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Cited by 53Nursing Diagnosis and DocumentationNursing education and managementElectronic Health Records Systems

Improving the quality of nursing documentation: An action research project

Open access
Okaisu, Elisha M., Kalikwani, Florence, Wanyana, Grace, Coetzee, Minette·2014·Curationis
DOI 10.4102/curationis.v37i2.1251
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Abstract

Background: Documentation is an important function of professional nursing practise. In spite of numerous improvement efforts globally, inadequate documentation continues to be reported as nurse authors investigate barriers and challenges. Objectives: The project aimed to improve nurses’ documentation of their patient assessments at the CURE Children’s Hospital of Uganda in order to enhance the quality of nursing practise. Method: An action research methodology, using repeated cycles of planning, intervention, reflection and modification, was used to establish best practise approaches in this context for improving nurses’ efficacy in documenting assessments in the patient record. The researchers gathered data from chart audits, literature reviews and key informant interviews. Through analysis and critical reflection, these data informed three cycles of systems and practise modifications to improve the quality of documentation. Results: The initial cycle revealed that staff training alone was insufficient to achievethe project goal. To achieve improved documentation, broader changes were necessary, including building a critical mass of competent staff, redesigned orientation and continuing education, documentation form redesign, changes in nurse skill mix, and continuous leadership support. Conclusion: Improving nursing documentation involved complex challenges in this setting and demanded multiple approaches. Evidence-based practise was the foundation of changes in systems required to produce visible improvement in practise. The involved role of leadership in these efforts was very important.

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Authors
Okaisu, E. M., Kalikwani, F., Wanyana, G., & Coetzee, M.
Affiliations
  • CURE Children’s Hospital of Uganda (UG)
  • University of Cape Town (ZA)
ORCID
Coetzee, Minette
Venue
Curationis
Publisher
AOSIS
Published
2014-10-29
Volume
37
Issue
2
Pages
E1-11
ISSN
  • 0379-8577 (ISSN-L)
  • 2223-6279
DOI
10.4102/curationis.v37i2.1251
OpenAlex
W2005394858
Cited by
53
References
43
Citations by year
2026: 5 · 2025: 3 · 2024: 1 · 2023: 5 · 2022: 2 · 2021: 6 · 2020: 11 · 2019: 6 · 2018: 7 · 2017: 4 · 2016: 3
FWCI
12.14
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • Curationis (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Topics
  • Health Sciences › Nursing › Issues, ethics and legal aspects › Nursing Diagnosis and Documentation
  • Health Sciences › Nursing › Research and Theory › Nursing education and management
  • Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
Keywords
nursing documentation, chart audit, nurse orientation, continuing education, leadership support, critical mass, evidence-based practice, pediatric nursing
MeSH terms
Child, Education, Humans, Nursing Process, Nursing Records, Pediatric Nursing, Quality Assurance, Health Care, Uganda

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