School of Nursing, Midwifery and Public Health, University of Canberra, Bruce, Australian Capital Territory, Australia.
Canberra Health Services & ACT Health, SYNERGY Nursing & Midwifery Research Centre, Canberra, Australian Capital Territory, Australia.
J Adv Nurs. 2023 Sep;79(9):3440-3455. doi: 10.1111/jan.15685. Epub 2023 Apr 27.
To understand how nurses talk about documentation audit in relation to their professional role.
Nursing documentation in health services is often audited as an indicator of nursing care and patient outcomes. There are few studies exploring the nurses' perspectives on this common process.
Secondary qualitative thematic analysis.
Qualitative focus groups (n = 94 nurses) were conducted in nine diverse clinical areas of an Australian metropolitan health service for a service evaluation focussed on comprehensive care planning in 2020. Secondary qualitative analysis of the large data set using reflexive thematic analysis focussed specifically on the nurse experience of audit, as there was the significant emphasis by participants and was outside the scope of the primary study.
Nurses': (1) value quality improvement but need to feel involved in the cycle of change, (2) highlight that 'failed audit' does not equal failed care, (3) describe the tension between audited documentation being just bureaucratic and building constructive nursing workflows, (4) value building rapport (with nurses, patients) but this often contrasted with requirements (organizational, legal and audit) and additionally, (5) describe that the focus on completion of documentation for audit creates unintended and undesirable consequences.
Documentation audit, while well-intended and historically useful, has unintended negative consequences on patients, nurses and workflows.
Accreditation systems rely on care being auditable, but when individual legal, organizational and professional standards are implemented via documentation forms and systems, the nursing burden is impacted at the point of care for patients, and risks both incomplete cares for patients and incomplete documentation.
Patients participated in the primary study on comprehensive care assessment by nurses but did not make any comments about documentation audit.
了解护士在其专业角色中如何谈论文档审核。
医疗服务中的护理文档通常作为护理质量和患者结果的指标进行审核。很少有研究探讨护士对这一常见过程的看法。
二次定性主题分析。
在 2020 年，对澳大利亚大都市卫生服务机构的九个不同临床领域进行了定性焦点小组（n=94 名护士），这是一项针对全面护理计划的服务评估。对大型数据集进行二次定性分析，使用反思性主题分析专门针对护士对审核的体验进行分析，因为参与者非常强调这一点，并且超出了主要研究的范围。
护士们：（1）重视质量改进，但需要感到参与到变革周期中，（2）强调“审核失败”并不等于护理失败，（3）描述审核文档既官僚又有助于构建建设性护理工作流程之间的紧张关系，（4）重视建立融洽关系（与护士、患者），但这常常与要求（组织、法律和审核）相冲突，此外，（5）描述为了审核而完成文档的重点会产生意想不到的和不良的后果。
文档审核虽然初衷良好且历史上有用，但对患者、护士和工作流程产生了意想不到的负面影响。
认证系统依赖于可审核的护理，但当通过文档表格和系统实施个别法律、组织和专业标准时，患者护理的护理负担会受到影响，并且存在患者护理不完整和文档不完整的风险。
患者参与了护士对全面护理评估的主要研究，但对文档审核没有任何意见。
