JMIR MEDICAL INFORMATICS

Kaihlanen et al

Original Paper

The Associations of Electronic Health Record Usability and User
Age With Stress and Cognitive Failures Among Finnish Registered
Nurses: Cross-Sectional Study
Anu-Marja Kaihlanen1, PhD; Kia Gluschkoff1, PhD; Hannele Hyppönen1, PhD; Johanna Kaipio2, PhD; Sampsa
Puttonen3, PhD; Tuulikki Vehko1, PhD; Kaija Saranto4, PhD; Liisa Karhe5, PhD; Tarja Heponiemi1, PhD
1

Finnish Institute for Health and Welfare, Helsinki, Finland2

Department of Computer Science, Aalto University, Helsinki, Finland

3

Finnish Institute of Occupational Health, Helsinki, Finland4

Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland

5

Finnish Nurses Association, Helsinki, Finland

Corresponding Author:
Anu-Marja Kaihlanen, PhD
Finnish Institute for Health and Welfare
P.O. Box 30
Helsinki, FI-00271
FinlandPhone: 358 295246033
Email: anu.kaihlanen@thl.fi

Abstract
Background: Electronic health records (EHRs) are expected to provide many clinical and organizational benefits. Simultaneously,
the end users may face unintended consequences, such as stress and increased cognitive workload, due to poor EHR usability.
However, whether the effects of usability depend on end user characteristics, such as career stage or age, remains poorly understood.
Objective: The objective of this study was to examine the associations of EHR usability and user age with stress related to
information systems and cognitive failures among registered nurses.
Methods: A cross-sectional survey design was employed in Finland in 2017. A total of 3383 registered nurses responded to thenationwide electronic survey. Multiple linear regression was used to examine the associations of EHR usability (eg, how easily
information can be found and a patient’s care can be documented) and user age with stress related to information systems andcognitive failures. Interaction effects of EHR usability and age were also tested. Models were adjusted for gender and employment
sector.
Results: Poor EHR usability was associated with higher levels of stress related to information systems (β=.38; P<.001). The
strength of the association did not depend on user age. Poor EHR usability was also associated with higher levels of cognitive
failures (β=.28; P<.001). There was a significant interaction effect between age and EHR usability for cognitive failures (β=.04;
P<.001). Young nurses who found the EHR difficult to use reported the most cognitive failures.
Conclusions: Information system stress due to poor EHR usability afflicts younger and older nurses alike. However, younger
nurses starting their careers may be more cognitively burdened if they find EHR systems difficult to use compared to older nurses.
Adequate support in using the EHRs may be particularly important to young registered nurses, who have a lot to learn and adopt
in their early years of practice.
(JMIR Med Inform 2020;8(11):e23623) doi: 10.2196/23623
KEYWORDS
electronic health records; usability; stress; cognitive failure; nurse

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Introduction
Electronic health record (EHR) systems have increasingly
replaced paper-based practices in hospitals, with the expectationof providing many clinical and organizational benefits [1,2].
Implementation of EHRs will inevitably change work practices
in health care [3,4] and, if not properly managed, may result inmany unexpected and unintended consequences. In addition to
the benefits identified (eg, reduction of medication errors),
health care professionals have reported disadvantages, such asincreased emotional strain and increased errors when trying tolearn and adapt to new technologies and managing theirworkflow disruptions [2,5,6]. Implementation and use of EHRs
have also required increased effort from professionals in
performing their typical task flow [7], which in turn has resulted
in increased cognitive workload and decreased cognitive
performance [8]. In addition to missing focus on proactive
workflow redesign during EHR implementation, earlier studies
have found that many of the unfavorable consequences areconnected with the usability issues of EHR systems, referring
to how easy the system is to use and how precisely andefficiently required tasks can be performed [9,10].
Nurses, as the largest group of health care professionals, are themain end users of the EHRs, and their daily work is greatly
influenced by ease of use as well as technical and functional
quality of the systems. According to previous studies, bothFinnish nurses and physicians are dissatisfied with the usabilityof their EHR systems [11]. Nurses’ experiences of the poor
usability of EHRs and how they can negatively affect workflow
appear to be consistent across countries [12,13]. Ease of use
and high quality of information systems promote the use oftechnology and support the management of care records [14].
However, EHRs that are perceived as difficult to use have beenshown to be associated with increased stress levels [15] andcognitive workload among nurses [16,17], which may
consequently increase the risk of cognitive failures [18].
Cognitive failure is defined as “a cognitively based error that
occurs during the performance of a task that a person is normallysuccessful in executing” [19]. The failure can occur in a person’s
memory functions, attention regulation, or actions [20], and theincidence is connected with work environment–related [18,21]
and individual factors [20].
So far, only limited and contradictory knowledge exists onwhether the consequences of poor EHR usability, particularly
stress or impairment in cognitive functions, could depend on
end user characteristics such as age. First, age-group differencesin the likelihood of experiencing EHR-related stress have notbeen found [22]. However, experienced (and thus likely older)nurses can have more negative attitudes toward the use of newtechnologies in clinical work [23]. They may potentiallyexperience more stress and higher cognitive workload than
younger professionals, who may adapt better todigitization-related changes [16]. Second, youth has been
associated with higher nursing informatics competence, suchas skills in electronic documentation and use of information
technology [24], which can make working with the EHRs easierand be a factor in protecting nurses’ well-being at work [15].
Nevertheless, while young nurses starting their careers may be
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Kaihlanen et al
more skilled in and used to using technology than older nurses,
they are still probably less experienced in using EHR systems
in their work. Multiple studies have suggested that integrating
EHRs into daily workflow and performing EHR-related tasks
may be easier and require less cognitive effort from moreexperienced EHR users than from novice users [17,25].
Based on our knowledge, there is little evidence of whether
nurses of a certain age are more at risk of experiencing stressor increased cognitive workload due to poor usability of EHR
systems. In light of previous evidence, differences may exist
between nurses of different ages, but the findings are mixed andthe potential moderating effect of EHR usability has not been
investigated. Moreover, previous studies examining the negative
outcomes linked to EHR usability, such as stress, have mainly
focused on physicians [26-28] and less on nurses [22].
Identifying those most at risk of experiencing EHR-related
disadvantages is important in order to provide them withadequate support in using the systems. Most importantly, thetopic requires further investigation because problems related to
EHR usability and subsequent issues of stress and impairment
in cognitive performance are notable threats to the quality ofcare and patient safety [18,29,30]. This study aimed toinvestigate the associations of EHR usability and user’s age
with stress related to information systems and cognitive failure
at work among registered nurses. Additionally, we examined
whether the possible associations of EHR usability with stressrelated to information systems and cognitive failures are
modified by user age.

Methods
Setting, Data Collection, and Participants
In 2017, a nationwide cross-sectional survey was conducted in
Finland on registered nurses’ experiences with currently used
EHR systems [15,31,32]. The data were collected with a
web-based questionnaire that was sent to all the registered nurses(n=29,283) who were members of the Finnish Nurses
Association and the National Association of Health and Welfare
Professionals and had provided an email address. Altogether,3607 of the 29,283 nurses responded to the questionnaire (a12.3% response rate). Nurses with missing information on anyof the demographic variables (age, gender, employment sector)
were excluded from the study (n=224), resulting in a final
sample of 3383 nurses. In the Finnish public health care system,
the EHR coverage has been 100% since 2010 [33]. Over 20
EHR brands are being used in different health and social caresettings [31].

Measurements
The EHR usability was measured with 7 ease of use–related
items (α=.84) from the validated National Usability-Focused
Health Information System Scale (NuHISS) [34]. The items
were as follows: (1) the arrangement of fields and functions islogical on a computer screen; (2) the systems keep me clearly
informed about what it is doing (eg, saving data); (3)terminology on the screen is clear and understandable (eg, titles
and labels); (4) routine tasks can be performed in astraightforward manner without the need for extra steps using
the system; (5) it is easy to obtain necessary patient information
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using the information system; (6) entering and documenting
patient data is quick, easy, and smooth; and (7) the informationon the nursing record is in an easily readable format. Items wererated on a 5-point scale (1=fully disagree to 5=fully agree). A
higher score on ease of use items indicates better experienced
usability.
Stress related to information systems was measured with 2 items(α=.62) that evaluated how often during the past half-year period
the person has been distracted, worried, or stressed about (1)constantly changing information systems and (2) difficult, poorly
performing information technology equipment or software [26].
The items were rated on a 5-point scale ranging from 1 (never)to 5 (very often). This measure has been previously used withphysicians and is associated with EHR usability and distress[27,35].
Cognitive failures were measured with 3 items (α=.59) modified
from the 15-item Workplace Cognitive Failure Scale (WCFS)[20,36]. The WCFS includes 3 dimensions: failure in memory,
failure in attention, and failure in action. Regarding the lengthof the survey questionnaire, we had to limit the number ofquestions and chose 1 item per dimension to measure nurses’
cognitive failures. The selection of these items was based on
their highest loadings for the 3 factors or dimensions ofcognitive failure [20]. Participants were asked to rate how often
they have faced situations at work where they (1) have notremembered a work-related password, set of numbers, etc(memory failure); (2) have not fully listened to the instructions
or requests they have received (attention failure); or (3) haveaccidentally started or closed the wrong device, system, or
program (action failure). Items were answered on a 5-point scaleranging from 1 (never) to 5 (several times a day).
Other variables included were age, gender, and employment
sector (1=hospital, 2=health center, 3=private sector, 4=social
services, or 5=other).

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Data Analysis
Continuous variables are summarized using mean and standard
deviation, and categorical variables are presented as the numberof participants and percentage. Multiple linear regression wasused to examine the associations of EHR usability and nurse’s
age with stress related to information systems and cognitive
failures. This method was chosen because the associations wereassumed to be linear, and it offered easily interpreted output
coefficients and a less complex algorithm compared to manyother methods. Analyses were conducted separately for both
dependent variables (stress related to information systems andcognitive failures). In the first step, EHR usability and age were
included as predictors in the model. In the second step, thecombined effect of EHR usability and age was tested by adding
an interaction term to the former model. Age was divided by
10 for the analysis to assess a given decade’s association andmake the estimated coefficients easier to interpret. All models
were adjusted for gender and employment sector. The analyses
were conducted using RStudio.

Results
Characteristics of the Participants
The majority of the participants were female (3204/3383,
94.7%). They were, on average, 46.2 years old (range: 22-66),
and over half of the participants worked in hospitals. There weredifferences in the estimated EHR usability (P<.001), stressrelated to information systems (P<.001), and cognitive failures(P=.02) between nurses working in different work environments.
The EHR usability was rated highest among nurses who worked
in social services. Nurses working in hospitals gave the lowest
EHR usability ratings and had more stress related to information
systems than nurses working in other fields. There were no
gender differences in the values of the variables studied.
Characteristics of the participants and descriptive statistics ofthe study variables are presented in Table 1.

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Table 1. Characteristics of the participants (N=3383) and descriptive statistics.
Characteristic

n (%)

Mean

SD

Minimum

MedianMaximum

Age, years

N/Aa

46.22

11.1

22

48

66

Male

169 (5.0)

N/A

N/A

N/A

N/A

N/A

Female3204 (94.7)

N/A

N/A

N/A

N/A

N/A

Other

10 (0.3)

N/A

N/A

N/A

N/A

N/A

Hospital1796 (53.1)

N/A

N/A

N/A

N/A

N/A

Health center

707 (20.9)

N/A

N/A

N/A

N/A

N/A

Private clinic

173 (5.1)

N/A

N/A

N/A

N/A

N/A

Social services

433 (12.8)

N/A

N/A

N/A

N/A

N/A

Other

274 (8.1)

N/A

N/A

N/A

N/A

N/A

Usability

N/A

3.04

0.78

1

3

5

SRISb

N/A

3.02

0.89

1

3

5

Cognitive failures

N/A

1.96

0.51

1

2

5

Gender

Employment sectoraN/A: not applicable.

b

SRIS: stress related to information systems.

Associations of EHR Usability and User Age With
Stress Related to Information Systems and Cognitive
Failures
The results of the linear regression analyses are shown in Table
2. The EHR usability was associated with both stress related to
information systems (β=.38; P<.001) and cognitive failures(β=.28; P<.001). Higher levels of usability were associated withlower levels of both stress related to information systems andcognitive failures. Age was associated with cognitive failures(β=.16; P<.001) but not with stress related to information

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systems. Younger nurses had higher levels of cognitive failurecompared to older nurses.
There was a significant interaction effect between age and EHR
usability for the cognitive failures (β=.04; P<.001). Younger
nurses who evaluated the EHR as difficult to use had the highest
levels of cognitive failures. Among older nurses, usability was
not associated with their cognitive failure levels (Figure 1).
There was no interaction effect between age and EHR usability
for the stress related to information systems (Figure 2). Figure
1 and Figure 2 illustrate the interaction effects.

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Table 2. The associations of age and EHR usability with stress related to information systems and cognitive failures.
Variable

Estimate

P value

Age

.10

.15

Gender.13.10

Hospital

Reference

N/Ab

Health center

.10

.03

Private clinic

.32

<.001

Social service

.18

<.001

Other

.16

.03

Usability

.38

<.001

Age × usability

.01

.80

Adjusted R2

0.16

N/A

Age

.16

<.001

Gender.02.74

Hospital

Reference

N/A

Health center

.08

.01

Private clinic

.03

.60

Social service

.00

.93

Other

.04

.33

Usability

.28

<.001

Age × usability

.04

<.001

Adjusted R2

0.04

N/A

SRISa

Employment sector

Cognitive failures

Employment sectoraSRIS: stress related to information systems.

b

N/A: not applicable.

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Figure 1. Interaction effect between EHR usability (ease of use) and user’s age for cognitive failures. The association is shown for low (mean − 1 SD),average, and high (mean + 1 SD) levels of ease of use. EHR: electronic health record.

Figure 2. Interaction effect between EHR usability (ease of use) and user’s age for information system–related stress. The association is shown forlow (mean − 1 SD), average, and high (mean + 1 SD) levels of ease of use. EHR: electronic health record.

Discussion
Principal Findings
This study examined the associations of EHR usability anduser’s age with stress related to information systems andhttp://medinform.jmir.org/2020/11/e23623/

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cognitive failures among Finnish registered nurses. The practicalgoal was to increase system vendors’, health care managers’,
and nursing educators’ awareness of the potential consequencesof poor EHR usability, a shared problem among nurses in many
countries that may jeopardize the quality and safety of care
[12,29]. As predicted, we found that EHR usability was
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associated with both stress related to information systems andcognitive failures. Nurses who provided higher usability ratings
had less stress and fewer cognitive failures compared to nurses
providing lower ratings. The nurses’ age, in turn, was not
associated with stress related to information systems, but it was
negatively associated with cognitive failures. We also found asignificant interaction effect between age and EHR usability
for cognitive failures, indicating that young nurses who rated
EHRs as difficult to use had the most cognitive failures.
The finding that young nurses’ cognitive functions may be more
impaired by poor EHR system usability compared to those ofolder nurses seems logical. The youngest nurses have probably
worked in the field for the shortest time, and the early stages ofa nursing career are known to be demanding and challenging,which can lead to their attentiveness and memory being strained[37,38]. In addition, older nurses with more experience of using
EHRs and various EHR brands may find it easier to integrate
information systems into daily workflow than less experienced
nurses [25]. A previous study has shown conflicting results andfound a relationship between higher age and increased risk ofcognitive failures among nurses [21]. However, this result was
explained by the fact that older nurses may have lower work
ability, which is associated with an increased risk of cognitive
failures in certain work environments [21]. Differences in work
environments also emerged in this study, and it appears that
EHRs may be particularly burdensome for nurses working in
hospital settings, who found the systems most difficult to use
and experienced the most stress compared to nurses working
in other environments. It would be important to find out theviews of nurses working in the hospital environment about the
weaknesses of EHRs and how systems should be developed to
improve their perceived usability and thereby reduce stress.
Due to new role adjustment, duties, responsibilities, and work
environments, many new nurses experience increased stressand emotional exhaustion [39]. These symptoms have been
associated with deterioration in cognitive performance (eg, inattention and memory functions), and this applies especially to
professions with high levels of work pressure and intense
cognitive demands, like nursing [40]. Although we only looked
at stress related to information systems in this study, it ispossible that the high level of strain early in their careers may
partly explain why young nurses in this study had morecognitive failures. Moreover, due to lack of expertise and thefact that the youngest generation of nurses are the most likely
to change jobs [41,42], they constantly have much to learn atwork. This, on top of a load caused by EHRs that are difficult
to use, may increase task stressors, such as performance
constraints, task uncertainty, or difficulties managing timepressure and frequent interruptions, all of which are shown tofoster cognitive failure [43].
It is evident that EHRs should support nurses in carrying out
their work tasks and not in turn increase workload, stress, or
cognitive burden. A recent review by Wisner et al concluded
that EHRs have the potential to support the cognitive work ofhealth care staff, but the scattering of information, information
complexity, and lack of chronology often hampers this.
Encountering problems while trying to find or synthesize
information can affect a nurse’s ability to achieve and maintain
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clinical understanding and situational awareness, which cancompromise patient safety [8]. Usability and stability of
information systems as well as end user involvement in systemdevelopment and work procedure planning may be significant
factors in alleviating stress related to information systems[15,26]. Since improving the usability of EHR systems seems
to be challenging, the importance of adequate orientation andsupport at work to use information systems is critical.
In this study, challenges were observed especially in young
nurses, whereby there is also a need to discuss whether current
nursing education provides students with adequate knowledge
and skills on how to use and integrate EHRs into daily work.
Shortcomings have been identified in both theoretical andpractical studies and, for example, in students’ opportunities topractice documentation with real EHR systems during theireducation [44,45]. The fact that using the systems can often
only be learned and practiced in the workplace after graduation
puts an additional burden on young nurses when there is still alack of mastery of the work and nursing as a whole. Moreover,the large number of different EHR brands and their differencesin usage logic, for example, may slow the process of learning
to use them.
Currently, work tasks that require the use of EHRs, such as
documentation, take up a significant portion of nurses’
day-to-day working hours [46]. Potential time pressure can bealleviated by having a high-quality information system [15].
Our study suggests that young nurses in particular could benefit
from well-designed and implemented EHR systems that support
routine tasks (eg, easy access to the information needed to treat
the patient). Another interesting finding was that while poor
usability of EHRs was associated with nurses’ higher stressrelated to information systems, the level of stress did not varysignificantly between younger and older nurses. In other words,
the levels of tolerance of EHR usability problems appeared tobe equal in nurses of different ages. The results of this study
contradict the stereotypical idea that millennial nurses who havegrown up with digitization and who are more accustomed tocoping with a variety of electronic platforms and tasks
simultaneously [47] would automatically be less burdened byinformation systems than those nurses who have had to learn
to work with them at a later age. Older nurses may compensate
for the slower adoption of information systems with theirexperience and better management of patients’ overall care.

Limitations
Possible limitations of this study should be considered wheninterpreting the results. First, in spite of representativeness of
the responses in a large sample of Finnish registered nurses[31], the response rate to the survey remained rather low. This
may limit the generalizability of the findings to a larger research
population. Second, we were able to use only 3 items from thescale measuring cognitive failures (WCFS), and the reliabilityof this measure (0.59) can be considered low. The WCFS has
demonstrated high internal consistency for the whole scale andsubscale level and the 3 items that were chosen for this study
are the most indicative of the 3 components (attention, memory,function) of cognitive failure [20]. Third, although we controlled
the analysis for gender and employment sector, we are aware
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that some other variables may have contributed to stress related
to information systems and cognitive failures as well (such as
how long a person has used the current EHR system). Finally,
the cross-sectional design did not allow the detection of causal
relationships of the variables under study. The data used in thisstudy was based on the first national survey of Finnish nurses
gathered using the validated NuHISS [34]. A resurvey will be
conducted in 2020, which will allow for further investigationof this topic.

Conclusions
Poor usability of EHRs can place a significant strain on the
day-to-day work of nurses. This study suggests that cognitive
performance, especially among young nurses, may be disturbed
due to poor EHR usability. Young nurses need support andfamiliarization in many aspects of nursing during their firstyears in practice, and attention should be paid to providing themwith appropriate support and training in the use of EHRs, whichtakes up a considerable amount of their working time. The
results indicate that young nurses, who are typically believed

Kaihlanen et al
to be fluent information technology users, may be burdenedwith poorly functioning information systems, possibly evenmore than their older colleagues are. System vendors have theprimary responsibility to ensure the usability of their systems
and to contribute to the quality of care and patient safety. It
could be useful to investigate whether some usability factors
are more critical than others. However, addressing the
weaknesses of EHRs may be slow. In order to tackle the adverse
consequences, it is important that employers provide adequate
support for the right groups and that educational institutions
provide students with adequate training in the use of EHRs.
Further research should pay attention to the experiences ofnurses of different ages and at different career stages in relation
to the use of EHRs. It would also be useful to investigate therelationship between EHR education received as a student andearly career stress and cognitive burden related to information
systems. Finally, studies with longitudinal designs are needed
to detect causal associations such as whether usability problems
lead to cognitive failures.

Acknowledgments
This work was funded by the Strategic Research Council at the Academy of Finland (project 327145) and the Ministry of Social
Affairs and Health (project 112241).

Authors' Contributions
AMK, KG, and TH conceptualized the study and developed the methodology. AMK and KG conducted the analysis. AMK wrote
the original draft. All authors reviewed and edited the manuscript. TH provided supervision for the study.

Conflicts of Interest
None declared.

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Abbreviations
EHR: electronic health record
NuHISS: National Usability-Focused Health Information System Scale
WCFS: Workplace Cognitive Failure Scale

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Edited by C Lovis; submitted 18.08.20; peer-reviewed by Q Do, J Tayaben; comments to author 26.09.20; revised version received
01.10.20; accepted 11.10.20; published 18.11.20
Please cite as:
Kaihlanen AM, Gluschkoff K, Hyppönen H, Kaipio J, Puttonen S, Vehko T, Saranto K, Karhe L, Heponiemi T
The Associations of Electronic Health Record Usability and User Age With Stress and Cognitive Failures Among Finnish Registered
Nurses: Cross-Sectional StudyJMIR Med Inform 2020;8(11):e23623
URL: http://medinform.jmir.org/2020/11/e23623/
doi: 10.2196/23623
PMID: 33206050©Anu-Marja Kaihlanen, Kia Gluschkoff, Hannele Hyppönen, Johanna Kaipio, Sampsa Puttonen, Tuulikki Vehko, Kaija Saranto,
Liisa Karhe, Tarja Heponiemi. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 18.11.2020. Thisis an open-access article distributed under the terms of the Creative Commons Attribution License(https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,provided the original work, first published in JMIR Medical Informatics, is properly cited. The complete bibliographic information,a link to the original publication on http://medinform.jmir.org/, as well as this copyright and license information must be included.

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