Conference Proceedings - School of Nursing & Midwifery - Trinity ...

School of Nursing & Midwifery, Trinity College Dublin: 8 th Annual Interdisciplinary Research Conference
Transforming Healthcare Through Research, Education & Technology: 7 th – 9 th November 2007
Conference Proceedings
of paper that nurses have to record on which may also lead to
duplication of documentation as many aspects of nursing care were
documented twice in both the observation sheets and again in the
green evaluation sheets.
The second form of data collection for this project included focus
groups which were conducted in February – March 2007. There
were 6 focus groups in total, 4 in UHG and 2 in MPH (Merlin Park
Hospital). Approximately 10 people from staff nurses to clinical
nurse specialists and clinical nurse managers attended each session.
Many issues were raised at theses groups. 4 pertinent questions
were asked in relation to nursing documentation. Firstly, the
participants were asked how they felt about the results of the audit.
The majority were not surprised but were quite fearful about the
legal repercussions that poor documentation may result in.
The second question raised was “What are the current challenges in
documenting patient care in the GUH”. The response to this
focused mainly on lack of time, too many documents to record in,
and lack of clarification as to the role of the nurse. In relation to a
better way of documenting most people aspired to pre printed
standardised care plans available on the hospital intranet and a tick
box system for documenting the daily basic nursing care
Also a better system of storing the nursing documentation was
discussed and a computerised paper less system was the response
of the majority and if that was not possible, a nursing booklet,
which would include the patient profile, nursing assessment and all
observation sheets, was recommended.
Everyone was then asked what he/she understood as his/her
responsibility in relation to documentation. In response to this the
majority knew that they were accountable and responsible for their
actions and documentation. However, many felt that the ward
managers have a key role in ensuring the documentation is up to
date, accurate and safe in case of legal scrutiny. A relevant number
of people did also recommend a documentation team to continually
observe nurses documentation on the wards.
Finally, in the current environment of health service reform and
service quality improvement, healthcare professionals are
increasingly required to demonstrate the effectiveness of what they
do and articulate how they are contributing to the quality of patient
and client care (Bjorvell et al, 2003). Nurses and Midwifes have
the potential to carry out a wide range of interventions in a variety
of health care settings and with patients and clients with varying
diverse needs. By identifying their interventions and measuring
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