Documentation and Nurses' Time Caring for Patients.

Abstract

The nursing shortage is growing to dangerous levels and is impacting public safety. The health system is anticipated to need 1.1 million additional nurses by 2022. One-third of the nursing workforce will retire in the next 10 to 15 years. Research has shown that having more nurses to care for patients decreases patient complications and even death.1 Required nursing documentation has risen exponentially, with charting taking more nursing time than direct patient care. Unnecessary documentation is dangerous. Incentivizing hospitals to reduce charting waste will save lives and help nurses stay at the bedside.After being away from direct patient care for 10 years, I returned to the intensive care unit as a bedside nurse during the COVID-19 pandemic. I was overwhelmed by the sheer volume of required documentation fields. The research supports my observation. In 2017, a time-motion study found that 33% of the nurses’ shift was spent interacting with technology.2 In comparison, time spent with the patients accounted for only 22% of a 12-hour shift. No one goes into nursing to spend endless hours charting.The documentation requirements have outpaced the nursing profession’s value of integrity. For example, 5 nursing interventions were to be documented every 2 hours, creating an impossible reality. Many of the hundreds of fields were not meaningful or even used for data analysis or research. The waste was astounding when critically ill patients needed urgent care.We must challenge the longstanding nursing mantra “if care was not charted, it was not done.” Health care has reached a tipping point in quality improvement initiatives. The literature demonstrates that lower patient-to-nurse ratios improve patient care. The charting volume rises with every new clinical update, yet there is a reluctance to remove any documentation. I think hospitals’ fear of lawsuits and reduced reimbursement have created this reluctance.Highly reliable organizations standardize processes across hospital systems. Although this approach improves patient care, it complicates the process of minimizing required documentation. Filling out all the mandatory fields to document the prevention of hospital-acquired conditions, accreditation requirements, and specialty certifications such as stroke prevents nurses from directly caring for patients.Solutions to this problem are multifactorial, and innovative leadership strategies are needed for a culture change. The concept of exnovation needs a role in our health care system. Exnovation stops inefficient processes that are no longer working by removing waste.3 Reducing nursing documentation time should be a top goal in the United States to ensure patient safety. Organizations must produce outcomes highlighting strategies that keep nurses in direct patient care.4Additional strategies include block charting, especially for drip titration, and limiting new checklists. Block charting is supported by regulatory bodies such as The Joint Commission and facilitates easier charting while still providing proper patient care.5 Bedside nurses can collaborate with informatics and quality experts to create protocols that meet standards of care and save precious nursing time. The Institute for Healthcare Improvement has acknowledged that while documentation is supposed to improve patient safety, burdensome documentation has the opposite effect.4 Just because a new tool or checklist worked in one setting, it is not universally meaningful in all environments. Careful vetting of tools with an easy process to remove antiquated documentation fields is called for.A Gallup poll has rated nurses as the most trusted profession for the past 20 years.6 Nurses need the public’s support to get us back to patient care. We need a culture change that rewards organizations that increase nurses’ time caring for patients.