Utilizing nursing standards in electronic health records: A descriptive qualitative study

Background: The electronic health record (EHR), including standardized structures and languages, represents an important data source for nurses, to continually update their individual and shared perceptual understanding of clinical situations. Registered nurses' utilization of nursing standards, such as standardized nursing care plans and language in EHRs, has received little attention in the literature. Further research is needed to understand nurses' care planning and documentation practice. Aims: This study aimed to describe the experiences and perceptions of nurses' EHR documentation practices utilizing standardized nursing care plans including standardized nursing language, in the daily documentation of nursing care for patients living in special dementia-care units in nursing homes in Norway. Methods: A descriptive qualitative study was conducted between April and November 2021 among registered nurses working in special dementia care units in Norwegian nursing homes. In-depth interviews were conducted, and data was analyzed utilizing reflexive thematic analysis with a deductive orientation. Findings Four themes were generated from the analysis. First, the knowledge, skills, and attitude of system users were perceived to influence daily documentation practice. Second, management and organization of documentation work, internally and externally, influenced motivation and engagement in daily documentation processes. Third, usability issues of the EHR were perceived to limit the daily workflow and the nurses' information-needs. Last, nursing standards in the EHR were perceived to contribute to the development of documentation practices, supporting and stimulating ethical awareness, cognitive processes, and knowledge development. Conclusion: Nurses and nursing leaders need to be continuously involved and engaged in EHR documentation to safeguard development and implementation of relevant nursing standards.