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Integrating Spatial Awareness Into Nursing EHR Design: A Scoping Review of Usability and Cognitive Load.

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Τίτλος: Integrating Spatial Awareness Into Nursing EHR Design: A Scoping Review of Usability and Cognitive Load.
Συγγραφείς: Taylor-Vaughan L; College of Nursing, University of Arizona, Tucson, AZ., Boyles S, Eyler D, DeBoe JC, Garcia A, Puma S, Gephart S
Πηγή: Computers, informatics, nursing : CIN [Comput Inform Nurs] 2026 Jul 01; Vol. 44 (7). Date of Electronic Publication: 2026 Jul 01.
Τύπος έκδοσης: Journal Article; Scoping Review
Γλώσσα: English
Στοιχεία περιοδικού: Publisher: Lippincott Williams & Wilkins Country of Publication: United States NLM ID: 101141667 Publication Model: Electronic Cited Medium: Internet ISSN: 1538-9774 (Electronic) Linking ISSN: 15382931 NLM ISO Abbreviation: Comput Inform Nurs Subsets: MEDLINE
Imprint Name(s): Original Publication: Hagerstown, MD : Lippincott Williams & Wilkins, c2002-
Ιατρικοί όροι (MeSH): Electronic Health Records* , Cognition* , User-Computer Interface* , Awareness*, Humans ; Digital Health
Περίληψη: Background: Usability challenges in electronic health records drive documentation burden and cognitive overload, especially in high-acuity settings. Current electronic health record design often fails to accurately reflect real-world clinical environments, disrupting workflow and decision-making processes. Integrating spatial awareness, which aligns physical clinical equipment with its digital representation, may enhance usability by reducing cognitive strain and fostering intuitive interaction.
Methods: This scoping review followed PRISMA-ScR guidelines. We searched 7 databases for peer-reviewed articles concerning the usability of electronic health records and cognitive load in relation to spatial awareness.
Results: Thirty-five articles met the inclusion criteria. Many were in acute care (71.4%). End-user populations: physicians (n=22, 62.9%), nurses (n=14, 40.0%), and other roles (n=8, 22.9%). Key findings included visual integration (88.6%), kinesthetic interaction (34.3%), and auditory cues (5.7%). Conventional fixes commonly improved entry speed but rarely reduced fragmentation or enhanced SA; no study implemented full room- or device-aligned spatial mapping. Most evaluations used prototype or custom systems (n=20, 57.1%).
Discussion: Despite advancements in interface technology, few systems achieve spatial integration within nursing workflows. Integrating spatial awareness represents a promising but untested design approach that warrants systematic evaluation alongside optimized, simpler solutions.
(Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.)
References: Levy DR, Withall JB, Mishuris RG, et al. Defining documentation burden (DocBurden) and excessive DocBurden for all health professionals: a scoping review. Applied Clinical Informatics 2024;15(5):898–913.
Olakotan O, Samuriwo R, Ismaila H, Atiku S. Usability challenges in electronic health records: impact on documentation burden and clinical workflow: a scoping review. Journal of Evaluation in Clinical Practice 2025;31(4):e70189.
Cho H, Nguyen OT, Weaver M, et al. Electronic health record system use and documentation burden of acute and critical care nurse clinicians: a mixed-methods study. Journal of the American Medical Informatics Association 2024;31(11):2540–2549.
De Groot K, De Veer AJE, Munster AM, Francke AL, Paans W. Nursing documentation and its relationship with perceived nursing workload: a mixed-methods study among community nurses. BMC Nursing 2022;21(1):34.
Cahill M, Cleary BJ, Cullinan S. The influence of electronic health record design on usability and medication safety: systematic review. BMC Health Services Research 2025;25(1):31.
Asgari E, Kaur J, Nuredini G, et al. Impact of electronic health record use on cognitive load and burnout among clinicians: narrative review. JMIR Medical Informatics 2024;12(1):e55499.
Gesner E, Dykes PC, Zhang L, Gazarian P. Documentation burden in nursing and its role in clinician burnout syndrome. Applied Clinical Informatics 2022;13(5):983–990.
Bartek B, Lou SS, Kannampallil T. Measuring the cognitive effort associated with task switching in routine EHR-based tasks. Journal of Biomedical Informatics 2023;141:104349.
Moy AJ, Schwartz JM, Chen R, et al. Measurement of clinical documentation burden among physicians and nurses using electronic health records: a scoping review. Journal of the American Medical Informatics Association 2021;28(5):998–1008.
Senathirajah Y, Kaufman DR, Cato KD, Borycki EM, Fawcett JA, Kushniruk AW. Characterizing and visualizing display and task fragmentation in the electronic health record: mixed methods design. JMIR Human Factors 2020;7(4):e18484.
Sweller J. Cognitive load during problem solving: effects on learning. Cognitive Science 1988;12(2):257–285.
Kahneman D. Thinking, Fast and Slow. Farrar, Straus and Giroux; 2011.
Miller GA. The magical number seven plus or minus two: some limits on our capacity for processing information. Psychological Review 1956;63(2):81–97.
Moy AJ, Hobensack M, Marshall K, et al. Understanding the perceived role of electronic health records and workflow fragmentation on clinician documentation burden in emergency departments. Journal of the American Medical Informatics Association 2023;30(5):797–808.
Gowda V, Schulzrinne H, Miller BJ. The case for medical device interoperability. JAMA Health Forum 2022;3(1):e214313.
Martens E, Haase HU, Mastella G, et al. Smart hospital: achieving interoperability and raw data collection from medical devices in clinical routine. Frontiers in Digital Health 2024;6:1341475.
Nielsen J. Usability Engineering. Morgan Kaufmann; 1994.
Dunn Lopez K, Chin CL, Leitao Azevedo RF, et al. Electronic health record usability and workload changes over time for provider and nursing staff following transition to new EHR. Applied Ergonomics 2021;93:103359.
Alboksmaty A, Aldakhil R, Hayhoe BWJ, Ashrafian H, Darzi A, Neves AL. The impact of using AI-powered voice-to-text technology for clinical documentation on quality of care in primary care and outpatient settings: a systematic review. EBioMedicine 2025;118:105861.
Schewe F, Vollrath M. Ecological interface design and head-up displays: the contact-analog visualization tradeoff. Human Factors 2023;65(1):37–49.
Gibson JJ. The theory of affordances. In: Shaw R, Bransford J, eds. Perceiving, Acting, and Knowing: Toward an Ecological Psychology . Lawrence Erlbaum Associates; 1977:67–82.
Vicente KJ, Rasmussen J. Ecological interface design: theoretical foundations. IEEE Transactions on Systems, Man, and Cybernetics 1992;22(4):589–606.
Effken JA, Loeb RG, Kang Y, Lin ZC. Clinical information displays to improve ICU outcomes. International Journal of Medical Informatics 2008;77(11):765–777.
Viautour J, Naegeli L, Braun J, et al. The visual patient avatar ICU facilitates information transfer of written information by visualization: a multicenter comparative eye-tracking study. Diagnostics (Basel) 2023;13(22):3432.
Lindsay MR, Lytle K. Implementing best practices to redesign workflow and optimize nursing documentation in the electronic health record. Applied Clinical Informatics 2022;13(3):711–719.
Tricco AC, Lillie E, Zarin W, et al. PRISMA extension for scoping reviews (PRISMA-scr): checklist and explanation. Annals of Internal Medicine 2018;169(7):467–473.
Arksey H, O’Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology 2005;8(1):19–32.
Peters MDJ, Marnie C, Tricco AC, et al. Updated methodological guidance for the conduct of scoping reviews. JBI Evidence Synthesis 2020;18(10):2119–2126.
Ahmed A, Chandra S, Herasevich V, Gajic O, Pickering BW. The effect of two different electronic health record user interfaces on intensive care provider task load, errors of cognition, and performance. Critical Care Medicine 2011;39(7):1626–1634.
Brown N, Eghdam A, Koch S. Usability evaluation of visual representation formats for emergency department records. Applied Clinical Informatics 2019;10(3):454–470.
Koch SH, Weir C, Westenskow D, et al. Evaluation of the effect of information integration in displays for ICU nurses on situation awareness and task completion time: a prospective randomized controlled study. International Journal of Medical Informatics 2013;82(8):665–675.
Plaisant C, Wu J, Hettinger AZ, Powsner S, Shneiderman B. Novel user interface design for medication reconciliation: an evaluation of Twinlist. Journal of the American Medical Informatics Association 2015;22(2):340–349.
Koch SH, Westenskow D, Weir C, et al. ICU nurses’ evaluations of integrated information displays on user satisfaction and perceived mental workload. Studies in Health Technology and Informatics 2012;180:383–387.
Rausch D, Kwade Z, Dahlweid M, Kozinova I, Nathoo S, Yasini M. Say goodbye to the ‘paper on screen’, rethinking presentation of and interaction with medical information. Studies in Health Technology and Informatics 2024;310:775–779.
Senathirajah Y, Kaufman D, Bakken S. The clinician in the driver’s seat: part 2 - intelligent uses of space in a drag/drop user-composable electronic health record. Journal of Biomedical Informatics 2014;52:177–188.
Middleton B, Bloomrosen M, Dente MA, et al. Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. Journal of the American Medical Informatics Association 2013;20(e1):e2–e8.
Farhadloo M, Sharma A, Shekhar S, Markovic SN. Spatial computing opportunities in biomedical decision support: the atlas-EHR vision. arXiv preprint 2023. doi:10.48550/arXiv.2305.09675 . (PMID: 10.48550/arXiv.2305.09675)
Langote M, Saratkar S, Kumar P, et al. Human–computer interaction in healthcare: comprehensive review. AIMS Bioengineering 2024;11(3):343–390.
Berg M. Implementing information systems in health care organizations: myths and challenges. International Journal of Medical Informatics 2001;64(2-3):143–156.
Contributed Indexing: Keywords: Cognitive load; Documentation burden; Electronic health records; Spatial awareness integration; Usability
Entry Date(s): Date Created: 20260129 Date Completed: 20260703 Latest Revision: 20260703
Update Code: 20260703
DOI: 10.1097/CIN.0000000000001473
PMID: 41607124
Βάση Δεδομένων: MEDLINE
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  Data: <searchLink fieldCode="MM" term="%22Electronic+Health+Records%22">Electronic Health Records*</searchLink> <br /><searchLink fieldCode="MM" term="%22Cognition%22">Cognition*</searchLink> <br /><searchLink fieldCode="MM" term="%22User-Computer+Interface%22">User-Computer Interface*</searchLink> <br /><searchLink fieldCode="MM" term="%22Awareness%22">Awareness*</searchLink><br /><searchLink fieldCode="MH" term="%22Humans%22">Humans</searchLink> ; <searchLink fieldCode="MH" term="%22Digital+Health%22">Digital Health</searchLink>
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  Data: Background: Usability challenges in electronic health records drive documentation burden and cognitive overload, especially in high-acuity settings. Current electronic health record design often fails to accurately reflect real-world clinical environments, disrupting workflow and decision-making processes. Integrating spatial awareness, which aligns physical clinical equipment with its digital representation, may enhance usability by reducing cognitive strain and fostering intuitive interaction.<br />Methods: This scoping review followed PRISMA-ScR guidelines. We searched 7 databases for peer-reviewed articles concerning the usability of electronic health records and cognitive load in relation to spatial awareness.<br />Results: Thirty-five articles met the inclusion criteria. Many were in acute care (71.4%). End-user populations: physicians (n=22, 62.9%), nurses (n=14, 40.0%), and other roles (n=8, 22.9%). Key findings included visual integration (88.6%), kinesthetic interaction (34.3%), and auditory cues (5.7%). Conventional fixes commonly improved entry speed but rarely reduced fragmentation or enhanced SA; no study implemented full room- or device-aligned spatial mapping. Most evaluations used prototype or custom systems (n=20, 57.1%).<br />Discussion: Despite advancements in interface technology, few systems achieve spatial integration within nursing workflows. Integrating spatial awareness represents a promising but untested design approach that warrants systematic evaluation alongside optimized, simpler solutions.<br /> (Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.)
– Name: Ref
  Label: References
  Group: RefInfo
  Data: Levy DR, Withall JB, Mishuris RG, et al. Defining documentation burden (DocBurden) and excessive DocBurden for all health professionals: a scoping review. Applied Clinical Informatics 2024;15(5):898–913.<br />Olakotan O, Samuriwo R, Ismaila H, Atiku S. Usability challenges in electronic health records: impact on documentation burden and clinical workflow: a scoping review. Journal of Evaluation in Clinical Practice 2025;31(4):e70189.<br />Cho H, Nguyen OT, Weaver M, et al. Electronic health record system use and documentation burden of acute and critical care nurse clinicians: a mixed-methods study. Journal of the American Medical Informatics Association 2024;31(11):2540–2549.<br />De Groot K, De Veer AJE, Munster AM, Francke AL, Paans W. Nursing documentation and its relationship with perceived nursing workload: a mixed-methods study among community nurses. BMC Nursing 2022;21(1):34.<br />Cahill M, Cleary BJ, Cullinan S. The influence of electronic health record design on usability and medication safety: systematic review. BMC Health Services Research 2025;25(1):31.<br />Asgari E, Kaur J, Nuredini G, et al. Impact of electronic health record use on cognitive load and burnout among clinicians: narrative review. JMIR Medical Informatics 2024;12(1):e55499.<br />Gesner E, Dykes PC, Zhang L, Gazarian P. Documentation burden in nursing and its role in clinician burnout syndrome. Applied Clinical Informatics 2022;13(5):983–990.<br />Bartek B, Lou SS, Kannampallil T. Measuring the cognitive effort associated with task switching in routine EHR-based tasks. Journal of Biomedical Informatics 2023;141:104349.<br />Moy AJ, Schwartz JM, Chen R, et al. Measurement of clinical documentation burden among physicians and nurses using electronic health records: a scoping review. Journal of the American Medical Informatics Association 2021;28(5):998–1008.<br />Senathirajah Y, Kaufman DR, Cato KD, Borycki EM, Fawcett JA, Kushniruk AW. Characterizing and visualizing display and task fragmentation in the electronic health record: mixed methods design. JMIR Human Factors 2020;7(4):e18484.<br />Sweller J. Cognitive load during problem solving: effects on learning. Cognitive Science 1988;12(2):257–285.<br />Kahneman D. Thinking, Fast and Slow. Farrar, Straus and Giroux; 2011.<br />Miller GA. The magical number seven plus or minus two: some limits on our capacity for processing information. Psychological Review 1956;63(2):81–97.<br />Moy AJ, Hobensack M, Marshall K, et al. Understanding the perceived role of electronic health records and workflow fragmentation on clinician documentation burden in emergency departments. Journal of the American Medical Informatics Association 2023;30(5):797–808.<br />Gowda V, Schulzrinne H, Miller BJ. The case for medical device interoperability. JAMA Health Forum 2022;3(1):e214313.<br />Martens E, Haase HU, Mastella G, et al. Smart hospital: achieving interoperability and raw data collection from medical devices in clinical routine. Frontiers in Digital Health 2024;6:1341475.<br />Nielsen J. Usability Engineering. Morgan Kaufmann; 1994.<br />Dunn Lopez K, Chin CL, Leitao Azevedo RF, et al. Electronic health record usability and workload changes over time for provider and nursing staff following transition to new EHR. Applied Ergonomics 2021;93:103359.<br />Alboksmaty A, Aldakhil R, Hayhoe BWJ, Ashrafian H, Darzi A, Neves AL. The impact of using AI-powered voice-to-text technology for clinical documentation on quality of care in primary care and outpatient settings: a systematic review. EBioMedicine 2025;118:105861.<br />Schewe F, Vollrath M. Ecological interface design and head-up displays: the contact-analog visualization tradeoff. Human Factors 2023;65(1):37–49.<br />Gibson JJ. The theory of affordances. In: Shaw R, Bransford J, eds. Perceiving, Acting, and Knowing: Toward an Ecological Psychology . Lawrence Erlbaum Associates; 1977:67–82.<br />Vicente KJ, Rasmussen J. Ecological interface design: theoretical foundations. IEEE Transactions on Systems, Man, and Cybernetics 1992;22(4):589–606.<br />Effken JA, Loeb RG, Kang Y, Lin ZC. Clinical information displays to improve ICU outcomes. International Journal of Medical Informatics 2008;77(11):765–777.<br />Viautour J, Naegeli L, Braun J, et al. The visual patient avatar ICU facilitates information transfer of written information by visualization: a multicenter comparative eye-tracking study. Diagnostics (Basel) 2023;13(22):3432.<br />Lindsay MR, Lytle K. Implementing best practices to redesign workflow and optimize nursing documentation in the electronic health record. Applied Clinical Informatics 2022;13(3):711–719.<br />Tricco AC, Lillie E, Zarin W, et al. PRISMA extension for scoping reviews (PRISMA-scr): checklist and explanation. Annals of Internal Medicine 2018;169(7):467–473.<br />Arksey H, O’Malley L. Scoping studies: towards a methodological framework. International Journal of Social Research Methodology 2005;8(1):19–32.<br />Peters MDJ, Marnie C, Tricco AC, et al. Updated methodological guidance for the conduct of scoping reviews. JBI Evidence Synthesis 2020;18(10):2119–2126.<br />Ahmed A, Chandra S, Herasevich V, Gajic O, Pickering BW. The effect of two different electronic health record user interfaces on intensive care provider task load, errors of cognition, and performance. Critical Care Medicine 2011;39(7):1626–1634.<br />Brown N, Eghdam A, Koch S. Usability evaluation of visual representation formats for emergency department records. Applied Clinical Informatics 2019;10(3):454–470.<br />Koch SH, Weir C, Westenskow D, et al. Evaluation of the effect of information integration in displays for ICU nurses on situation awareness and task completion time: a prospective randomized controlled study. International Journal of Medical Informatics 2013;82(8):665–675.<br />Plaisant C, Wu J, Hettinger AZ, Powsner S, Shneiderman B. Novel user interface design for medication reconciliation: an evaluation of Twinlist. Journal of the American Medical Informatics Association 2015;22(2):340–349.<br />Koch SH, Westenskow D, Weir C, et al. ICU nurses’ evaluations of integrated information displays on user satisfaction and perceived mental workload. Studies in Health Technology and Informatics 2012;180:383–387.<br />Rausch D, Kwade Z, Dahlweid M, Kozinova I, Nathoo S, Yasini M. Say goodbye to the ‘paper on screen’, rethinking presentation of and interaction with medical information. Studies in Health Technology and Informatics 2024;310:775–779.<br />Senathirajah Y, Kaufman D, Bakken S. The clinician in the driver’s seat: part 2 - intelligent uses of space in a drag/drop user-composable electronic health record. Journal of Biomedical Informatics 2014;52:177–188.<br />Middleton B, Bloomrosen M, Dente MA, et al. Enhancing patient safety and quality of care by improving the usability of electronic health record systems: recommendations from AMIA. Journal of the American Medical Informatics Association 2013;20(e1):e2–e8.<br />Farhadloo M, Sharma A, Shekhar S, Markovic SN. Spatial computing opportunities in biomedical decision support: the atlas-EHR vision. arXiv preprint 2023. doi:10.48550/arXiv.2305.09675 . (PMID: <searchLink fieldCode="PM" term="%2210%2E48550%2FarXiv%2E2305%2E09675%22">10.48550/arXiv.2305.09675)</searchLink><br />Langote M, Saratkar S, Kumar P, et al. Human–computer interaction in healthcare: comprehensive review. AIMS Bioengineering 2024;11(3):343–390.<br />Berg M. Implementing information systems in health care organizations: myths and challenges. International Journal of Medical Informatics 2001;64(2-3):143–156.
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