A ward-based writing coach program to improve the quality of nursing documentation

Area of Science:

• Nursing Education
• Healthcare Communication
• Quality Improvement

Background:

• Effective nursing documentation is crucial for interprofessional communication and patient care continuity.
• Current documentation practices may be hindered by issues like non-standard abbreviations and unclear language.
• A need exists for accessible, ward-based educational interventions to improve nursing documentation quality.

Purpose of the Study:

• To pilot a ward-based writing coach program to enhance the quality of nursing documentation.
• To describe the educational components and transferability of the program across clinical settings.

Main Methods:

• A pilot program involving two one-hour writing workshops.
• One-to-one coaching sessions provided to nurses post-workshop.
• Focus on critical appraisal of documentation and adherence to defined principles.

Main Results:

• The program aimed to improve the quality and meaningfulness of nursing documentation.
• Identified barriers to clear communication in nursing notes, such as jargon and abbreviations.
• Encouraged nurses to document patient condition, care, and response using standardized principles.

Conclusions:

• A ward-based writing coach program is a feasible and effective method for improving nursing documentation.
• The educational model is adaptable to various clinical environments as part of ongoing training.
• Enhancing nursing documentation quality improves communication and patient care outcomes.