Unprofessional behaviours experienced by hospital staff: qualitative analysis of narrative comments in a longitudinal survey across seven hospitals in Australia.

BACKGROUND: Unprofessional behaviours of healthcare staff have negative impacts on organisational outcomes, patient safety and staff well-being. The objective of this study was to undertake a qualitative analysis of narrative responses from the Longitudinal Investigation of Negative Behaviours survey (LION), to develop a comprehensive understanding of hospital staff experiences of unprofessional behaviours and their impact on staff and patients. The LION survey identified staff experiences and perceptions related to unprofessional behaviours within hospitals. METHODS: Two open-ended questions within the LION survey invited descriptions of unprofessional staff behaviours across seven hospitals in three Australian states between December 2017 and November 2018. Respondents were from medical, nursing, allied health, management, and support services roles in the hospitals. Data were qualitatively analysed using Directed Content Analysis (DCA). RESULTS: From 5178 LION survey responses, 32% (n = 1636) of participants responded to the two open-ended questions exploring staff experiences of unprofessional behaviours across the hospital sites surveyed. Three primary themes and 11 secondary themes were identified spanning, i) individual unprofessional behaviours, ii) negative impacts of unprofessional behaviours on staff well-being, psychological safety, and employee experience, as well as on patient care, well-being, and safety, and iii) organisational factors associated with staff unprofessional behaviours. CONCLUSION: Unprofessional behaviours are experienced by hospital staff across all professional groups and functions. Staff conceptualise, perceive and experience unprofessional behaviours in diverse ways. These behaviours can be understood as enactments that either negatively impact other staff, patients or the organisational outcomes of team cohesion, work efficiency and efficacy. A perceived lack of organisational action based on existing reporting and employee feedback appears to erode employee confidence in hospital leaders and their ability to effectively address and mitigate unprofessional behaviours.

Does health information technology improve acknowledgement of radiology results for discharged Emergency Department patients? A before and after study.

BACKGROUND: The inadequate follow-up of test results is a key patient safety concern, carrying severe consequences for care outcomes. Patients discharged from the emergency department are at particular risk of having test results pending at discharge due to their short lengths of stay, with many hospitals acknowledging that they do not have reliable systems for managing such results. Health information technology hold the potential to reducing errors in the test result management process. This study aimed to measure changes in the proportion of acknowledged radiology reports pre and post introduction of an electronic result acknowledgement system and to determine the proportion of reports with abnormal results, including clinically significant abnormal results requiring follow-up action. METHODS: A before and after study was conducted in the emergency department of a 450-bed metropolitan teaching hospital in Australia. All radiology reports for discharged patients for a one-month period before and after implementation of the electronic result acknowledgement system were reviewed to determine; i) those that reported abnormal results; ii) evidence of test result acknowledgement. All unacknowledged radiology results with an abnormal finding were assessed by an independent panel of two senior emergency physicians for clinical significance. RESULTS: Of 1654 radiology reports in the pre-implementation period 70.6% (n = 1167) had documented evidence of acknowledgement by a clinician. For reports with abnormal results, 71.6% (n = 396) were acknowledged. Of 157 unacknowledged abnormal radiology reports reviewed by an independent emergency physician panel, 34.4% (n = 54) were identified as clinically significant and 50% of these (n = 27) were deemed to carry a moderate likelihood of patient morbidity if not followed up. Electronic acknowledgement occurred for all radiology reports in the post period (n = 1423), representing a 30.4% (95% CI: 28.1-32.6%) increase in acknowledgement rate, and an increase of 28.4% (95% CI: 24.6-32.2%) for abnormal radiology results. CONCLUSIONS: The findings of this study demonstrate the potential of health information technology to improve the safety and effectiveness of the diagnostic process by increasing the rate of follow up of results pending at hospital discharge.

Fit Between Individuals, Tasks, Technology, and Environment (FITTE) Framework: A Proposed Extension of FITT to Evaluate and Optimise Health Information Technology Use.

Evaluating and optimising 'fit' between technology and clinical work is critical to ensure the intended benefits of technology implementations are achieved. Using a mixed method approach (structured observation, interviews, field notes) we collected data regarding users, tasks, technology, and factors impeding technology use from a sample of 38 clinicians on two wards at an Australian hospital. We used the FITT framework to assess the relationships between users, tasks, and technology. Our findings showed that even when adequate fit between users, tasks, and technology was attained additional factors related to the environment (including the temporal rhythms of a ward, infection control rooms, or space limitations) ultimately affected technology use. Thus, we propose the fit between individuals, task, technology and environment (FITTE) framework as a means to evaluate and optimise technology use by explicating the relationships between users, tasks, technology, and the environment in which they operate.

Strengthening resilience in military officer cadets: A group-randomized controlled trial of coping and emotion regulatory self-reflection training.

OBJECTIVE: This group-randomized control trial examined the efficacy of guided coping and emotion regulatory self-reflection as a means to strengthen resilience by testing the effects of the training on anxiety and depression symptoms and perceived stressor frequency after an intensive stressor period. METHOD: The sample was 226 officer cadets training at the Royal Military College, Australia. Cadets were randomized by platoon to the self-reflection (n = 130) or coping skills training (n = 96). Surveys occurred at 3 time points: baseline, immediately following the final reflective session (4-weeks postbaseline), and longer-term follow-up (3-months postinitial follow-up). RESULTS: There were no significant baseline differences in demographic or outcome variables between the intervention groups. On average, cadets commenced the resilience training with mild depression and anxiety symptoms. Analyses were conducted at the individual-level after exploring group-level effects. No between-groups differences were observed at initial follow-up. At longer-term follow-up, improvements in mental health outcomes were observed for the self-reflection group, compared with the coping skills group, on depression (Cohen's d = 0.55; 95% CI [0.24, 0.86]), anxiety symptoms (Cohen's d = 0.69; 95% CI [0.37, 1.00]), and perceived stressor frequency (Cohen's d = 0.46; 95% CI [0.15, 0.77]). Longitudinal models demonstrated a time by condition interaction for depression and anxiety, but there was only an effect of condition for perceived stressor frequency. Mediation analyses supported an indirect effect of the intervention on both anxiety and depression via perceived stressor frequency. CONCLUSIONS: Findings provide initial support for the use of guided self-reflection as an alternative to coping skills approaches to resilience training. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Balancing Risk and Resilience: A Comparison of the Use of a Test Result Management System Across Two EDs.

Understanding the context and nuances of clinical performance at the front-line can provide valuable insights into why the effects of Health Information Technology implementation might differ across sites. It also helps to inform the design of systems that support performance flexibility as clinicians respond to the changing demands of the clinical environment. This study explored the use of an electronic result acknowledgement (eRA) system by physicians at two Emergency Departments (EDs) at Australian metropolitan teaching hospitals to understand how electronic result acknowledgement is managed differently in response to varying environmental demands. Semi-structured, in-depth interviews relating to physician electronic test result acknowledgement processes were conducted with 21 emergency physicians. Physician use of the eRA system differed in four aspects: i) responsibility (i.e. who acknowledges test results); ii) types of tests acknowledged; iii) coordination and synchronisation (i.e. when acknowledgement occurred); and iv) documentation of follow-up actions.

What Factors Determine the Use of an Electronic Test Result Acknowledgement System? - A Qualitative Study Across Two EDs.

Electronic medical record-based test results management interventions hold the potential to reduce errors in the test result follow-up process. However, ensuring the adaptability of such systems to the clinical environment has proven challenging. The aim of this study was to explore how contextual factors can influence senior emergency physicians' experience and perceived impacts of an electronic result acknowledgement system across two Emergency Departments. Semi-structured, in-depth interviews relating to physician test result acknowledgement processes before and after system implementation were conducted with 14 senior Emergency Physicians across two Australian metropolitan teaching hospitals. Perceived impacts of the electronic test result acknowledgement system on test result endorsement varied in terms of: changes to workflow, impacts on patient safety; and changes to documentation practices. Existing work practices and the departmental staffing mix and roles play a part in determining the nature of change that an electronic result acknowledgement system is likely to produce.

What is the impact of an electronic test result acknowledgement system on Emergency Department physicians' work processes? A mixed-method pre-post observational study.

OBJECTIVE: To examine the impact of an electronic Results Acknowledgement (eRA) system on emergency physicians' test result management work processes and the time taken to acknowledge microbiology and radiology test results for patients discharged from an Emergency Department (ED). METHODS: The impact of the eRA system was assessed in an Australian ED using: a) semi-structured interviews with senior emergency physicians; and b) a time and motion direct observational study of senior emergency physicians completing test acknowledgment pre and post the implementation of the eRA system. RESULTS: The eRA system led to changes in the way results and actions were collated, stored, documented and communicated. Although there was a non-significant increase in the average time taken to acknowledge results in the post period, most types of acknowledgements (other than simple acknowledgements) took less time to complete. The number of acknowledgements where physicians sought additional information from the Electronic Medical Record (EMR) rose from 12% pre to 20% post implementation of eRA. CONCLUSIONS: Given that the type of results are unlikely to have changed significantly across the pre and post implementation periods, the increase in the time physicians spent accessing additional clinical information in the post period likely reflects the greater access to clinical information provided by the integrated electronic system. Easier access to clinical information may improve clinical decision making and enhance the quality of patient care. For instance, in situations where a senior clinician, not initially involved in the care process, is required to deal with the follow-up of non-normal results.

Evaluation research studies essential to ensuring health information systems meet the needs of users, including patients.

Electronic health records and the Internet will continue to transform how information is accessed and shared. Users of health data such as health professionals, governments, policymakers, researchers and patients themselves need to be able to access the right information at the right time and be confident in the quality of that information, whether personal, aggregated or knowledge based. It is essential to evaluate information systems and applications that claim to improve information quality and access in order to provide evidence that they support healthcare delivery and improve patient outcomes.

Documentation of clinical care in hospital patients' medical records: A qualitative study of medical students' perspectives on clinical documentation education.

BACKGROUND: Clinical documentation is essential for communication between health professionals and the provision of quality care to patients. OBJECTIVE: To examine medical students' perspectives of their education in documentation of clinical care in hospital patients' medical records. METHOD: A qualitative design using semi-structured interviews with fourth-year medical students was undertaken at a hospital-based clinical school in an Australian university. RESULTS: Several themes reflecting medical students' clinical documentation education emerged from the data: formal clinical documentation education using lectures and tutorials was minimal; most education occurred on the job by junior doctors and student's expressed concerns regarding variation in education between teams and receiving limited feedback on performance. Respondents reported on the importance of feedback for their learning of disease processes and treatments. They suggested that improvements could be made in the timing of clinical documentation education and they stressed the importance of training on the job. CONCLUSION: On-the-job education with feedback in clinical documentation provides a learning opportunity for medical students and is essential in order to ensure accurate, safe, succinct and timely clinical notes.

Emergency physicians' views of direct notification of laboratory and radiology results to patients using the Internet: a multisite survey.

BACKGROUND: Patients are increasingly using the Internet to communicate with health care providers and access general and personal health information. Missed test results have been identified as a critical safety issue with studies showing up to 75% of tests for emergency department (ED) patients not being followed-up. One strategy that could reduce the likelihood of important results being missed is for ED patients to have direct access to their test results. This could be achieved electronically using a patient portal tied to the hospital's electronic medical record or accessed from the relevant laboratory information system. Patients have expressed interest in accessing test results directly, but there have been no reported studies on emergency physicians' opinions. OBJECTIVE: The aim was to explore emergency physicians' current practices of test result notification and attitudes to direct patient notification of clinically significant abnormal and normal test results. METHODS: A cross-sectional survey was self-administered by senior emergency physicians (site A: n=50; site B: n=39) at 2 large public metropolitan teaching hospitals in Australia. Outcome measures included current practices for notification of results (timing, methods, and responsibilities) and concerns with direct notification. RESULTS: The response rate was 69% (61/89). More than half of the emergency physicians (54%, 33/61) were uncomfortable with patients receiving direct notification of abnormal test results. A similar proportion (57%, 35/61) was comfortable with direct notification of normal test results. Physicians were more likely to agree with direct notification of normal test results if they believed it would reduce their workload (OR 5.72, 95% CI 1.14-39.76). Main concerns were that patients could be anxious (85%, 52/61), confused (92%, 56/61), and lacking in the necessary expertise to interpret their results (90%, 55/61). CONCLUSIONS: Although patients' direct access to test results could serve as a safety net reducing the likelihood of abnormal results being missed, emergency physicians' concerns need further exploration: which results are suitable and the timing and method of direct release to patients. Methods of access, including secure Web-based patient portals with drill-down facilities providing test descriptions and result interpretations, or laboratories sending results directly to patients, need evaluation to ensure patient safety is not compromised and the processes fit with ED clinician and laboratory work practices and patient needs.

Releasing test results directly to patients: A multisite survey of physician perspectives.

OBJECTIVE: To determine physician perspectives about direct notification of normal and abnormal test results. METHODS: We conducted a cross-sectional survey at five clinical sites in the US and Australia. The US-based study was conducted via web-based survey of primary care physicians and specialists between July and October 2012. An identical paper-based survey was self-administered between June and September 2012 with specialists in Australia. RESULTS: Of 1417 physicians invited, 315 (22.2%) completed the survey. Two-thirds (65.3%) believed that patients should be directly notified of normal results, but only 21.3% were comfortable with direct notification of clinically significant abnormal results. Physicians were more likely to endorse direct notification of abnormal results if they believed it would reduce the number of patients lost to follow-up (OR=4.98, 95%CI=2.21-1.21) or if they had personally missed an abnormal test result (OR=2.95, 95%CI=1.44-6.02). Conversely, physicians were less likely to endorse if they believed that direct notification interfered with the practice of medicine (OR=0.39, 95%CI=0.20-0.74). CONCLUSION: Physicians we surveyed generally favor direct notification of normal results but appear to have substantial concerns about direct notification of abnormal results. PRACTICE IMPLICATIONS: Widespread use of direct notification should be accompanied by strategies to help patients manage test result abnormalities they receive.

Maternity patients' access to their electronic medical records: use and perspectives of a patient portal.

Patients have been able to access clinical information from their paper-based health records for a number of years. With the advent of Electronic Medical Records (EMRs) access to this information can now be achieved online using a secure electronic patient portal. The purpose of this study was to investigate maternity patients' use and perceptions of a patient portal developed at the Mater Mothers' Hospital in Brisbane, Australia. A web-based patient portal, one of the first developed and deployed in Australia, was introduced on 26 June 2012. The portal was designed for maternity patients booked at Mater Mothers' Hospital, as an alternative to the paper-based Pregnancy Health Record. Through the portal, maternity patients are able to complete their hospital registration form online and obtain current health information about their pregnancy (via their EMR), as well as access a variety of support tools to use during their pregnancy such as tailored public health advice. A retrospective cross-sectional study design was employed. Usage statistics were extracted from the system for a one year period (1 July 2012 to 30 June 2013). Patients' perceptions of the portal were obtained using an online survey, accessible by maternity patients for two weeks in February 2013 (n=80). Descriptive statistics were employed to analyse the data. Between July 2012 and June 2013, 10,892 maternity patients were offered a patient portal account and access to their EMR. Of those 6,518 created one (60%; 6,518/10,892) and 3,104 went on to request access to their EMR (48%; 3,104/6,518). Of these, 1,751 had their access application granted by 30 June 2013. The majority of maternity patients submitted registration forms online via the patient portal (56.7%). Patients could view their EMR multiple times: there were 671 views of the EMR, 2,781 views of appointment schedules and 135 birth preferences submitted via the EMR. Eighty survey responses were received from EMR account holders, (response rate of 8.1%; 80/985). The majority of respondents indicated they would use the portal and access their EMR for future pregnancies (86.2%; 69/80). Approximately half looked at their EMR after a visit with their care provider (51.3%); 41/80) and 37.5% (30/80) viewed their EMR before, to prepare for their visit. The majority (65.8%) thought that the EMR improved their ability to understand and recall appointments and almost half (48.1%) thought that with the EMR they were less likely to repeat pregnancy information to caregivers. This study provides the first Australian evidence of a patient portal system, tied to an EMR, working effectively in a maternity care context. It provides new evidence that portals can deliver benefits to maternity patients in terms of providing quick and easy access to current personal and general health information and support patients in their ability to recall and prepare for appointments.

The Impact for Patient Outcomes of Failure to Follow Up on Test Results. How Can We Do Better?

BACKGROUND: The World Health Organization-World Alliance for Patient Safety has identified test result management as a priority area. Poor test result follow-up can have major consequences for the quality of care, including missed diagnoses and suboptimal patient outcomes. Over the last three decades there has been considerable growth in the number of requests for pathology and radiology services which has added to the complexity of how patient care is delivered and test results are managed. This can contribute to a lack of clarity about where and with whom responsibility for test follow-up should reside: a problem that is compounded by a lack of clear definitions about what are critical, unexpected or significantly abnormal results. AIM OF THIS PAPER: This paper will present a narrative review highlighting key issues related to the problem of failure to follow up laboratory test results, and outline potential solutions. CONCLUSIONS: Information technology (IT) has the potential to enhance the performance and safety of test result management processes. Effective solutions must engage all stakeholders, including consumers, in arriving at decisions about who needs to receive results, how and when they are communicated, and how they are acknowledged and acted upon and the documentation of these actions.

Does an integrated Emergency Department Information System change the sequence of clinical work? A mixed-method cross-site study.

OBJECTIVES: (1) to describe Emergency Department (ED) physicians' and nurses' perceptions about the sequence of work related to patient management with use of an integrated Emergency Department Information System (EDIS), and (2) to measure changes in the sequence of clinician access to patient information. METHODS: A mixed method study was conducted in four metropolitan EDs. Each used the same EDIS which is a module of the hospitals' enterprise-wide clinical information system composed of many components of an electronic medical record. This enabled access to clinical and management information relating to patients attending all hospitals in the region. Phase one - data were collected from ED physicians and nurses (n=97) by 69 in-depth interviews, five focus groups (28 participants), and 26 h of observations. Phase two - physicians (n=34) in one ED were observed over 2 weeks. Data included whether and what type of information was accessed from the EDIS prior to first examination of the patient. RESULTS: Clinicians reported, and phase 2 observations confirmed, that the integrated EDIS led to changes to the order of information access, which held implications for when tests were ordered and results accessed. Most physicians accessed patient information using EDIS prior to taking the patients' first medical history (77/116; 66.4%, 95% CI: 57.8-75.0%). Previous discharge summaries (74%) and past test results (61%) were most frequently accessed and junior doctors were more likely to access electronic past history information than their senior colleagues (χ(2)=20.717, d.f.=1, p<0.001). CONCLUSIONS: The integrated EDIS created new ways of working for ED clinicians. Such changes could hold positive implications for: time taken to reach a diagnosis and deliver treatments; length of stay; patient outcomes and experiences.

Lessons learned from the introduction of an electronic safety net to enhance test result management in an Australian mothers' hospital.

This study describes the implementation and impact of an electronic test result acknowledgement (RA) system in the Mater Mothers' Hospital in Brisbane, Australia. The Verdi application electronically records clinicians' acknowledgement of the review of results. Hospital data (August 2011-August 2012) were extracted to measure clinicians' acknowledgement practices. There were 27,354 inpatient test results for 6855 patients. All test results were acknowledged. 60% (95% CI 59% to 61%) of laboratory and 44% (95% CI 40% to 48%) of imaging results were acknowledged within 24 h. The median time between report availability and acknowledgement was 18.1 h for laboratory and 1 day 18 h for imaging results. The median time from when a result was first viewed to its acknowledgement was 7 min for laboratory and 1 min for imaging results. The longest recorded time to acknowledgement was 38 days. Electronic RA provides a safety net to enhance test result management.

Effective notification of important non-urgent radiology results: a qualitative study of challenges and potential solutions.

INTRODUCTION: We report on the implementation of a Radiology Notification System (RNS), set up by the medical imaging department of a major Sydney teaching hospital in March 2010. This study aimed to investigate the views of the medical imaging department staff about: (i) the results follow-up problem encountered by the medical imaging department prior to the implementation of the RNS; (ii) what changes occurred following implementation of the RNS; and (iii) suggestions for improving the RNS. METHODS: This is a cross-sectional qualitative study incorporating semi-structured interviews with 16 staff (15 radiologists and 1 clerk) after the implementation of the RNS. Interviews were conducted in August/September 2011. RESULTS: The reasons behind the development of the RNS were related to: (i) major existing problems with the communication of results between the imaging department and hospital wards; (ii) cumbersome and inefficient paper-based notification systems; and (iii) the absence of standardised guidelines and procedures for radiology test notification and follow-up. The RNS managed to free up a significant proportion of radiologist time, resulting in greater efficiencies. Study participants also highlighted a number of areas for improvement, including the need for a 24-h service, feedback and acknowledgement of test results by clinicians and the standardisation of test management definitions and procedures. CONCLUSION: Test management systems can play an important part in enhancing safe and effective communications between wards and hospital departments. However, their uptake and sustainability will require the establishment of a multidisciplinary and hospital-wide collaboration that includes clinicians.

The impact of nurse practitioners on care delivery in the emergency department: a multiple perspectives qualitative study.

BACKGROUND: Despite well-articulated benefits, the introduction of Nurse Practitioners (NPs) in Australia has been slow. Poorly defined nomenclature relating to advanced practice roles in nursing and variations in such roles both across Australia and worldwide have resulted in confusion and uncertainty regarding the functions and roles of NPs. Qualitative studies focussing on the perceived impact on the care settings into which NPs are introduced are scarce, but are valuable in providing a complete contextual account of NPs in care delivery settings. This study aimed to investigate the perceived impact of the NP on the delivery of care in the ED by senior doctors, nurses, and NPs. Results will facilitate adoption and best use of this human resource innovation. METHODS: A cross-sectional qualitative study was undertaken in the Emergency Departments (EDs) of two large Australian metropolitan public teaching hospitals. Semi-structured, in-depth interviews were conducted with five nurse practitioners, four senior doctors (staff specialists and ED directors) and five senior nurses. Transcribed interviews were analysed using a grounded theory approach to develop themes in relation to the conceptualisation of the impact of the NP role on the ED. Member checking of results was conducted by revisiting the sites to clarify findings with participants and further explore emergent themes. RESULTS: The impact of the NP role was perceived differently by different groups of participants. Whilst NPs were observed to deliver few quantitative improvements to ED functioning from the perspective of ED directors, NPs believed that they assisted doctors in managing the increasing subacute presentations to the contemporary ED. NPs also believed they embraced a preventative paradigm of care which addressed the long term priorities of chronic disease prevention and cost containment in the broader healthcare environment. The ambiguous position of the NP role, which crosses the gap between nursing and medicine, emerged and resulted in a duality of NP governance. CONCLUSIONS: Interpretation of the NPs' role occurred through different frames of reference. This has implications for the development of the NP role in the ED. Collaboration and dialogue between various stakeholders, such as ED doctors and senior nursing management is required.

Perceptions of the effect of information and communication technology on the quality of care delivered in emergency departments: a cross-site qualitative study.

STUDY OBJECTIVE: We identify and describe emergency physicians' and nurses' perceptions of the effect of an integrated emergency department (ED) information system on the quality of care delivered in the ED. METHODS: A qualitative study was conducted in 4 urban EDs, with each site using the same ED information system. Participants (n=97) were physicians and nurses with data collected by 69 detailed interviews, 5 focus groups (28 participants), and 26 hours of structured observations. RESULTS: Results revealed new perspectives on how an integrated ED information system was perceived to affect incentives for use, awareness of colleagues' activities, and workflow. A key incentive was related to the positive effect of the ED information system on clinical decisionmaking because of improved and quicker access to patient-specific and knowledge-base information compared with the previous stand-alone ED information system. Synchronous access to patient data was perceived to lead to enhanced awareness by individual physicians and nurses of what others were doing within and outside the ED, which participants claimed contributed to improved care coordination, communication, clinical documentation, and the consultation process. There was difficulty incorporating the use of the ED information system with clinicians' work, particularly in relation to increased task complexity; duplicate documentation, and computer issues related to system usability, hardware, and individuals' computer skills and knowledge. CONCLUSION: Physicians and nurses perceived that the integrated ED information system contributed to improvements in the delivery of patient care, enabling faster and better-informed decisionmaking and specialty consultations. The challenge of electronic clinical documentation and balancing data entry demands with system benefits necessitates that new methods of data capture, suited to busy clinical environments, be developed.

Can technology change the work of nurses? Evaluation of a drug monitoring system for ambulatory chronic disease patients.

OBJECTIVE: To evaluate the impact of an electronic drug monitoring system (eDMS) for ambulatory rheumatology patients on time nurses spent on, and the process of, drug monitoring. METHODS: The study was conducted in the Rheumatology Department of a large metropolitan hospital. The eDMS, a module of the Hospital Clinical Information System (HCIS), was designed to allow electronic ordering and subsequent monitoring of ambulatory patients on long-term, immunosuppressive rheumatology medications. Quantitative measures collected before and after the intervention were: time spent on specific nursing activities; who nurses spent time with; format and location of documentation monitoring; and patient throughput. Qualitative data from interviews and observations were collected to ascertain the impact of the eDMS on nurses' monitoring activities. RESULTS: Nurses spent significantly less time on medication monitoring tasks (33.1% versus 26.4%, P=0.003) and significantly more time on patient care (6.5-18.1%, P<0.0001) following implementation of the eDMS. Nurses also spent significantly more time with patients (7.7-19.8%, P<0.0001) and relatives (0.4-3.7%, P=0.01) after the system was implemented. The time saved on monitoring allowed the number of nurse directed clinics and patient throughput to increase following eDMS implementation. Qualitative data supported results from the timing study with nurses reporting that the monitoring process was more standardised, safer, took less time and simplified documentation. CONCLUSIONS: The eDMS was associated with a reduction in time spent on the complex task of medication monitoring allowing nurses to spend a greater proportion of their time on other patient care activities.