Nursing Comprehension: Is There a Checkbox for That?

Abstract

The beginning of my nursing career coincided with the end of the paper-charting era. Every letter or digit I recorded was entered manually and with intention, and each shift ended with at least 1 narrative note. I was required to pause and synthesize all assessments, clinical changes, and interventions of that shift, or event, into a succinct but meaningful clinical story. At that time, one could flip through the nursing notes section of the paper chart and quite easily understand the events and progress of previous shifts. Today, with digital documentation in the electronic health record (EHR), we have more information than ever, but it is arguably less cohesive in telling a clear story. As a result, the information can seem less meaningful.These days, there is a digital check-box for nearly every nursing action—a barcode to be scanned for every medication administered, an algorithm that creates more checkboxes to address, a screening tool to be completed, and flow sheets populated with data pulled from other areas of the EHR. I recognize the many strengths in harnessing data to support best practices and drive electronic intelligence tools. For example, barcode scanning of medications has been shown to reduce errors of administration related to incorrect dosing or route, wrong drug selection, or wrong patient.1 However, this abundance of information may have diluted what is important and relevant for holistic care. In a systematic review, Nijor and colleagues2 found that information overload in the EHR may lead to increased errors.As digital documentation has increased, there has been a decrease in nursing competency and comprehension, particularly among novice nurses.3 Broadly, nurses may recognize abnormal assessments or vital signs and be able to articulate the function of an organ system, yet they may find it difficult to see the whole picture of the patient’s status. Nurses may struggle to pull the most important elements together amid all the information and requirements.4Nursing has long lived by, “If it isn’t documented, it isn’t done.”5 Are we currently in an era of overreliance on digital systems that has led to, “If there isn’t a prompt to document/assess/review, it won’t be done”? Without a prompt to stop and synthesize the information just documented, will the nurse put together the important clinical pieces of information that are recorded in different sections of the EHR?I do not believe digital documentation is all bad, but I do think we must consider how our use and design of it have impacted nurses’ comprehension of holistic patient care. How do we develop and maintain the wisdom and art of nursing amid a more complex digital age? How do we train our nurses to be and do what technology cannot? I ask these questions with a sincerely curious spirit and hope, knowing that when we find the synergy of the best of nursing and the best of technology, our workforce will be more satisfied and our patients will be safer.