This study of nurse communication and documentation in a representative sample of hospital medical–surgical units presents a picture of health information flow that is wrought with problems. The three key themes gleaned from the observations suggest that hospitals are vulnerable to undetectable sources of error that can seriously jeopardize the quality of care. The impact of wide variation in nurse documentation and communication practices is underscored when one realizes that it is possible for a patient to be cared for by six or more different nurses during a 48 h hospital stay. Since these six different nurses are never together at the same time, one must rely on the documentation and communication to ensure that the right information is carried forward. If, however, the content and format of the information conveyed varies by nurse, unit, and hospital or is not part of the permanent patient record (eg, scraps) as we found here, then it is hard to imagine how the meaning of such information can be interpreted as intended. It is no wonder that physicians, whose work flows typically cross multiple units and hospitals, do not read nursing documentation.
Causes for further concern were our observations that none of the units studied had centrally available patient care overviews that were electronic and easily accessible to the entire interdisciplinary care team. Since we also found that the non-nursing members of the team spent little time on the care units and rarely interacted with the nurses, this suggested to us that nursing information is not being used appropriately by the other health disciplines. Although the three themes identified in our data were not completely unexpected, we were surprised by the extent of negative implications that could reasonably be expected from this combination of conditions.
First, the lack of consistency in the data elements collected, words used, and processes of documenting and communicating at hand-offs across all units offered unlimited opportunities for information to be lost or misinterpreted, which increased vulnerability to errors. This is particularly problematic in today's high-acuity hospital settings, where any errors in information transfer can potentially lead to devastating consequences. The variation also adversely influences continuity of care as patients move across settings.
Second, the wide assortment of documentation, which was often home-devised, excessive, unit-specific, and included an unpredictable mix of paper and electronic formats, contributed additional opportunities for breeches to information flow. Although EHRs were available in all settings, we observed very little technological support for interdisciplinary and hand-off communication, showing underutilization of this potential resource. It also demonstrated that the available EHRs did not support nurses' need for organized and synthesized overview of their patients' status and care needs. As a result, we believe there are likely to be many more errors caused by electronic tools than previously estimated.13
Thus, in this representative sample of hospital units, the important goal of using EHRs to assist interdisciplinary healthcare teams in sharing patient care information in a meaningful way was elusive.
Third, duplication and redundancy were an accepted part of the everyday life of hospital units. Overall, information transactions across all units appeared to be more time-consuming and less effective than optimal because of the lack of systematization and standardization. This inefficiency leads to an unnecessary burden on nurses' time, which likely causes delays in care.
Fourth, although the importance of interdisciplinary communication was acknowledged on some units, similar to other studies of inadequate teamwork,14
it was apparent that the non-nursing professional team members had little to no understanding of the nursing care provided across all units. Moreover, the high volume of patient information to integrate from multiple forms made it difficult for the RNs to have a complete, thorough, and centralized overview of the patients' needs and status. Therefore it is highly unlikely that members of the interdisciplinary team had a shared understanding of the patient and that care was as adequately coordinated.
Finally, we acknowledge the limitations of this study based on the medical–surgical unit focus and the time period of the study (2005–2007). Nonetheless, we believe the results are more broadly generalizable because of our purposive sampling strategy and the fact that relevant conditions in the field have not changed dramatically since the study was conducted. We deliberately selected a wide range of medical–surgical units, as these units typically reflect the overall culture of a hospital. We drew these units from four diverse hospitals and balanced the numbers of experts and novices selected for the study to maximize the representativeness of our findings to hospital nurses. With regard to the study period, we have observed virtually no substantive changes to the major EHRs since the study that address the major deficiencies we found.