Nurses� perception of nursing services documentation barriers: A qualitative approach

Abstract

Background: Researches has shown that the quality of nursing documentation services in the world, including Iran, is far from existing standards. Understanding the barriers to improving the documentation of nursing services is essential for the first step. The aim of this study was to identify barriers to improving the nursing documentation services using the experience of nurses in the emergency department of one of the Iranian hospitals. Materials and Methods: This study is based on content analysis in accordance with the style of Graneheim in 2017 in the emergency department of one of the Iranian hospitals. This qualitative study was performed on 20 participant from different nursing grades including 17 nurses, 1 head nurse, and 2 members of the accreditation committee. The data were collected through semi-structured interviews and using interview guide and field note. Results: Research data have been explained in four main themes of qualification of documentation including sub-categories of the need for effective training, the need for training in the standards of documentation, and the necessity of skills in reporting; job burnout including sub-categories of job stress and work pressure; perceived control including sub-categories of planned control and effective monitoring and control; intra-organizational coordination including sub-categories of improving health information system and documentation management time, legal barrier for documentation including sub-categories of escaping from the law and legal liabilities. Conclusion: In this study, 599 primary codes were extracted and the main themes documentation competency, job burnout, perceived control, intraorganizational coordination, and legal barrier extracted. © 2018 by the authors; licensee Modestum Ltd., UK