Authors (including presenting author) :
Ho PLE(1), Kwok LPN(2), Yang SFA(2)
Affiliation :
(1)Quality & Safety Office, (2)Nursing Services Division, Tung Wah Eastern Hospital
Introduction :
Globally, the healthcare industry faces the challenges stemming from the aging population, mounting complexity of medical care and manpower shortage. There is growing concerns that nurses express swamping by paperwork, preventing them from providing direct care. The NHS (National Health Service) confederation in 2012 highlighted that duplication was the most frustrating issue for nurses when dealing with their paperwork. Lack of integration of various electronic systems does not enable the reduction of repetition. Tremendous paper work has progressively eroded the role of nurses.
Objectives :
Streamlining nursing documentation to reduce the duplication in paperwork with quality and safety maintained was the focus in this program.
Methodology :
The content of electronic and paper documentation in nutrition, fall, pain, intravenous care, pressure injury, wound and infection control were reviewed under the corporate, cluster, hospital and accreditation standard. Issues and improvement were discussed in different committees and stakeholders including frontline nurses and medical record office. Sharing forum was conducted to kick off the changes in Jun 2018. Reference on Hospital nursing documentation practice was also updated.
Result & Outcome :
Total 10 forms’ improvement was effective from 3 July 2018. 3 forms were obsoleted. 7 forms were revised with items deleted, documentation frequency decreased, indication refined and nursing intervention delineated into different levels. Moreover, initiation of risk assessment was expanded to include the deteriorating patient to maintain patient care quality. Evaluation was conducted in Dec 2018 with 30 samples collected based on the proportion of bed numbers of wards. Quality of nursing care was checked via documentation with 96.69% compliance under the framework of nursing process: assessment, diagnosis, planning, implementation and evaluation. Feedback from nurses regarding the streamline of nursing documentation was collected by using a self-reporting questionnaire. The overall satisfaction rate was 98.9% which was encouraging.
Paperwork is an integral part of delivering care. Nurses should not be forced to choose between paperwork and patient care. This program helps to revisit the content of various nursing documentation, in order to redirect the nurses to effectively prioritize and focus their energies on document of real value. Essence of quality care was reflected via the documentation of nursing process in this project. The role of nurses should not be eroded by tremendous paper work. Key areas around the burden of paperwork should be identified so that nurses have more time to care for their patient.
Co-location with:
