Strategies to Improve Compliance with Clinical Nursing Documentation Guidelines in the Acute Hospital Setting: A Systematic Review and Analysis

Abstract

Introduction This systematic review attempts to answer the following question – which strategies to improve clinical nursing documentation have been most effective in the acute hospital setting? Methods A keyword search for relevant studies was conducted in CINAHL and Medline in May 2019 and October 2020. Studies were appraised using the Joanna Briggs Institute (JBI) critical appraisal for quasi-experimental studies. The studies were graded for level of evidence according to GRADE principles. The data collected in each study were added to a Summary of Data (SOD) spreadsheet. Pre intervention and a post intervention percentage compliance scores were calculated for each study where possible i.e. (mean score/possible total score) × (100/1). A percentage change in compliance for each study was calculated by subtracting the pre intervention score from the post intervention score. The change in compliance score and the post intervention compliance score were both added to the SOD and used as a basis for comparison between the studies. Each study was analyzed thematically in terms of the intervention strategies used. Compliance rates and the interventions used were compared to determine if any strategies were effective in achieving a meaningful improvement in compliance. Results Seventy six full text articles were reviewed for this systematic review. Fifty seven of the studies were before and after studies and 66 were conducted in western countries. Publishing dates for the studies ranged from 1991 to 2020. Eleven studies included documentation audits with personal feedback as one of the strategies used to improve nursing documentation. Ten of these studies achieved a post intervention compliance rate ≥ 70%. Conclusion Notwithstanding the limitations of this study, it may be that documentation audit with personal feedback, when combined with other context specific strategies, is a reliable method for gaining meaningful improvements in clinical nursing documentation. The level of evidence is very low and further research is required.

Nursing Documentation in Accredited Hospital

“…In line with the previous author, organized documentation describes all the patient needs, assessment, and corresponding interventions (Muhlisin, 2011). Documentation in the proper format allows for easier updating by nurses (Bunting & de Klerk, 2022;De Groot et al, 2022). Moreover, collaborative actions with other health teams must be included as implementation of patient-centered care, and in order to improve patients' satisfaction (Purwandari et al, 2019).…”

Improving Documentation of Pain Reassessment after Pain Management Interventions in the NICU

“…Still, workload issues, time management, and reliance on tachycardia alone to detect pain could have contributed to the 80% upper compliance limit. Similar to previous studies, noncompliant nurses accepted the individual unmasked feedback [28][29][30][31] as we provided it in a nonthreatening confidential manner, and we did not report it to managers.…”

CRRT documentation education: Increasing compliance on a new electronic health record

“…A common feature of most literature that concerned education on nursing documentation was concern about the lack of high-quality studies that addresses this need. [5][6][7] The majority of papers reviewed were either not specific to nurses or focused on the academic training rather than professional practice and development where the intervention was aimed. CRRT is a specialized treatment modality and other than basic principles it is unlikely to be covered in undergraduate nursing education, [8] making this particularly challenging for the project.…”

“…Lastly, most studies showed that a multi-modal and longitudinal approach were superior at creating effective learning. [6,7,13] Educational strategies that applied to this project included performing a pre and post-intervention assessment, [5,14] including communicationbased affective content to increase caring, [15] and including personal feedback. [6]…”

“…[6,7,13] Educational strategies that applied to this project included performing a pre and post-intervention assessment, [5,14] including communicationbased affective content to increase caring, [15] and including personal feedback. [6]…”