An integrative review exploring the impact of Electronic Health Records (EHR) on the quality of nurse–patient interactions and communication

Abstract Aim To explore how nurses' use of electronic health records impacts on the quality of nurse–patient interactions and communication. Design An integrative review. Data sources MEDLINE®, CINAHL®, PscyINFO, PubMed, BNI and Cochrane Library databases were searched for papers published between January 2005 and April 2022. Review methods Following a comprehensive search, the studies were appraised using a tool appropriate to the study design. Data were extracted from the studies that met the inclusion criteria relating to sample characteristics, methods and the strength of evidence. Included empirical studies had to examine interactions or communication between a nurse and patient while electronic health records were being used in any healthcare setting. Findings were synthesized using a thematic approach. Results One thousand nine hundred and twenty articles were initially identified but only eight met the inclusion criteria of this review. Thematic analysis revealed four key themes, indicating that EHR: impedes on face‐to‐face communication, promotes task‐orientated and formulaic communication and impacts on types of communication patterns. Conclusion Research examining nurse–patient interactions and communication when nurses' use electronic health records is limited but evidence suggests that closed nurse–patient communications, reflecting a task‐driven approach, were predominantly used when nurses used electronic health records, although some nurses were able to overcome logistical barriers and communicate more openly. Nurses' use of electronic health records impacts on the flow, nature and quality of communication between a nurse and patient. Impact The move to electronic health records has taken place largely without consideration of the impact that this might have on nurse–patient interaction and communication. There is evidence of impact but also evidence of how this might be mitigated. Nurses must focus future research on examining the impact that these systems have, and to develop strategies and practice that continue to promote the importance of nurse–patient interactions and communication. Patient or Public contribution Studies examined within this review included patient participants that informed the analysis and interpretation of data.

'tension between caring and charting' when integrating EHRs that were not designed for perinatal patients and their specialty practice.
Interacting with the patient and family was perceived by nurses as integral to the quality of care during labour and birth and EHR was viewed as a 'potential threat to this dimension of their work' (Wisner et al., 2021).
For example, positively encouraging patient questions during doctor's consultations (Makoul et al., 2001); disrupting physician-patient Patient or Public contribution: Studies examined within this review included patient participants that informed the analysis and interpretation of data.

K E Y W O R D S
nurse-patient interactions, patient communication, electronic health record, integrative review, health information technology, person-centred care communications, due to long pauses during conversations and patients' avoiding talking while doctors used a keyboard (Greatbatch et al., 1993); and taking doctor's attention away from the patient, as they faced a 'dilemma of attention' between the computer and patient (Swinglehurst et al., 2011) and were pre-occupied with the computer, averting their gaze from patients (Greatbatch et al., 1993).
A recent review by Moore et al. (2020) explored the impact of health information technology on nurses' time and found that nurses spent more time on documenting care but also more time with the patient. Wisner et al. (2019) undertook a review examining EHR's impact on nurses' cognitive work; they found that nurses perceived EHR to affect their work and while it might be logical to conclude that this would include interaction with the patient, the report did not look at this specifically. Crampton et al.'s (2016) review examining the impact of health information technology on the clinical encounter and patient-clinician communication found clear implications for eye contact, gaze, relationship building but did not focus on nurse-patient interactions.

| Checklistapproach
EHR systems use an anticipatory approach to address patient needs via digital prompts. EHR checklists and scripts aim to assure nurses, managers and employers that fundamental aspects of care have been completed to promote patient safety. If patient risk assessments, checklists or care activities are not signed as completed by the nurse, then the EHR system provides a summary of missing care and requires urgent nursing actions.
Despite the logical rationale for EHR, there is concern that EHR reflects a medical and systems-based approach, rather than a patient-centred approach to care (Winkelman & Leonard, 2004). An unintended consequence of the dominance of the medical model within EHR scripts, is that a patient may be viewed 'as a body to do things to' (Feo & Kitson, 2016), rather than a person to engage with as part of an integrated care plan (Feo & Kitson, 2016;Kitson et al., 2014). Therefore, the task-orientated approach reflected in EHR scripts may conflict with a person-centred, holistic nursing approach that involves shared decision-making (McCormack & McCance, 2006).

| PracticesandstandardsforEHRuse
Hospital EHR systems are usually completed by nurses via a computer that may be located on a static desk or a mobile trolley that the nurse moves into the vicinity of the patient when conducting a nursing round. Some nurses may use a handheld device to access systems (Lang et al., 2019;Winstanley et al., 2017) though these are not currently widely used (Deloitte, 2019;Richardson et al., 2020).
There are several reported advantages and disadvantages of EHR use. Some reported advantages include improved communication between departments and reduced documentation errors (Shafiee et al., 2022), ease of use for nurses and improved data accessibility (Jones & Seckman, 2018;McBride et al., 2017;Sockolow et al., 2014).
Nurses must adhere to EHR user guidelines and standards, which are set out by the EHR provider, and reflect the specific EHR system being used. However, there is limited guidance on best practices when nurses use EHR to interact with patients. The American Academy of Family Practice (Ventres et al., 2006) and Wuerth et al. (2014) offer practical guidance to enhance patient's experiences when clinicians use EHR, that includes key areas, such as integrating typing around the needs of the patient; start with the patient's concerns; keep patient-centred rather than computer-centred and do not stop interacting with the patient (Ventres et al., 2006;Wuerth et al., 2014). While this guidance is useful, a detailed review of the evidence surrounding the effects of EHR on nurse-patient interactions will provide an in-depth understanding of how EHR influences interaction and what we can do to ensure any negative impacts are minimized.

| Aim
The aim of this integrative literature review is to explore how nurses' use of EHR impacts on the quality and person-centredness of nursepatient interactions.

| Design
An integrative review was conducted following Whittemore and Knafl's (2005) five-stage framework that included: problem identification, literature search, data evaluation, data analysis and presentation. The use of an integrative review allowed for the range of observational and multi-method data collection approaches and resulted in a comprehensive portrayal of the topic and its importance to nursing. The inclusion criteria for papers were as follows: (1) published in the English language; (2) examined the interactions or communication between a nurse and patient while EHR is being used by nurse(s) in any healthcare setting (see Table 2: Inclusion criteria).

| Literature search
Exclusion criteria were as follows: (1) published in a language other than English; (2) no examination of the interactions or communication between a nurse and patient while EHR is being used by nurse(s). For example, time and motion studies that coded nurses' actions for workload were excluded if they coded observed 'Patient Communication' as discussions with other healthcare professionals only, and there was no direct communication between the nurse and patient.
Search terms were discussed and confirmed with two healthcare librarians. Boolean operators AND/OR were used to combine key search words, synonyms (taking into account the international terms used for EHR) and truncations and to widen and narrow the search within the MEDLINE®, CINAHL®, PscyINFO, PubMed, BNI and Cochrane Library databases. The search was undertaken using the key words and synonyms for 'patient,' AND 'nurse,' AND 'interaction,' AND 'electronic patient records' (see Table 1: Keywords, synonyms and truncations).
Adjacent key words, to between three spaces, were included, using 'Adj3' for word patterns, for example, the words 'nurse*' and 'patient*.' To ensure the discovery of related words, there was an explosion of associated words such as 'Communication' within databases. Using 'Google Scholar Advanced Scholar' and Web of Science search engines did not find any additional studies. Initial searching was undertaken by the lead author and two University Health Care Librarians who were involved in the assessment of a selection of papers against the inclusion and exclusion criteria. Where it was not certain if a paper met the criteria, these papers were discussed with the co-authors.
A PRISMA (PRISMA) flow diagram was adapted from Moher et al. (2009) to present the sourcing, identification, inclusion and exclusion processes (see Figure 1).

| Qualityappraisal
Published critical appraisal tools were used to evaluate the included studies. A range of tools were used as appropriate to the design and methods of included studies. The Critical Appraisal Skills Programme (CASP) (CASP, 2022) checklist was used for appraising the methodological quality of qualitative studies (n = 3), whereas the Mixed Methods Appraisal Tool (MMAT) (Hong et al., 2018) was used for quantitative, and mixed methods studies (n = 5). Both critical appraisal tools are well-defined with clear directions relating to each appraisal question. The methodological quality of the included articles was assessed by the lead author and independently reviewed by the co-authors. Following quality appraisal, no studies were excluded, but the strengths and limitations of studies are acknowledged within the analysis of the papers, with greater weight given to the stronger papers.

| Dataextraction
Data were extracted from the eight studies that met the inclusion criteria relating to sample characteristics, methods, and strength of evidence, and observations relating to nurses' use of EHR impacting on nurse-patient interactions' (Whittemore & Knafl, 2005) (see Table 3: Main study characteristics and findings). Additionally, Table 4 offers an overview of the data collection methods used during observations within significant studies. The suitability of the extraction form was tested on two studies to ensure that it functioned.
The three authors independently reviewed all extracted data for accuracy.

| Synthesis
Data from the primary sources in this review were ordered, categorized, compared and summarized to inform an integrated conclusion about how nurses' use of EHR may impact on nurse-patient interactions (Miles & Huberman, 1994). Primary data were displayed using matrices for each category and iteratively compared to inform thematic analysis (Miles & Huberman, 1994).

Truncations used
Nurses Nurses, Nursing, Nursed Nurs* The emerging themes were discussed by the authors. Abstract conceptualized data were re-reviewed as new concepts formed to ensure consistency with primary sources (Whittemore, 2005). Due to the diversity of empirical sources within this review, the methodological quality of studies and value of information from papers, is acknowledged when discussing the following results and emerging themes.

| RE SULTS
Following the identification of 2374 relevant articles, the software package 'Endnote' was used to remove duplicate papers, leaving 2072. A review of the abstracts and titles of papers that potentially met the inclusion criteria left 1920 studies. The full texts of the 1920 articles were then screened for eligibility through the application of study exclusion and inclusion criteria, which left 12 papers. These 12 papers were re-checked against the inclusion and exclusion criteria by all three authors. Eight out of these 12 papers fully met the inclusion criteria.

| Characteristicsofincludedstudies
The eight studies included within this review represent data from 187 Nurses, 139 Patients, 11 Doctors and 13 Allied Health Professional from the United States (US) (Dowding et al., 2015;Fore et al., 2019;Gaudet, 2016;Gomes et al., 2016), United Kingdom (UK) (Rhodes et al., 2006(Rhodes et al., , 2008  Nurses) Overall theme: Rhodes et al. (2006) identified two contradictory features between 'patient-centred practice' and the 'emphasis on biomedical audit'; suggest achievement of former might be compromised by demands of latter.
One example consultation demonstrates a common feature in the dataset showing that the nurse's use of a 'computer template imposes a routine structure to the consultation and socializes the patient into what is considered acceptable behaviour' At no point does the nurse invite the patient to ask his own questions or express any concerns he might have. This was a feature of more than a third (9 of 25) of the consultations in the dataset and half of the consultations undertaken by a nurse (9 of

18)
The following features were common to many of the consultations in the dataset: • Nurses spent much of their time gazing at the computer screen or at papers on their desk • Questions were dictated by the checklist rather than following the natural flow of conversation. Questions were asked out of context. Nurses cut patients' answers short to ask the next question impact on nurse-patient interactions?
Themes Rhodes et al. (2008) (Rhodes et al., 2006(Rhodes et al., , 2008, and one study presented observed nursing care activities (Walker et al., 2019). Observation data collection methods across studies are presented in more detail in Table 4. . Some studies stated specifically where computers were located and being used by nurses, such as: adjacent to the head of each patient's bed (Gaudet, 2016); a laptop computer mounted on a wall (Gomes et al., 2016); or on a terminal in the medication room (Dowding et al., 2015).

| EHRimpedesonface-to-facecommunication
The impact of EHR use on face-to-face communication between the nurse and patient was observed in four studies (Burridge et al., 2018;Gaudet, 2016;Rhodes et al., 2006Rhodes et al., , 2008. Researchers observed that this was due to the logistics of computer use, as most nurses' attention was turned to the computer screen instead of towards the patient (Gaudet, 2016;Rhodes et al., 2006). Gaudet (2016)

| EHRpromotesatendencytowardstaskorientated communication
In addition to the perceived effect on face-to-face communication, four of the studies identified that task-orientated, checklistfocused communication dominated when nurses interacted with patients using EHR systems (Burridge et al., 2018;Gaudet, 2016;Rhodes et al., 2006Rhodes et al., , 2008. Nurses EHR use had the potential to create 'automatic' and 'machine-like interactions' between a nurse and patient (Gaudet, 2016) and was observed to disrupt informal communications and aspects of person-centred care, for example, 66% of nurses used EHR to conduct safety checks, focusing on checklists, rather than patients (Burridge et al., 2018). Rhodes et al. (2006 and2008) explored the contradictory features of 'patient-centred practice' and the 'emphasis on biomedical audit', and achieving the former was found to be compromised by the demands of the latter (Rhodes et al., 2006(Rhodes et al., , 2008. A common feature observed in Rhodes et al. (2006) study was that nurses' use of a computerized template forced a routine structure to the consultation and socialized 'the patient into what is considered acceptable behaviour' (Rhodes et al., 2006). Once requisite patient data were obtained and entered on the EHR system, nurses would immediately move on to the next checklist item. This was a feature of half of the primary care consultations undertaken by nurses (Rhodes et al., 2006). During consultations, Rhodes et al. (2006) observed that 'digression from the checklist agenda was discouraged' as the checklist templates imposed a routine of moving from one question to another, and the nurse did not invite the patient to express any concerns. Therefore, patients were treated as passive recipients of care, reflecting a task-orientated approach to care (Rhodes et al., 2006).

A shift towards a task allocation and a checklist approach is an
unintended consequence of the use of EHR; again, this is perceived by the participants reflecting on their approach to care when EHR is used.

| EHRpromotesaformulaic communication style
Unsurprisingly, the lack of face-to-face communication and the tendency towards a task-oriented approach identified in the studies seemed to lead to a formulaic approach to the delivery of nursing care. Two studies specifically mentioned how nurses' use of EHR af- and complexity of EHR tasks, such as information retrieval, hindered informal communications between the nurse and patient. However, this did not always seem to be the case as in contrast, some nurses in Dowding et al. (2015) study were observed to be adept at using the computer screen to promote positive communications and shared patient care-planning in US hospital wards (Dowding et al., 2015).
Furthermore, in interviews with nurses, Dowding et al. (2015) identified that nurses perceived that use of EHR systems improved their ability to communicate with patients by providing up-to-date information directly on the computer screen (Dowding et al., 2015).
However, during interviews nurses from both case sites reflected on the constant problems they had between documenting care and meeting care demands from patients (Dowding et al., 2015).
Therefore, it is evident that the formulaic communication style promoted by EHR influences nurse-patient communication; though not always negatively and these studies provide some guidance as to how good practice when using EHR might be developed.

| EHRimpactontypesof communication patterns
Five studies identified that EHR impacts on the types of commu- Nurse-patient interactions were identified by researchers as 'deliberative' or 'automatic' responses (Gaudet, 2016), or 'bureaucratic' or 'participative or patient centred' (Rhodes et al., 2008). Deliberative responses validated patients' replies, whereas automatic responses were characterized by limited exchange with a patient and a focus on the computer (Gaudet, 2016). Deliberative responses were evident on 12 occasions involving medication administration and automatic responses were present during 10 observations, when additional communication might have been warranted to ascertain the patient's need (Gaudet, 2016). Therefore, nurse-patient interactions reflecting automatic responses caused a barrier to open-ended questions and two-way communication, and patients' care needs may have been missed as nurse-patient conversations were concluded too early (Gaudet, 2016).
Two routine consultations in UK primary care diabetes clinics were deliberately compared to present two different styles of interaction, where a nurse's gaze was either predominantly towards the computer screen or directed more towards the patient. Two styles of 'bureaucratic' or 'participative or patient-centred' nurse-patient interactions were presented through the examination of these two primary care consultations (Rhodes et al., 2008). When the nurse's gaze was primarily towards the computer screen and a checklist approach was used, it was viewed as a 'bureaucratic' style of interaction. When the nurse's interactions were directed more towards the patient and the checklist agenda was suspended, it was deemed a 'participative or patient-centred' interaction (Rhodes et al., 2008).
Although one nurse gave priority to the EHR, which hindered patient participation, Rhodes et al. (2008) suggest that this is not necessarily a consequence of the use of EHR, as the other nurse suspended the use of a checklist. Rhodes et al. (2008) suggest that the differences between each encounter may relate to the 'active accomplishment of the nurse' and their ability to shift their gaze and bodily orientation between a computer screen and a patient.

| DISCUSS ION
We believe that this integrative review is the first to explore how nurses' use of EHR impacts on the quality of nurse-patient interac-  , 2006). Instead, these systems can cause a barrier between the patient and nurse and impede on face-to-face communication, due to the logistics of computer use and the types of devices being used (Gaudet, 2016;Rhodes et al., 2006Rhodes et al., , 2008. While EHR systems have the potential to assist in achieving a necessary care environment for positive nurse-patient interactions and communication to take place, this review suggests that this is not necessarily easily achieved, and nurses need to consciously change their behaviour for this to happen. The default situation seems to be that the use of EHR constrains a person-centred approach to care. In practice, there is limited guidance on best practices when nurses use EHR to promote 'shared power', shared decision-making and patient involvement. The American Academy of Family Practice (Ventres et al., 2006) and Wuerth et al. (2014) offer practical tips that clinicians can use to promote a patient-centred approach, such as starting with the patient's concerns, encouraging patient's active participation in building their charts and screen sharing with patients but it is not clear that these are based on empirical evidence. Voran et al. (2016) highlight a triangulated relationship between a healthcare provider, computer and patient, calling it a 'Magic Triangle'; whereby the computer has become an essential part of a provider-patient interaction. How a healthcare provider interacts with a patient while using a computer may promote or hinder patient participation (Voran et al., 2016). Directing the patient to the computer screen, for example, is suggested to be consistent with a patient-centred caring approach (Voran et al., 2016). Kumarapeli and de Lusignan (2013)  We did not identify research that specifically explored nurses' adaptation to the use of EHR, however some nurses do adapt their communication style when using the EHR technology (Rhodes et al., 2008), whereas others seem less able to do so (Gaudet, 2016;Rhodes et al., 2006Rhodes et al., , 2008. Crampton et al.'s (2016) review of computer use in the clinical encounter concurs, suggesting that the strategies employed by clinicians, clinicians' styles and the layout of the room, will all have an impact on the clinician-patient encounter; either positively or negatively.
One explanation for this is the way in which the use of EHR affects the nurses' gaze and posture (Rhodes et al., 2008). Two case studies from routine consultations in primary care diabetes clinics identified how nurses' gaze orientations reinforced their body orientations and led to different types of nurse-patient interactions, for example turning away from the patient towards the computer, systematically obstructing discussions and seemingly reluctant to engage with the patient's concerns (Rhodes et al., 2008). The nurse's body orientation in Case 1 had legs and torso turned towards the computer and the nurse appeared reluctant to engage with the patient's concerns, systematically obstructing discussion. In comparison, the nurse's body orientation in Case 2 signalled full attention through continued eye contact and by fully facing the patient, and the nurse encouraged the patient to expand conversation (Rhodes et al., 2008).
Although both nurses followed a computerized checklist, the second nurse did not allow its presence to dominate nurse-patient interactions, which suggests that not all nurses are detracted from face-toface communication when using EHR systems. Similarly, Dowding et al. (2015) observed that many nurses across both case study sites developed a 'sophisticated ability to juggle these competing demands' between the patient and the EHR system; documenting assessment information and vital signs immediately onto the EHR system by the patient's bedside (Dowding et al., 2015).
These case studies indicate that there are ways in which nurses can adapt the EHR systems to promote nurse-patient interactions.
Such adaptations require conscious action on the part of the nurse and the effectiveness of these adaptations requires further research. In addition, there have been calls in the UK for a more centralized approach when purchasing EHR systems to promote further consideration of interoperability and standardization and to include nurses in the design (Warren et al., 2019). For example, some clinical areas promoted 'Point-of-care' (as defined by Kitson, 2018) patient assessment and documentation; moving workstations on wheels into the vicinity of the patient at the point at which care was undertaken (Dowding et al., 2015;Gomes et al., 2016;Walker et al., 2019).
In contrast, Gaudet (2016)  There are several limitations to this review. Eight studies that met the inclusion criteria were undertaken in three countries and hence do not represent the global picture of nurse-patient interaction when EPR is used. Capturing the essence of nurse-patient interaction and communication is inherently complex and none of the studies identified were able to assess communication and interaction before the introduction of EHR. Therefore, a true comparison of nurse-patient interaction before and after the introduction of EHR is not possible. Interestingly, there is evidence that physicians are promoting the need for EHR training to improve doctor-patient interactions and communication, using strategies such as repositioning themselves and screen sharing to improve patient experience (Voran et al., 2016).

| Implicationsfornurseeducationandpractice
The nursing profession and nurse educators should follow suit, as nurses' style of communication and their approach towards patient communication when using EHR may affect patients' experiences.

| Implicationsforfutureresearch
The on-going development of EHR systems is likely to have farreaching effects on the future of nursing practice in both profound and subtle ways. Healthcare employers and system developers need to consider the unintended impact of nurses' use of EHR on the quality of nurse-patient interactions and communication. Technology companies and healthcare providers need to develop and support user-friendly EHR systems that promote, and not hinder, quality nurse-patient interactions and person-centred care. For example, devices that direct patients to their EHR care plan, may promote two-way communication and shared decision-making. However, we need to be mindful that not all patients can access this. Future studies are needed to evaluate nurses' use of different EHR systems and identify systems which promote two-way communication, shared decision-making and a person-centred approach to care. There are indications that nurses can use strategies to minimize the effects of the checklist approach on nurse-patient interaction, but these strategies are not extensively evaluated.
It is evident that there is a need for more international multi-method research studies that explore how nurses EHR use influences the quality of nurse-patient communication, across a range of healthcare settings.
Future research exploring nurses' use of EHR should include rigorous evaluation of the algorithms and other technology-mediated communication systems being used that includes the perspective of both patients and nurses to achieve these goals. The environments in which EHR systems are being used by nurses and the ergonomics surrounding their use must also be examined and taken account of when researching this area. This is important to ensure that nurses play an active role in the development of EHR and avoid being a passive recipient of technology.

| CON CLUS ION
It is internationally accepted that the essence of nursing practice is underpinned by a compassionate, holistic and person-centred approach to care. Globally, the importance of EHR to promote clinical safety standards is not disputed. However, there is evidence to suggest that compassionate, two-way nurse-patient interactions are hindered by the unreflective use of checklists underpinning EHR systems. Digital algorithms are dictating and changing contemporary nursing practice at a rapid rate, and we owe it to our future nursing profession and patients to engage fully with the developments surrounding this to ensure that our profession is not reduced to checklists and changed beyond recognition. Healthcare employers and technology companies developing future systems must include nurses' and patients' perspectives when evaluating EHR systems and take account of the environments in which they work to promote person-centred care and quality nurse-patient interactions.

AUTH O RCO NTR I B UTI O N S
All authors have agreed on the final version and meet at least one of the following criteria (recommended by the ICMJE*): (1) substantial contributions to conception and design, acquisition of data or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content. * http://www.icmje.org/ recom menda tions/.

Special thanks to Helen Walthall Director of Nursing Research and
Innovation at the Oxford University Hospitals NHS Foundation Trust for supporting the early stages of PhD discussion.

CO N FLI C TO FI NTE R E S T
No conflict of interest has been declared by the authors.

PEER R E V I E W
The peer review history for this article is available at https://publo ns.com/publo n/10.1111/jan.15484.