Health professionals in a hospital that implemented use of electronic health records in 2010 were asked about their views on moving towards a paperless NHS
Little research has been undertaken to ascertain nurses’ views of a paperless NHS so health professionals in a hospital in the West Midlands were asked about the initiative through face-to-face interviews and a focus group. This article outlines their responses. It shows that some were unaware of the scheme, while others were generally positive about electronic healthcare records (EHRs) but concerned about their use in practice.
Citation: Onifade A, Sque M (2016) Views on and perceptions of a paperless NHS. Nursing Times; 112: 32/33/34, 12-14.
Authors: Adams Onifade is a freelance, self-employed registered nurse in Birmingham; Magi Sque is Professor of Clinical Practice and Innovation with a joint appointment with The Royal Wolverhampton NHS Trust and the University of Wolverhampton, Faculty of Education, Health and Wellbeing, Centre for Health and Social Care Improvement, Wolverhampton.
- This article has been double-blind peer reviewed
- Scroll down to read the article or download a print-friendly PDF here
In February 2013, the health secretary Jeremy Hunt directed the NHS to go paperless by 2018, stating that a paperless NHS would improve service delivery, give nurses more time to care and enable health professionals to access healthcare records at the click of a button (Department of Health, 2013; Hunt, 2013).
Although the emergence of electronic health records (EHRs) is spreading across healthcare facilities worldwide, reports indicate health professionals are reluctant to embrace them (Luchenski et al, 2013; Ståhl et al, 2011). Emerging evidence revealed that, since the health secretary’s mandate, no study has been carried out in the UK on nurses’ attitudes towards, or awareness of, a 2018 paperless NHS. Evidence is also lacking in how nurses would adapt to paperless healthcare delivery in England (Bolger et al, 2013; Baillie et al, 2012). Most studies available are from the US, Canada, Australia and Japan, explaining the gap in knowledge highlighted by Ajami and Bagheri-Tadi (2013).
The journey towards EHRs began in 2002 with the National Programme for IT (NPfIT). The Lorenzo patient record system acquired by many of the NHS trusts in England failed to achieve the set objectives so, by 2005, the £12bn project was disbanded (Greenhalgh and Keen, 2013; Sheikh et al, 2011). According to Triggle (2010), this was one of the most costly failures in the history of the NHS.
Greenhalgh and Keen (2013) and Bolger et al (2013) reported that the term “electronic health record” also covers terms such as health information technology, electronic medical records, computerised physician order entry, electronic client records, personal health records, digital medical record, computerised patient records and clinical information system. In this study, the word EHR is used to represent all the synonyms of paperless healthcare records.
This research aimed to explore nurses’ attitudes and perceptions of a paperless NHS by 2018 at a West Midlands hospital, with a view to identifying potential problems and making recommendations to facilitate a smooth transition to electronic healthcare delivery. The study aimed to:
- Elicit nurses’ attitudes toward the NHS being paperless by 2018;
- Assess nurses’ awareness about a paperless NHS;
- Understand how nurses will adapt to paperless healthcare delivery.
A broad computerised literature search on key databases – British Nursing Index, CINAHL, MEDLINE, EBSCOhost, PubMed and Cochrane Library – was conducted. To be included the article had to be:
- An original research paper;
- Peer reviewed;
- Related to “nurses’ attitudes”, “paperless or electronic patient records or its synonyms”;
- Written in English;
- Published between 2002 and 2014.
Eleven research studies – six qualitative, four quantitative and one mixed-method – were identified and their findings organised into themes. Broadly speaking, three themes emerged:
- Nurses’ attitudes towards EHRs;
- Nurses’ concerns about EHRs;
- Barriers to the implementation of EHRs from nurses’ perspectives.
The majority of evidence claimed nurses had positive attitudes towards EHRs, in line with the findings of Bolger et al (2013).
An acute urban NHS hospital in the West Midlands was an early adopter of EHRs and started implementing them in 2010. Nurses working here were recruited to the study via flyers and posters displayed in staff common room following ward manager’s approval. Volunteers signified their interest by responding to the contact details provided in the posters and flyers.
A total of 10 volunteers were recruited into the study. They were divided into two groups. Five participants were involved in the individual face-to-face interviews (FtF) and five in one focus group (FG). The FtF interviews consisted of all staff nurses whilst; two healthcare assistants (HCA), two staff nurses and a ward sister formed the FG. The individual FtF interviews lasted between 30-40 minutes and FG 55 minutes. Data collection was conducted between April and June 2015. The focus group enabled a group of nurses to sit together in a collegiate manner to discuss an issue of common interest and compare the findings from the five individual interviews.
Interviews and focus group data were transcribed and subjected to thematic analysis as advocated by Parahoo (2014) and Braun and Clarke (2013).
Sixteen sub-themes were identified and, from these, five major themes emerged:
- EHR usage;
- Awareness of a paperless agenda;
- Nurses’ views and attitudes towards national paperless agenda;
- Perceived benefits of a national EHR programme;
- Perceived problems with the implementation of national EHR programme.
From the interviews and the focus group, it became clear that the nurses use EHRs mainly for drug administration:
“I use EPR daily for drug administration, admission and discharges of patients, checking blood results, referrals to other clinicians and to update patients’ hand overs” (Nurse, FtF Interview).
“I don’t use it the way you nurses do. I only use it to check my off duty, my emails unlike you nurses who do drugs, hand-overs and all sorts” (Healthcare assistant, FG).
Although the EHR has many features, the ability to use these depends on the user’s role, skills and responsibilities. For example, it was reported that only senior nurses were able to carry out more tasks on the EHR such as admission and discharges, complete electronic handovers, make internal and external referrals, and access laboratory results and investigations. Similar findings were reported by Baillie et al (2012).
Awareness of the paperless agenda
Despite the ministerial mandate issued in 2013 (two years before this study took place), all the participants claimed they were unaware of the plan to make the NHS paperless by 2018. They agreed no one had spoken to them in the organisation or from the professional body about the mandate. Many were either unaware until they either took part in the study or noticed the poster promoting it.
Perceived benefits of a paperless NHS
Supporting the findings of Kipturgo et al (2014), Bolger et al (2013) and Baillie et al (2012), most of the nurses expressed positive attitudes towards the national paperless agenda. All participants acknowledged that EHRs offer many benefits to the NHS which was similar to other studies (Baillie et al, 2012; Stevenson and Nilsson, 2012).
Participants claimed EHRs were better than paper charts, which were sometimes written illegibly.
Some nurses also said that, since the EHR was introduced, there had been a reduction in the number of drug errors in clinical areas (Bolger et al, 2013; Greenhalgh and Keen 2013).
Participants thought EHRs saved time compared with using paper charts, which was consistent with the findings of Ajami and Bagheri-Tadi (2013). Additionally, it was reported that EHRs removed clutters, including piles of notes, charts and forms that were always lying around in clinical areas. Participants also said EHR reduced the duplication of information, which was time consuming and often irrelevant.
One participant said:
“I look forward to the transition because I find the heaps of papers annoying and much time is wasted on repetitive documentations.” (Sister, FG)
It was reported that with EHRs, nurses were able to record care in a timely manner. One said:
“It will improve patient care and save us money on printing.” (Sister, FG).
The study also found that EHRs improved communication within and outside of clinical areas. A participant said:
“We will spend less time chasing the doctors, pharmacists, social workers, occupational therapists and others as referrals will be done and acted upon online.” (Nurse, FG)
Problems with a paperless NHS
HCAs were skeptical in their attitude towards the paperless agenda. It emerged that a lack of computer literacy and minimal usage of the EHR system for their roles influenced their negative attitude.
No previous study was found in the literature that sought the views of HCAs. This requires further investigation.
Some participants had concerns about the paperless agenda. They said there were insufficient computer and that during working hours some users had to wait for a free computer to be able to carry out duties. One participant said:
“My ward, like all other wards, does not have enough computers to successfully do our jobs as nurses. To carry out drug rounds on the EHR we still struggle to get access to computers especially during the day when the doctors, pharmacist, physiotherapist and so on are around using all them. We have only two [computers on wheels (COWs)] on the ward and two laptops.Therefore medications are either delayed or these professionals must come back if we are already using the systems.” (Nurse, FtF interview).
The nurses added that the COWs used in the hospital were too big for nurses to push around to each individual patient’s bedside. Participants were also worried about the EHR software packages. The EHR required multiple logins and so were difficult to navigate. One participant said:
“I usually forget my passwords because you have to log in every time to use EHR. I end up having many passwords for each menu, which makes me confused and logs me out. I wish we can have only one password for everything.” (Nurse, FG).
There were also no backups during power outages. Participants said the current EHR system was not user friendly for nurses and HCAs – most of the nurses and all of the HCAs said they were not equally and adequately trained to use it to its fullest potential. One participant said:
“Unless they give us lots of training, most of us may continue to struggle and therefore continue to use paper charts.” (HCA, FG).
Participants therefore felt nurses should be involved in EHR design and planning for their implementation:
“Nurses must be able to voice their requirements in the design and implementation of paperless agenda otherwise problems will arise.” (Nurse, FtF interview).
“The nurses must be engaged at all levels in the implementation stage.” (Nurse, FtF interview).
To achieve a paperless NHS, participants said the government needed to invest more in the project to buy more computers and portable devices, which are durable and easily available to all staff.
“To realise the 2018 target date, the government must demonstrate commitment through nurses’ engagement, procurement of more computers and lay out strategies to support the transition.” (Sister, FG)
The NHS was also tasked with ensuring the EHR systems were universally available across the NHS, so when staff move from one organisation to another they do not need to learn how to use a new system. One participant recognised the importance of this:
“These computer systems must be the same across the NHS otherwise when staff move to different areas it will be problematic.” (Nurse, FtF interview).
Participants thought the cost of implementing a paperless agenda in a financially stretched NHS may be unrealistic and felt more funds had to be invested into the programme. One said:
“The NHS needs more money to pursue the agenda.” (HCA, FG)
Recommendations of what participants felt needs to be done before the 2018 target date of a paperless NHS are outlined in Box 1.
Box 1. Recommendations
- Increased public awareness especially for nurses and healthcare assistants which will prepared them for the 2018 paperless agenda
- Nurses, particularly IT trained nurses should be incorporated into the designing of programs that support nursing roles on the EHRs
- Concrete ongoing training and support available 24/7 should be set up for all cadres of nurses before and after the implementation of EHRs.
- The government should provide more funds to support the implementation of EHRs
- EHRs should be universal across the NHS
The study generated new knowledge. As an example, there had been no mention of HCAs in relation to EHRs in any of the previous studies. HCAs have a role in healthcare delivery and must be involved in concepts developed to support healthcare services.
The study showed that all nurses and HCAs who participated were unaware of the planned 2018 paperless agenda, which is less than three years away. Although the nurses were positive about the initiative, it is important to acknowledge and attempt to address the concerns raised. NHS leaders must engage with nurses and HCAs to understand their perspectives and design a programme so the project has a better chance of succeeding, rather than failing as was the case with NPfIT.
As a qualitative study, the findings cannot be generalised. Participants were from the same single ward of the NHS hospital in the West Midlands so the sample size was not large enough to represent the views, attitudes and perceptions of all nurses. Generally, all participants appeared to welcome the EHR system because they believed it would benefit patients and the NHS as a whole. They cautioned however, that the introduction of EHRs needed to be strategically planned with all stakeholders including IT departments and the vendors. Participants suggested that having staff involved from the outset could help minimise any resistance and difficulties that could emanate from using the system.
- The Department of Health and the NHS must step up preparation for a paperless NHS by increasing awareness about it among nurses
- More money must be invested in the programme to procure more computers, tablets, mobile phones, palmtops and personal digital assistants before the 2018 target date
- Nurses and healthcare assistants should be given ongoing training about the use of electronic health records before 2018
- IT departments need to develop and incorporate into electronic health records software packages facilities for nursing duties, such as personal hygiene, wound dressing and observations
- A standard programme across all NHS trusts would mean nurses can change jobs without needing additional systems training
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