'It's all about ticks': A secondary qualitative analysis of nurse perspectives about documentation audit

• Published in: Journal of advanced nursing 2023-09, Vol.79 (9), p.3440-3455
• Main Authors: Michl, Gabriella, Paterson, Catherine, Bail, Kasia
• Format: Article
• Language: English
• Subjects: Audits; Bureaucracy; Care plans; Clinical outcomes; Clinical standards; Documentation; Health services; Medical records; Nurses; Nursing; Nursing care; Occupational roles; Patients; Qualitative research; Quality management; Value
• ISSN: 0309-2402; 1365-2648
• DOI: 10.1111/jan.15685

To understand how nurses talk about documentation audit in relation to their professional role. Nursing documentation in health services is often audited as an indicator of nursing care and patient outcomes. There are few studies exploring the nurses' perspectives on this common process. Secondary qualitative thematic analysis. Qualitative focus groups (n = 94 nurses) were conducted in nine diverse clinical areas of an Australian metropolitan health service for a service evaluation focussed on comprehensive care planning in 2020. Secondary qualitative analysis of the large data set using reflexive thematic analysis focussed specifically on the nurse experience of audit, as there was the significant emphasis by participants and was outside the scope of the primary study. Nurses': (1) value quality improvement but need to feel involved in the cycle of change, (2) highlight that 'failed audit' does not equal failed care, (3) describe the tension between audited documentation being just bureaucratic and building constructive nursing workflows, (4) value building rapport (with nurses, patients) but this often contrasted with requirements (organizational, legal and audit) and additionally, (5) describe that the focus on completion of documentation for audit creates unintended and undesirable consequences. Documentation audit, while well-intended and historically useful, has unintended negative consequences on patients, nurses and workflows. Accreditation systems rely on care being auditable, but when individual legal, organizational and professional standards are implemented via documentation forms and systems, the nursing burden is impacted at the point of care for patients, and risks both incomplete cares for patients and incomplete documentation. Patients participated in the primary study on comprehensive care assessment by nurses but did not make any comments about documentation audit.