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Nursing Documentation: An Evaluation of an Action Research Project
Grete Vabo1, Åshild Slettebø2, Mariann Fossum2
1University of Agder, Faculty of Health and Sport Sciences, Kristiansand, Norway.
Studies in Health Technology and Informatics
|June 23, 2016
Summary
Improving nursing documentation is complex. Healthcare professionals found the process complicated, faced competing interests, and stressed the need for strong leadership for success in electronic health record system development.
Area of Science:
- Nursing Practice
- Health Informatics
- Action Research
Background:
- Nursing documentation is crucial for patient care and healthcare system efficiency.
- Improving documentation practices, particularly with electronic health record (EHR) systems, presents ongoing challenges.
- Action research offers a framework for evaluating and enhancing clinical processes.
Purpose of the Study:
- To evaluate an action research project aimed at improving nursing documentation.
- To identify barriers and facilitators in the nursing documentation process within Norwegian municipalities.
- To understand healthcare professionals' perceptions of implementing and using EHR systems for documentation.
Main Methods:
- Explorative research design.
- Qualitative data collection through four focus group interviews and two individual interviews.
- Content analysis of interview data to identify key themes.
Main Results:
- Healthcare professionals perceived the documentation process as complicated.
- Competing interests among stakeholders were identified as a significant challenge.
- The presence of a clear and visible leader was highlighted as crucial for successful implementation.
- Stakeholder collaboration and involvement are vital for developing effective EHR systems.
Conclusions:
- Successful improvement of nursing documentation requires addressing process complexity and competing interests.
- Effective leadership and stakeholder engagement are essential for the successful adoption of EHR systems.
- Findings underscore the importance of a participatory approach in health informatics development.
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