Currently submitted to: JMIR Nursing
Date Submitted: Dec 15, 2025
Open Peer Review Period: Dec 23, 2025 - Feb 17, 2026
(currently open for review)
Warning: This is an author submission that is not peer-reviewed or edited. Preprints - unless they show as "accepted" - should not be relied on to guide clinical practice or health-related behavior and should not be reported in news media as established information.
Association Between EHR-based Nursing Workload and Turnover: A Retrospective Cohort Study
ABSTRACT
Background:
Nurse turnover is a major challenge for health systems, and workload is a key driver. Traditional workload measures rely on surveys or staffing ratios and may not reflect nurses’ real-time clinical demands. EHR audit logs provide granular measures of clinical activity and cognitive burden, but their relationship with nurse turnover has not been well characterized.
Objective:
To evaluate whether electronic health record (EHR)–derived measures of nursing workload are associated with turnover among inpatient nurses.
Methods:
We analyzed staff nurses working on medical and surgical inpatient units at a large academic medical center from January 1 to December 31, 2022. Data included de-identified demographics (age, sex, years since licensure, service group), shift characteristics (number of shifts worked, night-shift proportion, timing, location), and EHR audit logs. Audit logs captured (a) EHR activity patterns (information review, medication administration, alert management, navigation, documentation, communication), (b) patient load, and (c) cognitive load (patient switching). Associations between workload measures and turnover were assessed using mixed-effects logistic regression adjusting for demographics and shift characteristics.
Results:
Among 432 nurses (84% female; median age 27 [IQR 23–36]) contributing 6,812 shifts and 13 million EHR actions, 84 (19%) left the institution in 2022. A higher proportion of medication administration actions was associated with increased odds of turnover (OR 2.20; 95% CI 1.36–3.54), whereas greater alert engagement (OR 0.48; 95% CI 0.32–0.72) and more years since licensure (OR 0.57; 95% CI 0.38–0.84) were associated with lower turnover odds.
Conclusions:
EHR-derived workload measures—particularly greater medication administration burden and lower alert engagement—were independently associated with turnover risk. Patterns of EHR use may help identify nurses at elevated risk of leaving and inform targeted workforce retention strategies.
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