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. How- ever, studies show its poor quality. Objectives: This study compared nurses’ and head nurses’ perspectives on the factors behind the quality of nursing documenta- tion. Methods: This descriptive-correlational study was conducted in 2017 in Valiasr (PBUH) Hospital, Birjand, Iran. Accordingly, 140 eli- gible nurses and all 15 head-nurses in the hospital were recruited to the study through simple random sampling and census, respec- tively. 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 organiza- tional 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.