'It's all about ticks': A secondary qualitative analysis of nurse perspectives about documentation audit.
data accuracy
documentation
nursing audit
nursing records
patient care planning
quality improvement
Journal
Journal of advanced nursing
ISSN: 1365-2648
Titre abrégé: J Adv Nurs
Pays: England
ID NLM: 7609811
Informations de publication
Date de publication:
Sep 2023
Sep 2023
Historique:
revised:
02
03
2023
received:
06
06
2022
accepted:
07
04
2023
medline:
11
8
2023
pubmed:
28
4
2023
entrez:
28
4
2023
Statut:
ppublish
Résumé
To understand how nurses talk about documentation audit in relation to their professional role. Nursing documentation in health services is often audited as an indicator of nursing care and patient outcomes. There are few studies exploring the nurses' perspectives on this common process. Secondary qualitative thematic analysis. Qualitative focus groups (n = 94 nurses) were conducted in nine diverse clinical areas of an Australian metropolitan health service for a service evaluation focussed on comprehensive care planning in 2020. Secondary qualitative analysis of the large data set using reflexive thematic analysis focussed specifically on the nurse experience of audit, as there was the significant emphasis by participants and was outside the scope of the primary study. Nurses': (1) value quality improvement but need to feel involved in the cycle of change, (2) highlight that 'failed audit' does not equal failed care, (3) describe the tension between audited documentation being just bureaucratic and building constructive nursing workflows, (4) value building rapport (with nurses, patients) but this often contrasted with requirements (organizational, legal and audit) and additionally, (5) describe that the focus on completion of documentation for audit creates unintended and undesirable consequences. Documentation audit, while well-intended and historically useful, has unintended negative consequences on patients, nurses and workflows. Accreditation systems rely on care being auditable, but when individual legal, organizational and professional standards are implemented via documentation forms and systems, the nursing burden is impacted at the point of care for patients, and risks both incomplete cares for patients and incomplete documentation. Patients participated in the primary study on comprehensive care assessment by nurses but did not make any comments about documentation audit.
Sections du résumé
AIM
OBJECTIVE
To understand how nurses talk about documentation audit in relation to their professional role.
BACKGROUND
BACKGROUND
Nursing documentation in health services is often audited as an indicator of nursing care and patient outcomes. There are few studies exploring the nurses' perspectives on this common process.
DESIGN
METHODS
Secondary qualitative thematic analysis.
METHODS
METHODS
Qualitative focus groups (n = 94 nurses) were conducted in nine diverse clinical areas of an Australian metropolitan health service for a service evaluation focussed on comprehensive care planning in 2020. Secondary qualitative analysis of the large data set using reflexive thematic analysis focussed specifically on the nurse experience of audit, as there was the significant emphasis by participants and was outside the scope of the primary study.
RESULTS
RESULTS
Nurses': (1) value quality improvement but need to feel involved in the cycle of change, (2) highlight that 'failed audit' does not equal failed care, (3) describe the tension between audited documentation being just bureaucratic and building constructive nursing workflows, (4) value building rapport (with nurses, patients) but this often contrasted with requirements (organizational, legal and audit) and additionally, (5) describe that the focus on completion of documentation for audit creates unintended and undesirable consequences.
CONCLUSION
CONCLUSIONS
Documentation audit, while well-intended and historically useful, has unintended negative consequences on patients, nurses and workflows.
IMPACT
CONCLUSIONS
Accreditation systems rely on care being auditable, but when individual legal, organizational and professional standards are implemented via documentation forms and systems, the nursing burden is impacted at the point of care for patients, and risks both incomplete cares for patients and incomplete documentation.
NO PATIENT OR PUBLIC CONTRIBUTION
UNASSIGNED
Patients participated in the primary study on comprehensive care assessment by nurses but did not make any comments about documentation audit.
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
3440-3455Subventions
Organisme : University of Canberra
Informations de copyright
© 2023 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.
Références
Allen, D. (2017). From polyformacy to formacology. Retrieved October 18, 2021, from https://orca.cardiff.ac.uk/100331/1/BMJ%20QS%20Editorial%20V2.postprint.pdf
Australian Commission on Safety and Quality in Health Care. (2017). National Safety and Quality Health Service Standards (2nd ed.). ACSQHC.
Bail, K., Cook, R., Gardner, A., & Grealish, L. (2009). Writing ourselves into a web of obedience: A nursing policy analysis. International Journal of Nursing Studies, 46(11), 1457-1466. https://doi.org/10.1016/j.ijnurstu.2009.04.005
Bail, K., Merrick, E., Bridge, C., & Redley, B. (2021). Documenting patient risk and nursing interventions: Record audit. AJAN-The Australian Journal of Advanced Nursing, 38(1), 36-41. https://doi.org/10.37464/2020.381.167
Bakker, A. B., Demerouti, E., & Sanz-Vergel, A. I. (2014). Burnout and work engagement: The JD-R approach. Annual Review of Organisational Psychology and Organisational Behaviour, 1(1), 389-411. https://doi.org/10.1146/annurev-orgpsych-031413-091235
Bjorvell, C., Wredling, R., & Thorell-Ekstrand, I. (2003). Prerequisites and consequences of nursing documentation in patient records as perceived by a group of registered nurses. Journal of Clinical Nursing, 12(2), 206-214. https://doi.org/10.1046/j.1365-2702.2003.00723.x
Björvell, C., Wredling, R., & Thorell-Ekstrand, I. (2003). Improving documentation using a nursing model. Journal of Advanced Nursing, 43(4), 402-410. https://doi.org/10.1046/j.1365-2648.2003.02751.x
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77-101. https://doi.org/10.1191/1478088706qp063oa
Braun, V., & Clarke, V. (2019). Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health, 11(4), 589-597.
Brown, B., Gude, W. T., Blakeman, T., van der Veer, S. N., Ivers, N., Francis, J. J., Lorencatto, F., Presseau, J., Peek, N., & Daker-White, G. (2019). Clinical performance feedback intervention theory (CP-FIT): A new theory for designing, implementing, and evaluating feedback in health care based on a systematic review and meta-synthesis of qualitative research. Implementation Science, 14(40), 40. https://doi.org/10.1186/s13012-019-0883-5
Carver, C. S., & Scheier, M. F. (1982). Control theory: A useful conceptual framework for personality-social, clinical, and health psychology. Psychological Bulletin, 92(1), 111-135. https://doi.org/10.1037/0033-2909.92.1.111
Charalambous, L., & Goldberg, S. (2016). ‘Gaps, mishaps and overlaps’. Nursing documentation: How does it affect care? Journal of Research in Nursing, 21(8), 638-648. https://doi.org/10.1177/1744987116678900
Cheevakasemsook, A., Chapman, Y., Francis, K., & Davies, C. (2006). The study of nursing documentation complexities. International Journal of Nursing Practice, 12(6), 366-374. https://doi.org/10.1111/j.1440-172X.2006.00596.x
Christina, V., Baldwin, K., Biron, A., Emed, J., & Lepage, K. (2016). Factors influencing the effectiveness of audit and feedback: nurses' perceptions. Journal of Nursing Management, 24(8), 1080-1087. https://doi.org/10.1111/jonm.12409
Clarke, T., Kelleher, M., & Fairbrother, G. (2010). Starting a care improvement journey: Focusing on the essentials of bedside nursing care in an Australian teaching hospital. Journal of Clinical Nursing, 19(13-14), 1812-1820. https://doi.org/10.1111/j.1365-2702.2009.03173.x
De Groot, K., Triemstra, M., Paans, W., & Francke, A. L. (2019). Quality criteria, instruments, and requirements for nursing documentation: A systematic review of systematic reviews. Journal of Advanced Nursing, 75(7), 1379-1393. https://doi.org/10.1111/jan.13919
de Marinis, M. G., Piredda, M., Pascarella, M. C., Vincenzi, B., Spiga, F., Tartaglini, D., Alvaro, R., & Matarese, M. (2010). 'If it is not recorded, it has not been done!’? Consistency between nursing records and observed nursing care in an Italian hospital. Journal of Clinical Nursing, 19(11-12), 1544-1552. https://doi.org/10.1111/j.1365-2702.2009.03012.x
Drobny, S. D., Snell, A., Morris, L., Harshbarger, C., Village, P., & Fischer, S. A. (2019). Collaborative rural nurse peer review: A quality improvement project. Journal of Nursing Care Quality, 34(1), 22-27. https://doi.org/10.1097/NCQ.0000000000000331
Fore, A., Islim, F., & Shever, L. (2019). Data collected by the electronic health record is insufficient for estimating nursing costs: An observational study on acute care inpatient nursing units. International Journal of Nursing Studies, 91(1), 101-107. https://doi.org/10.1016/j.ijnurstu.2018.11.004
Galič, M., Timan, T., & Koops, B.-J. (2017). Bentham, Deleuze and beyond: An overview of surveillance theories from the panopticon to participation. Philosophy & Technology, 30(1), 9-37. https://doi.org/10.1007/s13347-016-0219-1
Giesbers, S. A., Schouteten, R. L. J., Poutsma, E., van der Heijden, B. I. J. M., & van Achterberg, T. (2021). Towards a better understanding of the relationship between feedback and nurses' work engagement and burnout: A convergent mixed-methods study on nurses' attributions about the ‘why’ of feedback. International Journal of Nursing Studies, 117, 103889. https://doi.org/10.1016/j.ijnurstu.2021.103889
Griffiths, P., Recio-Saucedo, A., Dall'Ora, C., Briggs, J., Maruotti, A., Meredith, P., Smith, G. B., & Ball, J. (2018). The association between nurse staffing and omissions in nursing care: A systematic review. Journal of Advanced Nursing, 74(7), 1474-1487. https://doi.org/10.1111/jan.13564
Guba, E. G., & Lincoln, Y. (1989). Fourth generation evaluation. Sage.
Harrington, L. (2019). Future model for nursing documentation: Extinction. Nurse Leader, 17(2), 113-116. https://doi.org/10.1016/j.mnl.2018.12.005
Harvey, C., Thompson, S., Otis, E., & Willis, E. (2020). Nurses' views on workload, care rationing and work environments. Journal of Nursing Management, 28(4), 912-918. https://doi.org/10.1111/jonm.13019
Harvey, C. L., Thompson, S., Willis, E., Meyer, A., & Pearson, M. (2018). Understanding how nurses ration care. Journal of Health Organization and Management, 32, 494-510. https://doi.org/10.1108/JHOM-09-2017-0248
Havens, D. S., & Aiken, L. H. (1999). Shaping systems to promote desired outcomes: The magnet hospital model. The Journal of Nursing Administration, 29(2), 14-20.
Heartfield, M. (1996). Nursing documentation and nursing practice: A discourse analysis. Journal of Advanced Nursing, 24(1), 98-103. https://doi.org/10.1046/j.1365-2648.1996.15113.x
International Council of Nurses. (2012). The ICN code of ethics for nurses. https://www.icn.ch/sites/default/files/inline-files/2012_ICN_Codeofethicsfornurses_%20eng.pdf
Iula, A., Ialungo, C., de Waure, C., Raponi, M., Burgazzoli, M., Zega, M., Galletti, C., & Damiani, G. (2020). Quality of care: Ecological study for the evaluation of completeness and accuracy in nursing assessment. International Journal of Environmental Research and Public Health, 17(9), 3259. https://doi.org/10.3390/ijerph17093259
Ivers, N., Brown, B., & Grimshaw, J. (2020). Clinical performance feedback and decision support. In M. Wensing, R. Grol, & J. Grimshaw (Eds.), Improving patient care: The implementation of change in health care Vol. 3, pp. 235-251. John Wiley & Sons. https://doi.org/10.1002/9781119488620.ch13
Ivers, N. M., Grimshaw, J. M., Jamtvedt, G., Flottorp, S., O'Brien, M. A., French, S. D., Young, J., & Odgaard-Jensen, J. (2014). Growing literature, stagnant science? Systematic review, metaregression and cumulative analysis of audit and feedback interventions in health care. Journal of Internal Medicine, 29, 1534-1541. https://doi.org/10.1007/s11606-014-2913-y
Jansson, I., Pilhamar, E., & Forsberg, A. (2011). Factors and conditions that have an impact in relation to the successful implementation and maintenance of individual care plans. Worldviews on Evidence-Based Nursing, 8(2), 66-75. https://doi.org/10.1111/j.1741-6787.2010.00195.x
Johnson, L., Edward, K.-L., & Giandinoto, J.-A. (2018). A systematic literature review of accuracy in nursing care plans and using standardised nursing language. Collegian, 25(3), 355-361. https://doi.org/10.1016/j.colegn.2017.09.006
Johnson, M., Jefferies, D., & Langdon, R. (2010). The nursing and midwifery content audit tool (NMCAT): A short nursing documentation audit tool. Journal of Nursing Management, 18(7), 832-845. https://doi.org/10.1111/j.1365-2834.2010.01156.x
Kärkkäinen, O., Bondas, T., & Eriksson, K. (2005). Documentation of individualized patient care: A qualitative metasynthesis. Nursing Ethics, 12(2), 123-132. https://doi.org/10.1191/0969733005ne769oa
Kebede, M., Endris, Y., & Zegeye, D. T. (2017). Nursing care documentation practice: The unfinished task of nursing care in the University of Gondar Hospital. Informatics for Health and Social Care, 42(3), 290-302. https://doi.org/10.1080/17538157.2016.1252766
Kelly, L. A., McHugh, M. D., & Aiken, L. H. (2012). Nurse outcomes in magnet® and non-magnet hospitals. The Journal of Nursing Administration, 42(10 Suppl), S44-S49. https://doi.org/10.1097/01.NNA.0000420394.18284.4f
Kluger, A. N., & DeNisi, A. (1996). The effects of feedback interventions on performance: A historical review, a meta-analysis, and a preliminary feedback intervention theory. Psychological Bulletin, 119(2), 254-284.
Kutney-Lee, A., Stimpfel, A. W., Sloane, D. M., Cimiotti, J. P., Quinn, L. W., & Aiken, L. H. (2015). Changes in patient and nurse outcomes associated with magnet hospital recognition. Medical Care, 53(6), 550-557. https://doi.org/10.1097/MLR.0000000000000355
Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Sage.
Long-Sutehall, T., Sque, M., & Addington-Hall, J. (2011). Secondary analysis of qualitative data: A valuable method for exploring sensitive issues with an elusive population? Journal of Research in Nursing, 16(4), 335-344. https://doi.org/10.1177/1744987110381553
Michl, G., Paterson, C., & Bail, K. (2021). Audits have an impact on the nurse's professional role and psychological wellbeing: An integrative systematic review. University of Canberra.
Moldskred, P. S., Snibsøer, A. K., & Espehaug, B. (2021). Improving the quality of nursing documentation at a residential care home: A clinical audit. BMC Nursing, 20(1), 1-7. https://doi.org/10.1186/s12912-021-00629-9
Nation, J., & Wangia-Anderson, V. (2019). Applying the data-knowledge-information-wisdom framework to a usability evaluation of electronic health record system for nursing professionals. Online Journal of Nursing Informatics, 23, 1.
Nowell, L. S., Norris, J. M., White, D. E., & Moules, N. J. (2017). Thematic analysis: Striving to meet the trustworthiness criteria. International Journal of Qualitative Methods, 16(1), 160940691773384. https://doi.org/10.1177/1609406917733847
NSW Government. (2021). Pressure injury prevention and management, policy directive. https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2021_023.pdf
Nursing and Midwifery Board of Australia. (2016). Registered nurse standards for practice. https://www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards/registered-nurse-standards-for-practice.aspx
Paans, W., Sermeus, W., Nieweg, R. M. B., & Van der Schans, C. P. (2010). Prevalence of accurate nursing documentation in patient records. Journal of Advanced Nursing, 66(11), 2481-2489. https://doi.org/10.1111/j.1365-2648.2010.05433.x
Paterson, C., Roberts, C., & Bail, K. (2021). “Paper care not patient care”: Nurse and patient experiences of comprehensive risk assessment and care plan documentation in hospital. Journal of Clinical Nursing, 32, 523-538. https://doi.org/10.1111/jocn.16291
Peters, M. (2017). Design of an automated audit-and-feedback process to improve postopioid-assessment documentation using participatory action research (10608177)[Ph.D.]. The University of Utah.
Pousette, A., Larsman, P., Eklöf, M., & Törner, M. (2017). The relationship between patient safety climate and occupational safety climate in healthcare - A multi-level investigation. Journal of Safety Research, 61, 187-198. https://doi.org/10.1016/j.jsr.2017.02.020
Prideaux, A. (2011). Issues in nursing documentation and record-keeping practice. British Journal of Nursing, 20(22), 1450-1454. https://doi.org/10.12968/bjon.2011.20.22.1450
Ramukumba, M. M., & El Amouri, S. (2019). Nurses' perspectives of the nursing documentation audit process. Health SA Gesondheid, 24, 1-7. https://doi.org/10.4102/hsag.v24i0.1121
Redley, B., & Raggatt, M. (2017). Use of standard risk screening and assessment forms to prevent harm to older people in Australian hospitals: A mixed methods study. BMJ Quality & Safety, 26(9), 704-713. https://doi.org/10.1136/bmjqs-2016-005867
Roberts, S. J. (2006). Oppressed group behavior and nursing. In L. Andrist, P. Nicholas, & K. Wolf (Eds.), A history of nursing ideas pp. 23-33. Jones & Bartlett Learning.
Ruggiano, N., & Perry, T. E. (2019). Conducting secondary analysis of qualitative data: Should we, can we, and how? Qualitative Social Work, 18(1), 81-97. https://doi.org/10.1177/1473325017700701
Sandelowski, M. (1986). The problem of rigor in qualitative research. Advances in Nursing Science, 8, 27-37.
Saranto, K., & Kinnunen, U.-M. (2009). Evaluating nursing documentation - research designs and methods: Systematic review. Journal of Advanced Nursing, 65(3), 464-476. https://doi.org/10.1111/j.1365-2648.2008.04914.x
Singer, S. J., Falwell, A., Gaba, D. M., Meterko, M., Rosen, A., Hartmann, C. W., & Baker, L. (2009). Identifying organizational cultures that promote patient safety. Health Care Management Review, 34(4), 300-311. https://doi.org/10.1097/HMR.0b013e3181afc10c
Sinuff, T., Muscedere, J., Rozmovitz, L., Dale, C. M., & Scales, D. C. (2015). A qualitative study of the variable effects of audit and feedback in the ICU. BMJ Quality & Safety, 24(6), 393-399. https://doi.org/10.1136/bmjqs-2015-003978
Smyth, S., Whalen, M., Maliszewski, B., & Gardner, H. (2021). Audit and feedback: An evidence-based practice literature review of nursing report cards. Worldviews on Evidence-Based Nursing, 18(3), 170-179. https://doi.org/10.1111/wvn.12492
Stevenson, A., & Lindberg, C. A. (Eds.). (2015). New Oxford American Dictionary (3rd ed.). Oxford University Press.
Tajabadi, A., Ahmadi, F., Sadooghi Asl, A., & Vaismoradi, M. (2019). Unsafe nursing documentation: A qualitative content analysis. Nursing Ethics, 27(5), 1213-1224. https://doi.org/10.1177/0969733019871682
Taylor, H. (2003). An exploration of the factors that affect nurses' record keeping. British Journal of Nursing, 12(12), 751-758. https://doi.org/10.12968/bjon.2003.12.12.11338
Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349-357. https://doi.org/10.1093/intqhc/mzm042
Tuti, T., Nzinga, J., Njoroge, M., Brown, B., Peek, N., English, M., Paton, C., & van der Veer, S. N. (2017). A systematic review of electronic audit and feedback: Intervention effectiveness and use of behaviour change theory. Implementation Science, 12(61), 61. https://doi.org/10.1186/s13012-017-0590-z
Vabo, G., Slettebø, Å., & Fossum, M. (2017). Participants' perceptions of an intervention implemented in an action research nursing documentation project. Journal of Clinical Nursing, 26(7-8), 983-993. https://doi.org/10.1111/jocn.13389
Verrall, C., Abery, E., Harvey, C., Henderson, J., Willis, E., Hamilton, P., Toffoli, L., & Blackman, I. (2015). Nurses and midwives perceptions of missed nursing care - A south Australian study. Collegian, 22(4), 413-420. https://doi.org/10.1016/j.colegn.2014.09.001
Viana, C. D., de Bragas, L. Z. T., Lazzari, D. D., Garcia, C. T. F., & Moura, G. M. S. S. D. (2016). Implementation of concurrent nursing audit: An experience report. Texto & Contexto-Enfermagem, 25(1), 1-7. https://doi.org/10.1590/0104-070720160003250014
Wang, N., Hailey, D., & Yu, P. (2011). Quality of nursing documentation and approaches to its evaluation: A mixed-method systematic review. Journal of Advanced Nursing, 67(9), 1858-1875. https://doi.org/10.1111/j.1365-2648.2011.05634.x