The study of healthcare worker documentation complexities
Main Article Content
Keywords
nursing documentation, mixed methods research, nursing practice.
Abstract
This study aimed to explore complexities in nursing documentation and related factors. Nursing documentation has been one of the most important functions of nurses since the time of Florence Nightingale because it serves multiple and diverse purposes. Current health-care systems require that documentation ensures continuity of care, furnishes legal evidence of the process of care and supports evaluation of quality of patient care. However, nursing documentation has not served such objectives because of its complexities.This study explores nursing documentation complexities and related factors through both qualitative and quantitative methodologies. The study used multiple methods of inquiry: in-depth interviewing; participant observation; nominal group processing; focus group meetings; time and motion study of nursing activities; and auditing of completeness of nursing documentation. Complexities in nursing documentation include three aspects: dis- ruption, incompleteness and inappropriate charting. Related factors that influenced documentation comprised: limited nurses’ competence, motivation and confidence; ineffective nursing procedures; and inadequate nursing audit, supervision and staff development.These findings suggest that complexities in nursing documentation require extensive resolution and implicitly dictate strategies for nurse managers and nurses to take part in solving these complicated obstacles.
References
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11 de la Cuesta C. The nursing process: From development to implementation. Journal of Advanced Nursing 1983; 8: 365– 371.
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14 Lutjen LRJ. The nature and use of nursing diagnosis in hospitals. Nursing Diagnosis 1993; 4: 107–113.
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18 Martin A, Hinds C, Felix M. Documentation practices of nurses in long-term care. Journal of Clinical Nursing 1998; 8: 345–352.
19 Miller P, Pastorino C. Daily nursing documentation can be quick and thorough. Nursing Management 1990; 21: 47–52.
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29 Mason GMC, Attree M. The relationship between research and the nursing process in clinical practice. Journal of Advanced Nursing 1997; 26: 1045–1049.
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31 Anderson JE, Briggs LL. Nursing diagnosis: A study a qual- ity and supportive evidence. Image: The Journal of Nursing Scholarship 1988; 20: 141–144.
32 Barnum BJS. Nursing Theory—Analysis, Application, Evalua- tion, 4th edn. Philadelphia, PA, USA: J.B. Lippincott, 1994.
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34 Choonhapran P, Raksataya S, Puangtip C. Analysis of the State of Using Nursing Diagnosis in Governmental Hospitals. Bangkok: Chulalongkorn University, 1991.
35 Oeasomboon K. A study of supporting factors in using nursing process of nurses in the hospitals under the juris- diction of the Bangkok metropolitan (MEd thesis (Nursing administration)). Bangkok: Chulalongkorn University, 1994.
36 Mason C. Guide to practice or ‘load of rubbish’? The influ- ence of care plans on nursing practice in five clinical areas in Northern Ireland. Journal of Advanced Nursing 1999; 29: 380–387.
37 Heartfield M. Nursing documentation and nursing prac- tice: A discourse analysis. Journal of Advanced Nursing 1996; 24: 98–103.
38 Manthey M. Who owns a staff nurse’s time? Nursing Management 1988; 19: 22–24.
39 Boston C, Vestal K. Work transformation: Why the new health-care imperative must focus both on people and process. Hospitals and Health Networks 1994; 68: 50–55.
40 Manuel P, Alster K. Unlicensed personnel no cure for an ailing health-care system. Nursing and Health Care 1994; 15: 18–21.
41 Mills ME, Tibury MS. Restructuring: Safety, quality and cost Nursing Administrations perspective. Nursing Policy Forum 1995; 1: 17–19.
42 Cardona P, Tappen RM, Terrill M, Acosta M, Eusebe MI. Nursing staff time allocation in long-term care. A work sampling study. Journal of Nursing Administration 1997; 27: 28–36.
43 Urden LD, Roode JL. Work sampling. A decision-making tool for determining resources and work redesign. Journal of Nursing Administration 1997; 27: 34–41.
44 Lofland J. Analyzing Social Settings: A Guide to Qualitative Observation and Analysis. Belmont, CA, USA: Wadsworth, 1971.
45 Chuto N. Qualitative Research. Bangkok: P.N. Publishers, 1997.
46 Watanakit P. The Study of Time Motion and Nursing Activities on Patient’s Needs in Ministry of Public Health Hospitals,Thailand. Department of Health, Nonthaburi, Thailand, 1994.
47 Tappen RM, Weiss SA, Whitehead DK. Essentials of Nursing Leadership and Management: Concept and Practice, 3rd edn. Philadelphia, PA, USA: F.A. Davis, 1998.
48 Ketsigha V. Principle of Construction and Analysis of Research Instruments. Bangkok: Thai Wathanapanich, 1987.
49 Minichiello V, Sullivan G, Greenwood K, Axford R. Hand- book of Research Methods in Health Sciences. Sydney: Addison- Wesley Longman Australia Pty Limited, 1999.
50 Delbecq AL, Van de Ven AH, Gustafson DH. Group Tech- niques for Program Planning a Guide to Nominal Group and Delphi Processes. Dallas, TX, USA: Scott, Foresaman & Co, 1975.
51 Winter R, Munn-Giddings C. A Handbook for Action Research in Health Social Care. London: Routledge, 2001.
52 Kemmis S, McTaggart R. The Action Research Planner, 3rd edn. Waurn Ponds, Victoria, Australia: Deakin University, 1990.
53 Swansburg RC, Swansburg RJ. Management and Leadership for Nurse Managers, 3rd edn. Misisauga, Canada: Jones & Bartlett Publishers Canada, 2002.
54 Ehnfors M, Smedby B. Nursing care as documented in patient records. Scandinavian Journal of Caring Sciences 1993; 7: 209–220.
55 Ratchukul S. Analysis of nurses’ note in general hospitals, Bangkok metropolitan (Medical thesis (Nursing administra- tion)). Bangkok: Chulalongkorn University, 1986.
56 Eggland ET, Heinemann DS. Nursing Documentation: Chart- ing, Recording, and Reporting. Philadelphia, PA, USA: J.B. Lippincott, 1994.
57 Irwin B, Patterson A, Boag P, Power M. Management of urinary incontinence in a UK trust. Nursing Standard 2001; 16: 33–37.
58 Törnkvist L, Gardulf A, Strender L. The opinions of nurs- ing documentation held by district nurses and by nurses at primary health-care centres. Vard i Norden 1997; 17: 18– 25.
59 Ehrenberg A. Nurses’ perceptions concerning patient records in Swedish nursing homes. Vard i Norden 2001; 21: 9–14.
60 Pedersen A. A data-driven approach to work redesign in nursing units. Journal of Nursing Administration 1997; 27: 49–54.
2 Iyer PW, Camp NM. Nursing Documentation: A Nursing Pro- cess Approach, 2nd edn. St. Louis, MO, USA: Mosby-Year Book, 1995.
3 Boonyanuruck P, Tuntipalacheeva K. Nursing Documenta- tion. Bangkok: The Division of Nursing Education of Edu- cation Department, Chulalongkorn University, 1981.
4 Fischbach FT. Documenting Care Communication, the Nursing Process and Documentation Standards. Philadelphia, PA, USA:
F.A. Davis, 1991.
5 Lush M, Lush C. Documentation. In: Lindeman CA, McAthie M (eds). Fundamentals of Contemporary Nursing Prac- tice. Philadelphia, PA, USA: W.B. Saunders, 1999; 241–271.
6 Seinaruck W. Nursing Diagnosis, 2nd edn. Khonkeon, Thailand: Khonkeon Karnpim, 1999.
7 Parsley K, Corrigan P. Quality Improvement in Nursing and Health. London: Chapman & Hall, 1994.
8 Ehnfors M. Nursing documentation practice on 153 hospi- tal wards in Sweden as described by nurses. Scandinavian Journal of Caring Sciences 1993; 7: 201–207.
9 Gosondilock S. Effects of the use of primary nursing assign- ment system in intensive care unit toward the use of nursing process and satisfaction of nurses and patients (MN thesis (Nursing administration)). Bangkok: Chulalongkorn Uni- versity, 1993.
10 Webb C, Pontin D. Evaluating the introduction of primary nursing:The use of a care plan audit. Journal of Clinical Nurs- ing 1997; 6: 395–401.
11 de la Cuesta C. The nursing process: From development to implementation. Journal of Advanced Nursing 1983; 8: 365– 371.
12 Griffiths P. An investigation into the description of patients’ problems by nurses using two different needs-based nursing models. Journal of Advanced Nursing 1998; 28: 969–977.
13 Potikosoom K. Practice development in nursing notes.
Journal of Songkha Nakarinth Nursing 1999; 19: 1–19.
14 Lutjen LRJ. The nature and use of nursing diagnosis in hospitals. Nursing Diagnosis 1993; 4: 107–113.
15 Aidoor N. Use and effectiveness of psychiatric nursing care plan. Journal of Advanced Nursing 1991; 16: 177–181.
16 Cheevakasemsook A. A comparison of recording effective- ness by using integrated nursing process and problem- oriented nursing record models (MEd thesis (Nursing administration)). Bangkok: Chulalongkorn University, 1991.
17 Mungmool P. A comparison of recording effectiveness by using need-focus and problem-oriented nursingrecord models, psychiatric hospital (MN thesis (Nursing adminis- tration)). Bangkok: Chulalongkorn University, 1995.
18 Martin A, Hinds C, Felix M. Documentation practices of nurses in long-term care. Journal of Clinical Nursing 1998; 8: 345–352.
19 Miller P, Pastorino C. Daily nursing documentation can be quick and thorough. Nursing Management 1990; 21: 47–52.
20 Howse E, Bailey J. Resistance to documentation—A nurs- ing research issue. International Journal of Nursing Studies 1992; 29: 371–380.
21 The Iowa Intervention Project Research Team. Proposal to bring nursing into the information age: Iowa intervention project. Image: The Journal of Nursing Scholarship 1997; 29: 275–281.
22 Hincheeranun S, Yucktirat C, Sayawan D, Puwanun P, Atsadaporn P, Pimpong S. Report of Evaluating Ward Recon- struction for Nursing Quality of Care Improvement. Bangkok: Siriraj Hospital, 1989.
23 Wills LJ. The perceptions of labor and delivery nurses con- cerning medical record documentation (Digital dissertation MAI 37/03). From ProQuest, Abstract (database), 1999, June, p. 916.
24 Oeasomboon K. A study of supporting factors in using nursing process of nurses in the hospitals under the juris- diction of the Bangkok metropolitan (MEd thesis (Nursing administration)). Bangkok: Chulalongkorn University, 1994.
25 Christensen P, Kenney JW. Nursing Process Application of Conceptual Models, 4th edn. St. Louis, MO, USA: Mosby- Year Book, 1995.
26 Taylor C, Lillis C, LeMone P. Fundamentals of Nursing: The Art and Science of Nursing Care, 3rd edn. Philadelphia, PA, USA: J.B. Lippincott, 1997.
27 White L. Basic Nursing: Foundations of Skills & Concepts. Albany, NY, USA: Delmar, a Division of Thomson Learn- ing, 2002.
28 Allen D. Record-keeping and routine nursing practice:The view from the wards. Journal of Advanced Nursing 1998; 27: 1223–1230.
29 Mason GMC, Attree M. The relationship between research and the nursing process in clinical practice. Journal of Advanced Nursing 1997; 26: 1045–1049.
30 Turkoski BB. Nursing diagnosis in press. Nursing Outlook
1988; 36: 142–144.
31 Anderson JE, Briggs LL. Nursing diagnosis: A study a qual- ity and supportive evidence. Image: The Journal of Nursing Scholarship 1988; 20: 141–144.
32 Barnum BJS. Nursing Theory—Analysis, Application, Evalua- tion, 4th edn. Philadelphia, PA, USA: J.B. Lippincott, 1994.
33 Varcoe C. Disparagement of the nursing process: The new dogma? Journal of Advanced Nursing 1996; 23: 120–125.
34 Choonhapran P, Raksataya S, Puangtip C. Analysis of the State of Using Nursing Diagnosis in Governmental Hospitals. Bangkok: Chulalongkorn University, 1991.
35 Oeasomboon K. A study of supporting factors in using nursing process of nurses in the hospitals under the juris- diction of the Bangkok metropolitan (MEd thesis (Nursing administration)). Bangkok: Chulalongkorn University, 1994.
36 Mason C. Guide to practice or ‘load of rubbish’? The influ- ence of care plans on nursing practice in five clinical areas in Northern Ireland. Journal of Advanced Nursing 1999; 29: 380–387.
37 Heartfield M. Nursing documentation and nursing prac- tice: A discourse analysis. Journal of Advanced Nursing 1996; 24: 98–103.
38 Manthey M. Who owns a staff nurse’s time? Nursing Management 1988; 19: 22–24.
39 Boston C, Vestal K. Work transformation: Why the new health-care imperative must focus both on people and process. Hospitals and Health Networks 1994; 68: 50–55.
40 Manuel P, Alster K. Unlicensed personnel no cure for an ailing health-care system. Nursing and Health Care 1994; 15: 18–21.
41 Mills ME, Tibury MS. Restructuring: Safety, quality and cost Nursing Administrations perspective. Nursing Policy Forum 1995; 1: 17–19.
42 Cardona P, Tappen RM, Terrill M, Acosta M, Eusebe MI. Nursing staff time allocation in long-term care. A work sampling study. Journal of Nursing Administration 1997; 27: 28–36.
43 Urden LD, Roode JL. Work sampling. A decision-making tool for determining resources and work redesign. Journal of Nursing Administration 1997; 27: 34–41.
44 Lofland J. Analyzing Social Settings: A Guide to Qualitative Observation and Analysis. Belmont, CA, USA: Wadsworth, 1971.
45 Chuto N. Qualitative Research. Bangkok: P.N. Publishers, 1997.
46 Watanakit P. The Study of Time Motion and Nursing Activities on Patient’s Needs in Ministry of Public Health Hospitals,Thailand. Department of Health, Nonthaburi, Thailand, 1994.
47 Tappen RM, Weiss SA, Whitehead DK. Essentials of Nursing Leadership and Management: Concept and Practice, 3rd edn. Philadelphia, PA, USA: F.A. Davis, 1998.
48 Ketsigha V. Principle of Construction and Analysis of Research Instruments. Bangkok: Thai Wathanapanich, 1987.
49 Minichiello V, Sullivan G, Greenwood K, Axford R. Hand- book of Research Methods in Health Sciences. Sydney: Addison- Wesley Longman Australia Pty Limited, 1999.
50 Delbecq AL, Van de Ven AH, Gustafson DH. Group Tech- niques for Program Planning a Guide to Nominal Group and Delphi Processes. Dallas, TX, USA: Scott, Foresaman & Co, 1975.
51 Winter R, Munn-Giddings C. A Handbook for Action Research in Health Social Care. London: Routledge, 2001.
52 Kemmis S, McTaggart R. The Action Research Planner, 3rd edn. Waurn Ponds, Victoria, Australia: Deakin University, 1990.
53 Swansburg RC, Swansburg RJ. Management and Leadership for Nurse Managers, 3rd edn. Misisauga, Canada: Jones & Bartlett Publishers Canada, 2002.
54 Ehnfors M, Smedby B. Nursing care as documented in patient records. Scandinavian Journal of Caring Sciences 1993; 7: 209–220.
55 Ratchukul S. Analysis of nurses’ note in general hospitals, Bangkok metropolitan (Medical thesis (Nursing administra- tion)). Bangkok: Chulalongkorn University, 1986.
56 Eggland ET, Heinemann DS. Nursing Documentation: Chart- ing, Recording, and Reporting. Philadelphia, PA, USA: J.B. Lippincott, 1994.
57 Irwin B, Patterson A, Boag P, Power M. Management of urinary incontinence in a UK trust. Nursing Standard 2001; 16: 33–37.
58 Törnkvist L, Gardulf A, Strender L. The opinions of nurs- ing documentation held by district nurses and by nurses at primary health-care centres. Vard i Norden 1997; 17: 18– 25.
59 Ehrenberg A. Nurses’ perceptions concerning patient records in Swedish nursing homes. Vard i Norden 2001; 21: 9–14.
60 Pedersen A. A data-driven approach to work redesign in nursing units. Journal of Nursing Administration 1997; 27: 49–54.
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Aug 17, 2022
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Rahma Muhammad Ahmed Daba, Hameed AHMD AL KHARMANI, MOHAMMED HADI M AL YAMI, Ysanne Chapman, S. M. A. Mohammad M. M. A. T. H. M. A. A. F. A. A. M. A. A. M. , S. moufarh saleh harisi,. (2022). The study of healthcare worker documentation complexities. Journal of Population Therapeutics and Clinical Pharmacology, 29(04), 366-376. https://doi.org/10.53555/jptcp.v29i04.5359
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How to Cite
Rahma Muhammad Ahmed Daba, Hameed AHMD AL KHARMANI, MOHAMMED HADI M AL YAMI, Ysanne Chapman, S. M. A. Mohammad M. M. A. T. H. M. A. A. F. A. A. M. A. A. M. , S. moufarh saleh harisi,. (2022). The study of healthcare worker documentation complexities. Journal of Population Therapeutics and Clinical Pharmacology, 29(04), 366-376. https://doi.org/10.53555/jptcp.v29i04.5359