Comparing Nurses’ and Head Nurses’ Perspectives on the Factors Behind the Quality of Nursing Documentation

Abstract

Background: Nursing documentation has significant roles in giving coherence to teamwork, making effective use of healthcare providers’ knowledge, improving care quality, maintaining care continuity, and identifying changes in patients’ conditions. However, studies show its poor quality. Objectives: This study compared nurses’ and head nurses’ perspectives on the factors behind the quality of nursing documentation. Methods: This descriptive-correlational study was conducted in 2017 in Valiasr (PBUH) Hospital, Birjand, Iran. Accordingly, 140 eligible nurses and all 15 head-nurses in the hospital were recruited to the study through simple random sampling and census, respectively. They filled out a researcher-made 26-item questionnaire about factors behind the quality of nursing documentation. Because of the non-normal distribution of the study variables, the Mann-Whitney U, Kruskal-Wallis, and Friedman tests were used for data analysis. The level of significance was set at less than 0.05. Results: Head nurses did not significantly differ from nurses respecting the mean scores of personal, managerial, and organizational factors behind the documentation quality (P > 0.05). The highest-scored factors were organizational factors. Conclusions: Organizational factors are the most important factors behind the quality of nursing documentation. Thus, adequate nurse staffing and avoidance from assigning non-nursing responsibilities to nurses are recommended to improve the quality of nursing documentation.