Factors Influencing Information Distortion in Electronic Nursing Records: Qualitative Study

BackgroundInformation distortion in nursing records poses significant risks to patient safety and impedes the enhancement of care quality. The introduction of information technologies, such as decision support systems and predictive models, expands the possibilities for using...

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Main Authors: Jianan Wang, Yihong Xu, Zhichao Yang, Jie Zhang, Xiaoxiao Zhang, Wen Li, Yushu Sun, Hongying Pan
Format: Article
Language:English
Published: JMIR Publications 2025-04-01
Series:Journal of Medical Internet Research
Online Access:https://www.jmir.org/2025/1/e66959
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author Jianan Wang
Yihong Xu
Zhichao Yang
Jie Zhang
Xiaoxiao Zhang
Wen Li
Yushu Sun
Hongying Pan
author_facet Jianan Wang
Yihong Xu
Zhichao Yang
Jie Zhang
Xiaoxiao Zhang
Wen Li
Yushu Sun
Hongying Pan
author_sort Jianan Wang
collection DOAJ
description BackgroundInformation distortion in nursing records poses significant risks to patient safety and impedes the enhancement of care quality. The introduction of information technologies, such as decision support systems and predictive models, expands the possibilities for using health data but also complicates the landscape of information distortion. Only by identifying influencing factors about information distortion can care quality and patient safety be ensured. ObjectiveThis study aims to explore the factors influencing information distortion in electronic nursing records (ENRs) within the context of China’s health care system and provide appropriate recommendations to address these distortions. MethodsThis qualitative study used semistructured interviews conducted with 14 nurses from a Class-A tertiary hospital. Participants were primarily asked about their experiences with and observations of information distortion in clinical practice, as well as potential influencing factors and corresponding countermeasures. Data were analyzed using inductive content analysis, which involved initial preparation, line-by-line coding, the creation of categories, and abstraction. ResultsThe analysis identified 4 categories and 10 subcategories: (1) nurse-related factors—skills, awareness, and work habits; (2) patient-related factors—willingness and ability; (3) operational factors—work characteristics and system deficiencies; and (4) organizational factors—management system, organizational climate, and team collaboration. ConclusionsAlthough some factors influencing information distortion in ENRs are similar to those observed in paper-based records, others are unique to the digital age. As health care continues to embrace digitalization, it is crucial to develop and implement strategies to mitigate information distortion. Regular training and education programs, robust systems and mechanisms, and optimized human resources and organizational practices are strongly recommended.
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spelling doaj-art-a8beb71fa2304582a12ad6cb9bbd9f1d2025-08-20T03:06:14ZengJMIR PublicationsJournal of Medical Internet Research1438-88712025-04-0127e6695910.2196/66959Factors Influencing Information Distortion in Electronic Nursing Records: Qualitative StudyJianan Wanghttps://orcid.org/0009-0003-0827-3134Yihong Xuhttps://orcid.org/0000-0001-6177-8316Zhichao Yanghttps://orcid.org/0009-0004-9665-6115Jie Zhanghttps://orcid.org/0009-0001-3639-9231Xiaoxiao Zhanghttps://orcid.org/0009-0009-8154-7203Wen Lihttps://orcid.org/0009-0008-0701-5121Yushu Sunhttps://orcid.org/0009-0007-2690-9086Hongying Panhttps://orcid.org/0000-0001-5597-1793 BackgroundInformation distortion in nursing records poses significant risks to patient safety and impedes the enhancement of care quality. The introduction of information technologies, such as decision support systems and predictive models, expands the possibilities for using health data but also complicates the landscape of information distortion. Only by identifying influencing factors about information distortion can care quality and patient safety be ensured. ObjectiveThis study aims to explore the factors influencing information distortion in electronic nursing records (ENRs) within the context of China’s health care system and provide appropriate recommendations to address these distortions. MethodsThis qualitative study used semistructured interviews conducted with 14 nurses from a Class-A tertiary hospital. Participants were primarily asked about their experiences with and observations of information distortion in clinical practice, as well as potential influencing factors and corresponding countermeasures. Data were analyzed using inductive content analysis, which involved initial preparation, line-by-line coding, the creation of categories, and abstraction. ResultsThe analysis identified 4 categories and 10 subcategories: (1) nurse-related factors—skills, awareness, and work habits; (2) patient-related factors—willingness and ability; (3) operational factors—work characteristics and system deficiencies; and (4) organizational factors—management system, organizational climate, and team collaboration. ConclusionsAlthough some factors influencing information distortion in ENRs are similar to those observed in paper-based records, others are unique to the digital age. As health care continues to embrace digitalization, it is crucial to develop and implement strategies to mitigate information distortion. Regular training and education programs, robust systems and mechanisms, and optimized human resources and organizational practices are strongly recommended.https://www.jmir.org/2025/1/e66959
spellingShingle Jianan Wang
Yihong Xu
Zhichao Yang
Jie Zhang
Xiaoxiao Zhang
Wen Li
Yushu Sun
Hongying Pan
Factors Influencing Information Distortion in Electronic Nursing Records: Qualitative Study
Journal of Medical Internet Research
title Factors Influencing Information Distortion in Electronic Nursing Records: Qualitative Study
title_full Factors Influencing Information Distortion in Electronic Nursing Records: Qualitative Study
title_fullStr Factors Influencing Information Distortion in Electronic Nursing Records: Qualitative Study
title_full_unstemmed Factors Influencing Information Distortion in Electronic Nursing Records: Qualitative Study
title_short Factors Influencing Information Distortion in Electronic Nursing Records: Qualitative Study
title_sort factors influencing information distortion in electronic nursing records qualitative study
url https://www.jmir.org/2025/1/e66959
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