Home care nurses’ views regarding nursing documentation in relation to perceived documentation burden: a focus group study.

Abstract

Background: Accurate nursing documentation is essential for providing safe and efficient patient care. Increased documentation influences nurses’ documentation burden. Literature indicates that challenges with the electronic health record (EHR) documentation may affect the perceived documentation burden. Thus, an improved understanding of the perceived documentation burden is needed. Aims: The study aims to gain in-depth knowledge about the views of home care nurses regarding nursing documentation in relation to perceived documentation burden. The secondary aim is to explore whether these views vary between home care nurses with different educational levels. Method: This study was conducted following an explorative, qualitative design using homogeneous focus groups (nurses with bachelor’s degrees) and heterogeneous focus groups (nurses with bachelor’s and secondary degrees). The transcripts were analysed using the thematic analysis method by Braun and Clarke (2006). Results: A total of four focus groups (n = 28) were conducted: one face-to-face and three online. Several factors were found to increase the perceived documentation burden: the lack of perceived usefulness and importance of the documentation, which was higher for organisation-related documentation compared to client-related documentation; non-user-friendly EHR systems; lack of information exchange among healthcare professionals; organisational characteristics such as low level of organisational support; and poor integration of different documentation systems. Nurses with bachelor’s degrees experienced a higher documentation burden than nurses with secondary degrees. Conclusion and recommendations: Documentation burden is caused by various factors. Home care nurses should be assisted by user-friendly EHR systems in which information can be transferred from other healthcare professionals’ systems. Additionally, organisations should work closely with nurses to critically assess their documentation activities. Future research should focus on further investigating the differences between home care nurses with bachelor’s and secondary degrees.