Nurses’ perception of nursing services documentation barriers: a qualitative approach
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PhD candidate in Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad. Iran
Assistant Professor, Medical-Surgical Nursing Department, Faculty of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
Department of Medical- Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
Assistant Professor, Medical-Surgical Nursing Department, Faculty of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran.
Assistant professor Department of Reproductive Health and Midwifery, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran
Online publish date: 2018-03-03
Publish date: 2018-03-03
Electron J Gen Med 2018;15(3):em28
Researches has shown that the quality of nursing documentation services in the world, including Iran, is far from existing standards. Understanding the barriers to improving the documentation of nursing services is essential for the first step. The aim of this study was to identify barriers to improving the nursing documentation services using the experience of nurses in the emergency department of one of the Iranian hospitals.

Materials and Methods:
This study is based on content analysis in accordance with the style of Graneheim in 2017 in the emergency department of one of the Iranian hospitals. This qualitative study was performed on 20 participant from different nursing grades including 17 nurses, 1 head nurse, and 2 members of the accreditation committee. The data were collected through semi-structured interviews and using interview guide and field note.

Research data have been explained in four main themes of qualification of documentation including sub-categories of the need for effective training, the need for training in the standards of documentation, and the necessity of skills in reporting; job burnout including sub-categories of job stress and work pressure; perceived control including sub-categories of planned control and effective monitoring and control; intra-organizational coordination including sub-categories of improving health information system and documentation management time, legal barrier for documentation including sub-categories of escaping from the law and legal liabilities.

In this study, 599 primary codes were extracted and the main themes documentation competency, job burnout, perceived control, intra-organizational coordination, and legal barrier extracted.

1. Wang N, Hailey D, Yu P. Quality of nursing documentation and approaches to its evaluation: a mixed‐method systematic review. J Adv Nurs. 2011;67(9):1858-75. https://doi.org/10.1111/j.1365... PMid:21466578.
2. Soto CM KK, Simon SR. Quality and correlates of medical record documentation in the ambulatory care setting 2002. BMC Health Serv Res 2002 Dec 10;2(1):22. https://doi.org/10.1186/1472-6... PMid:12473161 PMCid:PMC140026.
3. Stewart K, Doody O, Bailey M, Moran S. Improving the quality of nursing documentation in a palliative care setting: a quality improvement initiative. International journal of palliative nursing. 2017;23(12):577-85. https://doi.org/10.12968/ijpn.....
4. Lee TT. Nurses’ perceptions of their documentation experiences in a computerized nursing care planning system. Journal of Clinical Nursing. 2006;15(11):1376-82. https://doi.org/10.1111/j.1365... PMid:17038098.
5. Vabo G, Slettebo A, Fossum M. Nursing Documentation: An Evaluation of an Action Research Project. Stud Health Technol Inform. 2016;225:842-3. PMid:27332370.
6. Ofi BaS, O. Nursing Documentation: Experience of the Use of the Nursing Process Model in Selected Hospitals in Ibadan, Oyo State, Nigeria. Int J Nurs Pract. 2012;18:354-62. https://doi.org/10.1111/j.1440... PMid:22845635.
7. Wang N, Yu P, Hailey D. The quality of paper-based versus electronic nursing care plan in Australian aged care homes: A documentation audit study. International Journal of Medical Informatics. 2015;84(8):561-9. https://doi.org/10.1016/j.ijme... PMid:26004340.
8. Houghton C, Casey D, Shaw D, Murphy K. Rigour in qualitative case-study research. Nurse Res. 2013;20(4):12-7. https://doi.org/10.7748/nr2013... PMid:23520707.
9. Wang Q. The Discussion about Nursing Quality Management in Emergency Department. Journal of Nursing. 2015;4(1):19-22. https://doi.org/10.18686/jn.v4....
10. Blair W, Smith B. Nursing documentation: Frameworks and barriers. Contemp Nurse. 2012;41(2):160-8. https://doi.org/10.5172/conu.2... PMid:22800381.
11. Zhou F HY, Guo H, Liu H. Attitude, Knowledge, and Practice on Evidence-Based Nursing among Registered Nurses in Traditional Chinese Medicine Hospitals: A Multiple Center Cross-Sectional Survey in China. . J Evid Based Complementary Altern Med. 2016. https://doi.org/10.1155/2016/5... PMid:27528882 PMCid:PMC4978845.
12. Taheri N, Barzabad PA, Yazdanpanah A. Comparative study of nursing group personnel number to active bed of hospitals affiliated to yasuj medical sciences university with existing standards and factors effective on it in 2015. Int J Clin and Biomed Res 2016;2(4):17-23.
13. Maia B, Barros A, Barros Barbosa A, da Silva P, Nauside M, Gomes Castelo Branco LM, et al. technical and scientific compilation about audit and quality management: an integrative review. Journal of Nursing UFPE/Revista de Enfermagem UFPE. 2017;3. https://doi.org/10.5205/1981-8....
14. Pittman P, Bass E, Hargraves J, Herrera C, Thompson P. The future of nursing: Monitoring the progress of recommended change in hospitals, nurse-led clinics, and home health and hospice agencies. J Nurs Adm. 2015;45(2):93-9. https://doi.org/10.1097/NNA.00... PMid:25581003.
15. Asiri SA RW, Al-Surimi K, Da’ar OO, Ahmed A. The association of leadership styles and empowerment with nurses’ organizational commitment in an acute health care setting: a cross-sectional study. BMC nursing. 2016;15(38). https://doi.org/10.1186/s12912....
16. Weeger A, Haase M, editors. How Social Capital between Medical and IT Professionals Shapes the Outcomes of Health Information System Implementation Endeavours. ECIS;2016. PMid:26940035.
17. Kim K-K, Kim I-S, Lee W-H. Perception of legal liability by registered nurses in Korea. Nurse Educ Today. 2007;27(6):617-26. https://doi.org/10.1016/j.nedt....