Notes on Nursing Documentation: Quality criteria and views of nurses and patients

Nursing documentation is not an aim in itself; it is a vital source of information for nursing staff and essential for the patient’s safety and the quality of nursing care. However, there are indications that the quality of nursing documentation is often sub-optimal. How this quality can be improved was not clear. This thesis aims to give a better understanding of the quality criteria and the views of nurses and patients on electronic nursing documentation. A systematic review of systematic reviews focussed on what quality criteria nursing documentation should meet. Four of the eleven reviews indicate that alignment of the documentation with the phases of the nursing process is a criterion for high-quality documentation. Furthermore, seven reviews report that the use of standardized terminologies improves the quality of nursing documentation. In addition, three reviews show that electronic documentation is preferred and that the user-friendliness of electronic health records is an important quality criterion. A nationwide survey showed that nursing staff only feel moderately supported in their documentation by the use of electronic health records. Only half of these nursing staff used a standardized terminology. The extent to which nursing staff felt supported in their documentation was not associated with the use of a standardized terminology. Nursing staff were less positive about whether the information in the electronic health records was accurate, and whether the electronic health records were user-friendly. A mixed-methods study showed that community nurses estimated that they spent twice as much time on clinical documentation of the care for patients as on organizational documentation, concerning financial aspects. The time spent on organizational documentation was related to nurses’ perceived workload, while the time spent on clinical documentation was not. Organizational documentation in particular resulted in a high workload among nurses. Still, clinical documentation also added to their workload, particularly because of the limited user-friendliness of electronic health records. A qualitative interview study showed that community nurses tailored the extent and ways in which they promoted patient participation in documentation to the individual patients. This tailoring depended on patients’ trust in nurses and the nursing process. Nurses perceived various challenges in patient participation, such as technical problems, limited user-friendliness of electronic health records, or time pressure. Furthermore, patient-related challenges include vulnerable conditions, and limited digital skills among patients. Nurses often fell back on verbal communication with patients about what they documented. A qualitative interview study among home-care patients showed that they differed in their need and ability to participate in nursing documentation. Four patient types were identified. 1. ‘high need, high ability’; 2. ‘high need, low ability’; 3. ‘low need, high ability’; and 4. ‘low need, low ability’ to participate in nursing documentation. Patients in the first two types felt a need for participation because they were interested in the documentation. Patients in the last two types did not feel such a need. Patients in the first and third types felt highly able to participate. Patients in the second and fourth types felt less able to participate in the documentation, because they lacked digital skills, or lacked support from nurses. An nationwide survey focussed on nurses’ attitudes towards the use of patient portals and personal health environments. Most of the nurses reported the use of a patient portal to give patients access to their records. More community nurses actively promoted the use of patient portals than hospital nurses. According to the nurses, personal health environments were used much less often. Only one tenth of nurses believed that personal health environments had additional value for their patients. The attitudes of community nurses were slightly more positive than those of hospital nurses.