# Introduction

Electronic health records (EHRs) are digitalized versions of patient medical records that contain essential information needed for patient care, such as medical history and diagnoses, medications, treatment plans, and allergies (Jedwab et al., 2019). EHRs are intended to increase efficiency in nursing workflows (Abu Raddaha, 2018; Strudwick et al., 2018) and have rapidly replaced paper-based documentation methods (Jedwab et al.). The digitalization of patient records improves patient care outcomes by increasing the ease, accessibility, and quality of nursing documentation (Gaughan et al., 2022; Jedwab et al.; Kutney-Lee et al., 2019; Özer et al., 2020). Nurses, being the largest group of healthcare professionals, are one of the primary end users of EHRs, and have a considerable impact on their implementation (Strudwick et al.). However, nurses’ perceptions that the EHR systems are challenging to use could lead to frustration and user dissatisfaction (Heponiemi et al., 2021). Prolonged frustration with EHRs use is associated with nurses’ negative work experience and resultant decreased quality of patient care (Yontz et al., 2015). Understanding nurses’ perceptions of EHR usability can enhance the use of this technology, ultimately improving nurses’ workflows, job satisfaction, and quality of patient care (Abu Raddaha; Strudwick et al.).

Although EHRs are increasingly becoming recognized as a standardized system for patient charting across most inpatient settings, they may also complicate nurses’ workflow practices (Winckler, 2021). Moreover, while EHRs can improve information accessibility, barriers to their uptake continue to exist (Manca, 2015). For example, successful adaptation to EHR use can be negatively impacted by issues related to patient data accessibility, workflow challenges, interface design flaws, technical issues, lack of interoperability, increased time spent on documenting, and poor user training (Arikan et al., 2022; Bristol et al., 2018; Dudding et al., 2018; Despins & Wakefield 2018; Gaughan et al., 2022; Graham et al., 2018; Heponiemi et al., 2021; Kutney-Lee et al., 2019; McBride et al., 2023; Özer & Santas 2020; Rogers et al., 2013; Ting et al., 2021; Tolentino et al., 2021; Topaz et al., 2016; Winckler; Wisner et al., 2021; Yontz et al., 2015).

The available body of research explored EHRs usability from the lens of financial costs, privacy issues, and procurement practices, with less attention paid to the perception of EHRs usability among nurses (Strudwick et al., 2018). Since nurses are one of the largest EHRs end users (Strudwick et al.), it is important to understand nurses’ perceptions of EHRs usability to ensure EHRs seamless integration and optimal use within nursing practice (Abu Raddaha, 2018).

## Objective

The purpose of this scoping review was to examine the available literature on nurses’ perception of EHRs usability within inpatient hospital settings. The insights gained from this review can inform the development of user-centered EHR enhancements that streamline nursing workflows, reduce documentation burden and ultimately enhance patient care efficiency.
# Methods

This scoping review was guided by the advanced version of Arksey and O’Malley’s (2005) methodological approach for scoping reviews (Levac et al., 2010) and by the methodological steps of the Joana Brigs Institute (Peters et al., 2015). The methodological approach of Arksey and O’Malley includes five steps: 1) identifying the research question; 2) identifying relevant studies; 3) study selection; 4) charting the data, 5) collating, summarizing, and reporting the results (Arksey & O’Malley; Levac et al.). The Joana Brigs Institute methodological approach includes 11 steps: 1) title; 2) background; 3) review question/objective; 4) inclusion criteria; 5) types of participant; 6) concept; 7) context; 8) searching; 9) extracting and charting the results; 10) discussion; and, 11) conclusions and implications for research and practice (Peters et al.). This scoping review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) (Sarkis-Onofre et al., 2021).

## Identifying Research Question

This scoping review was guided by the following research question: “What is known regarding nurses’ perceptions of the electronic health records (EHRs) usability within inpatient clinical settings?” The sub-questions were: 1) What are nurses’ perceptions of the ease of information accessibility?; 2) How does the EHR affect nursing workflow?; 3) Which design and technology features of the EHR influence usability?; 4) How does the time nurses spend using the EHR affect the nurse-patient relationship?; and 5) Does user training impact the usability of the EHR?

The **target population** in this study was nurses; the **concept of interest** was the usability of EHRs, the **outcome of interest** was nurses’ perceptions of EHRs usability, and the **context** was inpatient hospital settings (Levac et al., 2010).

## Identifying Relevant Studies

### Search Strategies

The following electronic databases were queried to identify and retrieve data: PubMed, CINAHL, and Scopus. These databases contain a range of research domains aligned with nursing, health-related, and technology topics that aided in addressing our scoping review question (Peters et al., 2015). Boolean operators, MeSH terms, truncations, and wild cards were explored and used based on the unique database requirements to obtain a comprehensive search outcome (Table 1).

### Inclusion and Exclusion Criteria

This review included only primary research studies with a target population of Registered Nurses (RNs) and Registered Practical Nurses (RPNs) providing direct patient care in inpatient hospital settings. Searches were limited to studies published in English. Studies with a primary focus on nurses’ perceptions of EHR usability or ease-of-use were considered for inclusion. The publication date range was set from January 1, 2013, to July 1, 2024, allowing this review to uncover nuanced changes in trends of EHR adoption and implementation during this period (Atasoy et al., 2019). Studies published in North America, Europe, or Australia were included, as these geographical locations utilize similar EHR systems, enabling meaningful narrative comparisons across selected studies (Aminpour et al., 2014).

Studies on Nurse Practitioners, clinical nurse leaders, nurse managers, nursing students, physicians, and patients were excluded from this review, as these populations use EHRs differently than RNs and RPNs. For example, nurses in leadership positions utilize EHR for administrative purposes and accurate documentation oversight (Soriano et al., 2019), while nursing students may not have access to the same EHR features that nurses have (Baillie et al., 2013). On the other hand, Nurse Practitioners and physicians use additional EHRs features (e.g., diagnostic purposes, order placement) (Watson et al., 2021). Patient use of EHRs differs, as they access their health information through a portal that has a different interface and features than the EHR accessed by the healthcare team members (Dendere et al., 2019)their role in patient engagement, and their impact on health care delivery in order to identify factors and best practices for successful implementation of this technology and areas that require further research. Methods: A systematic search for articles in the PubMed, CINAHL, and Embase databases was conducted using keywords associated with patient engagement, electronic health records, and patient portals and their respective subject headings in each database. Articles for inclusion were evaluated for quality using A Measurement Tool to Assess Systematic Reviews (AMSTAR.

This review also excluded articles that discussed the usability of EHRs in settings such as Long-Term Care, walk-in clinics, and other outpatient facilities, as the usability of the EHRs in these settings significantly differs from EHRs usability in inpatient settings in terms of nursing workflows and system design (Aminpour et al., 2014; Comstock, 2018). For example, EHRs designed for inpatient settings are tailored to the needs of the hospital (Aleem, 2024) and are built for a high-stakes environment wherein healthcare providers rely on EHR for immediate decision making (e.g., vital signs, blood work) whereas in outpatient settings, care is episodic, less urgent, and the information collected may be different (e.g., patient history) (Aleem, 2023; Simbo AI, n.d.).

### Selecting the Studies

The extracted data were exported to the Covidence web-based software (Veritas Health Innovation, 2023). Covidence streamlined the review process by identifying duplicates and offering additional tools for data screening and charting.

<table><caption>Table 1 — *Search Strategies*</caption><tr><td>DatabaseSubject HeadingsSearch StrategyPubMedMeSH terms(((Nurs*[MeSH
						Major Topic]) AND (perception[Text Word] OR attitude[Text Word] OR
						experience[Text Word] OR opinion[Text Word] OR perspective[Text Word]))) AND
						(electronic health record OR EHR OR electronic medical record OR EMR[MeSH
						Major Topic]). CINAHLSubject headings(nurs*) AND (perception OR attitude OR
						perspective OR opinion OR experience) AND (electronic health record OR EHR
						OR electronic medical record OR EMR). ·      Limiters - Published Date:
						20130101-20240701·      Expanders - Apply equivalent subjects·      Narrow
						by Language: - English·      Narrow by Subject Major: - electronic health
						records·      Search modes - Boolean/PhraseScopusKey words(nurs* OR  rn OR
						rpn ) AND (perception OR perspective OR attitude OR experience OR opinion)
						AND ("electronic health record" OR "electronic medical record" OR ehr OR
						emr) AND (LIMIT-TO (SUBJAREA, "NURS") OR LIMIT-TO (SUBJAREA, "HEAL")) AND
						(LIMIT-TO (PUBYEAR, 2023) OR LIMIT-TO (PUBYEAR, 2022 OR LIMIT-TO (PUBYEAR,
						2021) OR  LIMIT-TO (PUBYEAR, 2020) OR LIMIT-TO (PUBYEAR, 2019) OR LIMIT-TO
						(PUBYEAR,  2018) OR LIMIT-TO (PUBYEAR, 2017) OR LIMIT-TO (PUBYEAR, 2016) OR
						LIMIT-TO (PUBYEAR, 2015) OR LIMIT-TO (PUBYEAR, 2014) OR LIMIT-TO (PUBYEAR,
						2013)) AND (LIMIT-TO (LANGUAGE, "English")) AND (LIMIT-TO (EXACTKEYWORD,
						"Electronic Health Record") OR LIMIT-TO (EXACTKEYWORD, "Electronic Health
						Records") OR LIMIT-TO (EXACTKEYWORD, "Electronic Medical Record")) AND
						(LIMIT-TO (EXACTKEYWORD,"Nurse"))</td></tr></table>

The data sources uploaded to the Covidence underwent a two-step review process. Step one involved a review of the article title and abstract according to the inclusion criteria (above mentioned). Step 2 involved a full-text reading of the included articles that passed the title and abstract screening step to validate the inclusion of the data sources for the review. A review of bias (critical appraisal) of articles was not required using a scoping review methodology (Munn et al., 2018).

## Collating, Summarizing, and Reporting the
				Results

### Search Outcome

The initial search outcome across three databases (PubMed, CINAHL and Scopus) resulted in 1040 articles. After removing duplicates, 846 studies were selected for step 1 screening. Three reviewers (SJM, KM and EO) independently conducted the title and abstract screening (step 1), followed by a full-text screening (step 2). Studies were excluded based on ineligible concept, context, population, study design, or geographical location according to the inclusion and exclusion criteria. A minimum of two reviewers (SJM, KM and EO) independently screened the titles, abstracts and full texts. Any disagreements were resolved through group discussions to reach a consensus on whether to include the data source. In total, 20 articles were deemed eligible for this scoping review (Figure 1, end of document).

### Charting the Data

In alignment with Arksey and O’Malley’s (2005) methodology, relevant data were extracted into a data charting table embedded within Covidence software (Table 2, end of document). To ensure consistency in the extraction process, three reviewers (SJM, KM and EO) independently extracted data from the first two studies. Subsequently, two of the three reviewers (SJM, KM and EO) extracted data from the remaining 18 articles (Table 2, end of document). The data were screened to identify common issues and benefits of the use of EHR (Table 3, end of document).

## Ethical Considerations

An ethics certificate is not required for a scoping review of existing literature, as it does not involve human participants or primary data collection.
# Results

## Overview of the Studies’ Characteristics

A total of 20 primary studies, published between January 1, 2013, and July 1, 2024, were included in this scoping review. These studies employed a variety of designs: quantitative (n=4), mixed methods (n=1), cross-sectional (n=7), and qualitative (n=8). The studies were conducted in the United States (n=16), Canada (n=1), and Europe (n=3). The inpatient clinical settings in studies included medical-surgical units, labour and delivery departments, acute care units and unspecified inpatient settings. The sample sizes ranged from 8 to 12,377 nurses.

The extracted evidence addressing nurses’ perceptions of EHRs usability within inpatient hospital settings was narratively synthesized (Levac et al., 2010) and deductively organized into the following themes: 1) ease of information accessibility; 2) nursing workflow challenges; 3) EHR design, technical issues, and interoperability; 4) impact of the EHR on the nurse-patient relationship; and 5) user training (Table 3, end of document).

## Theme 1 – Ease of Information Accessibility

Ease of information accessibility refers to how the EHR operates as a system to access patient information (McBride et al., 2023). This review has identified positive and negative examples of how EHR may augment diminished information access.

### Positive Impact of EHR on Information Accessibility

Out of 20 reviewed, three studies reported that nurses found EHRs made patient information easily accessible, and the ease of accessibility eliminated nurses’ need to search for missing data (Bristol et al., 2018; Schenk et al., 2016; Winckler, 2021). Bristol et al. found that nurses perceived EHRs as beneficial for patient care, as the consistent flow of information could be accessed by members of the allied healthcare team. Similarly, Winckler reported that nurses viewed EHRs as reflecting real-time care activities, thereby contributing to better structure and report patient care. Nurses also noted that EHRs improved communication and data sharing between interdisciplinary team members (Bristol et al.; Despins & Wakefield, 2018; Gaughan et al., 2022).

### Negative Impact of EHR on Information Accessibility

Six of 20 studies expressed concerns about patient information accessibility issues, including the need to search for the required patient information in multiple locations within the EHRs (Bristol et al., 2018; Despins & Wakefield, 2018; Dudding et al., 2018; McBride et al., 2023; Schenk et al., 2016; Tolentino et al., 2021). Four studies reported increased workflow-related stress resulting from the need to examine large amounts of information to find the required patient information (Bristol et al.; McBride et al.; Schenk et al.; Winckler, 2021). Suboptimal patient information accessibility also resulted in the omission of critical cues. For instance, Despins and Wakefield found that nurses were concerned about not being able to recognize critical changes in a patient’s condition due to difficulty accessing information. Bristol et al. found that slow computer systems negatively impacted EHRs usability and resulted in more stress reported by nurses.

## Theme 2 – Nursing Workflow Challenges

Nursing workflow encompasses the processes nurses follow to provide care, including the sequence, type, and timing of nursing care activities (Mador & Shaw, 2009). Findings from this review indicate that nurses viewed EHR systems as tools designed to enhance their workflow (Bristol et al., 2018; Kutney-Lee et al., 2019). However, when the system did not function seamlessly, they reported care interruptions and fragmented clinical documentation (Bristol et al.; Kutney-Lee et al.; McBride et al., 2023; Tolentino et al., 2021; Topaz et al., 2016). Additionally, nurses emphasized the importance of EHR systems that aligned with and supported their existing workflow (Bristol et al.; McBride et al.).

The requirement for formulaic responses (e.g., a drop-down menu) was identified as a challenge for nursing workflow, particularly when it restricts nurses’ ability to document patients’ important information. In response, nurses resorted to workaround strategies, such as typing in free text boxes (Topaz et al., 2016). The reliance on structured responses may also contribute to a perceived loss of autotomy, as it limits nurses’ ability to apply critical thinking while using the EHR (Tolentino et al., 2021). Furthermore, nurses expressed frustration when they had to adjust their workflows to fit the EHRs system rather than having the EHR system adapt to their established workflows (Schenk et al., 2016; Tolentino et al.).

Nurses in two studies reported that EHRs contribute to duplicate charting, reducing efficiency (Bristol et al. 2018; Wisler et al., 2021). Some also found EHRs to be of limited utility when they failed to incorporate a nursing perspective (Bristol et al.). Additionally, a large-scale survey revealed that up to 50% (n=12,377) of nurses were not consulted before the EHRs implementation (Kuteny-Lee et al., 2019). Duplicate charting not only extended the time required for documentation but also led to frustration among nurses (Bristol et al.; Tolentino et al., 2021). The repetitive nature of charting further reinforced the perception of increased documentation time (Dudding et al., 2018). Moreover, nurses spent additional time planning how to enter the information into EHRs, further contributing to documentation burdens (Winckler, 2021).

## Theme 3 – EHR Design, Technical Issues, and
				Interoperability

The design of EHRs comprises elements such as the layout, data entry fields, and system cues reflecting how the system was developed to meet the healthcare provider’s needs (i.e., documentation and patient care) (Heponiemi et al., 2021). Malfunctions in these elements can lead to various technical issues as system failures or slow loading times) (Arikan et al., 2022). In addition, a lack of integration between different EHRs platforms (i.e., EPIC and Cerner) used across departments or facilities results in poor interoperability, that is, the ability of systems to communicate, exchange and use data effectively (Graham et al., 2018). This limitation hinders continuity of care across different locations. Six studies identified nurses’ concerns regarding poor interoperability (Bristol et al., 2018; Gaughan et al., 2022; Graham et al.; McBride et al., 2023; Topaz et al., 2016; Winckler, 2021). Reported challenges included a lack of standardization and communication between EHR systems within and across facilities (Gaughan et al.; Winckler). Nurses in three studies suggested a need for improving standardization of EHRs and better system interfacing between hospital departments, believing these changes would enhance EHRs usability and workflow efficiency (Bristol et al.; Graham et al.; Topaz et al.). However, some nurses also expressed that their requests for design improvements were not adequately addressed (McBride et al.).

Poor design and limited functionality were also identified as barriers to nurses effectively utilizing the information available in the EHRs (Heponiemi et al., 2021; Rogers et al., 2013). Heponiemi et al. found that malfunctioning EHRs increased nurses’ stress and cognitive overload, leading to errors such as accidentally opening the wrong system or struggling to recall multiple passwords. In another study, nurses reported a lack of trust in the EHR design due to its shortcomings, which hindered effective use (Rogers et al.). Standardized data entry templates embedded in the EHRs contributed to nurses’ perceived loss of autonomy in their roles (Gaughan et al., 2022; Tolentino et al., 2021; Winckler, 2021). In addition, nurses in intensive care and medicine settings associated certain EHRs design features, such as embedded task reminders, with a reduction of critical thinking, negatively impacting their decision-making processes (Gaughan et al.; Tolentino et al.). Two studies highlighted that EHRs design often lacked comprehensiveness, preventing nurses from fully documenting their assessments (Kutney-Lee et al., 2019; Wisner et al., 2021). For example, nurses in a labour and delivery setting frequently relied on free text entry to accurately capture changes in the newborn’s status (Kutney-Lee et al.).

Seven studies reported technical issues as barriers to technology acceptance, including slow or failing systems, computer malfunctions, inadequate equipment, and poorly timed automatic hardware and software updates sometimes occurring during critical nursing interventions, such as medication administration. Slow Internet connections further compound these challenges (Arikan et al., 2022; Bristol et al., 2018; Dudding et al., 2018; Tolentino et al., 2021; Topaz et al., 2016; Winckler, 2021; Yontz et al., 2015). Two studies identified shortfalls in equipment required to access the EHR as a cause of nursing frustration (Arikan et al.; Bristol et al.). Five studies reported that slow system performance not only frustrated nurses but also impeded their workflow (Bristol et al.; Dudding et al.; Tolentino et al.; Winckler; Yontz et al.).

## Theme 4 – Impact of the EHR on the Nurse-Patient
				Relationship

Nurses interviewed by Gaughan et al. (2022) reported that EHRs enhanced their job performance, contributed to better patient outcomes, and helped prevent charting errors. In addition, nurses in three studies reported that user-friendly EHRs reduced time spent on documentation, allowing them to dedicate more time to patient care (Arikan et al., 2022; Schenk et al., 2016; Yontz et al., 2015). Nurses perceived EHRs to be user-friendly when they were considered reliable (Schenk et al.). They also found EHRs more efficient than paper charting, as they centralized all patient information in one accessible location (Arikan et al.).

Not all nurses viewed the EHR positively. A common concern across studies was the amount of time spent on documentation. In the Kurtney-Lee’s (2019) study, which included a large sample size (n=12 377), 55.4% of the nurses reported that EHRs interfered with certain aspects of direct patient care. Nurses felt that EHRs documentation reduced the time available to direct patient care, hindering their ability to build therapeutic nurse-patient relationships (Graham et al., 2018; Kutney-Lee et al.; McBride et al., 2023; Ross, 2020; Wisner et al., 2021). Frustration stemmed from the increased time required for EHR documentation compared to paper charting, which nurses perceived as limiting their time for direct care (Arikan et al., 2022; Dudding et al., 2018; Graham et al.; McBride et al.; Ross; Schenk et al., 2016; Tolentino et al., 2021).

## Theme 5 – User Training

Implementing and sustaining EHRs in healthcare organizations can be challenging due to the need for extensive user training. This training often requires a combination of videos, didactic sessions, availability of EHRs super-users to provide ongoing support, or other educational strategies, all of which demand additional time and resources (Heponiemi et al., 2021). Nurses have identified a need for more comprehensive EHR training, as proper preparedness is linked with increased perceived ease of use and improved nurse well-being (Heponiemi et al.; Zaman et al., 2021). However, only one study reported that nurses received adequate EHR training (Yontz et al., 2015) while five other studies found that nurses received poor or incomplete training (Bristol, 2018; Graham et al., 2018; Heponiemi et al.; Topaz et al., 2016; Zaman et al.). Insufficient training before EHR implementation led to increased reports of problems, such as difficulty focusing on patient care, which, in turn, could negatively impact the quality of care (Bristol et al.).

Despite the initial stress and frustration related to the implementation of EHR, research shows that most nurses adapted to using these systems over time (Heponiemi et al., 2021; Schenk et al., 2021). For instance, after six months, nurses in one study experienced less stress, a more favourable attitude and reduced anxiety toward EHRs (Heponiemi et al.). Interestingly, Rogers et al. (2013) found that while many nurses initially disliked adopting EHR systems, most expressed a preference for continuing using EHRs over returning to paper charting.
# Discussion

This scoping review aimed to synthesize the literature on nurses’ perceptions of the usability of EHRs in inpatient hospital settings. Given that nurses represent the largest group of EHR end users, understanding their perceptions of EHRs usability is crucial. The findings highlight factors that can hinder nurses’ positive views on both the initial and ongoing usability of EHRs in clinical settings. Five themes emerged from this review: 1) ease of information accessibility; 2) challenges for nursing workflow; 3) EHR design, technical issues, and interoperability; 4) impact of the EHR on the nurse-patient relationship; and 5) the importance of user training. Addressing these implications for clinical practice, research, and policy is essential for gaining nurses’ support for the successful implementation and continued use of EHRs.

The review findings revealed conflicting perceptions of EHRs usability among nurses, particularly regarding the ease of accessing patient information within a multidisciplinary team or across different healthcare facilities (Bristol et al., 2018; Dudding et al., 2020; Despins & Wakefield, 2018; McBride et al., 2023; Schenk et al., 2016; Tolentino et al., 2021; Ozer & Santas, 2020; Winckler, 2021). EHRs that were not fully accessible online were often viewed as frustrating, hindering nurses’ ability to gain a comprehensive understanding of the full clinical picture, and increasing patient safety risks (Kutney-Lee et al., 2019; Wisner et al., 2021). Consistent with the findings of this review, Kutney-Lee et al. (2021) reported that poor EHR usability increased stress and job dissatisfaction, contributing to nurses’ decision to leave their care setting. It was also reported that inadequate EHR usability was linked to negative impacts on surgical patient outcomes and increased patient mortality (Kutney-Lee et al., 2021).

Similar to the findings of this review, nurses in a previous study reported challenges with accessing and locating information, such as notes on patient records (Rathert et al., 2019). The conflicting experiences expressed by nurses in the Rathert et al. study and this scoping review suggest that perceptions regarding EHRs usability widely vary among nurses. Moy et al. (2023) found that relevant patient information could be overlooked when EHR documentation does not align with departments or nurses’ workflows. Furthermore, the vast amount of information in the EHR was often perceived as more overwhelming than beneficial (Moy et al.), a concern also noted in this review. Both this review and Moy et al.’s study highlight the importance of tailoring EHRs systems to better meet the practical needs of nurses.

Weir et al. (2021) found that EHRs design needs to be improved by tailoring it to the psychological needs of healthcare workers, as these factors impact their cognition and emotional state. For instance, Weir et al. suggest that EHR should have a sense of meaning – designed to prompt healthcare workers to engage with the information presented and evaluate it. This recommendation aligns with the concerns raised by nurses in this scoping review, namely the frustration associated with the loss of critical thinking, as noted by Gaughan et al. (2022) and Tolentino et al. (2021).

In alignment with the findings of this review, Dunn et al. (2021) reported that nurses identified significant design flaws, such as multiple steps for a simple task, which contributed to the perception of an increased workload. However, in contrast to this review, Dunn et al. found that nurses did not perceive an increased workload or time burden associated with the new EHR implementation. These differing opinions may be related to the length of time the EHR has been in place. Dunn et al. found that users experienced less overall workload at the 30–32-month mark of EHR implementation. Similarly, this review found that the general sense of dread associated with the EHR decreased over time. Thus, the perceived effectiveness and positive impact of EHR usability among nurses maybe closely tied to the duration of EHR use since its implementation (Zaman et al., 2021).

A recurring concern in this review was the standardization of EHRs and its perceived impact on nurses’ autonomy, critical thinking and comprehensiveness of the documentation (Gaughan et al., 2022; Tolentino et al., 2021). Moy et al. (2023) found that, in an emergency department setting, excessive standardization hindered staff workflow, increased documentation insufficiencies and negatively affected clinicians’ clinical judgment (Moy et al.) On the other hand, standardization of EHRs was seen as essential to achieving interoperability, ensuring that different EHR systems across healthcare organizations can seamlessly exchange patient information in a timely manner (Rathert et al., 2019). A scoping review by Li et al. (2022) concluded that increased EHRs interoperability positively impacts patient safety.

Another key finding of this review was the inadequate training provided to nurses on EHRs use (Bristol, 2018; Graham et al., 2018; Heponiemi et al., 2021; Topaz et al., 2016; Zaman et al., 2021). Nurses, in another study, emphasized the need for ongoing training to support EHR use (Rathert et al., 2019). They felt that adopting EHR would have been easier with more comprehensive training in general technology, both before and during implementation (Arikan et al., 2022; Rogers et al., 2013; Ross, 2020; Zaman et al.). Additionally, studies found that nurses with prior EHRs training or advanced technological skills adapted more easily to new EHRs systems and found them more effective for documentation (Arikan et al.; Zaman et al.). Thus, expanding training opportunities may enhance EHR usability among nurses. To address this need, Ting et al. (2021) suggest engaging nurses in additional safe-paced online training and providing readily accessible usability resources, including peer support from colleagues.

## Future Directions

Future research directions related to EHRs usability should focus on the themes identified by this review. Further observation of nurses in each unique clinical area is needed so the EHR design is tailored to the workflow needs of the nurses working in specific inpatient settings. Issues of interoperability and patient information accessibility among providers from different healthcare organizations can be improved by investigating innovative solutions to provide a secure way to share patient information and developing data-sharing frameworks that include input from nurses. To increase the effectiveness of training for nurses, future studies can investigate: the implementation of simulation-based scenarios, the optimal way to participate in these additional trainings (on-site or remotely), best practices for education and training related to EHRs implementation (Ross, 2020), or specific changes in training needed for different inpatient units (Dudding et al., 2018).

Examining what EHR design elements impact the nurse-patient relationship could lead to EHR improvement, leading to better patient care (Wisner et al., 2021; Zaman et al., 2021). Investigating the disruptions in patient care related to the EHR and possible improvements to workflow resulting from the use of EHRs should be evaluated (Lee & McElmurry, 2010; Rogers et al., 2013). A gap identified in this study is that it is unclear if the unique interface characteristics of the EHRs used by nurses played a role in perceived usability from a nursing perspective. Future studies can focus on the comparative usability of different EHR interfaces to determine what specific design elements influence nurses’ EHR usability. Additional studies are needed to determine if previous experience with digital modalities, including other EHRs, impacts nurses’ ability to learn how to use the EHR.

## Strengths and Limitations

A comprehensive search of three large databases with a 10-year date range increased the overall strength of this review. This review covered different inpatient clinical settings (i.e., labour and deliver, medicine, acute care and critical care), allowing a comprehensive insight into nursing perceptions on EHR use. However, findings in this scoping review should be interpreted considering some limitations. Only articles published in English were included. Searching in other scientific databases, and including more languages, may have yielded other relevant studies, offering insights not captured in this review. Additionally, differences in nursing culture (e.g., policies, leadership, working conditions) were not captured across all included studies, making it difficult to evaluate their impact on nurses’ perceptions of EHR usability. The research team also acknowledges the unintentional omission of the search term licence practical nurse (LPN) which is not used in all countries included in this review and is a synonym for the term Registered Practical Nurse (RPN). The omission of the term LPN in the initial search may have impacted our search outcomes and findings identified in this scoping review.
# Conclusion

This scoping review explored nurses’ perceptions of EHR usability in inpatient hospital settings. Findings highlighted several factors that positively influenced nurses’ experiences, such as real-time access to consolidated patient information, the ability to track patterns and trends in patient status, and enhanced interprofessional collaboration. However, numerous challenges were identified, including system interoperability issues that made it difficult to retrieve the information, inadequate training, and disruptions in their workflow. Nurses also expressed concerns about prolonged documentation requirements, which reduced time for direct patient care and hindered therapeutic nurse-patient relationships. These findings provide valuable insights into the complexity of EHR usability from a nurse’s perspective. Future research should focus on addressing these challenges to optimize EHR design, enhance training strategies, and improve system interoperability, ultimately supporting nursing workflow and enhancing patient care quality.

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