It’s well known that nurses nationwide are overworked. As Electronic Health Record (EHR) systems have been implemented and become more advanced, nurses spend an extraordinary amount of time documenting their notes. This is time taken away from bedside nursing duties.
A team of experienced nurses and nursing informatics specialists at Missouri-based Mercy set out to explore options for providing relief to their nurses. The team sat down with their nursing staff to learn about their pain points. The analysis found that nurses were spending an average of 20 percent of their time documenting during a 12-hour shift, and it had become a burden. The satisfaction among nurses with the EHR had been declining to the 58th percentile, which is below the national average. The team launched Project ANEW, Advancing Nursing Efficiency and Workflows, to implement changes based on their findings.
Cheryl Denison, B.S.N., R.N., Mercy's systems clinical integration director, noted in Mercy’s submission, “By incorporating human factor principles and actively engaging end users, we were able to decrease time spent documenting, enhance nursing efficiency, and improve overall trust and satisfaction with technology and the EHR.
The team updated flowsheet documentation, removed redundancy, and eliminated more than 150 million clicks per year. Over the last 30 days, a decrease in time spent on documentation was maintained from an average of 167 minutes of documentation time to 130 minutes. Additionally, the usage of tools and reports related to clinical decision-making increased. Coordination and communication among the care team were enhanced, and nurses' satisfaction improved. A recent EHR satisfaction survey showed that satisfaction increased to the 60th percentile.
For those accomplishments, the editors of Healthcare Innovation have named Mercy the Third-Place Winner in our annual Innovator Awards Program.
Denison describes her position as connecting nursing technology and people using nursing informatics. With the new initiative, the team tried to figure out how technology could support the workflows needed by nurses. Mercy Executive Director of NursingIinformatics Tracy Breece, M.S.N., R.N., N.I.-B.C., C.P.H.I.M.S., provides leadership to the strategic plan. She underscores the “work that we're doing is to improve the health and well-being of the bedside nurse to eliminate duplication and promote efficiency.” Mercy Center for Evidence and Inquiry System Director of Clinical Practice, Jill D. Seys, D.N.P., M.B.A., R.N., N.E.A.-B.C., E.B.P.-C., supports evidence in inquiry. About her role with the project, Seys says, “We want not to have the technology drive what the nurse does; we want to have evidence drive our practice.”
Part of what kickstarted Project ANEW was realizing that nurses needed help, which became more apparent after the last COVID surge early in 2022. The team was already doing different things to help nurses, including picking up trash. They soon realized that technology wasn’t supporting nurses’ needs. “Nurses were dealing with changes on a daily basis,” Denison explains, “that led to increased burnout.” Furthermore, Denison continues, “The nurses felt they had no voice.” The increase in technology use, the changing patient population, and new nurses coming in who may not be as prepared led to what Denison calls “a crumbling of the foundation of nursing.”
Mercy’s EHR vendor informed the team that Mercy nurses exceeded the national average documenting time. With that, the EHR satisfaction scores dropped post-pandemic. Initially, the team figured they could just give the nurses tips on efficiency. But they soon discovered they needed to go back to baseline. “We know nurses are excited when they can implement evidence-based practice,” Denison says, “We do the clinical inquiry to understand what it should look like and bring that to the table.” Since change happened so rapidly and there was a lack of communication, nurses had many duplicate processes. For example, they were documenting something in five different places. The team was able to introduce quick fixes to address such inconveniences.
Another concern the nurses raised was the time things took. Steps had been added to help solve issues, but documenting things multiple times became an ordeal. There were also misunderstandings around processes. Further education was needed around nursing indicators such as fall risk and skin assessment. Denison indicates that more research and evidence were required to ensure they addressed these gaps. Breece explains that process improvement was needed in different domains. One domain being the hardware in the work environment; for example, infusion pumps and mobile phones. Another was software integration with the EHR. “We uncovered that some nurses, 15 years post initial training, were still using the EHR in the way they were originally trained,” Breece says, “They hadn't taken advantage of the innovation of the evolution around our EHR and our environment.” Together with training teams, the team initiated further education on how to navigate the EHR efficiently.
The team discovered similar trends in Mercy’s various communities and provided each chief nursing officer with an executive summary of their findings. Mercy has over 50 hospitals, and more than 10,000 nurses across its four state system.
Betty Jo Rocchio, D.N.P., C.R.N.A., C.E.N.P., Mercy senior vice president and system chief nursing executive, sponsored the project. The team agrees that this initiative would not have been possible without her support. Denison underscores the importance of senior leader support to replicate this process.
The team has further advice for hospitals that want to replicate what they have accomplished. “The very first thing I would tell them,” Denison says, “is to spend time among nurses.” The team agrees that listening to the nurses made this project successful. Within Mercy, nurses were part of evidence-based groups to provide input. A simple and effective workspace for nurses is essential. “When a nurse goes from one place to the next, it needs to be intuitive,” Denison says.
The same is true for using the EHR. Design is essential, the team says. Streamlined documentation is another necessity. “Many of us designed our EHR based on project paper processes,” Denison notes, “we need to get into a new mindset and streamline that documentation.” She points out, "Nurses need to understand what and when they need to document, and I think that goes along with streamlining your documentation. If you have too many things out there, nurses feel very uncomfortable with leaving blanks because they don't want to be legally held accountable for something that they know they did.”
The team also indicates that nurses are becoming more mobile with smartphones and tablets. This helps nurses document in real-time instead of going back to their desks, which can affect the patient's overall care, the team states. “We need to try to automate as much as possible,” Denison says, “utilize and rethink Artificial Intelligence (AI).”
When discussing the team's challenges, culture change was mentioned. “I think culture is one of the biggest hurdles that we've had to overcome, especially as we start moving into these AI pieces,” Denison answers. Indeed, Sey adds, “Nurses referenced how they were trained when Epic was first implemented here and how they still rely upon some of that early teaching.” Denison also mentions they needed to pivot quickly as the project became more significant than initially planned.
Regarding next steps, Denison says they will continue to work on streamlining documentation and improving the nurses' tools. “I think we're still continuing to fill in the gaps that we were talking about with the foundation, making sure that our foundation is solid so that we can build upon these with these other tools,” she says. “We want to ensure that what we build is based on evidence,” Breece adds. “The future will be focused on the bedside nurse,” Breece reiterates, “but we’re also going to focus on the nursing leaders.”
SIDEBAR: Solving for Patient Assignment Challenges
The Mercy team simultaneously worked on another project, aptly named Workload. This initiative was started after the team identified a challenge in patient assignment. Tracy Breece described the issue in their submission to our Innovator Awards: “[N]urses applied a non-scientific approach to assignments, leading to perceived unfairness and unmet patient needs.”
The team researched the factors impacting nurses’ workloads to equalize workload distribution. “Our innovation,” Breece wrote, “applying the patient and environmental factors to a technology algorithm creating a score to reflect the demand for nursing time measured and equally distributed per patient team.” They used a weighted approach. Breece further explained, “Validation of the workload score occurred through a correlation of individual nurses' perception survey with the custom-designed EHR workload score. Results were a low positive Pearson correlation of 0.34, guiding us to further study.” For the second improvement cycle, the NASA Task Load index was used. After the study, custom-based rules in the EHR were adjusted.
The outcome of this initiative was the implementation of measures to ensure a more balanced distribution of nursing workloads, which improved overall efficiency. Breece quoted a charge nurse on the use of the workload score, “I was able to place new patients coming to the floor in rooms that better fit the needs of the pods as well as choose nurses for the oncoming shift.”
Regarding workload, Seys explains, “There's a lot of work you see across the industry focusing on ratios, and what we know from the evidence is that ratios are not the best method to use.” She adds that Rocchio challenged the team with the question, “How do we better understand the drivers of the burden of work endured by our nurses every day caring for our patients?” Could the workload be the same for a nurse with three patients and another with five patients when assigning work differently? “We want them to end their shift feeling like they completed the work expected of them,” Seys says.
The team looked at critical drivers that increase the nurse's workload to help quantify the actual workload. Some of these things were documenting medications, but other more challenging things to quantify were interpersonal relationships with patients and discharge planning. “We are on a journey to align the evidence into what we can extract from the tools and what's available through our vendors to better define workload and better align and allocate resources,” Seys explains.
“Workload was a direct result of our sessions around efficiency,” Breece adds, “You can increase efficiency as much as you can until you have to ask yourself what else in the environment is adding to the burden.” Previously, resources were allocated based on a numerical value instead of being paired to assignments. Seys says, “If we only allocate our resources based on the nurse-to-patient ratio, we're missing out.”
“Perception really is reality,” Seys says, “It’s been important in our journey to use the NASA Task Load index.” She explains that the tool helps the team better understand how nurses are perceiving the burden of their work. “Once we match the workload of the patient to the nurses that are available to work, we match the nurse and his or her skill set back to the patient level of care,” Breece explains, “That is going to be the full circle for us, and that's where we're headed in the future with this project.”
Mercy’s team is passionate about their projects and plans continuing improvements.