Nursing documentation in the Emergency Department: nurses' perspectives

Abstract

Nursing documentation is a required aspect of care, but for various reasons it can be curtailed. Nursing records are a critical aspect of communication and without them coordinated and safe care can be difficult to achieve. Study aim: To explore emergency nurses' perspectives and practices about the quality, importance and value of emergency nursing documentation in relation to their personal beliefs, past experiences and preferred systems of documentation; the practical and contextual factors that influence documentation practices within an emergency department (ED); their interests in documentation tools or systems; and their interests in relation to further development of documentation practices and systems. Methodology and design: A qualitative descriptive study (informed by Sandelowski, 2000b). Ten emergency nurses from one ED in New Zealand were recruited. Participants were interviewed using interactive interview methods, and completed a Likert scale to identify the relevance of internationally recognised general influences on documentation to their own practices in the context of an ED. Findings: The participants' practices were influenced by factors in the workplace including competing priorities for time for example care provision versus documentation, competition for access to patient records, and extant culture in relation to the purpose, content and frameworks for documentation. Documentation practices were influenced by the participant's own clinical histories, philosophies, familiarity with particular frameworks and education. The participants recommended routes to development through partnership, participation and process engagement. Recommended strategies included document development, knowledge advancement and support. These findings were reported qualitatively and reveal areas of agreement and divergence. Contribution and consequences: These results compare well to the general literature regarding known influences on documentation. Importantly they provide insight and generate new knowledge into context specific influences and to the relevance of personal histories to documentation practices. A consequence of this research will be to better understand the context and practice of nursing documentation in ED, the factors that influence it and the potential means for development which support the legal and professional goals of optimal documentation.