Unsafe nursing documentation: A qualitative content analysis.
Documentation
content analysis
ethics
nursing
patient safety
Journal
Nursing ethics
ISSN: 1477-0989
Titre abrégé: Nurs Ethics
Pays: England
ID NLM: 9433357
Informations de publication
Date de publication:
Aug 2020
Aug 2020
Historique:
pubmed:
4
9
2019
medline:
7
4
2021
entrez:
4
9
2019
Statut:
ppublish
Résumé
Nursing documentation as a pivotal part of nursing care has many implications for patient care in terms of safety and ethics. To explore factors influencing nursing documentation from nurses' perspectives in the Iranian nursing context. This qualitative study was carried out using a qualitative content analysis of data collected from 2018 to 2019 in two urban areas of Iran. Semi-structured interviews (n = 15), observations, and reviews of patients' medical files were used for data collection. This study was conducted in accordance with the ethical principles of research and regulations in terms of confidentiality of data, anonymity, and provision of informed consent. The main theme of this study was "unsafe documentation." Two categories, "types of errors in reporting" and "reasons of errors in reporting," and 12 subcategories were developed indicating factors influencing nursing documentation in the Iranian nursing context. In general, individual, organizational, and national factors affected nursing documentation in Iran. In this respect, hiring more nurses, application of reforms in the healthcare management structure, devising appropriate regulations regarding division of labor, constant education of healthcare staff, establishment of clinical governance, improvement of interpersonal relationships, development of hardware and software techniques for documentation, and provision of support should be done to improve the quality of nursing documentation. The above-mentioned suggestions can help nurses with a safe, ethical, lawful, and reliable documentation in nursing practice.
Sections du résumé
BACKGROUND
BACKGROUND
Nursing documentation as a pivotal part of nursing care has many implications for patient care in terms of safety and ethics.
OBJECTIVES
OBJECTIVE
To explore factors influencing nursing documentation from nurses' perspectives in the Iranian nursing context.
METHODS
METHODS
This qualitative study was carried out using a qualitative content analysis of data collected from 2018 to 2019 in two urban areas of Iran. Semi-structured interviews (n = 15), observations, and reviews of patients' medical files were used for data collection.
ETHICAL CONSIDERATIONS
METHODS
This study was conducted in accordance with the ethical principles of research and regulations in terms of confidentiality of data, anonymity, and provision of informed consent.
FINDINGS
RESULTS
The main theme of this study was "unsafe documentation." Two categories, "types of errors in reporting" and "reasons of errors in reporting," and 12 subcategories were developed indicating factors influencing nursing documentation in the Iranian nursing context.
CONCLUSION
CONCLUSIONS
In general, individual, organizational, and national factors affected nursing documentation in Iran. In this respect, hiring more nurses, application of reforms in the healthcare management structure, devising appropriate regulations regarding division of labor, constant education of healthcare staff, establishment of clinical governance, improvement of interpersonal relationships, development of hardware and software techniques for documentation, and provision of support should be done to improve the quality of nursing documentation. The above-mentioned suggestions can help nurses with a safe, ethical, lawful, and reliable documentation in nursing practice.
Identifiants
pubmed: 31476968
doi: 10.1177/0969733019871682
doi:
Types de publication
Journal Article
Langues
eng