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Unsafe nursing documentation: A qualitative content analysis
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 carrie...
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| Published in: | Nursing ethics 2020-08, Vol.27 (5), p.1213-1224 |
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| Main Authors: | , , , |
| Format: | Article |
| Language: | English |
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| cites | cdi_FETCH-LOGICAL-c365t-e60483bbd3b3a4d4bd075f29c3907537baebebcfbac66577c9c3115aefff52cd3 |
| container_end_page | 1224 |
| container_issue | 5 |
| container_start_page | 1213 |
| container_title | Nursing ethics |
| container_volume | 27 |
| creator | Tajabadi, Ali Ahmadi, Fazlollah Sadooghi Asl, Afsaneh Vaismoradi, Mojtaba |
| description | 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. |
| doi_str_mv | 10.1177/0969733019871682 |
| format | article |
| fullrecord | <record><control><sourceid>proquest_cross</sourceid><recordid>TN_cdi_proquest_miscellaneous_2284000520</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sage_id>10.1177_0969733019871682</sage_id><sourcerecordid>2284000520</sourcerecordid><originalsourceid>FETCH-LOGICAL-c365t-e60483bbd3b3a4d4bd075f29c3907537baebebcfbac66577c9c3115aefff52cd3</originalsourceid><addsrcrecordid>eNp1kM1LwzAYxoMobk7vnqTgxUs1H82XeBnDLxh4ceeSpMnoaNOtaYX996Z0Kgw8JeH5Pc_75gHgGsF7hDh_gJJJTghEUnDEBD4BU5RxnkIp5CmYDnI66BNwEcIGQsix4OdgQiLFJBNT8LTyQTmb-L4NpV8nRWP62vpOdWXjH5N5sutVVQ7PL5uYxndRS5RX1T6U4RKcOVUFe3U4Z2D18vy5eEuXH6_vi_kyNYTRLrUMZoJoXRBNVFZkuoCcOiwNkfFCuFZWW22cVoYxyrmJCkJUWeccxaYgM3A35m7bZtfb0OV1GYytKuVt04ccY5HFz1EMI3p7hG6avo37RirDEgqKKIkUHCnTNiG01uXbtqxVu88RzIdm8-Nmo-XmENzr2ha_hp8qI5COQFBr-zf138BvUoOAUA</addsrcrecordid><sourcetype>Aggregation Database</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>2429085153</pqid></control><display><type>article</type><title>Unsafe nursing documentation: A qualitative content analysis</title><source>Applied Social Sciences Index & Abstracts (ASSIA)</source><source>SAGE</source><creator>Tajabadi, Ali ; Ahmadi, Fazlollah ; Sadooghi Asl, Afsaneh ; Vaismoradi, Mojtaba</creator><creatorcontrib>Tajabadi, Ali ; Ahmadi, Fazlollah ; Sadooghi Asl, Afsaneh ; Vaismoradi, Mojtaba</creatorcontrib><description>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.</description><identifier>ISSN: 0969-7330</identifier><identifier>EISSN: 1477-0989</identifier><identifier>DOI: 10.1177/0969733019871682</identifier><identifier>PMID: 31476968</identifier><language>eng</language><publisher>London, England: SAGE Publications</publisher><subject>Adult ; Clinical governance ; Confidentiality ; Content analysis ; Division of labor ; Documentation ; Documentation - standards ; Documentation - statistics & numerical data ; Ethics ; Female ; Health care ; Hiring ; Humans ; Informed consent ; Interpersonal relations ; Interviews as Topic - methods ; Iran ; Male ; Medical ethics ; Nurses ; Nursing ; Nursing care ; Nursing Care - methods ; Nursing Care - standards ; Nursing Care - statistics & numerical data ; Patient Safety - standards ; Patient Safety - statistics & numerical data ; Patients ; Professional practice ; Qualitative Research ; Regulation ; Unsafe ; Urban areas</subject><ispartof>Nursing ethics, 2020-08, Vol.27 (5), p.1213-1224</ispartof><rights>The Author(s) 2019</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c365t-e60483bbd3b3a4d4bd075f29c3907537baebebcfbac66577c9c3115aefff52cd3</citedby><cites>FETCH-LOGICAL-c365t-e60483bbd3b3a4d4bd075f29c3907537baebebcfbac66577c9c3115aefff52cd3</cites><orcidid>0000-0002-1961-7735</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>314,778,782,27907,27908,30982,79115</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/31476968$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Tajabadi, Ali</creatorcontrib><creatorcontrib>Ahmadi, Fazlollah</creatorcontrib><creatorcontrib>Sadooghi Asl, Afsaneh</creatorcontrib><creatorcontrib>Vaismoradi, Mojtaba</creatorcontrib><title>Unsafe nursing documentation: A qualitative content analysis</title><title>Nursing ethics</title><addtitle>Nurs Ethics</addtitle><description>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.</description><subject>Adult</subject><subject>Clinical governance</subject><subject>Confidentiality</subject><subject>Content analysis</subject><subject>Division of labor</subject><subject>Documentation</subject><subject>Documentation - standards</subject><subject>Documentation - statistics & numerical data</subject><subject>Ethics</subject><subject>Female</subject><subject>Health care</subject><subject>Hiring</subject><subject>Humans</subject><subject>Informed consent</subject><subject>Interpersonal relations</subject><subject>Interviews as Topic - methods</subject><subject>Iran</subject><subject>Male</subject><subject>Medical ethics</subject><subject>Nurses</subject><subject>Nursing</subject><subject>Nursing care</subject><subject>Nursing Care - methods</subject><subject>Nursing Care - standards</subject><subject>Nursing Care - statistics & numerical data</subject><subject>Patient Safety - standards</subject><subject>Patient Safety - statistics & numerical data</subject><subject>Patients</subject><subject>Professional practice</subject><subject>Qualitative Research</subject><subject>Regulation</subject><subject>Unsafe</subject><subject>Urban areas</subject><issn>0969-7330</issn><issn>1477-0989</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2020</creationdate><recordtype>article</recordtype><sourceid>7QJ</sourceid><recordid>eNp1kM1LwzAYxoMobk7vnqTgxUs1H82XeBnDLxh4ceeSpMnoaNOtaYX996Z0Kgw8JeH5Pc_75gHgGsF7hDh_gJJJTghEUnDEBD4BU5RxnkIp5CmYDnI66BNwEcIGQsix4OdgQiLFJBNT8LTyQTmb-L4NpV8nRWP62vpOdWXjH5N5sutVVQ7PL5uYxndRS5RX1T6U4RKcOVUFe3U4Z2D18vy5eEuXH6_vi_kyNYTRLrUMZoJoXRBNVFZkuoCcOiwNkfFCuFZWW22cVoYxyrmJCkJUWeccxaYgM3A35m7bZtfb0OV1GYytKuVt04ccY5HFz1EMI3p7hG6avo37RirDEgqKKIkUHCnTNiG01uXbtqxVu88RzIdm8-Nmo-XmENzr2ha_hp8qI5COQFBr-zf138BvUoOAUA</recordid><startdate>202008</startdate><enddate>202008</enddate><creator>Tajabadi, Ali</creator><creator>Ahmadi, Fazlollah</creator><creator>Sadooghi Asl, Afsaneh</creator><creator>Vaismoradi, Mojtaba</creator><general>SAGE Publications</general><general>SAGE PUBLICATIONS, INC</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7QJ</scope><scope>ASE</scope><scope>FPQ</scope><scope>K6X</scope><scope>K9.</scope><scope>NAPCQ</scope><scope>7X8</scope><orcidid>https://orcid.org/0000-0002-1961-7735</orcidid></search><sort><creationdate>202008</creationdate><title>Unsafe nursing documentation: A qualitative content analysis</title><author>Tajabadi, Ali ; Ahmadi, Fazlollah ; Sadooghi Asl, Afsaneh ; Vaismoradi, Mojtaba</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c365t-e60483bbd3b3a4d4bd075f29c3907537baebebcfbac66577c9c3115aefff52cd3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2020</creationdate><topic>Adult</topic><topic>Clinical governance</topic><topic>Confidentiality</topic><topic>Content analysis</topic><topic>Division of labor</topic><topic>Documentation</topic><topic>Documentation - standards</topic><topic>Documentation - statistics & numerical data</topic><topic>Ethics</topic><topic>Female</topic><topic>Health care</topic><topic>Hiring</topic><topic>Humans</topic><topic>Informed consent</topic><topic>Interpersonal relations</topic><topic>Interviews as Topic - methods</topic><topic>Iran</topic><topic>Male</topic><topic>Medical ethics</topic><topic>Nurses</topic><topic>Nursing</topic><topic>Nursing care</topic><topic>Nursing Care - methods</topic><topic>Nursing Care - standards</topic><topic>Nursing Care - statistics & numerical data</topic><topic>Patient Safety - standards</topic><topic>Patient Safety - statistics & numerical data</topic><topic>Patients</topic><topic>Professional practice</topic><topic>Qualitative Research</topic><topic>Regulation</topic><topic>Unsafe</topic><topic>Urban areas</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Tajabadi, Ali</creatorcontrib><creatorcontrib>Ahmadi, Fazlollah</creatorcontrib><creatorcontrib>Sadooghi Asl, Afsaneh</creatorcontrib><creatorcontrib>Vaismoradi, Mojtaba</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>Applied Social Sciences Index & Abstracts (ASSIA)</collection><collection>British Nursing Index</collection><collection>British Nursing Index (BNI) (1985 to Present)</collection><collection>British Nursing Index</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Premium</collection><collection>MEDLINE - Academic</collection><jtitle>Nursing ethics</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Tajabadi, Ali</au><au>Ahmadi, Fazlollah</au><au>Sadooghi Asl, Afsaneh</au><au>Vaismoradi, Mojtaba</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Unsafe nursing documentation: A qualitative content analysis</atitle><jtitle>Nursing ethics</jtitle><addtitle>Nurs Ethics</addtitle><date>2020-08</date><risdate>2020</risdate><volume>27</volume><issue>5</issue><spage>1213</spage><epage>1224</epage><pages>1213-1224</pages><issn>0969-7330</issn><eissn>1477-0989</eissn><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.</abstract><cop>London, England</cop><pub>SAGE Publications</pub><pmid>31476968</pmid><doi>10.1177/0969733019871682</doi><tpages>12</tpages><orcidid>https://orcid.org/0000-0002-1961-7735</orcidid></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 0969-7330 |
| ispartof | Nursing ethics, 2020-08, Vol.27 (5), p.1213-1224 |
| issn | 0969-7330 1477-0989 |
| language | eng |
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| source | Applied Social Sciences Index & Abstracts (ASSIA); SAGE |
| subjects | Adult Clinical governance Confidentiality Content analysis Division of labor Documentation Documentation - standards Documentation - statistics & numerical data Ethics Female Health care Hiring Humans Informed consent Interpersonal relations Interviews as Topic - methods Iran Male Medical ethics Nurses Nursing Nursing care Nursing Care - methods Nursing Care - standards Nursing Care - statistics & numerical data Patient Safety - standards Patient Safety - statistics & numerical data Patients Professional practice Qualitative Research Regulation Unsafe Urban areas |
| title | Unsafe nursing documentation: A qualitative content analysis |
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