Google Scholar. This awareness might reduce nurses perceived workload associated with documentation activities. Dementia (London). Hereby we used a weaving approach in which we brought the findings from the quantitative survey and qualitative focus groups together on a thematic basis and arranged them according to the research questions [37]. The importance of good documentation in nursing McCarthy B, Fitzgerald S, O'Shea M, Condon C, Hartnett-Collins G, Clancy M, et al. The quality of mixed methods studies in health services research. Keep records of all evidence and decisions - The Nursing An empirical study of perception versus reality. Michel L, Waelli M, Allen D, Minvielle E. The content and meaning of administrative work: a qualitative study of nursing practices. How many men and women received a striking-off order? Regarding organizational documentation, 58% of the nurses reported a high perceived workload. https://doi.org/10.1016/j.healthpol.2018.05.014. the ability of the midwife practitioner to meet legal requirements. They did not always see the added value of filling in those sections, making this a burdensome activity. Still, lengthy clinical documentation might be challenging for nurses as well. Nursing A systematic literature review. On top of that, further integrating clinical documentation in individual patient care and improvements in the electronic health records are needed [45, 48]. WebIntroduction The Code contains the professional standards that registered nurses, midwives and nursing associates 1 must uphold. The focus groups that were organized after the survey gave additional and more in-depth insights, particularly regarding nurses views on the two types of documentation and the user-friendliness of electronic health records. NMC Record keeping: Guidance for nurses and midwives You are already busy sorting out all the shifts, all the patients who are starting and stopping home care etc. There is no question that poor or absent record keeping is still one of the most common issues in nursing and midwifery, affecting care for babies and mothers. It all costs extra time and you have to do a lot of clicking. (Focus group 3, online). 2019;75(7):137993. 2006;31(2):13744. Tates K, Zwaanswijk M, Otten R, Van Dulmen S, Hoogerbrugge PM, Kamps WA, et al. This manages all complaints of allegations relating to the standards and conduct of practitioners practice. Analyses were conducted using STATA, version 16.1. WebNurses, midwives and nursing associates must act in line with the Code, whether they are providing direct care to individuals, groups or communities or bringing their professional Closure of incidents and service requests resolved by other IT resolver groups, confirming closures details and acceptance with customers. Fraczkowski D, Matson J, Dunn LK. You need to bring your passport and required documentation for your ID check by the NMC. Factors facilitating dementia case management: results of online focus groups. They estimated that they spent significantly less time on organizational documentation, namely on average 3.6 (SD 4.0; median 2.0) hours a week (Wilcoxon signed-ranked test: p<0.000). SOAP Notes Some nurses did however mention that documenting the formal care needs assessment (which is a requirement for home care financed by health insurers in the Netherlands) consumed a lot of their time. In addition, confirmability of the findings was enhanced by including verbatim statements made by participants in the results section of this paper. The Midwives Rules and Standards make it clear that midwives are accountable for the quality and retention of their documentation (NMC 2012a). Then I know for certain that itll come back in spades some other way: someone elses documentation burden will be reduced, but not mine. (Focus group 1, face-to-face). Another finding in our study was that although clinical documentation was also associated with a high workload, time spent on organizational documentation was considered even more problematic. A convergent mixed-methods design was used, in which a quantitative survey with qualitative focus groups were combined to develop in-depth understanding of the relationship between documentation activities and perceived nursing workload [36, 37]. Aim. A quantitative survey was completed by 195 Dutch community nurses and a further 28 community nurses participated in qualitative focus groups. Role purpose - The Nursing and Midwifery Council J Am Med Inform Assoc. J Adv Nurs. Google Scholar. The NMC is the statutory body which regulates the practice of nurses, midwives and specialist community public health nurses. Potential participants of the focus groups were informed about the study in an information letter. Hoogendoorn ME, Brinkman S, Spijkstra JJ, Bosman RJ, Margadant CC, Haringman J, et al. OECD. 2017;16(1):113. This includes but is not limited to patient records. https://doi.org/10.1186/1471-2288-9-15. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. De Groot, K., De Veer, A.J.E., Munster, A.M. et al. It is signed and your name printed (according to the format for the trust or other employer). The development of a nursing subset of patient problems to support interoperability. Thematic analysis: striving to meet the trustworthiness criteria. Previous research by Fraczkowski, Matson [45];Michel, Waelli [20];Moy, Schwartz [46];Vishwanath, Singh [47];Wisner, Lyndon [30] indicated that electronic clinical documentation is associated with documentation burden by health care professionals. In general, the community nurses participating in the qualitative focus groups experienced a high workload due to documentation as well. The standards and guidance produced by our regulatory body, the Nursing and Midwifery Council (NMC), concerning the role and responsibilities of the midwife in the context of effective documentation and professional practice (NMC 2008, 2009a, 2012a) will be explored, analysed and applied to practice. It is anticipated that having read this chapter, the reader will be able to describe the various forms of record keeping used in contemporary practice and discuss the rationale for maintaining comprehensive, contemporaneous records in relation to professional accountability. (survey). The research questions guiding the present study were: (a) Do community nurses perceive a high workload due to clinical and/or organizational documentation? As record, ing is a key aspect of midwifery practice, this will impact on many areas identified in the annual report, Midwives are working in increasingly demanding clinical environments. A total of 195 community nurses completed the questionnaire (response rate 38.4%). They found clinical documentation necessary and useful for providing good nursing care. https://doi.org/10.1093/jamia/ocz231. about wound care, cost them too much time. All records relating to the care of the woman or baby must be kept securely for 25 years (p18). Documentation The latter group said that the limited user-friendliness was one reason why they spent so much time on documentation and experienced a high workload. A second limitation is that we used a self-developed survey questionnaire. WebWhilst it can repeatedly related to the legitimate importance of precise record keeping, it is essential to remember which documentation be also a good way starting communicate How to undertake effective record-keeping and documentation PubMed However, the intention is that it should be used for guidance together with the Midwives Rules and Standards to strive for excellence in record keeping. It should be dated and the time included using a 24-hour clock. In the focus groups participants had more opportunity to reflect on and to discuss the value of clinical documentation versus organizational documentation, and this may have resulted in more positive views on clinical documentation. Nursing documentation and its relationship with perceived nursing Nursing Theres already a high workload. One of the largest departments at the NMC is the Fitness to Practise Directorate. To increase the response rate, two electronic reminders were sent to nurses who had not yet responded. Measurement of clinical documentation burden among physicians and nurses using electronic health records: a scoping review. J Adv Nurs. One of these standards determines the Details of how the practice of midwives is supervised (NMC 2012b, p28). Nurs Inform. There is evidence that the client collaborated with the practitioner in the construction of the records; for example, statements from the client are included in language that supports the clients involvement. The extent to which nurses perceived a high workload was related to time spent on organizational documentation in particular. Nurses were eligible to participate in a focus group if they met the same inclusion criteria as used for the survey participants. Evaluating the impact of electronic health records on nurse clinical process at two community health sites. Braun V, Clarke V. Using thematic analysis in psychology. Moreover, peer debriefing was applied with a group of peer researchers who were not involved in the study. A total of 28 community nurses participated in the four focus groups. https://doi.org/10.1111/jan.13919. First, the quantitative survey was performed and findings from this quantitative component were subsequently enriched by the findings of the qualitative focus groups [37, 38]. This enabled specific recommendations to be made that can help reduce the workload of nurses. Nursing documentation is used to establish effective communication between non-medical and medical staff, between nurses and, between families, as well as to Electronic health record usability and workload changes over time for provider and nursing staff following transition to new EHR. Nursing documentation: frameworks and barriers. Qual Res Psychol. Recently, handover has become a process central to the delivery of high-quality and safe patient care. The level for determining statistical significance was 0.05. Examples include increasing birth rates, increasing numbers of women with diverse cultures and complex physical needs, such as obesity, women with high-risk pregnancies wishing to birth at home and in some areas, midwives working with lim, ited resources and staff shortages. There is a lot of information with good documentation in nursing. The time that nurses spent on documentation can be substantial and burdensome. In addition, most studies on the documentation burden focus solely on the hospital setting, e.g. Clinical nursing documentation is essential in letting nurses continuously reflect on their choice of interventions for patients and the effects of their interventions. It is a unique instrument, in that midwifery is the only profession to enjoy the ben, efits of Supervision of Midwives (SoM). Jargon, abbreviations, irrelevant speculation and offensive subjective statements should not be included. This could include patient notes, care plans, and medication administration records. No specific funding was received for the focus groups. Article After the survey, we conducted four qualitative focus groups from February to May 2020. Handover in Nursing: A Concept Analysis Under the current Midwives Rules (rule, 13) (NMC 2012a), each of the 15 LSA regions must submit an annual report to the NMC, which analyses the contents to ensure the standards for SoM are being met. Since this is a nationwide panel, respondents worked in a variety of organizations across the Netherlands. Therefore, it is vital to the quality and continuity of nursing care [1, 2]. How to improve change of shift handovers and collaborative grounding and what role does the electronic patient record system play? Good record keeping helps to protect the welfare of patients and clients (NMC 2005, p6). Webhave important information, including mock OSCEs, which will help you. The audio recording of the face-to-face focus group was transcribed verbatim. Despite the evident importance of nursing documentation, time spent on documentation can be substantial and therefore it can be experienced as onerous for nurses. Lastly, there was no association between the perceived workload and whether the nursing process was central in the electronic health records. 2018;122(8):82736. However, we based the questionnaire on relevant literature, including the Nursing Process-Clinical Decision Support Systems Standard [12, 31]. The focus groups were led by two authors (KdG and AM) and supported by an interview guide with open questions, see Table1. BMC Nurs 21, 34 (2022). For this study, the survey was sent by email to all 508 community nurses who were members of the Nursing Staff Panel. These focus groups were performed in order to deepen and refine the insights gained from the survey data. 2021;30(1112):164552. The entire questionnaire was pre-tested for comprehensibility, clarity and content validity by nine nursing staff members. O'Cathain A, Murphy E, Nicholl J. In other words, nurses were just as likely to experience a high workload due to clinical documentation as due to organizational documentation. In Available from: http://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf. Wilcoxon signed-ranked tests were conducted to answer the first research question (1a), since the two variables measuring the perceived workload were ordinal and the two variables measuring the estimated time spent on documentation were not normally distributed. PubMed Any alterations or additions are dated, timed and signed in such a way that the original entry can still be clearly read. Royal College of Nursing https://doi.org/10.1177/2057158518773906. Health Serv Res. The transcripts of all the focus groups were analysed by two authors (KdG and AM). However, our study showed no association between the extent of nurses perceived workload and whether the electronic health records was following the nursing process. Spending a great deal of time on organizational documentation gave feelings of frustration and a high perceived workload. At the time of writing there were four systematic reviews related to nursing documentation. Essential task or meaningless burden? Reflect on this exercise and identify areas for further development. Hagenaars LL, Van Hilten O, Klazinga NS, Jeurissen PPT. The quantitative data provided a broad and representative picture of the possible presence of a relationship between perceived workload and documentation activities. Like the survey respondents, virtually all community nurses in the focus groups were positive about how the nursing process was integrated in the electronic health records they worked with. All authors read and approved the final manuscript. Whilst it is often related to of legal signs from accurate record keeping, it is essential to remember so Furthermore, the quality of the reporting was ensured by following the guidelines in Good Reporting of A Mixed Methods Study [44]. Sum MT, Chebor MA. BMC Med Res Methodol. Publication date: January 2020 Review date: January 2022 By using this website, you agree to our Next, four qualitative focus groups were conducted in an iterative process of data collection - data analysis - more data collection, until data saturation was reached. To put this in context, this accounts for only 0.3% of all practitioners, and midwives make up only a small proportion of this percentage because there are significantly fewer midwives on the register compared to the numbers of nurses. Next, two questions focussed specifically on clinical documentation, namely whether the electronic health record of individual patients was user-friendly and whether the nursing process was central in this record. Buckingham: Open University Press McGraw-Hill; 2014. https://doi.org/10.1787/9789264224568-en. J Nurs Manag. All authors contributed to the drafting and revision of the article. The Importance of Good Documentation in Nursing | Newcross Elaborating on the limited user-friendliness, nurses in the focus groups explained that some mandatory sections or headings in the electronic health records, e.g. The OECD uses the term organizational documentation to refer to the documentation of issues regarding personnel planning and coordinating different shifts, for instance. And if the patient also needs help with ADL, you have to go back via the care plan again. Webimportant functions. Richtlijn Verpleegkundige en Verzorgende Verslaglegging [Guideline nursing documentation]. In relation to standards of record keeping, compare and contrast the percentage of cases of poor record keeping in the reports. Other research also indicated that duplication in documentation is a problem for nurses and is accompanied with negative views on documentation [11]. WebSupport ICT Services Knowledge Management by ensuring that appropriate levels of technical knowledge, processes and documentation are present within the team. A self and peer audit tool for monitoring the standard of records will be introduced to enable the reader to apply the knowledge and skills in practice, to evaluate and enhance the development of their own record keeping competencies. The focus-group transcripts were analysed using an iterative process of data collection - data analysis - more data collection. This expectation was met, as the last focus group produced no new insights that were relevant for answering the research questions. Consequently, there is international consensus that clinical nursing documentation has to reflect the phases of the nursing process, namely assessment, diagnosis, care planning, implementation of interventions and evaluation of care or if relevant handover of care [2, 3, 6,7,8]. Therefore, a reduction in the time needed specifically for organizational documentation is important. WebNursing documentation is used to establish effective communication between non-medical and medical staff, between nurses and, between families, as well as to establish effective The Code - The Nursing and Midwifery Council 2016;24(4):44957. To date it was unknown if documentation activities are related to the workload that nurses perceive. Is nursing and midwifery clinical documentation a burden? Int J Med Inform. Documentation in nursing is crucial for patients continuity of care, determining clinical reimbursement, avoiding malpractice, and facilitating communication Nursing workload: a concept analysis. WebNMC Code Standards Relevant to Record Keeping To download a copy of the code click here There are standards throughout the Code that are indirectly related to record keeping 253) to monitor the performance of the local supervising, ities (LSA) to ensure they are meeting the required standards for statutory Supervision of Midwives. The NMC states in the Guidelines for Records and Record Keeping that it is not a rule book that will provide the answers to every question or issue that could ever arise (NMC 2005, p5). Research indicates documentation time has reached an extreme form [9,10,11]. Quality criteria, instruments and requirements for nursing documentation: a systematic review of systematic reviews. Elaborating further on clinical documentation specifically, we explored the perceived workload in relation to two features of the electronic health records, namely user-friendliness and whether the record matches with the nursing process. Within this process, the six steps of thematic analysis were followed, namely becoming familiar with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and reporting [42]. Despite the increasing levels in education for pre-registration programmes and the move towards an all-graduate profession for nurses and direct-entry midwifery (NMC 2009b, 2010), the standards of record keeping remain variable from year to year. [] The systems for communicating with other disciplines and medication systems arent linked to one another. Distinguishing between types of documentation may provide more insight into the possible relationship between documentation and perceived nursing workload. A limitation of this mixed-methods study is that the survey participants and focus-group participants differed in age: the focus-group participants were on average younger than the survey participants. Still, nurses did not find this kind of documentation burdensome due to the perceived relevance and usefulness of the documentation of the care needs assessment. Although survey data showed that nurses estimated that they spent twice as much time on clinical documentation as on organizational documentation, the workload they perceived from these two types of documentation was comparable. We used an online survey questionnaire that mostly consisted of self-developed questions as, to our knowledge, no instrument was available that included questions on both clinical documentation and organizational documentation. That is another extra documentation burden, and that takes up extra time too. (Focus group 1, face-to-face). But the perceived workload of nurses and the related factors is a rather unexplored area. Tackling wasteful spending on health. The Nursing and Midwifery Council's (NMC) (2018) Code requires nurses to put the interests of people using or needing nursing services first. Whilst it is often related to of legal signs from accurate record keeping, it is essential to remember so documentation is also a good fashion of communicating with your colleagues. Increasingly, medical records are pivotal to medicolegal cases and litigation. 2013;82(7):58092. No statistically significant differences in perceived workload were found between the two types of documentation (Wilcoxon signed-ranked test: p=0.124). On the one hand, there is clinical documentation, which directly concerns the nursing care for individual patients. For instance, it was unknown to date if perceived workload is associated with specific types of documentation activities and the actual time spent on these activities. Nursing workload, nurse staffing methodologies and tools: a systematic scoping review and discussion. Community nurses often perceive a high workload due to clinical and organizational documentation activities. I think the frustration comes much more from the organizational side. WebDocumentation of nursing care is an important source of reference and communication between nurses and other health care providers (Martin et al, 1999). For instance, the survey result on how many nurses perceived a high workload from clinical documentation activities was compared to the focus groups results on nurses views as to why they did or did not perceive a high workload from these activities. Pediatr Crit Care Med. By integrating data from the quantitative and qualitative components, an in-depth and credible picture was obtained of the relationship between specific documentation activities and perceived nursing workload [36, 37]. Focus-group participants found organizational documentation particularly redundant. The audio recording of the face-to-face focus group was transcribed verbatim. Examining the phenomenon of the administrative burden in health care, allied health and respiratory care. Looking at clinical documentation, no statistically significant correlation was found between nurses estimated time spent on this type of documentation and their perceived high workload (Spearmans rank correlation 0.135; p=0.058). Although nurses spent twice as much time on clinical documentation as on organizational documentation, the workload they perceived from these types of documentation was comparable. Dunn Lopez K, Chin CL, Leito Azevedo RF, Kaushik V, Roy B, Schuh W, et al. The nurses who were sent the online survey were participants drawn from a Dutch nationwide research panel known as the Nursing Staff Panel (https://www.nivel.nl/en/panel-verpleging-verzorging/nursing-staff-panel). For optimal integration of clinical documentation in patient care, it is important that the electronic health records reflect the phases of the nursing process [6, 31].
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