Is nursing and midwifery clinical documentation a burden? An empirical study of perception versus reality

To measure time spent on clinical documentation and nurses and midwives' perceptions of this aspect of their role.

Nurses and midwives rely on accurate documentation when planning care. However, documenting and communicating care can be onerous, time-consuming and at times duplicated or redundant. While documentation provides a record and means of communicating care, it should not detract from the delivery of care.

An observational time and motion study and survey design reported using the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.

The study was conducted with Western Australian nurses and midwives working in a private not-for-profit hospital from July-October 2019. An observational study was undertaken to measure the practice of documentation on each shift. Participants' perceptions of clinical documentation were measured using a self-report survey.

A total of 120 hr of observation were undertaken. Total observed time spent on documentation was 28.1% on morning shifts, 22.7% on afternoon shifts and 20.9% on night duty. The mean self-reported time for clinical documentation was 50.4% on morning shifts, 40.7% on afternoon shifts and 37.9% on night duty. Issues with duplication and unnecessary paperwork were identified.

Although participants tended to overestimate time spent on documentation, it still consumed a significant proportion of time. Frustrations with paperwork may amplify nurses' negative perceptions of documentation. Clinical documentation needs to be reviewed, revised and reduced to release time back to direct patient care and reduce clinician dissatisfaction.

Clinical documentation is required in all areas of clinical practice and forms an important legal record. Understanding the demands of clinical documentation can assist in reviewing and improving documentation to release time back to direct patient care.