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Objective: To evaluate the impact of using an academic electronic medical record program on first-year nursing students' confidence and skill in E-documentation after their hospital clinical placement. Background: Registered nurses are the largest user group of health information technology systems such as patient electronic medical records (eMR). As such, nurse undergraduate programs need to reflect contemporary practices and respond to emerging trends including digital technology, however integration of eMR learning has not occurred in many countries. To address this gap, a fit-for-purpose academic eMR simulation program was developed by nursing academics and a university Learning Design Department member. Study Design and Methods: A quasi-experimental study design, with self-administered pre-test, post-test surveys, was used with a convenience sample of all first-year nursing students at one regional university in NSW Australia in 2019 and 2021. Results: A total of 105 students completed the surveys (9.7% pre, and 7.4% post-test survey). Only 23% of respondents received training during hospital clinical placement on eMR and electronic observation charts. There was a significant increase in participant confidence and knowledge in documenting in electronic adult observational charts and notes after using the academic eMR program and attending clinical placement. Three themes emerged from the qualitative data: preparation for practice; more exposure increases confidence; and we can't forget the patient. Conclusion: Students acknowledged the need for repeated practice using an academic eMR program in university learning environments to ensure they would be work-ready. The identified challenge was the communication barrier (computer on wheels) and the potential negative impact on person-centred care and therapeutic communication. Implications for research, policy and practice: Further research is required to determine whether repeated practice with electronic documentation is best placed within a curriculum to increase learner confidence. Simulations that incorporate workstations on wheels should be tested to determine best practice for therapeutic communication. What is already known about this topic? • Registered nurses are the largest user group of health information technology systems. • Nursing undergraduate program needs to reflect contemporary practices including digital technologies. • Integration of eMR education in undergraduate nursing programs has not occurred in many countries. What this paper adds: • Evaluation of a fit-for-purpose academic electronic medical record program integrated into an undergraduate nursing student's curriculum. • There was a significant increase in participant confidence and knowledge in documenting in electronic adult observational charts and notes after using the academic eMR program. • Digital technology education tailored for students of different age groups may be required. [ABSTRACT FROM AUTHOR]

Objective: The aim was to explore and compare documentation of the nursing process for patient safety in two nursing documentation systems: paper and digital records. Background: The 'nursing process' (assessment, planning, intervention, and evaluation) is recommended by professional nursing registration and health service accreditation bodies as a key component of understanding nurses' clinical reasoning. Nurses' responsibility for patient safety must be supported by comprehensive documentation practices. Study design and methods: A retrospective audit of twenty clinical care records (N = 20) randomly selected from a single acute medical ward at a tertiary hospital in Australia; ten from a digital trial that replicated selected paper forms and ten paper records as controls. The audit was conducted by two nurse researchers using a purpose built data extraction tool. Results: Patient age, gender and primary diagnoses were similar for the digital and paper care records. Documentation of the full nursing process was low in both record types, and comprehensiveness of nursing documentation was similar across the paper and digital records. Compared to the paper documents, the digital documents were more often rated as 'complete' (p<0.05). Documentation of risk to skin integrity (p<0.05) and evidence of completed nursing interventions to address risks were more frequent (p<0.05) in digital records. Discussion: The findings of this study highlight an important gap in comprehensive documentation of the nursing process that supports and informs the clinical reasoning of nurses for patient safety. Improvements in digital documents reflect future opportunity to enhance the quality of nurse documentation using technology specific strategies such as prompts, visualisation and nudge. Conclusion: This research identifies that both paper and digital systems of hospital documentation may fail to capture and communicate the clinical reasoning of nurses. Digital systems have the potential to improve capture of the clinical reasoning and nursing process. What is already known about the topic? * Professional registration and healthcare accreditation bodies recommend nurses' clinical decision making is underpinned by processes of assessment, planning, intervention and evaluation. * Poor capture of nurses' clinical decision making in their documentation has negative consequences for the continuity, quality and safety of care; including inadequate detection of deterioration and escalation of care. * Electronic systems are expected to enhance capture of nurse decision making in documentation. What this paper adds: * Nurses' clinical reasoning was poorly captured in both paper and digital documentation systems. * Nurses documented their intervention responses to identified patient risks more often in the digital system compared to paper records. * Digital systems offer an opportunity to proactively nudge nurses towards improved documentation of nursing processes. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effects of a communitybased chronic heart failure management program, delivered by nurse practitioners, on self-care behaviour, quality of life and hospital readmissions. Background: Chronic heart failure is a complex condition associated with high rates of hospital readmissions. However, many hospitalisations in patients with chronic heart failure are potentially preventable with better self-management and access to specialised healthcare support. Nurse practitioners have an advanced scope of practice, making them well credentialed to support patients with chronic heart failure. Study design and methods: This study compared self-care behaviour and quality of life in patients who had attended a nurse-practitioner led chronic heart failure management service (SmartHeart) (n=58) compared with patients receiving usual care (n=58), but no nurse practitioner support. Self-care behaviour was assessed using the Self Care Heart Failure Index and quality of life was assessed using the Short Form-36 and Minnesota Living with Heart Failure Questionnaire. Hospitalisation records were extracted from medical records using data-linkage. Results: Patients who received nurse-practitioner support had better self-care behaviour (p<0.05), mental component summary of the Short Form-36 (p<0.05) and heart failure specific quality of life (p<0.05). All-cause hospitalisations were delayed (p<0.05) and length of stay was shorter (p<0.05) in the group receiving nurse practitioner support, but there were no differences in chronic heart failure related admissions. Discussion: A chronic heart failure support program, operating in a community setting and delivered by nurse practitioners, enhanced self-care, improved psychosocial health and reduced time in hospital. Conclusion: Chronic heart failure management delivered by nurse practitioners can improve self-care behaviour and quality of life, and reduced hospital admissions, compared with usual care. What is already known about the topic? • Chronic heart failure is a complex health issue requiring disease-specific management that needs to be tailored to the individual. However, many patients with chronic heart failure don't receive adequate support to manage their condition. What does this paper add: • A chronic heart failure management service, delivered in primary care by nurse practitioners, improved self-management and quality of life and was associated with a lower rate of hospitalisations compared with usual care alone. [ABSTRACT FROM AUTHOR]