ID Design Press, Skopje, Republic of Macedonia Open Access Macedonian Journal of Medical Sciences. 2018 Aug 20; 6(8):1527-1532. https://doi.org/10.3889/oamjms.2018.303 eISSN: 1857-9655 Public Health Improving Nursing Care Documentation in Emergency Department: A Participatory Action Research Study in Iran Seyed Majid Vafaei1, Zahra Sadat Manzari2*, Abbas Heydari2, Razieh Froutan2, Leila Amiri Farahani3 1PhD Candidate in Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran; 2Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran; 3Department of Reproductive Health and Midwifery, School of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran Abstract Citation: Vafaei SM, Manzari ZS, Heydari A, Froutan R, BACKGROUND: Standardization of documentation has enabled the use of medical records as a primary tool for Amiri Farahani L. Improving Nursing Care Documentation evaluating health care functions and obtaining appropriate credit points for medical centres. However, previous in Emergency Department: A Participatory Action Research Study in Iran. Open Access Maced J Med Sci. studies have shown that the quality of medical records in emergency departments is unsatisfactory. 2018 Aug 20; 6(8):1527-1532. https://doi.org/10.3889/oamjms.2018.303 AIM: The aim of this study was improving the nursing care documentation in an emergency department, in Iran. Keywords: Documentation; Health Services Research; Action Research; Nursing; Emergency Service; Hospital MATERIAL AND METHODS: This collaborative action research study was carried out in two phases to improve *Correspondence: Dr. Zahra Sadat Manzari. Assistant nursing care documentation in cooperation with individuals involved in the process, from February 2015 to Professor, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran. E-mail: December 2017 in an affiliated academic hospital in Iran. The first phase featured virtual training, an educational [email protected] workshop, and improvements to the hospital information system. The second phase involved the recruitment of Received: 26-May-2018; Revised: 22-Jul-2018; human resources, the implementation of continuous codified training, the establishment of an appropriate reward Accepted: 27-Jul-2018; Online first: 19-Aug-2018 and penalty system, and the review of patient education forms. Copyright: © 2018 Seyed Majid Vafaei, Zahra Sadat Manzari, Abbas Heydari, Razieh Froutan, Leila Amiri RESULTS: The interventions improved nursing documentation quality score of 73.20%, which was the highest Farahani. This is an open-access article distributed under the terms of the Creative Commons Attribution- accreditation ranking provided by Iran’s Ministry of Health and Medical Education in 2017. In other words, this NonCommercial 4.0 International License (CC BY-NC 4.0) study caused a 32% improvement in the quality of nursing care documentation in the hospital. Funding: This research did not receive any financial support CONCLUSION: The appropriate practices for improving nursing care documentation are employee participation, Competing Interests: The authors have declared that no managerial accountability, nurses’ adherence to documentation standards, improved leadership style, and competing interests exist continuous monitoring and control. Introduction provides regulatory and observatory standards that facilitate evidence-based processes [8] [9]. Documentation likewise serves as a tool for research, In the nursing profession, documentation is a qualitative assessment, and the provision of records critical part of quality improvement [1], which in turn, is for medical jurisprudence. Written evidence of a major factor that affects the transparency of nursing patients’ progress is essential in nursing care because practices [2]. Documentation plays a vital role in the such evidence ensures the organisation of nursing appropriate planning of nursing care services, the services based on logical thinking for clinical decisions accurate recording of daily events, and the [10]. satisfaction and well-being of patients [3] [4]. It can Despite the criticality of documentation, also be used to plan and evaluate patient care [3]. however, studies conducted in Iran showed that the The documentation of nursing services is important for quality of medical records in the country’s hospitals is some other reasons. It facilitates communication and unsatisfactory [8] [11]. Research that compared world collaboration [5], organises the nursing care chain [6], standards with those of Iran revealed that nurses in smoothens decision making about patient care and other countries exhibit more desirable quality safety, ensures professional accountability [7], and regarding adhering to documentation principles and _______________________________________________________________________________________________________________________________ Open Access Maced J Med Sci. 2018 Aug 20; 6(8):1527-1532. 1527 Public Health _______________________________________________________________________________________________________________________________ standards [12]. The insufficient quality of nursing documents were evaluated as accurate, professional, service documentation remains one of the main and concise. challenges in Iran’s nursing profession [13], with years In the studies conducted by Dehghan et al., of clinical interventions failing to achieve significant [19], Darmer et al., [20], Ofi et al., [21], Gugerty et al., change [14]. [22], Lees [4], and Corben [17], a nursing service To address this issue, the current study was auditing method was used to provide valid, clear, and conducted to improve the nursing care documentation encoded data and consequently improve patient care in the emergency department of an affiliated academic (Lees) and coordination in the process of recording hospital in Iran. nursing interventions by the treatment team Ofi et al., [21]. Asserted that a nursing audit is an important part of risk management and quality assurance processes because the appraisal of patient records reduces errors and improves poor standards. Documentation Material and Methods is also a powerful tool for improving the quality of nursing care as it paves the way for formulating global standards for care. Ning claimed that electronic The study was carried out in a 233-bed documentation designed to enhance the quality of academic affiliated hospital located in Khorasan nursing care is somewhat better than paper-based Razavi Province. The hospital’s emergency documentation, but such evaluation requires more department is the major trauma centre in the province comprehensive consideration. In the research of Vabo and comprises 24 active beds as well as admission, et al., [18] and Lees et al., [4], nursing staff training outpatient, radiology, and triage sectors that admit an was found to play an important role in improving the average of 470 elective patients and 89 inpatients documentation of nursing services. Feng found that daily. The emergency medical staffs include 32 although the use of clinical care classification may nurses, 12 nursing assistants, 9 general physicians, generate numerous results, it is, in fact, ineffective in and 3 emergency physicians. The documentation obtaining findings regarding the effects of the nursing system for nursing services is a paper and an intervention on patient care quality. The nurses electronic system. The 20-year presence of participating in the study use free text to evaluate researchers in nursing management positions in this nursing care outcomes. This intervention style, hospital failed to contribute to the total accreditation according to the author, has been unsuccessful in score of the hospital, which gained only 42.2% in improving the documentation and development of 2014. nursing services. The study was of a participatory action To determine the status quo in the case research design based on Kemmis’s model [15]. For hospital, an instrument used to evaluate the quality of the action research process, the model features a nursing care documentation was extracted from circular structure, with each circle containing four Esmaeilian et al., [23]. The reliability of the instrument steps: problem definition and planning, action, was determined through concurrent validation and observation, and reflection. We systematically comparison with previous instruments in a survey reviewed 14 articles, among which the action research administered to 200 patients discharged from the conducted by Lees et al., [4], Okaisu et al., [16], emergency department of the investigated hospital Corben et al., [17], and Vabo et al., [18] involved the (Cronbach’s alpha=82%). [1] The validity of the use of revision methods in the correction of evaluation instrument was evaluated based on comments from tools, workshops, and documentation forms to professors at Mashhad University of Medical Sciences improve the documentation of nursing services. The and Iran University of Medical Sciences. Validity was interventions implemented in these works provided confirmed after modifications to the instrument were valid data and created procedural unity for the made. The instrument was scored based on four process of intervention in nursing care documentation categories of documentation: white = 0 (no in the examined organisations. The authors indicated documentation), incomplete = 1 (one required items),