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PubMedGoogle Scholar. However, our study showed no association between the extent of nurses perceived workload and whether the electronic health records was following the nursing process. Moore EC, Tolley CL, Bates DW, Slight SP. However, this view would not be shared by the NMC at a Fitness to Practise Conduct and Competence Committee. Nivel: Utrecht; 2017. 2019;75(7):137993. Two of the principles of good record keeping from the nursing and midwifery council 2009, suggests all handwriting should be legible and records should be accurate and recorded in such a way that the meaning is clear. Nurses time allocation and multitasking of nursing activities: a time motion study. At the time of writing there were four systematic reviews related to nursing documentation. Zwaanswijk M, Van Dulmen S. Advantages of asynchronous online focus groups and face-to-face focus groups as perceived by child, adolescent and adult participants: A survey study. Anyone you share the following link with will be able to read this content: Sorry, a shareable link is not currently available for this article. In The questions were inspired by the results of the survey data, e.g. No statistically significant association was found between a perceived high workload and whether the nursing process was central in the records (Wilcoxon rank-sum test: p=0.542), see Table6. J Couns Psychol. This enabled specific recommendations to be made that can help reduce the workload of nurses. All authors contributed to the drafting and revision of the article. Online focus groups as a tool to collect data in hard-to-include populations: Examples from paediatric oncology. This awareness might reduce nurses perceived workload associated with documentation activities. Posted on April 29, 2022 by Samantha Mednikoff. In addition, confirmability of the findings was enhanced by including verbatim statements made by participants in the results section of this paper. De Lange J, Deusing E, Van Asch IF, Peeters J, Zwaanswijk M, Pot AM, et al. This design has been proven to be particularly useful for achieving a deep understanding of relationships [36, 38]. Focus-group participants were recruited through the professional network of two authors (KdG and AM), open calls on social media (LinkedIn and Facebook), and through snowball sampling. V&VN [Dutch Nurses Association]. 2020;27(5):798807. In addition, the survey showed no associations between community nurses perceived workload and the user-friendliness of electronic health records. 2011;67(9):185875. volume21, Articlenumber:34 (2022) A possible explanation is that most community nurses (78.7%) already found that the nursing process was central in their electronic health records. Documentation is an important part of the communication process. Mller-Staub M, De Graaf-Waar H, Paans W. An internationally consented standard for nursing process-clinical decision support Systems in Electronic Health Records. Nursing documentation and its relationship with perceived nursing workload: a mixed-methods study among community nurses. 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. Google Scholar. Cookies policy. But the perceived workload of nurses and the related factors is a rather unexplored area. The funder had no role in conducting this research. It is a unique instrument, in that midwifery is the only profession to enjoy the ben, efits of Supervision of Midwives (SoM). [Administratieve pressure: more than a matter of time]. Most of the community nurses in the survey agreed that the electronic health records in which they documented information about the nursing care for individual patients were user-friendly (78.8%). They perceived a high workload when they had to register information only for the sake of these rules and regulations. https://doi.org/10.1016/j.ijnurstu.2019.03.003. https://doi.org/10.1136/amiajnl-2012-000894. Flemming D, Hbner U. https://doi.org/10.1016/j.ijmedinf.2013.03.004. It is not an optional extra to be fitted in if circumstances allow. These findings are in line with previous research that indicated that documentation can be burdensome to nurses [9, 10]. 2010;47(7):84654. https://doi.org/10.1177/1471301216634959. The roles and functions of the NMC and how these impact on practitioners are explored in greater detail in Chapter 13 [ED: please check chapter cross-reference]. The entire questionnaire was pre-tested for comprehensibility, clarity and content validity by nine nursing staff members. Cooper AL, Brown JA, Eccles SP, Cooper N, Albrecht MA. Paying for performance in health care: implications for health system performance and accountability. Introduction. 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 limited resources and staff shortages. Distinguishing between types of documentation may provide more insight into the possible relationship between documentation and perceived nursing workload. 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. Results of a systematic literature review. Part of It should be dated and the time included using a 24-hour clock. Supervision of Midwives is a framework for supporting midwives and safeguarding mothers and their babies and provides a mechanism for every practising midwife in the UK (LSAMO National Forum 2009). Furthermore, other healthcare professionals, such as general practitioners or pharmacists, often use different electronic systems for their clinical documentation. Challenges to nurses efforts of retrieving, documenting, and communicating patient care information. Attitudes of nursing staff towards electronic patient records: a questionnaire survey. Nurses believed spending substantial time on clinical documentation was worthwhile, while spending a great deal of time on organizational documentation led to frustration. In other words, nurses were just as likely to experience a high workload due to clinical documentation as due to organizational documentation. Moreover, studies showed a poor match between different electronic health records both in the digital formats that are used and in the professional vocabulary and standard terminologies used [50, 51]. More than half of the community nurses in the survey said that they perceived a high workload due to clinical and/or organizational documentation, see Table 4. They described organizational documentation in particular as cumbersome, redundant and too repetitive in nature. Transcripts from the online focus groups were taken directly from the discussion site. Focus-group participants mentioned that various rules and regulations imposed by their employers and/or national organizations, such as health insurers, also affected the amount of organizational documentation. The characteristics of the participants are presented in Tables2 and 3. The NMCs Fitness to Practise processes focus on individual practitioners. In addition, further research should focus on the integration of clinical documentation in patient care and the user-friendliness of electronic health records. 2018;2018:11376. Research often focusses only on the objective nursing workload, measured and expressed in actual time spent caring for a patient and/or staffing ratios [33]. 2014;7(756). J Clin Nurs. 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. 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. It seems important that all nurses are made aware that clinical nursing documentation is important for providing good patient care. Moy AJ, Schwartz JM, Chen RJ, Sadri S, Lucas E, Cato KD, et al. We distinguished between a high workload due to clinical documentation and a high workload due to organizational documentation. Nursing workload, nurse staffing methodologies and tools: a systematic scoping review and discussion. Griffiths P, Saville D, Ball J, Jones J, Pattison N, Monks T, et al. 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. This could include patient notes, care plans, and medication administration records. Hence, we consider the questionnaire to be a comprehensive and content valid instrument to assess nurses experiences with documentation in relation to their perceived workload. WebDocumentation of nursing care is an important source of reference and communication between nurses and other health care providers (Martin et al, 1999). Community nurses often perceive a high workload due to clinical and organizational documentation activities. Water is available throughout the centre and exam, if needed. We excluded 24 respondents who did not meet these criteria. The objective nursing workload and perceived nursing workload in Intensive Care Units: Analysis of association. On the one hand, there is clinical documentation, which directly concerns the nursing care for individual patients. Consider the factors that could impact on the percentage rates. Because they saw clinical documentation as directly connected to individual patient care, they were less negative about the time they had to spend on clinical documentation compared with organizational documentation. SOAP notes are an essential piece of information about the health status of the patient as well as a communication document between health professionals. It all costs extra time and you have to do a lot of clicking. (Focus group 3, online). https://doi.org/10.1016/j.ijmedinf.2010.09.006. Jefferies D, Johnson M, Griffiths R. A meta-study of the essentials of quality nursing documentation. (NMC, 2009). Netherlands Institute for Health Services Research (Nivel), PO Box 1568, 3513CR, Utrecht, The Netherlands, Kim De Groot,Anke J. E. De Veer&Anneke L. Francke, Thebe Wijkverpleging [Home care organization], Lage Witsiebaan 2a, 5042DA, Tilburg, The Netherlands, Nursing Science, Programme in Clinical Health Sciences, University Medical Centre Utrecht, PO Box 85500, 3508GA, Utrecht, The Netherlands, Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam University Medical Centre and Vrije Universiteit Amsterdam, Van der Boechorststraat 7, 1081BT, Amsterdam, The Netherlands, Research Group Nursing Diagnostics, School of Nursing, Hanze University of Applied Sciences, Petrus Driessenstraat 3, 9714CA, Groningen, The Netherlands, Department of Critical Care, University Medical Centre Groningen, PO Box 30.001, 9700RB, Groningen, The Netherlands, You can also search for this author in Int J Med Inform. 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. Administratieve druk: mr dan kwestie van tijd. Any alterations or additions are dated, timed and signed in such a way that the original entry can still be clearly read. Int J Med Inform. Moreover, peer debriefing was applied with a group of peer researchers who were not involved in the study. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. Int J Humanit Soc Sci. 6. No statistically significant association was found between how often the nurses perceived a high workload and the user-friendliness of electronic health records (Wilcoxon rank-sum test: p=0.166), see Table5. You are welcome to bring your own water bottle, which can be refilled at the centre. Kieft RAMM, Vreeke EM, De Groot EM, Volkert PA, Francke AL, Delnoij DMJ. That is another extra documentation burden, and that takes up extra time too. (Focus group 1, face-to-face). 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. For them it was evident that this documentation was an important part of their work. https://doi.org/10.1111/j.1365-2648.2011.05634.x. Nevertheless, the survey in particular showed that community nurses often did perceive a high workload due to clinical documentation as well. https://doi.org/10.1177/1609406917733847. The quantitative data provided a broad and representative picture of the possible presence of a relationship between perceived workload and documentation activities. In our organization, they also want everyone to do refresher courses to keep their registration as a nurse, so you need to register that too. 2019;19(1):160. https://doi.org/10.1186/s12911-019-0891-z. Medical notes are a vital means of communication between all those providing care to the patient and also of relevant communication with patients themselves and their relatives. Mller-Staub M, Abt J, Brenner A, Hofer B. American Nurses Association (ANA). The tone and quality of the communication are such that the clients understanding is ensured. Web6. Nursing workload: a concept analysis. Then the reports about the wound are under the care plan again. 2010;16(2):11224. 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]. https://doi.org/10.1097/00004010-200604000-00007. For this study, the survey was sent by email to all 508 community nurses who were members of the Nursing Staff Panel. A systematic literature review. In contrast, nurses might be more open to clinical documentation since this documentation is essential to high-quality nursing care [1, 2, 23]. PubMed Documentation: historical perspectives, purposes, benefits and challenges as faced by nurses. Yet focus-group participants did point towards the impact of limited user-friendliness on their perceived workload. about the patients medical condition and about the care provided by healthcare professionals. BMC Med Res Methodol. BMC Res Notes. 2009;9(15). They refined their analyses in discussions together and with two other authors (AF and WP), which ultimate led to consensus about the main themes. 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). 4. Any dialogue with the patient/client should be included in a form that would provide evidence of client participation in their care. BMC Nurs 21, 34 (2022). 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. Other recent studies also linked the limited usability or user-friendliness of electronic health records to nurses perceived time pressure [29, 49]. That can lead to you having three different medication systems in one team, for example. (Focus group 4, online). The code explains accountability in terms of taking individual responsibility, stating that, As a professional, you are personally accountable for actions and omissions in your practice and must always be able to justify your decisions (NMC 2008, p1). This chapter discusses and analyses the legal and professional framework that governs midwifery practice and the accountability of the midwife in relation to the documentation of her records. 2010;79(11):77891. However, the intention is that it should be used for guidance together with the. Braun V, Clarke V. Using thematic analysis in psychology. These include a range of clinical, administrative and educational uses such as: helping to improve accountability showing how decisions related to patient The level for determining statistical significance was 0.05. The development of a nursing subset of patient problems to support interoperability. Tyler DA, Parker VA, Engle RL, Brandeis GH, Hickey EC, Rosen AK, et al. The present study revealed that the majority of community nurses participating in the survey and focus groups perceived documentation as a cause of their high workload. Creswell JW, Plano Clark VL. The OECD uses the term organizational documentation to refer to the documentation of issues regarding personnel planning and coordinating different shifts, for instance. Yet when the electronic health records follow the phases of the nursing process, this might be supportive for nurses clinical documentation [31]. BMC Nursing The time that nurses spent on documentation can be substantial and burdensome. Available from: http://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf. https://doi.org/10.1111/jan.13919. Poor record keeping is a significant practice issue, which could ultimately mean that a midwife could be removed from the register if she fails to reach the required standard. On the contrary, that documentation helps me and my fellow nurses to give our patients good, appropriate care. (Focus group 4, online). Since documenting organizational and financial issues is not directly related to patient care, these aspects of documentation might be perceived negatively by nurses [22]. Wilcoxon rank-sum tests were conducted to examine associations between perceived workload and user-friendliness (research question 2a) and the nursing process (research question 2b). Moreover, according to professional standards and guidelines, clinical documentation should be considered as an integral part of providing nursing care [24,25,26]. The data that support the findings of this study are available from the corresponding author upon reasonable request. This means she/he is professionally accountable to the NMC and furthermore, she/he has a contractual accountability to her employer, in addition to UK law, for her actions. 2016;45(2):1526. Tackling wasteful spending on health. De Groot K, Triemstra M, Paans W, Francke AL. Thematic analysis: striving to meet the trustworthiness criteria. You are welcome to bring your own water bottle, which can be refilled at the centre. The study was conducted in compliance with the principles of the General Data Protection Regulation, by strictly safeguarding the anonymity of the participants. Wisner K, Lyndon A, Chesla CA. 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]. A quantitative survey was completed by 195 Dutch community nurses and a further 28 community nurses participated in qualitative focus groups. Chapter 19 [ED: please check chapter cross-reference] explains the function of Supervision of Midwives further. PubMed Wang N, Hailey D, Yu P. Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review. Substandard record keeping is also mirrored in the Annual Fitness to Practise Report (NMC 2011a) and in the Confidential Enquiry into Maternal Deaths report (Centre for Maternal Child Enquiry 2011). A key recommendation for care organizations and software developers is to improve electronic health records in terms of their user-friendliness [4, 31]. Chapter 19 [ED: please check chapter cross-reference] explains the function of Supervision of Midwives further. https://doi.org/10.1186/s12912-022-00811-7, DOI: https://doi.org/10.1186/s12912-022-00811-7. WebSupport ICT Services Knowledge Management by ensuring that appropriate levels of technical knowledge, processes and documentation are present within the team. Within this, the midwife is expected to use professional judgement to make decisions that will enhance client care through her documentation. KdG, AdV and AM carried out the data collection.

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