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July/August 2025 | Volume 43 Number 4 165

Nursing Economic$

Nurses are the largest

group of health care

providers in the

United States and the largest

group of health informa tion

users of health information

technology (HIT) and electronic

health record (EHR; Institute of

Medicine, Roundtable on

Evidence-Based Medicine,

2019). Nurses at one of New

Jersey’s largest health systems

had been spending 25% (or 40

minutes) more than the national

average in their shifts in docu -

mentation tasks, according to

the Nursing Efficiency Assess -

ment Tool (NEAT, 2021). In

addition, they were required to

complete admission assessments

containing well over 200 ques -

tions, consuming over one hour

of nursing time to complete.

An internal documentation

burden reduction workgroup

(DBRW) was organized to

respond to a clarion call to

action. Nurses from each site

volunteered to participate in the

DBRW, based upon the princi -

ples of shared governance and

optimizations needed, the

systematic planning and

implementation of the change,

and support for adopting new

documentation practices

Reduction of Nursing Documentation Burden and the Impact Upon Nursing Care Opportunities, Patient Outcomes, and Perception of Usability: A Research Study Mary Ann T. Donohue-Ryan Denise Fochesto

Natalie A. Peleg Mildred Ortu Kowalski

robust support for clinical nurse

decision-making by system and

site leadership. Change theory

provided a foundation to

identify the necessary

Reduction of nursing documentation burden and the impact upon nursing care opportunities, patient outcomes, and perception of usability: A research study. Nursing Economic$, 43(4), 165-181. https://doi.org/10.62116/NEC.2025.43.4.165

The purpose of this Institutional Review Board (IRB)-approved, repeat- ed-measures research study was to measure the effectiveness of one health system’s clinical nurse-led documentation burden reduction workgroup in terms of actual time saved, measures of missed nursing care opportunities (Kalisch et al., 2011), usefulness of the electronic health record (EHR; USE Survey; Lund, 2001), nurse-driven quality out- comes, and nurses’ self-reported nature and quality of their meal breaks. Data were compared from baseline to end of study over a peri- od of 20 months and timed to collect data following modifications designed to reduce documentation tasks. As a reflection of self-care, time for nurses’ break shifted from less than 15 minutes of actual reported break time to 16+ minutes at a significant level of p < 0.001. Other significant findings included 76% improvements in missed nurs- ing care and overall reported usefulness, satisfaction, and ease of use of the EHR (Mean = 4.46, SD = 1.43) to timepoint 3 (T3; Mean = 5.02, SD = 1.39), t (755) = -5.45, at p < 0.001. Keywords: Documentation burden, clinical decision-making, nurses’ work environment.

July/August 2025 | Volume 43 Number 4166

(Lewin, 1951; Wojciechowski et

al., 2016). DBRW members acted

as subject matter experts and

were highly motivated to reduce

documentation, recognizing the

imperative to align with existing

accreditation/regulatory stand -

ards. Additionally, nursing

informaticists from each site

were included in the workgroup

and held a distinct role in site-

specific documentation review

sessions. The DBRW com -

menced on June 25, 2021, and

work consisted of two phases –

optimizing the adult admission

assessment as a first priority, and

then, turning the focus to high-

volume flowsheets.

The adult admission

assessment was selected to be

undertaken first to reduce

redundancy and bring value to

the documentation of a patient’s

admission intake. The

workgroup chose to adopt the

guiding principles first published

by Englebright and colleagues

(2021) – the Nursing Knowl -

edge Big Data Science (NKBDS)

Admission History Task Force

framework. These guiding

principles (see Figure 1) were

fundamental to the project to

ensure the DBRW was consistent

in rationale for data structure

and for determining the docu -

mentation relevant to the

assessment at hand. Among the

key considerations was to ensure

all EHR content was essential for

patient care, and therefore,

required to be collected upon

admission due to its projected

impact upon overall clinical

decisions and care. As a result,

assessments were reviewed for

adherence to the nursing scope

of practice, as well as the

rationale to be documented by

nursing. To avoid the EHR from

becoming a checklist, “yes/no”

responses were restricted unless

no other way was determined to

document a necessary element.

The Admission Assessment

phase of the project ran over the

course of several months.

Meetings consisted of reviewing

current state, recommendations

based on the guiding principles,

and the potential impact to

documentation, such as the

number of questions removed

or the enhanced value to the

patient’s course of hospitaliza -

tion. After the Admission

Assessment optimizations were

implemented, the DBRW quickly

turned to high volume flow -

sheets as the next phase of the

documentation burden

reduction project. The work

effort to optimize the Head-to-

Toe assessment was much

greater than the Admission

Assessment; therefore, a more

structured strategy was used to

avoid project delays. The

assessment was divided into

body systems. Based on the

complexity and relative nature

of the body system, each body

system was added to a project

schedule. As reported previously

(Donohue-Ryan et al., 2023),

the standards and guidelines

published by voluntary and

regulatory accreditation bodies

were incorporated into all

modifications of the EHR.

Research Problem and Knowledge Gap

The study purpose was to

conduct a comparative analysis

of nurses working in adult

inpatient units to analyze

modification of documentation

practices, potential changes in

missed nursing care opportuni -

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Figure 1. Guiding Principles for Content, Structure, and Format

Guiding Principles for Content Guiding Principles for Structure and Format

Content is essential to patient care and impacts clinical decisions.

Element addresses a single, structured concept or component.

Content addresses a regulatory or policy requirement. Options within answer sets are to be as minimum as necessary to promote accuracy and clarity.

Content is evidence-based and best practice. Use plain language to convey clear intention and purpose. Content is most appropriately (best) documented by a nurse. Avoid yes/no responses. Content is relevant to the continuum of care specific to time performed.

Keep options clear and concise. Avoid abbreviations, acronyms, brand names (utilize crosswalks when necessary).

Source: Adapted from Englebright et al., 2021; and D.L. Boyd, personal communication, June 12, 2024.

July/August 2025 | Volume 43 Number 4 167

ties, patient outcomes, percep -

tion of ease of use, and nurses’

time for breaks during their

last shift worked. It has been

observed that a burnout crisis

in health workers was long -

standing and preceded the

COVID-19 pandemic (Nigam et

al., 2023). Given the advent of

COVID-19, however, and its

profound impact upon our

nation’s nurses (American

Nurses Foundation, 2023;

Sampaio et al., 2021), the focus

upon the state of nursing’s

workplace has been magnified.

As Leaver and colleagues (2022)

observed, health care in general,

and nursing in particular, has

been irrevocably changed in the

aftermath of the COVID-19

pandemic. Berlin and colleagues

(2023), in their study of nursing

workforce trends, noted that not

feeling valued by their organiza -

tion and not having a manage -

able workload were the two top

reasons for nurses’ resignations.

One chief contributor to

unmanageable workload is

undue interference by the very

information technology that was

originally intended to increase

efficiency (Siwicki, 2020).

McBride and colleagues (2023)

noted that there are gaps in

knowledge related to the

association of emotional distress

to EHRs as well as EHRs’ impact

on nurses. The authors recom -

mended targeted research

focused on workload and overall

well-being.

Brief Overview of Methodology

This study sought to fill the

gap in knowledge about the

relationship of a strategic docu -

mentation burden reduction

initiative upon nurses’ ability to

take time for self-care (break

time) and other aspects of

patient- and nurse-focused

outcomes.

Participants, Sample, and Inclusion/Exclusion Criteria

This was a comparative

survey study of clinical nurses

working in adult inpatient units

(medical-surgical and ICU),

working more than 50% of the

time at the bedside, and docu -

menting in the Epic® workspace.

The goal was to analyze planned

modifications of documentation

practices and their potential

impact on changes in nursing

care, patient outcomes, percep -

tion of ease of use, and nurses’

times for breaks during their last

shift worked. The Atlantic Health

System Institutional Review

Board (IRB) review of the

research proposal determined

exempt status on September 27,

2021. Nurses were excluded

from the study if employed in

ambulatory care areas or on

units that did not use adult

inpatient documentation. Nurses

who were members of the

DBRW, advocating and deter -

mining changes in their own

documentation, were also

excluded from participation in

the research survey process. A

convenience sample of nurses

met the inclusion criteria and

were recruited for their partici -

pation by clinical nurses who

served as co-investigators of the

study.

The human resources

department, working closely

with one of the co-primary

investigators, identified the

population of nurses who

documented in the adult

inpatient workspace as 1559

nurses across the health system.

To calculate sample size, we

used the Qualtrix sample size

calculator, with a Confidence

Level of 95%, a Margin of Error

of 5%, and the population size

of 1559, to arrive at the ideal

sample size of 309 respondents.

A target sample of 309 and

maximum sample of 1559 were

calculated; this would provide an

adequate sample to show a

reduction in mean documenta -

tion time of 40 minutes between

baseline and post-implementa -

tion at 20 months.

Data Collection Surveys were collected using

a Research Electronic Data

Capture (REDCap) database.

Eligible participants were

emailed a link to access the

survey. Newly hired nurses were

excluded from the study. Inclu -

sion and exclusion criteria

remained the same throughout

the study. However, due to nurse

availability, registered nurse (RN)

turnover, and other factors

contributing to attrition, the

same nurses did not necessarily

participate at each timepoint.

Ethical Considerations A notification at the begin -

ning of the survey informed

participants that completion of

the survey served as consent to

use the information collected for

research purposes. No identifiers

were included on the survey, and

each participant created a self-

assigned unique code. Permis -

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July/August 2025 | Volume 43 Number 4168

sion was granted by the authors

of the MISSCARE, USE instru -

ments, and the use of the two

questions derived from the RN

Satisfaction Survey (NDNQI).

IRB approval with exempt status

was granted on September 21,

2021. Clinical nurses at each site

served as study co-investigators

and helped recruit participants

in the study using a QR code that

was embedded in fliers dissemi -

nated to the nursing units.

Participation in the study

constituted informed consent,

was voluntary, and could be

withdrawn at any time.

Analytical/Statistical Methods Participants were asked to

complete a baseline set of

surveys that were repeated at

approximately 12 months after

the first set of planned modifica -

tions had occurred (T2) that

were designed to reduce docu -

mentation burden to the EHR.

A third set of surveys timepoint 3

(T3) was completed once all

modifications were introduced

into the EHR. Before and after

the intervention, data were

collected from six sources at the

three study points.

Source 1. Variables included

participant’s years of experience

as an RN, age, gender, highest

education achieved in nursing,

shift worked, and presence/

absence of national board

certification. The medical center

where the nurse worked was

identified.

Source 2. Administration of

two questions derived from the

NDNQI RN Satisfaction Survey

(Madans & Potter, 2024; Press

Ganey Associates, 2024) and

used with permission related to

meal breaks during the last shift

worked. Information about the

meal breaks provided insight

into one element of a healthy

workplace environment (Choi &

Miller, 2018; Madans & Potter,

2024; Press Ganey Associates,

2024).

Source 3. Administration of

the MISSCARE Survey (Section A

of the survey only) was included

in this study (Dabney et al.,

2019). Beatrice J. Kalisch first

identified the phenomenon of

missed care by nurses in 2006.

Since then, missed care has

become an important measure

of quality (Dabney et al., 2019;

Hessels et al., 2019). Part A, used

in this study, provides a list of 25

tasks for review by the nurse.

Tasks include activities such as

feeding the patient while the

food is warm, ambulating, and

assessing patients. A Likert scale

from 1 to 5, with 1 = never

missed and 5 = always missed,

was used by the nurse to record

how often a task is missed (or

not). Based on this scoring, a

lower overall score indicates

fewer tasks missed.

The validity and reliability

of the MISSCARE survey were

originally established in 2009

(Kalisch & Williams); validity

was 0.64 to 0.86, and reliability

based on test/re-test of the Part

A section was 0.87. In a large

(N = 574) study, Hessels and

colleagues (2019) reported

reliability of 0.95. In 2021, the

reliability of Part A was reported

by Dabney and colleagues

(2019) as 0.95. With validity and

reliability established, the

MISSCARE survey is widely used

(Dabney et al., 2019; Heng et al.,

2023; Hessels et al., 2019) to

determine missed care

opportunities as reported by

nurses.

Source 4. Administration of

the USE Survey measured

usefulness, ease of use, ease of

learning, and satisfaction of the

EHR (Lund, 2001). Thirty Likert-

style questions comprise the USE

Survey; some are negatively

worded. Options for answering

include strongly disagree (1) to

strongly agree (7), and a “not

applicable” option is also

available.

To establish reliability and

validity, Gao and colleagues

(2018) conducted a study with

150 individuals familiar with

two well-known electronic

platforms; one platform is used

for Microsoft® Word documents,

and the other is widely used to

order items from a global online

distributor. Participants com -

pleted both the established

System Usability Scale (SUS)

(Brooke, 1996) and the USE

questionnaire. These two scales

were selected because they are

both able to be applied to wide

variety of applications.

Reliability and validity were

measured for the USE survey for

both the MS Word™ platform

and ordering platform. Overall

scores for both scales indicated

the platform for ordering items

had higher ratings in satisfaction

and ease of use than the MS

Word™ document platform.

Validity for the USE study was

established with strong Pearson

r correla tion, with the SUS of

0.60 to 0.81 for all domains, with

ease of use being the strongest

correlation. The overall

Cronbach’s alpha for the USE

questionnaire was 0.98, with

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July/August 2025 | Volume 43 Number 4 169

domain Cronbach alpha scores

all above 0.80, indicating good

reliability.

Source 5. The impact of

patient-focused documentation

on established patient outcomes

was reviewed. Compliance of

nursing staff to nationally

defined quality outcomes was

evaluated using the National

Database of Nursing Quality

Indicators® (NDNQIs; Lake et al.,

2024; Madaris & Potter, 2024;

Montalvo, 2007; Press Ganey

Associates, Inc, 2024). NDNQI

measures were created by the

American Nurses Association

(ANA, 1999) in 1998 and are

recognized standardized bench -

marks for health care quality in

facilities (Madaris & Potter,

2024). Results are reported by

size of hospital and location.

Variables are standardized by

reporting the percentage

surveyed (hospital-acquired

pressure injury [HAPI], HAPI

stage 2 or greater, physical

restraint use) or per 1000

patient days (falls, falls with

injury, catheter-related urinary

tract infection [CAUTI], central

line-acquired bloodstream

infection [CLABSI], ventilator-

associated events) (Harolds &

Miller, 2022; Lake et al., 2024).

NDNQIs reported in this

research included: falls with

injury, HAPI, CLABSI, CAUTI, and

restraint use. A comparison of

NDNQI pre- and post-imple -

mentation of documentation

reduction practices was com -

pleted. The NDNQIs were

supplied by Press Ganey

Associates, Inc. (2024).

Source 6. The Nursing

Efficiency Assessment Tool

(NEAT) is a proprietary tool

created by the EHR vendor, Epic,

to quantify the amount of time

nurses spend in documentation

activities and provide guidance

for educational opportunities.

Time spent on assessments was

compared from pre- to post-

implementation periods by

system and institution was

calculated.

Results

The study took place

between July 2021 and July 2023

(see Figure 2). A total of 1347

surveys were collected at three

timepoints: baseline (n = 489),

12 months (T2, n = 442), and 20

months (T3, n = 416). Partici -

pants were health system team

members (employees); members

of the DBRW were excluded

from results. Nurses were not

required to identify their study

participation at prior study

intervals.

As shown in Table 1, most

participants were between the

ages of 25 to 34 years. Approxi -

mately one-third at each time -

point were in their first position

as RN. Only a few (< 3.07%) were

on orientation. Reflective of the

system team member popula -

tion, most participants were

female (> 87.98%). At least one

participant at each timepoint

identified as non-binary, with

the most non-binary responses

received at T3 (n = 3, 0.72%). At

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Figure 2. Study Timeline

July 2021 Aug 2021 Oct/Nov 2021 Dec 2021 Jan 2022 March 2022 Nov 2022 Feb 2023 Mar 2023 Jul 2023

Endorsement

System CNOs issued a Call to Action

Workgroup

Review guidelines and optimization recommendations: Nurse Practice Council Approval

Baseline Survey 11/15/2021

Go Live

New Admission Assessment released

to production

Survey

T2 Survey 11/7/2022

Go Live

New Head-to-Toe Assessment released

to production

Kick Off

Concept approved at AHS

Research + Innovation Council and Nurse Practice

Council

Training

Training material developed and distributed

Governance Presentations

Workgroup

Head-to-Toe assessment optimization

Training

Training material developed & distributed

Survey

T3 Survey 7/26/2023

July/August 2025 | Volume 43 Number 4170

each timepoint (see Figure 2),

the majority of nurses reported

the BSN as their highest level of

education (> 68.17%). There

were no differences seen

between baseline and T3 for

nurses aged 55 to 65 years. The

differences between baseline

and T3 for those younger than

age 25 years persisted. The

differences were statistically

significant (p < 0.05). A two-

propor tion test was used to

compare demographic variables.

If one timepoint calculation had

five or fewer calculations, a

Fischer’s exact test was used to

calculate p values for both

comparisons (baseline to T2,

and baseline to T3) (see Table 1).

NDNQI Satisfaction Questions (Meal Breaks)

The total duration of meal

break most frequently reported

was between 16 to 30 minutes at

each timepoint. The second

most common duration of break

time was less than 15 minutes.

Up to 19.78% of nurses (T2)

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Table 1. Demographics

Baseline n = 489

Timepoint 2 n = 442

Timepoint 3 n = 416

p-Value BL to TP2

p-Value BL to TP3

Are you an Atlantic Health System employee?

Must be yes Must be yes Must be yes — —

Are you a member of the Nursing Documentation Advisory group?

Must be no Must be no Must be no — —

On orientation – Yes, n (%) 15 (3.07%) 6 (1.36%) 7 (1.68%) 0.073 0.698 2 proportions First position as an RN – Yes, n (%) 171 (34.97%) 138 (31.22%) 131 (31.49%) 0.224 0.932 2 proportions Age, n (%) (years)

25-34 171 (34.97%) 156 (35.29%) 144 (34.62%) 0.917 0.835 2 proportions 35-44 98 (20.04%) 82 (18.55%) 89 (21.39%) 0.565 0.298 2 proportions 45-54 89 (18.20%) 86 (19.46%) 74 (17.79%) 0.624 0.53 2 proportions 55-65 77 (15.75%) 92 (20.81%) 71 (17.07%) 0.046 0.161 2 proportions Over 65 4 (0.82%) 8 (1.81%) 6 (1.44%) 0.246 0.79 Fisher’s exact Under 25 years old (< 25) 50 (10.22%) 17 (3.85%) 30 (7.21%) < 0.001 0.031 2 proportions Missing 0 (0.00%) 1 (0.23%) 2 (0.48%) 0.475 0.614 Fisher’s exact

Gender, n (%) Female 445 (91%) 398 (90.05%) 366 (87.98%) 0.619 0.334 2 proportions Male 42 (8.59%) 41 (9.28%) 46 (11.06%) 0.714 0.388 2 proportions Non-binary/Them 2 (0.41%) 1 (0.23%) 3 (0.72%) > 0.999 0.36 Fisher’s exact Missing 0 (0.00%) 2 (0.45%) 1 (0.24%) 0.225 > 0.999 Fisher’s exact

Highest Level of Education, n (%) Associate Degree in Nursing 88 (18.00%) 67 (15.16%) 66 (15.87%) 0.244 0.775 2 proportions Bachelor’s Degree in Nursing 336 (68.71%) 323 (73.08%) 290 (69.71%) 0.142 0.276 2 proportions Diploma 8 (1.64%) 6 (1.36%) 6 (1.44%) 0.916 2 proportions Doctoral Degree – Non-Nursing 2 (0.41%) 0 (0.00%) 1 (0.24%) 0.726 0.485 Fisher’s exact Doctoral Degree in Nursing 1 (0.20%) 0 (0.00%) 1 (0.24%) 0.501 0.485 Fisher’s exact Master’s Degree – Non-Nursing 4 (0.82%) 6 (1.36%) 8 (1.92%) > 0.999 0.595 Fisher’s exact Master’s Degree in Nursing 48 (9.82%) 38 (8.60%) 43 (10.34%) 0.531 0.385 2 proportions Missing 2 (0.41%) 2 (0.45%) 1 (0.24%) 0.520 > 0.999 Fisher’s exact

Are you nationally board certified? Yes, n (%)

299 (61.15%) 280 (63.35%) 272 (65.38%) > 0.999 0.488

0.538 2 proportions

*If one of the p-value calculations had 5 or less, Fisher’s exact was used for both p-values. Note: BL = baseline

July/August 2025 | Volume 43 Number 4 171

reported not having a break of at

least 15 minutes. This decreased

to 13.94% at T3.

An increase in duration of

break is observed at T3 (see

Table 2), with more nurses

reporting a break between 16 to

30 minutes, and fewer reporting

a break less than 15 minutes. We

were able to increase the

percentage of nurses who did

not have a break or who had less

than 15 minutes to having 16

minutes or more of break time

(p < 0.001). Over time, more

nurses reported that they were

able to sit down for a break.

Some but not all nurses were

completely free of patient

responsibilities during their

break.

NDNQI Quality Outcome Data A review of the relevant

quarters of NDNQI quality

outcome data for falls with

injury, HAPIs, CLABSIs, CAUTIs,

and restraint use was completed.

Overall, NDNQI outcomes were

maintained or improved over

the course of the study.

Missed Nursing Care (MISSCARE) Opportunities

Measured on a 5-point Likert

scale ranging from 1 = always

missed to 5 = never missed,

25 tasks were evaluated for

frequency of missed care. The

values for missed care were

dichotomized to yes or no for

analysis. Yes (missed) included

always missed, frequently

missed, and occasionally missed.

No (not missed) included

responses of rarely or never

missed. Percentages missed for

each task were compared using

a two proportions test.

Of the 25 tasks reported in

the MISSCARE survey, all but six

categories improved over time

from baseline to T3 (p ≤ 0.05).

Of the improvements noted, all

were observed from baseline to

T3, and many improvements

were additionally observed from

baseline to T2 (e.g., vital signs

assessed as ordered). Eleven

tasks showed a decrease in

missed care from T2 to T3 (see

Table 3).

The six categories that did

not improve over time were

ambulation, mouthcare, hand -

washing, patient assessment,

intravenous or central line care,

and response to call light. Hand -

washing, patient assess ment, and

intravenous and central line care

had low missed care scores at

baseline; thus, improvement was

harder to achieve.

Usefulness, Satisfaction, and Ease (USE) Survey

For each question of the

USE survey, the mean scores

increased from baseline (Mean =

4.46, SD = 1.43) to T3 (Mean =

5.02, SD = 1.39), t(755) = -5.45, p < 0.001. Therefore, over time,

familiarity with the changes in

the EHR were perceived as more

useful and easier to use, and

nurses were satisfied with using

the revised EHR. Most values

stayed the same between

baseline and T2. Ten items were

identified as showing improve -

ment as early as 12 months

between baseline and T2. Items

that showed positive responses

early were observed in each

domain: usefulness (2), ease of

use (5), and satisfaction (3).

Note that usefulness and

ease of use are similar, as are

their related domains (Lund,

2001). Therefore, it is not

surprising to observe early

recognition of both ease of use

and usefulness. Nurse satisfac -

tion is also driven by usefulness

and ease of use. The eight items

with the highest scores, observed

only at T3, were related to

usefulness, ease of use, and ease

of learning. This provides

important new information

about attaining the highest

scores for usefulness, satisfac -

tion, and ease of use by 20

months (T3).

Nursing Efficiency Assessment Tool (NEAT) Data

For each study site, a

decrease in time to document

per person was observed.

Improvements ranged from 2.5

to 5.3 minutes per assessment.

Comparisons from pre- to post-

implementation were com -

pleted for each facility and for

the system, a combination of all

five facilities. An analysis of all

facilities showed a statistically

significant decrease in documen -

tation time, when comparing

nurses’ charting time from

baseline to timepoint 2 (T2),

using a two-sample t test

(t [177] = 6.73, p < 0.001).

Discussion

Results of this study demon -

strated that inpatient nurses

who utilized the adult inpatient

units (medical-surgical and

ICUs) documentation platform

experienced an increase in

duration of meal breaks, with

more nurses reporting a break

between 16 to 30 minutes. This

was critically important to our

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July/August 2025 | Volume 43 Number 4172

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Table 2. Experience

Baseline n = 489

Timepoint 2 n = 442

Timepoint 3 n = 416

Number of hours usually worked per week, n (%) < 30 hours 66 (13.5%) 54 (12.22%) 59 (14.18%) 30 hours or more per week 411 (84.05%) 376 (85.07%) 356 (85.58%) Work hours 12 (2.45%) 10 (2.26%) 0 (0.00%) Missing 0 (0.00%) 2 (0.45%) 1 (0.24%)

Usual shift you work, n (%) Days (8- or 12-hour shift) 329 (67.28%) 300 (67.87%) 306 (73.56%) Evenings (8-hour shift) 0 (0.00%) 1 (0.23%) 1 (0.24%) Nights (8- or 12-hour shift) 159 (32.52%) 140 (31.67%) 109 (26.20%) Missing 1 (0.20%) 1 (0.23%) 0 (0.00%)

Rotates between days, nights or evenings, Yes, n (%) 38 (7.77%) 40 (9.05%) 32 (7.69%) Experience (time working as an RN), n (%)

> 10 years 213 (43.56%) 210 (47.51%) 186 (44.71%) > 2 years to 5 years 106 (21.68%) 99 (22.4%) 84 (20.19%) > 5 years to 10 years 96 (19.63%) 87 (19.68%) 88 (21.15%) > 6 months to 2 years 61 (12.47%) 42 (9.5%) 52 (12.5%) Up to 6 months or less 13 (2.66%) 3 (0.68%) 3 (0.72%) Missing 0 (0.00%) 1 (0.23%) 3 (0.72%)

Experience (time in your current role as an RN), n (%) > 10 years 142 (29.04%) 147 (33.26%) 133 (31.97%) > 2 years to 5 years 116 (23.72%) 100 (22.62%) 83 (19.95%) > 5 years to 10 years 88 (18.00%) 85 (19.23%) 75 (18.03%) > 6 months to 2 years 102 (20.86%) 93 (21.04%) 110 (26.44%) Up to 6 months or less 40 (8.18%) 15 (3.39%) 11 (2.64%) Missing 1 (0.20%) 2 (0.45%) 4 (0.96%)

Nationally board certified, n (%) 299 (61.15%) 280 (63.35%) 271 (65.14%) Current Atlantic Health System hospital, n (%)

Chilton Medical Center 49 (10.02%) 50 (11.31%) 52 (12.5%) Hackettstown Medical Center 26 (5.32%) 22 (4.98%) 24 (5.77%) Morristown Medical Center 219 (44.79%) 204 (46.15%) 188 (45.19%) Newton Medical Center 48 (9.82%) 39 (8.82%) 41 (9.86%) Overlook Medical Center 147 (30.06%) 126 (28.51%) 111 (26.68%) Missing 0 (0.00%) 1 (0.23%) 0 (0.00%)

continued on next page

July/August 2025 | Volume 43 Number 4 173

study, conducted in the imme -

diate post-COVID-19 period,

when as it is now, nurses’ self-

care needs remain para mount to

the nursing profession as it is to

the provision of global health

care (International Council of

Nurses, 2023a, b). The study’s

primary goal was to examine if

the DBRW truly did return time

to clinical nurses for mental and

physical replenishment. Once

results were known, we quickly

partnered with our health

system’s manager of Workforce

Well-Being and strategized ways

to fill the time saved with health-

related options for clinical

nurses. Such strategies include

strengthening the role of our

unit-based wellness champions;

working with Virgin Pulse, our

electronic wellness platform to

expand accessibility for nurses;

providing wellness information

during our sites’ resiliency

rounding programs; conferenc -

ing with ANA’s Healthy Nurse,

Healthy Nation™ program leader

to align wellness priorities; and

finally, identifying nurses’ self-

care preferences during a follow-

up wellness survey distributed

during Nurses’ Week 2023.

Findings from this study may

assist other health systems to

seek help with reducing docu -

mentation burden initia tives to

galvanize efforts to use time

savings for nurses’ self-care

initiatives. As discussed above,

there is much literature to

describe the ill effects our

nation’s current health care

environment has wrought upon

nurses and nursing’s ability to

attract and retain a workforce in

numbers large enough and

experienced enough to safely

care for an older, sicker and

more complex population in the

future (Carroll et al., 2024; Holub

& Giegerich, 2023; Johnson et

al., 2025; Sloss et al., 2024).

Awareness of the potential to

significantly lessen the burden

that electronic documentation

systems often impose should

empower clinical nurses and the

leaders who make boardroom

decisions to create documenta -

tion burden reduction work -

groups. However, more research

is needed about the relationship

of individual and collective

components of EHRs and their

specific impact upon nurses, as

well as upon all clinicians and

providers.

Equal in importance to our

study was that no erosion to our

nurses’ ability to positively

impact our health system’s high-

quality standards of care would

occur. Of the 25 tasks measured

in the MISSCARE survey (Dabney

et al., 2019), all but six improved

over time. All improvements

were observed from baseline

to T3, and many additional

improvements were noted from

T2 to T3. The six that did not

improve were already low at the

onset of the study (meaning,

Nursing Economic$

Table 2. (continued) Experience

Baseline n = 489

Timepoint 2 n = 442

Timepoint 3 n = 416

Total duration of your meal break(s), n (%) Did not have a break 75 (15.34%) 87 (19.68%) 58 (13.94%) < 15 minutes 170 (34.76%) 149 (33.71%) 100 (24.04%) 16-30 minutes 222 (45.40%) 187 (42.31%) 225 (54.09%) 31-45 minutes 22 (4.50%) 15 (3.39%) 29 (6.97%) 46-60 minutes 0 (0.00%) 4 (0.90%) 3 (0.72%) Missing 0 (0.00%) 0 (0.00%) 1 (0.24%)

Most appropriate description of your meal break(s), n (%) I was able to sit down for a break and was completely free of patient responsibilities.

38 (7.77%) 55 (12.44%) 69 (16.59%)

I was able to sit down for a break during the shift but was not free of patient.

326 (66.67%) 282 (63.80%) 280 (67.31%)

I was not able to sit down for a break during my shift. 125 (25.56%) 105 (23.76%) 67 (16.11%)

July/August 2025 | Volume 43 Number 4174

Nursing Economic$

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July/August 2025 | Volume 43 Number 4 175

Nursing Economic$ Ta

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July/August 2025 | Volume 43 Number 4 177

rarely missed by the nurse);

therefore, improvement was not

projected to occur very much, if

at all, over time. Interestingly,

nurses in our study also experi -

enced improvement in their

usefulness and ease of use (Lund,

2001), particularly at T3, indica -

ting that reduction in documen -

tation burden may indeed

contribute to overall nursing

satisfaction. Interest ingly, RN

staffing, as measured by the

NDNQI, remained constant, and

improvement in survey scores

was not attributed to more

nurses being hired.

In terms of the actual DBRW,

sections of the admission

assessment and head-to-toe

assessment required interdisci -

plinary engagement and/or

participation from Respiratory

Therapy, Care Management,

Social Services, and physicians/

advanced practice practitioners,

to name a few. Their valuable

input was evaluated for all

changes for reduction, and

ensured best practice and

adherence to regulations were

considered. During the review of

documentation, some elements

of the Admission Assessment

were no longer utilized by

ancillary departments or was

documented elsewhere;

therefore, the non-valued added

items could be easily removed.

Our health system had a

Charting by Exception policy

since the implementation of our

EHR, which outlined the process

for documenting assessment

findings outside of our defined

limits. Despite repeated educa -

tional efforts and auditing,

nursing found it challenging to

release the age-old philosophy

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July/August 2025 | Volume 43 Number 4178

of “if it was not documented, it

was not done.” With the Head-

to-Toe assessment changes, EHR

guardrails are now implemented

that prevent double documen -

tation in which the nurse would

chart if the body system met all

defined limits, as well as each

specific finding with the body

system. This supported our

health system’s Charting by

Exception policy and released

the nurse’s perceived obligation

to chart redundant findings. This

resulted in a culture change for

inpatient units and other

departments in the system.

Vehicles for staff education

about all modifications were

the use of existing education,

practice, and informatics flashes;

in-person and virtual unit and

daily huddles; staff meetings; our

unit-based, site-specific, and

system-shared governance

Professional Development

Councils; and e-learnings.

Adult inpatient units were

the project’s initial focus; since

then, the initiative expanded to

the pediatric service line. Other

service lines and programs, such

as stroke, began a proactive

review of documentation and

requirements to offer additional

optimizations to further reduce

required assessment elements.

A new Informatics

subcommittee of our System

Nurse Practice Council was also

formed that reviews all new EHR

documentation requests. The

Informatics subcommittee is

charged with ensuring any

changes meet best practice,

regulations, and policy guide -

lines; is best suited for nursing

documentation; and is not

duplicative. When nurses are

empowered to make decisions

in a shared governance environ -

ment, as in our health system,

positive change is not only

encouraged, it is well supported

by resources that extend beyond

nursing. Requests for any EHR

modifications are investigated

and vetted thoroughly, prior to

System Nurse Practice Council

presentation to ensure that

proper change control proce -

dures, both operational and

technical, are adhered to at all

times.

Limitations

Five of the six hospitals in

the health system participated in

the first phase of the DBRW, the

admission assessment. All six

hospitals contributed to the

second phase of the initiative,

the head-to-toe assessment. This

was due to the sixth hospital

becoming a clinical affiliate and

adopting the enterprise EHR in

between phases. This could have

potentially impacted the sixth

hospital’s perception of the

head-to-toe assessment because

they had utilized a different EHR

prior and had only one year’s

experience with the system’s

EHR before implementing the

new assessment. Due to the

timing of the Admission Assess -

ment and Head-to-Toe modifi -

ca tions, the sixth hospital was

excluded from the research

study to maintain a similar

survey population; therefore,

survey results do not represent

all six hospitals within the health

system.

Due to the voluntary nature

of the surveys and availability of

nurses to participate, the cohort

of nurses at each survey time -

point differed. Demograp hic

variables between baseline

and T3 were not statistically

different. There were, however,

significant differences in

age groups 55 to 65 years

(increased) and nurses under

age 25 years (decreased) seen

between T1 and T2. Although

demo graphic variables were

similar from the start to the end

of the study, differing partici -

pants at each survey is a limita -

tion of the study. The EHR at our

health system is Epic; therefore,

out comes may differ from other

EHR platforms and may affect

the project outcomes. A time-

motion study was not conduct -

ed; therefore, real-time saved

and economic impact was not

measured. The decision not to

quantify financial cost savings

was deliberate in that our study’s

goal was to restore time savings

back to nurses for self-care.

Outcomes related to time saved

are based on analyses of time on

the computer while doing the

assessment. While the impact of

COVID-19 upon our nursing

workforce was also considered

in our quest to reduce documen -

tation, it also caused a gap in

data because NDNQI data were

not submitted for the first two

quarters in 2020 due to the

pandemic. Further, the project’s

focus was limited to adult

inpatient documentation, and

therefore, did not represent all

nursing practice areas.

Data collection for this study

commenced in November 2021

(baseline), about 18 months

from the first surge of the

COVID-19 pandemic (March

2020) and again in November

Nursing Economic$

July/August 2025 | Volume 43 Number 4 179

2022 (T2) just as another surge

hit the northeastern United

States in the third pandemic

winter (beginning in October

2022). Our hospital was not

unique in that so-called

‘streamlined’ charting was the

norm, and the Centers for

Medicare & Medicaid Services

(CMS, 2020) defined this

approach as “Put Patients over

Paperwork,” to “promote more

time for patient care.” Such

documentation requirement

reductions were welcomed by

national policy experts at the

time (Sinsky & Linzer, 2020) as

by our staff. However, once the

pandemic surges receded, and

the severity of patient acuity

along with it, so did the CMS

forgiveness for bypassing

previously required elements of

documentation. In our health

system, there was no policy per

se about what segments of

documentation could be

reduced or eliminated during

COVID-19. However, across the

United States, a full return to

health care documen tation was

gradual, and finally occurred on

May 23, 2023, with the publica -

tion of CMS rules related to the

end of the COVID-19 emer -

gency (CMS, 2023). It is possible

that nurses’ recognition of the

true burden excessive documen -

tation represents was magnified

by the re-establish ment of its

demands. Therefore, one

recommendation may be to

distribute study surveys in the

future, whenever planned

modifications to the EHR occur

or at intervals designed to assess

nurses’ opportunities for self and

patient care, the impact upon

nursing sensitive patient

outcomes, and overall satisfac -

tion with the nurses’ documen -

tation platform.

Conclusions

Results from this study

demonstrated that medical-

surgical and ICU nurses docu -

menting in the Epic electronic

platform at a large health system

in New Jersey saw improve -

ments in their overall workplace

experience after a focused

workgroup eliminated and/or

reduced non-value-added

documentation elements. Once

modifications were enculturated

into daily routines, measures of

usefulness, satisfaction, and ease

of use improved. The burden

to nursing practice was also

reduced as self-reported in

measures of missed nursing care

opportunities and time for well-

being (defined as break time).

Importantly, shifting the

priority from providing care to

sick(er) patients and their

families, and instead, focusing

upon ever-hungry electronic

devices that demand exponen -

tially more of nurses’ time,

impinges upon nurses’ ability to

care for their patients and take

valuable breaks and periodic

pauses for their own wellness

opportunities and self-care. As

discussed above, the literature

comprehensively supports

aggressive goals to reduce

documentation burden and

supports the recommendation

(as presented here) for stress-

reduction and wellness oppor -

tunities. Taking an admini -

strative approach that promotes

more rejection, as opposed to a

culture of automatic acceptance

of more documentation and

computer time associated with

them, may help increase

awareness of how the lack of

documentation guardrails

hinders nursing care and self-

care practices in nurses in other

organizations.

Above all, time savings

realized from documentation

reduction initiatives may easily

be in danger of being lost again,

to the consternation of all

participants in such documen -

tation burden reduction pro -

jects. Hospital administrators,

nursing leaders, and frontline

managers have the capacity and

responsibility to sustain the gain,

as well as normalize and pro -

mote the sacredness of nurses’

break time. A standar dized

approach, such as scheduling

break times without interrup -

tions, using the concept of a

peer ‘break buddy’ to ensure

patient coverage during breaks,

and rewarding nurses who take

their breaks, are some ideas that

gained traction after the study

concluded. Collaborating with

our health system’s wellness

champions really helped place

nurses’ wellness first and

foremost.

Reduction in documentation

is an essential component of a

positive workplace culture and

in alignment with all major

national and global professional

organizations. Holmgren and

colleagues (2024) proposed that

policy-makers and regulators

incorporate documentation

burden initiatives as central to

the mandates of the 21st

Century Cures Act of 2016

(Hudson & Collins, 2017).

Addressing the two goals as

Nursing Economic$

July/August 2025 | Volume 43 Number 4180

interchangeable, critical

components of functional

interoperability initiatives are

necessary to fully realize

associated quality improvement

and associated cost-reduction

benefits. It is incumbent upon

all nurses to innovate and be

accountable so we may all reap

the benefits of meeting the

American Medical Informatics

Association’s (2022) 25 X 5 goal

to reduce documentation

burden to 25% of current state

in five years. $

Mary Ann T. Donohue-Ryan, PhD, RN, APN, PMHCNS-BC, NEA-BC, CPHQ, FACHE Executive Nurse Leader Chilton Medical Center Atlantic Health System Pompton Plains, NJ Associate Editor, Nursing Economic$ Denise Fochesto, MSN, RN, APN-BC Director Atlantic Health System Morristown, NJ Natalie A. Peleg, MSN, RN, NI-BC Senior Manager Atlantic Health System Morristown, NJ Mildred Ortu Kowalski, PhD, RN, NE-BC Nurse Researcher Atlantic Health System Morristown, NJ Acknowledgments: The authors gratefully acknowledge the support of Dr. Trish O’Keefe, Senior Vice President, Chief Nurse Executive, Atlantic Health System and President, Morristown Medical Center and the CNOs of Atlantic Health System, as well as the clinical nurses who participated in the study.

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