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The Hidden Impact of Nursing Documentation Requirements

P. McLiesh, R. Wiechula, and P. Rasmussen 1
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1 Adelaide Nursing School, University of Adelaide, Australia

Background: Patient assessment is the cornerstone of nursing care. How assessment is conducted
and then documented has changed significantly over time. The impact of those changes has been
poorly recognised and measured.

Objective: To determine if compliance with existing patient assessment documentation requirements
negatively affects expert nurses satisfaction and care delivery. Research was conducted to explore
the existing institutional factors that guide documentation requirements and how they are
experienced by expert nurses.

Methods: Expert nurses were asked whether the complexity of existing requirements negatively
affected their ability to deliver patient care. Institutional factors that influenced how and who
designed documentation requirements were identified and mapped. These were established
through interviews, direct observations and mapping of relevant documents and policies related
to patient assessment documentation.

Results: The expert nurses’ identified that the current documentation requirements were time
consuming, onerous, and interfered with their ability to deliver care efficiently. Complex requirements
and an inability to individualise their practice frustrated the nurses. Standardisation of documentation
requirements resulted in a disproportionate emphasis on documentation compliance, which
frustrates nurses and reduced their capacity to deliver care.

Conclusion: The requirements that determine how and when nurses document nursing care have
Oral Presentation Abstracts
been poorly coordinated, resulting in complex and time-consuming processes. Neither the time
nurses spend documenting patient needs nor the impact of those requirements has been adequately
measured. Experts recognise that existing documentation requirements do not suit their needs but
are not sure how to change the requirements. A disproportionate focus on documentation
compliance has resulted in measuring the effect of care using surrogate measures such as
compliance, rather than measuring the impact of nursing care against patient outcomes.

Expanding our understanding of the impact of current documentation requirements will allow the
profession to refine those requirements to enhance nurses’ satisfaction, improve nursing retention
rates and maximise the efficiency of care delivery.

Keywords: assessment, documentation, expert practice, institutional ethnography

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Correspondence: Paul McLiesh, Adelaide Nursing School, University of Adelaide, Australia
E-mail: paul.mcliesh@adelaide.edu.au

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