving professionals in the design of EHR systems or other information technology development seems to take place mainly in discussions [
3,
4,
47]. This is an unfortunate state of affairs since user experiences should be a key component of information technology system development. Based on job-demands theory [
48], the lack of opportunities to influence working practices likely decreases well-being at work [
47,
49].
The present study was not without limitations. First, reaching the informants via an e-mail survey proved difficult and the response rate remained low. This was the first Finnish survey related to RNs’ experiences in EHR user and well-being at work and in the next survey in 2020, the informing of coming survey needs to intensify. However, the study presents a cross-sectional study of a large sample of RNs in Finland. Second, we used self-reporting measures: Related to nurses’ wellbeing at work, these were well-known and validated; and related to EHR-related factors, measures were consistent with factors from the cross-sectional studies of physicians. Nevertheless all of the EHR-related factors also showed good reliability and in the analysis, we controlled many variables, such as age, sex and employment sector, but of course, some other variables may impact to time pressure and psychological distress too. Third, thus our findings give a picture of RNs working in Finnish healthcare the results of the research are not directly generalizable; but the results should be tested in other healthcare systems using different kinds of EHR systems or varying ways of organizing healthcare in the various implementation stages of EHR systems.
The EHR systems, the users, the work organization and other social and healthcare providers involved in patient care interact with each other. Simple technical solutions for challenges in healthcare are no longer sought, and the expectations regarding EHR systems as the single element that solves the problems in the management of patient care have turned from optimistic to pessimistic [
50]. Comparing with the widely used survey instrument [
51] to that we used in this study both instruments measure mostly the same elements, but additionally we measured the reliability of information systems (e.g. system downtime), which was associated to high time pressure. To fix the usability problems of EHR systems, the first important step is to identify them [
3,
10,
47]. For example, on the individual level, navigating between multiple screens has been identified as a usability barrier, and poor stability as a potential source of patient safety problems [
3,
17,
27,
52,
53]. Likewise, in tailoring the training to the personnel, it is crucial to first ask and identify their opinion on what important skills they are missing [
7]. It must also be remembered that information technology competence is not merely about an individual’s skills, but also about the organization-level habits of working processes and practices that are shared with other healthcare professionals [
6]. The management of new working processes requires a clear vision and goal communication, management support, effective information on the implementation of the service and its implementation benefits, as well as the involvement of professionals [
54].
Building care pathways for typical patient cases is an option to strengthen integrated care for patients in modern digital healthcare. This would also ease the nurses’ decision-making process in care management. In a sustainable solution to improving EHR usability should involve healthcare organizations, including front-line staff, working with the EHR software developers. Descriptions of care pathways may provide a shared platform and understanding to integrate the patient treatment points and flow of information between the patient and professionals within an organisation and if needed between organisations [
47]. In addition, political toolkits like the Nursing Association’s e-Health Strategy try to emphasize RNs’ eHealth competence and participation in development work. Healthcare providers and politicians should care about improving the working life of those who deliver care in order that they achieve better care, better health at the population level, and lower healthcare costs [
55]. All in all, user-friendly EHR systems and digital tools are needed, along with training and coaching personnel in using digital services in tailoring patient care to help improve patient-centred care.
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