CHALLENGES OF NURSING DOCUMENTATION IN CORONARY CARE UNIT: A QUALITATIVE STUDY OF NURSES' EXPERIENCES

Ghobadian Diali, Amaneh and Toulabi, Tahereh and Gholami, Mohammad and Tarrahi, Mohammad Javad and Khademi, Mojgan (2016) CHALLENGES OF NURSING DOCUMENTATION IN CORONARY CARE UNIT: A QUALITATIVE STUDY OF NURSES' EXPERIENCES. The IIOAB Journal – Institute of Integrative Omics and Applied Biotechnology Journal, 7 (8). pp. 134-140.

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Abstract

ABSTRACT Evidence shows that there are challenges in nursing documentation in CCU. Studying nurses’ experiences of documentation can help acquire a deep understanding about documentation-related challenges and develop strategies for promoting documentation. The purpose of the study was to explore nurses’ experiences of documentation in CCU. This descriptive qualitative research was conducted in 2015 by using the conventional content analysis approach. A purposive sample of fifteen nurses was recruited. Unstructured interviews were held for data collection. Data analysis was done by using the Graneheim and Lundman’s content analysis approach. Data trustworthiness was maintained through the criteria Lincoln and Guba. The study participants’ experiences of documentation in CCU fell into three main themes including ‘Documentation: an instrument for or a barrier to conscious and safe care’, ‘Reality-documentation-principles gap’, and ‘Dynamic management-person interaction and high-quality condition for documentation’. Nursing documentation has a contradictory nature for nurses and is perceived differently from ‘an instrument for care provision’ to ‘a barrier to care provision’. However, the gap between realities and documentations diminishes the value of documentations. Managerial supervision and provision of necessary infrastructures for reality-based documentation can enhance the quality of nursing documentation in CCU.

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