Authors: Vabo G, Slettebø Å, Fossum M
J Clin Nurs. 2017 Apr;26(7-8):983-993
AIMS AND OBJECTIVES: The aim of this study is to describe healthcare professionals' experiences and perceptions of an intervention implemented in an action research project conducted to improve nursing documentation practices in four municipalities in Norway.
BACKGROUND: Documentation of individualized patient care is a continuing concern in healthcare services and could impacts the quality and safety of healthcare. Use of electronic systems has made some aspects of documentation more comprehensive, but creation of an individualized care plan remains a pressing issue.
DESIGN: A qualitative descriptive design was used.
METHODS: An action research project was conducted between 2010-2012 to improve the content and quality of nursing documentation in community healthcare services in four municipalities. One year after the project was completed four focus group interviews were conducted with healthcare professionals, one for each involved municipality. Two unit managers were interviewed individually. Qualitative content analysis was used.
RESULTS: Three themes emerged: healthcare professionals perceived competing interest; they experienced that they had to manage complexity and changes; and they highlighted a clear and visible leader as important for success.
CONCLUSIONS: Quality improvement activities are essential. Healthcare professionals experience a complicated situation when electronic health record systems do not support workflow. Further research is recommended to focus on the functionality and user interface of electronic health record systems, and on the role of leadership when implementing changes in clinical practice.
RELEVANCE TO CLINICAL PRACTICE: Stronger cooperation among policymakers, electronic health record system vendors, and healthcare professionals is essential for improving electronic health record systems and documentation practices. Involvement of end-users in these improvements can make a difference in the way the systems are perceived in the clinical workflow.