Improving nursing documentation using the SBAR-D framework among nurses in an acute inpatient ward: a best practice...

Area of Science:

• Nursing Informatics
• Healthcare Quality Improvement
• Clinical Communication

Background:

• Electronic nursing documentation is crucial for legal and quality assurance.
• Nurses often find electronic documentation time-consuming and burdensome.

Purpose of the Study:

• To enhance nursing documentation quality and effectiveness.
• To implement a free-text documentation framework using SBAR-D in a general medicine ward.

Main Methods:

• Utilized the JBI Evidence Implementation Framework, a seven-phase approach.
• Employed audit, feedback, and barrier management strategies.
• Developed and implemented a novel SBAR-D communication tool for nursing documentation.

Main Results:

• Achieved 80% compliance with best practice recommendations.
• Identified 3 barriers and successfully implemented 7 strategies to address them.
• Quantified time savings resulting from the implementation.

Conclusions:

• The SBAR-D framework significantly improved compliance with logical, sequential nursing documentation.
• The pilot's success led to expansion into four additional acute wards.
• The framework is being adopted hospital-wide as standard operating procedure and integrated into staff training.