case study for nursing documentation

• Reference Manager
• Simple TEXT file

People also looked at

Original research article, patient safety through nursing documentation: barriers identified by healthcare professionals and students.

• 1 Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway
• 2 Centre for Care Research Mid-Norway, Levanger, Norway
• 3 Faculty of Nursing and Health Sciences, Nord University, Namsos, Norway
• 4 Centre for Development of Institutional and Home Care Services, Municipality of Aafjord, Norway

Background: Although access to accurate patient documentation is recognized as a prerequisite for delivering of safe and continuous municipal elderly care, healthcare professionals often fail to provide comprehensive clinical information in an accurate and timely manner. The aim of this study was to understand the perceptions of healthcare professionals and healthcare students regarding existing barriers to patient safety through the performance of documentation practices.

Methods: Using a qualitative, exploratory design, this study conducted six focus group interviews with nurses and social educators ( n = 12) involved in primary care practice and nursing and social educator bachelor’s degree students from a University College ( n = 11). Data were analyzed using qualitative content analysis.

Results: Four themes emerged from the analysis, which described barriers to patient safety and quality in documentation practices: “Individual factors,” “Social factors,” “Organizational factors,” and “Technological factors.” Each theme also included several sub-themes.

Conclusion: According to the findings, several barriers negatively influenced documentation practices and information exchange, which may place primary care patients in a vulnerable and exposed situation. To achieve successful documentation, increased awareness and efforts by the individual professional are necessary. However, primary care services must facilitate the achievement of these goals by providing adequate resources, clear mission statements, and understandable policies.

Introduction

High-quality patient documentation in primary care is crucial for ensuring the quality of care, continuity of care, and patient safety. For many years, the quality of nursing documentation has been reported as inadequate ( Hellesø and Ruland, 2001 ; Blair and Smith, 2012 ; Akhu-Zaheya et al., 2018 ). Thus, knowledge about primary care staff perceptions of barriers to documenting in electronic health records is necessary to ensure patient safety in the services.

The elderly population is expected to grow in both European and American countries in the near future, which will be accompanied by increased demand for elderly healthcare services. This growing patient population will require both complex medical treatment and nursing care ( Ministry of Health and Care Services, 2012 ; Kulik et al., 2014 ). To ensure the effective use of healthcare resources and improve patient outcomes, many Western countries are attempting to transfer responsibilities from specialist care to primary care. This change has resulted in patients who are treated in municipalities being frailer and presenting with more advanced, complex, and treatment-demanding issues ( Gautun and Syse, 2017 ; Næss et al., 2017 ). In Norway, we have enacted “the Coordination reform” ( Ministry of Health and Care Services, 2009 ), a collaborative model for the provision of care services between hospital care and primary care, which is similar to the international concept of “integrated care” ( Ahgren, 2014 ; Ferrer and Goodwin, 2014 ). The implementation of such increased and formalized coordination strategies represents a political focus as a potential tool for ensuring the efficacy and safety of elderly care.

This increased complexity in primary care nursing requires awareness and a focus on providing appropriate nursing-supportive tools, such as high-quality electronic patient records (EPRs) as a main tool for nursing documentation practices. The provision of sufficient documentation of healthcare associated with the patients’ physical and mental health issues is particularly important among elderly patients because even minor changes in health status could be symptoms of severe or acute illnesses ( Gray et al., 2002 ; Chong and Street, 2008 ; Cerejeira and Mukaetova-Ladinska, 2011 ). Any lapse in mental or physical health requires specific medical, nursing, and caring actions to be taken ( Marengoni et al., 2011 ).

The implementation of EPR as a tool for documenting healthcare has resulted in major changes and increased requirements for nursing documentation ( Ammenwerth et al., 2003 ). EPR implementation was intended to replace handwritten documentation practice and improve documentation structures to promote increased standardization ( Hellesø and Ruland, 2001 ). In Norway, nursing homes and community care document care electronically use one of only three EPR systems ( The Norwegian Directorate of eHealth, 2018 ). The EPR documentation practice consists typically of income notes, patient mapping, nursing actions, daily notes and -evaluation as well as discharge notes. E-messaging modules, medication, and collaboration with other professionals such as doctors and physiotherapists are included and used as well. In any case, to complete the documentation requirements, there seems to be a need for paper-based supportive systems, which tend to involve checklists, calendars, books, and post-it notes ( Keenan et al., 2013 ). Nursing procedures and other supportive systems, such as tools for reporting adverse events, are either included in the chosen EPR system or solved in external systems. This study addresses this broad documentation practice.

Both legislation and practice for nursing documentation in healthcare services vary among countries; however, primary care nurses occupy a unique position within healthcare structures worldwide. Primary care nurses often work with few other nurses in primary care wards, or they meet patients alone at the patients’ homes. Therefore, they are often required to assess and evaluate patients, acting independently of other colleagues. Home-health nurses might not have access to online EPRs, which would allow for them to consult previous nursing interventions and evaluations, and they must perform their own documentation, which they may be unable to do until they return to the home care center office ( Olsen et al., 2013 ).

Even though EPR was implemented over a decade ago and is widely used in primary care in Norwegian municipalities, healthcare services continue to face documentation challenges that result in adverse events. Studies have shown that primary care employees often struggle to coordinate patient information in the EPRs ( Gehring et al., 2012 ; Melby et al., 2018 ), and primary healthcare documentation continues to be both incomplete and inaccurate ( Tuinman et al., 2017 ; Moldskred et al., 2020 ).

Patient safety and EPR documentation tasks are closely connected. Documentation in EPR is important to ensure continuity, quality, and safety of patient care. EPRs represent a communicative and collaborative tool, in addition to serving as the written record for which actions have been implemented.

Various definitions of patient safety have emerged over time ( Mitchell, 2008 ), including:

Patient safety is a discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. Patient safety is also an attribute of health care systems; it minimizes the incidence and impact of, and maximizes recovery from, adverse events ( Emanuel et al., 2008 , p. 16).

The World Health Organization (WHO) vision for patient safety is “A world where every patient receives safe healthcare, without risks and harm, every time, everywhere” ( WHO, 2017 , p. 4). In this vision, it is stated that, until recently, patient safety research has primarily focused on the hospital setting rather than primary care. The WHO strategy “Safer primary care” focuses on nine improvement areas: patient engagement, education and training, human factors, administrative errors, diagnostic errors, medication errors, multimorbidity, transitions of care, and electronic tools ( WHO, 2012 ). These focus areas are all relevant to the context of patient safety and documentation.

Elderly patients often suffer from comorbidities, which require complex and tight regimes of treatment and care ( Marengoni et al., 2011 ). Meeting this demand requires high-quality nursing homes and ambulant healthcare services capable of working among elderly patients outside of hospital settings. The coordination of treatment and care, documentation, and patient information exchange represent particular challenges, and these areas have been characterized as being of particular risk for adverse events ( Olsen et al., 2012 ; Blais et al., 2013 ; Olsen et al., 2013 ; Gjevjon 2014 ; Wekre, 2014 ).

Patient safety can be evaluated by mapping adverse events that occur in healthcare units. Studies have shown that 1–24 adverse incidents occur during every 100 consultations in the primary care context ( Panesar et al., 2015 ). A link between patient safety and inadequate documentation has previously been reported by studies examining documentation and adverse events in primary care. For example, Andersson et al. (2018) examined serious adverse events reports submitted by nurses in Swedish nursing homes to the Health and Social Care Inspectorate and found that a “lack of competence” and “incomplete or lack of documentation” were the two most common factors that contributed to adverse events.

This study has identified few articles focusing on the connection between patient safety and nursing documentation practices at home health nursing services or nursing homes. Additionally, there is a need observed for additional research projects that focus on students’ experiences regarding the practice of patient documentation and the use of EPRs.

Social educators are employed in municipal care: in nursing homes and home healthcare units in Norway. They take part in a variety of nursing and caring tasks and activities, but their profession has more substantial knowledge in caring for people with various forms of disability than Registered Nurses. They have a deeper focus on rehabilitation and habilitation for disabled patients. On the other hand, Registered Nurses have a deeper awareness of the medical issues of nursing, as understanding of all kind of illness and its consequences, as well as medical treatment and medication ( Grung, 2016 ). Nevertheless, when social educators are employed within the healthcare domain in Norway they are obligated to act under the same legislation guidelines regarding documentation as Registered Nurses. Understanding the experiences and perceptions of these staff members can also influence their contributions to collaboration in healthcare services. Therefore, the aim of this study was to better understand the perceptions of healthcare professionals and healthcare students regarding existing barriers to patient safety through the performance of documentation practices.

A descriptive, exploratory design ( Polit and Beck, 2012 ) with a focus group methodology was applied to provide insights into the perceptions of nurses, social educators, and students and to understand their experiences in terms of patient safety and their documentation practices. To secure accurate and complete reporting of the study, the COREQ checklist ( Tong et al., 2007 ) was used as a guideline.

Sample and Setting

The study was conducted between March 2015 and June 2015 at three3 primary care agencies and one University College located in central Norway. In the chosen region, all municipalities use the same EPR system—one of three main systems used in primary care in Norway—and similar to all other systems being used this one responds to the legislation requirements for digital documentation of healthcare information in Norway as well as GDPR regulations which Norway joined in 2018 ( Ministry of Health and Care Services, 2012 ; The Norweigian Directorate of eHealth, 2019 ). This particular EPR solution, as is the case for the other two EPR systems, offers an enlarged EPR solution where the EPR module is connected to other relevant modules; for example, basic personal information, billing, and medication order modules.

Purposive sampling was used to recruit participants. The inclusion criteria for the nurses and social educators included that they were employed in primary healthcare (nursing homes or home nursing care) and that they were involved in direct patient care. The inclusion criteria for students included regular enrollment as a nursing or social educator student (at the bachelor-degree level) and previous practice in nursing homes and/or in-home healthcare settings as part of their education. Whereas the professionals were recruited by their ward managers, the students were recruited by contact persons at the University College. Both professionals and students were forwarded written information about the study, and all signed a consent form prior to participating in the study.

In total, 12 nurses and social educators and 11 students (22 women and one man) volunteered for this study. The mean working experience among the nurses and social educators was 13°years (ranging from 1 to 25 years), and their mean age was 40.5°years (ranging from 23 to 51°years). The students’ mean age was 23°years (ranging from 22 to 28°years). six of the students were in their final semester of a 3 years degree program, and five were in their penultimate year. The participants were interviewed in six focus groups; three groups of nurses and social educators (“staff informants”) and three groups of students. The sizes of the groups ranged from 3–5 participants, which is considered an optimal size for focus groups ( Kitzinger 1995 ).

Data Collection

Focus group interviews were used to study perceptions among the group participants ( Polit and Beck, 2012 ). In the focus groups, the participants were invited to reflect upon and compare each other’s views and experiences to contribute to a broader understanding of patient safety and documentation practices ( Kitzinger, 1995 ).

The study applied an interview guide, which was developed based on performing a literature search and including previous clinical experiences and knowledge among the researchers. The interview guide included these areas:

Descriptions of patient information exchanges, collaborative procedures, and documentation practices applied during patient transfer.

Descriptions of daily nursing and care planning, communications, and documentation processes.

Uncovering whether EPR solutions meet professional needs with regard to patient information.

Descriptions of communications or EPR documentations that have caused or could cause adverse events.

As described by Krueger and Casey (2009) , the focus group interviews were performed by two researchers: a moderator and an assistant. The moderator guided the discussion while the assistant kept track of the tape recording, made notes, and summarized the discussion. The focus group interviews lasted from 90 to 120 min, and all audio was recorded and transcribed verbatim.

Data Analysis

Data were analyzed using qualitative content analysis ( Krippendorff, 2018 ). The authors listened to each recorded interview and simultaneously read the transcribed text to obtain an overall view of the data. The texts were re-read several times to allow reflection on barriers to patient safety through the documentation practices for healthcare professionals and healthcare students. Then, the text was broken down into meaning units (i.e., words, phrases and sentences that relate to the same central meaning), which were condensed and labeled with a code. Based on similarities and differences, the codes were compared and sorted into nine sub-themes and four main themes. All authors participated in the data analysis and jointly discussed possible approaches to each theme until a consensus was reached ( Patton, 2012 ).

By following Lincoln and Guba (1985) criteria, several strategies were used to enhance the trustworthiness of the study. Credibility was supported by including an adequate number of professional and student informants, encouraging dialogue in the focus group sessions, and by discussing the interpretation of data until a consensus on themes and sub-themes was reached. Providing descriptions of informants, data collection, analysis, and quotes from the focus group interviews enabled each individual reader to assess the transferability of the study findings to other contexts. Dependability and confirmability were achieved by using audio-recording during the interviews and transcribing all interviews verbatim and by having all authors discussing the data interpretations together.

Ethical Considerations

The study was implemented in accordance with the Declaration of Helsinki ( World Medical Association, 2001 ). Formal permission to perform data collection was obtained from the authorities at all municipalities and the University College. All nurses, social educators, and students were written-informed of the study and provided informed consent to participate. They were made aware of their rights to withdraw from the study at any time without consequence. The project was conferred with the Norwegian Center for Research Data (NSD), which concluded it not being notifiable.

The focus group analysis resulted in the identification of four main themes to describe the perceptions held by healthcare professionals and healthcare students regarding existing barriers to patient safety through the performance of documentation practices in primary care: 1) Technological barriers, 2) Organizational barriers, 3) Social barriers, and 4) Individual barriers. As shown in Table 1 , each of these themes included several sub-themes. All participants responded based on experiences using the same EPR system to perform documentation tasks. In the presentation of results, the municipal nurses and social educators are described as a single group, referred to as “staff” or “nurse”. Quotes from the focus group sessions are used to elucidate the themes and sub-themes.

TABLE 1 . Themes and sub-themes describing barriers for patient documentation.

Technological Barriers

This theme included three sub-themes and refers to the technological obstacles that the nursing staff and students were required to overcome when documenting patient care. The informants of this study described unstable system access as one of the main technological challenges. All participants described experiencing time-consuming log-in procedures, lasting more than 5 min each time, and not particularly connected to the EPR system itself but to the municipal server setup system requiring several levels of log-on procedures. Encountering this barrier would result in participants leaving the computer without logging off as expected, or they would ask a colleague to perform documentation on their behalf to avoid using their time for waiting for system access. They admitted that both practices were against security rules. Another example was unannounced system downtime caused by random and unforeseen internet issues, which could occur in the middle of documentation or while using the EPR system for shift reports or doctor’s visits. These experiences prevented the informants from using the system completely. Nursing staff and students had described experiencing the loss of system access due to planned, unannounced technical maintenance. These episodes resulted in a lack of trust in the EPR system, and respondents reported the regular use of paper-based backups for the most important patient information, such as patient personalia, patient contacts, and medication lists.

Further, the respondents presented the EPR system as incomplete, with deficient system usability and user interface that did not support their needs and requirements for daily nursing documentation routines, resulting in the use of a paper-based documentation system as a supplement to secure documentation, information exchange, and patient safety. One example was a staff informant group who still used the previous manual documentation system as a back-up:

When we need to find information about a patient, we must first go to the EPR system to see if we can find it there. If it is not there, we must look in the ‘Kardex’. It can take some time, then, if you are unsure where to find it.

Deficient system usability and user interface were found to be risk factors for adverse events. Multiple areas could be used to document the same information within the EPR system, which made documentation fragmented and difficult to rediscover when the nursing staff required the information. The EPR system did not follow the logical nursing planning structure that the informants expected and were trained for, which also increased the potential for adverse events. One staff informant stated:

…and it is a bit scary in everyday life because we are actually responsible for what we do, and when the system is designed so that you are tricked into making mistakes, as we do our job.

Usability and interface problems also included small fonts and compressed text that made information difficult to read and was another possible risk for adverse events.

The final technological barrier was the lack of technical support . When informants experienced problems, such as the system being down or log-on problems, these issues could only be addressed during a normal working day between 08:00–16:00, with no support offered during night shifts, weekends, or holidays. This lack of support was another reason many of the staff informants relied on paper-based backups and handwritten notes that would later be added to the EPR system. Paper-based backup routines were viewed as a necessary workaround; however, all participants admitted that paper backups were a safety risk because documentation became fragmented and paper notes could be lost.

Organizational Barriers

This theme includes two sub-themes and refers to barriers within the organizational system, which made informants struggle when documenting patient information. Even though the informants of this study had experience using the same EPR system, each municipality was able to some extent to technically adjust the system setup according to their existing or desired organizational routines. This ability resulted in some variety in documentation routines. Thus, informants reported both shared and unique organizational documentation challenges and barriers between the focus groups.

Many of the organizational barriers were ascribed to inappropriate documentation routines in the unit. The EPR system was implemented many years ago, and it included areas suitable for registrations. However, some units maintained old routines, using notes, lists, and notebooks to document care. Some focus groups reported the reduced use of paper-based documentation, even though some paper-based routines were maintained due to technical issues, as described above. Other routines were maintained despite an awareness of the possibility of causing adverse events. The complete and expected reorganization of documentation routines was simply never initiated after implementing the EPR. In one of the student groups having experiences from a variety of municipalities, this frustration was shared:

A big source of error is that you always have to remember where to look for things; where to check the patch, the medications, where to find time appointments, and there, and there, and there and in addition you have to take care of the patients and keep them in mind, and then you have to keep in mind if there is any wound procedure, and then you have to keep in mind inhalation and the eye drop form in the closet, and. -You have to constantly go and keep in mind!

This inappropriate routine was confirmed by the student informant groups, who faced even more substantial challenges when attempting to retrieve information from multiple sources.

Furthermore, this theme also addressed a severe barrier to patient safety: inappropriate routines that included a lack of patient information. A lack of patient information either caused adverse events, or these adverse events were avoided by the clinical skills of the nursing staff or, as described by study informants, pure luck. Nursing staff had experienced rigid organizational EPR routines, in which only a few persons were permitted to add or change basic patient information. One example provided was an acute situation in which no family information could be found. The nurse involved traced the phone number of the patient’s daughter on the internet because she knew her name, but this informant said, ‘ It was a bit hectic to find the daughters phone number, and simultaneously trying to save the patient`s life while waiting for the ambulance to come ’. Lack of such information could lead to phone calls to the wrong individuals and a breach of confidentiality.

Staff informants had experienced not being allowed to add medical diagnoses to the EPR system because this task was reserved for the patient’s doctor. However, if the doctor did not perform this task diligently, the nurses had to guess which underlying illness the patient suffered to complete their nursing observations and actions. Lacking blood sample results was a recurring problem that was reported by multiple groups of informants. These results did exist, but sample information was not found. Partly, the results were not sent as e-messages and thereby not found within the EPR system as expected, or results were not inserted into the EPR system when received through a letter or phone call. Much time and effort were spent tracking answers to determine the correct administration of medications, potentially causing harm to the patients. In a staff focus group, one informant told:

Yes, we can wait for several days for answers for blood samples (…), and quite a few nurses get frustrated. We take a test on Monday and do not receive a response from the doctor before Thursday. So, then you should be happy that the nurse knows the users and give them what they think is right. It’s a big problem in the rural areas. It takes time.

One result of the different documentation practices in the various units was a fragmented documentation structure , which led to confusing patient information . This barrier was viewed as an organizational reinforcement of the technological barrier due to the organization allowing so much confusion in the structure of the EPR system. In the focus group sessions, the informants discussed the lack of overview of patient information in their documentation practice. In all of the focus group meetings, the informants discussed the time spent searching for patient information within the fragmented patient information structure. “ There is a lot of paper lying all around.”

Both within the EPR system and between the EPR system and the paper-based supplementation systems, time was spent searching for, checking, and double-checking information. Both students and nursing staff experienced the documentation structure as a risk for patient safety. Furthermore, variations were found in the structure of care planning within the EPR system. Our informants reported the availability of both firm templates for documenting nursing actions and evaluations in addition to day-to-day reporting practices. Day-to-day reporting did not provide a broad overview and represented a risk of losing important follow-up areas for each patient. In contrast, a care-planning template with too much detail could overly fragment patient information and increase the risk of adverse events.

Another identified risk area was patient transfer reports. Our groups discussed the lack of a transfer documenting template and the various shapes of the reports. The following quote from one staff informant was representative for concerns expressed among all groups interviewed:

It is not specified what to write in the transfer report, so it is left to each person to decide and what she emphasizes of observations.

Poor reports increased the risks for adverse events, which could often only be prevented by making phone calls to verify the necessary information required for medical treatments and nursing follow-up.

Social Barriers

This theme included two sub-themes associated with barriers to patient documentation that were not recognized as being caused by the organizational structures of the units. The main social barrier associated with an increased risk of adverse events was that documentation had lower priority compared with other tasks in the caring unit. Practical, daily tasks and patient-oriented work had higher priority and were more accepted among the nursing staff than spending time on the computer. During hectic shifts, our informants would rather relieve their colleagues than update the EPR. Thus, documentation tasks were postponed. This finding was confirmed by some student informants, who had received negative feedback if they spent too much time reading or updating the EPR instead of participating in direct patient-related activities. Our informants provided multiple examples in which they did not spend time learning how to use the EPR system or did not know where to document their nursing actions, and they described the dilemma. One staff informant said:

It is the issue of closeness to the patient. It is central in our caring to spend time with the patient. Documentation becomes a secondary issue, which I feel have to get into the heads of nurses: they must understand the importance of documentation! Why should you read? To stay updated.

A reoccurring issue that appeared in the focus group discussions was obvious avoidance regarding documentation practices in some units. The study found unequal attitudes towards the documentation of adverse events, even if the informants all agreed that the public strategy in their working units was to welcome such registration. However, the social attitude was that documenting an adverse event could be viewed as a form of self-punishment rather than as an opportunity for common learning and improvement. One of the focus groups consisting of staff participants discussed their proactive system developed to report and address adverse events, which was accepted and followed by staff members. The unit maintained a quality system known to everyone, and deviations from procedures were marked and reported as an adverse event and was followed up by leaders, as the procedure required. But even here:

We have had many plenary discussions now about the positivity of documenting deviations (…), but we think there is a lot below the surface that is not registered and reported.

This response revealed a developing culture for the handling of adverse events, which continued to face cultural challenges. The staff informants discussed their experiences with social change, moving towards a more pro-active attitude regarding the documentation and learning from the mistakes that led to adverse event registrations.

Individual Barriers

This theme includes two sub-themes and refers to the barriers associated with personal characteristics that may influence a staff member’s documentation practices. The barrier lack of motivation to comply with routines and policies was neither a result of the organizational regime nor a social structure within the units. When documenting nursing actions, the units had routines and procedures designating where in the EPR system nursing assessments and measures should be documented, but these guidelines were not always followed. Some staff informants admitted that they did not want to use the available tablet personal computer (PC) to document the EPR.

We act so different. Some of us document and take it very seriously. Document everything (…) everything done in a day, while others are better at documenting what is relevant for the patient care (…) And some do not write at all.

The staff informants stated that they and their colleagues did not always read the EPR when they began their shifts or did not thoroughly examine the documentation, such as when administering medications. Important information could be missed, leading to adverse events of varying degrees of severity. Time shortage or not sharing the same sense of responsibility for documentation were the explanations given for not accomplishing documentation tasks, either in a standardized way or at all. However, not having complete and sufficient patient information is a risk factor for adverse events and was also a stress factor for our informants in their daily work.

Our focus group informants discussed their common experiences of inadequacy, insecurity, and lack of knowledge regarding the ability to document patient information properly. In particular, staff informants experienced a lack of confidence, skills, and knowledge necessary for documentation tasks, even if they had have received both an education and formal training on the topic.

It’s easier not to do it, when you are insecure, than to do it. It is about they don’t exactly know how to do it … and then they do not; not document at all, leaving it to someone who can. And then there are a few who are very good at it, and the days they are not here, then it will not be done.

Basic information and communications technology (ICT) skills varied among the participants and strengthened the sense of insecurity described above. Our student groups did not address such insecurity in the same manner as our staff informants did. The challenge included where to search for or document patient care.

It feels safer to document it all under “general information” because you have not analyzed so much yourself then, on your own.

They reported low confidence in their own and their colleagues’ ability to place documentation elements correctly in the EPR system, resulting in a fundamental concern regarding the quality of patient documentation and a constant fear that adverse events will occur. To overcome these barriers, they searched for, checked, and double-checked available patient information sources within and outside the EPR system to secure the quality of care. They had to rely on oral handover for adequate patient information.

You must ask the nurses you work with; maybe they know, but it is not certain you get the right answer.

Individual use of phrases in documentation practice was also discussed in the focus groups. The student groups, in particular, felt unsafe when nurses used phrases and words not familiar to them; however, staff informants also expressed problems with individual approaches toward documenting language, subsequently making it difficult to contextualize follow-up activities.

Our informants worried about their ability to remember all messages and tasks and their ability to accomplish their documenting duties correctly, particularly during busy periods. The documentation of drug administration was a major challenge reported for individual documentation practices among our informants. Most adverse event reports were associated with the area of medication. One student representative had the following experience:

One of our patients had anti-constipation treatment without being constipated: His elimination status was just not recorded anywhere.

Another example was not being aware of a missing blood sampling that was necessary to perform medication adjustments, resulting in incorrect medication; this error was recognized as a potential patient safety risk.

Uncertainty among the nursing staff was observed by the student groups, making them insecure during their practical study periods. Students also experienced expectations among the nurse staff, who expected them to know without being taught:

It is not documented anywhere! (…) and then they just said that I will learn this as I am working here more permanently.

This expectation of tacit knowledge frustrated them and made them anxious about potentially harming the patients due to a lack of patient information.

This study aimed to better understand the perceptions of healthcare professionals and healthcare students regarding the barriers to patient safety through the performance of documentation practices. The results demonstrated that technological, organizational, social, and individual barriers to nursing documentation pose potential risks to patient safety. Our results could be associated with seven of the nine areas outlined in the WHO strategy “Safer primary care” (2012). Follow-up thematic reports ( WHO, 2016 ) underpin the study’s results by many converging elements that involve safety risks.

Technological barriers were a basic challenge reported by our participants. Unstable system access, deficient EPR usability, and poor user interfaces, together with scarce technical support, did not support their nursing practice needs. The respondents struggled to document and access sufficient information to perform daily care. Similar findings were reported in Priestman et al. (2018) and in a review by Stevenson et al. (2010) and followed up by a study in 2012 where nurses reported that the EPR does not support their nursing practice ( Stevenson and Nilsson, 2012 ). WHO (2016) also emphasized the increased use of technical devices in primary care to improve patient safety. The report admitted that poorly designed EPR systems might create more work and frustration among staff, similar to our findings. A literature review by Gesulga et al. (2017) also recognized barriers, such as user resistance arising from data security concerns. Technological tools, such as EPRs aim for but do not necessarily achieve the prevention of human errors and the improvement of information exchange. Such tools can also create additional human work or new ways of working. Thus, the nursing staff became dependent on technological usability and stability to provide nursing and care and secure patient safety ( Dekker, 2016 ).

One of this study’s four main themes was organizational barriers, also identified as a main patient safety area by WHO (2012) ; WHO (2016) . Barriers were identified in this study, such as incomplete or inaccurate documentation routines and fragmented documentation structures. Kutney-Lee et al. (2019) also found correlations between organizational issues, such as work environment, patient safety and EPR system usability. Many documentation errors by use of the EPR systems can be caused by deficiencies in the organizational structure in a care unit, such as patient transfers, something many participants also described in the study, including “poorly written or illegible discharge summaries” ( WHO, 2016 ). “Transitions of care” is also emphasized as a focus area by WHO (2016) as well as in other studies ( Graabæk et al., 2019 ; Patel and Landrigan, 2019 ). This topic identifies several risk areas related to patient safety that were also discussed by our informants: increased adverse events, delays in receiving appropriate treatment, and lost tests or blood sample results. Studies suggest interventions to prevent safety risks such as standardization of documentation and discharge information ( Törnvall and Jansson, 2017 ; De Groot et al., 2019 ), all of which were supported by our informants: for both transition situations and to improve the documentation structure in general.

Two sub-themes were regarded as social barriers to documentation in the EPR. The study found that spending time documenting had a lower priority than other tasks and that in some units, the staff groups showed avoidance behavior toward documenting practices. Similar negative attitudes toward documentation have been reported previously, such as in Bøgeskov and Grimshaw-Aagaard (2018) research, in which nurses in hospitals perceived documentation as being a meaningless burden that hindered them from focusing on the patient. When the safety culture within staff groups undermines documentation tasks, identifying whether the underlying reasons for these attitudes and behaviors are associated with the priority of direct patient care or whether other causalities exist is imperative ( Barkhordari-Sharifabad et al., 2017 ).

Individual barriers to documentation practices included both a lack of motivation for documenting practices and the informant’s sense of inadequacy, insecurity, and lack of knowledge regarding correct documentation procedures. Designing systems that better support the nursing staff can contribute to their motivation to comply with the established routines and policies for documenting tasks ( Stevenson et al., 2010 ). Improved system usability may reduce the occurrence of potential adverse events and increase patient safety ( Williams, 2019 ). One area associated with severe patient risk that was reported in our work was nursing staff not correctly updating or carefully reading the EPR when handling medication. WHO (2016) confirmed, in line with our results, “workload and time pressure” and “lack of accuracy in the patient record” as factors that increased the risk of patient safety harm. This is also found by other studies ( Al-Jumaili and Doucette 2018 ; Dunn Lopez et al., 2021 ). There appears to be a need for a more systematic approach to handling medication information, such as computerized decision support systems ( Marasinghe, 2015 ).

Reasons for not using the tablet PC for documentation were not provided in our result. However, tablets may reduce the time spent on documentation, as reported in the reviews by Dall’ora et al. (2020) and Blair and Smith (2012) . Lack of time was discussed by the healthcare staff as a reason for not documenting or postponing documentation tasks during their shift, as also noted by Söderberg et al. (2009) : therefore, it is necessary to cross this barrier to patient safety by providing an understanding of the use of the EPR as an efficient way of documentation time in contrast to time spent walking around, collecting necessary information among colleagues in the unit.

Lack of training, which was also emphasized by our informants, in our view, was regarded as an individual issue rather than an organizational problem. Our participants indicated inadequacy, insecurity, and lack of knowledge among their individual challenges but did not necessarily describe these issues as part of the organizational strategy because they had all received training sessions within their units. Bing-Jonsson et al. (2016) investigated the sufficiency of nursing staff competence in Norwegian community elderly care and found that documentation is one of the areas where nurses, auxiliary nurses, and assistants may have insufficient competence. The authors concluded that education and training alone appeared to have a limited impact on competence, potentially due to health professionals having unclear roles and inadequate standards for judging their own competence; they perform many of the same tasks, regardless of formal competence based on education ( Bing-Jonsson et al., 2016 ).

The student informants in our study described nursing staff who sometimes omitted the documentation of patient information and expected the students to know without being taught (i.e., tacit knowledge). Staff members in long-term elderly care often know their patients quite well and, therefore, may find documentation redundant because they maintain a lot of information “in their heads” ( Østensen et al., 2019 ).

Strengths and Limitations

One strength of this study is that the sample included a combination of healthcare professionals with considerable experience and bachelor-degree students with an outside view of the workplace. The students had experience from health services in several municipalities during their practical studies and contributed with useful reflections on similarities and differences between these areas in the focus group interviews. Only one man attended the study, which could be considered a limitation. However, this skewed gender distribution is reflective of the large proportion of women employed in elderly care.

The student informants were recruited from the University College where all authors were employed, but none of the authors were involved in assessing these participants’ academic elements of their studies. All students were made aware that participating in the research would have no impact on their progression through their bachelor’s program.

The use of a topic-based interview guide, instead of narrow questions, contributed to data-rich discussions in the focus groups. The authors experienced an open and trusting atmosphere during the sessions, where all informants shared honest reflections and described real challenges from practice. Lively discussions, both in the staff focus groups and the student focus groups, contributed to rich qualitative data. The years between data collection and publication may be seen as a limitation in the study, but we have also learned that changes due to digitalization in healthcare take many years to implement and adopt, as described by Morris et al. (2011) . Thus, we suggest that the experiences will still be relevant for healthcare organizations preparing for the implementation of ICT tools. The fact that the study involved one EPR solution may be regarded as a limitation. On the other hand, one may also consider this as a strength, because all informants reported on their experiences from a common starting point when describing their challenges. Involving municipalities with other EPR solutions could have expanded the picture of challenge. On the other hand it could have given responses based on more unequal prerequisites referring to various EPR systems. This could further have drawn attention away from challenges described in the result of this study, and more toward variations between EPR systems as such.

The fact that all 3 authors were involved in the analysis process was also an advantage. Due to the qualitative design, the results cannot be generalized. However, because the documentation of patient information is an important part of any healthcare professional’s practice, the study results could be transformed and applied to several other contexts in healthcare.

Conclusion and Implications

In this study, our results identified several barriers that negatively influenced patient documentation practices, exposing patients in primary care to increased safety risks and potentially harmful situations. To enhance and secure patient safety, increased individual, social, organizational, and technological support is necessary to overcome these barriers to ensure that optimal patient information is available when required for nursing care. To achieve this aim, primary care services must facilitate the necessary improvements by prioritizing technical, economic, and human resources for system development, training, and the definition of clear mission statements and policies.

The study results may inform various stakeholders in designing, implementing, using, and teaching EPR systems:

• System vendors may gain more knowledge of the complexity in nursing staff’s everyday lives, and to what extent implemented EPR systems still fail to meet the needs for documentation and information exchange continuing to risks of adverse events.

• Health service leaders and ICT leaders should pay close attention to system implementation and adoption phases paving the path for their staff members, not underestimating the complexity in documentation and information exchange in their caring units, all in order to secure and improve patient safety.

• Staff members and healthcare students may learn how colleagues and co-students experience their EPR documentation practice, reflecting upon their own situation regarding patient safety and EPR use.

• Teaching organizations at high school and university level may become more effectively supported in their focus on teaching their students documentation in both theory and practice as well as the connectivity between structured EPR use for documentation and an improved level of patient safety.

• System vendors may gain more knowledge of the complexity of nursing staff practices and the fact that implemented EPR systems still do not meet the needs for documentation and information exchange but continue to pose risks of adverse events.

• Health service leaders and ICT leaders should pay close attention to system implementation and adoption phases: This study shows the need for these leaders to pave the path for their staff members and not to underestimate the complexity in documentation and information exchange in their caring units: all in order to secure and improve patient safety.

• Staff members and healthcare students may learn how colleagues and co-students experience their EPR documentation practice, engaging in reflection about their own situation regarding patient safety and EPR use.

• Teaching organizations at high school and university level may be better supported in their focus on teaching their students documentation in both theory and practice: This study could also deepen the understanding of the connectivity between structured EPR use for documentation and the necessary level of patient safety.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

Ethical review and the approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We would like to thank our participants, students and nursing staff participants as well as their leaders for time spent in the focus group discussions: for sharing experiences and thoughts with the research team in order to achieve the results of the study.

Ahgren, B. (2014). The Path to Integrated Healthcare: Various Scandinavian Strategies. Int. J. Care Coord. 17, 52–58. doi:10.1177/2053435414540606

CrossRef Full Text | Google Scholar

Akhu-Zaheya, L., Al-Maaitah, R., and Bany Hani, S. (2018). Quality of Nursing Documentation: Paper-Based Health Records versus Electronic-Based Health Records. J. Clin. Nurs. 27 (3–4), e578–e589. doi:10.1111/jocn.14097

PubMed Abstract | CrossRef Full Text | Google Scholar

Al-Jumaili, A. A., and Doucette, W. R. (2018). A Systems Approach to Identify Factors Influencing Adverse Drug Events in Nursing Homes. J. Am. Geriatr. Soc. 66 (7), 1420–1427. doi:10.1111/jgs.15389

Ammenwerth, E., Mansmann, U., Iller, C., and Eichstädter, R. (2003). Factors Affecting and Affected by User Acceptance of Computer-Based Nursing Documentation: Results of a Two-Year Study. J. Am. Med. Inform. Assoc. 10, 69–84. doi:10.1197/Fjamia.M111810.1197/jamia.m1118

Andersson, Å., Frank, C., Willman, A. M., Sandman, P.-O., and Hansebo, G. (2018). Factors Contributing to Serious Adverse Events in Nursing Homes. J. Clin. Nurs. 27 (1−2), e354–e362. doi:10.1111/jocn.13914

Barkhordari-Sharifabad, M., Ashktorab, T., and Atashzadeh-Shoorideh, F. (2017). Obstacles and Problems of Ethical Leadership from the Perspective of Nursing Leaders: A Qualitative Content Analysis. J. Med. Ethics Hist. Med. 10, 1.

PubMed Abstract Google Scholar

Bing-Jonsson, P. C., Hofoss, D., Kirkevold, M., Bjørk, I. T., and Foss, C. (2016). Sufficient Competence in Community Elderly Care? Results from a Competence Measurement of Nursing Staff. BMC Nurs. 15, 5. doi:10.1186/s12912-016-0124-z

Blair, W., and Smith, B. (2012). Nursing Documentation: Frameworks and Barriers. Contemp. Nurse 41, 160–168. doi:10.5172/conu.2012.41.2.160

Blais, R., Sears, N. A., Doran, D., Baker, G. R., Macdonald, M., Mitchell, L., et al. (2013). Assessing Adverse Events Among home Care Clients in Three Canadian Provinces Using Chart Review. BMJ Qual. Saf. 22 (12), 989–997. doi:10.1136/bmjqs-2013-002039

Bøgeskov, B. O., and Grimshaw-Aagaard, S. L. S. (2018). Essential Task or Meaningless burden? Nurses’ Perceptions of the Value of Documentation. NJNR 39, 9–19. doi:10.1177/2057158518773906

Cerejeira, J., and Mukaetova-Ladinska, E. B. (2011). A Clinical Update on Delirium: from Early Recognition to Effective Management. Nurs. Res. Pract. 2011, 1–12. doi:10.1155/2011/875196

Chong, C. P., and Street, P. R. (2008). Pneumonia in the Elderly: a Review of the Epidemiology, Pathogenesis, Microbiology, and Clinical Features. South. Med. J. 101, 1141–1145. doi:10.1097/smj.0b013e318181d5b5

Dall’ora, C., Griffiths, P., Hope, J., Barker, H., and Smith, G. B. (2020). What Is the Nursing Time and Workload Involved in Taking and Recording Patients’ Vital Signs? A Systematic Review. J. Clin. Nurs. 29, 2053. doi:10.1111/jocn.15202

De Groot, K., Triemstra, M., Paans, W., and Francke, A. L. (2019). Quality Criteria, Instruments, and Requirements for Nursing Documentation: A Systematic Review of Systematic Reviews. J. Adv. Nurs. 75 (7), 1379–1393. doi:10.1111/jan.13919

Dekker, S. (2016). Patient Safety: A Human Factors Approach . Boca Raton: CRC Press . doi:10.1201/b10942

CrossRef Full Text

Dunn Lopez, K., Chin, C.-L., Leitão Azevedo, R. F., Kaushik, V., Roy, B., Schuh, W., et al. (2021). Electronic Health Record Usability and Workload Changes over Time for Provider and Nursing Staff Following Transition to New EHR. Appl. Ergon. 93, 103359. doi:10.1016/j.apergo.2021.103359

Emanuel, L., Berwick, D., Conway, J., Combes, J., Hatlie, M., Leape, L., et al. (2009). “What Exactly Is Patient Safety?,” in Advances in Patient Safety: New Directions and Alternative Approaches . Editors H. Kerm, B., J., B, M., A. Keyes, M., and L. Grady (Rockville (MD): Agency for Healthcare Research and Quality) ), 95, 13–24. doi:10.30770/2572-1852-95.1.13

Ferrer, L., and Goodwin, N. (2014). What Are the Principles that Underpin Integrated Care?. Int. J. Integr. Care 14, e037. doi:10.5334/ijic.1884

Gautun, H., and Syse, A. (2017). Earlier Hospital Discharge: a challenge for Norwegian Municipalities. Nord J. Soc. Res. 8, 1–17. doi:10.7577/njsr.2204

Gehring, K., Schwappach, D. L., Battaglia, M., Buff, R., Huber, F., Sauter, P., et al. (2012). Frequency of and Harm Associated with Primary Care Safety Incidents. Am. J. Manag. Care 18, e323–37. doi:10.7892/BORIS.14040

Gesulga, J. M., Berjame, A., Moquiala, K. S., and Galido, A. (2017). Barriers to Electronic Health Record System Implementation and Information Systems Resources: A Structured Review. Proced. Comput. Sci. 124, 544–551. doi:10.1016/j.procs.2017.12.188

Gjevjon, E. L. R. (2014). Continuity in Long-Term home Health Care. Perspectives of Managers, Patients and Their Next of Kin. [dissertation]. Oslo: Faculty of Medicine, University of Oslo Available at: http://urn.nb.no/URN:NBN:no-44164 (Accessed October 15, 2020).

Google Scholar

Graabæk, T., Terkildsen, B. G., Lauritsen, K. E., and Almarsdóttir, A. B. (2019). Frequency of Undocumented Medication Discrepancies in Discharge Letters after Hospitalization of Older Patients: a Clinical Record Review Study. Ther. Adv. Drug Saf. 10, 2042098619858049. doi:10.1177/2042098619858049

Gray, L. K., Smyth, K. A., Palmer, R. M., Zhu, X., and Callahan, J. M. (2002). Heterogeneity in Older People: Examining Physiologic Failure, Age, and Comorbidity. J. Am. Geriatr. Soc. 50, 1955–1961. doi:10.1046/j.1532-5415.2002.50606.x

Grung, R. M. (2016). The Role of the Norwegian Social Educator. Learn. Disabil. Pract. 19 (10), 24–26. doi:10.7748/ldp.2016.e1810

Helleso, R., and Ruland, C. M. (2001). Developing a Module for Nursing Documentation Integrated in the Electronic Patient Record. J. Clin. Nurs. 10, 799–805. doi:10.1046/j.1365-2702.2001.00557.x

Keenan, G., Yakel, E., Dunn Lopez, K., Tschannen, D., and Ford, Y. B. (2013). Challenges to Nurses' Efforts of Retrieving, Documenting, and Communicating Patient Care Information. J. Am. Med. Inform. Assoc. 20 (2), 245–251. doi:10.1136/amiajnl-2012-000894

Kitzinger, J. (1995). Qualitative Research: Introducing Focus Groups. BMJ 311, 299–302. doi:10.1136/bmj.311.7000.299

Krippendorff, K. (2018). Content Analysis: An Introduction to its Methodology . California, USA: SAGE Publications .

Krueger, R. A., and Casey, M. A. (2009). Focus Groups: A Practical Guide for Applied Research . California, USA: SAGE Publications .

Kulik, C. T., Ryan, S., Harper, S., and George, G. (2014). Aging Populations and Management. Amj 57, 929–935. doi:10.5465/amj.2014.4004

Kutney-Lee, A., Sloane, D., Bowles, K., Burns, L., and Aiken, L. (2019). Electronic Health Record Adoption and Nurse Reports of Usability and Quality of Care: The Role of Work Environment. Appl. Clin. Inform. 10, 129–139. doi:10.1055/s-0039-1678551

Lincoln, Y. S., and Guba, E. G. (1985). Naturalistic Inquiry . Beverly Hills, CA: Sage .

Marasinghe, K. M. (2015). Computerised Clinical Decision Support Systems to Improve Medication Safety in Long-Term Care Homes: a Systematic Review. BMJ Open 5 (5), e006539. doi:10.1136/bmjopen-2014-006539

Marengoni, A., Angleman, S., Melis, R., Mangialasche, F., Karp, A., Garmen, A., et al. (2011). Aging with Multimorbidity: a Systematic Review of the Literature. Ageing Res. Rev. 10, 430–439. doi:10.1016/j.arr.2011.03.003

Melby, L., Obstfelder, A., and Hellesø, R. (2018). “We Tie Up the Loose Ends”: Homecare Nursing in a Changing Health Care Landscape. Glob. Qual. Nurs. Res. 5, 233339361881678–2333393618816780. doi:10.1177/2333393618816780

Ministry of Health and Care Services (2012). Morgendagens Omsorg”. Available at: https://www.regjeringen.no/contentassets/34c8183cc5cd43e2bd341e34e326dbd8/no/pdfs/stm201220130029000dddpdfs.pdf (Accessed October 15, 2020), [Governmental white paper. St. 29 (2012–2013), Tomorrow's care]

Ministry of Health and Care Services (2009). Samhandlingsreformen. Available at: https://www.regjeringen.no/contentassets/d4f0e16ad32e4bbd8d8ab5c21445a5dc/no/pdfs/stm200820090047000dddpdfs.pdf (Accessed October 15, 2020), [Governmental white paper. St. 29 (2012–2013, The coordination Reform]

Mitchell, P. H. (2008). “Defining Patient Safety and Quality Care,” in Patient Safety and Quality: An Evidence-Based Handbook for Nurses . Editor R. G. Hughes (Rockville (MD): Agency for Healthcare Research and Quality (US ). doi:10.1016/j.aorn.2009.09.014

Moldskred, P. S., Snibsøer, A. K., and Espehaug, B. (2020). Improving the Quality of Nursing Documentation at A Residential Care Home: A Clinical Audit. BMC Nurs. 23, 577–585. doi:10.21203/rs.3.rs-80580/v1

Morris, Z. S., Wooding, S., and Grant, J. (2011). The Answer Is 17 years, what Is the Question: Understanding Time Lags in Translational Research. J. R. Soc. Med. 104 (12), 510–520. doi:10.1258/jrsm.2011.110180

Næss, G., Kirkevold, M., Hammer, W., Straand, J., and Wyller, T. B. (2017). Nursing Care Needs and Services Utilised by home-dwelling Elderly with Complex Health Problems: Observational Study. BMC Health Serv. Res. 17, 645. doi:10.1186/s12913-017-2600-x

Olsen, R. M., Hellzén, O., Skotnes, L. H., and Enmarker, I. (2012). Content of Nursing Discharge Notes: Associations with Patient and Transfer Characteristics. Ojn 02 (3), 277–287. doi:10.4236/ojn.2012.23042

Olsen, R. M., Østnor, B. H., Enmarker, I., and Hellzén, O. (2013). Barriers to Information Exchange during Older Patients' Transfer: Nurses' Experiences. J. Clin. Nurs. 22 (19–20), 2964–2973. doi:10.1111/jocn.12246

Østensen, E., Bragstad, L. K., Hardiker, N. R., and Hellesø, R. (2019). Nurses' Information Practice in Municipal Health Care-A Web‐like Landscape. J. Clin. Nurs. 28, 2706–2716. doi:10.1111/jocn.14873

Panesar, S. S., deSilva, D., Carson-Stevens, A., Cresswell, K. M., Salvilla, S. A., Slight, S. P., et al. (2015). How Safe Is Primary Care? A Systematic Review. BMJ Qual. Saf. 25, 544–553. bmjqs-2015-004178. doi:10.1136/bmjqs-2015-004178

Patel, S. J., and Landrigan, C. P. (2019). Communication at Transitions of Care. Pediatr. Clin. North America 66 (4), 751–773. doi:10.1016/j.pcl.2019.03.004

Patton, M. Q. (2012). Qualitative Research and Evaluation Methods . California, USA: SAGE Publications .

Polit, D., and Beck, C. (2012). Nursing Research: Generating and Assessing Evidence for Nursing Practice . 9th eds. NY: Lippincott Williams & Wilkins .

Priestman, W., Sridharan, S., Vigne, H., Collins, R., Seamer, L., and Sebire, N. J. (2018). What to Expect from Electronic Patient Record System Implementation: Lessons Learned from Published Evidence. BMJ Health Care Inform. 25 (2), 92–104. doi:10.14236/jhi.v25i2.1007

Söderberg, J., Grankvist, K., Brulin, C., and Wallin, O. (2009). Incident Reporting Practices in the Preanalytical Phase: Low Reported Frequencies in the Primary Health Care Setting. Scand. J. Clin. Lab. Invest. 69, 731–735. doi:10.3109/00365510903007018

Stevenson, J. E., Nilsson, G. C., Petersson, G. I., and Johansson, P. E. (2010). Nurses' Experience of Using Electronic Patient Records in Everyday Practice in Acute/inpatient ward Settings: A Literature Review. Health Inform. J 16, 63–72. doi:10.1111/j.1365-2648.2011.05786.x10.1177/1460458209345901

Stevenson, J. E., and Nilsson, G. (2012). Nurses' Perceptions of an Electronic Patient Record from a Patient Safety Perspective: a Qualitative Study. J. Adv. Nurs. 68 (3), 667–676. doi:10.1111/j.1365-2648.2011.05786.x

The Norwegian Directorate of eHealth (2018). A Brief Overview of Health IT Collaboration and Interoperability in Five Countries in 2018. Available at: https://ehelse.no/publikasjoner/a-brief-overview-of-health-it-collaboration-and-interoperability-in-five-countries-in-2018 (Accessed October 15, 2020).

The Norwegian Directorate of eHealth (2019). Implementation of GDPR in Health Care Sector in Norway. Available at: https://ehelse.no/personvern-og-informasjonssikkerhet/implementation-of-gdpr-in-health-care-sector-in-norway (Accessed October 15, 2020).

Tong, A., Sainsbury, P., and Craig, J. (2007). Consolidated Criteria for Reporting Qualitative Research (COREQ): a 32-item Checklist for Interviews and Focus Groups. Int. J. Qual. Health Care 19 (6), 349–357. doi:10.1093/intqhc/mzm042

Törnvall, E., and Jansson, I. (2017). Preliminary Evidence for the Usefulness of Standardized Nursing Terminologies in Different fields of Application: A Literature Review. Int. J. Nurs. Terminol Knowledge 28 (2), 109–119. doi:10.1111/2047-3095.12123

Tuinman, A., de Greef, M. H. G., Krijnen, W. P., Paans, W., and Roodbol, P. F. (2017). Accuracy of Documentation in the Nursing Care Plan in Long-Term Institutional Care. Geriatr. Nurs. 38 (6), 578–583. doi:10.1016/j.gerinurse.2017.04.007

Wekre, L. J. (2014). Implementation of Multidose Drug Dispensing in a Home Care Setting: Changes in Safety of Medicines Management. Trondheim: Norwegian University of Technology and Science . [dissertation], Available at: http://hdl.handle.net/11250/264576 .

WHO (2017). Patient Safety: Making Health Care Safer . Geneva: World Health Organization Available at: https://www.who.int/patientsafety/publications/patient-safety-making-health-care-safer/en/ (Accessed October 15, 2020).

WHO (2012). “Safer Primary Care,” in A Global challenge. The Safer Primary Care Expert Working Group . Geneva: Word Health Organization Available at: https://www.who.int/patientsafety/summary_report_of_primary_care_consultation.pdf (Accessed October 15, 2020).

WHO (2016). Safer Primary Care: Technical Series . Geneva: Word Health Organization Available at: https://www.who.int/patientsafety/topics/primary-care/technical_series/en/ (Accessed October 15, 2020).

Williams, A. (2019). Nursing Informaticians Address Patient Safety to Improve Usability of Health Information Technologies. Stud. Health Technol. Inform. 257, 501–507. doi:10.3233/978-1-61499-951-5-501

World Medical Association (2001). World Medical Association Declaration of Helsinki. Ethical Principles for Medical Research Involving Human Subjects. Bull. World Health Organ. 79 (4), 373–374. Available at: http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=106094131&site=ehost-live (Accessed October 15, 2020).

Keywords: electronic patient record, nursing, patient safety, primary health care, documentation, focus group

Citation: Bjerkan J, Valderaune V and Olsen RM (2021) Patient Safety Through Nursing Documentation: Barriers Identified by Healthcare Professionals and Students. Front. Comput. Sci. 3:624555. doi: 10.3389/fcomp.2021.624555

Received: 31 October 2020; Accepted: 17 May 2021; Published: 01 June 2021.

Reviewed by:

Copyright © 2021 Bjerkan, Valderaune and Olsen. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Jorunn Bjerkan, [email protected]

This article is part of the Research Topic

Personalized Digital Health and Patient-Centric Services

Volume 18 Supplement 1

Selected articles from the 6th Biennial International Nursing Conference

• Open access
• Published: 16 August 2019

Nursing care activities based on documentation

• Mira Asmirajanti 1 ,
• Achir Yani S. Hamid 2 &
• Rr. Tutik Sri Hariyati 2  

BMC Nursing volume  18 , Article number:  32 ( 2019 ) Cite this article

74k Accesses

29 Citations

1 Altmetric

Metrics details

Nurses engage in various activities from the time of a patient’s admission to his or her discharge from the hospital, helping patients to meet their needs. Each of the activities should be documented properly as authentic and crucial evidence. This study aimed to identify nursing activities in the delivery of nursing care based on the documentation completed.

A quantitative design with a retrospective approach was used, in which 240 medical records from Dr. Kariadi Hospital in Semarang, dating from July through September 2016, were obtained and assessed. The records were randomly selected based on the 10 most common medical and surgical diseases and a hospital stay of more than 3 days. The instrument for collecting the data from the patient progress notes used an observations form. The data were analyzed using univariate statistics and needed to be at least 80% of the values for a certain criteria for it to be considered. The results were analyzed to compare the standard of care.

It was revealed that nursing activities in the delivery of nursing care were insufficient. These activities, according the standard of nursing activities, included the assessment of the functional status of decubitus risk (20.8%), biological status (0.4%), formulation of a nursing diagnosis (20.8%), identification of patients’ home needs (41.3%), quality of life (66.3%), collaboration intervention in drug administration (60.8%), monitoring of vital signs (23.3%), monitoring of daily living activities (37.5%), mobilization/rehabilitation (37.5%), outcome (46.7%), and resume activities nursing (0.8%).

Conclusions

Nursing activities are very important within the hospital and must solve the problems that the patient needs. Every nursing activity should produce documentation with critical thinking. If nursing documents are not clear and accurate, inter-professional communication and an evaluation of nursing care cannot be optimal. Nursing activity and documentation should be continuously directed, controlled, and evaluated by a nurse manager. The quality of nursing activities should always be good to increase patient satisfaction, patient safety, and cost-effectiveness.

Nurses are involved in many activities in a hospital from patient admission through discharge. They provide continuous 24-h patient care, which is divided into several shifts [ 1 ]. Patient care includes performing assessments, stating nursing diagnoses, developing intervention plans, implementing care, and making evaluations to modify or terminate care [ 2 ]. Examples of nursing interventions include discharge planning and education, the provision of emotional support, self-hygiene and oral care, monitoring fluid intake and output, ambulation, the provision of meals, and surveillance of a patient’s general condition [ 3 ]. The delivery of nursing care should involve the patient. A nurse respectfully communicates, coordinates, and integrates nursing care, provides education and information, and considers the comprehensive and continuous physical and emotional comfort of the patient [ 4 ]. In addition, a nurse employs an appropriate strategy to establish a good rapport with a patient and is able to understand a patient’s condition in such a way that they can motivate him or her to actively participate in every nursing activity [ 5 ].

Each nursing activity should consider patient safety. Nurses are responsible for preventing patients from falling and from developing pressure ulcers, urinary tract infections, and nosocomial infections [ 6 ]. They provide education and information regarding the procedures involved in nursing interventions beforehand and involve patients for their own safety; effective communication is the key to patient safety [ 7 ].

Nursing activity that has been completed or that will take place should be properly documented. Accurate documentation and reports play a pivotal role in health services [ 8 ]. This documentation is necessary to identify nursing interventions that have been provided to patients and to show patient progress during hospitalization [ 9 ]. It is also an indicator of nurse performance and the nursing service quality in a hospital. Documentation provides details of patient condition, nursing interventions that have been provided, and patient response to the intervention(s) [ 10 ].

Nursing documentation also serves as an effective tool of inter-professional communication between nurses and other health professionals for delivering ongoing nursing care, evaluating patient progress and outcomes, and providing constant patient protection [ 11 ]. High-quality nursing documentation may improve the effectiveness of communication between health professionals in first- and higher-level healthcare facilities [ 12 ].

The documentation should be saved for an appropriate length of time and should be concise and clear; complete, accurate, and up-to-date documentation will protect a nurse in a court of law [ 13 ]. Correct documentation may encourage a nurse to establish continuity between the diagnosis, intervention, progress, and evaluation of the outcome [ 14 ]. A previous study revealed that 54.7% of nursing documents were of poor quality and 71.6% were incomplete [ 15 ]. Supervision by the head nurse is required for complete, concise, and accurate documentation of nursing care [ 16 ]. The information above provides a platform for managers and nurses to better understand the delivery of nursing care.

A quantitative, cross-sectional, and retrospective study used the medical records of discharged patients. The medical records concerned patients who had been hospitalized for more than 3 days at the medical surgical ward.

Setting and sample

The study was conducted in DK Hospital of Semarang from October until December 2016. Data were obtained from July to September 2016 from 240 medical records of patients with the 10 most common medical surgical diseases. The 240 medical records were randomly selected by simple random methods based on even and odd numbers. Ethical clearance procedures were followed. Medical records data were maintained confidentially, were used only for research purposes, and were not disseminated for other purposes.

Data collection

The authors recorded all nursing activities performed by nurses from the time of a patient’s admission until his or her discharge via an observation form that had been developed by referring to patient progress notes. This observation form consists of nursing activities and had been tested for validity and reliability to achieve optimal data. The validity and reliability results were r Alpha > 0.90 and coefficient kappa > 0.80.

Data analysis

The collected data were assigned codes, inputted into a computer, and cleared of unnecessary information. The data were checked during entry and compilation before analysis. After checking the data for completeness, missing values, and coding questionnaires, data were entered into the computer and analyzed. Univariate analysis was used to identify the frequency and percentage of nursing activities performed. The results were analyzed to compare the standard of care with the hospital accreditation standard and needed to be at least 80% of the values for a certain criteria for it to be considered.

A total of 240 medical records for patients who had been hospitalized for more than 3 days in the medical surgical ward were obtained and analyzed. Data were obtained from the documentation completed by nurses while providing nursing care for each patient. These activities involved patient identification, assessment, nursing diagnosis formulation, discharge planning, education, intervention, monitoring and evaluation, mobilization/rehabilitation, and nursing outcomes. The results are presented in Table  1 below.

The results show that the nurses performance on some nursing activities were below standard (80%). Some nursing activities which needed to be optimized including the assessment of functional status, risk of a pressure ulcer (20.8%), assessment of biological aspect (0.4%), formulation of a nursing diagnosis (20.8%), collaboration in drug administration (60.8%), monitoring of vital signs (23.3%), monitoring of activities of daily living (ADL) (37.5%), mobilization/rehabilitation (37.5%), nursing outcome (46.7%), identification of patients’ home (41.3%), quality of life (66.3%), and nursing activities resumé (0.8%).

The results also indicated that nursing activities were not implemented in compliance with the nursing process; for example, some nurses had not properly performed a biological assessment before proceeding to formulate their diagnosis and perform an intervention. Although the interventions were properly executed, the mobilization and monitoring activities could be improved. Nurses rarely formulated a nursing diagnosis before the expected outcome; however, these two activities should be performed in order, since it may affect the planned nursing intervention. The nurses did not properly identify the patients’ home needs in discharge planning, nor did they create an optimal nursing activities resumé.

The results revealed that nursing activities to solve problems and meet patient needs in the provision of nursing care were not systematically performed and critical thinking was not applied during the nursing process. A previous study asserted that the nursing process incorporates the assessment, nursing diagnosis, planning, implementation, evaluation, and documentation [ 16 ]. The phases in the nursing process are interconnected and become a continuous cycle. Therefore, steps in this process are interrelated, interactive, and cannot stand alone [ 17 ].

It was also shown that some nurses did not perform a biological assessment, yet they proceeded to formulate nursing diagnoses and perform interventions. A nursing diagnosis, however, should be based on the assessment result and used as reference in determining the intervention [ 18 ]. Nurses should consider using a nursing process that complies with the input, process, and output in formulating an intervention, since it may affect the quality of care and patient safety in general [ 19 ]. Patient safety is a fundamental concern for all nurses and health professionals, from the patient’s admission to the hospital until discharge; therefore, it is required that every nursing process is implemented according to the standards applied and in a sustainable manner. If these standards are not observed, then the nurses and other health professionals would not meet patient needs and may even compromise patient safety.

It was shown that nursing activities in identifying the patients’ home needs and quality of life during discharge planning were not properly implemented. Discharge planning is a crucial nursing activity that facilitates a patient’s readiness regarding his or her discharge from the hospital; it allows a patient to be safely transferred from the hospital to their own home. Lack of nursing support in this activity has previously resulted in an increased number of patient readmissions [ 20 ]. Although discharge planning also involves other healthcare professionals, the nurse has the longest amount of time to interact with the patient. The nurse should understand the patient’s condition, recognize their ability to accept it, and improve the readiness of the patient and their family for continuing care at home.

The collaboration intervention of drug administration was not fully implemented. Nurses should provide education regarding the function, composition, and side effects of a drug and adverse reactions that may occur with uncontrolled use. Therefore, a nurse should ensure that a patient has been properly informed of the drug prescribed by a physician. A previous study revealed that collaboration in drug administration in provision of nursing care may improve patient satisfaction and reduce their stress and anxiety [ 5 ].

The findings revealed that nursing activities in vital signs and ADL monitoring were not correctly implemented. Monitoring is a critical nursing activity and identifies a patient’s condition and ability to meet their daily needs so that a nurse may devise an appropriate intervention. A previous study revealed that nurses played a pivotal role in helping patients to recuperate by performing an assessment, monitoring, intervention, evaluation, and provision of support [ 21 ], immediately recognizing a change in a patient’s condition, health promotion, preventing morbidity, improving patient satisfaction, and quality of care.

In the present study, nursing activities in patient mobilization/rehabilitation were not properly executed. Patient mobilization/rehabilitation is an activity that must be implemented immediately after a patient’s hemodynamic parameters are stabilized in order to improve their physical condition. A previous study stated that nurses should pay heed and motivate patients in rehabilitation to ensure effective and cost-effective care [ 22 ].

The present findings also showed that nursing activities in deciding the patient outcome were not optimal. The determination of outcome serves to evaluate how much progress has been made by a patient following the delivery of nursing care. Indeed, one study claimed that the determination of outcome reflected the unique contribution of nursing care toward patient safety [ 23 ].

The present findings of improper nursing activities may have resulted from numerous factors, such as having to perform a large number of non-nursing duties, manual documentation, a lack of standards in documenting patient progress notes, and the exclusion of nursing care in calculating remuneration.

All nursing activities should be properly documented as authentic information and used to evaluate nursing care and professional competency. Nursing documentation is an essential component of professional practice to improve the quality of nursing care and should be accurate and complete [ 24 , 25 ]. Complete documentation encourages nurses to work effectively and appropriately [ 14 ].

Some nursing activities have been done properly, but they were not continuously in compliance with the nursing process. Nursing care was not systematically performed and critical thinking was not applied during the nursing process. Many nurses did not do a biological assessment, yet they proceeded to formulate nursing diagnoses and perform interventions. Nursing activities in identifying patients’ home needs and quality of life during discharge planning, collaboration intervention of drug administration, vital signs and ADL monitoring, patient mobilization/rehabilitation. and deciding the patient outcome were not properly implemented.

The nursing process should be properly implemented in order to improve patient and nurse satisfaction, quality of care, patient safety, and cost-effectiveness, as well as to reduce the average length of stay. A nurse who has completed nursing activities is required to document the care provided, according to the standard applied. Nursing activities and documentation may be more likely to be optimal if they are regularly directed, controlled, and evaluated by the nurse manager. A nurse and patient satisfaction survey should also be periodically conducted to evaluate the quality of nursing activities in the delivery of nursing care for patients.

Abbreviations

Activities of daily living

Needleman J, Hassmiller S. The role of nurses in improving hospital quality and effiesncy: real world result. Health Aff. 2009;4(4) Available from: https://www.healthaffairs.org/doi/10.1377/hlthaff.28.4.w625 .

Moon M, Moorhead S. Relationship of nursing diagnoses, nursing outcomes, and nursing interventions for patient care in intensive care units [Internet]. University of Lowa; 2011. Available from: https://ir.uiowa.edu/cgi/viewcontent.cgi?article=3414&context=etd .

Blackman I, Henderson J, Willis E, Hamilton P, Toffoli L, Verrall C, Abery E, Harvey C. Factors influencing why nursing care is missed. J Clin Nurs. 2014;1–10. Available from: https://s3.amazonaws.com/academia.edu.documents/46692871/Factors_influencing_why_nursing_care_is_20160621-11206-ei495u.pdf?response-contentdisposition=inline%3B%20filename%3DFactors_influencing_why_nursing_care_is.pdf&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential=AKIAIWOWYYGZ2Y53UL3A%2F20190715%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20190715T052903Z&X-Amz-Expires=3600&X-Amz-SignedHeaders=host&X-Amz-Signature=52f4c76966a7c2b53e2480df4115fb05b29a67727d7c012b9b2d9171958b7ad0 .

Kitson A, Marshall A, Bassett K, Zeitz K. What are the core elements of patient-centred care ? A narrative review and synthesis of the. J. Adv. Nurs . , no. May, pp. 3–15, 2012. Available from: https://www.researchgate.net/publication/227341065 .

Larsson IE, Sahlsten MJM, Segesten K, Plos KAE. “Patients ’ Perceptions of Nurses ’ behaviour that influence patient participation in nursing care : a critical incident study,” Nurs. Res. Pract., vol. 2011, 2011.

Boltz M, Capezuti E, Wagner L, Rosenberg M, Secic M. “Patient safety in medical-surgical units : can nurse certification make a difference ?,” J Acad Medical-Surgical Nurses, 2013. Available from: https://www.researchgate.net/publication/235883890 Patient.

Brock D, Abu-Rish E, Chiu C-R, Hammer D, Wilson S, Vorvick L, et al. Interprofessional education in team communication: working together to improve patient safety. Postgrad Med J. 2013;89(1057):642–51 Available from: http://pmj.bmj.com/lookup/doi/10.1136/postgradmedj-2012-000952rep .

Article   Google Scholar  

Hariyati R, Delimayanti M. Widyatuti. Developing Protototype of The Nursing Management Information System in Puskesmas and Hospital, Depok Indonesia. Bus Manag. 2011;5(22):9051–8 Available from: https://www.researchgate.net/profile/Mera_Kartika_delimayanti/publication/267566791_Developing_protototype_of_the_nursing_management_information_system_in_Puskesmas_and_hospital_Depok_Indonesia/links/548e403d0cf2d1800d842323 .

Jefferies D, Langdon R. The Nursing and Midwifery Content Audit Tool (NMCAT): A short nursing documentation audit tool. J Manage. 2010; Available from: https://www.researchgate.net/publication/47427859 .

Jefferies D, Johnson M, Nicholls D, Lad S. “A ward-based writing coach program to improve the quality of nursing documentation,” Int JMed Inform . , 2011. Available from: SciVerse ScienceDirect Nurse Education Today journal homepage: www.elsevier.com/nedt

Jefferies D, Johnson M, Griffiths R. A meta-study of the essentials of quality nursing documentation. Int J Nurs Parctice. 2010;16:112–24. Available from: https://s3.amazonaws.com/academia.edu.documents/7596024/fulltext.pdf?response-content-disposition=inline%3B%20filename%3DA_meta_study_of_the_essentials_of_qualit.pdf&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential=AKIAIWOWYYGZ2Y53UL3A%2F20190715%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20190715T061736Z&X-Amz-Expires=3600&X-Amz-SignedHeaders=host&X-Amz-Signature=af9317f4c3fc395afb1969023804b6e6b1aa24f9b4eff8c1c1b740b0fb2b62da .

Wang N, Hailey D, Yu P. Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review. J Adv Nurs. 2011:1–18. Available from: https://pdfs.semanticscholar.org/3e3f/e0cdccea47d641976e1da2dd570be0236fc4.pdf .

Wong FWH. Chart audit strategies to improve quality of nursing documentation. J Nurses Staff Dev. 2009;25(2):1–6 Available from: https://pdfs.semanticscholar.org/1a68/279791ba2b9def698bbbf1790f571a65b5b6.pdf .

Paans W, Sermeus W, Nieweg R, Schans C. Prevalence of accurate nursing documentation in patient records. J Adv Nurs. 2003;2010. Available from: https://s3.amazonaws.com/academia.edu.documents/39795890/Prevalence_of_accurate_nursing_documenta20151108-15401-1ltyi5m.pdf?response-content-disposition=inline%3B%20filename%3DPrevalence_of_accurate_nursing_documenta.pdf&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Credential=AKIAIWOWYYGZ2Y53UL3A%2F20190715%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Date=20190715T062417Z&X-Amz-Expires=3600&X-Amz-SignedHeaders=host&X-Amz-Signature=38a3db1881a29727602dfbd843c49c0367dad80b20437245bb36c555efbcce2e .

Siswanto LMH, Hariyati RTS, Sukihananto. Faktor-faktor yang berhubungan dengan kelengkapan pendokumentasian asuhan keperawatan. J Keperawatan Indones. 2013;16(2):77–84 Available from: http://www.jki.ui.ac.id/index.php/jki/article/viewFile/5/5 .

Wirawan EA, Novitasari D, Wijayanti F. Hubungan antara supervisi kepala ruang dengan pendokumentasian asuhan keperawatan di rumah sakit umum daerah ambarawa. J Manag Keperawatan. 2013;1(1):1–6 Available from: https://jurnal.unimus.ac.id/index.php/JMK/article/viewFile/943/995 .

Google Scholar  

Craven R, Hirnle C, Jensen S. Fundamentals of Nursing : Human Health and Function, seventh. Philadelphia: Lippincott Williams & Wilkins; 2013.

Haapoja A. The nursing process, a tool to enhance clinical care - a theoretical study: University of Applied Sciences NOVIA; 2014. Available from: https://www.theseus.fi/bitstream/handle/10024/76170/The_Nursing_Process_AH.pdf?sequence=1&isAllowed=y

Aydin N, Akansel N. Determination of accuracy of nursing diagnoses used by nursing students in their nursing care plans. Int J Caring Sci. 2013;6(2) Available from: http://repository.embuni.ac.ke/bitstream/handle/123456789/1120/Aydin%20nursing%20diagnoses.pdf?sequence=1 .

Gardner A, O’Connell J, Gardner GE. Using the Donabedian framework to eximine the quality and safety of nursing servie innovation. J Clin Nurs. 2013;23:145–55 Available from: http://eprints.qut.edu.au/56460/3/56460.pdf .

Sulistyawati W. Hubungan Implementasi Asesmen Kompetensi dengan Pelaksanaan Discharge Planning. J Care. 2016;4(3). Available from: https://jurnal.unitri.ac.id/index.php/care/article/viewFile/442/440 .

Pelt CE, Anderson MB, Pendleton R, Foulks M, Peters CL, Gililland JM. Arthroplasty today improving value in primary total joint arthroplasty care pathways : changes in inpatient physical therapy staf fi ng. Arthroplast Today. Elsevier Inc; 2016;4–8. Available from: https://doi.org/10.1016/j.artd.2016.02.003

Olsson L, Hansson E, Ekman I. “A cost-effectiveness study of a patient-centred integrated care pathway,” no. Johnell 1997, 2009. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2648.2009.05017.x

D’Amour D, Dubois C, Tchouaket E, Clarke S, Blais R. The occurrence of adverse events potentially attributable to nursing care in medical units : cross sectional record review. Int J Nurs Stud. 2014;51:882–91 Available from: http://www.medsp.umontreal.ca/IRSPUM_DB/pdf/28217.pdf .

Frigstad SA, Nøst TH, André B. “Implementation of Free Text Format Nursing Diagnoses at a University Hospital ’ s medical department exploring nurses ’ and nursing students ’ experiences on use and usefulness . a qualitative study,” Hindawi Publ Corp . , vol. 2015, 2015. Available from: https://www.hindawi.com/journals/nrp/2015/179275/

Download references

Acknowledgements

The authors would like to thank the Faculty of Nursing, Universitas Indonesia for financial support. Their grateful thanks also go to the informants who participated in the study and openly shared their thoughts and experiences.

The publication cost of this article was funded by PITTA Universitas Indonesia grant, under grant no.365/UN2.R3.1/HKP.05.00/2017.

Availability of data and materials

The data and materials used for analysis and make conclusion are available from the corresponding author on reasonable request.

About this supplement

This article has been published as part of BMC Nursing Volume 18 Supplement 1, 2019: Selected articles from the 6th Biennial International Nursing Conference. The full contents of the supplement are available online at https://bmcnurs.biomedcentral.com/articles/supplements/volume-18-supplement-1 .

Author information

Authors and affiliations.

Nursing Program, Faculty of Health Sciences, Esa Unggul University, Jakarta, 11510, Indonesia

Mira Asmirajanti

Faculty of Nursing Universitas Indonesia, Jln. Prof. Dr. Bahder Djohan, Kampus UI, Depok, West Java, 16424, Indonesia

Achir Yani S. Hamid & Rr. Tutik Sri Hariyati

You can also search for this author in PubMed   Google Scholar

Contributions

All authors contributed to the writing and editing of the manuscript. All authors read and reviewed the final manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Achir Yani S. Hamid .

Ethics declarations

Ethics approval and consent to participate.

Ethical clearance had been granted to the authors prior to the study by the Research Ethics Committee of the Faculty of Nursing at the Universitas Indonesia (No: 2513/UN2.F12.D/HKP.02.04/2016).

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Cite this article.

Asmirajanti, M., Hamid, A.Y.S. & Hariyati, R.T.S. Nursing care activities based on documentation. BMC Nurs 18 (Suppl 1), 32 (2019). https://doi.org/10.1186/s12912-019-0352-0

Download citation

Published : 16 August 2019

DOI : https://doi.org/10.1186/s12912-019-0352-0

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Nursing activity
• Nursing documentation
• Quality of nursing

BMC Nursing

ISSN: 1472-6955

• General enquiries: [email protected]

• Research note
• Open access
• Published: 23 September 2019

Nursing documentation practice and associated factors among nurses in public hospitals, Tigray, Ethiopia

• Hagos Tasew   ORCID: orcid.org/0000-0002-0886-815X 1 ,
• Teklewoini Mariye 1 &
• Girmay Teklay 1  

BMC Research Notes volume  12 , Article number:  612 ( 2019 ) Cite this article

63k Accesses

25 Citations

Metrics details

The objective of this study was to investigate documentation practice and factors affecting documentation practice among nurses working in public hospital of Tigray region, Ethiopia.

In this study, there were 317 participants with 99.7% response rate. The result of this study shows that practice nursing care documentation was inadequate (47.8%). Inadequacy of documenting sheets AOR = 3.271, 95% CI (1.125, 23.704), inadequacy of time AOR = 2.205, 95% CI (1.101, 3.413) and with operational standard of nursing documentation AOR = 2.015, 95% CI (1.205, 3.70) were significantly associated with practice of nursing care documentation. To conclude, more than half of nurses were not documented their nursing care. Employing institutions should provide training on documentation of nursing care to enhance knowledge and create awareness on nurses’ documentation to nursing directors and chief executive officer to access adequate documenting supplies besides employing more nurses.

Introduction

Nursing documentation is the record of nursing care that is planned and delivered to individual patients by qualified nurses or other caregivers under the direction of a qualified nurse [ 1 ]. Nursing documentation is the principal clinical information source to meet legal and professional requirements [ 2 ]. It is a vital component of safe, ethical and effective nursing practice whether done manually or electronically [ 3 ]. Nursing documentation should fulfill the legal requirements of nursing care documentation [ 4 ].

According to a survey done by WHO it has been shown that poor communication between health care professionals is one factor for medical errors [ 5 ]. There are also evidence indicating that nursing documentation has relationship with patient mortality [ 6 ]. Although keeping a patient record is part of their professional obligation, many studies identified deficiencies in practice of documentation among nurses across the globe [ 7 , 8 ]. It has been reported that nursing records are often incomplete [ 8 , 9 ], lacked accuracy and had poor quality [ 10 , 11 ]. The challenges for documentation reported so far, include shortage of staff [ 12 , 13 ], inadequate knowledge concerning the importance of documentation [ 12 , 13 , 14 , 15 ], patient load [ 12 , 14 ], lack of in-service training [ 14 , 15 ] and lack of support from nursing leadership [ 12 ].

As a remedy for these, many researchers recommended to use a multidisciplinary approach like to develop policies and guidelines on nursing care documentation [ 12 , 13 , 15 ] and provide sustained continuing training opportunities for nurses on effectiveness of documentation [ 7 , 12 , 13 , 16 , 17 ]. The nursing leaders are also expected to support, motivate [ 12 , 17 ] and increase the number of staffs [ 15 ] for a better documentation practice.

Studies from South Africa and Ugandan reported deficiency in attitudes, knowledge and practice behaviors [ 17 , 18 ]. The studies done in Kenya and Ghana also evidenced lack of standardized method and insufficient information of nursing documentation [ 12 , 13 ]. In Ethiopia, inadequacy of data collection with lack of quality was found to be a problem [ 18 , 19 , 20 , 21 ]. The objective of the study was to assess nursing documentation practice and associated factors of nursing documentation practice in public hospitals of Tigray, Ethiopia.

A quantitative descriptive cross-sectional study design was used. The study was conducted from November 1–17, 2017. The source population for this study were all nurses who are working in government owned hospitals of Tigray region. Sample size was determined formula taking the proportion as 37.4% from previous study conducted in Northern Amhara region public hospital [ 14 ], 95% confidence interval (CI), and 5% margin of error. The final sample size was 317. Selection of hospitals for the study was carried out using simple random sampling after all hospitals in the region was identified. The study participants were selected based on the lottery method and the numbers of samples in each hospital were selected according to proportional allocation formula.

Nurses working in inpatient wards and outpatient departments; nurses having work status as a professional nurse at least for 6 months and those who were voluntary to participate were included in the study.

A structured self-administered questionnaire was developed to collect data regarding nursing documentation practice and its associated factors. Practice and knowledge of nursing documentation questions were developed based on the national guideline prepared by the FMOH (EHRIG), various books written on nursing documentation and literatures related to the topic [ 14 , 15 , 22 , 23 ].

Prior to the actual data collection, the items were pre-tested with 5% (16 samples) of the total sample size of nurses working in Adwa hospital with self-administer questionnaire and the results were used to check reliability, consistency and completeness of the questionnaire and some improvements were done on the wordings. Reliability of the questioner was checked using Cronbach alpha (0.79).

Documentation practice

Practice of study participants measured using 10 multiple-choice items. A value of 3, 2, 1 and zero was scored for “always”, “sometimes”, “rarely” and “never” options respectively. For questions in which there were multiple correct and incorrect responses (n = 8), the scoring system used the proportion of correct responses [ 15 ].

Knowledge of documentation

The knowledge of study participants measured using 10 items with multiple options and scoring based on a number of responses given in each question. A value of 1 and 0 was scored for “yes” and “no and I don’t know” options respectively.

The attitude of practice

Attitude of the study participants measured by using the Likert scale questions with 10 items.

The collected data were checked for completion and cleaned manually then the data were entered into computer by SPSS version 22 software was used both for data entry and for analysis. Descriptive statistics like mean, frequency and percentage. Binary logistic regression was used for inferential statistics. Bi-variable and multivariable logistic regression were applied to measure strength of association.

Good practice

Those respondents who scored above or equal to the mean score of practice questions.

Good knowledge

Those respondents who scored above or equal to the mean score of knowledge questions [ 14 ].

Favorable attitude

Those respondents who scored above or equal to the mean score of attitude questions [ 14 ].

Socio-demographic characteristics of respondents

A 317 respondents participated in this study out of which 316 returned the questionnaires made the response rate 99.7%. From 316 nurses who participated in this study, 207 (65.5%) were females and 109 (34.5%) were males. Two hundred eight (65.5%) fall within the ranges of 25–34 years age group. Most of the respondents were holding bachelor degree 279 (88.3%). One hundred two (48.1%) of them were senior nurse professionals while 148 (46.8%) were junior nurse professionals and 11 (5.1%) were junior clinical nurses. One third of the participants were worked as a nurse for 2–5 years when 107 (33.9%) and 100 (31.6%) of them worked for more than 5 years and less than 2 years respectively ( Table  1 ).

Practice of nurses towards nursing documentation practice

A total of 10 multiple option questions were used that had a potential score of 12 and the mean score was 7.26 (S.D ± 2.03). For this study, participant performance was categorized into good and poor practice with scores 7.26 (mean value) or above as good, while those below the mean score as having poor practice. One hundred fifty-one (47.8%) of the respondents scored to have good practice and the rest 165 (52.2%) of the study subjects scored below the mean.

Among all nurses, 230 (72.8%) of them check nursing notes written by their colleagues from which most 130 (56.5%) said the notes are incomplete. Concerning the system of documentation, majority 262 (82.2%) of them denied for application of computerized nursing documentation in their hospital. Regarding the practice of patient care documentation, most 165 (52.2%) of the respondents had poor nursing documentation practice (Table  2 ).

Knowledge of respondents towards nursing documentation

A total of 10 multiple choice questions were used to measure the knowledge of respondents regarding nursing documentation and the mean score was 4.9 (SD ± 1.9). The minimum score was 1.5 and the maximum 9. The total mean score for knowledge questions was 4.9. Of all the respondents, 136 (43%) subjects scored above or equal to the mean value and the rest 180 (57%) of them scored below the mean. One hundred eighty (57%) of the respondents were found to have poor knowledge of documentation.

Attitude of respondents towards nursing documentation

Participants’ attitudes were assessed via a Likert scale, with item scores ranging from strongly agree (5) to strongly disagree (1) which had a potential score of 50. The total mean score for attitude was 42 (S.D ± 4.9) and scores greater or equal to the mean was categorized as favorable and unfavorable for scores below the mean. In this study the overall attitude score of the study participants showed that above half of respondents 176 (55.7%) had favorable attitude and the remaining 140 (44.3%) had unfavorable attitude.

Reason for poor nursing care documentation practice

Out of the 128 (40.5%) of respondents who do not document every care provided to a patient. Most 65 (41.9%) of them reported their reason to be lack of time followed by shortage of documenting sheets, inadequate staff, lack of motivation from supervisors and lack of obligation from employing institution by 38 (24.5%), 28 (18.1%), 17 (11%) and 7 (4.5%) respectively.

Factor associated with documentation practice of nursing care plan

Using binary logistic regression, crude odds ratio with 95% confidence interval was calculated to determine statistical significance and strength of association between each variable. Variables having a p value < 0.25 in the bivariate logistic analysis were entered into the multivariable logistic analysis and adjusted odds ratios were then calculated to investigate association with controlled confounding variables.

According to finding of this study, those nurses who are unfamiliar with operational standard of the nursing documentation were two times more likely to have poor nursing documentation practice than those who are familiar (AOR = 2.015, 95% CI 1.205, 3.370). Additionally, lacked time and those who lacked documentation sheets were two times [AOR = 2.205, 95% CI (1.101, 3.413)] and three times [AOR = 3.271, 95% CI (1.125, 23.704)] more likely to perform poor nursing documentation when compared to those with adequate time and adequate documenting sheets respectively (Table  3 ).

This cross-sectional study aimed to investigate nursing documentation practice and associated factors among nurses in public hospitals of Tigray, Ethiopia.

The finding of this study showed that familiarity with operational standard of nursing documentation, lack of time and inadequacy of documenting sheets had a significant effect on nursing care documentation practice.

The result of this study shows that practice nursing care documentation was inadequate (47.8%) among nurses similar to Nigeria [ 24 ] where both the documentation practice and knowledge were found to be insufficient. This finding is higher from Indonesia 33.3% [ 23 ] and University of Gondar hospital (37.4%) [ 14 ]. This discrepancy might be due to difference in the study period since there might be information difference with time gap because the studies were done before 2 years and after technology had faster growth like smart care introduced in most hospitals of Ethiopia. The other reason could be nurses educational development variation across the countries [ 25 ]. Most (52.2%) of the study participants in this study revealed poor nursing documentation practice which coincides with a study done in Felege Hiwot referral hospital (87.5%) [ 19 ] where medication administration errors were due to nursing documentation error [ 19 ]. This finding is lower than a finding from South Africa 68.3% [ 22 ] and Nigeria 70% [ 15 ]. This might be due to insufficient knowledge as indicated in those studies favorability of the working environment and organizational structure.

Some barriers have been identified to hinder the nursing documentation practice in this study. Those nurses who are familiar with the availability operational standard of nursing documentation were two times more likely to document their care compared to the unfamiliar ones. Similarly, lack of time and scarcity of sheet were leading factors that negatively influence the nursing documentation practice in this study. Respondents who had lack of time were two times more likely to document (41.9%) similar to a study conducted in Nigeria (41.7%) [ 15 ] and England (47%).

Despite its non-significant association, knowledge has shown association with documentation practice in other studies. The knowledge level of participants was 43% in this study which contradicts with the finding from University of Gondar hospital (58.3%) [ 14 ], South Africa (74.9%) [ 22 ], Iraq (59%) [ 16 ] and Indonesia (82.7%) [ 23 ].These inconsistencies might be related to socio demographic variability of the study participants or difference in familiarity to the documentation guideline [ 14 ].

Conclusions

Nursing care documentation practice was poor among nurses. Inadequacy of documenting sheets, lack of time and familiarity with operational standard of nursing documentation were factors associated with nursing care documentation practice. The following recommendation should forward to the healthcare facilities:

Provide a training program to enhance the knowledge of nurses and to familiarize them with institutional policy regarding documentation and provide adequate documentation materials.

Limitations

Since this study is based on self-reported data, most of the variables might have been exposed for social desirability bias.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

adjusted odd ratio

confidence interval

Federal Ministry of Health

inter quartile range

Statistical Package for Social Sciences

Urquhart C, Currell R, Grant MJ, Hardiker NR. Nursing record systems: effects on nursing practice and healthcare outcomes. Cochrane Data Base Syst Rev. 2009;1:1–66.

Google Scholar  

Daskein R, Moyle W, Creedy D. Aged-care nurses’ knowledge of nursing documentation: an Australian perspective. J Clin Nurs. 2009;18:2087–95.

Article   Google Scholar  

College of Registered Nurses of Nova Scotia. Documentation guidelines for registered nurses. 2012; http://www.crnns.ca .

The Federal Democratic Republic of Ethiopia. The criminal code of FDRE: proclamation No. 414/2004. 9 May 2005: Addis Ababa, Ethiopia.

Ente C, Oyewumi A, Mpora OB. Healthcare professionals’ understanding and awareness of patient safety and quality of care in Africa: a survey study. Int J Risk Saf Med. 2010;22(2):103–10.

Collins SA, et al. Relationship between nursing documentation and patients’ mortality. Am J Crit Care. 2013;22(4):306–13.

Lindo J, et al. An audit of nursing documentation at three public hospitals in Jamaica. J Nurs Scholarsh. 2016;48(5):499–507.

Broderick MC, Coffey A. Person centred care in nursing documentation. Int J Older People Nurs. 2013;8(4):309–18.

Jasemi M, et al. Knowledge and practice of Tabriz teaching hospitals’ nurses regarding nursing documentation. Thrita. 2012;2(2):133–8.

Gomes DC, et al. Terms used by nurses in the documentation of patient progress. Revista Gaúcha de Enfermagem. 2016;37(1):e53927.

Considine J, Trotter C, Currey J. Nurses’ documentation of physiological observations in three acute care settings. J Clin Nurs. 2016;25(1–2):134–43.

Johnson BB. Nursing documentation as a communication tool: (a case study from Ghana); 2011.

Sum MT, Chebor MA. Documentation: historical perspectives, purposes, benefits and challenges as faced by nurses. Int J Hum Soc Sci. 2013;3(16):236–40.

Kebede M, Endris Y, Zegeye DT. Nursing care documentation practice: the unfinished task of nursing care in the University of Gondar Hospital. Inform Health Soc Care. 2016;42:1–13.

Taiye BH. Knowledge and practice of documentation among nurses in Ahmadu Bello University Teaching Hospital. IOSR J Nurs Health Sci (IOSR-JNHS). 2015;4(6):1–6.

Hameed RY, Allo RR. Assessment of nurses’ knowledge about nursing documentation. Kufa J Nurs Sci. 2014;4(1):137–44.

Nakate G, et al. Knowledge and Attitudes of Select Ugandan Nurses towards Documentation of Patient Care. Afr J Nurs Midw. 2015;2(1):056.

Vital Wave Consulting. Health information systems in developing countries, in a landscape analysis; 2009. p. 69–70.

Feleke SA, Mulatu MA, Yesmaw YS. Medication administration error: magnitude and associated factors among nurses in Ethiopia. BMC Nurs. 2015;14(1):53.

Wong R, Bradley EH. Developing patient registration and medical records management system in Ethiopia. Int J Qual Health Care. 2009;21(4):253–8.

Tola K, et al. Improving completeness of inpatient medical records in Menelik II Referral Hospital, Addis Ababa, Ethiopia. Adv Public Health. 2017;2017:5.

Olivier JM, Kyriacos U. Record keeping: self-reported attitudes, knowledge and practice behaviours of nurses in selected Cape Town hospitals. Prof Nurs Today. 2011;15(4):8–9.

Motea P, Rantetampang AL, Pongtikuc A. The factor relate to job performance of nurse with health nursing documentation at Paniai General Hospital Papuan Province. Int J Sci Basic Appl Res (IJSBAR). 2016;30(4):231–47.

Oseni O, Adejumo P. Nurses’ reported practice and knowledge of wound assessment, assessment tools and documentation in a selected hospital in Lagos, Nigeria. Afr J Med Med Sci. 2014;43(2):149–57.

CAS   PubMed   Google Scholar  

Nursalam, F., L. Dang, and Y. Arief. Nursing Education in Indonesia: Todays and Future Trends. In: Shanghai International Nursing Conference, Shanghai China; 2009.

Download references

Acknowledgements

The authors wish to acknowledge the nurses who helped immensely in data collection and study participants.

No funding was received.

Author information

Authors and affiliations.

Department Nursing, College of Health Science, Aksum University, Aksum, Ethiopia

Hagos Tasew, Teklewoini Mariye & Girmay Teklay

You can also search for this author in PubMed   Google Scholar

Contributions

HT: Conceived the study, designed questionnaire, data collection, directed data analysis. All authors participated in questionnaire design, data collection, data analysis, manuscript writing. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Hagos Tasew .

Ethics declarations

Ethics approval and consent to participate.

Ethical clearance was obtained from the Institutional Review Board (IRB) of Aksum University (AKU), College of Health Sciences, Department of Nursing. Official letter was Obtained to acquire permission from administrations of the selected hospitals. Approvals were obtained from the participating hospitals to administer the questionnaire to the concerned population and a written consent was obtained from each respondent, explaining the aims and objectives of the research. Confidentiality was ensured as well during the course of the study.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Cite this article.

Tasew, H., Mariye, T. & Teklay, G. Nursing documentation practice and associated factors among nurses in public hospitals, Tigray, Ethiopia. BMC Res Notes 12 , 612 (2019). https://doi.org/10.1186/s13104-019-4661-x

Download citation

Received : 22 January 2019

Accepted : 18 September 2019

Published : 23 September 2019

DOI : https://doi.org/10.1186/s13104-019-4661-x

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Documentation
• Associated factors

BMC Research Notes

ISSN: 1756-0500

• Submission enquiries: [email protected]
• General enquiries: [email protected]

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• SAGE Open Nurs
• v.8; Jan-Dec 2022

Strategies to Improve Compliance with Clinical Nursing Documentation Guidelines in the Acute Hospital Setting: A Systematic Review and Analysis

Jeanette bunting.

1 Joondalup Health Campus Librarian, Joondalup, Western Australia, Australia

Melissa de Klerk

2 Joondalup Health Campus Library Technician, Joondalup, Western Australia, Australia

Introduction

This systematic review attempts to answer the following question – which strategies to improve clinical nursing documentation have been most effective in the acute hospital setting?

A keyword search for relevant studies was conducted in CINAHL and Medline in May 2019 and October 2020.

Studies were appraised using the Joanna Briggs Institute (JBI) critical appraisal for quasi-experimental studies. The studies were graded for level of evidence according to GRADE principles.

The data collected in each study were added to a Summary of Data (SOD) spreadsheet. Pre intervention and a post intervention percentage compliance scores were calculated for each study where possible i.e. (mean score/possible total score) × (100/1). A percentage change in compliance for each study was calculated by subtracting the pre intervention score from the post intervention score. The change in compliance score and the post intervention compliance score were both added to the SOD and used as a basis for comparison between the studies. Each study was analyzed thematically in terms of the intervention strategies used. Compliance rates and the interventions used were compared to determine if any strategies were effective in achieving a meaningful improvement in compliance.

Seventy six full text articles were reviewed for this systematic review. Fifty seven of the studies were before and after studies and 66 were conducted in western countries. Publishing dates for the studies ranged from 1991 to 2020.

Eleven studies included documentation audits with personal feedback as one of the strategies used to improve nursing documentation. Ten of these studies achieved a post intervention compliance rate ≥ 70%.

Notwithstanding the limitations of this study, it may be that documentation audit with personal feedback, when combined with other context specific strategies, is a reliable method for gaining meaningful improvements in clinical nursing documentation. The level of evidence is very low and further research is required.

Clinical documentation is the process of creating a written or electronic record that describes a patient's history and the care given to a patient ( Blair & Smith, 2012 ; Wilbanks et al., 2016 ). It serves as an important communication tool for the exchange of information between healthcare providers and it is stored in a printed or electronic medical record ( Duclos-Miller, 2016 ; Mishra et al., 2009 ). According to Wilbanks et al. (2016) good quality documentation has been defined as documentation that is correct and comprehensive, uses clear terminology, is legible and readable, timely, concise and plausible.

Poor nursing documentation in the acute care setting may have negative impacts on patient outcomes and may also result in litigation ( Duclos-Miller, 2016 ). Therefore it is important to determine if there are any strategies that will provide meaningful improvements in the quality of nursing documentation in the acute care setting.

At the time of writing there were four systematic reviews related to nursing documentation. Three ( Johnson et al., 2018 ; Müller-Staub et al., 2006 ; Saranto et al., 2014 ) examined the impacts of standardized nursing languages (SNL) on the quality of nursing documentation. They were narrative reviews, and include studies that were not necessarily confined to the acute sector. They demonstrated that SNL will improve the quality of nursing documentation, assist in the fulfilment of the legal requirements of documentation and facilitate the use of an electronic health record (EHR). One systematic review ( McCarthy et al., 2019 ) examined the effects of electronic nursing documentation and found that utilizing an END system could improve the quality of nursing documentation, decrease documentation errors and increase compliance with nursing documentation guidelines.

These systematic reviews were narrative in structure and no attempt has been made to determine if the improvement in each of the studies reviewed is a clinically meaningful improvement. The aim of this systematic review is to qualitatively and quantitatively analyze the literature in an attempt to determine which strategies to improve compliance with clinical nursing documentation guidelines, and improve the quality of nursing documentation, have been most effective in the acute setting.

A systematic review of the literature was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines, where possible.( Page et al., 2021a , b )

Search Strategy

A keyword search for relevant studies was conducted in CINAHL and Medline in May 2019 and again October 2020, due to the time that had elapsed. The only limitations were for articles in peer reviewed journals that were written in English. An analysis of the text words contained in the titles, abstracts and index terms found in relevant articles was used to inform the search strategy. The reference lists of articles selected for inclusion were hand searched for additional articles. The full search strategy for CINAHL is found in Appendix 1 .

Inclusion and exclusion criteria

Studies were included if they were quantitative research investigating strategies to improve clinical nursing documentation in acute hospitals. Where possible, the quantitative components of mixed method studies were also included. The nursing documentation components of studies that also involved allied health or medical documentation were included where possible. Studies were not excluded by intervention, we attempted to include as many studies as possible (See Table 1 ).

Table 1.

Inclusion and Exclusion Criteria.

Study selection

Abstract and title screening from the database results lists was initially performed by the principal reviewer and citations were downloaded into EndNote X9 if they appeared relevant. The abstracts in EndNote were then screened independently by both reviewers and conflicts were resolved by discussion. Full text screening was undertaken by the principal reviewer.

Data extraction

A Summary of Data (SOD) excel spreadsheet was prepared by the principal reviewer. For each study that met the selection criteria the following data were extracted - author, year of publication, country of origin, study title, aims, study design, setting, sample size, method of randomization, interventions used, instruments used to collect data, statistical analyzes performed, outcome measures, results and conclusions.

Quality appraisal

Studies included in this systematic review were quasi-experimental studies and were appraised for risk of bias by the principal reviewer using the JBI critical appraisal for quasi-experimental studies ( Tufanaru et al., 2017 ). The JBI Critical Appraisal Checklist for Randomized Controlled Trials ( Tufanaru et al., 2017 ) was used for the only RCT included in the review. For before and after studies, the pre intervention group was not considered to be a control group. The statistical analyzes performed in the studies were evaluated for appropriateness with reference to the Flow chart for hypothesis tests, categorical and numerical data, found on the back inside cover of Medical Statistics at a Glance by Petrie and Sabin (2020)

Rating the certainty of the evidence was undertaken using the principles of GRADE when a meta-analysis has not been performed ( Murad et al., 2017 )

The analysis was performed by the principal reviewer. Where possible each study was quantitatively analyzed such that the data collected in each study were used to calculate a pre intervention and a post intervention percentage compliance score i.e. (mean score/possible total score) × (100/1). A percentage change in compliance for each study was calculated by subtracting the pre intervention score from the post intervention score. The change in compliance score and the post intervention compliance score were both added to the SOD excel and used as a basis for comparison between the studies.

For each study, a meaningful compliance rate was defined as a post intervention compliance rate ≥ 70%, using the definition of compliance as defined within the study . This was chosen as it seems a satisfactory return on investment for the time, effort and resources that are often expended to improve nursing compliance with clinical documentation.

Each study was analyzed thematically in terms of the intervention strategies used. The themes were education alone, audit and feedback, EHR versus paper health record, SNL, EHR modifications, new forms, guidelines, and system changes. Each study was coded according to all of the intervention strategies that were applied, and the codes were recorded on the SOD spreadsheet. See Table 2 for a definition of each of the themes.

Table 2.

Definition of the Themes.

This review is as a narrative synthesis with a quantitative component. For each of the thematic strategies, the post intervention compliance scores were compared to determine if any of the strategies were effective in achieving a meaningful improvement in the quality of nursing documentation. Studies that achieved large improvements in compliance from a very low initial compliance base may not have achieved a final compliance rate of ≥ 70%, therefore good performances may have been missed in this analysis. To compensate for this, studies that achieved an improvement of ≥ 50% were also identified and analyzed in terms of strategies employed.

Ethics approval was sought and was not required.

An initial search was performed in May 2019. Due to the time that had elapsed, a follow up search was performed in October 2020. See Figure 1 PRISMA Diagram below

PRISMA diagram for searches conducted in 2019 and again in 2020 due to the time that had elapsed

Studies were excluded after full text review if they did not meet the inclusion criteria for this study (see Table 1 ).

No studies were excluded after critical appraisal, we attempted to include as many studies as possible.

Seventy six full text articles were reviewed for this study. See Appendix 2 for The Summary of Data table. You can download the data in the SOD spreadsheet from here https://osf.io/8r49s/files/

Fifty seven of the studies were before and after studies, with the remainder being cross sectional studies (six), Plan Do Study Act studies (four), non-randomized controlled studies (four), time course analyzes (two), randomized trials (two) and one randomized controlled trial. Sixty six studies were conducted in western countries including the USA, Canada, Europe, the UK and Australia. The remainder were conducted in Jordan, Kenya, Brazil, Iran and Singapore. Publishing dates for the studies ranged from 1991 to 2020, all but seven of the studies were conducted in the last 20 years.

Nine of the studies included in this review used education as their only strategy to improve nursing compliance with clinical documentation ( Cone et al., 1996 ; Finn, 1997 ; Griffiths et al., 2007 ; Jackson, 2010 ; Lieow et al., 2019 ; Linch et al., 2017 ; Müller-Staub et al., 2008 ; Mykkänen et al., 2012 ; Phillips et al., 2019 ). Of these studies, four had a post-intervention compliance rate ≥ 70% ( Jackson, 2010 ; Lieow et al., 2019 ; Müller-Staub et al., 2008 ; Mykkänen et al., 2012 ).

Twenty two studies had audit and feedback as one of the strategies used to improve compliance with nursing documentation ( Azzolini et al., 2019 ; Bernick & Richards, 1994 ; Cline, 2016 ; Elliott, 2018 ; Ellis et al., 2007 ; Esper & Walker, 2015 ; Gerdtz et al., 2013 ; Gloger et al., 2020 ; Gordon et al., 2008 ; Goulding et al., 2015 ; Hayter & Schaper, 2015 ; Hom et al., 2019 ; Jacobson et al., 2016 ; Kamath et al., 2011 ; Okoyo Nyakiba et al., 2014 ; O’Connor et al., 2014 ; Porter, 1990 ; Stocki et al., 2018 ; Tejedor et al., 2013 ; Trad et al., 2019 ; Unaka et al., 2017 ; Wissman et al., 2020 ). Sixteen of these studies had a final compliance rate ≥ 70%. However if the feedback is personal, the number of studies with a compliance rate ≥ 70% improves to ten out of 11 studies ( Bernick & Richards, 1994 ; Cline, 2016 ; Elliott, 2018 ; Esper & Walker, 2015 ; Gloger et al., 2020 ; Hayter & Schaper, 2015 ; Jacobson et al., 2016 ; Kamath et al., 2011 ; O’Connor et al., 2014 ; Unaka et al., 2017 ; Wissman et al., 2020 ). Download Table 3 Audit and personal feedback from here https://osf.io/8r49s/files/

When audit and feedback are combined with the use of a pre-existing EHR the results are also encouraging ( Cline, 2016 ; Elliott, 2018 ; Esper & Walker, 2015 ; Gerdtz et al., 2013 ; Gloger et al., 2020 ; Hayter & Schaper, 2015 ; Hom et al., 2019 ; Jacobson et al., 2016 ; Kamath et al., 2011 ; Tejedor et al., 2013 ; Unaka et al., 2017 ). Ten of the 11 studies had a final compliance rate ≥ 70%.

Thirteen studies compared EHR with paper records as one of the strategies for increasing nursing documentation compliance ( Akhu-Zaheya et al., 2018 ; Ammenwerth et al., 2001 ; Dahlstrom et al., 2011 ; Gunningberg et al., 2008 ; Gunningberg et al., 2009 ; Higuchi et al., 1999 ; Hübner et al., 2015 ; Larrabee et al., 2001 ; Mansfield et al., 2001 ; Rabelo-Silva et al., 2017 ; Rykkje, 2009 ; Thoroddsen et al., 2011 ; Tubaishat et al., 2015 ). Six of these studies demonstrated a final compliance rate ≥ 70% when an EHR was utilized. It should be noted that Larrabee et al. (2001) had a high compliance rate, however the improvement was 0.2%. Two studies, ( Akhu-Zaheya et al., 2018 ; Rykkje, 2009 ) demonstrated a decline in compliance when comparing EHR to paper based records.

Ten studies involved the use of SNL as one of the strategies to improve nursing documentation ( Björvell et al., 2002 ; Darmer et al., 2006 ; Larrabee et al., 2001 ; Melo et al., 2019 ; Müller-Staub et al., 2007 ; Nøst et al., 2017 ; Rabelo-Silva et al., 2017 ; Rykkje, 2009 ; Thoroddsen et al., 2011 ; Thoroddsen & Ehnfors, 2007 ). Four of these studies had a final compliance rate ≥ 70% ( Larrabee et al., 2001 ; Müller-Staub et al., 2007 ; Thoroddsen et al., 2011 ; Thoroddsen & Ehnfors, 2007 ). It should be noted that although Larrabee et al. (2001) had a final compliance rate of 84.2%, the improvement was 0.2%.

Ten studies utilized EHR modifications as one of the strategies to improve nursing documentation ( Bruylands et al., 2013 ; Chineke et al., 2020 ; Esper & Walker, 2015 ; Gerdtz et al., 2013 ; Hom et al., 2019 ; Jacobson et al., 2016 ; Kamath et al., 2011 ; Nielsen et al., 2014 ; Sandau et al., 2015 ; Tejedor et al., 2013 ). Seven of these studies had a final compliance rate ≥ 70% ( Chineke et al., 2020 ; Esper & Walker, 2015 ; Hom et al., 2019 ; Jacobson et al., 2016 ; Kamath et al., 2011 ; Nielsen et al., 2014 ; Tejedor et al., 2013 ). Prompts were used in four of the studies ( Chineke et al., 2020 ; Hom et al., 2019 ; Kamath et al., 2011 ; Sandau et al., 2015 ), and except for Sandau et al. (2015) they all had a final compliance of ≥ 80%.

Thirty two studies used new forms as one of their strategies for improving nursing documentation ( Aparanji et al., 2018 ; Björvell et al., 2002 ; Bono, 1992 ; Cahill et al., 2011 ; Chineke et al., 2020 ; Christie, 1993 ; Dahlstrom et al., 2011 ; de Rond et al., 2000 ; Dehghan et al., 2015 ; Elliott et al., 2017 ; Ellis et al., 2007 ; Enright et al., 2015 ; Florin et al., 2005 ; Förberg et al., 2012 ; Gerdtz et al., 2013 ; Gordon et al., 2008 ; Hayter & Schaper, 2015 ; Higuchi et al., 1999 ; Hospodar, 2007 ; Hübner et al., 2015 ; Kamath et al., 2011 ; Karp et al., 2019 ; Khresheh & Barclay, 2008 ; Mansfield et al., 2001 ; Mitchell et al., 2010 ; Nomura et al., 2018 ; Nøst et al., 2017 ; O’Connor et al., 2014 ; Stewart et al., 2009 ; Stocki et al., 2018 ; Thoroddsen & Ehnfors, 2007 ; Unaka et al., 2017 ). Seventeen of the 32 studies had a final compliance rate ≥ 70%.

Twelve studies included changes to guidelines, procedures or policies as one of the strategies to improve nursing documentation ( Considine et al., 2006 ; Elliott, 2018 ; Flores et al., 2020 ; Gordon et al., 2008 ; Gunningberg et al., 2008 ; Habich et al., 2012 ; Jacobson et al., 2016 ; Margonary et al., 2017 ; Mitchell et al., 2010 ; Nomura et al., 2018 ; Trad et al., 2019 ; Turner & Stephenson, 2015 ). Five of these studies achieved a final compliance rate ≥ 70% ( Elliott, 2018 ; Flores et al., 2020 ; Gordon et al., 2008 ; Jacobson et al., 2016 ; Nomura et al., 2018 ). It should be noted that the results for Elliott (2018) must be used with caution as some negative results may have left out in the final calculation of compliance rates.

Ten studies included administrative or system changes as one of the strategies to improve nursing documentation ( Ammenwerth et al., 2001 ; Dehghan et al., 2015 ; Enright et al., 2015 ; Gerdtz et al., 2013 ; Kamath et al., 2011 ; Mansfield et al., 2001 ; Meyer et al., 2019 ; Okoyo Nyakiba et al., 2014 ; Stewart et al., 2009 ; Trad et al., 2019 ). All of the system changes improved nursing documentation, six of them had a final compliance rate ≥70% ( Ammenwerth et al., 2001 ; Enright et al., 2015 ; Kamath et al., 2011 ; Mansfield et al., 2001 ; Meyer et al., 2019 ; Stewart et al., 2009 ).

Thirty six studies achieved a meaningful compliance rate i.e. a post intervention compliance score ≥ 70%. Download Table 4 Compliance ≥ 70% from here https://osf.io/8r49s/files/

Seven of the studies had an improvement rate of ≥ 50% ( Chineke et al., 2020 ; Gordon et al., 2008 ; Hayter & Schaper, 2015 ; Kamath et al., 2011 ; Müller-Staub et al., 2007 ; Porter, 1990 ; Unaka et al., 2017 ). The post intervention compliance rate was ≥ 80% for all of them, except Hayter and Schaper (2015) , where the final compliance rate was 72%.

There are serious concerns regarding the certainty of the evidence, and the evidence has been graded as very low due to methodological limitations and issues with imprecision, inconsistency and publication bias (See Table 5 )

Table 5.

Certainty of Evidence.

Of the nine studies that used education alone as the strategy to improve nursing documentation, four resulted in a meaningful compliance rate. It was not possible to determine if the form of the education that was applied, e.g. lectures, simulation, case discussion or demonstrations, had any influence on the final outcome of documentation compliance. The number of studies was too small and the descriptions of the education supplied was not always adequate enough to draw any conclusions.

In terms of the hours devoted to education, one study, Müller-Staub et al. (2008) , involved 22.5 h of education for a final compliance rate of 94.5%. However another study, Linch et al. (2017) had 30 h of instruction and discussion for a final compliance rate of 45%, therefore it is difficult to draw any conclusions as to whether the amount of time spent on education has any effect on documentation compliance. Bearing in mind the small number of studies that utilized education alone, it appears education alone will improve compliance, however it may not improve compliance to a meaningful extent.

When documentation auditing with personal or individual feedback was one of the strategies utilized, ten out of the 11 studies achieved a compliance rate of 70% or more (see Table 3 https://osf.io/8r49s/files/ ). This suggests that auditing and personal

feedback, combined with other context specific strategies such as education, new forms, new templates or EHR modifications, may be a reliable strategy for improving compliance. However the results for Elliott (2018) should be used with caution as some negative results may have been left out in the final calculation of compliance rates. When an EHR was used to conduct the audits, the improvement in compliance rate seems to be reliably high; ten out of the 11 studies that used an EHR to conduct the audits achieved a compliance rate of ≥ 70%. This may be due to the fact that the time consuming audit process is made more efficient by using an EHR for data extraction ( Lieow et al., 2019 ).

Thirteen studies utilized an EHR as one of the strategies to improve nursing documentation, six of these achieved a meaningful compliance rate, however for one of these, Larrabee et al. (2001) , the improvement was 0.2% It appears from these studies that introducing an EHR may not guarantee a meaningful improvement in nursing documentation, and it may even be counterproductive as shown by the studies Rykkje (2009) and Akhu-Zaheya et al. (2018) . In nearly all of the studies the EHR system was not described or named therefore it was not possible to determine if the nature of the EHR had any effect on the results.

Standardized Nursing Language was used in ten studies, four of them achieved a compliance rate of ≥ 70%. The use of NANDA and NIC appears to be more effective than PES or VIPS for improving nursing documentation compliance. Four out of the six studies that used NANDA and NIC had a final compliance rate ≥ 80% ( Larrabee et al., 2001 ; Müller-Staub et al., 2007 ; Thoroddsen et al., 2011 ; Thoroddsen & Ehnfors, 2007 ); however it should be remembered that Larrabee et al. (2001) had 0.2% improvement. Standardized Nursing Language will improve nursing documentation, however it may not improve to a meaningful extent.

Of the 10 studies that used EHR modification, seven achieved a meaningful compliance rate. For the purposes of this systematic review, new or reconfigured EHR templates, are included in the next section - New Forms. Many different EHR modifications were used across the various studies (see Table 2 ), and there are indications that prompts in the EHR may be useful in improving compliance, however there is no single modification that ensures meaningful compliance.

For the purposes of this systematic review new forms included new or modified paper forms and new or modified EHR templates. Thirty two of the studies included new forms as one of the strategies to improve nursing documentation, seventeen of these studies improved nursing documentation to a meaningful degree.

Of the 12 studies that used the creation of new guidelines or changes to existing guidelines as a strategy, five achieved a meaningful compliance rate. It appears that guidelines will improve nursing documentation but not always to a meaningful degree.

Ten studies utilized administrative or system changes as one of the strategies to improve compliance. The studies were too heterogeneous for any single strategy to be proven effective at providing a meaningful improvement. All of the studies that used system changes showed improved nursing documentation, six out of the ten studies demonstrated improvement to a meaningful degree.

In the future, issues with clinical nursing documentation may be dealt with by technological means, for example the use of digital scribes. Digital scribes will employ advances in speech recognition, natural language processing, artificial intelligence, machine learning and clinical decision support technologies, to translate clinical encounters into meaningful and accurate records ( Coiera et al., 2018 ). However speech recognition systems and artificial intelligence will need to be vastly improved before the benefits outweigh the risks of using a digital scribe. Meanwhile strategies to improve nursing documentation remains a relevant topic for research.

Limitations of the Study

Full text screening and the quantitative and thematic analyzes were performed by one reviewer, this may have caused some bias in the results. There was no funding for this systematic review, therefore full text access to all of the articles that appeared in the search results was not possible, this may have resulted in some relevant research not being included in the final analysis. The research articles that were analyzed in this project were very heterogeneous in terms of design, statistical analyzes and strategies employed, meaning that traditional systematic review meta-analysis was not possible, and the percentage analysis that was undertaken was rudimentary at best. Only data that could be converted to percentages were included, therefore some data were missed in the analysis.

The studies usually combined many strategies, making it difficult to tease out the effects of any single strategy. The time that elapsed between the intervention and the post intervention audits varied between the studies and was not analyzed in this systematic review. This may have disadvantaged the studies that used a longer time interval to determine if the improvements in documentation were sustained over time. The level of certainty of the evidence is very low, (see Table 5 ). These limitations could be overcome by a follow up study, focusing on audit and personal feedback and utilizing more rigorous statistical analyzes.

Implications for Practice

Documentation audits with personal feedback should be considered as one of the strategies to be utilized when attempts are made to improve the quality of nursing documentation.

Notwithstanding the limitations of this study, it may be that documentation audit with personal feedback, when combined with other context specific strategies, is a reliable method for gaining meaningful improvements in nursing clinical documentation. Utilizing an EHR to perform the audits may be beneficial to the process, by making the audit process more efficient. The certainty in the evidence is very low, therefore using audit and personal feedback as a strategy to improve clinical nursing documentation is an area that would benefit from more research.

Appendix 1. Search strategy in CINAHL October 2020.

Search limiters – Peer reviewed, in English. Date range: May 2019 - Oct 2020

Appendix 2. Summary of data.

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iD: Jeanette Bunting https://orcid.org/0000-0002-0828-4015

• Akhu-Zaheya L., Al-Maaitah R., Bany Hani S. (2018). Quality of nursing documentation: Paper-based health records versus electronic-based health records . Journal of Clinical Nursing (John Wiley & Sons, Inc.) , 27 ( 3–4 ), e578–e589. 10.1111/jocn.14097 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Ammenwerth E., Eichstädter R., Haux R., Pohl U., Rebel S., Ziegler S. (2001). A randomized evaluation of a computer-based nursing documentation system . Methods of Information in Medicine , 40 ( 2 ), 61–68. 10.1055/s-0038-1634465 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Aparanji K., Kulkarni S., Metzke M., Schmudde Y., White P., Jaeger C. (2018). Quality improvement of delirium status communication and documentation for intensive care unit patients during daily multidisciplinary rounds . BMJ Open Quality , 7 ( 2 ), e000239–e000239. 10.1136/bmjoq-2017-000239 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Azzolini E., Furia G., Cambieri A., Ricciardi W., Volpe M., Poscia A. (2019). Quality improvement of medical records through internal auditing: A comparative analysis . Journal of Preventive Medicine and Hygiene , 60 ( 3 ), E250–E255. 10.15167/2421-4248/jpmh2019.60.3.1203 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Bernick L., Richards P. (1994). Nursing documentation: A program to promote and sustain improvement . Journal of Continuing Education in Nursing , 25 ( 5 ), 203–208. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=rzh&AN=107397873&site=ehost-live&scope=site [ PubMed ] [ Google Scholar ]
• Björvell C., Wredling R., Thorell-Ekstrand I. (2002). Long-term increase in quality of nursing documentation: Effects of a comprehensive intervention . Scandinavian Journal Of Caring Sciences , 16 ( 1 ), 34–42. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=cmedm&AN=11985747&site=ehost-live&scope=site [ PubMed ] [ Google Scholar ]
• Blair W., Smith B. (2012). Nursing documentation: Frameworks and barriers . Contemporary Nurse: A Journal for the Australian Nursing Profession , 41 ( 2 ), 160–168. 10.5172/conu.2012.41.2.160 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Bono B. J. (1992). Assessment and documentation of the breastfeeding couple by health care professionals . Journal of Human Lactation , 8 ( 1 ), 17–22. Retrieved from 10.1177/089033449200800119 [ PubMed ] [ Google Scholar ]
• Bruylands M., Paans W., Hediger H., Müller-Staub M. (2013). Effects on the quality of the nursing care process through an educational program and the use of electronic nursing documentation . International Journal of Nursing Knowledge , 24 ( 3 ), 163–170. 10.1111/j.2047-3095.2013.01248.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cahill H., Jones A., Herkes R., Cook K., Stirling A., Halbert T., Gattas D. J. (2011). Introduction of a new observation chart and education programme is associated with higher rates of vital-sign ascertainment in hospital wards . Bmj Quality & Safety , 20 ( 9 ), 791–796. 10.1136/bmjqs.2010.045096 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Chineke I., Adams Curry M., Bell W., Flood D., Mishra P., Power S., Bernal-Mizrachi L. (2020). Improving documentation of pain and constipation management within the cancer center of a large urban academic hospital . JCO Oncol Pract , 16 ( 3 ), e251–e256. 10.1200/jop.19.00332 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Christie J. (1993). Does the use of an assessment tool in the accident and emergency department improve the quality of care? Journal Of Advanced Nursing , 18 ( 11 ), 1758–1771. Retrieved from 10.1046/j.1365-2648.1993.18111758.x [ PubMed ] [ Google Scholar ]
• Cline M. A. (2016). Increasing RN accountability in professional practice: Development of a pain reassessment documentation scorecard . The Journal Of Nursing Administration , 46 ( 3 ), 128–131. 10.1097/NNA.0000000000000311 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Coiera E., Kocaballi B., Halamka J., Laranjo L. (2018). The digital scribe . npj Digital Medicine , 1 ( 1 ), 58. 10.1038/s41746-018-0066-9 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Cone K. J., Anderson M. A., Johnson J. A. (1996). The effect of in-service education on emergency nurses’ documentation of physical assessment . Journal of Emergency Nursing , 22 ( 5 ), 398–402. 10.1016/s0099-1767(96)80159-0 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Considine J., Potter R., Jenkins J. (2006). Can written nursing practice standards improve documentation of initial assessment of ED patients? Australasian Emergency Nursing Journal , 9 ( 1 ), 11–18. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=rzh&AN=106352052 &site=ehost-live&scope=site [ Google Scholar ]
• Dahlstrom M., Best T., Baker C., Doeing D., Davis A., Doty J., Arora V. M. (2011). Improving identification and documentation of pressure ulcers at an urban academic hospital . Joint Commission Journal on Quality & Patient Safety , 37 ( 3 ), 123–130. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=rzh&AN=104846681&site=ehost-live&scope=site [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Darmer M. R., Ankersen L., Nielsen B. G., Landberger G., Lippert E., Egerod I. (2006). Nursing documentation audit--the effect of a VIPS implementation programme in Denmark . Journal Of Clinical Nursing , 15 ( 5 ), 525–534. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=cmedm&AN=16629961&site =ehost-live&scope=site [ PubMed ] [ Google Scholar ]
• de Rond M. E., de Wit R., van Dam F. S., Muller M. J. (2000). A pain monitoring program for nurses: Effects on communication, assessment and documentation of patients’ pain . Journal of Pain and Symptom Management , 20 ( 6 ), 424–439. 10.1016/s0885-3924(00)00209-8 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Dehghan D., Dehghan M., Sheikhrabori A. (2015). The quality of clinical documentation of patients admitted to an Iranian teaching hospital: A two-year impact of clinical governance . Asian Journal of Nursing Education and Research , 5 ( 2 ), 159. 10.5958/2349-2996.2015.00033.6 [ CrossRef ] [ Google Scholar ]
• Duclos-Miller P. A. (2016). Improving nursing documentation and reducing risk . HCPro, a division of BLR. [ Google Scholar ]
• Elliott D., Allen E., McKinley S., Perry L., Duffield C., Fry M., Roche M. (2017). User compliance with documenting on a track and trigger-based observation and response chart: A two-phase multi-site audit study . Journal Of Advanced Nursing , 73 ( 12 ), 2892–2902. 10.1111/jan.13302 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Elliott L. (2018). Standardizing documentation: A place for everything . MEDSURG Nursing , 27 ( 1 ), 32–37. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=rzh&AN=128049904&site=ehost-live&scope=site [ Google Scholar ]
• Ellis J. A., McCleary L., Blouin R., Dube K., Rowley B., MacNeil M., Cooke C. (2007). Implementing best practice pain management in a pediatric hospital . Journal for Specialists in Pediatric Nursing , 12 ( 4 ), 264–277. 10.1111/j.1744-6155.2007.00121.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Enright K., MacMillan M., Lymburner P., Sodoski C., Gollee S., Carvalho M., Almeida B. (2015). Improving documentation of oral chemotherapy at a community cancer center . Journal Of Oncology Practice , 11 ( 3 ), 213–215. 10.1200/JOP.2014.003111 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Esper P., Walker S. (2015). Improving documentation of quality measures in the electronic health record . Journal of the American Association of Nurse Practitioners , 27 ( 6 ), 308–312. 10.1002/2327-6924.12169 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Finn L. (1997). Clinical. Nurses’ documentation of infection control precautions: 2 . British Journal of Nursing , 6 ( 12 ), 678–684. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=rzh&AN=107349953 &site=ehost-live&scope=site [ PubMed ] [ Google Scholar ]
• Flores C. J., Lakkundi A., McIntosh J., Freeman P., Thomson A., Saxon B., Ross B. (2020). Embedding best transfusion practice and blood management in neonatal intensive care . BMJ Open Quality , 9 ( 1 ), e000694. 10.1136/bmjoq-2019-000694 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Florin J., Ehrenberg A., Ehnfors M. (2005). Quality of nursing diagnoses: Evaluation of an educational intervention . International Journal of Nursing Terminologies & Classifications , 16 ( 2 ), 33–43. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens& db=rzh&AN=106528371&site=ehost-live&scope=site [ PubMed ] [ Google Scholar ]
• Förberg U., Johansson E., Ygge B.-M., Wallin L., Ehrenberg A. (2012). Accuracy in documentation of peripheral venous catheters in paediatric care: An intervention study in electronic patient records . Journal Of Clinical Nursing , 21 ( 9–10 ), 1339–1344. 10.1111/j.1365-2702.2011.03949.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Gerdtz M. F., Waite R., Vassiliou T., Garbutt B., Prematunga R., Virtue E. (2013). Evaluation of a multifaceted intervention on documentation of vital signs at triage: A before-and-after study . Emergency Medicine Australasia: EMA , 25 ( 6 ), 580–587. 10.1111/1742-6723.12153 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Gloger A. N., Nakonezny P. A., Phelan H. A. (2020). Use of tailored feedback improves accuracy of delirium documentation in the burn ICU: Results of a performance improvement initiative . Journal of Burn Care & Research: Official Publication of the American Burn Association , 41 ( 2 ), 299–305. 10.1093/jbcr/irz153 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Gordon D. B., Rees S. M., McCausland M. P., Pellino T. A., Sanford-Ring S., Smith-Helmenstine J., Danis D. M. (2008). Improving reassessment and documentation of pain management . Joint Commission Journal on Quality & Patient Safety , 34 ( 9 ), 509–517. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=rzh&AN =105550853&site=ehost-live&scope=site [ PubMed ] [ Google Scholar ]
• Goulding L., Parke H., Maharaj R., Loveridge R., McLoone A., Hadfield S., Sandall J. (2015). Improving critical care discharge summaries: A collaborative quality improvement project using PDSA . BMJ Quality Improvement Reports , 4 ( 1 ), 1-8. 10.1136/bmjquality.u203938.w3268 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Griffiths P., Debbage S., Smith A. (2007). A comprehensive audit of nursing record keeping practice . British Journal Of Nursing (Mark Allen Publishing) , 16 ( 21 ), 1324–1327. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=cmedm&AN=18073669&site=ehost-live&scope=site [ PubMed ] [ Google Scholar ]
• Gunningberg L., Dahm M. F., Ehrenberg A. (2008). Accuracy in the recording of pressure ulcers and prevention after implementing an electronic health record in hospital care . Quality & Safety in Health Care , 17 ( 4 ), 281–285. 10.1136/qshc.2007.023341 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Gunningberg L., Fogelberg-Dahm M., Ehrenberg A. (2009). Improved quality and comprehensiveness in nursing documentation of pressure ulcers after implementing an electronic health record in hospital care . Journal of Clinical Nursing (Wiley-Blackwell) , 18 ( 11 ), 1557–1564. 10.1111/j.1365-2702.2008.02647.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Habich M., Wilson D., Thielk D., Melles G. L., Crumlett H. S., Masterton J., McGuire J. (2012). Evaluating the effectiveness of pediatric pain management guidelines . Journal of Pediatric Nursing , 27 ( 4 ), 336–345. 10.1016/j.pedn.2011.06.002 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hayter K. L., Schaper A. M. (2015). CONTROLLING PAIN. Improving pain documentation with peer chart review . Nursing , 45 ( 7 ), 58–63. 10.1097/01.NURSE.0000463673.52336.80 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Higuchi K. A., Dulberg C., Duff V. (1999). Factors associated with nursing diagnosis utilization in Canada . Nursing Diagnosis: ND: The Official Journal Of The North American Nursing Diagnosis Association , 10 ( 4 ), 137–147. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=cmedm&AN=10786554&site=ehost-live&scope=site [ PubMed ] [ Google Scholar ]
• Hom L. A., Chan Salcedo C., Revenis M., Martin G. R. (2019). Quality improvement interventions to improve critical congenital heart disease screening . Pediatric quality & safety , 4 ( 5 ), e221–e221. 10.1097/pq9.0000000000000221 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hospodar M. (2007). Sticking together! A creative approach to documenting insulin double checks . Rehabilitation Nursing: The Official Journal Of The Association Of Rehabilitation Nurses , 32 ( 1 ), 6–8. Retrieved from 10.1002/j.2048-7940.2007.tb00142.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Hübner U., Schulte G., Sellemann B., Quade M., Rottmann T., Fenske M., Rienhoff O. (2015). Evaluating a proof-of-concept approach of the German health telematics infrastructure in the context of Discharge management (Vol. 216). Netherlands: IOS Press. https://ebooks.iospress.nl/publication/40257 . [ PubMed ] [ Google Scholar ]
• Jackson S. E. (2010). The efficacy of an educational intervention on documentation of pain management for the elderly patient with a hip fracture in the emergency department . JEN: Journal of Emergency Nursing , 36 ( 1 ), 10–15. 10.1016/j.jen.2008.08.022 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Jacobson T. M., Thompson S. L., Halvorson A. M., Zeitler K. (2016). Enhancing documentation of pressure ulcer prevention interventions . Journal of Nursing Care Quality , 31 ( 3 ), 207–216. 10.1097/NCQ.0000000000000175 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Johnson L., Edward K.-L., Giandinoto J.-A. (2018). A systematic literature review of accuracy in nursing care plans and using standardised nursing language . Collegian , 25 ( 3 ), 355–361. 10.1016/j.colegn.2017.09.006 [ CrossRef ] [ Google Scholar ]
• Kamath B. D., Donovan E. F., Christopher R., Brodbeck J., Slone C., Marcotte M. P. (2011). Using improvement science to increase accuracy and reliability of gestational Age documentation . American Journal of Perinatology , 28 ( 8 ), 1–8. 10.1055/s-0031-1285096 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Karp E. L., Freeman R., Simpson K. N., Simpson A. N. (2019). Changes in efficiency and quality of nursing electronic health record documentation after implementation of an admission patient history essential data Set. CIN: Computers, Informatics . Nursing , 37 ( 5 ), 260–265. 10.1097/CIN.0000000000000516 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Khresheh R., Barclay L. (2008). Implementation of a new birth record in three hospitals in Jordan: A study of health system improvement . Health Policy And Planning , 23 ( 1 ), 76–82. Retrieved from 10.1093/heapol/czm039 [ PubMed ] [ Google Scholar ]
• Larrabee J. H., Boldreghini S., Elder-Sorrells K., Turner Z. M., Wender R. G., Hart J. M., Lenzi P. S. (2001). Evaluation of documentation before and after implementation of a nursing information system in an acute care hospital . Computers in Nursing , 19 ( 2 ), 56–68. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=rzh&AN=107022870&site=ehost-live&scope=site [ PubMed ] [ Google Scholar ]
• Lieow J. L. M., Chen F. S. M., Song G., Tang P. S., Kowitlawakul Y., Mukhopadhyay A. (2019). Effectiveness of an advanced practice nurse-led delirium education and training programme . International Nursing Review , 66 ( 4 ), 506–513. 10.1111/inr.12519 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Linch G., Lima A. A. A., Souza E. N., Nauderer T. M., Paz A. A., da Costa C. (2017). An educational intervention impact on the quality of nursing records . Revista Latino-Americana de Enfermagem , 25 , e2938. 10.1590/1518-8345.1986.2938 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mansfield J. A., Dodds K. L., Mallory T. H., Lombardi A. V., Adams J. B. (2001). Linking the orthopaedic office-hospital continuum: Results before and after implementation of an automated patient health history project . Orthopedic Nursing , 20 ( 2 ), 51–60. Retrieved from 10.1097/00006416-200103000-00013 [ PubMed ] [ Google Scholar ]
• Margonary H., Hannan M. S., Schlenk E. A. (2017). Quality improvement initiative on pain knowledge, assessment, and documentation skills of pediatric nurses . Pediatric Nursing , 43 ( 2 ), 65–70. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=cmedm&AN=29394479&site=ehost-live&scope=site [ PubMed ] [ Google Scholar ]
• McCarthy B., Fitzgerald S., O’Shea M., Condon C., Savage E., Hartnett-Collins G., Bergin M. (2019). Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review . Journal of Nursing Management (John Wiley & Sons, Inc.) , 27 ( 3 ), 491–501. 10.1111/jonm.12727 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Melo L. S. d., Figueiredo L. d. S., Pereira J. d. M. V., Flores P. V. P., Cavalcanti A. C. D. (2019). Effect of an educational program on the quality of nursing process recording . Acta Paulista de Enfermagem , 32 ( 3 ), 246–253. 10.1590/1982-0194201900034 [ CrossRef ] [ Google Scholar ]
• Meyer L. K., Nanassy A. D., Lavella H., Arthur L. G., Grewal H. (2019). Cohorting trauma patients in a medical/surgical unit at a level I pediatric trauma center to enhance interdisciplinary collaboration and documentation . Journal Of Trauma Nursing: The Official Journal Of The Society Of Trauma Nurses , 26 ( 1 ), 17–25. 10.1097/JTN.0000000000000418 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mishra A. K., Bhattarai S., Bhurtel P., Bista N. R., Shrestha P., Thakali K., Pathak S. R. (2009). Need for improvement of medical records . JNMA; Journal of the Nepal Medical Association , 48 ( 174 ), 103–106. Retrieved from https://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=cmedm&AN=20387347&site=ehost-live&scope=site [ PubMed ] [ Google Scholar ]
• Mitchell I. A., McKay H., Van Leuvan C., Berry R., McCutcheon C., Avard B., Lamberth, P. (2010). A prospective controlled trial of the effect of a multi-faceted intervention on early recognition and intervention in deteriorating hospital patients . Resuscitation , 81 ( 6 ), 658–666. 10.1016/j.resuscitation.2010.03.001 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Müller-Staub M., Lavin M. A., Needham I., van Achterberg T. (2006). Nursing diagnoses, interventions and outcomes - application and impact on nursing practice: Systematic review . Journal of Advanced Nursing , 56 ( 5 ), 514–531. 10.1111/j.1365-2648.2006.04012.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Müller-Staub M., Needham I., Odenbreit M., Lavin M. A., van Achterberg T. (2007). Improved quality of nursing documentation: Results of a nursing diagnoses, interventions, and outcomes implementation study . International Journal of Nursing Terminologies & Classifications , 18 ( 1 ), 5–17. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=rzh&AN=106298993&site=ehost-live&scope=site [ PubMed ] [ Google Scholar ]
• Müller-Staub M., Needham I., Odenbreit M., Lavin M. A., van Achterberg T. (2008). Implementing nursing diagnostics effectively: Cluster randomized trial . Journal of Advanced Nursing , 63 ( 3 ), 291–301. 10.1111/j.1365-2648.2008.04700.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Murad M. H., Mustafa R. A., Schünemann H. J., Sultan S., Santesso N. (2017). Rating the certainty in evidence in the absence of a single estimate of effect . Evidence-based Medicine , 22 ( 3 ), 85–87. 10.1136/ebmed-2017-110668 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Mykkänen M., Saranto K., Miettinen M. (2012). Nursing audit as a method for developing nursing care and ensuring patient safety. NI 2012 : 11t h International Congress on Nursing Informatics, June 23-27, 2012, Montreal, Canada. International Congress in Nursing Informatics (11th : 2012 : Montreal, Quebec), 2012, 301–301. Retrieved from 10.1073/pnas.83.5.1532 [ CrossRef ]
• Nielsen G., Peschel L., Burgess A. (2014). Essential documentation elements: Quality tool for the emergency department nurse . Advanced Emergency Nursing Journal , 36 ( 2 ), 199–205. 10.1097/TME.0000000000000020 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Nomura A. T. G., Pruinelli L., da Silva M. B., Lucena A. d. F., Almeida M. d. A. (2018). Quality of electronic nursing records: The impact of educational interventions during a hospital accreditation process . Computers, Informatics, Nursing: CIN , 36 ( 3 ), 127–132. 10.1097/CIN.0000000000000390 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Nøst T. H., Frigstad S. A., André B. (2017). Impact of an education intervention on nursing diagnoses in free-text format in electronic health records: A pretest-posttest study in a medical department at a university hospital . Nordic Journal of Nursing Research , 37 ( 2 ), 100–108. 10.1177/2057158516668081 [ CrossRef ] [ Google Scholar ]
• O’Connor T. L., Raposo E. A., Heller-Wescott T. (2014). Improving trauma documentation in the emergency department . Journal Of Trauma Nursing: The Official Journal Of The Society Of Trauma Nurses , 21 ( 5 ), 238–243. 10.1097/JTN.0000000000000071 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Okoyo Nyakiba J., McMillan M., Kenyatta G. (2014). Reporting and documentation of adverse drug reactions by health care professionals at a Kenyan public hospital: A best practice implementation project . JBI Database of Systematic Reviews & Implementation Reports , 12 ( 7 ), 521–533. 10.11124/jbisrir-2014-1362 [ CrossRef ] [ Google Scholar ]
• Page et al. (2021a). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews . BMJ , 372 , n71. 10.1136/bmj.n71 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Page et al. (2021b). PRISMA 2020 Explanation and elaboration: Updated guidance and exemplars for reporting systematic reviews . BMJ , 372 , n160. 10.1136/bmj.n160 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Petrie A., Sabin C. (2020). Medical statistics at glance . Wiley-Blackwell. [ Google Scholar ]
• Phillips M. E., Gilmore R. A., Sheffield M. C., Phan S. V. (2019). Pain assessment documentation after opioid administration at a community teaching hospital . Journal Of Pharmacy Practice , 32 ( 2 ), 179–185. 10.1177/0897190017751207 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Porter Y. (1990). Evaluation of nursing documentation of patient teaching . Journal of Continuing Education in Nursing , 21 ( 3 ), 134–137. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=cmedm&AN=2112175 &site=ehost-live&scope=site [ PubMed ] [ Google Scholar ]
• Rabelo-Silva E. R., Dantas Cavalcanti A. C., Ramos Goulart Caldas M. C., Lucena A. F., Almeida M. A., Linch G. F., Müller-Staub M. (2017). Advanced nursing process quality: Comparing the international classification for nursing practice (ICNP) with the NANDA-international (NANDA-I) and nursing interventions classification (NIC) . Journal of Clinical Nursing , 26 ( 3–4 ), 379–387. 10.1111/jocn.13387 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Rykkje L. (2009). Implementing electronic patient record and VIPS in medical hospital wards: Evaluating change in quantity and quality of nursing documentation by using the audit instrument Cat-ch-Ing . Nordic Journal of Nursing Research & Clinical Studies / Vård i Norden , 29 ( 2 ), 9–13. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=rzh&AN=105395041&site=ehost-live&scope=site [ Google Scholar ]
• Sandau K. E., Sendelbach S., Fletcher L., Frederickson J., Drew B. J., Funk M. (2015). Computer-assisted interventions to improve QTc documentation in patients receiving QT-prolonging drugs. American Journal Of Critical Care: An Official Publication . American Association Of Critical-Care Nurses , 24 ( 2 ), e6–e15. 10.4037/ajcc2015240 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Saranto K., Kinnunen U. M., Kivekäs E., Lappalainen A. M., Liljamo P., Rajalahti E., Hyppönen H. (2014). Impacts of structuring nursing records: A systematic review . Scandinavian Journal of Caring Sciences , 28 ( 4 ), 629–647. 10.1111/scs.12094 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Stewart S., Bennett S., Blokzyl A., Bowman W., Butcher I., Chapman K., Wenzel S. (2009). ‘Measurement Monday’: One facility’s approach to standardizing skin impairment documentation . Ostomy Wound Management , 55 ( 12 ), 49–53. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=rzh&AN=105277966&site=ehost-live&scope=site [ PubMed ] [ Google Scholar ]
• Stocki D., McDonnell C., Wong G., Kotzer G., Shackell K., Campbell F. (2018). Knowledge translation and process improvement interventions increased pain assessment documentation in a large quaternary paediatric post-anaesthesia care unit . BMJ Open Quality , 7 ( 3 ), e000319–e000319. 10.1136/bmjoq-2018-000319 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Tejedor S. C., Garrett G., Jacob J. T., Meyer E., Reyes M. D., Robichaux C., Steinberg J. P. (2013). Electronic documentation of central venous catheter-days: Validation is essential . Infection Control and Hospital Epidemiology , 34 ( 9 ), 900–907. 10.1086/671736 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Thoroddsen A., Ehnfors M. (2007). Putting policy into practice: Pre- and posttests of implementing standardized languages for nursing documentation . Journal of Clinical Nursing , 16 ( 10 ), 1826–1838. 10.1111/j.1365-2702.2007.01836.x [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Thoroddsen A., Ehnfors M., Ehrenberg A. (2011). Content and completeness of care plans after implementation of standardized nursing terminologies and computerized records . Computers, Informatics, Nursing: CIN , 29 ( 10 ), 599–607. 10.1097/NCN.0b013e3182148c31 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Trad W., Flowers K., Caldwell J., Sousa M. S., Vigh G., Lizarondo L., Parker D. (2019). Nursing assessment and management of incontinence among medical and surgical adult patients in a tertiary hospital: A best practice implementation project . Jbi Database of Systematic Reviews and Implementation Reports , 17 ( 12 ), 2578–2590. 10.11124/jbisrir-d-19-00110 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Tubaishat A., Tawalbeh L. I., Al Azzam M., AlBashtawy M., Batiha A.-M. (2015). Electronic versus paper records: Documentation of pressure ulcer data . British Journal of Nursing , 24 ( 6 ), S30–S37. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip,athens&db=rzh&AN=103783030&site=ehost-live&scope=site [ PubMed ] [ Google Scholar ]
• Tufanaru C., Munn Z., Aromataris E., Campbell J., Lisa H. (2017). Chapter 3: Systematic reviews of effectiveness . In Aromataris E M. Z. (Ed.). Joanna Briggs Institute Reviewer’s Manual. [ Google Scholar ]
• Turner A., Stephenson M. (2015). Documentation of chemotherapy administration by nursing staff in inpatient and outpatient oncology/hematology settings: A best practice implementation project . JBI Database Of Systematic Reviews And Implementation Reports , 13 ( 10 ), 316–334. 10.11124/jbisrir-2015-2157 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Unaka N. I., Statile A., Jerardi K., Dahale D., Morris J., Liberio B., Brady P. (2017). Improving the readability of pediatric hospital medicine discharge instructions . Journal of Hospital Medicine , 12 ( 7 ), 551–557. 10.12788/jhm.2770 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Wilbanks B. A., Geisz-Everson M., Boust R. R. (2016). The role of documentation quality in anesthesia-related closed claims: A descriptive qualitative study . Computers, informatics, nursing : CIN , 34 ( 9 ), 406–412. 10.1097/CIN.0000000000000270 [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Wissman K. M., Cassidy E., D’Amico F., Hoy C., Vissari T., Baumgartner M. (2020). Improving pain reassessment and documentation rates: A quality improvement project in a teaching hospital’s emergency department . Journal of Emergency Nursing , 46 ( 4 ), 505–510. 10.1016/j.jen.2019.12.008 [ PubMed ] [ CrossRef ] [ Google Scholar ]

Log in using your username and password

• Search More Search for this keyword Advanced search
• Latest content
• Current issue
• Write for Us
• BMJ Journals More You are viewing from: Google Indexer

You are here

• Volume 21, Issue 1
• What is a case study?
• Article Text
• Article info
• Citation Tools
• Rapid Responses
• Article metrics

• Roberta Heale 1 ,
• Alison Twycross 2
• 1 School of Nursing , Laurentian University , Sudbury , Ontario , Canada
• 2 School of Health and Social Care , London South Bank University , London , UK
• Correspondence to Dr Roberta Heale, School of Nursing, Laurentian University, Sudbury, ON P3E2C6, Canada; rheale{at}laurentian.ca

https://doi.org/10.1136/eb-2017-102845

Statistics from Altmetric.com

Request permissions.

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

What is it?

Case study is a research methodology, typically seen in social and life sciences. There is no one definition of case study research. 1 However, very simply… ‘a case study can be defined as an intensive study about a person, a group of people or a unit, which is aimed to generalize over several units’. 1 A case study has also been described as an intensive, systematic investigation of a single individual, group, community or some other unit in which the researcher examines in-depth data relating to several variables. 2

Often there are several similar cases to consider such as educational or social service programmes that are delivered from a number of locations. Although similar, they are complex and have unique features. In these circumstances, the evaluation of several, similar cases will provide a better answer to a research question than if only one case is examined, hence the multiple-case study. Stake asserts that the cases are grouped and viewed as one entity, called the quintain . 6  ‘We study what is similar and different about the cases to understand the quintain better’. 6

The steps when using case study methodology are the same as for other types of research. 6 The first step is defining the single case or identifying a group of similar cases that can then be incorporated into a multiple-case study. A search to determine what is known about the case(s) is typically conducted. This may include a review of the literature, grey literature, media, reports and more, which serves to establish a basic understanding of the cases and informs the development of research questions. Data in case studies are often, but not exclusively, qualitative in nature. In multiple-case studies, analysis within cases and across cases is conducted. Themes arise from the analyses and assertions about the cases as a whole, or the quintain, emerge. 6

Benefits and limitations of case studies

If a researcher wants to study a specific phenomenon arising from a particular entity, then a single-case study is warranted and will allow for a in-depth understanding of the single phenomenon and, as discussed above, would involve collecting several different types of data. This is illustrated in example 1 below.

Using a multiple-case research study allows for a more in-depth understanding of the cases as a unit, through comparison of similarities and differences of the individual cases embedded within the quintain. Evidence arising from multiple-case studies is often stronger and more reliable than from single-case research. Multiple-case studies allow for more comprehensive exploration of research questions and theory development. 6

Despite the advantages of case studies, there are limitations. The sheer volume of data is difficult to organise and data analysis and integration strategies need to be carefully thought through. There is also sometimes a temptation to veer away from the research focus. 2 Reporting of findings from multiple-case research studies is also challenging at times, 1 particularly in relation to the word limits for some journal papers.

Examples of case studies

Example 1: nurses’ paediatric pain management practices.

One of the authors of this paper (AT) has used a case study approach to explore nurses’ paediatric pain management practices. This involved collecting several datasets:

Observational data to gain a picture about actual pain management practices.

Questionnaire data about nurses’ knowledge about paediatric pain management practices and how well they felt they managed pain in children.

Questionnaire data about how critical nurses perceived pain management tasks to be.

These datasets were analysed separately and then compared 7–9 and demonstrated that nurses’ level of theoretical did not impact on the quality of their pain management practices. 7 Nor did individual nurse’s perceptions of how critical a task was effect the likelihood of them carrying out this task in practice. 8 There was also a difference in self-reported and observed practices 9 ; actual (observed) practices did not confirm to best practice guidelines, whereas self-reported practices tended to.

Example 2: quality of care for complex patients at Nurse Practitioner-Led Clinics (NPLCs)

The other author of this paper (RH) has conducted a multiple-case study to determine the quality of care for patients with complex clinical presentations in NPLCs in Ontario, Canada. 10 Five NPLCs served as individual cases that, together, represented the quatrain. Three types of data were collected including:

Review of documentation related to the NPLC model (media, annual reports, research articles, grey literature and regulatory legislation).

Interviews with nurse practitioners (NPs) practising at the five NPLCs to determine their perceptions of the impact of the NPLC model on the quality of care provided to patients with multimorbidity.

Chart audits conducted at the five NPLCs to determine the extent to which evidence-based guidelines were followed for patients with diabetes and at least one other chronic condition.

The three sources of data collected from the five NPLCs were analysed and themes arose related to the quality of care for complex patients at NPLCs. The multiple-case study confirmed that nurse practitioners are the primary care providers at the NPLCs, and this positively impacts the quality of care for patients with multimorbidity. Healthcare policy, such as lack of an increase in salary for NPs for 10 years, has resulted in issues in recruitment and retention of NPs at NPLCs. This, along with insufficient resources in the communities where NPLCs are located and high patient vulnerability at NPLCs, have a negative impact on the quality of care. 10

These examples illustrate how collecting data about a single case or multiple cases helps us to better understand the phenomenon in question. Case study methodology serves to provide a framework for evaluation and analysis of complex issues. It shines a light on the holistic nature of nursing practice and offers a perspective that informs improved patient care.

• Gustafsson J
• Calanzaro M
• Sandelowski M

Competing interests None declared.

Provenance and peer review Commissioned; internally peer reviewed.

Read the full text or download the PDF:

• Login / Register

‘Nearly a week has passed already since International Nurses Day 2024’

STEVE FORD, EDITOR

• You are here: Research and innovation

Warning over ‘inaccurate and incomplete’ nurse record keeping

06 January, 2017 By Nicola Merrifield

Patient care information is often being recorded by nurses in an “inaccurate, inconsistent, repetitive and incomplete” way, leading to potential safety concerns, according to researchers.

A study at a large acute trust in England, which was led by researchers in Nottingham, found nurses sometimes completed documentation retrospectively without full knowledge that care had actually been completed.

“Nurses working with older patients find current documentation time-consuming… resulting in gaps, mishaps and overlaps of information” Study authors

One nurse in the study described a case in which a patient collapsed, but when their notes were consulted there was no information about why they had been admitted.

In other instances, documentation had been filled in before nurses had carried out procedures to ensure they did not forget ahead of any potential audits.

The researchers – Liz Charalambous, a staff nurse at Nottingham University Hospitals NHS Trust, and Sarah Goldberg, a professor in older persons’ care at Nottingham University – also heard nurses that could not always find the information they needed, despite it being recorded in several places.

Missing information, errors and duplications were partly being caused by nurses feeling exasperated by the sheer amount of paperwork they had to complete, and the fact they believed it was often repetitive and took them away from patient care, according to the study authors.

“The findings raised a number of professional and ethical issues in that nurses were reporting suboptimal and potentially unsafe care” Study authors

The study – titled ‘Gaps, mishaps and overlaps’. Nursing documentation: How does it affect care? and published in the Journal of Research in Nursing  – looked at nurse documentation for older patients on acute wards in England. It involved in-depth interviews at the start of 2015, with eight nurses employed by Nottingham University Hospitals NHS Trust.

Accurate record keeping was particularly important for older hospital patients due to the complexity of care they require and the problems with communication they often experience, noted the study, which also highlighted that they accounted for a high proportion of acute NHS beds.

“This research reveals that nurses working with older patients living with frailty find current documentation time-consuming to complete and sometimes unnecessary to the delivery of care, resulting in gaps, mishaps and overlaps of information,” said the study authors.

“The findings raised a number of professional and ethical issues in that nurses were reporting suboptimal and potentially unsafe care,” they added, noting that the researchers had raised the issues with the trust involved in the study.

’Inaccurate and incomplete’ nurse record keeping causing safety concerns

Sarah Goldberg

The researchers recommended that the current system of documentation for older patients in acute settings be “extensively revised”.

“In view of the increased numbers of people needing care and a forecast global shortage of nurses, new ways must be found to streamline and reduce the amount of nursing documentation to support the delivery of quality care,” they concluded.

As an example, the study authors said electronic methods for documenting care provided a “unique opportunity” to speed up and improve record keeping.

They also suggested the introduction of a manual with core care plans for common conditions in each speciality that nurses could then reference when recording care, before adding personalised notes.

In addition, a document at the patient’s bedside with details of what is important to them while in hospital would help to provide person-centred care, said the researchers.

“This system would allow nurses to have more control over the planning of care, as it can be amended as required, but would not generate large amounts of paperwork,” said the researchers.

“The introduction of electronic document keeping has further improved safety” Daljit Athwal

Meanwhile, the study highlighted the need for different systems within organisations to be compatible with each other.

Nottingham University Hospitals NHS Trust highlighted to Nursing Times  that the research had been carried out two years ago and that only a small number of nurses had taken part in the study.

Its deputy director of nursing, Daljit Athwal, said:“Each of our nurses are accountable for updating documentation to ensure the safety of our patients.”

She also noted that the Care Quality Commission “did not raise documentation or record keeping concerns” when they last inspected the trust’s hospitals, the findings of which were published in a report last year.

“The introduction of electronic document keeping for observations, handover and bed management has further improved safety and our responsiveness to patients’ needs,” she added.

• Add to Bookmarks

Related articles

Record keeping is important BUT I am nurse working on a busy medical ward I recently had a patient who had a bad fall,when managment were informed first question was did he have a falls pathway,not is the patient okay or what was the situation or stafling on the ward,come on get real how can a bit of paper stop a patient falling.there is far too much paper work we have no time to observe patients so they will fall .

I think the term ‘hospital’ is outdated the term ‘cattle market’ is a better description…agree entirely with the first poster ‘is the patient ok?’ Is asked way down the list of questions if a patient falls. I can no longer be a part of the unsafe, unrelenting, badly organised, badly managed not fit for purpose NHS that is commonplace in the ‘hospital’ I feel I am putting my pin on the line on a daily basis and the strain that is placed on my physical and mental wellbeing on a daily basis is too much. Nurses are not respected as the multi skilled professionals that they are or for the amazing work that they do. Too busy to have a break to eat properly to even go to the bathroom, expected to have an infinite capacity to care for our patients but who cares for us…certainly not the NHS shame on you…

Have your say

Sign in or Register a new account to join the discussion.