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This literature review consists of an appraisal of nursing cognitive overload and electronic documentation burden literature. Review findings are synthesized into two themes: 'user-centered redesign' and 'cognitive support needed for nurses.' Identified literature gaps are presented with recommendations.
Key Words: Cognitive overload, documentation burden, nursing documentation, electronic health record (EHR).
Over the past decade, health care has experienced a wide-spread implementation of the electronic health record (EHR). The EHR initiative stemmed from the need to improve healthcare quality and safety, then was enhanced by legislation. The American Recovery Reinvestment Act of 2009 (ARRA) encompassed the enactment of the Health Information Technology for Economic and Clinical Health (HITECH) Act (ARRA, 2009). The ARRA provided $49 billion in financial incentives for healthcare organizations to comply with technology guidelines to include the implementation and use of the EHR (ARRA, 2009). However, healthcare organizations were required to meet specific deadlines to receive these financial incentives. These deadlines lead to aggressive EHR implementation timelines.
Swift implementations may not have considered a systematic assessment of the organization's workflows, interprofessional roles, and clinical team communications. Consequently, the post-EHR implementation literature has provided evidence of unintended consequences due to EHR implementation (Bristol et al., 2018; Dudding et al., 2017; Gephart et al., 2015). Some examples of unintended consequences involve unfavorable workflow changes, generation of new errors, never-ending changes, more clinician work, negative user emotions, overdependence on technology, conflicts between electronic and paper-based systems, unfavorable changes in communication, and unexpected institutional power structure (Campbell et al., 2006; Jones et al., 2011).
The significance of unintended consequences involves negative effects related to clinician practice and patient outcomes. According to Gephart and colleagues (2015), the majority of research on unintended consequences is focused on physician research and physician practice. As a result, little is known about the relationship between nursing practice and unintended EHR consequences.
Cognitive overload and electronic documentation burden are also considered unintended consequences of EHR implementation. Cognition entails perception, reasoning, recollection, and judgment (Padden, 2019). In nursing practice, the nurse utilizes these cognitive characteristics to apply critical-thinking and decision-making to patient care. An example of a nurse using cognitive characteristics may entail the nurse's decision to call the rapid response team after recognizing a patient has developed a delayed response to questions...