What is the problem with nursing documentation? Perspective of Indonesian nurses

Kamil, Hajjul; Rachmah, Rachmah; Wardani, Elly

doi:10.1016/j.ijans.2018.09.002

Cited by 44 publications

(52 citation statements)

References 25 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…For example, nurses should be provided with education and training that presents the evidence about documentation and bias using specific examples of their own writing both when they are initially onboarded into a nursing position but also at regular intervals throughout their career as scholars suggest that nurses require ongoing support to maintain standards (Blair & Smith, 2012). Furthermore, researchers highlight that education has the most pressing affect on quality of documentation as defined by nursing staff (Kamil, Rachmah, & Wardani, 2018); specifically education improves motivation to document well (Mediarti, Rehana, & Abunyamin, 2018).…”

Section: Relevance To Clinical Practicementioning

confidence: 99%

How forensic mental health nurses’ perspectives of their patients can bias healthcare: A qualitative review of nursing documentation

Martin

Ricciardelli

Dror

2020

Journal of Clinical Nursing

View full text Add to dashboard Cite

Aims and Objectives Our aim was to examine the notes produced by nurses, paying specific attention to the style in which these notes are written and observing whether there are concerns of distortions and biases. Background Clinicians are responsible to document and record accurately. However, nurses’ attitudes towards their patients can influence the quality of care they provide their patients and this inevitably impacts their perceptions and judgments, with implications to patients’ care, treatment, and recovery. Negative attitudes or bias can cascade to other care providers and professionals. Design This study used a retrospective chart review design and qualitative exploration of documentation using an emergent theme analysis. Methods We examined the notes taken by 55 mental health nurses working with inpatients in the forensic services department at a psychiatric hospital. The study complies with the SRQR Checklist (Appendix S1) published in 2014. Results The results highlight some evidence of nurses’ empathic responses to patients, but suggest that most nurses have a style of writing that much of the time includes themes that are negative in nature to discount, pathologise, or paternalise their patients. Conclusions When reviewing the documentation of nurses in this study, it is easy to see how they can influence and bias the perspective of other staff. Such bias cascade and bias snowball have been shown in many domains, and in the context of nursing it can bias the type of care provided, the assessments made and the decisions formed by other professionals. Relevance to Clinical Practice Given the critical role documentation plays in healthcare, our results indicate that efforts to improve documentation made by mental health nurses are needed and specifically, attention needs to be given to the writing styles of the notation.

show abstract

Section: Relevance To Clinical Practicementioning

confidence: 99%

How forensic mental health nurses’ perspectives of their patients can bias healthcare: A qualitative review of nursing documentation

Martin

Ricciardelli

Dror

2020

Journal of Clinical Nursing

View full text Add to dashboard Cite

show abstract

“…First, healthcare providers are willing to adopt new clinic-based records and processes for child contact screening if they perceived them to be bene cial to patient care, easy to implement, and not time constraining. Existing literature from South Africa and other settings has documented nurse fatigue with excessive recordkeeping [17][18][19]. Furthermore, a recent systematic review examining child TB contact management in high burden settings found a lack of tools to support documentation was a common barrier to successful management of child TB contacts [20].…”

Section: Discussionmentioning

confidence: 99%

“Symptom Screening is Easier, but You Can Miss…”: Perceptions of Nurse-led Symptom-based Screening to Promote Tuberculosis Preventive Therapy in the Context of a Cluster Randomized Trial in South Africa

Salazar-Austin

Milovanovic

West

et al. 2020

Preprint

View full text Add to dashboard Cite

Background: Tuberculosis is a top-10 cause of under-5 mortality, despite policies promoting tuberculosis preventive therapy (TPT). We previously conducted a cluster randomized trial to evaluate the effectiveness of symptom-based versus tuberculin skin-based screening on child TPT uptake. Symptom-based screening did not improve TPT uptake and nearly two-thirds of child contacts were not identified or not linked to care. Here we qualitatively explored healthcare provider perceptions of factors that impacted TPT uptake among child contacts.Methods: Sixteen in-depth interviews were conducted with key informants including healthcare providers and administrators who participated in the trial in Matlosana, South Africa. The participants’ experience with symptom-based screening, study implementation strategies, and ongoing challenges with child contact identification and linkage to care were explored. Interviews were systematically coded and thematic content analysis was conducted. Results: Participants’ had mixed opinions about symptom-based screening and high acceptability of the study implementation strategies. A key barrier to optimizing child contact screening and evaluation was the supervision and training of community health workers. Conclusions: Symptom screening is a simple and effective strategy to evaluate child contacts, but additional pediatric training is needed to provide comfort with decision making. New clinic-based child contact files were highly valued by providers who continued to use them after trial completion. Future interventions to improve child contact management will need to address how to best utilize community health workers in identifying and linking child contacts to care. Trial Registration: The results presented here were from research related to NCT03074799, retrospectively registered on 9 March 2017.

show abstract

“…8 In addition, inadequate competencies, lack of supervision, inaccuracy of timely documentation, and inconclusive yet irrelevant notes between health providers were among the issues found during the implementation of the integrated patient progress documentation sheets. [8][9][10] The issues presented here with the use of paper-based patient documentation are prevalent in the literature. With paper-based documentation, standards and requirements for high-quality documentation and communication among health professionals are lacking.…”

Section: Introductionmentioning

confidence: 99%

“…In addition, mistakes such as incorrect procedure, missing names and signatures of the care provider, and delayed time of verification were also prevalent in the patient progress documentation sheets that were evaluated. 8,10 Possible solutions using technology were agreed upon among the health professionals to tackle such problems. 8 Before the software system design stage, several focus group discussions (FGDs) and interviews took place with various health professionals.…”

mentioning

confidence: 99%

<p>Exploring Health Professionals’ Perceptions on Health-ID, an Electronic Integrated Patient Progress Documentation System: A Qualitative Study in Indonesia</p>

Kamil¹,

Rachmah²,

Irvanizam³

et al. 2020

JMDH

Self Cite

View full text Add to dashboard Cite

What is the problem with nursing documentation? Perspective of Indonesian nurses

Cited by 44 publications

References 25 publications

How forensic mental health nurses’ perspectives of their patients can bias healthcare: A qualitative review of nursing documentation

How forensic mental health nurses’ perspectives of their patients can bias healthcare: A qualitative review of nursing documentation

“Symptom Screening is Easier, but You Can Miss…”: Perceptions of Nurse-led Symptom-based Screening to Promote Tuberculosis Preventive Therapy in the Context of a Cluster Randomized Trial in South Africa

<p>Exploring Health Professionals’ Perceptions on Health-ID, an Electronic Integrated Patient Progress Documentation System: A Qualitative Study in Indonesia</p>

Contact Info

Product

Resources

About