Unsafe nursing documentation: A qualitative content analysis

Abstract

Background Nursing documentation as a pivotal part of nursing care has many implications for patient care in terms of safety and ethics. Objectives To explore factors influencing nursing documentation from nurses’ perspectives in the Iranian nursing context. Methods This qualitative study was carried out using a qualitative content analysis of data collected from 2018 to 2019 in two urban areas of Iran. Semi-structured interviews (n = 15), observations, and reviews of patients’ medical files were used for data collection. Ethical considerations This study was conducted in accordance with the ethical principles of research and regulations in terms of confidentiality of data, anonymity, and provision of informed consent. Findings The main theme of this study was “unsafe documentation.” Two categories, “types of errors in reporting” and “reasons of errors in reporting,” and 12 subcategories were developed indicating factors influencing nursing documentation in the Iranian nursing context. Conclusion In general, individual, organizational, and national factors affected nursing documentation in Iran. In this respect, hiring more nurses, application of reforms in the healthcare management structure, devising appropriate regulations regarding division of labor, constant education of healthcare staff, establishment of clinical governance, improvement of interpersonal relationships, development of hardware and software techniques for documentation, and provision of support should be done to improve the quality of nursing documentation. The above-mentioned suggestions can help nurses with a safe, ethical, lawful, and reliable documentation in nursing practice.