Nursing Burnout in a Digital Era

            Living in a digital era has many benefits. I can order my coffee from my phone and it will be hot and ready when I go pick it up, I can create a digital shopping cart and someone will deliver my groceries to my car when I’m finished with work in the evening, I can even earn an advanced degree from my living room. Our digital world is meant to make our lives easier and less complicated. Why then, as healthcare has implemented electronic health records, are more nurses experiencing stress and burnout? I have seen nurses quit their jobs because of increased levels of stress learning how to operate a new charting system. I have had nurses who have worked with different systems in the past struggle insurmountably with our electronic medical record. I have read error reports that blame the health record and state information wasn’t flagged in the chart to alert them of an issue. Working with an electronic health record (EHR) is not optional in our ever-changing digital environment. However, finding a way to make the EHR user-friendly, interoperable and organized is essential to the well-being of all healthcare providers.

Identification and Explanation of the Issue

            Burnout is described as a syndrome in which employees experience high levels of emotional exhaustion, depersonalization or cynicism, and low levels of feeling accomplished from their work (Dyrbye et al., 2017). Studies have shown health care providers, including nurses, experience higher than expected levels of depression and burnout in their current jobs (Dyrbye et al., 2017).  Some warning signs of burnout include fatigue, anger, feelings of helplessness, negativity and irritability (ECRI Institute, 2016). What happens when physicians, advanced practice nurses and registered nurses start feeling burnout? It is the patients that will be affected. Burnout has been shown to negatively affect safety and quality of care, decrease patient satisfaction and reduce clinician work effort (Dyrbye et al., 2017). One stated implication of this stress was initially implemented with the intent to better the healthcare industry and increase the efficiency of care delivery: the electronic medical record.

            There have been a number of studies completed that list work processes, specifically electronic documentation, as a main component of work-related stress in healthcare (Dyrbye et al., 2017).  When the electronic medical record was made available, the plan was designed to improve our nation’s healthcare delivery system by making patient records digital (Reisman, 2017).  The benefits of a digital healthcare world cannot be overlooked. The EHR has brought with it many positive factors, including increased access to health care, improvements in quality and decrease in cost (Ozair, Jamshed, Sharma & Aggarwal, 2015). However, one of the unintended consequences of the evolution of the electronic medical record was increased regulations and an abundance of new tasks for medical providers resulting in increased stress and cases of burnout due to poor interoperability and usability of the system (Dyrbye et al., 2018).  Interoperability allows healthcare data to be shared between systems. What makes systems truly interoperable is the ability to not only exchange the data, but clinicians can then use the data to make informed decisions (Reisman, 2017). Have you worked in a system that has poor interoperability? When systems do not speak to one another, more work is created for the nurse and other providers completing the documentation. Multiple records are kept of the same intervention because the system is not able to get this information from the other documentation record. Lab values are entered in multiple places, x-rays are viewed on a different system, vital signs are found on yet another screen. This dysfunctionality causes angst and stress and increased workload for the nurse. Nurses and doctors have been found to spend a significant portion of their work day in front of a screen entering information into the EHR (ECRI Institute, 2016).  When clinicians are spending more time in front of a computer than they are with their patients, decreased patient satisfaction and decrease in work satisfaction will be the result.

Proposed Interventions and Solutions

            The ultimate goal of health care providers is to do no harm. Patient safety is of utmost importance and the essential driver to decision making in healthcare. The EHR has the potential benefits of creating a safer and more efficient healthcare delivery system when the implementation is done correctly. The EHR can be intertwined with drug resource libraries alerting doctors and nurses of possible drug interactions, the patient profile can alert the nurse of possible drug allergies, and calculations can be done automatically when the computer knows the patient’s weight. One of the ongoing complaints of an electronic health record is the complicated ordering system. Simplifying the EHR documentation templates to create a record that contains relevant and valuable information is essential (Hochman, 2018). When nurses are spending an extreme amount of time clicking sections on a computer screen, that is valuable time spent away from their patient. In one study, the author found that it took more than 200 mouse clicks and over 700 keystrokes to finish one outpatient encounter in a clinic (Hochman, 2018). Finding ways to simplify charting, yet still fulfill the required documentation points is valuable to create an efficient and effective working environment. Hochman (2018), suggests finding ways to enhance patient care through technology, for example, having physicians use an electronic scribble pad that then turns the writing into text within the EHR and is automatically sent to the pharmacy and the nurse for review. This would be a faster way of prescribing new medications compared to searching through the drug library in a computerized order entry system. Focusing on capturing required information and eliminating the actions that do not add value is one way to enhance the medical record (Ommaya et al., 2018). Technology has so many benefits when implemented in a thoughtful and logical way. Utilizing the available technology to the best of its ability is going to enhance the patient experience and provide better working environments for nurses at all levels.

Remaining Challenges

            One of the challenges of creating an optimal working environment for nurses is that many of these medical records have already been implemented. When many different systems were initially executed, they were done so without a standardized thought process. The rapid pace in which these systems were implemented did not allow time for redesign or significant clinician input (Ommaya et al., 2018). The Institute of Medicine (IOM) recognizes poor usability of health information technology within healthcare as a major barrier to providing safe and efficient care (Roman, Ancker, Johnson, & Senathirajah, 2017). It is a considerable financial investment to change a system after it has been in place or to add in additional functionalities to create better working systems. However, insufficient navigation and poor usability of an EHR have been shown to increase workload and increase the potential for medical errors (Roman, Ancker, Johnson, & Senathirajah, 2017). Stress, burnout and medical errors also have a significant financial implication on an institution. Although challenges remain, there is hope with recognition and acknowledgment of the current concerns.

Nursing Implications

            Nurses spend half of their time charting documentation requirements and entering data into the EHR (Ommaya et al., 2018). With this requirement being so time-consuming, nurses are left with less time to dedicate to patient care. Nurses have stated dissatisfaction with the design of the medical record and the difficulty in navigation as main stressors in their work (Ommaya et al., 2018). When new systems are put into place, nursing input should be considered as a priority. Nurse involvement from the very beginning will help to create a system in which charting is logical and efficient while still providing all of the necessary requirements for meaningful use. Creating a system that is beneficial to the care provided will create a work environment that nurses enjoy. When nurses can get back to the primary focus of caring for the patient, everyone involved will benefit. Less stress and higher work satisfaction will mean better care and increased outcomes for our patients.

Meridith

References:

Dyrbye, L., Shanafelt, T., Sinsky, C., Cipriano, P., Bhatt, J., Ommaya, A.,… Meyers, D. (2017). Burnout among health care professionals: A call to explore and address this underrecognized threat to safe, high-quality care. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. doi: 10.31478/201707b

ECRI Institute. (2016, Dec. 14). Burnout in healthcare: The elephant in the room. Risk Management Reporter. Retrieved from https://www.ecri.org/components/HRC/Pages/RMRep1216.aspx

Hochman, M. (2018). Electronic health records: A quadruple win, a quadruple failure, or simply time for a reboot? Journal of General Internal Medicine, 33(4), 397-399. Doi: 10.1007/s11606-018-4337-6

Ommaya, A., Cipriana, P., Hoyt, D., Horvath, K., Tang, P., Paz, H., … Sinsky, C. (2018). Care-centered clinical documentation in the digital environment: Solutions to alleviate burnout. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. doi: 10.31478/201801c

Ozair, F., Jamshed, N., Sharma, A., and Aggarwal, P. (2015). Ethical issues in electronic health records: A general overview. Perspectives in Clinical Research, 6(2), 73-76. Doi: 10.4103/2229-3485.153997

Reisman, M. (2017). EHRs: The challenge of making electronic data usable and interoperable. Pharmacy and Therapeutics, 42(9), 572-575. PMID: 28890644

Roman, L., Ancker, J., Johnson, S., and Senathirajah, Y. (2017). Navigation in the electronic health record: A review of the safety and usability literature. Journal of Biomedical Informatics, 67, 69-79. Doi: 10.1016/j.jbi.2017.01.005