Project – Electronic Health Record Usability, Clinical Documentation Burden and Nurses’ Work Performance: A Study of Selected Tertiary Hospitals in South-West Nigeria.

CHAPTER ONE

INTRODUCTION

Topic: Electronic Health Record Usability, Clinical Documentation Burden and Nurses’ Work Performance: A Study of Selected Tertiary Hospitals in South-West Nigeria

1.1 Background to the Study

The increasing application of information and communication technology in healthcare delivery has transformed the way medical information is collected, stored, processed, retrieved and communicated among healthcare professionals. One of the most significant developments in this transformation is the introduction of Electronic Health Records (EHRs), which provide digital platforms for documenting and managing patients’ health information throughout the process of care. Electronic Health Records are designed to improve the accessibility, accuracy, organisation and continuity of clinical information while supporting communication and decision-making among healthcare professionals. Unlike traditional paper-based records, electronic systems enable authorised users to retrieve patients’ medical histories, record clinical observations, document nursing interventions, monitor treatment progress and communicate relevant information across departments. The World Health Organization (WHO, 2021) emphasises the importance of digital health technologies in strengthening health systems and improving the delivery of essential healthcare services. Similarly, Kruse et al. (2016), in their systematic review of the benefits and challenges associated with electronic health records, identified improved information accessibility, better coordination of care and enhanced clinical documentation as important potential benefits of EHR implementation. These developments have made electronic health records an increasingly important component of modern hospital management, particularly in tertiary healthcare institutions where large volumes of patient information must be managed efficiently.

The usability of electronic health records is an important factor determining whether healthcare professionals can effectively utilise digital systems in their daily clinical activities. Usability refers to the extent to which a technological system can be used by intended users to achieve specified objectives effectively, efficiently and satisfactorily within a particular working environment. In the context of nursing practice, EHR usability involves the simplicity of system navigation, clarity of the interface, ease of entering and retrieving information, speed of operation, reliability, accessibility and compatibility with routine nursing responsibilities. A system may possess advanced technological features but still create difficulties for nurses when its design is complicated, its response time is slow or its documentation procedures do not correspond with actual clinical workflows. The International Organization for Standardization (ISO, 2018), through ISO 9241-11, identifies effectiveness, efficiency and satisfaction within a specified context of use as essential dimensions of usability. Furthermore, Park et al. (2024), in their systematic review of nurses’ perceptions of electronic health record usability, found that poor usability could contribute to increased workload, workarounds and potential threats to patient safety. Their findings demonstrate that the usefulness of electronic health records depends not only on their technological capabilities but also on how easily nurses can interact with them while carrying out their professional responsibilities.

Nurses occupy a central position in hospital healthcare delivery because they provide continuous patient monitoring, administer medications, perform clinical procedures, coordinate patient care and communicate essential health information to other members of the healthcare team. These responsibilities require accurate and timely documentation to ensure continuity, accountability and effective clinical decision-making. Electronic health records have therefore become increasingly relevant to nursing practice because they provide structured platforms for recording patients’ vital signs, medication administration, nursing assessments, treatment responses and other clinical activities. However, the effectiveness of these systems depends on their ability to support rather than interrupt nursing workflows. Tolentino and Gephart (2021), in their integrative review of nurses’ experiences with electronic health records, identified functional, physical, perceptual, cognitive, psychological and social dimensions of user experience. Their findings showed that suboptimal system design, navigation difficulties and workflow mismatches could result in interruptions and workarounds among nurses. Similarly, Park et al. (2024) established that electronic health record usability should be evaluated in relation to nurses’ satisfaction, work performance and patient safety. Therefore, assessing EHR usability among nurses is essential for determining whether digital documentation systems adequately support the practical demands of nursing care in tertiary hospitals.

Despite the potential benefits of electronic health records, their use may introduce additional documentation responsibilities that increase the administrative and cognitive demands placed on nurses. Clinical documentation burden refers to the time, effort and mental resources healthcare professionals devote to recording, reviewing, updating and managing clinical information as part of patient care. This burden may arise from repetitive data entry, excessive documentation requirements, poorly organised templates, multiple screen navigation, duplication of information, system interruptions and the need to complete records within specified periods. Although clinical documentation is necessary for professional accountability, communication and continuity of care, excessive documentation requirements may reduce the time available for direct patient interaction. Moy et al. (2021), in their scoping review of clinical documentation burden among physicians and nurses using electronic health records, identified several dimensions of documentation burden, including general workload, clinical documentation and review, after-hours electronic health record activities, administrative tasks, cognitive effort, workflow fragmentation and patient interaction. Their review also established that documentation burden was measured through different time and effort-related indicators, demonstrating that it extends beyond the actual act of entering information into an electronic system. Similarly, Baumann et al. (2018), in a systematic review of electronic health records and clinical documentation time, reported that the proportion of observed working time spent on documentation increased among nurses from approximately 9% before EHR implementation to 23% after implementation in the studies reviewed. This finding illustrates why documentation burden deserves attention when evaluating the consequences of digital health technologies for nursing practice.

Clinical documentation burden has important implications for nurses’ work performance because nursing responsibilities require a balance between documentation, direct patient care, communication, clinical assessment and timely execution of medical instructions. When nurses spend excessive time navigating electronic systems or completing repetitive documentation tasks, they may experience increased workload, mental fatigue, interruptions and reduced opportunities for direct interaction with patients. Work performance in nursing refers to the extent to which nurses effectively and efficiently discharge their professional responsibilities in accordance with established clinical standards and institutional expectations. It may be assessed through indicators such as timeliness of nursing interventions, accuracy of clinical records, quality of patient monitoring, task completion, communication, responsiveness and effective utilisation of working time. Cho et al. (2024), in their mixed-methods investigation of electronic health record use and documentation burden among acute and critical care nurses, examined the factors contributing to nurses’ documentation experiences through system usage records, interviews and surveys. Their findings highlighted opportunities for improving the usability of electronic health record systems to reduce documentation-related difficulties. Furthermore, Moy et al. (2021) identified workflow fragmentation, excessive electronic health record workload and reduced patient interaction as important dimensions of documentation burden. These findings suggest that the relationship between electronic documentation and nursing performance is complex because digital systems may improve access to clinical information while simultaneously creating additional demands on nurses’ time and attention.

In Nigeria, the adoption of electronic health records has become an important aspect of ongoing efforts to strengthen healthcare information management and improve hospital service delivery. However, the implementation and effective utilisation of digital health systems may be affected by infrastructural, organisational, technological and human resource challenges. Issues such as inadequate computer availability, inconsistent electricity supply, limited internet connectivity, software interruptions, insufficient training and resistance to technological change may affect healthcare professionals’ ability to use electronic systems effectively. Babalola et al. (2025), in their study of electronic medical record perceptions and barriers among physicians and nurses in general hospitals in Lagos State, found that healthcare workers generally had positive perceptions of electronic medical records, but identified insufficient computers, inconsistent power supply, hardware and software failures and poor internet connectivity as major barriers to their utilisation. In another Nigerian study, Eleke et al. (2024) evaluated an Electronic Nursing Process Documentation Form across seven tertiary hospitals involving 872 nurses. Their findings showed that the electronic nursing documentation form was perceived as more useful than traditional pen-and-paper documentation, with mean usefulness scores of 3.46 and 3.03 respectively. The researchers concluded that the electronic nursing documentation solution had potential for improving documentation processes in resource-constrained Nigerian hospitals. These studies demonstrate that electronic documentation has considerable potential in the Nigerian healthcare system, although its successful implementation requires attention to usability, infrastructure, training and the actual working experiences of nurses.

South-West Nigeria provides an important geographical context for investigating electronic health record usability, clinical documentation burden and nurses’ work performance because the region accommodates several major tertiary healthcare institutions that serve diverse populations and provide specialised medical services. These institutions handle substantial volumes of clinical information and provide services across different medical specialties, thereby creating considerable documentation and coordination responsibilities for nursing personnel. The increasing need for accurate electronic documentation, timely information retrieval and effective communication makes the usability of digital health systems particularly important in these institutions. Onyeabor et al. (2025), in their study of digital healthcare system usability and performance in three referral and university teaching hospitals in Southern Nigeria, found that 79.4% of participating clinicians identified gaps in system features, while 80.2% reported experiences of slow, unresponsive systems or prolonged interruptions that affected workflow efficiency. Although the study covered clinicians generally rather than nurses exclusively, its findings demonstrate the relevance of system usability and technical reliability within Nigerian tertiary healthcare environments. Furthermore, Eleke et al. (2024) established the potential usefulness of electronic nursing documentation in Nigerian tertiary hospitals, while Park et al. (2024) emphasised the relationship between EHR usability, nursing performance and patient safety. Against this background, the present study seeks to examine electronic health record usability, clinical documentation burden and nurses’ work performance in selected tertiary hospitals in South-West Nigeria. The study will specifically investigate the usability of existing electronic health record systems, the documentation demands experienced by nurses, the extent to which these demands influence their work performance and the relationship among the three variables, with a view to generating evidence that can support improvements in nursing practice and hospital information management.

1.2 Statement of the Problem

The introduction of electronic health records into hospital healthcare delivery was intended to improve clinical documentation, facilitate information accessibility, enhance communication and promote efficient patient management. However, the practical experience of nurses using these systems may differ from their intended benefits, particularly when the technology is not adequately designed around the realities of nursing workflows. In some hospital environments, nurses may encounter complicated system interfaces, slow response times, difficulties retrieving patient information, repeated login requirements and challenges navigating different documentation sections. Such limitations may make routine clinical documentation more demanding and interfere with the smooth execution of nursing responsibilities. Park et al. (2024) established that poor electronic health record usability could contribute to increased workload, workarounds and potential patient safety concerns. Similarly, Onyeabor et al. (2025) found that a substantial proportion of clinicians in selected Nigerian teaching hospitals experienced system interruptions and identified missing system features as limitations affecting workflow efficiency. The problem, therefore, is that electronic health record systems that are expected to improve nursing efficiency may create additional operational difficulties when their usability does not adequately correspond with nurses’ clinical needs.

Another major concern is the possibility that electronic health records may increase clinical documentation burden among nurses. Nursing practice involves continuous patient observation, medication administration, clinical assessments, treatment monitoring, health education and communication with other healthcare professionals. These responsibilities already place considerable demands on nurses’ time and professional attention. When electronic systems require repeated data entry, multiple documentation procedures, excessive form completion or duplication of clinical information, nurses may spend additional time performing administrative tasks instead of attending directly to patients. Baumann et al. (2018) reported an increase in the proportion of nurses’ observed working time devoted to documentation following EHR implementation in the studies reviewed. Moy et al. (2021) also identified excessive workload, documentation and review activities, cognitive demands and workflow fragmentation as important dimensions of clinical documentation burden. Although electronic documentation is essential for maintaining accurate clinical records, excessive documentation demands may create an imbalance between administrative responsibilities and direct nursing care. This raises concerns about the extent to which nurses in selected tertiary hospitals in South-West Nigeria experience documentation burden and the factors contributing to such experiences.

Furthermore, clinical documentation burden may have implications for nurses’ work performance, particularly in tertiary hospitals where the volume of patients, complexity of medical conditions and need for continuous monitoring require efficient use of working time. Nurses are expected to provide timely interventions, maintain accurate patient records, administer prescribed treatments, monitor clinical changes and coordinate care with other professionals. However, when a considerable proportion of their working hours is devoted to navigating electronic systems and completing documentation requirements, their ability to perform these responsibilities efficiently may be affected. The resulting difficulties may include delays in completing nursing tasks, reduced time for direct patient interaction, increased mental fatigue, interruptions and challenges maintaining an effective workflow. Cho et al. (2024) highlighted documentation-related challenges among acute and critical care nurses and identified the need for improvements in the usability of electronic health record systems. Similarly, Tolentino and Gephart (2021) reported that poorly designed electronic health record interfaces could create workflow interruptions and communication difficulties for nurses. The problem is therefore not simply whether nurses use electronic health records, but whether the time and effort required to use these systems support or undermine their overall work performance.

The central problem addressed by this study is the limited context-specific empirical understanding of the relationship between electronic health record usability, clinical documentation burden and nurses’ work performance in selected tertiary hospitals in South-West Nigeria. Although existing studies have examined electronic medical record adoption, nurses’ perceptions of digital documentation and the usability of healthcare information systems, there remains a need to investigate how these factors interact within the daily professional experiences of nurses working in tertiary hospitals. For instance, Babalola et al. (2025) investigated perceptions and barriers to electronic medical record use among healthcare professionals in Lagos general hospitals, while Eleke et al. (2024) evaluated the usefulness of an electronic nursing documentation form across seven Nigerian tertiary hospitals. However, these studies did not comprehensively establish the combined relationship between EHR usability, clinical documentation burden and nurses’ work performance in selected tertiary hospitals in South-West Nigeria. This creates an important research gap concerning whether user-friendly electronic health record systems reduce documentation difficulties and whether excessive documentation demands are associated with nurses’ work performance. Addressing this gap is necessary to provide evidence that can guide hospital administrators, nursing managers, health information technology professionals and policymakers in improving electronic documentation systems and strengthening the quality and efficiency of nursing services.

1.3 Objectives of the Study

The main objective of this study is to examine electronic health record usability, clinical documentation burden and nurses’ work performance in selected tertiary hospitals in South-West Nigeria.

The specific objectives are to:

1. Assess the level of electronic health record usability among nurses in selected tertiary hospitals in South-West Nigeria.

2. Examine the extent of clinical documentation burden experienced by nurses in the selected tertiary hospitals.

3. Determine the relationship between electronic health record usability and nurses’ work performance in the selected tertiary hospitals.

4. Examine the influence of clinical documentation burden on nurses’ work performance in selected tertiary hospitals in South-West Nigeria.

1.4 Research Questions

The following research questions will guide the study:

1. What is the level of electronic health record usability among nurses in selected tertiary hospitals in South-West Nigeria?

2. To what extent do nurses experience clinical documentation burden in the selected tertiary hospitals?

3. What is the relationship between electronic health record usability and nurses’ work performance?

4. How does clinical documentation burden influence nurses’ work performance in selected tertiary hospitals in South-West Nigeria?

1.5 Research Hypothesis

The following null hypothesis will guide the study:

H₀: There is no statistically significant relationship among electronic health record usability, clinical documentation burden and nurses’ work performance in selected tertiary hospitals in South-West Nigeria.

1.6 Significance of the Study

The findings of this study will be significant to nurses, hospital management, nursing administrators, healthcare policymakers, health information technology professionals, patients, researchers and students.

Nurses: The study will provide useful information about how electronic health record usability and documentation requirements affect their daily professional responsibilities. It will help nurses identify the importance of user-friendly digital systems, appropriate documentation practices and effective time management. The findings may also encourage improvements in the way nurses interact with electronic health records while maintaining attention to direct patient care.

Hospital Management: The study will provide hospital administrators with evidence regarding the effectiveness and challenges associated with electronic health record systems. It may assist management in identifying system limitations, reducing unnecessary documentation procedures and improving the technological environment in which nurses perform their duties. The findings may also guide decisions concerning investment in improved digital infrastructure and technical support.

Nursing Administrators: Nursing managers and heads of departments may benefit from the findings when developing strategies for improving nursing workflows and allocating responsibilities. The study may help them understand how documentation requirements influence nurses’ workload, time management and performance. It may also support the development of training programmes that improve nurses’ competence in using electronic documentation systems.

Healthcare Policymakers: The findings may provide useful evidence for policymakers responsible for digital health development and healthcare workforce management in Nigeria. The study may contribute to policies that promote effective electronic health record implementation, appropriate documentation standards, continuous digital skills development and improved working conditions for nurses.

Health Information Technology Professionals: The study will provide information that may assist software developers, health informatics professionals and system administrators in understanding the practical experiences of nurses using electronic health records. It may encourage the development of systems with simplified navigation, reduced repetitive data entry, improved information retrieval and better alignment with nursing workflows.

Patients: Patients may benefit indirectly from the findings through improvements in nursing efficiency and the quality of healthcare services. Where electronic documentation systems are easier to use and documentation demands are appropriately managed, nurses may have more opportunities to concentrate on patient monitoring, communication and timely clinical interventions.

Researchers and Students: The study will contribute to existing literature on electronic health records, clinical documentation burden, nursing informatics and healthcare workforce performance. It will provide a foundation for further investigations into digital health implementation and its implications for nursing practice, particularly within Nigerian tertiary healthcare institutions.

1.7 Scope of the Study

The study will focus on electronic health record usability, clinical documentation burden and nurses’ work performance in selected tertiary hospitals in South-West Nigeria.

Content Scope: The study will examine the usability of electronic health record systems, including ease of navigation, accessibility, system responsiveness, reliability and user satisfaction. It will also investigate clinical documentation burden, including time spent documenting, repetitive data entry, documentation workload, system interruptions and administrative demands. Furthermore, it will examine nurses’ work performance in relation to efficiency, timeliness, accuracy, task completion and quality of nursing responsibilities.

Geographical Scope: The study will be conducted in selected tertiary hospitals located within South-West Nigeria. The geographical coverage will be limited to the hospitals selected for the research.

Population Scope: The study population will comprise registered nurses working in the selected tertiary hospitals. Nurses involved in direct patient care and clinical documentation will constitute the principal respondents.

Variable Scope: Electronic health record usability will serve as the independent variable, clinical documentation burden will constitute an additional explanatory variable, while nurses’ work performance will serve as the dependent variable.

1.8 Operational Definition of Terms

Electronic Health Record (EHR): This refers to a digital system used for collecting, storing, retrieving, updating and managing patients’ health information within a healthcare institution.

Electronic Health Record Usability: This refers to the extent to which nurses can use electronic health record systems effectively, efficiently and satisfactorily when performing clinical documentation and other professional responsibilities.

Clinical Documentation: This refers to the systematic recording of patients’ health information, including nursing assessments, vital signs, medication administration, treatment procedures, observations and responses to care.

Clinical Documentation Burden: This refers to the time, effort, workload and mental demands associated with recording, reviewing, updating and managing patients’ clinical information.

Nurses’ Work Performance: This refers to the extent to which nurses effectively and efficiently carry out their professional responsibilities, including patient monitoring, medication administration, clinical documentation, communication and nursing interventions.

Tertiary Hospitals: These are specialised healthcare institutions that provide advanced medical services, specialised treatment, clinical training and, in many cases, medical research.

Nursing Workflow: This refers to the sequence of activities and responsibilities undertaken by nurses in providing patient care, documenting clinical information and coordinating healthcare services.

System Usability: This refers to the ease, efficiency, accessibility and user satisfaction associated with operating a digital healthcare system.

Documentation Time: This refers to the amount of working time nurses devote to entering, reviewing, updating and completing patients’ electronic health records.

Workflow Efficiency: This refers to the ability of nurses to complete their professional responsibilities accurately and within appropriate periods without unnecessary interruptions or administrative difficulties.

Project – Electronic Health Record Usability, Clinical Documentation Burden and Nurses’ Work Performance: A Study of Selected Tertiary Hospitals in South-West Nigeria.