Nursing documentation: Mind the gap?

Liz Charalambous is a qualified nurse on a female, acute medical HCOP (Health Care for Older People) ward at Queen’s Medical Centre, Nottingham University Hospital Trust. She is currently a PhD student at The University of Nottingham. She tweets at @lizcharalambou and is a regular guest blogger for the BGS. Her blogs are her own opinion and do not represent the opinion of her employer or any other organisation. Co-author and supervisor, Dr. Sarah Goldberg, is an associate professor at The University of Nottingham. She tweets as @se_goldberg

Introduction

New research out this week highlights the importance of nursing documentation for older patients in an acute hospital setting. The research ‘Gaps, Mishaps and Overlaps: Nursing Documentation, how Does it Affect Care?’ published in The Journal of Research in Nursing found that paperwork is time consuming to complete, takes nurses away from caring for patients, and can be counterproductive to delivering good quality nursing care to older people in hospital.

The study was undertaken as a response to my clinical work as a Staff Nurse on a HCOP acute medical ward, and following years of frustration at the sheer volume of paperwork which demands attention. It explores the views and experiences of registered nurses towards documentation at an acute hospital trust in England. They expressed a common belief that there is too much unnecessary paperwork, it takes up too much of their time, and can be inaccurate and repetitive. Nurses also felt they were continually being audited which affected how they completed and prioritised the paperwork.

The findings of the study, which aimed to understand how documentation affects the quality of patient care in acute, older person wards, interviewed nurses to discover their views and experiences. Nurses expressed exasperation over the time it took to complete the paperwork which they felt was repetitive and of no benefit to patients. All of those interviewed felt that the amount of time spent completing documentation was excessive and took them away from the patients, with evidence that, in some cases, the documentation itself was counterproductive to delivering safe and effective care.

Importance of Paperwork

It is a legal and professional requirement that nurses maintain accurate records. The nurses, doctors, therapists, and many other healthcare professionals who make up the multi-disciplinary team, are working in an increasingly busy and fast paced environment and subsequently rely on written records for information about patients. This means that skilful, streamlined, and accurate communication is crucial to deliver excellent and safe care.

Methodology

Following ethical approval, the qualitative research accessed eight participants and used thematic analysis. It appears that nurses are working harder and faster than ever before under extremely challenging conditions. The research highlights how we need to find new ways to manage documentation, particularly in the care of older people with acute illness in hospital, who may have dementia and other underlying conditions, multiple comorbidities, and complex personal and social needs.

Problems

Nurses said they were spending time writing in patient records when they could have been caring for them at the bedside. It was also found that they were rushing essential care, missing breaks and staying behind after their shift had finished, to complete paperwork. Nurses expressed anger and feeling stressed at having to stay behind when they had already worked a twelve and a half hour shift.

Some paperwork was found to be inaccurate and that a higher priority was placed upon completing documentation over ‘hands on’ care. It was also found that different systems of electronic recording were incompatible with each other and this led to problems. For example, nurses described how they were unable to contact relatives when patients had moved to clinical areas with a different record system. Other problems included staff being unable to locate information, such as urine results, despite it being recorded in numerous places in the records. On the other hand some vital information, such as the medical condition of patients, was found not to be recorded at all.

Nurses reported feeling under pressure to prioritise paperwork that was being audited and so felt a sense of surveillance and being monitored through the documentation. However, they expressed a need to write in the patients’ records to achieve a sense of protection and they felt this was a way of defending themselves in case of future problems.

The Future

The recommendations of the study are that nurses should be involved in the design and development of future nursing documentation. New technology, such as digital and electronic formats, are gradually being introduced and may offer a way of providing a solution, but it is crucial that this must be managed intelligently to ensure it is effectively integrated into paper based documentation. New ways must be found to streamline and reduce the amount of existing documentation to ensure it supports the individual needs of patients, and efficiently supports the delivery of quality care.

The paper entitled ‘’ Gaps, Mishaps, and Overlaps’ Nursing Documentation: How does it affect Care?’ identifies practical problems with the paperwork nurses must use on hospital wards and offers solutions. Published in The Journal of Research in Nursing, it is available online, and is open access.