A grounded theory of the implementation of medical orders by clinical nurses.

OBJECTIVE: To explore the process of implementing medical orders by clinical nurses, and identify specific areas of concern in the implementation process, and uncover strategies to address these concerns. BACKGROUND: The implementation of medical orders is a crucial responsibility for clinical nurses, as they bear legal accountability for the precise implementation of directives issued by medical practitioners. The accurate implementation of these orders not only shapes the quality and safety of healthcare services but also presents numerous challenges that demand careful consideration. METHOD: This study employed a qualitative design using a grounded theory approach to construct a comprehensive theoretical framework grounded in the insights and experiences of nurses operating within the hospital settings of Iran. The study encompassed 20 participants, comprising 16 clinical nurses, two nurse managers, and two specialist doctors working in hospital settings. The selection process involved purposeful and theoretical sampling methods to ensure diverse perspectives. Data collection unfolded through in-depth, individual, semi-structured interviews, persisting until data saturation was achieved. The analytical framework proposed by Corbin and Strauss (2015) guided the process, leading to the development of a coherent theory encapsulating the essence of the study phenomenon. FINDINGS: The primary finding of the study underscores the significance of 'legal threat and job prestige' highlighting diverse repercussions in case of errors in the implementation of medical orders. At the core of the investigation, the central variable and the theory of the study was the 'selective and tasteful implementation of orders to avoid legal and organizational accountability.' This indicated a set of strategies employed by the nurses in the implementation of medical orders, encapsulated through three fundamental concepts: 'accuracy in controlling medical orders,' 'untruth documentation,' and 'concealment of events. The formidable influence of legal threats and job prestige was further compounded by factors such as heavy workloads, the doctor's non-compliance with legal instructions for giving verbal orders, the addition of orders by the doctor without informing nurses, and pressure by nursing managers to complete documentation. The resultant psychological distress experienced by nurses not only jeopardized patient safety but also underscored the intricate interplay between legal implications and professional standing within the healthcare framework. CONCLUSION: Alleviating staff shortages, enhancing the professional rapport between doctors and nurses, offering legal support to nursing staff, implementing measures such as recording departmental phone conversations to deter the non-acceptance of verbal orders, fostering an organizational culture that embraces nurse fallibility and encourages improvement, and upgrading equipment can ameliorate nurses' apprehensions and contribute to the safe implementation of medical orders.

Nursing documentation and its relationship with perceived nursing workload: a mixed-methods study among community nurses.

BACKGROUND: The time that nurses spent on documentation can be substantial and burdensome. To date it was unknown if documentation activities are related to the workload that nurses perceive. A distinction between clinical documentation and organizational documentation seems relevant. This study aims to gain insight into community nurses' views on a potential relationship between their clinical and organizational documentation activities and their perceived nursing workload. METHODS: A convergent mixed-methods design was used. A quantitative survey was completed by 195 Dutch community nurses and a further 28 community nurses participated in qualitative focus groups. For the survey an online questionnaire was used. Descriptive statistics, Wilcoxon signed-ranked tests, Spearman's rank correlations and Wilcoxon rank-sum tests were used to analyse the survey data. Next, four qualitative focus groups were conducted in an iterative process of data collection - data analysis - more data collection, until data saturation was reached. In the qualitative analysis, the six steps of thematic analysis were followed. RESULTS: The majority of the community nurses perceived a high workload due to documentation activities. Although survey data showed that nurses estimated that they spent twice as much time on clinical documentation as on organizational documentation, the workload they perceived from these two types of documentation was comparable. Focus-group participants found organizational documentation particularly redundant. Furthermore, the survey indicated that a perceived high workload was not related to actual time spent on clinical documentation, while actual time spent on organizational documentation was related to the perceived workload. In addition, the survey showed no associations between community nurses' perceived workload and the user-friendliness of electronic health records. Yet focus-group participants did point towards the impact of limited user-friendliness on their perceived workload. Lastly, there was no association between the perceived workload and whether the nursing process was central in the electronic health records. CONCLUSIONS: Community nurses often perceive a high workload due to clinical and organizational documentation activities. Decreasing the time nurses have to spend specifically on organizational documentation and improving the user-friendliness and intercommunicability of electronic health records appear to be important ways of reducing the workload that community nurses perceive.

Patient participation in electronic nursing documentation: an interview study among community nurses.

BACKGROUND: Patient participation in nursing documentation has several benefits like including patients' personal wishes in tailor-made care plans and facilitating shared decision-making. However, the rise of electronic health records may not automatically lead to greater patient participation in nursing documentation. This study aims to gain insight into community nurses' experiences regarding patient participation in electronic nursing documentation, and to explore the challenges nurses face and the strategies they use for dealing with challenges regarding patient participation in electronic nursing documentation. METHODS: A qualitative descriptive design was used, based on the principles of reflexive thematic analysis. Nineteen community nurses working in home care and using electronic health records were recruited using purposive sampling. Interviews guided by an interview guide were conducted face-to-face or by phone in 2019. The interviews were inductively analysed in an iterative process of data collection-data analysis-more data collection until data saturation was achieved. The steps of thematic analysis were followed, namely familiarization with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and reporting. RESULTS: Community nurses believed patient participation in nursing documentation has to be tailored to each patient. Actual participation depended on the phase of the nursing process that was being documented and was facilitated by patients' trust in the accuracy of the documentation. Nurses came across challenges in three domains: those related to electronic health records (i.e. technical problems), to work (e.g. time pressure) and to the patients (e.g. the medical condition). Because of these challenges, nurses frequently did the documentation outside the patient's home. Nurses still tried to achieve patient participation by verbally discussing patients' views on the nursing care provided and then documenting those views at a later moment. CONCLUSIONS: Although community nurses consider patient participation in electronic nursing documentation important, they perceive various challenges relating to electronic health records, work and the patients to realize patient participation. In dealing with these challenges, nurses often fall back on verbal communication about the documentation. These insights can help nurses and policy makers improve electronic health records and develop efficient strategies for improving patient participation in electronic nursing documentation.

Nursing patient record practice and associated factors among nurses working in North Shewa Zone public hospitals, Ethiopia.

Background: Nursing documentation is an essential component of nursing practice and has the potential to improve patient care outcomes. Poor documentation of nursing care activities among nurses has been shown to have negative impacts on healthcare quality. Objective: To assess the nursing documentation practice and its associated factors among nurses working in the North Shewa Zone public hospitals, Ethiopia. Method: An institution-based cross-sectional study was conducted at the North Shewa Zone public hospitals. A simple random sampling technique was used to select 421 nurses. A pretested, structured, self-administered questionnaire was used to gather the data. Data were entered into Epi Data version 3.1, and SPSS version 25 was used for further analysis. Binary logistic regressions were performed to identify the independent predictors of nursing documentation practice. Adjusted odds ratio was calculated and a p-value less than 0.05 with 95% confidence interval (CI) was considered as statistically significant. Result: A total of 421 respondents took part, giving the survey a 100% response rate. The overall good practice of nursing care documentation was 51.1%, 95% CI (46.6, 55.8). In addition, 43.2%, 95% CI (38.5, 48.0) and 35.6%, 95% CI (30.9, 40.1), of nurses had good knowledge of and favorable attitudes toward nursing care documentation. Availability of operational standards for nursing documentation [adjusted odds ratio (AOR) = 1.76; 95% CI: 1.18, 2.64], availability of documenting sheets (AOR = 1.51; 95% CI: 1.01, 2.29), and a monitoring system (AOR = 1.61; 95% CI: 1.07, 2.41) were significantly associated with nursing care documentation practice. Conclusion: Nearly half of nursing care was not documented. The practice of nursing care documentation was significantly influenced by the availability of operational standards, documenting sheets, and monitoring systems. To improve the documentation practice, a continuous monitoring system and access to operational standards and documenting sheets are needed.

Usability Study of an Electronic Medical Record From the Nurse Practitioners' Practice: A Qualitative Study Using the Think-Aloud Technique.

INTRODUCTION:  Ensuring the usability of electronic medical records (EMRs) is crucial for healthcare providers to offer efficient, effective, and safe patient care. Nurse practitioners (NPs) are integral to the healthcare system and are essential in managing patient workflows. However, few studies assess NPs' perspectives on how EMR usage affects workflow and patient care quality. METHOD: In this study, the "think-aloud technique" was utilized for usability testing. It involves observing users (NPs) as they complete their everyday tasks on the EMR while vocalizing their thoughts and emotions. This method has been proven reliable and valid through various research, such as a systematic review. RESULTS: The EMR system used by NPs can create a heavy cognitive workload, have limited functionality, can lead to unintended errors, and may experience technical difficulties. CONCLUSION: The EMR system used by NPs is challenging due to three main issues: high cognitive workload, limited system functionality, and technical problems. To improve the system, it is recommended to reduce the cognitive burden by customizing the user interface to fit the NPs' needs, enhancing the system's functionality by adding essential features and fixing any technical issues.

The Communicating Narrative Concerns Entered by Registered Nurses (CONCERN) Clinical Decision Support Early Warning System: Protocol for a Cluster Randomized Pragmatic Clinical Trial.

BACKGROUND: Every year, hundreds of thousands of inpatients die from cardiac arrest and sepsis, which could be avoided if those patients' risk for deterioration were detected and timely interventions were initiated. Thus, a system is needed to convert real-time, raw patient data into consumable information that clinicians can utilize to identify patients at risk of deterioration and thus prevent mortality and improve patient health outcomes. The overarching goal of the COmmunicating Narrative Concerns Entered by Registered Nurses (CONCERN) study is to implement and evaluate an early warning score system that provides clinical decision support (CDS) in electronic health record systems. With a combination of machine learning and natural language processing, the CONCERN CDS utilizes nursing documentation patterns as indicators of nurses' increased surveillance to predict when patients are at the risk of clinical deterioration. OBJECTIVE: The objective of this cluster randomized pragmatic clinical trial is to evaluate the effectiveness and usability of the CONCERN CDS system at 2 different study sites. The specific aim is to decrease hospitalized patients' negative health outcomes (in-hospital mortality, length of stay, cardiac arrest, unanticipated intensive care unit transfers, and 30-day hospital readmission rates). METHODS: A multiple time-series intervention consisting of 3 phases will be performed through a 1-year period during the cluster randomized pragmatic clinical trial. Phase 1 evaluates the adoption of our algorithm through pilot and trial testing, phase 2 activates optimized versions of the CONCERN CDS based on experience from phase 1, and phase 3 will be a silent release mode where no CDS is viewable to the end user. The intervention deals with a series of processes from system release to evaluation. The system release includes CONCERN CDS implementation and user training. Then, a mixed methods approach will be used with end users to assess the system and clinician perspectives. RESULTS: Data collection and analysis are expected to conclude by August 2022. Based on our previous work on CONCERN, we expect the system to have a positive impact on the mortality rate and length of stay. CONCLUSIONS: The CONCERN CDS will increase team-based situational awareness and shared understanding of patients predicted to be at risk for clinical deterioration in need of intervention to prevent mortality and associated harm. TRIAL REGISTRATION: ClinicalTrials.gov NCT03911687; https://clinicaltrials.gov/ct2/show/NCT03911687. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/30238.

Nurses' Experiences of Documenting the Mental Health of Older Patients in Long-Term Care.

Nursing documentation is repeatedly reported to be insufficient and unsatisfactory. Although nurses should apply a holistic approach, they tend to document physical needs more often than other caring dimensions. This study aimed to describe nurses' experiences documenting mental health in older patients receiving long-term care. Individual interviews were conducted with nine nurses and were analyzed by content analysis. One main theme, two categories and seven sub-categories emerged. The findings showed that the nurses perceived mental health as an ambiguous phenomenon that could be difficult to observe, interpret, and agree upon. Thus, the nurses were uncertain about what concepts and words corresponded to their observations. They also struggled with finding the right words to create accurate and complete documentation without breaking confidentiality or diminishing the dignity of the patient. The findings are relevant for nurses in different types of healthcare services and in the educational context to ensure comprehensive nursing documentation.

Nurses' perspectives of the nursing documentation audit process.

BACKGROUND: Nursing has an obligation to the public to develop measures for the quality of care to enhance patient safety and efficiency of the system. The first hospital to introduce the clinical audit of nursing documentation was in Abu Dhabi. The rationale was the recognition of the link between clinical audits and the quality of patient care and safety. This article recognises the importance of documentation audits in nursing practice and the role of nurses related to conducting audits in a selected hospital in Abu Dhabi. Many studies have shown the potential benefits of documentation audits to evaluate or assess the quality of recorded nursing assessments and care. AIM: The aim of this study was to explore nurses' perspectives of the documentation audit process. METHOD: The study adopted an exploratory, descriptive qualitative approach using the evaluation method. Data were collected using three focus group interviews consisting of 4 informatics and 13 documentation link nurses involved in the implementation of the clinical audit on nursing documentation in the selected hospital. Thematic analysis was used to analyse the data. RESULTS: Three major themes evolved from the research findings: implementation of documentation audit, evaluation of audit and measures to improve documentation audit. Strengths and weaknesses of the documentation audit were articulated by the nurses. Generally, nurses were satisfied with the audit process and made recommendations on improvements. CONCLUSION: Processes adopted by the team were reasonable and useful, and the preparation and planning for the clinical audit were regarded as areas of strength. Areas of weaknesses in the implementation processes identified included dissemination of findings and executing improvements. This could be improved with necessary support from the hospital management, especially with regard to release time to implement required changes. The complexity of auditing electronic versus paper-based nursing documentation is acknowledged.

Nurses' information exchange during older patient transfer: prevalence and associations with patient and transfer characteristics.

INTRODUCTION: To ensure continuity of care, it is important to effectively communicate the health status of older patients who are transferred between health care organizations. The objectives of this study were to: (1) evaluate the prevalence of nursing transfer documents, and (2) identify patient and transfer characteristics associated with the presence of nursing transfer documents for older patients transferred from home care to hospital and back to home care again after hospitalization. METHODS: Nursing documents were reviewed from a total of 102 records of older inpatients admitted from home care to medical wards at a local hospital in central Norway and later discharged home. Frequencies were used to describe patient and transfer characteristics, and the prevalence of transfer documents. Pearson's χ(2) test and logistic regression were used to identify possible associations between patient and transfer characteristics and the presence of nursing transfer documents. RESULTS: While nursing admission notes were present in 1% of the patient transfers from home care to the hospital, 69% of patient discharges from the hospital to home care were accompanied by nursing discharge notes. Patient and transfer characteristics associated with the presence of a nursing discharge note were age, gender, medical department facility, and length of hospital stay. CONCLUSIONS: The low prevalence of nursing transfer documents constitutes a challenge to the continuity of care for hospitalized home care patients. Patient and transfer characteristics may impact the nurses' propensity to exchange patient information. These findings emphasize the need for nurses and managers to improve the exchange of written information. While nurses must strive to transfer accurate patient information at the right place and at the right time, the managers must facilitate this by providing appropriate guidelines and standards, as well as adequate personnel and resources.

A comparative study on effect of e-learning and instructor-led methods on nurses' documentation competency.

BACKGROUND: Accurate recording of the nursing care indicates the care performance and its quality, so that, any failure in documentation can be a reason for inadequate patient care. Therefore, improving nurses' skills in this field using effective educational methods is of high importance. Since traditional teaching methods are not suitable for communities with rapid knowledge expansion and constant changes, e-learning methods can be a viable alternative. To show the importance of e-learning methods on nurses' care reporting skills, this study was performed to compare the e-learning methods with the traditional instructor-led methods. METHODS: This was a quasi-experimental study aimed to compare the effect of two teaching methods (e-learning and lecture) on nursing documentation and examine the differences in acquiring competency on documentation between nurses who participated in the e-learning (n = 30) and nurses in a lecture group (n = 31). RESULTS: The results of the present study indicated that statistically there was no significant difference between the two groups. The findings also revealed that statistically there was no significant correlation between the two groups toward demographic variables. However, we believe that due to benefits of e-learning against traditional instructor-led method, and according to their equal effect on nurses' documentation competency, it can be a qualified substitute for traditional instructor-led method. CONCLUSIONS: E-learning as a student-centered method as well as lecture method equally promote competency of the nurses on documentation. Therefore, e-learning can be used to facilitate the implementation of nursing educational programs.