The Introduction Of Electronic Records Nursing Essay

The government are committed to the introduction of electronic records in the NHS, with a focus on being "paper free" by 2018. This has particular implications for the workforce of Specialist Community Public Health Nurses, predominantly due to their demographic and information technology capabilities. There are further potential issues arising from the use of skills mix within teams, and their role in record keeping and governance. This article advocates use of practice teachers as change agents and use of educational theory to empower and support the workforce during the introduction to electronic records. Robust information governance and record keeping policies are essential in driving the introduction of electronic health records successfully; clinical supervision is a suitable arena for support and feedback from the workforce before, during and after the change, to ensure quality and governance are at the forefront of practice. To support a successful transition from paper to electronic records, it is essential to view resistance as predictable and to learn from other areas who have already introduced electronic records. It is recommended that the workforce’s information technology skills and learning styles are assessed early on, with this information used to inform education programmes.

Introduction

The introduction of electronic health records is part of an ongoing government commitment to computerise all NHS patient records, and builds on the government’s commitment to a "paper free" NHS by 2018. This will have an impact on the Specialist Community Public Health Nurse workforce, particularly in relation to resistance and barriers to change. Practice teachers are well placed to lead and encourage the SCPHN workforce to be positive about the proposed changes by taking an educational approach, utilising educational theory to identify strategies for educating different generations of the workforce. Maintaining and improving quality of service, clinical governance and risk management will be integral to the change whilst SCPHNs continue to delegate to and support skills mix staff. Clinical supervision is identified as an enabling factor to support the workforce throughout the change to electronic records.

The introduction of electronic health records reflects the constantly evolving relationship of the public with information technology. The government vision of "a paper free NHS by 2018" reflects a focus on reducing the burden of data collection (National Audit Office 2011). Continual adaption to external and internal changes is essential to keep up with the advances and demands of healthcare. Constant change can destabilise the workforce; an organisation’s response to external changes can affect internal changes. Effects of cuts in public spending and NHS reforms may impact on the introduction of electronic records, indicating that more flexibility than a top-down approach is required (Anderson and Ackerman Anderson 2010). A transactional change such as the introduction of electronic health records in the current climate of transformational change in the NHS has the potential to disaffect the workforce.

Resistance and barriers to change

Driving forces within the NHS are promoting the change to electronic records; as well as external forces such as policy and advances in technology, there are also internal forces such as improved IT systems, organisation culture and financial management. The NHS (2008) found that it is not resistance, but an inadequate response to resistance that hinders change, therefore by seeing resistance to electronic records as predictable, and anticipating and responding to the workforce’s needs during change, negativity can be avoided. Information Technology can be seen as a culture as well as a skill; however there is a general perspective that healthcare professionals lack computer experience. The average age of health visitors and school nurses is 45, an age group who did not grow up with technology and can therefore fear incompetence and failure whist using information technology (NHS Information Centre 2011, Taylor and Rose 2005). The age group of the workforce makes resistance to electronic records inevitable and predictable; it is recommended that a robust assessment and education programme to engage the workforce is in place prior to the introduction of electronic health records. The change should be enforced by a power-coercive approach, supported by mandatory training, amended record keeping policies and all means to using paper records removed, leaving no alternative but acceptance to electronic records.

The NHS pledged that change will always benefit service users; electronic health records benefits include improved patient safety, time efficiency, enhanced accountability, better clinical and cost effectiveness through audit and feedback for commissioning of services based on need (Liddell et al 2008). Furthermore, evidence indicates a reduced occurrence of litigation whilst using electronic health records (Virapongse et al 2008). Conversely, barriers to the introduction of electronic health records include privacy concerns, security of data, cost issues, lack of time and training, workload and lack of motivation (McGinn et al 2011). Despite time efficiency being a benefit there can be more time spent on electronic health records than paper, with increased time spent inputting information due to cumbersome interfaces (Sheikh et al 2011). The National Institute for Health and Clinical Excellence (2008) advocate giving the workforce good quality information, talking to key stakeholders and aligning national standards and local policies to overcome barriers. Some of the benefits of electronic health records can also be barriers; to reduce resistance to change the workforce should be provided with information about improved outcomes, feedback given and listened to and developing systems tailored to clinical areas.

Leadership and the role of the practice teacher

To introduce a major change such as the introduction of electronic records, senior leadership and clinical buy-in are important factors. Although usability of the system within the workforce is essential, the quality of the implementation process is just as important as the system being implemented. Furthermore, all stakeholders need to be identified and support the change (Ludwick and Doucetta 2009). Although management skills are important, the dynamics of leadership are essential to cope with the rapidly developing healthcare system, with project leaders chosen for interpersonal qualities rather than management skills more likely to engage the workforce. Often, managers over-estimate their leadership qualities, these skills can be developed through education and training (Nilsson and Furåker 2012). Leaders who have contact with the workforce are more effective at role modelling and encouraging leadership in others (Curtis et al 2011). Leadership qualities are an important aspect of nursing regardless of position in the organisation, with recruitment and retention of nurse leaders essential for future planning (Willcocks 2012).

Key members of the workforce can act as change agents, be a catalyst for change, and encourage acceptance of electronic health records. The change agent requires a holistic perspective on how the organisation works; it is essential to align proposed changes to the goals of the organisation (Massey and Williams 2006). A change agent can be any member of an organisation, with ‘everyday leadership’ by frontline staff advocated to bring about effective change. However, frontline workers have insufficient time within their roles to innovate and initiate change (Bevan 2009). Practice teachers are required to have a commitment to lead and contribute to education in practice, with their clinical backgrounds enhancing their credibility amongst the workforce (NMC 2008, Smith et al 2009). Therefore it is essential that they understand the changing health care environment and the needs of learners, and are proficient in liaising with members of the multi-disciplinary team (Stanley and Dougherty 2006). The practice teacher-learner partnership can be mutually rewarding and enhance professional development, with the practice teacher’s career advanced when their learners’ accomplishments are recognised (Coates 2012). Practice teachers are well-placed, credible and respected within the workforce to act as agents of change, and as leaders encouraging the workforce to be positive about changes through education.

Educational approach to electronic records

In order to drive forward the electronic health records project, an educational approach is required. The DoH (2012) reports that innovation in technology and the workforce demographic influences healthcare education plans within public health. A breakdown of the SCPHN workforce indicates approximately 62% are over 45 and predominantly "Baby Boomers", who place responsibility for learning on the quality of teaching (Herrman 2008). Whilst there is an advantage for older learners to be taught by someone of a similar age, an appropriate teaching style is just as important. Adults require a different educational approach to children; pedagogy is resisted by adult learners, who prefer andragogy; rather than a behaviourist approach, which is teacher-centred, adult learners prefer a humanistic approach, whereby the learner’s actions create the learning situation and the teacher is a facilitator and provider of resources (Rogers 2002). Additionally, older learners prefer a mixture of traditional and contemporary self directed learning approaches (Mantzana et al 2010). Older students highly value peer support and mentoring, social influence impacts greatly on nurses’ perceptions of electronic health records, with primary influence being from "superusers" – staff from the skills mix who have robust IT knowledge, and who are designated as mentors (Holtz and Krein 2011). The introduction of electronic health records should be supported with early assessment of practitioners’ information technology skills, which should be used to facilitate education which is geared towards participants’ learning needs. There should be peer "superusers" allocated within teams to mentor and support the learners.

Information governance

The use of electronic health records can improve clinical governance as well as facilitating effective communication, providing it is implemented in a way that maximises potential gains (Cresswell et al 2011); it is emphasised that electronic health records will enhance care and accountability (Pullen and Loudon 2006). Historically, record keeping promotes patient care, however Spencer et al (2012) voiced concerns that "copy and paste" functions might discourage data synthesis compared to written notes. Despite well publicised guidance on information governance regarding electronic health records, healthcare professionals are not always knowledgeable about data protection legislation in practice (Naughton et al 2012). Clinical governance advocates that healthcare professionals are responsible for pro-active management of clinical risk by continuing professional development and learning from mistakes (Bird 2005). Continuous improvement of quality, robust information governance and lessons learnt from others’ experiences are fundamental to the success of the introduction of electronic health records.

With the introduction of electronic health records, robust protection of information is required. As information is intangible, risk analysis is complex and difficult, requiring a holistic risk assessment (Gerber and von Solms 2005). Electronic health records should not be viewed unless related to intervention, therefore measures should be in place to ensure service users’ privacy. Robust information governance and appropriate record keeping policies, as well as mandatory training, are essential to support the workforce to achieve best practice in their record keeping. Although electronic health records may not save nursing time, they are highly effective in storing, manipulating and displaying data for quality improvement. However, in the current financial climate this can result in tensions between quality and target-driven requirements by commissioners. Correspondingly, in the USA electronic health records also encourage development of value-based competition (Hillestad et al 2005). To measure how the new system is performing there should be regular evaluation by audit, with results analysed and compared to earlier audits of paper record, with evaluations informing further education strategies. Arguably, the evaluations could lead to unwanted and unpopular changes in commissioning and contracting out of services.

Implications for skills mix staff

Clinical skills mix staff will also be required to be proficient at using electronic health records. Glasper (2012) found that skill-mix pressures accompanying the economic downturn are stretching the resilience of the nursing workforce, and changing the role of the healthcare professional; skills mix do not have the underpinning theory or accountability that a registered professional has; however skills mix are attractive to organisations as work can be broken down into low skill jobs to achieve the same productivity at a lower cost. A SCPHN is accountable for delegating work appropriately to skills mix; however Cowley (1993) cautions that healthcare professionals are becoming de-skilled due to fragmentation of their role by using skills mix. SCPHNs being required to support and monitor quality of electronic documentation by skills mix, whilst having to simultaneously adapt to the change themselves may cause dissatisfaction, and adversely affect team-working and motivation. Skills mix staff could be the designated "superusers" within teams taking on a mentoring role to SCPHNs learning how to use electronic records; this has the potential to disempower the SCPHN, and to blur professional boundaries.

Feedback and monitoring

Feedback from the workforce regarding the introduction of electronic health records is essential. Clinical supervision would be a suitable arena to facilitate this, and to encourage reflection. SCPHNs are vulnerable to stress and burnout due to complex frontline work, impinging upon their capacity to think clearly and make decisions undermining good practice. Despite this, clinical supervision is often not prioritised, particularly by SCHPNs who receive regular safeguarding supervision. Barriers included time out from caseloads, a culture of nurses being expected to "get on with it" and not revealing difficulties due to a fear of being seen as not coping. There was also a perception that supervision was for identifying and punishing bad practice rather than developing good practice (Wallbank and Hatton 2011). Historically, clinical supervision can be considered a low priority in practice, and seen as a punitive rather than supportive process. To overcome this, line managers should support and encourage clinical supervision within the workforce to change perspectives, with supervision being written into job descriptions. This would empower nurses to participate and enable reflection, enhanced accountability and quality monitoring during the change to electronic records.

Conclusion

The government’s ongoing commitment to computerising health records is driving changes in health records. However, introducing a transactional change such as electronic health records during a period of transformational change in the NHS is inevitably going to destabilise the workforce. Fundamentally, the age of the workforce indicates that resistance to electronic health records is predictable; requiring educative programmes and support aligned to learning styles. By using an educational approach, practice teachers are well placed and have credibility to act as change agents, to provide leadership and a positive view of the change. As healthcare demands and expectations by the public increase, SCPHNs are in a key position to influence and lead colleagues through change, and to maintain a direct relationship between leadership and quality of care.