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Open Access Publications from the University of California

The Electronic Health Record's Impact on Labor and Delivery Nurses' Cognitive Work

  • Author(s): Wisner, Kirsten
  • Advisor(s): Lyndon, Audrey
  • et al.

The Electronic Health Record’s Impact on Labor and Delivery Nurses’ Cognitive Work


Background and objective: Despite recognition that electronic health record (EHR) use has introduced cognitive challenges for clinicians, few studies have evaluated its impact on the cognitive dimension of nurses’ work. Labor and delivery nurses may encounter unique challenges when using the electronic health record since they also interact with an electronic fetal monitoring system. This study sought to explore labor and delivery nurses’ perceptions of the EHR’s impact on their cognitive work with the goal of identifying patient safety implications.

Methods and setting: This was a grounded theory study using dimensional and situational analysis. Data were interviews and observations with 21 labor nurses at two community hospitals in the Western United States.

Results: The ways that nurses configured care when using the EHR varied across participants and sites and depended on how easily they integrated it into their practice. Individual, group, and situational factors facilitated or constrained integration. This took place in a dynamic, high-acuity, specialty clinical environment while using EHRs that were not designed for pregnant women. Nurses used clinical decision support and other cognitive support features that rarely worked as intended due to the lack of EHR customization to account for pregnancy physiology and unique risk factors in the perinatal patient. Nurses viewed the quality of their relationships with patients and their families as an integral part of caring for laboring women and felt that interaction with the EHR sometimes threatened this dimension of their work.

Conclusions: When nurses were unable to integrate the EHR into care it resulted in numerous consequences that have important safety implications. Available cognitive support features lacked the specialty-specific support needed to care for laboring women and instead required nurses to track information in other ways that added to their cognitive burden and work routines. As a result, nurses and patients were not benefitting from the intended decision support and patient safety protections offered by appropriate risk assessment screens or critical alerts. These findings have important implications for the configuration and design of EHRs in perinatal settings.

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