Abstract
Objectives The purpose of this study is to understand the relationship between documentation burden and clinician burnout syndrome in nurses working in direct patient care. The Office of the National Coordinator considers documentation burden a high priority problem. However, the presence of documentation burden in nurses working in direct patient care is not well known. Furthermore, the presence of documentation burden has not been linked to the development of clinician burnout syndrome.
Methods This paper reports that the results of a cross-sectional survey study comprised of three tools: (1) The burden of documentation for nurses and mid-wives survey, (2) the system usability scale, and (3) Maslach's burnout inventory for medical professionals.
Results Documentation burden has a weak to moderate correlation to clinician burnout syndrome. Furthermore, poor usability of the electronic health record (EHR) is also associated with documentation burden and clinician burnout syndrome.
Conclusion This study suggests that there is a relationship between documentation burden and clinician burnout syndrome. The correlation of poor usability and domains of clinician burnout syndrome implies the need for more work on improving the usability of EHR for nursing documentation. Further study regarding the presence of documentation burden and its correlation to clinician burnout syndrome should focus on specific areas of nursing to understand the drivers of documentation burden variation within and across specialty domains.
Keywords: documentation, burnout, electronic health record, health care providers, documentation burden, nurse burnout
Background and Significance
Clinician burnout syndrome in nursing has become more prevalent in recent years. 1 Nurses who experience burnout may exhibit symptoms such as emotional exhaustion, lack of empathy, low self-esteem, and the feeling that they are not able to achieve personal accomplishments. 2 Consequences of burnout include physical and somatic symptoms, increase in absenteeism, and turnover. 3 Approximately 38% of nurses report experiencing at least one symptom of burnout. 4 In addition, the average national turnover rate for bedside nurses increased from 16.8% in 2019 to 18.7% in 2021. 5 The cost of turnover equates to over $40,000 per bedside nurse. 5 6 Nursing staff turnover places patients at risk for poor outcomes as experienced nurses are replaced with new and less experienced staff. 7 Factors identified as contributors to burnout include high stress environments, moral distress, and job dissatisfaction. 8 9 10 Documentation of patient care, specifically the burden of documentation is a contributing factor and thus should be studied further. 11
Documentation burden is defined as the increased effort and time demand to document patient care in the EHR. 12 For the purpose of this paper, the constructs for effort include EHR workload and usage, clinical documentation/review, and cognitively cumbersome work. 12 Nurses' time and effort 12 to document patient care, create the burden that nurses experience when attempting to document during their workday. 13 Local, State, and Federal policies have been shown in the past to increase health care providers workload, thus increasing the effort needed to complete documentation tasks within a limited amount of time. 11 The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 have exacerbated documentation burden. 14 The HITECH Act implemented electronic clinical quality measures to track the viability of the electronic health record (EHR) while attempting to improve the quality of patient care. 15 The Nurse Practice Acts from several states are an example of how policies can potentially drive documentation when they stipulate that specific aspects of patient care must be documented. 16 17 18 In addition, many nurses have been taught the phrase “if it was not documented, it was not done.” 19 These examples drive the nurse to document all activities (e.g., assessments, medication administration, and patient education) related to patient care. 14 15 20 21
Usability is defined as “the effectiveness, efficiency, and satisfaction with which the intended users can achieve their tasks in the intended context of product use.” Poor EHR usability may contribute to an increased risk of patient harm 22 23 and has been linked to symptoms of burnout in physicians. 24 Poor usability is also considered a domain of documentation burden. 25 However, the effect of usability of EHR and its association with burnout in nurses is not known. 11
Nurses are the largest group of EHR end-users in health care. 26 Nurses have been shown to document in the EHR between 600 and 800 data points per 12-hour shift. 27 This equals one data point per 1.11 minutes. 28 The increased documentation time demand associated with the emergence of EHRs provides an additional stressor to clinicians in the acute care setting. 29 30 These workplace stressors can lead to negative side effects to mental health such as clinician burnout syndrome. 31 While there are studies assessing the impact of documentation burden among primary care providers and its association with clinician burnout syndrome (e.g., physicians and nurse practitioners), there is little published evidence to understand documentation burden focused on nurses. 12
Purpose
The purpose of this research is to explore documentation burden among nurses and whether it is a contributing factor to clinician burnout syndrome. The study includes two specific aims: (1) to examine the relationship between documentation burden and clinician burnout syndrome, (2) to describe the association of usability in the EHR on the nurses' perception of documentation burden.
Methods
Using a cross sectional survey design, we report on the association between documentation burden and clinician burnout syndrome. A 68-item survey was distributed via email from May 2020 to September 2020 using Qualtrics Survey software. 32 The survey consisted of three validated instruments; Maslach's Burnout inventory-Human Services Survey for Medical Personnel (MBI-HSSMP), Burden of Documentation for Nurses and Mid-wives (BurDoNsaM), and the System Usability Survey (SUS).
The MBI-HSSMP consists of 22 items in three domains: emotional exhaustion, depersonalization, and personal accomplishment. Each domain contains a set of questions which generates a score to determine the level of burnout for that domain. Questions in each domain are rated from 0 (never) to 6 (every day). Each score determined the frequency score of high, moderate, and low. The higher the score, the higher the frequency of nurse experiencing that domain of burnout. 33 Internal reliability of each scale was determined through over 80 previously published studies with Cronbach alphas for each domain ranging from 0.71 to 0.90. 34 35 36 The primary investigator paid for licenses to use the tool in a web survey format.
The second set of questions in the online survey consisted of BurDoNsaM. This validated survey tool consists of 26 items and six subscales: view of clinical documentation, burden of documentation, hospital leadership and documentation, time taken to complete documentation, documentation issues and solutions, and intervention evaluation ( Table 1 ). Four questions were omitted from the time to complete documentation sub-survey scale because they were too specific and focused on inpatient nursing care. Each subscale generated a score to quantify the level of burden within that domain. 37 Using data from this study, we calculated the reliability for each subscale and Cronbach alphas ranged from 0.46 to 0.80.
Table 1. Burden of documentation for nurses and mid-wives a .
| Strongly disagree | Disagree | Slightly disagree | Slightly agree | Agree | |
|---|---|---|---|---|---|
| View of clinical documentation sub-scale | |||||
| Generally, the documentation is easy to complete | |||||
| Generally, the documentation I complete is complex | |||||
| The documentation I complete adds value to patient care | |||||
| I believe documentation is essential for communication | |||||
| The documentation I complete aids communication | |||||
| The documentation I complete ensures continuity in patient care | |||||
| The documentation I complete ensures quality in patient care | |||||
| Documentation assists new nurses and midwives to remember their professional tasks | |||||
| The quantitative measures used in documentation do not show the true value of “good” nursing care | |||||
| Burden of documentation sub-scale | |||||
| Double documentation (duplication) is an avoidable burden | |||||
| Some of the documentation and paperwork is unnecessary | |||||
| Some documentation is completed to meet the national standards but does not assist patient care | |||||
| There is too much documentation and too little time | |||||
| The volume of paperwork impedes patient care | |||||
| Our documentation and paperwork create confusion | |||||
| Hospital leadership and documentation sub-scale | |||||
| The leadership understands the demands documentation and paperwork place on us | |||||
| I get to contribute to the development of relevant clinical documentation and paperwork | |||||
| Time taken to complete documentation | |||||
| There is enough time to complete paperwork | |||||
| I finish work late because of outstanding clinical documentation and paperwork | |||||
Reproduced with permission from Brown et al 2020 37 .
The third tool, the SUS, consists of 10 items and measures the usability of software and other technology. Using Cronbach's coefficient α , the reliability of the SUS is 0.9. 38 39 The validity of the SUS has been confirmed across multiple studies. 40 41 The items included in SUS are rated on a 5-point Likert scale. The score generated from the Likert scale was calculated using a specific formula specified by the SUS which determines the level of usability for the EHR the nurse used. 42 Due to the broad nature of this study, the specific EHRs used were not identified. However, nurses reported using EHRs from acute and homecare settings.
Sample and Project Setting
An invitation to the survey was distributed via email distribution lists for the RN-BSN, graduate and doctoral nursing programs at the University of Massachusetts-Boston, which enrolls approximately 565 students. To achieve a higher response rate, snowball sampling was used wherein participants were encouraged to forward the email invite to others. The inclusion criteria were registered nurses with at least 1 year of experience. In addition, the participants must have experienced documenting patient care in the EHR. The exclusion criteria were registered nurses with less than 1 year of experience, completed patient care documentation on paper only, or health care workers who are not registered nurses. IRB approval was obtained.
Analysis of Documentation Burden and Clinician Burnout Syndrome
To determine the presence of burnout among the study participants, the MBI scores for each domain of burnout were calculated using Maslach's formula. 33 Then the average scores of each subdomain of the BurDoNsaM were calculated. The BuRDoNSaM is not designed to have an overall measure of documentation burden and thus, could not be calculated. A Pearson correlation test was conducted to test the association between two variables for each domain of both constructs. The analysis was conducted using IBM SPSS statistical software.
Analysis of System Usability Scale and Clinician Burnout Syndrome
Analysis of system usability scale and clinician burnout syndrome in this study consists of the level of burnout for each domain in Maslach's burnout inventory and correlated to the results in the BurDoNsaM survey. The SUS was correlated to the level of burnout for each domain to assess if perceived usability of the EHR is a factor that contributes to clinician burnout syndrome. A Pearson correlation test was conducted to test the association between two variables.
Results
This study examined the possible relationships between documentation burden in nursing, usability of the EHR, and clinician burnout syndrome. The total number of responses to the survey was 85 participants. Due to the snowball sampling method, the total response rate cannot be determined. The respondents with missing data were removed from the analysis which resulted in a total of 69 participants in the final analysis. Despite the removed participants the strength of the correlation coefficient between the variables ranged from small to medium ( r = 0.1–0.4) for significant correlations. The p -value was set at 0.05.
Burden of Documentation and Clinician Burnout Syndrome
Table 2 describes the demographics of the respondents including their nursing specialty. The majority of the participants identified as female between the ages of 21 to 34 and were primarily White. The nursing specialties ranged from acute and critical care to home hospice care. Table 3 describes the average level of burnout for each domain in the Maslach Burnout Inventory. The mean of each domain was calculated. Participants experienced a moderate level of burnout across all three domains.
Table 2. Demographics of respondents.
| Sex | Frequency | Percent (%) |
|---|---|---|
| Male | 4 | 5.8 |
| Female | 64 | 92.8 |
| Missing | 1 | 1.4 |
| Age | ||
| 21–34 | 41 | 59.4 |
| 35–44 | 17 | 24.6 |
| 45–54 | 9 | 13 |
| 55–64 | 2 | 2.9 |
| Race | ||
| White or Caucasian | 57 | 82.6 |
| Black or African American | 4 | 5.8 |
| Asian | 6 | 8.7 |
| Other | 2 | 2.9 |
| Nursing specialty | ||
| Critical care | 23 | 33.3 |
| Acute care | 23 | 33.3 |
| Acute mental health | 2 | 2.9 |
| Pediatrics or neonatal | 2 | 2.9 |
| Maternity | 3 | 4.3 |
| Operating room/surgery | 2 | 2.9 |
| Ambulatory care | 6 | 8.7 |
| Nursing home/long-term care facility | 2 | 2.9 |
| Home care | 3 | 4.3 |
| Hospice | 3 | 4.3 |
| Total participants | 69 |
Table 3. Mean for each domain of Clinician Burnout syndrome.
| Domains of Clinician Burnout syndrome | Mean | Interpretation 33 |
|---|---|---|
| Emotional exhaustion | 26.36 | Moderate |
| Depersonalization | 8.32 | Moderate |
| Personal accomplishment | 37.87 | Moderate |
Table 4 describes the correlational results between the BurDoNsaM Sub-Scales and the domains of clinician burnout syndrome. A Pearson correlation test was conducted comparing the variables of the burden of documentation sub-scale and emotional exhaustion. These two variables demonstrated a weak to moderate positive correlation. Furthermore, when the Pearson correlation test to compare the burden of documentation sub-scale and depersonalization was conducted, it also demonstrated a weak positive correlation. The burden of documentation subscale was correlated to the clinician burnout domain of personal accomplishment; there is a negative correlation noted but it is not statistically significant. The Pearson correlation was repeated for each domain of clinician burnout syndrome and the value of clinical documentation subscale which did not demonstrate a significant relationship. In addition, the time to document subscale was correlated to the domains of clinician burnout syndrome and was not found to have a significant correlation between the variables. However, when the hospital leadership and documentation subscale was compared with domains of clinician burnout syndrome, it was noted that emotional exhaustion demonstrated a moderate negative correlation, and depersonalization demonstrated a weak negative correlation.
Table 4. Results of Pearson correlation coefficient (r), including significance ( p ) between documentation burden and Clinician Burnout syndrome .
| BurDoNsaM sub-scale | Emotional exhaustion | Depersonalization | Personal accomplishment |
|---|---|---|---|
| Burden of documentation |
p
= 0.001
r = 0.404 |
p
= 0.015
r = 0.292 |
p
= 0.344
r = − 0.116 |
| Value of clinical documentation |
p
= 0.605
r = − 0.63 |
p
= 0.403
r = − 0.102 |
p
= 0.660
r = 0.054 |
| Time taken to complete documentation |
p
= 0.163
r = − 0.170 |
p
= 0.816
r = − 0.028 |
p
= 0.196
r = 0.157 |
| Hospital leadership and documentation |
p
= 0.000
r = − 0.549 |
p
= 0.026
r = − 0.336 |
p
= 0.268
r = 0.268 |
System Usability Scale and Clinician Burnout Syndrome
Table 5 includes the correlational analysis between the system usability scale and the domains of clinician burnout syndrome. We found a weak negative, but a statistically significant ( p <0.001) correlation between system usability and emotional exhaustion. The correlations between the system usability scale and depersonalization and personal accomplishment were not statistically significant.
Table 5. Results of two Pearson correlation coefficient ( r ), including significance ( p ) between survey items for of the BurDoNsaM Survey .
| Burden of documentation sub-scale items | Emotional exhaustion | Depersonalization | Personal accomplishment |
|---|---|---|---|
| Double documentation (duplication) is an avoidable burden |
p
= 0.320
r = 0.122 |
p
= 0.785
r = 0.33 |
p
= 0.468
r = − 0.089 |
| Some of the documentation and paperwork is unnecessary |
p
= 0.179
r = 0.164 |
p
= 0.116
r = 0.191 |
p
= 0.744
r = − 0.040 |
| Some documentation is completed to meet the national standards but does not assist patient care |
p
= 0.054
r = 0.233 |
p
= 0.099
r = 0.200 |
p
= 0.985
r = − 0.002 |
| There is too ρ much documentation and too little time |
p
= 0.003
ρ = 0.350 |
p
= 0.109
ρ = 0.195 |
p
= 0.808
ρ = 0.030 |
| The volume of paperwork /documentation impedes patient care |
p
= 0.000
ρ = 0.462 |
p
= 0.006
ρ = 0.392 |
p
= 0.111
ρ = − 0.194 |
| Our documentation and paperwork creates confusion |
p
= 0.000
ρ = 0.420 |
p
= 0.006
ρ = 0.327 |
p
= 0.189
ρ = − 0.160 |
Table 6 includes the results of the system usability scale and the BurDoNsaM subscales. The system usability score and the average documentation burden subscale score demonstrated a negative weak correlation. The system usability scale score was also found to have a significant weak positive correlation with the value of documentation subscale score. The correlation between the system usability scale score and time to document subscale score was not significant.
Table 6. Results of Pearson correlation coefficient ( r ), including significance ( p ) between usability and Clinician Burnout syndrome .
| Emotional exhaustion | Depersonalization | Personal accomplishment | |
|---|---|---|---|
| System usability scale |
p
= 0.002
r = − 0.360 |
p
= 0.095
r = − 0.203 |
p
= 0.789
r = 0.033 |
Discussion
Documentation burden in nursing is not reported in the literature as frequently as the presence of phenomenon in physicians. 43 44 45 The focus on the discipline of nursing rather than medicine in general is equally important as nurses make up the majority of health care workforce in the United States. 46 This study does support the idea that documentation burden is present in nurses across many health care settings. 12
The data analysis in this study showed statistically significant correlations between documentation burden and two domains of clinician burnout syndrome: emotional exhaustion and depersonalization. The instructions for calculating the Maslach Burnout Inventory discuss that all three domains of burnout do not dictate an overall level of burnout. Rather, if the domains of emotional exhaustion and depersonalization show a higher score, then the person is experiencing a higher level of burnout. 47 However, the domain of personal accomplishment determines that if lower is the average score, higher is the level of burnout. 33 In addition, other aspects of documentation burden, such as hospital leadership, which includes administrators, executives, and managers, who oversee hospital operations, and documentation, provide a significant correlation to emotional exhaustion and depersonalization. This suggests that external factors of hospital leadership to support the process of documentation have a significant effect on the level of burnout. 48 49
Usability is an important issue. This study found a negative correlation between the burden of documentation subscale and usability scale score. In other words, as the EHR usability score decreases, the level of documentation burden increases. This study also found a significant correlation between emotional exhaustion and BurDoNsaM survey items related to the volume and time to complete paperwork.
Since burnout is a cause of nurses leaving patient care, 50 it is important to understand additional contributing factors of documentation burden and to find solutions. The idea of documentation burden has been quantified, 12 however, the correlation to long-term consequences, such as clinician burnout syndrome, is not found in the literature. 11 Current literature suggests that it would be important to understand if the frequency of documentation is another aspect of documentation burden. 51
Once the causation of documentation burden has been clarified, it is necessary to find additional solutions outside of the usual discussions which have been identified in the executive summary in the National Library of Medicine, “25 by 5 Summit,” which convened in 2021, and recommended the use of clinical decision support, and artificial intelligence algorithms to analyze current patient data. 52 Optimization of the EHR may be a possible solution because the goal is to improve usability. This study found that the decrease in usability has an inverse association with emotional exhaustion.
Optimization could be a short-term solution addressing the need to track quality indicators and other data collection needs. Unfortunately, other solutions found in the literature continue to be focused solely on physicians. 53 More work is needed exploring nursing workflow and documentation burden. It may be necessary to look beyond the EHR itself to other areas to help facilitate documentation and decreased documentation time demands because of the unique needs of nurses when caring for patients. Possible solutions such as a more proactive artificial intelligence which utilizes video and voice recognition of assessments and wearable devices to display documentation in an augmented reality format could be considered. 54 55 Utilization of these technologies could decrease documentation time demand while improving job satisfaction.
The authors here acknowledge the limitations of the study. The first limitation is a very low number of study participants ( n = 69). In addition, the removal of almost 20% of the respondents due to missing data also may significantly affect the results. The 69 participants included in this study do not accurately reflect the entire population of nurses in the United States. In addition, the low response rate could be due to many factors such as the time the survey was distributed during the height of the COVID-19 pandemic. Also, because of the use of snowball sampling method, we could not determine the response rate. Further research should focus on repeating the study and exploring differences across specialties in nursing. A higher response rate could be encouraged if an investigator could be present in the environment that is being surveyed to encourage study participation.
Furthermore, the study design is cross-sectional and not longitudinal, thus levels of burnout could increase or decrease over time. In addition, the presence of possible increased stress due to the COVID-19 pandemic could have elevated clinician burnout inventory scores with participants. Despite the fact that an internet search revealed that some documentation in acute care was reduced at the height of the pandemic, it is unclear if the study participants experienced a reduction in documentation. 56 Other limitations include unknown interpersonal and environmental factors which could have affected the level of burden and burnout perceived by the study participants.
Conclusion
The correlation between documentation burden, emotional support, and depersonalization suggests that nurses are affected by documentation burden. It also suggests that usability is a contributing factor to documentation burden and to clinician burnout syndrome. The implications are that interventions should be designed, tested, and implemented to improve EHR usability for nurses as well as other interventions such as machine learning and clinical decision support that could help facilitate documentation without increasing burden. It is important that these interventions should be created with input from nurses who are working in that environment.
Clinical Relevance Statement
Patient outcomes have been shown to be improved when nurses experience a decrease in symptoms of clinician burnout syndrome. 57 As documentation burden has been found to be a significant problem across health care, it is important to understand that it is associated with symptoms of clinician burnout syndrome. Utilizing tools to identify what aspects of documentation burden contribute to clinician burnout syndrome, it provides increased clarity on the problems, such as the usability of the EHR and where to focus possible solutions.
Multiple Choice Questions
-
How many data points per minute that nurses have been found documenting patient care during a 12-hour shift?
3.5.
1.1.
10.4.
20.2.
Correct Answer: The correct answer is option b. It has been shown that nurses can document up to 1.1 data points per minute during a 12-hour shift.
-
The usability of the EHR has been significantly associated with which symptom of clinician burnout syndrome?
Personal accomplishment.
Depersonalization.
Mental instability.
Emotional exhaustion.
Correct Answer: The correct answer is option d. The usability of the EHR has been associated with emotional exhaustion. This could be construed as poor usability increases documentation time demand.
-
According to Maslach's Burnout Inventory, the three domains of clinician burnout syndrome include emotional exhaustion, depersonalization, and:
Personal accomplishment.
Depersonalization.
Mental instability.
Emotional exhaustion.
Correct Answer: The correct answer is option a. Personal accomplishment is the third domain of Maslach's Burnout syndrome.
Funding Statement
Funding None.
Conflict of Interest None declared.
Protection of Human and Animal Subjects
The study was performed in compliance with the World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research Involving Human Subjects, and was reviewed by University of Massachusetts-Boston Institutional Review Board.
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