"It Has to Be Done Manually": A Qualitative Study of Clinical Nursing Information System as Both Enforcer and Barrier in Nursing Work.

PURPOSE: The Clinical Nursing Information System (CNIS) is a cornerstone of nursing informatics, yet its adaptability to the dynamic, context-dependent realities of clinical practice remains inadequately understood. Although existing research has quantitatively evaluated CNIS application outcomes, the ways nurses interact with the system and the adaptive strategies they develop have received insufficient attention. This study explored nurses' lived experiences of CNIS use, examining how they perceive and respond to system functions, adapt their clinical workflows, and develop practical strategies when system design diverges from real-world patient care. METHODS: A qualitative study was conducted at a tertiary hospital, involving 22 purposively sampled participants (15 nurses, 7 nurse managers). Semi-structured interviews were analyzed using thematic analysis. RESULTS: Three themes emerged. (1) The system as a tool for rule embedding and enforcement: explicit efficiency gains in standardized care. Structured documentation reduced manual burden, prevented errors, and ensured full-process traceability. (2) The system as a cause of clinical context mismatch: hidden barriers in complex practice. The generic knowledge base was misaligned with specialty-specific needs; poor data integration forced nurses to revert to manual monitoring. (3) Adapting to the system: experience-based adjustments and workarounds. Junior nurses used the system's structured framework as an operational guide, whereas senior nurses actively modified system-generated content based on clinical judgment; manual cross-checking, external notes, and unit-level conventions constituted invisible workarounds. CONCLUSIONS: CNIS functions simultaneously as an enforcer of standardization and a barrier to contextualized care. Nurses' workarounds, though essential for patient safety and care continuity, constitute an unquantified hidden workload and signal critical system deficiencies. Future development should move beyond expanding functionality toward a system-adaptation paradigm, using participatory design to integrate nurses' experiential wisdom into flexible, context-responsive functions that support nursing quality and safety.