Voices From the Frontline: A Qualitative Study of Nurses’ Experiences With Documentation and Its Influence on Patient Safety

Abstract

Aim: This study aimed to explore nurses’ perceptions, experiences, and challenges related to clinical documentation and its influence on patient safety in Saudi Arabia. Background: Nursing documentation, a critical aspect of clinical practice, directly influences patient safety, care continuity, and legal accountability. Despite the increasing adoption of electronic health records, nurses continue to encounter numerous challenges in maintaining accurate and timely documentation, particularly in high-pressure healthcare environments. Methods: A qualitative descriptive design was employed. Nine nurses with at least two years of clinical experience from various teaching hospitals in Saudi Arabia were recruited through purposive sampling. Data were collected through face-to-face semistructured interviews conducted between June and September 2023. Thematic analysis was conducted following an inductive coding approach supported by MAXQDA software to identify recurring themes and subthemes. Results: Three major themes emerged: (1) the perceived value of documentation as a legal and clinical tool; (2) barriers to effective documentation, including time constraints, lack of training, inconsistent practices, and weak handovers; and (3) nurses’ efforts to improve documentation quality despite feeling unheard in institutional decision-making. The participants highlighted a shift in perception, viewing documentation not only as a protective measure but also as a key component of patient safety and care quality. Conclusion: The findings underscore the need for improved documentation training, standardized practices, and greater involvement of nurses in policy development. Addressing these gaps may enhance documentation accuracy, reduce burden, and promote safer patient outcomes.