Whilst the four mechanisms of NPT provided a framework for structuring the findings, for interpretation purposes, the inter-related nature of these should be considered.
Coherence – participant understanding of why ERS has been implemented
Participants were divided regarding their understanding of why the ERS had been implemented. Amongst those with responsibility for facilitating implementation and assisting colleagues with ERS, coherence was strong - coinciding with the official perspective of the institution as enabling the organisation to move towards a paperless environment. These participants attributed ERS implementation to the need for improved: accessibility and availability of records, efficiency, research and communication with other health and care organisations. They also had strong expectations that the system would bring benefits and have a positive impact on practice. For example, some participants reported that they anticipated it would remove risks associated with patients losing and forgetting paper notes, improve clinical audits and facilitate enhanced access to patient information, as staff assumed it would be integrated within and between healthcare organisations. A reciprocal relationship existed between participants’ ‘coherence’ regarding ERS implementation and whether they thought the system would lead to benefits prior to its implementation.
Doctor (consultant) 070202: There were lots of negatives with hand written notes they were often not contemporaneous bits of paper go missing so…I mentioned wanting something robust to stand up in court with but paper notes may not provide that…either so…you know hopefully it was going to fill some gaps left by paper notes and hopefully allow better communication with other healthcare providers.
This was in contrast to those (the majority) who had no involvement in ERS implementation who felt that they had not been informed as to why the system was introduced, therefore, did not have the anticipated benefits, causing some clinicians to feel as though the new system had been enforced upon them without explanation.
Specialist Senior Midwife 051602: ‘well somebody likes it so that’s why we’re doing it’ that’s been said and ‘even If it doesn’t work we’ve got no choice’ has also been said.
Cognitive participation – staff engagement and commitment to ERS
If a technology is to be embedded into routine practice clinicians need to be prepared to invest their time and be engaged in its application (cognitive participation) [14]. This is dependent on certain factors that ‘promote or inhibit’ individuals use of the technology, which are discussed below.
Training and support
The trust attempted to ensure participant’s continued commitment to engaging with and using the ERS by providing additional resources such as extra training, ‘lessons learned’ emails and electronic guidance for complex tasks; clearly if staff are expected to use the system, they need to understand how to use it. However, participants criticised the delivery (too simplistic, dogmatic), varied content (some staff only received basics of ERS) and timing (too far in advance of or after implementation) of training. The amount of training received also varied, with some participants receiving none, a single 30 min or whole day training sessions. A senior midwife attributed this variation to different roles of staff requiring different uses of the ERS, however participants cited issues with staff being able to ‘fit in’ training amongst busy work schedules and shift patterns:
Midwife (Birth Centre) 091203: every so often they’d put a few days in but you’ve got midwives that work permanent nights so how do you catch them?.
In addition to formal training, throughout implementation, a support team that consisted of a group of seconded members of clinical staff were responsible for helping staff to use the system. Despite criticising the support team’s availability (Weekday office hours only), participants praised their assistance during early implementation; particularly for those with poor computer literacy. The support team were also responsible for rectifying data entry errors on the system made by staff, who only had the capacity to input, and so could not edit information within the ERS. A group of clinicians that received extra training on the system who were considered ‘super-users’ were available when they were on duty and helped clinical colleagues rectify errors made on the system:
Midwife (Birth Centre) 081203: some of the more senior staff, I think they were called super-users they got additional training, so that was helpful in the unsocial hours, so obviously on a night shift, or on bank holidays, or weekends when the team weren’t there they could…problem shoot.
Barriers to engaging with the system
Participants perceived there to be a reluctance to accept the ERS and the change associated with its implementation among staff within the maternity unit, which negatively impacted on their engagement with and willingness to invest their time into the ERS. Despite an understanding among many that there were positive reasons for introducing the ERS, the historical use of paper records (and the positive view of these) made staff hesitant about the prospect of a paperless environment.
Midwife (labour ward and maternity assessment centre) 133002: I have a specific way of writing it and I have written it that way for an awfully long time and when I go to type it and writing a very small box although I can put as much in there as I want it doesn’t flow as easily…things like that and…it feels a little bit disjointed whether that will improve the more we do it but I am worried that there will be an issue.
Secondly, participants felt that the maternity unit had already been subject to vast amounts of ‘top-down’ policy change (from local and wider NHS initiatives) relating to increased data collection and audit requirements for maternity services. Additionally, participants who had been working at the trust for a number of years were affected by the implementation of the former (failed) electronic record system and did not distinguish between the two systems. These individuals had expected to be using an ERS within a paperless environment 7 years ago and so viewed the implementation as slow and with scepticism:
Midwife (Maternity Assessment Centre) 062712: the way it has been rolled out with them saying it will be rolled out in six months and we are now 7 years down the line it is probably going to be…I will be retired by the time it comes in (235–237).
Collective action – ERS usage by participants
In addition to individuals understanding why the ERS was introduced (coherence), or willingness to engage with and invest time into the system (cognitive participation) the following benefits and barriers may have promoted or inhibited the extent that the ERS was used.
Realised benefits
Although some participants reported that they were yet to see clinical benefits from the ERS, others felt that benefits had started to emerge. As expected, in contrast to paper records, the ERS was perceived to have enabled more reliable clinical audits to be conducted. Participants also reported that as more reliable information relating to the case mix of the maternity unit and work patterns is collected, financial benefits are occurring as the hospital is now able to charge commissioners (Clinical Commissioning Groups) more accurately for the care it provides:
Doctor (Consultant) 180703: we were struggling to charge the correct tariffs and we could see that a computer system like this was going to make it easier for us to charge the correct tariffs from the CCGs for the pregnant women and that has proven correct (52–55).
Participants cited a number of clinical benefits, which were largely associated with staff having access to patient records 24 h a day and records no longer being the patients' responsibility. Participants provided a number of examples, where this has been beneficial to the safety and quality of care provided. For instance: checking the importance or reason for visits prior to appointments; alerting community midwives in the event of patients failing to attend appointments; mitigating risks associated with patients forgetting or losing their records and accessing records in emergencies. Further benefits of the ERS in comparison to paper records included: simple data entry methods (e.g. tick boxes), prompts for additional information during alternative care (e.g. water births), improved communication with GPs who can now receive electronic notifications when patients are discharged or prescribed medication and increased legibility and conciseness of records. Clinicians also acknowledged that they no longer have to write the same information into numerous forms as the ERS populates relevant sections of the record. These findings suggest that participants had some positive experiences of, or awareness of colleagues having realised benefits from using the ERS since its implementation, and this in turn would be expected to positively influence their continuing engagement with (cognitive participation) and use of the ERS (collective action):
Midwife (Antenatal clinic and day unit) 150308: I’m not having to try and read illegible handwriting now because that’s always been a major barrier with providing care (143–144).
Barriers to using the system
The ERS was not ‘fully’ implemented during the period when the interviews took place and so not all aspects of care were inputted onto the ERS e.g. anaesthetic alerts; with paper still used in these situations. Paper was also used to communicate with other departments due to the ERS not being integrated with other electronic departmental systems within the trust. The mix of paper and electronic media and lack of integration between departmental systems was perceived to have raised the risk that clinical information may be missed. Additionally, the ERS could not communicate or share information with other healthcare organisations, with the procedures for granting other organisations access either unknown or considered too complex. This was considered an additional risk of the ERS as previously, unless women lost or forgot their paper records, they would have had them on their person when attending other healthcare organisations. One participant described the implications of these issues for participants who relocate for safe guarding issues:
Midwife (Birth Centre) 081203: women who haven’t booked with a midwife who may be moved from a different area because they are trying to go under the radar, they might have safe guarding concerns, they might be frightened that their baby is going to be taken away from them and they deliver at other trusts and that’s a way to try and escape that and we don’t have access to that persons records if they come from somewhere where they don’t have our system (177–181).
The staged approach to implementing the ERS meant that the extent that paper was used throughout the maternity unit varied, with some wards described as paperless whilst others were reliant on paper or both. Participants using both paper and electronic records expressed their frustration at the additional time it was taking them to ‘do everything twice’. Participants also raised concerns that important information may be being missed or not documented adequately in either record system. A variety of reasons for this were provided including: perceptions that some staff still see the paper record as the primary record, greater detail being entered into paper notes than on the ERS, staff not being aware and/or checking both sets of notes and insufficient time to document in both records:
Doctor (Registrar) 161111: I know that the system team they are stressing on the point that everything should be on the system, however for one reason or another I don’t know whether the systems down or whatever, some patients they still do have handheld notes or they have some of the documentation of their history on the paper work and other things on the system (107–109).
In addition, some staff perceived the ERS to increase the potential for inputting errors, particularly following system upgrades or when new members of staff (e.g. junior doctors) that were not used to the ERS joined the wards; which also contributed to their unwillingness to use the system:
Doctor (consultant) 191812: Our junior medical staff change, anything from every four to every 12 months and when our new staff come then it takes them a while to get used to it. So introducing people to the system takes longer and as I say we just upgraded it to change and so all of us go back a step in terms of learning (180–184).
Reflexive monitoring – staff appraisal of the ERS
Throughout the interviews, participants appraised the system by identifying a number of additional factors that have promoted (future benefits) and inhibited (disadvantages) their use of the system.
Disadvantages
Some participants perceived it to be more time consuming to enter information onto the ERS compared with paper records. Participants also explained how technical issues such as the system crashing and the time required to log into the ERS for each patient was lengthening appointments and discharge. Whilst some participants who had been using the ERS for longer did explain that the ERS was becoming quicker to use, many felt that the trust were underestimating the added time pressures associated with the ERS:
Midwife (Maternity Assessment Centre) 062712 I can’t see it [entering information electronically] being feasible when it’s very busy for me to physically be able to do it and then I’ll have concerns over my record keeping (202–203).
A minority of participants anticipated that although they expected the ERS to negatively affect their interaction with patients, ‘they made a concerted effort’ and had successfully avoided this. For participants who felt that the system had a detrimental effect on their relationship with patients, this was attributed to staff being required to leave the bedside to access the computer. Participants also described how because they had to physically turn away from the patient and concentrate more when using the computer, they felt they were not giving patients enough attention. However, of those that reported a negative impact, a proportion felt that they are now spending as much time with patients as they did when using the paper records and suggested that the detrimental impact on their interactions may be constrained to early implementation. Any potential detrimental impact of the ERS and interaction with patients was also perceived to have consequences for patient safety:
Doctor (Consultant) 070202: I don’t have a midwife in the clinic with me anymore because she has to log in separately and put her information in and there seeing patients separate to us. So particularly when there is a complex psycho-social case, maybe domestic violence, maybe extreme poverty, drug issues whatever, previously you would see them together, so you would establish a bit of a rapport a relationship with the patient and one of you would pick up on some things the other will pick up on others. You need to approach those cases subtly now they’ll go to a midwife who just does the blood pressure and the way make sure they’ve got the right leaflets and then they come along to me for the medical consultation….and I won’t be aware of what’s gone on in the midwives room (123–128).
Anticipated benefits
In light of the limited benefits and various barriers and disadvantages experienced since the ERS was implemented, it may be that as well as being a requirement to undertake their job, staff continue to use the system as they expect benefits to emerge in the future. A number of participants reported expectations that the ERS, once fully implemented, will enable all patient information to be stored in one place; something which is predicted to be of benefit in emergency situations as the ERS will alert staff to allergies and risk factors. Once the ERS is integrated within and across healthcare organisations, participants also expected quicker referral times as they will no longer have to wait for letters. Additional anticipated benefits included improvements to: patient flow, research, audit, performance and planning, record security and accuracy and fewer missing records:
Doctor (Consultant) 042202: in an emergency situation as soon as I know name and date of birth or something like that, if I open that I know about…yes this women had a road traffic accident and such and such she had a blood transfusion such and such and she got allergy to penicillin and she is now 28 weeks pregnant. If the women is not in a state to talk to me that is one I’m expecting… so that has to be able to give me that complex background (127–134).