RESUMO
BACKGROUND: Real-time documentation is a novel process that changes nursing workflow; however, nurses' experiences of real-time documentation are unknown. AIM: This study aimed to explore nurses' experiences with real-time documentation in an orthopaedic ward. DESIGN: This qualitative study took a phenomenological-hermeneutic approach. METHODS: Data were generated from three semi-structured focus group interviews with 18 nurses from an orthopaedic ward. Data analysis was based on Ricoeur's theory of narrative and interpretation and included naïve reading, structural analysis and critical interpretation, and discussion. RESULTS: Five themes emerged from the structural analysis: 1) nurses were initially sceptical and outside of their comfort zone; 2) implementation required support from the head nurse and other colleagues; 3) increased time with patients led to better relationships, but nurses lacked time for reflection; 4) increased patient involvement could also present challenges; and 5) documentation became more integrated into orthopaedic nursing. CONCLUSION: Real-time documentation improved orthopaedic nursing documentation and increased patient involvement. Nurses spent more time with patients, leading to better relationships, but they had decreased time with their colleagues and the opportunity to reflect. Real-time documentation leads to changes in workflow, so, nurses should be provided with training and the opportunity to reflect.
