Introduction:

Good clinical documentation provides evidence for safe, high-quality, continuous patient care. Nevertheless, fostering effective nursing documentation practices in this digital age remains a significant challenge. Time-consuming and burdensome perceptions towards documentation, negatively impacts maintenance of accuracy and legal prudence [1]. Following organisation-wide implementation of digitised health records, an internal review highlighted significant variation in nursing documentation practices. The limited extent traditional pedagogical approaches can meaningfully improve documentation [2] prompted exploration of alternative strategies to identify and address perceived contextual barriers to effective digital documentation. Drawing on improvement methodology, this educational initiative aimed to transform electronic nursing documentation by encouraging critical thinking, evidencing of rationale behind contributions to nursing care and realigning to the nursing process.

Methods:

A simulation-based workshop was developed with stakeholders and delivered to 75 nurses and healthcare assistants in one UK acute hospital. Pedagogically informed by the process of double loop reflection [3], the workshop consisted of three simulated exercises centred around a single-patient, pre-recorded scenario; 1) electronic documentation of a care episode, 2) writing a witness statement for the coroner, and 3) presenting at a mock coroner’s court inquest. Each activity was followed by a facilitated debrief. The aim was to encourage participants’ to critically evaluate their underlying perspectives and documentation practices to transform habitual thinking and actions beyond standardised electronic templates. Participants completed a pre and post-course surveys to evaluate the learning intervention.

Results:

There was an overall increase in self-reported confidence in documenting challenging clinical situations, with the proportion of those ‘completely’ confident increasing by over threefold from 9.4% to 32.4%. Several themes emerged during qualitative analysis. This included changes in perspective towards nursing documentation with a particular emphasis on importance, thoroughness, and efficiency alongside an intention to change documentation practice. Systemic and cultural factors were also identified as potential inhibitors to changes in behaviour.

Discussion:

Simulated experiences that actively engage participants in critical reflection and discourse can provide transformative learning experiences in nursing. Immediate self-reported changes in participants’ perceptions of the evidential quality of digital documentation suggests promise that may support future changes in practice. However, the process also surfaced barriers to action and change, including systemic and cultural factors. This will inform ongoing organisational learning regarding enhancing documentation effectiveness. Future work will focus on expanding and evaluating the longitudinal impact of this educational intervention and supporting wider improvement efforts to address the identified contextual barriers.

Ethics statement:

Authors confirm that all relevant ethical standards for research conduct and dissemination have been met. The submitting author confirms that relevant ethical approval was granted, if applicable.

References

1. De Groot K, Triemstra M, Paans W, Francke AL. Quality criteria, instruments, and requirements for nursing documentation: A systematic review of systematic reviews. Journal of Advanced Nursing 2019. 2019;75:1379–13931.

2. Bunting J, de Klerk M. Strategies to improve compliance with clinical nursing documentation guidelines in the acute hospital setting: a systematic review and analysis. SAGE Open Nursing. 2022;8.

3. Argyris C, Schon D. Organizational learning: A theory of action perspective. Reading, Massachusetts: Addison-Wesley Publishing Co; 1978.