Patient Safety Through Nursing Documentation: Barriers Identified by Healthcare Professionals and Students

被引:21
作者
Bjerkan, Jorunn [1 ,2 ]
Valderaune, Victor [3 ,4 ]
Olsen, Rose Mari [2 ,3 ]
机构
[1] Nord Univ, Fac Nursing & Hlth Sci, Levanger, Norway
[2] Ctr Care Res Midnorway, Levanger, Norway
[3] Nord Univ, Fac Nursing & Hlth Sci, Namsos, Norway
[4] Ctr Dev Inst & Home Care Serv, Municipality Of Aagord, Norway
来源
FRONTIERS IN COMPUTER SCIENCE | 2021年 / 3卷
关键词
electronic patient record; nursing; patient safety; primary health care; documentation; focus group; QUALITATIVE RESEARCH; PERSPECTIVE; RECORD;
D O I
10.3389/fcomp.2021.624555
中图分类号
TP39 [计算机的应用];
学科分类号
081203 ; 0835 ;
摘要
Background: Although access to accurate patient documentation is recognized as a prerequisite for delivering of safe and continuous municipal elderly care, healthcare professionals often fail to provide comprehensive clinical information in an accurate and timely manner. The aim of this study was to understand the perceptions of healthcare professionals and healthcare students regarding existing barriers to patient safety through the performance of documentation practices. Methods: Using a qualitative, exploratory design, this study conducted six focus group interviews with nurses and social educators (n = 12) involved in primary care practice and nursing and social educator bachelor's degree students from a University College (n = 11). Data were analyzed using qualitative content analysis. Results: Four themes emerged from the analysis, which described barriers to patient safety and quality in documentation practices: "Individual factors," "Social factors," "Organizational factors," and "Technological factors." Each theme also included several sub-themes. Conclusion: According to the findings, several barriers negatively influenced documentation practices and information exchange, which may place primary care patients in a vulnerable and exposed situation. To achieve successful documentation, increased awareness and efforts by the individual professional are necessary. However, primary care services must facilitate the achievement of these goals by providing adequate resources, clear mission statements, and understandable policies.
引用
收藏
页数:11
相关论文
共 64 条
[1]   The path to integrated healthcare: Various Scandinavian strategies [J].
Ahgren, Bengt .
INTERNATIONAL JOURNAL OF CARE COORDINATION, 2014, 17 (1-2) :52-58
[2]   Quality of nursing documentation: Paper-based health records versus electronic-based health records [J].
Akhu-Zaheya, Laila ;
Al-Maaitah, Rowaida ;
Hani, Salam Bany .
JOURNAL OF CLINICAL NURSING, 2018, 27 (3-4) :e578-e589
[3]   A Systems Approach to Identify Factors Influencing Adverse Drug Events in Nursing Homes [J].
Al-Jumaili, Ali Azeez ;
Doucette, William R. .
JOURNAL OF THE AMERICAN GERIATRICS SOCIETY, 2018, 66 (07) :1420-1427
[4]   Factors affecting and affected by user acceptance of computer-based nursing documentation:: Results of a two-year study [J].
Ammenwerth, E ;
Mansmann, U ;
Iller, C ;
Eichstädter, R .
JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION, 2003, 10 (01) :69-84
[5]   Factors contributing to serious adverse events in nursing homes [J].
Andersson, Asa ;
Frank, Catharina ;
Willman, Ania M. L. ;
Sandman, Per-Olof ;
Hansebo, Goerel .
JOURNAL OF CLINICAL NURSING, 2018, 27 (1-2) :E354-E362
[6]  
[Anonymous], 2022, ESSENTIALS NURSING R
[7]  
[Anonymous], CONTENT ANAL INTRO I
[8]  
Barkhordari-Sharifabad M, 2017, J MED ETHICS HIST ME, V10
[9]   Sufficient competence in community elderly care? Results from a competence measurement of nursing staff [J].
Bing-Jonsson P.C. ;
Hofoss D. ;
Kirkevold M. ;
Bjørk I.T. ;
Foss C. .
BMC Nursing, 15 (1)
[10]   Nursing documentation: Frameworks and barriers [J].
Blair, Wendy ;
Smith, Barbara .
CONTEMPORARY NURSE, 2012, 41 (02) :160-168