Nurses’ Workarounds in Electronic Nursing Records for Pressure Injuries: A Mixed-Methods Study (Preprint)

BACKGROUND Electronic Nursing Records (ENR) are essential tools for documenting pressure injury (PI) care and ensuring patient safety. However, nurses often adopt workarounds that deviate from standard procedures, which may affect documentation quality and workflow efficiency. Understanding the reasons and contexts of these workarounds is critical for improving clinical practice and electronic record systems. OBJECTIVE This study aimed to examine the prevalence, patterns, and motivations of nurses’ workarounds in pressure injury electronic nursing records (PIs-ENR) using a mixed-methods approach. METHODS In the first stage, 160 nurses from a regional hospital in Taiwan completed the PIs-ENR Workarounds instrument. Descriptive statistics and bivariate correlation analyses were conducted to identify relationships between demographic factors and workarounds. In the second stage, 18 nurses participated in focus groups and created empathy maps related to PIs-ENR workarounds. Qualitative content analysis was performed, and findings were mapped onto the revised Sociotechnical Electronic Health Record Workaround Analysis (SEWA) framework. Pain points and workflow challenges were further explored. RESULTS The mean PIs-ENR workaround score was 2.75 (SD = 0.36), indicating that workarounds frequently occurred. Age and years of experience were positively correlated with workaround frequency. Significant correlations were also observed among subdomains of PIs-ENR documentation. Qualitative analysis revealed that efficiency was the predominant rationale for workarounds, followed by social norms, task inference, and commitment to patient interaction. Key pain points included excessive treatment activities, limited staffing, unclear task division, frequent revisions of operating standards, and complex or non-user-friendly electronic systems. CONCLUSIONS Nurses commonly adopt workarounds in PIs-ENR to manage high workloads, prioritize patient care, and navigate complex documentation systems. These findings highlight the need to optimize ENR design, align workflows with clinical practice, and address staffing and administrative challenges to enhance documentation quality and patient safety.