The Study Of Mechanism Of Mental Workload And Performance In Nursing Task Of Electronic Health Record System

BackgroundWith the ever-growing adoption of health information technology,electronic health records system(EHRs),as a digital form of patient health information designed to improve health service delivery and care quality,play an important role in the hospital information management.As the major workforce in clinical practice,nurses are deeply affected by EHRs.EHRs nursing tasks are typical human-machine interactive tasks in health care,and EHRs play an integral role in modern care to facilitate documentation practice such as assessment,care planning and evaluation.The optimization of EHRs nursing tasks while taking account the multilevel factors including personal,task,technology and environment are pivotal for promoting working efficiency and patient safety.ObjectivesThe study was conducted with the following aims:(1)To describe the experience of workload in EHRs nursing task by employing qualitive research method;(1)to analysis nurses’ mental workload,performance and potential influencing and their interactions by using naturalistic observation and questionnaire investigation;(3)to verify causality between multilevel factor and mental workload and performance by conducting psychological behavioral experiment,thus to construct the mechanism of mental workload and performance in EHRs nursing task.Contents and Methods1.Work experience of nurses in EHRs task: A qualitative studyPhenomenological qualitative research method was adopted.Purposive sampling was conducted by recruiting registered nurses who were EHRs users in two tertiary hospitals from May to June,2021.Field observation and semi-structured deep interviews were employed in qualitative data collection.Data were analyzed following the Colaizzi’s phenomenological data analysis method,thus to category the perceived task characters,work strategy,influencing factors and major problems in EHRs task.2.Predictors of nurses’ mental workload and performance in EHRs task: An observational studyA prospective observational study was conducted in a tertiary hospital from June to October,2021.Data collection were guided by the hypothetical model of influencing mechanism of mental workload and task performance.An observer documented nurses’ electronic health record task interruptions,reactions(task switching or concurrent multitasking)and performance(errors and near errors)during one-shift observation sessions.Questionnaires were administered at the end of the electronic health record task observation to measure nurses’ mental workload for EHRs tasks,task difficulty,system usability,professional experience,competency self-efficacy,and mood.Multivariate linear regression analysis and path analysis was used to test a hypothetical model.3.Mechanism of mental workload and performance in EHRs task: A psychological behavioral experiment(1)Construction of clinical scenarios for experiment.Criteria for clinical scenarios and experiment subject were analyzed by literature review.Medical records in a tertiary hospital were selected and evaluated according to the standards of nursing documentation,the main errors and characters were summarized thus to framing the drift of four clinical scenarios.Expert consultation with 10 experts was used for amending and finalizing the experiment materials.(2)Psychological behavioral experiment.Factorial design of 2(experience level:expert and novice)×2(difficulty level: low and high)× 2(continuity: continuous and interrupted)were employed in psychological behavioral experiment.A sample of 50 nurses were recruited from November to December,2021.Participants were required to perform four clinical scenarios which were presented in a random order.Eye movement indictors and behavioral index were documented by a portable eye tracker.Performance was measured by the errors of clinical scenario’s tasks.General linear models were used to test the differences between factors.Results1.Work experience of nurses in EHRs task: A qualitative studyTwelve nurses were observed and interviewed.Five themes and 17 sub-themes were identified,that were important and tedious nursing tasks(sub-themes: hierarchical control for the quality of documentation,simple and tedious task characteristics,task synchronous result in adjustable rework),frequent interruptions and interactions in tasks(sub-themes:interactive task context,professional requirements for dealing with complex situations),paradox between timeliness and dynamics(sub-themes: time-validity of EHRs task,dynamics in nursing tasks,violations by corrective action),the challenges in multidimensional fitness(confusion in system design,bottleneck of digital coverage,difficulty in functional achievement,expectation of well-designed interactive interface,insufficient in hardware equipment),and acceptance and adaptation of systems(sub-themes: opposing,understanding,acceptance,optimization).2.Predictors of nurses’ mental workload and performance in EHRs task: An observational studyIn our study,152 observation shifts were conducted,and 145 with completed data(validation rate was 95.39%).the mean electronic health record task duration was 84.69(SD56.68)minutes per shift,including 3122.18(SD 19.08)seconds of task switching and 335.90(SD 2.79)seconds of concurrent multitasking.Overall,2871 nursing interruptions occurred,of these interruptions,71.37% were priority events leading to task switching,and 28.63%led to concurrent multitasking.The incidence of error or near error was 158,while 68.35%of errors were self-corrected by nurses.The total mean mental workload level in electronic health record tasks was 44.57(SD 14.08).The task difficulty index was 33.30(SD 6.27).The system usability score was 56.94(SD 13.71).The professional competency was 53.92(SD 10.94).The self-efficacy score was 29.92(SD 5.45).The level positive affect was 27.10(SD 7.31)while the negative affect was15.65(SD 3.81).A multiple linear regression model was computed to investigate predictor variables that had a significant influence on the global NASA-TLX score and performance.The multiple linear regression model for NASA-TLX with the predictors of negative affect,task difficulty,performance,interruption duration explained 37.30% of the variation in mental workload(F=22.379,P<0.001).The multiple linear regression model for performance with the predictors of mental workload,professional title and task duration explained 22.70% of variation in performance(F=15.096,P<0.001).A path analysis model with adequate fit indices is presented(GFI=95.80,P<0.001).There is a relationship between concurrent multitasking,task switching and task time.Task time,task difficulty and system usability had direct effects on mental workload.Task performance was influenced by mental workload and professional title.Negative effect was mediated the path from task performance to mental workload.3.Mechanism of mental workload and performance in EHRs task: A psychological behavioral experiment(1)Construction of clinical scenarios for experiment.A total number of 234 medical records were selected and evaluated,the main errors and characters were summarized thus to framing the drift of four clinical scenarios.Consultation from 10 experts with a positive coefficient 100% and authority coefficient 0.76 amended and finalized the experiment material,which included 2 low difficulty and 2 high difficulty scenarios.The task including two sub tasks named browsing and extracting medical information(6 tasks)and nursing decision-making(6 tasks).(2)Psychological behavioral experiment.Of 50 meeting the criteria for inclusion and completed the experiment,49 provided the validated data of which 24 were expert nurses.The level of subjective mental workload measured by NASA-TLX was 41.64(SD 11.46)in novices and 35.69(SD 13.98)in experts respectively.The result of general linear models supported the significant effect in working experience(F=13.186,P<0.001)and task difficulty(F=20.401,P<0.001)while the variable of continuity(F=0.973,P=0.325)was not found to be statistically significant.The analysis of objective mental workload measured by the portable eye tracker showed that working experience and task difficulty are statistically significant to mental workload and task performance.Take the total mean time for completing the task of browsing and extracting medical record information for example,the total time were 130664.05(SD 69656.87)ms in novices and 138699(SD 61425.73)ms in experts.The result of general linear models supported the significant effect of task difficulty on mental workload(F=9.612,P=0.002),that is nurses conducting the difficult task spent more time than the easy one,the levels were 150333.76(SD 77067.50)ms and 121926.66(SD 48095.80)ms respectively.The total mean time for completing the task of nursing decision-making were 183292.14(SD 87696.66)ms in novices and 169830.53(SD67385.11)ms in experts.The result of general linear models supported the significant effect of task difficulty on mental workload(F=5.831,P=0.0017),that is nurses in difficult task spent more time than easy one,the levels of mental workload were 190372.89(SD 86619.81)ms and 162749.79(SD 66590.44)ms respectively.Regarding to the task performance,the incidence of error in the novices was 7.75(SD 4.38)while 5.59(SD 2.71)in experts.The result of general linear models supported the significant effect of working experience(F=21.651,P<0.001)and task difficulty(F=19.207,P<0.001)on task performance while the variable of continuity(F=0.117,P=0.733)was not found to be statistically significant.The Pearson correlation revealed the relationship between mental workload and task performance(r=0.188,P<0.001).Conclusions1.The major stereotype for EHRs task in nurses are important and tedious.The characteristics of highly interactive,timeliness,low priority and suboptimal design could result in negative working experience and task outcomes.2.Interruptions are common phenomenon in EHRs task.Task switching and concurrent multitasking resulting from interruptions could extend working duration thus to increase mental workload.3.Working experience is a key variable in this mechanism framework that influences the mental workload and task performance.4.Task difficulty could increase mental workload and lead to compromised task performance.While task difficulty in EHRs nursing task with a moderate level are appropriate for matching nurses’ cognitive capacity,which served as the guarantee for task performance.5.Negative emotion both form pre and during EHRs nursing task could increases mental workload of nurses.The negative emotion raised from perceived compromised performance could be a mediating variable to mental workload.6.The relationship between mental workload and task performance are in linear,that means higher the level of mental workload is,more error incidence will be.However,as performance are partially influenced by mental workload,interventions such as the hierarchical quality management strategy could promote task performance.