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Empowering Nurses to Focus on Patient Care 2024
Apr 2024

Empowering Nurses to Focus on Patient Care 2024

Reducing Nurse Documentation Burden

Authored by:  Lauren Manzione, 04/19/2024 | Read Time: 6 minutes

Four years after the start of the COVID-19 pandemic, nurses are still experiencing significant stress and burnout—according to the American Nurses Foundation’s Mental Health and Wellness Survey 4, nearly two-thirds of nurses in 2023 felt their job caused them a great deal of stress. Lengthy and repetitive charting can be a contributor, but KLAS’ Arch Collaborative data shows it doesn’t have to be. This report explores the impact of unnecessary charting on nurses and outlines a three-step process organizations can use to reduce unproductive charting and empower nurses to focus on patients, thereby reducing both burnout and turnover and saving organizations money.

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steps for reducing unnecessary charting

Unproductive Charting Detrimental to Nurse Productivity & Well-Being 

Arch Collaborative data shows that unproductive charting is a significant time waste. Specifically, 35% of nurses report spending three or more hours per week on unproductive charting. The data also identifies a connection between poor nursing efficiency and higher rates of burnout—nurses who report more than three hours of unproductive charting in a week report higher levels of burnout than those who do not. Given this added stress, it is unsurprising that these nurses also report a higher likelihood of leaving their organization.

† The Arch Collaborative survey defines unproductive charting as charting that is duplicative or adds no value.

The Nurse Perspective

Comments come from nurse respondents to the Arch Collaborative EHR Experience Survey

“Nursing charting takes up so much time that it decreases patient care significantly.” 

“[Charting] takes time away from our patients. For example, for patients with CRRT, a recent update (about two years ago) added an additional three clicks every hour to care for this very sick patient population. Three clicks means less time with patients, which means less care, which means poorer outcomes.“

“Things requiring charting are verging on ridiculous and make it difficult to provide patient care due to the immense amount of charting required.”

burnout & turnover - by self-reported time spent on unproductive charting contributors to burnout - by self-reported time spent on unproductive charting

While not all nurses follow through with their intentions to leave, preliminary Arch Collaborative data indicates that nurses who report an intention to leave their organization are 5x more likely to actually leave within two years. Given the expense of staff turnover, helping nurses become more efficient and satisfied can lead to significant cost savings for organizations. With staffing shortages cited as one of the top three contributors to nursing burnout, nursing turnover can further exacerbate the current state of burnout, leading to more financial loss and an increased burden on existing nurses.

cost of nurse turnover

Steps for Reducing Unnecessary Charting

Efforts to reduce unnecessary charting should focus on helping nurses feel that the EHR enhances, rather than hinders, their delivery of patient care. Arch Collaborative data indicates that nurses who report less time on unproductive charting have higher general satisfaction with the EHR than nurses who report more unproductive charting. This higher satisfaction is evident across all aspects of the EHR measured by the Arch Collaborative survey, though the biggest divergence is seen in nurse agreement that the EHR enables efficiency, patient-centered care, quality care, and patient safety (for more information about the NEES metrics, see this report on drivers of clinician EHR satisfaction).

So what can organizations do to improve the nurse outlook? The next sections highlight three steps based on analysis of Arch Collaborative data.

‡ The Arch Collaborative measures satisfaction with the EHR via the Net EHR Experience Score (NEES). Each individual nurse’s responses to the Arch Collaborative EHR Experience Survey regarding core factors such as the EHR’s efficiency, functionality, impact on care, and so on are aggregated into an overall NEES, which represents a snapshot of the nurse’s overall satisfaction with the EHR environment at their organization. A NEES can range from -100 (all negative feedback) to 100 (all positive feedback).

step 1 iconStep 1: Assess Current State of Charting through Surveys and Usage Data

The first step in reducing unproductive charting is to complete a comprehensive assessment of the nurse experience across your organization. This can be accomplished in multiple ways, but using industry-wide data about inefficient charting in addition to organization-specific data and feedback from individual nurses can help generate buy-in to improve nurse efficiency:

  • Internal perception surveys can be used to ask nurses to self-report their experience and satisfaction.
  • Additional benchmarking information—such as KLAS’ Arch Collaborative survey—can be used in lieu of or to supplement an internal survey.
  • Additionally, some EHR vendors provide EHR usage tools—such as Epic’s NEAT or Oracle Health’s LightsOn—that can provide details on which users spend a disproportionate amount time on certain tasks.

Key Groups to Focus On

Each organization’s individual circumstances vary, so organizations will want to assess their own nurses to ensure they direct their efforts to the groups most in need at their own organization. However, the Arch Collaborative’s collective data reveals some general trends:

  • The nursing groups most impacted by unproductive charting are full-time RNs and those practicing in inpatient settings.
  • The specialties in the Arch Collaborative who report the highest frequency of unproductive charting are critical care, perinatal (mother/baby), med/surg, and acute care.

Learn from Your Peers

Houston Methodist uses Epic Signal and NEAT data to identify and address EHR issues. They also foster collaboration through shared ownership councils and committees that include nursing and support personnel, and they focus on improving workflows and end-user/clinician efficiency based on user feedback. The organization also uses virtual nursing to alleviate the nursing documentation burden and enhance the patient experience.

percentage reporting 3+ hours of unproductive charting per week - by job demographics

step 2 iconStep 2: Optimize Nursing Flow Sheets in Problem Areas Using Nurse/Informatics Input

After completing the assessment, it is time to identify problem areas and make an improvement plan. Some areas may need substantial flow sheet changes; in other areas, improvement might be achieved simply through additional training. In these latter instances, you can move directly to step 3.

For areas that need to be revamped, create a multidisciplinary team to prioritize which flow sheets need optimization, ensure charting matches nurse workflows, and remove unnecessary clicks and duplicative fields. Additionally, this team should establish standard procedures and criteria for making future charting changes. The team should include the following:

  • Frontline nurses and nursing leadership: Frontline nurses can explain how the documentation is used, identify redundancies, and speak to the effects of unnecessary charting on patient care and burnout. Nursing leadership can provide a broader perspective to ensure continuity across focus areas.
  • Informaticists: Informaticists will be able to highlight the technology’s capabilities and limitations and identify ways to create flow sheets that are streamlined but still in sync with the nurse workflow.
  • EHR vendor resources: Organizations should also partner with their EHR vendor to include the right kind of expertise where it is needed.
  • Stakeholders with regulatory expertise: These resources add value to the process by ensuring that regulations are met and that unnecessary tasks are removed when regulations change.

Nurses who report having a more active role in optimizing the EHR generally report fewer hours spent on unproductive charting. They also have higher satisfaction with the EHR. Many nurses view this collaboration as an active partnership between all key stakeholders—end users, IT resources, and the EHR vendor.

One way to involve nurses in EHR governance is to create a standard process (such as a ticketing system) for the submission, review, and implementation of EHR optimization requests from nurses. Keeping nurses apprised of the status of their requests throughout the process will help manage expectations. Nurses should also receive regular updates about any changes to flow sheets and be given additional training as needed.

The Nurse Perspective

Comment comes from a nurse respondent to the Arch Collaborative EHR Experience Survey

“The redundancy is overwhelming at times. The documentation is considerably more cumbersome than the documentation at my previous, Magnet-designated hospital. At my previous hospital, the nurses contributed to the reduction of excessive documentation by having a representative nurse on the domain team with [the EHR]. The domain team met bimonthly to go over documentation and review policies and procedures together. It saved the hospital money and incidental overtime by having simplified and precise documentation.”

satisfaction with ehr metrics - by self-reported time spent on unproductive charting

Learn from Your Peers

Sutter Health’s multidisciplinary team dramatically improved the efficiency and satisfaction of their perioperative nurses by fostering collaboration between nurses and the IT support team to streamline the nursing workflow and documentation requirements.

CentraCare Health uses nurse optimizers to connect nursing with the organization’s information systems group. This collaboration helps nurses stay engaged and provides the information systems group with EHR-improvement ideas.

TidalHealth Peninsula Regional has reduced their nurses’ documentation burden by fixing existing issues through strong clinical engagement and IT support and also preventing additional burden by adhering to defined change management protocols for nursing documentation requirements.

step 3 iconStep 3: Provide Consistent, Workflow-Specific Training

The third crucial step in the process is to provide consistent training. Nurses who get better training generally report fewer hours of unproductive charting.

percentage who agree that ehr training is sufficient - by self-reported time spent on unproductive charting

Receiving initial training that is specific to their workflow can help newly hired nurses start off on the right foot with efficient charting practices. Ideally, nurses’ initial EHR training teaches them the best way to perform a function for their role rather than showing them a variety of ways to complete the same task.

Learn more about providing workflow-specific training in the Arch Collaborative’s Clinician Training 2023 report.

Ongoing training is just as vital to efficient charting. Educating nurses about flow-sheet changes is an essential part of the optimization process. Additionally, organizations can always look for ways to help nurses chart more efficiently, regardless of whether a flow sheet has been changed. Nurses who are newer to the profession generally report fewer hours of unproductive charting (see chart). Those who have been in the field for five or more years could benefit the most from additional training to master the most up-to-date and efficient charting methods.

The Nurse Perspective

Comment comes from a nurse respondent to the Arch Collaborative EHR Experience Survey

“Not everyone is trained the same, and if we all chart differently, it can make it harder to find medical information than in a paper chart.”

percentage reporting 3+ hours of unproductive charting per week - by years practicing medicine

Another strategy that can improve charting efficiency is to standardize organizational charting practices and include charting by exception as the model. Training nurses to chart only patient data that is outside of expected norms can help reduce charting time and make documentation quicker to review—all without requiring any actual changes to the EHR.

The Nurse Perspective

Comments come from nurse respondents to the Arch Collaborative EHR Experience Survey

“Charting should be simple and not take away from patient care. I see a lot of repetitive motions, such as daily safety care, every hour. We should chart by exception and note changes.”

“All the charting impedes patient care. I don’t waste time with care plans or notes unless there is something critical that happens. Unless there is a change with my patient that needs to be communicated or elaborated on, there is no reason to duplicate information that is in the flow sheets into a note. Your flow sheets can tell the patient’s story on their own. I chart by exception also.”

Learn from Your Peers

To prevent a backlog of EHR-optimization requests and increase nurse satisfaction with informatics, Amsterdam UMC developed an ongoing training program with the understanding that many nurse EHR requests and inefficiencies could be addressed with better training. In addition, their ticket triage and ambassador program ensure two-way communication between nurses and support resources.

At Valley Children’s Hospital, nurse and IT teams focused on optimizing the most frequently used nurse flow sheets and ensured nurses on the task force received recognition from leadership. They also adapted and streamlined existing training and implemented lunch-and-learns led by nurses who are highly efficient at charting to help shift the culture to documentation by exception, dispelling the common sentiment that if it wasn’t documented, it didn’t happen.

What Is the KLAS Arch Collaborative?

The Arch Collaborative is a group of healthcare organizations committed to improving the EHR experience through standardized surveys and benchmarking. To date, almost 300 healthcare organizations have surveyed their end users and over 440,000 clinicians have responded. Reports such as this one seek to synthesize the feedback from these clinicians into actionable insights that organizations can use to revolutionize patient care by unlocking the potential of the EHR.

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This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price. Please see the KLAS DATA USE POLICY for information regarding use of this report. © 2019 KLAS Research, LLC. All Rights Reserved. NOTE: Performance scores may change significantly when including newly interviewed provider organizations, especially when added to a smaller sample size like in emerging markets with a small number of live clients. The findings presented are not meant to be conclusive data for an entire client base.