With electronic care records being rolled out in England, nurse leaders, managers and frontline nurses need to prepare to change how patients’ records are kept
Ros Moore, RNT, RN, is chief nursing officer for Scotland; Mike Jones, RMN, is national clinical lead for mental health nursing, and mental health product manager, London Programme for IT.
Moore R, Jones M (2010) What can nurse leaders and staff nurses do to prepare to implement electronic care records? Nursing Times; 106: 13, early online publication.
The NHS in England is in the process of developing and rolling out electronic care records (click here for more information). This article examines the issues that frontline nurses, nurse leaders and managers should consider when implementing ECRs.
Keywords Electronic care record, IT, leadership, Change management, Training
- This article has been double-blind peer reviewed
- Predict and manage the potential barriers and risks.
- Use a multifaceted approach to change management.
- There are four areas of action for effective implementation: partnerships, people, processes and technology.
There are many challenges facing nurses involved in making the change from a paper based to an electronic record system and effective leadership plays a vital role in the process (see www.nhscarerecords.nhs.uk). Nurses leading the transition have to be able to translate the strategic vision for the electronic care records (ECR) into a tangible product for frontline staff with positive benefits and they need to develop a workforce that understands the technological portal through which it is accessed.
Understanding and overcoming barriers
Mustain et al (2008) pointed out that fear, apathy and competing priorities were the three main barriers they faced when introducing electronic records to an acute facility in the US; factors that will no doubt resonate with nurse leaders in this country.
The fear may be related to the technology itself or the need to learn new working processes. Apathy, on the other hand, emerges during lengthy implementation projects which are inevitably delayed by organisational issues, equipment problems or minor to severe software glitches. This increases the chance of encountering the third barrier, that of competing priorities, as new policies, service demands or new projects compete for attention and resources.
These barriers may be at the root of change fatigue, a phenomenon that appears to be increasing in nursing. Change fatigue is often demonstrated by lack of engagement, scepticism or frustration. These problems can result in the sort of negative behaviours highlighted in a study of three hospitals implementing computerised care planning, where staff used various strategies to avoid writing and updating electronic care plans (Edmondson et al, 2001, cited by the National Nursing Research Unit, 2009). The study concluded that despite the implementation plan being delivered and the organisation perceiving the change as successful, there was a failure to assimilate the system into routine practice long after the change had occurred. This identifies the importance of truly effective change management in this process.
In the past, the management of change was often presented as a logical process comprising a series of linear steps or actions to achieve a successful outcome. However, as Nadler (1998) pointed out: “Real change in real organisations is intensely personal and enormously political.” Change is a messy and complicated business, more akin to progressing through the grieving process (Turner, 2002) than a clearly staged journey with measurable milestones.
Reineck (2007) described an alternative approach to change which may be more relevant given the evidence above. This approach would still have at its heart a well planned and resourced programme of activity but the management of change would take place through a multifaceted approach using power, reasoning and re-education and involving structural, behavioural and technological approaches. Table 1 outlines these principles and their potential application to implementing the ECR.
Making the change
The issues that nurses need to address to ensure effective implementation of ECRs in their area tend to fall into four interconnected areas - partnerships, people, processes and technology (Fig 1).
Implementation leads need to establish strong partnerships at all levels if they are to succeed. At the delivery end, key partnerships involve frontline staff, the IT team responsible for resourcing the equipment and the electronic record system developers (who may or may not be a commercial company). However, it is likely that the organisation’s executive will have allocated a board sponsor who will also be a key partner along with the finance director, HR director and non-executive directors.
Partnerships should extend to other units or teams that may have an interest in the change and to those outside the organisation involved in the patient care pathway. Education providers are also useful partners as they can ensure the change is reflected in educational programmes and advise on issues such as evaluation and change management.
Lymbery (2006) described the vast differences in power and culture between various occupational groupings, and the inherently competitive nature of professions jostling for territory in the same areas of activity. He suggestedthat these issues cannot be resolved unless they are properly understood; a rhetorical appeal to the unmitigated benefits of “partnership” alone will not produce more effective joint working.
This is particularly pertinent to the partnership between clinical staff, trust IT employees and systems suppliers whose language, concerns and priorities are often different. Mutual respect and understanding can be developed by building strategies such as action learning into the change process. Action learning is based on the relationship between reflection and action. The focus is on the issues and problems that individuals identify and planning future action with the structured support of the partnership group. This approach helps people to learn from each other, and generates collective ownership and strong accountability for goals and risks.
Who needs to be involved?
Clinical ownership is crucial (Mustain et al, 2008; Edmondson et al, 2001) and it is vital that nursing staff of all grades and any support staff are involved as early as possible in all aspects of implementation. It is this involvement that allows nurses to feel they have ownership of introducing the ECR. They need clear leadership from their manager, ensuring that each staff member knows what is expected of them, making use of existing skills and expertise. Visiting professionals also need to be involved, such as medical staff, diabetic specialist nurses or community psychiatric nurses, as they may have different needs to regular staff in terms of access.
What skills are needed?
It is likely that nurses involved in implementation will have different attitudes towards the ECR and varying degrees of knowledge about its purpose, structure and content. Developing a shared vision is vital. Since levels of competence also vary in relation to IT, each person’s level needs to be assessed to ensure appropriate training and support is offered. At this early stage, “buddies” and “champion users” can be identified to support less confident staff and ensure they do not become marginalised.
Nurse leaders should also consider updating or adapting record keeping skills of those staff who do not have the skills required to record contemporaneous information electronically, as they will not make best use of systems available to them (Timmons, 2001). At the same time leaders must be clear that the act of changing record systems cannot guarantee improvements in quality and safety (Urquhart and Currell, 2005). Therefore staff must be clear about the part they play and their expectations managed to achieve progressive continued implementation.
The two main areas that need to be addressed are process mapping and training.
Process mapping: this may be new for some nurses, but should be seen as part of reflective practice. It allows system users to identify the process “as is” and the process “to be”. In “as is” mapping it is important for staff to properly explore their current processes. They may find there are steps that are not fully understood or that are in place due to custom and practice rather than because they are necessary. It is only when staff have the opportunity to reflect on these process steps that they can begin to start to think about the “to be” process mapping. This involves looking at how they plan to work after the ECR system is in place. Staff may be tempted to try to mould the system around their existing practices, that is, the processes they identified in the “as is” mapping exercise. By spending time and creativity on the “to be” mapping, more benefit can be accrued by looking at all the possible options for working differently and smarter following the ECR’s introduction.
An example of “as is” and “to be” process mapping could involve looking at how (general) assessments are undertaken. Information in the current process may be gathered in separate documents at varying points in time, such as during nursing triage in A&E, followed by a medical assessment in the same place. A decision to admit is then made and the ward may also carry out a nursing and separate medical assessment. Using the ECR to best advantage is likely to involve having a single (comprehensive) assessment completed over time, with successive professionals adding to the clinical data, reducing the potential for duplicate, or even worse, conflicting information. This example shows that process mapping must involve all relevant staff, not just nurses.
Training requirements: as mentioned earlier, system training alone is insufficient; individuals and teams must review current recordkeeping practices and consider the practical, procedural and professional implications of the new approach. However, this section assumes that has already taken place. Actual system training needs to be driven by timing as much as anything else, in that staff must be trained how to use the system as near to their “go live” date as possible. If training takes place too early, staff may need to spend time reading manuals during the going live phase since they may have forgotten elements of what they were taught. Staff who have been trained on ECRs have often raised the same issue, that is, during training the system should reflect, as far as possible, how it will look when it goes live. For example, it would be useful to use existing ward names to create familiarity and to help gain system acceptance.
It is also important to involve staff in the “go live” planning so that education, training and confidence are there at the right time. Access control is one area where this can be useful. Most ECRs use role based access control where access is based on need. For example, healthcare assistants may have read-only access to care plans, whereas registered staff all have read and write access to that area. Establishing early in the process who needs to access records, what kind of access they need, then making sure they have it for training will do much to prevent some of those early glitches that so often frustrate and de-motivate staff, and to ensure that information governance issues and system security are understood. This should include permanent and “visiting staff” such as students.
The technology used depends on setting but many models are available and staff should be involved in ensuring that a “best fit” approach is taken. One criticism that frontline nurses have raised is that access to ECRs is often difficult when sharing terminals or when equipment is static. Nursing managers must recognise this problem, because if access is compromised, then use of the ECR will also be compromised. In a ward setting this can be achieved through mobile devices or having terminals at various points where a laptop can be connected, for example in a handover room or meeting room, or by having a wireless environment which can be accessed anywhere patients may be in the hospital. In community settings mobile devices are required. Staff need to be assured that the equipment they require is available, reliable and secure. This is where strong strategic partnerships at board level and between suppliers come into play to ensure that the costs of equipment are understood and accepted, that efficient system support is in place and that security requirements are in place. It is then the role of nurse leaders to ensure protocols are in place to manage this locally.
Ensuring nursing staff have appropriate skills and support greatly increases the probability of successfully implementing the ECR but it is extremely important that once the system is live staff continue to receive regular training and ongoing assessment. This will ensure that their confidence continues to grow and that the potential improvements in quality, safety and convenience can be realised for patients, and for staff in their practice.
It is clear then that effective leadership and sound change management processes are vital ingredients in making the shift from paper to electronic records. However, nurse leaders, managers and practitioners should not underestimate the complexity of implementation in a “live setting” where the integrity of NHS services have to be maintained and where patient safety is paramount; nor the scope of this very fundamental change to professional nursing practice.
It is therefore essential that the DH, NHS, NHS Connecting for Health and professional organisations work in partnership with those involved in ECR implementation to capture and translate learning to national guidance that will support high quality care in all settings and excellence in nursing practice.
Edmondson AC et al (2001) Disrupted routines: team learning for new technology. Cited in: National Nursing Research Unit (2009) From bench to bedside. What role for nurses in helping the NHS make better and quicker use of technological innovations?Policy+, Issue 19. London: King’s College London.
Fry H et al (2000) A Handbook for Teaching and Learning in Higher Education. London: Kogan Page.
Lymbery M (2006) United we stand? Partnership working in health and social care and the role of social work in services for older people.BritishJournal of Social Work; 36: 7, 1119-1134.
Mustain JM et al (2008) Change readiness assessment for conversion to electronic medical records. Journal of Nursing Administration; 38: 9, 379-85.
Nadler DA (1998) Champions of Change: How CEOs and their Companies are Mastering the Skills of Radical Change. San Francisco: Jossey Bass.
Reineck C (2007) Models of change. Journal of Nursing Administration; 37: 9, 388-9.
Timmons S (2001)Resistance to computerized care planning systems by qualified nurses working in the UK NHS. Methods of InformationMedicine; 42: 4, 471-6.
Turner S (2002) Tools for Success. A Manager’s Guide. Change Cycle. London: McGraw Hill Professional.
Urquhart C, Currell R (2005) Reviewing the evidence on nursing record systems. Health Informatics Journal; 11: 1, 33-44.