A Survey-Based Approach to Streamlining Nursing Documentation Practices at Hospital Settings

Iszaid bin Idris*

Hospital Bera, Jalan Majlis, 28200 Bandar Bera, Pahang. Malaysia

*Corresponding Author’s Email: iszaid_bijaksana@yahoo.com.my

Abstract

Introduction: The meticulous recording of patient inf ormation not only f acilitates communication among healthcare providers but also plays a crucial role in maintaining patient saf ety. The manual nature of charting poses a risk of errors and can be time-consuming for nurses. Objective: The study aim to explore the perspective of nursing observational charts practice at Pahang’s government hospitals in 2023. Method: This is a cross-sectional survey conducted among nurses across various hospitals in 2- month duration. After randomisation, nurses meeting the inclusion and exclusion criteria were enrolled in the study. Descriptive and inf erential statistics were computed to analyse the data. Result: A total of 582 nurses responded, the study found on average, 8.1 ± 2.7 SD standard charts were required during admission, and 3.0 ± 1.9 SD additional charts may required to supplement the standard charts per patient. Discussion: The study revealed that the adoption of a combined chart was associated with a 2.2 times improvement in the ease of nursing documentation practices. Conclusion: Having all relevant inf ormation in one place could reduce the need for nurses to navigate through multiple forms.

Keywords: Observation Chart; Nurses Efficiency; Patient’s Documentation; Streamlining Nursing Practice

Introduction

In the dynamic realm of healthcare, the documentation practices of nursing prof essionals serve as the cornerstone for ef f ective patient care delivery. At present, the worldwide nursing workforce comprises an estimated 28 million individuals, constituting 59% of the total healthcare personnel (World Health Organization, 2020). The meticulous recording of patient inf ormation not only f acilitates communication among healthcare providers but also plays a crucial role in maintaining patient saf ety, ensuring continuity of care, and meeting regulatory requirements (Ahn et al., 2021). The nursing observational chart plays a paramount role in shaping the patient care plan, serving as a critical tool for healthcare prof essionals to monitor and assess various aspects of a patient's condition. It provides a systematic and organized way to record vital inf ormation, f acilitating timely interventions and inf ormed decision- making (Muinga et al., 2021). The use of observation charts is an essential aspect of patient care, allowing healthcare prof essionals to monitor and document a patient's vital signs and overall condition over time.

A study shows nurses spend a signif icant portion of their shif t on documentation tasks, with estimates ranging f rom 20% to 50% of their time (Baumann et al., 2018). One study showed that nurses take more than 6 minutes to record a vital sign per patient (Dall’Ora et al., 2021). While other study reported that the average time spent on documentation per patient is approximately 33 minutes (Gesner et al., 2022). Nurses' observational charts play a crucial role in patient care, but several challenges in their use can create difficulties for healthcare prof essionals. One study suggest that up to 84% omitted nursing care activities can happen as a result of improper charting and documentation (Saar et al., 2021). This can impact the quality of care as nurse’s grapple with the demands of extensive documentation (Gesner et al., 2022).

The manual nature of charting poses a risk of errors and can be time-consuming for nurses, potentially leading to increased stress and burnout (Lorkowski et al., 2021). Additionally, these challenges may af f ect other stakeholders in the healthcare system (Muinga et al., 2021). For doctors, navigating through complex or disorganized charts may hinder ef f icient decision-making and coordination of care (Warren et al., 2021). Patients may experience delays or inconsistencies in the delivery of care if nurses encounter difficulties in accessing or updating their charts. From an administrative standpoint, managing and organizing paper-based charts can be resource-intensive and may contribute to inef f iciencies in hospital workflows (Uzun & Cerit, 2023).

By engaging nursing prof essionals in this endeavour, the study aim to explore the perspective of nursing observational charts practice at Pahang’s government hospitals in 2023. It does so with the aim of laying the foundation for f uture improvements in streamlining nursing documentation practices and ef f iciency. The concept of monitoring patients' vital signs dates back to the early development of modern medicine. However, the formalization of systematic observation and recording started gaining prominence in the late 19th century (DeLaune et al., 2023). Florence Nightingale, a pioneer in nursing and healthcare, emphasized the importance of systematic data collection and analysis in nursing practice (Atan et al., 2021). Her work during the Crimean War in the mid-19th century highlighted the need for caref ul observation and documentation of patient conditions (Elena & Olga, 2020).

As healthcare practices advanced, so did the tools used for patient observation and nurse’s documentation. The early observation charts were often basic, handwritten records that included essential vital signs such as temperature, pulse, respiration rate, and blood pressure (Petrovskaya, 2023). With the growth of healthcare institutions and the standardization of nursing practices in the 20th century, observation charts became more structured and standardized. Printed forms with specific sections for each vital sign and additional notes were introduced (Atan et al., 2021). The late 20th century and early 21st century witnessed signif icant advancements in healthcare technology (Petrovskaya, 2023). Automated monitoring devices and electronic health records (EHRs) started to replace or complement traditional paper-based nursing observation charts (Lindsay & Lytle, 2022). These technologies allowed nurses for more accurate and ef f icient documentation of patient data in modern health f acility.

Research Methodology

A cross-sectional survey was conducted among nursing volunteers f rom public hospitals in the state of Pahang, Malaysia. Participants were randomly selected f rom various wards, departments, and hospitals and were f ully inf ormed about the survey. They subsequently agreed to participate by volunteering to complete an online Google Form questionnaire.

The survey material was constructed via extensive review of the current literature. It was validated by experts in the nursing f ield and piloted, yielding a Cronbach's alpha exceeding 0.70. The inclusion criteria for this study encompassed both male and female individuals at all levels of nursing ranks, including Chief Hospital Nurse Supervisor, Nurse Supervisor, Head Nurse, Trained Nurse, and Community Nurse. Participants were required to have a proficient understanding of either Bahasa Melayu or the English language. Exclusion criteria involved volunteers with less than 6 months of work experience in a hospital setting in Pahang to prevent bias. No personal identif ication inf ormation was collected f rom the volunteers.

The survey comprised a total of 25 questions, and data collection occurred f rom 23rd June 2023 to 23rd August 2023, spanning a two-month period. Data were extracted using cloud-based software, specif ically Google Sheets with restricted access. The focus of the extraction was on socio- demographic f actors (such as age, sex, work position, and years of experience), job profiles (including hospital name and method of documentation), work practices (number of charts, additional charts, time to register the chart, and time to f ill up the chart), and perceptions of newer nursing observational charts using Likert scales.

The collected data f rom respondents were downloaded and stored using Microsoft Excel version 2007. Subsequently the data were analyzed using Epi Inf o™ version 7.2. Descriptive statistics were presented graphically, with continuous variables expressed as means (M) with standard deviations (SD) and compared using appropriate parametric tests. Categorical variables were presented as numbers (%) and compared using Fisher's exact test as appropriate. Signif icance was determined using odds ratios, 95% conf idence interval with a signif icance level of p-value set at less than 0.05 (two-sided).

Ethical Considerations

This research has been registered with the National Medical Research Register under the ID: NMRR ID-24-00386-C5J, dated January 31, 2024.

Result

A total of 582 nurses responded to the survey, with the majority being f emale (n=571, 98.1%) compared to male (n=11, 1.9%). The average age of the respondents was 36.7 ± 6.1 SD years old, ranging between 25 to 55 years old. The average number of respondents per hospital in this study was 52.9 ±51.7 SD. It was observed that the majority of respondents were f rom Hospital Sultan Haji Ahmad Shah in the Temerloh district (n=191, 33%), followed by Hospital Bera (n=86, 15%), Hospital Muadzam Shah (n=68, 12%), Hospital Tengku Ampuan Afzan Kuantan (n=52, 9%), Hospital Kuala Lipis (n=47, 8%), Hospital Jengka (n=41, 7%), Hospital Sultanah Hajjah Kalsom Cameron Highlands (n=30, 5%), Hospital Bentong (n=27, 4%), Hospital Pekan (n=26, 4%), Hospital Rompin (n=13, 2%), and Hospital Raub (n=1, 0%). Table 1 displays the f requency distribution of surveyed nurses at government hospitals in Pahang, Malaysia.

Table 1: Frequency Distribution of Survey Nurses at Government Hospital in Pahang, 2023

The majority of participants in this survey were non-administrator nurses (n=520, 89%), including Juruawat Terlatih and Jururawat Masyarakat, in contrast to administrator nurses (n=62, 11%), as depicted in Figure 1(a). Our observations revealed that most hospitals in this study still relied on manual based observation charts (n=403, 69%) rather than digital-based ones (n=46, 8%). The remaining respondents employed a combination of both types of observational charts (n=133, 23%), as illustrated in Figure 1(b). On average, participants reported 13.1 ± 6.0 SD years of work experience, with a range of 1 to 30 years, as shown in Figure 1(c). Our study found that, on average, 8.1 ± 2.7 SD standard charts were required during admission, as displayed in Figure 1(d). Additionally, an average of 3.0 ±1.9 SD additional charts may be needed to supplement the standard ones. Furthermore, our investigation revealed that, on average, 6.8 ± 3.1 SD minutes were required to register each chart, while an average of 5.8 ± 3.2 SD minutes were needed to f ill out each chart.

Figure 1: Proportion of a) Group of Nurses, b) Method of Documentation, c) Level of Experiences, and d) Number of Standard Charts Initiated

Amongst basal and previous condition, there were no signif icant diff erent in respondance’s sex, age, experiences, ranks, numbers of forms used and numbers of additional forms used. However, our study showed using a combined chart is associated with a 2.2 times improvement in the attitude of nursing towards documentation practices as shown in table 2.

Table 2: Odd Ratios between Facilitating Factor and Attitude towards Documentation Practice

This study employs a weighted average (w.a) of 3.91, calculated as 35.22/9, which surpasses the threshold indicative of high perception. We found that transitioning to newer charts, particularly consolidating nursing observational charts, demonstrated several advantages, including signif icant paper conservation (92%), elimination of repeated tasks during form f illing (91%), and time savings in recording and assessing changes in the patient's condition (89%). However, lower perception was noted in various aspects such as vital signs assessment, human resource demand reduction, decreased clinical workload, and implementation strategy satisf action as demonstrated in Table 3.

Table 3: Perception for Combining Nursing Observational Chart

Note: N= 582, SA = Strongly Agree; A = Agree; UN= Undecided; D = Disagree; SD = Strongly Disagree. Decision: weighted average (w.a) =35.22/9 = 3.91. Above w.a considered high perception.

Discussion

The presented study investigates the ef f iciency of nursing documentation practices through a survey- based approach, focusing on 582 respondents in various government hospitals in Pahang, Malaysia. The majority of participants were f emale, and the average age of respondents was approximately 36.7 years. The study also explored the distribution of respondents across different hospitals, with Temerloh district having the highest participation. The f indings indicated that manual-based observation charts, utilising pen and paper were still widely used (69%), with a smaller percentage utilizing digital-based charts (8%), and a notable portion employing a combination of both (23%). It is understandable that these hospitals were yet to adopt Hospital Inf ormation Systems in their clinical practices.

The f inding shows that on average nurses employed more than 8 charts during and another 3 additional charts during admission. A closed examination on the data showed nurses uses more paper per patients to f ulf il the duty for documentation and this f inding is consistent with other study (Atan et al.,2021). These charts include: Vital sign chart, Temperature chart, Intake-output-f eeding Chart, Pain Score chart, Glucose monitoring chart, Morse Fall Score, Braden Skin Score, and Thrombophlebitis Chart. Furthermore, some patient may require additional observational charts such as: foetal kick chart, labor progress chart, pad chart, dengue chart, snake bite chart, Glasgow Coma Scale chart, skin assessment chart, drip regime chart, nursing assessment chart, circulation chart, wound chart, COVID- 19 screening chart, and many more. Hence the time to register and to f ill-up each individual charts varies between hospitals (Theresia & Reñosa, 2023).

One of the key f indings of the study highlighted nurse’s perception towards the potential advantages of transitioning to newer, more integrated charts. This can be shown with the nurse’s attitude towards their documentation practice. The benef its of such transition include: conservation of paper usage, elimination of repeated tasks during form completion, and time savings in recording and assessing changes in patients' conditions (Muinga et al., 2021). On the other hand, the study has yet to show any relationship between the ease of nursing documentation against respondent characteristics, such as sex, age, experience, and the number of forms used. Combining those charts may provide benef icial to their clinical work process. Nurses were having conf licting opinion regarding combining the chart that it will f acilitate recording the vital sign, reduced the workload, reduce human resource, or it will improve productivity (Gesner et al., 2022). Replication between unif ied observational charts and implementation strategy for all hospital were unf avourable. Our study demonstrate that nurses agree towards transitioning to more integrated charts as it will save more paper wastage apart f rom saf e more time by eliminating repeating task in their clinical work process (Saar et al., 2021). We believe the readiness of nurses to takes up such innovative challenges should be acknowledged and be utilised to streamlining nursing documentation practice (Petrovskaya, 2023).

We revealed that the adoption of a combined chart was associated with a 2.2 times improvement in the ease of nursing documentation practices. This emphasizes the potential positive impact of integrating and streamlining documentation processes, providing a practical solution for enhancing ef f iciency in healthcare settings (Lindsay & Lytle, 2022). A combined chart may be designed to focus on patient- centred care, ensuring that the documentation process aligns with the needs and pref erences of both healthcare providers and patients (Lorkowski et al., 2021). If nurses are adequately trained on the use of combined charts and become f amiliar with the system, they may f ind it more comfortable and convenient to navigate (Atan et al., 2021). Familiarity with the chart structure and data presentation can contribute to increased ef f iciency (Muinga et al., 2021). Furthermore, a well-organized and intuitive layout can contribute to ease of use, making it simpler for nurses to input and retrieve inf ormation.

The study has several limitations such as the study period is too shorts, and only looked into Pahang states which may or may not be applicable to private health institution or others states. Hence, f uture study should take into consideration wider time f rame and bigger population.

Conclusion

In conclusion, the study contributes valuable insights into the current state of nursing documentation practices in government hospitals in Pahang, Malaysia. The f indings underscore the importance of considering the advantages of adopting more integrated charting methods to improve ef f iciency and address challenges in the documentation process. Combined charts or documentation may f acilitate a more streamlined and cohesive workflow for nurses.

Conflict of Interest

The authors declare that they have no competing interests.

Acknowledgement

We would like to thank the Director General of Health Malaysia and Director of Pahang State Health Department for his permission to publish this article. No f unding was applicable.

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