Korean J Health Promot.  2024 Sep;24(3):110-117. 10.15384/kjhp.2024.00115.

Nurses’ Experiences with the Use of Electronic Nursing Record: A Qualitative Study

• LEE YH
• KIM MS
• KIM HJ

• KMID: 2560496
• DOI: http://doi.org/10.15384/kjhp.2024.00115

Abstract

Background
The electronic nursing record has contributed to improving nursing practice and ensuring nursing quality, but it is still incomplete in supporting nursing workflow. The purpose of this study is to explore the experience of using the electronic nursing record by nurses working in frontline care for trauma, emergency, and infectious disease-exposed patients.
Methods
The study employed a qualitative descriptive design and qualitative content analysis. In-depth interviews were conducted with 10 nurses working in emergency, trauma, and critical care units in the tertiary hospital.
Results
The nurses’ experiences with the use of the electronic nursing record emerged into three subjects (improvements to electronic nursing record implementation, benefits of electronic nursing record implementation, electronic nursing record user factors), five categories (information finding and sharing function, information input function, facilitating efficient communication, ensuring record quality, need for education), and eight subcategories.
Conclusions
Electronic nursing record supports the visualization of special information such as emergency and infection, and has the advantage of facilitating communication between medical staff. Both support better clinical decision-making. However, system instability and low nursing friendliness delay nursing work in the process of inputting, confirming, and sharing information. Copy-andpaste practices, poor quality of records, and insufficient electronic nursing record education were identified as factors to be changed on the user side. Improvement of nursing-friendly interfaces, optimization of nursing workflows, and participation of nurses in the improvement process are necessary. We should also focus on developing electronic nursing record education programs.

Keyword

Electronic medical record; Nursing records; User-centered design; Qualitative research