Abstract
Introduction: Nursing documentation is essential for ensuring a safe, high-quality and continuous nursing care and research work. By means of documentation nurses communicate with each other, other members of the healthcare team and other care providers. The aim of the present research was to investigate nurses' opinions about the importance of nursing documentation. Methods: For the purposes of the study, a quantitative non-experimental research design was employed. A quota sampling included the nursing employees in ten Slovenian hospitals. The survey was composed of closed-ended questions. The data were collected from June 1, 2012 to March 31, 2013. The response rate was 44.95 %. A total of 592 respondents participated in the research, 47.3 % with secondary education and 52.7 % with completed undergraduate study programme. Chrombach's coefficient alpha was 0.898. Descriptive statistics, Kolmogorov-Smirnov test, Spearman's correlation coefficient, and Mann-Whitney U test were used. Results: Nurses with at least college degree attributed more importance to documentation compared to those with secondary education (p = 0.001). Statistically significant correlation was not established (p = 0.98). However, a negative correlation was identified between the time used for documentation and positive attitude towards documentation (p = 0.04). Discussion and conclusion: Nurses perceive documentation as an important part of their work. They believe that documentation enhances transparency, quality and continuity of care, and patient safety. It would be necessary to identify the differences in practices and perceptions of handovers between nurses and other healthcare providers.
Highlights
Nursing documentation is essential for ensuring a safe, high-quality and continuous nursing care and research work
Regardless of different formats proposed by various authors, nursing documentation should include information to identify the patient/ consumer, the healthcare provider, the clinical reasoning for the choice of care, the client's response and/or outcome of the interventions, and future plans (Kohek & Vogrinčič, 2004; Ramšak Pajk & Šušteršič, 2005; College and Association of Registered Nurses of Alberta, 2013)
If a task performed by nurses is not entered into the nursing documentation, it may be assumed in a legal context that this task has not been performed (Ramšak Pajk, 2006; Kulhanek, 2010; College & Association of Registered Nurses of Alberta, 2013)
Summary
Nursing documentation is essential for ensuring a safe, high-quality and continuous nursing care and research work. Discussion and conclusion: Nurses perceive documentation as an important part of their work They believe that documentation enhances transparency, quality and continuity of care, and patient safety. Good communication is essential to performing systematic, professional and quality work, including nursing practice It ensures continuity of care, reflects and increases professionalism, and provides grounds for assessment of nursing practice (Rajkovič, 2010). Regardless of different formats proposed by various authors, nursing documentation should include information to identify the patient/ consumer, the healthcare provider, the clinical reasoning for the choice of care, the client's response and/or outcome of the interventions, and future plans (Kohek & Vogrinčič, 2004; Ramšak Pajk & Šušteršič, 2005; College and Association of Registered Nurses of Alberta, 2013). If a task performed by nurses is not entered into the nursing documentation, it may be assumed in a legal context that this task has not been performed (Ramšak Pajk, 2006; Kulhanek, 2010; College & Association of Registered Nurses of Alberta, 2013)
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