Nurses’ understanding of quality documentation: A qualitative study in a Mental Health Institution

Abstract

Background: Nursing documentation is an integral part of nursing practice that is planned and delivered to individual patients by qualified nurses to provide evidence of the standard of care. The quality of nursing documentation is the inscriptions of all categories of nurses, including students, to record nursing care to facilitate continuity of care and patients’ safety.

Objectives: This study aimed to explore and describe the psychiatric nurses’ comprehension of the quality of nursing documentation in the selected mental health institution in Gauteng province.

Method: The qualitative, explorative-descriptive and contextual design was used. The target population was all nurses directly involved in patient care. Individual face-to-face semistructured interviews were used to collect data. Braun and Clarke’s (2022) six steps of the thematic descriptive analysis method were adopted to allow the second author to identify themes and recapitulate data.

Results: The two themes and subthemes that emerged from the findings include nurses’ understanding of the impact of quality documentation on patient care outcomes and support needs to improve the quality of nursing documentation.

Conclusion: Understanding the quality of nursing documentation is an essential element for producing continuous clinical communication and reflection on the everyday activities of nursing care that are planned and implemented on individual patients’ progress reports.

Contribution: The study contributes to nursing practice, as its results can be used to measure the quality of the primary source of clinical information improvements, allowing healthcare professionals to communicate with each other about a patient’s care.