While electronic care records offer many opportunities, they also present practical and professional challenges for nurses, which the profession must be prepared to tackle
Ros Moore, RNT, RN, is chief nursing officer for Scotland; Gill Stonham, RN, is head of strategic alignment and knowledge management, NHS Connecting for Health.
Moore R, Stonham G (2010) Examining the impact of electronic care records on confidentiality and nursing practice. Nursing Times; 106: 14, early ionline publication.
Electronic care records have significant implications for both frontline nurses and the wider profession. The two articles published in last week’s issue discussed how the electronic care record (ECR) can support and bring benefit to frontline nurses’ role from a practical perspective. They also discussed the scope and complexity of the change management challenges underpinning implementation of ECRs in the NHS in England.
This final article examines the issues nurses must consider when introducing and using this system. These include access, information governance and matters such as confidentiality.
Keywords Electronic care records, Professional issues, Accountability
- This article has been double blind peer reviewed
- ECRs present significant opportunities for nurses to improve practice.. However, they raise a range of practical and professional concerns for nurses that must be tackled.
- Coherent professional leadership and action nationally and locally plus high levels of nurse engagement, are vital to ensure the success of this initiative.
Professional implications for nurses using the ECR
Although electronic care records (ECRs) present significant opportunities for nurses to enhance their practice, practitioners will inevitably have concerns about the move from paper to electronic systems.
Professional associations such as the Royal College of Nursing have always encouraged members to embrace the opportunities presented by e-health in all its forms through discussion forums, research information and professional guidance (RCN, 2006) but in a joint report published with Bournemouth University they also highlighted a number of professional concerns raised by nurses about working in electronic environments (Baker et al, 2007).
Along with practical concerns such as access to computer hardware and the need for more training and engagement, the report raised issues about confidentiality and security of electronic systems and their ability to capture or follow the reality of nursing practice. It also examined more complex professional fears about data being used to covertly monitor individual performance, that standardisation may reduce professional judgement and that computers divert nurses from direct care (Baker et al, 2007).
These concerns are neither new nor uncommon – similar issues have been raised in a number of studies in the past (Kossman, 2008; Darbyshire, 2004; Kirshbaum, 2004; Timmons, 2003). However given the key role that nurses have at the frontline of NHS services and their function as primary information managers, such concerns cannot and indeed must not be ignored if the potential of ECRs for patients and clinicians is to be realised.
Access to hardware
Access to computers and other hardware remains a real barrier to nurses using the ECR in practice settings. The situation across the NHS remains highly variable with some nurses enjoying the benefits of electronic records via highly portable and reliable hardware, while others remain frustrated by a single static computer per team or inappropriate or unreliable mobile technology. Nurse leaders must learn from those organisations that have provided staff with the appropriate hardware so that nurses can engage more effectively in procurement.
Making sure that frontline nurses and nurse leaders understand and demonstrate rigorous information governance will also help tackle some practical concerns about the ECR.
At a policy level, information governance can be defined as “the structures, policies and practice of [professional nursing] to ensure the confidentiality and security of all records, and especially patient records and to enable use of them for the benefit of individual patients and the public good” (adapted from Cayton, 2006).
This is not a new requirement; in common with other clinical groups, nurses have practised information governance as part of their professional codes of conduct and recordkeeping standards for many years. The obligations to maintain confidentiality and record security do not diminish with the ECR but require re-framing to fit the content and nature of electronic records and the changing recordkeeping practices they demand.
At a practice level, nurses need to consider how this translates into professional action in ways that demonstrate professional clarity, accountability, transparency, coherence and consistency as well as being realistic, practicable, deliverable and measurable. Some of the key elements of information governance are set out below.
Information governance requires that all nurses look at how the content of their existing nursing records is set out, to consider the extent to which, if audited, it would be structured, prospective and actionable, unambiguous and measurable.
An Audit Commission (2009) report found that clinical records remain highly variable in quality, with many reported to be unauditable. This situation would be less likely with electronic records, particularly if nursing grasps this opportunity to build a clinical content library made up of generic and specialist pre-defined elements of assessment and care, which are based on best practice and evidence, that can be re-used to support the process of assessment and care planning across multiple pathways.
Such a library would be supported by a system of professional assurance and governance that brings together the evidence base with practical access, at the point of care. This requires greater collaboration within the profession, with clear lines of accountability, governance and contribution at all levels to ensure that the needs of nursing, as part of a wider clinical body, are clearly defined, consistent, and seen as important and integral to a patient’s shared electronic record.
The argument for professionally assured content systems that can be used in all nursing records becomes more crucial when we consider that electronic care records may be shared under tight control across a number of provider organisations. Content also supports the reporting of outcomes and the achievement of quality indicators to commissioners and patients alike.
We know that poor quality records and documentation can lead to significant clinical and patient safety risks, and so enabling nurses to maintain the highest levels of recordkeeping standards remains a continuing objective. There is a legal imperative for all nurses to maintain a comprehensive, accurate and accountable record as a fundamental requirement.
This is another area that would benefit from collaborative work between nurse leaders and professional bodies to ensure that professional guidelines reflect electronic working and to determine the policies and procedures required in a structured and integrated ECR environment. This is an approach strongly advocated by the Royal College of General Practitioners and NHS Connecting for Health in the recently published guidance on shared professional records (RGCP, 2009).
Confidentiality and security
The NHS Confidentiality Code of Practice is clear that record security and record confidentiality remain the responsibility of all clinical practitioners (Department of Health, 2003). The NHS Care Record Guarantee for England, re-issued in July 2009, reinforces the responsibilities and sets out a number of obligations under which a patient’s electronic record will be managed, to promote confidence among patients and the public (National Information Governance Board for Health and Social Care, 2009). These obligations include:
- How and when a record may be shared;
- The responsibilities of those staff accessing a record including the need for information accuracy;
- The audit trail that will link record access to practitioners;
- The contractual consequences for practitioners who breach their professional duty of confidentiality.
Nurses need to have a clear understanding of these obligations and hold personal accountability for them. Part of this personal accountability includes awareness of those policies that govern access to patients’ electronic record, including managing passwords, which should not be shared with colleagues, and should be changed regularly and memorised rather than written down.
As well as a good understanding of service policies and procedures, nurses also need to have a broad understanding of the key legislation that surrounds personal information. The Data Protection Act 1998 sets out a number of principles that govern the way structured personal and sensitive information may be processed irrespective of whether it is held in a paper or electronic format (Office of Public Sector Information, 1998). This legislation covers clinical records and nurses should ensure they are up to date with local management arrangements, including who is the data protection officer for their organisation and how the act supports patients’ access to their record.
In many healthcare organisations, the Caldicott guardian will work alongside the data protection officer (DH and The Caldicott Committee, 1997). The Caldicott guardian “should be, where practicable, a senior health professional with access to the most senior tier of management within an organisation” (Cayton, 2006). This is very often the director of nursing or the medical director but whoever the guardian is, “they must be seen as separate from other management and sectoral influences, thereby engendering confidence in their independence and integrity” (Cayton, 2006). Their appointment must always avoid any conflict of interests and their role is to ensure that local data sharing protocols are in place, detailing the standards that will apply when confidential information is disclosed or shared with other organisations and agencies.
The Caldicott principles include justification to share, the minimum usage of patient identifiable information, access on a “need to know” basis, and individual awareness and understanding of relevant legislation. These principles apply to both paper and electronic records. However, as we move to a healthcare service in which ECRs are seen as routine, adherence to such obvious principles will be much easier as they support new and innovative models of care delivery that depend on the sharing of integrated, structured, consistent and professionally assured content.
Professional issues for nursing
While access and good information governance will go a long way towards tackling some of the practical concerns expressed by nurses, challenging questions remain about the impact of electronic records in areas such as clinical judgement, nursing practice, skills and identity (Greenhalgh et al, 2009; Baker et al, 2007; Darbyshire, 2004). With electronic records rapidly becoming the norm for frontline nurses, it is essential that these questions are debated openly by the profession and investigated through evaluation and research. Even then the answers may not be clear cut, and such issues are resistant to the sort of linear problem solving favoured in nursing. Instead complex issues like this will require new ways of conceptualising, new ways of working (Davis, 2000) and a willingness to learn from non traditional practice areas.
Clinical judgement, decision making and nursing skills
One such area is NHS Direct, the 24 hour teleconsultation service where nurses have been routinely using computerised decision support software and electronic records to support their clinical practice for several years. Despite initial concerns about diminishing clinical and professional skills, studies sited by Hunt (2008) have emphasised the nurses’ central role as active decision makers using professional judgement to seek consensus with the software and overriding it as required. Hunt (2008) points out that, rather than being deskilled by the technology, many NHS Direct nurses experience increasing levels of knowledge and judgement. The potential educative benefits of computerised systems for nurses in a face to face setting were also highlighted by Lee (2006), who found that using electronic records improved descriptions of patient problems and care strategies.
However, the importance of critical thinking skills in achieving these benefits cannot be over emphasised. Nurses using any electronic system in any setting must constantly question the content so that diligence is not lessened. Practitioners need to be aware of where the clinical information held for each patient receiving care comes from, and be ready and empowered to question, re-evaluate and modify it.
Technology and caring
Another concern that nurses often raise is the impact of technology on the caring role, that is, the fear that electronic records may mean more time with computers and less time with patients. The evidence is not conclusive either way.
Greehalgh et al (2009) suggested that although electronic records may improve secondary functions such as reporting and audit, primary clinical work may become less efficient. Kossman et al (2008) reported that nurses working in a community hospital felt that care was safer but quality decreased due to the time spent on electronic records. However, evidence from the field offers a different picture with large mobile working initiatives such as the one in Lincolnshire PCT demonstrating clearly the potential of electronic systems to release time to care. What we do know is that electronic systems and records inevitably affect the distribution and content of work tasks and that existing recording practices have to change. Once this is accepted and understood, nurse leaders can stop nurses from trying to shoehorn their existing recordkeeping practices - some of which may be outdated and inefficient - into the new system, and help them adapt through training, supervision and by providing updated operational policies.
Much less tangible are the questions about the impact of technology on nursing identity. One recurring theme that tends to emerge in the aftermath of high profile hospital failures and reports such as Hungry to be Heard (Age Concern, 2006) is that advancing technological care and medical substitution have somehow diminished nursing’s traditional commitments to caring and human relationships.
As views are divided and the evidence is inconclusive (London Network for Nurses and Midwives 2007), we might look again at the experience of NHS Direct nurses. While their work challenges the normative notions of traditional “hands-on” models of practice, it seems the nurses do retain a strong sense of nursing identity and alignment to traditional values of nursing and holistic, empathetic practice. In addition, by learning new skills and adapting old ones, they have added a significant cognitive element to their professional identity as a result of changing knowledge, analytical and communication skills (Snelgrove, 2009).
It is not disputed that caring must be at the centre in an e-enabled nursing world is not under dispute. All four UK chief nursing officers reinforced this through Modernising Nursing Careers (DH, 2006) and in practice frameworks such as Confidence in Caring (DH, 2007) that stress the need for technical, interpersonal and caring competences in equal measure. Providing the profession is prepared to take ownership, there is a good chance that by modernising working practices, securing our evidence base, realising our commitment to integrated multiagency care, facilitating partnership working with patients and improving information giving, that ECRs may serve to protect rather than detract from nursing’s core values. The development of data standards will also make the caring elements of nursing much more visible and therefore subject to quality monitoring and commissioning (Baker et al, 2007).
The practical and professional issues presented here demonstrate the need for strong and coherent action at national with high levels of nurse engagement to take this agenda forward; a conclusion echoed in the recent report by the Prime Ministers Commission on the Future of Nursing and Midwifery (PM Commission 2010).
Good governance could begin with professional assurance of the core components of clinical content in ECRs. Nurses must recognise that professional accountability is central to this, and mechanisms need to be put into place now to ensure dialogue with other clinical groups to ensure we get it right. The confidentiality and security of electronic clinical records remains with us all, but our ability to bring compliance up to the highest standards is made significantly easier in an electronic world.
Leadership is also essential if we are to address some of the difficult issues raised in this article. This will involve partnership working at local and national level with system providers, managers, educators, professional associations, policy makers and regulators to ensure that nurses are prepared through education, research and policy to practice safely and effectively in an e-care world.
As Dame Catherine Hall (1982), a pioneer in this field, said: “In all scientific and technological developments, man is and must remain the master. Man must never become the minion because his birthright is that of intellectual being. It is he who must solve the problems and identify the implications of technical marvels of this and every age and it is he who must make the moral judgements as to their usage. As nurses it is for us to determine how we can use computer science appropriately and effectively in the facilitation and contribution of our profession in the provision of care.”
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