The Quality of Clinical Documentation of Patients Admitted to an Iranian Teaching Hospital: A two-year Impact of Clinical Governance

Dorsa Dehghan¹, Mahlagha Dehghan², Akbar Sheikhrabori³*

¹Lecturer, Department of Pediatric Nursing, School of Nursing and Midwifery, Islamic Azad University Kerman Branch, Kerman, Iran

²PhD in Nursing, Department of Medical Surgical Nursing, School of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran

³MSc in Nursing, Department of Prehospital Emergency, Kerman University of Medical Sciences, Kerman, Iran

*Corresponding Author Email: pearllike2002@yahoo.com, m_dehghan86@yahoo.com , p.shykhrabori@gmail.com

ABSTRACT:

Background and Objective: One basic and fundamental source of information in health care is the patient record, of which nursing documentation is a part. Despite continuous and consistent advice from quality-improvement programs and professional bodies over several years, achieving and maintaining good standards of clinical documentation is still a problem in the health profession. In Iran, implementation of clinical governance was approved in 2006. As the implementation of health policies in Iran is centralized and there is no especial difference among provinces, this research sought to determine the effect of clinical governance on improving nursing documentation in Kerman, Iran.

Material and Methods: This was a quasi-experimental study conducted in an instructional hospital in Kerman. Documentation of medical records by nurses in the first quarter of 2010 and the fourth quarter of 2012 were assessed. Random stratified sampling was used and 330 records were chosen at random. A researcher made checklist was used to assess the documentation’s structure and content. Descriptive statistics and analytical statistics were used to analyze the data. SPSS version 16 was used to analyze the data.

Results: There were no differences between nurse's demographic data before and after two years (P>0.05) except attendance in training workshop (P < 0.05). The nursing documentation score improved more structurally than contently after two-year clinical governance implementation (P < 0.05).

Conclusion: Although some efforts were made to improve nursing documentation by implementing a clinical governance program, these were not sufficient and more attempts are needed.

KEYWORDS: Nursing documentation, clinical governance, nursing record, quality improvement, quality assurance

INTRODUCTION:

The basic condition of offering therapeutic services with appropriate quality is coherent and coordinated effort of the health-care team as 24 hours a day and without interruption. To achieve this objective, the permanent association of members for sharing and exchange of information is essential. Reporting and documentation are the main communicative techniques used for the health-care providers to assess quality, type and continuity of cares.¹ Because nurse is often the first caregiver, information who she/he registers to inform other caregivers of the patient's condition, behavior and his/her responses is very important, and it should be quite clear, accurate and complete.² Furthermore, the detailed documentation and in accordance with professional standards is the most important thing that nurses can conduct to protect themselves against allegations of wrong performance or negligence. Furthermore, incomplete, vague and unclear record, recording at the inappropriate time, and writing personal deductions are among cases that legally discredit nursing records.³ The nursing documentation except for the communicative and legal roles has also other important roles such as educational, research, auditing and evaluating that shows the importance and value of a proper and accurate nursing documentation.²

Studies have shown that about 38% of nurses' shift time spends for nursing documentation. Recording nursing cares is a sign of offering care and its quality so, each its failure can indicate not to provide adequate care for patient. Furthermore, studies have shown that one case out of every 4 occupational neglects occurred in the care of patient is related to errors of nursing records.⁴ Mashoufi et al., also stated in their study that only about half of the data were recorded by the nurses.⁵In addition, Ghazanfari et al., showed in their study regarding knowledge and performance of nurses about the principles of nursing documentation that 85% of nurses had inappropriate recording performance.⁴ Although, errors that have occurred in the nursing records may not be detected but they may have a serious effect on the quality of cares.²

Given that today treatment is not the only goal of therapeutic centers, steps can be taken to improve therapeutic services quality by enhancing quality of data, completing patients' medical records, and nursing documentations.⁴ To date, in different countries, different methods and tools have been used to address the many problems of the health system and consequently, the problems related to documentation and improving the quality of health systems. Clinical governance was discussed among these methods for the first time in National Health Service (NHS) of England as a strategy offered by the government and to enhance the quality of clinical cares in the 1990s. ^{6, 7} Since, the World Health Organization has recommended implementing of clinical governance to its members, a preliminary program was presented to the Board of Trustees at Tehran University. Following elementary surveys and discussion and study of the matter at some meetings' Board of Directors, consequently in accordance with paragraph 45 approved of the twenty-third meeting of the Board of Trustees' the University (February 14, 2006), the university was allowed to implementing clinical governance.⁸

Various models and patterns can be found to define and describe the clinical governance. One of the patterns used in the England national medical system is 7-axis or 7-column model that according to its comprehensiveness has been introduced as the suggested model by The Ministry of Iran Health, Treatment and Medical Education.⁸ This model includes patient and public involvement, use of information, education & training, clinical effectiveness, staff & staff management, risk management and clinical audit.⁹ Within the clinical governance framework, Verifying roles in the health care system has been considered as an essential affair and the suitable tool have been provided to achieve a health system in which its goal is offering the best service. Scally and Donaldson stated the prospect of clinical governance in 1998 as follows: ‘To maintain high standards, clinical governance is the main vehicle for continuously improving the quality of patient care. Clinical governance is a system through which NHS organizations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellent clinical care will flourish.ʼ^10-12

It seems that organizational supervision is a key factor in improving the nursing documentation.¹³ Furthermore, according to Gordon et al., repeated educations, change in the papers of documentation, the direct and wide leadership with continuous and accurate audit and feedback, transparency, clear and objective accountability are essential to promote documentation of patients' pain.¹⁴These strategies all are involved in clinical governance plan. In Iran, the implementation of clinical governance was a change that emphasized on improvement and assurance of health care quality. Thus, every part of the hospital, including nursing and nursing cadre had also included in this program. It should be noted that health policies has been centralized in Iran and major difference doesn’t exist among provinces in the implementation of clinical governance. The purpose of this study was to investigate the quality of nursing documentation (records of patients' admitting to the medical-surgical wards, intensive care units (ICUs) and emergency department (ED)) and its improvement after about two years since implementation of the clinical governance.

MATERIALS AND METHODS:

Study design:

This study was a quasi-experimental study that was conducted at one of a teaching hospital affiliated to the Kerman University of Medical Sciences in 2012. Since 2011, implementation of clinical governance has begun in Medical Sciences University of Kerman and its affiliated hospitals. One of these hospitals where clinical governance was actively implementing was randomly selected for the study.

Implementation of Clinical Governance:

The nursing service manager was interviewed after obtaining permission from the Kerman University of Medical Sciences and presenting the permission to the relevant hospital, about how the clinical governance were implementing, especially measures that has been taken in regard to enhance the quality of nursing documentation. According to the nursing service manager and existing documents during implementation of clinical governance, a total of 572 hours of training classrooms was conducted about concepts of clinical governance for head nurses and nursing supervisors. The presence of head nurses and supervisors was mandatory in these meetings. They were responsible for conveying the learned concepts to their own staff. 22 workshops were also conducted on the concept of clinical governance for nursing staff. The presence of nurses was optional at the workshops. Nursing service manager with a professional management MA degree (MBA) and a faculty member with a PhD degree in Health Education and 4 general practitioners affiliated to Province Health Center and Kerman University of Medical Sciences were responsible for teaching and managing meetings and workshops. In addition to training sessions on clinical governance, two 5-hour workshops on how to documenting nursing care had conducted during two years of implementing clinical governance. Nursing staff attendance was also optional at these meetings. Head nurses were also obligated to accurately control nursing records.¹⁵ Furthermore, the two forms of “patient education” and “patient assessment of nursing care quality” were added to improve nursing documentation to the patient's records.

Instrument:

The used instrument to audit nursing records was a researcher-made checklist which included both the structure and content parts. The part of structure consists of 16 items (Item 16 had 9 sub-items) which was adjusted in the three-degree range of Likert (complete record = 2, incomplete record = 1, no record = 0) and the content part included 20 items for control admission reports that was adjusted in the four-degree range of Likert (complete record = 3, incomplete record = 2, no record = 1, not necessary = 0). Checklist validity was performed by using the content validity so that researcher prepared checklist by study of literature and offered it to 10 experts until they specify adequacy of each item based on five-point Likert scale (quite appropriate, appropriate, no idea, inappropriate, quite inappropriate). Percentage of quite appropriate and appropriate options selected by experts and their mean were considered respectively as validity coefficient of each item and checklist validity coefficient. Correspondingly, the validity coefficient of each item ranged from 0.72 to 1.0 and validity coefficients of the structure and content parts were respectively 91.7 and 96.7 %. Furthermore, the validity coefficient of total checklist was 95.3%. To determine reliability of the checklist, inter-rater reliability was calculated. Kappa coefficient was 0.81 that was acceptable. The total score was calculated based on 100 and was placed in five categories including very bad (0-19.9), bad (20-39.9), average (40-59.9), good (60-79.9) and very good (80-100).

Data collection and sampling:

Nursing records related to the last three months (January, February, March) 2011 (prior to the implementation of the clinical governance) and the current three months (October, November and December) 2012 of this hospital were audited. It should be noted that any document of nursing report related to the admission of patient was audited. The sample size required in this study was estimated 330. Stratified random Sampling was used. All wards of the hospital were divided in to three categories of the medical-surgical wards, ICUs and ED and considering the desired sample size, 55 samples were randomly selected per class before and after the implementation of clinical governance. A table of random numbers was used to select records. Other research variables such as gender, ward type, degree of nurses who documented the records, and shift (morning, afternoon, evening) were extracted by using medical records. Then, the other variables such as age, marital status, work experience, employment type and experience of attending in workshops about documentation were obtained through questioning the personnel and nursing office.

Ethical consideration:

Kerman University of Medical Sciences (KUMS) approved this project. After approval of KUMS and the clinical centers, we provided information for the nursing manager and the nurses. The information addressed 1) the goal and objectives of the study, 2) the confidentiality of the data, and 3) the participants would be anonymous. Then the informed consent was obtained verbally. Finally, we appreciated those who participated.

Statistical analysis:

Descriptive statistics (frequency and percentage, mean and standard deviation) and analytical statistics (Fisher's exact test, chi-square, Mann-Whitney U test and ANOVA (Analysis Of Variance)) were used for data analysis. Eta squared and Spearman correlation coefficients were used to determine the relationship between quality of nursing documentation and demographic variables. SPSS statistical software of version 16 was used for data analysis. It should be noted in this study that the level of significance and Type II error were considered respectively 0.05 and 10%.

RESULTS:

Among 165 medical records studied before and after the implementation of clinical governance were respectively 1 nursing record related to ICUs as well as 3 nursing records related to ICUs and 1 nursing record related to the emergency department without nurse's name and signature. Furthermore, 8 nursing records (2, 2 and 4 nursing records respectively related to the medical-surgical wards, ICUs and ED) before the implementation of clinical governance and 3 nursing records (2 and 1 respectively related to the medical-surgical wards and ED) after the implementation of clinical governance didn’t existed in the medical records. From this respect, there was no significant difference between before and after the implementation of clinical governance (P > 0.05 and F = 4.08). The average nurses' age were in both groups before and after the implementation of clinical governance 32.84 ± 7.42 and 31.11 ± 6.13 years, respectively (P > 0.05). Almost 91% of nurses were female in two groups before and after implementation of clinical governance. 71% and about 65% nurses, respectively, before and after implementation of clinical governance were married (p > 0.05). Before and after implementation of clinical governance, more than 60% of nursing records had written by nurses who had bachelor's of science (BSc). Nursing experience were 85.05 ± 102.07 and 58.31 ± 69.30 months, respectively before and after the implementation of clinical governance (P > 0.05). In terms of employment status, 27.30 % were hired, 29.30 % were contract workers (type 1), 26.70 % were contract workers (type 2), and 10.70 % were committed before the implementation of clinical governance and this variable was respectively 15%, 32%, 27%, and 21% after the implementation of clinical governance. Statistically, no significant difference was observed between the two groups (P > 0.05). 16% of nurses before the implementation of clinical governance and nearly 32% of nurses after the implementation of clinical governance had experience of participating in the specialized documentation workshops. This difference was statistically significant (P = 0.01). Before the implementation of clinical governance, 30%, 36% and 29% of audited records were respectively related to the morning, evening and night shifts and after the implementation of clinical governance, these values were respectively, 26%, 32% and 41 % (P > 0.05). It should also be noted the number of nursing records from the medical-surgical wards, ICUs and ED was equal due to the sampling method (Table 1).

Table 1. Variables distribution before and after Clinical Governance

Groups

variables

Before Clinical Governance

(n = 165)

After Clinical Governance (n = 165)

Test statistic

Nursing records

Having nurse's name

Not having nurse's name

Undocumented

156 (94.50%)

1 (0.60%)

8 (4.80%)

158 (95.80%)

4 (2.40%)

3 (1.80%)

Fisher's Exact Test = 4.08

P value = 0.13

Unit

Medical-Surgicals

ICUs

Emergency

55 (33.33%)

c² = 0.00

P value > 0.99

Age (yr)

Mean = 32.84

SD^* = 7.42

Mean = 31.11

SD = 6.13

Mann-Whitney U: Z = - 1.85

p value = 0.06

Gender^1,2

Female

Male

Not clear^***

144 (90.60%^**)

6 (3.80%)

9 (5.70%)

146 (91.20%)

7 (4.40%)

7 (4.40)

Fisher's Exact Test = 4.45

P value = 0.22

Marital status¹^,2

Single

Married

Others

Not clear

30 (21.00%)

101 (70.60%)

3 (2.10%)

9 (6.30%)

47 (30.10%)

101 (64.70%)

3 (0.60%)

7 (4.60%)

Fisher's Exact Test = 4.45

P value = 0.22

Degree^1,2

Diploma in nursing

Bachelor of Nursing

MS in nursing

Not clear

44 (26.70%)

112 (67.90%)

0 (0.00%)

9 (5.40%)

30 (18.40%)

125 (76.70%)

1 (0.60%)

7 (4.30%)

Fisher's Exact Test = 4.6

P value = 0.20

Clinical Nursing Experience (mo)

Mean = 86.05

SD = 102.07

Mean = 58.31

SD = 69.30

Mann-Whitney U: Z = - 0.24

p value = 0.81

Type of employment¹^,2

Hired

Contract recruiters-1^a

Contract recruiters-2^b

Committed^c

Not clear

41 (27.30%)

44 (29.30%)

40 (26.70%)

16 (10.70%)

9 (6.00%)

24 (15.30%)

50 (31.80%)

43 (27.40%)

33 (21.00%)

7 (4.50%)

c² = 8.40

P value = 0.50

Attendance in training workshop¹^,2

Yes

Not clear

23 (16.00%)

112 (77.80%)

9 (6.30%)

50 (31.80%)

100 (63.70%)

7 (4.50%)

c²₌ 10.37

P value= 0.01

Shift³

Morning (7:30- 13:30)

Afternoon (13:30- 19:30)

Night (19:30- 7:30)

Not clear

48 (29.80%)

58 (36.00%)

47 (29.20%)

8 (4.90%)

41 (25.60%)

51 (31.90%)

65 (40.60%)

3 (1.90%)

c²₌ 6.16

P value= 0.10

Missing data in variables were because of:

1. Some of nursing documentation had no nurse signature to identify nurse’s demographic data.

2. Some of nurse’s had been no longer in the hospital and no data about them were existed.

3. researcher-made missing

* Standard Deviation

** valid percent

*** Unable to find data because of no nursing admission record or no nurse signature.

a. Annually contracted with payment similar to hired.

b. Annually contracted with payment less than hired.

c. It is obligatory to work for government for two years with payment less than the others.

Table 3. Association between Nursing Documentation Quality Score and variables

Nursing Documentation Quality Score vs.

Mean (SD)

Statistic test (ANOVA/Spearman's rho)

P value

Group

Before Clinical Governance

After Clinical Governance

1.62 ± 0.16

1.66 ± 0.14

F = 6.33

h²^* = 0.02

0.01

Unit

Medical-Surgicals

ICUs

Emergency

1.63 ± 0.15

1.62 ± 0.15

1.66 ± 0.16

F = 1.30

h²= 0.01

0.28

Age

1.64 ± 0.15

r = 0.04

0.45

Gender

Female

Male

1.65 ± 0.15

1.60 ± 0.09

F = 11.56

h² = 0.07

< 0.001

Marital status

Single

Married

Others

1.62 ± 0.16

1.65 ± 0.14

1.55 ± 0.17

F = 8.59

h² = 0.08

< 0.001

Degree^**

Diploma in nursing

Bachelor of Nursing

1.62 ± 0.15

1.65 ± 0.15

F = 8.94

h² = 0.08

< 0.001

Clinical Nursing Experience

1.64 ± 0.15

r = 0.04

0.51

Type of Employment

Hired

Contract recruiters-1

Contract recruiters-2

Committed

1.62 ± 0.14

1.65 ± 0.16

1.65 ± 0.14

1.66 ± 0.15

F = 6.06

h² = 0.07

< 0.001

Attendance in training workshop

Yes

1.65 ± 0.16

1.64 ± 0.14

F = 11.07

h² = 0.07

< 0.01

Shift

Morning (7:30- 13:30)

Afternoon (13:30- 19:30)

Night (19:30- 7:30)

1.62 ± 0.15

1.63 ± 0.14

1.68 ± 0.14

F = 12.46

h² = 0.11

< 0.01

*Eta squared

** Just one MS in nursing degree were existed so this not considered for calculation.

DISCUSSION:

The findings of study showed that significant differences existed between the records quality score before and after two years since the implementation of clinical governance. This difference was significant in terms of records structure, but was not statistically significant in terms of nursing records content. Furthermore, a significant relationship existed between the nursing records quality and variables of gender, marital status, education degree, and employment status, attendance in training workshop and work shift.

The literature review showed that the nursing records quality score in Dehghan et al., study had no significant change after the implementation of clinical governance than before it.¹⁵ Nursing documentation quality has improved in the present study that differs with the above study results. The main reason for this difference can be that in Dehghan et al. study, 24-hour nursing records were examined¹⁵ while admission records have examined in the present study. Therefore, since patient admission records are considered by most of health care providers and head nurses also more carefully monitor them, nurses more accurately attempt to record patients' admission data. In addition, in the present study the quality of nursing records were improved more structurally than contently that is consistent with Dehghan et al., study.¹⁵ One of the main reasons that caused not to less improvement of content of nursing documentation whether in the present study or in the Dehghan et al. study is lack of a regular system of nursing care intervention such as nursing process and thus, documentation.¹⁵The nursing process is used for implementation of nursing care in most developed countries and nursing documentation also record based on the nursing process. However, in Iran nursing care are performed without using nursing process and no legal requirement exists for the use of nursing process. Therefore, it is not entirely clear how to provide cares and how to record them for most nurses. Using organizational changes and the VIPS model (Well-being, Integrity, Prevention, Security) training have caused to improve the quality of nursing documentation in Björvell and et al. study.¹⁶ Furthermore, using the VIPS model has significantly improved the nursing documentation and nurses' knowledge about nursing diagnosis as well as nursing planning and interventions in another study¹⁷ which confirm the obtained results of present study. Unlike the present study, nursing documentation both structurally and in terms of content was promoted after the implementation of continuing education in study's Abbass Zadeh et al.and Khoddam et al.^{1, 2} One reason for the difference of the results of the Abbass Zadeh et al.² study with the present study is that in their study, the researchers designed a scenario and asked the nurses to record it. It appears this method cannot well evaluate existing realities in clinic because the specified scenario is not an actual scenario. Furthermore, only three days was interval between offering training and control nurses' documentation skill in this study. It seems that this limited time is a little interval for evaluating nurses' actual skills in field of the documentation. The reliability of the used checklist has not been reported in Khoddam et al. study¹ and it appears the used checklist have not enough integrity.

According to the results of the present study, almost all nursing records had good or very good quality structurally, but only 30% content of nursing records were as moderate. This amount represents the low quality of content of nursing records. These results are consistent with findings of Dehghan et al. study.¹⁵ However, in Dehghan et al. study, content of 25% of records (nursing records that related to length of being hospitalized except admission and discharge records, we called it 24-hour nursing records) were as good or very good that this is different with present study. It seems the content quality of admission records is better than 24-hour records. Jasemi et al. also reported that quality of 100% of nursing documentations were as moderate.¹⁸ Results of Khoddam et al. study also confirm the results of the present study. The nursing documentation structure quality score was more than its content quality score in their study.¹ Gunningberg et al. also showed that the comprehensiveness and quality of nursing documentation were inadequate.¹⁹ Record of issues such as signing, correct abbreviations, and assessing patient basic needs had a significant deficient in another study.²⁰ Ghazanfari et al. also reported that only 5.6 % nursing documentation were as good and the content of nursing records was incomplete.⁴

Jasemi et al. reported that women had recorded nursing cares significantly better than men that confirm the present study results.¹⁸ The present study showed that nursing records quality was better in married than single nursing staff but such a relationship didn’t observe in Dehghan et al. study.¹⁵ Uys and Booyens also reported the number of registered nurses and non-nursing support staff as well as the kind of ward had a major impact on the quality of documentation.²¹ Records' quality of nurses working in surgical than medical wards also was better in Jasemi et al. study.¹⁸ Furthermore, Dehghan et al. also found that the quality of ICUs records were better than those of medical-surgical wards.¹⁵ A significant relationship existed between the education level of nursing staff and nursing records quality in present study so that records quality was better in nurses who had BSc than nurses who had diploma. Although the average nursing records quality score was more in ED than ICUs and medical-surgical wards but this amount was not statistically significant. Therefore, according to the present study and the cited studies^{15, 18, 21}, it appears increasing the need for acute and critical cares have a major impact on quality of nursing reports. Employment type of nursing staff had a relationship with the quality of nursing records in the present study so that quality of documentation by committed nurses was higher than other groups. Dehghan et al. study also confirms this finding.¹⁵ It seems being novice and incentive for being employed are factors to increase productivity and improving the quality of novice nurses performance. Ghazanfari et al. found that there is a significant relationship between the quality of nursing records and attending in workshops⁴ that confirms the results of the present study. But this finding was in contrast with result of Dehghan et al. study.¹⁵ It should be noted although, nursing records quality score of nurses who participated in workshops (specialized documentation workshop) was better, but this effect was more in terms of structure quality and content of nursing records yet was as weak in the present study. Therefore, in addition to the necessity of follow-up for conducting workshops, continuous monitoring and auditing and providing feedback to the nursing staff are essential. Nursing records quality was better in evening and night than morning shift in the present study that is inconsistent with the results of Dehghan et al. study.¹⁵ One reason could be the arrangement of nursing staff in shifts. The committed and contract recruiters (type-2) nurses in compare with contract recruiters (type-1) and hired nurses have more evening and night shifts. Thus, more motivation and desire for recruitment can be a factor for improving the performance quality of these nurses.

Due to the point that the nursing documentation assessment is somewhat subjective, authors cannot control its impact on how to nursing records assessment. It cannot be claimed that the deficiencies of nursing records (especially from the content dimension) has been precisely because of nurses' carelessness or due to lack of necessity for recording that data. Although, the mean difference for nursing records quality scores before and after implementation of clinical governance has been more than the mean difference of nursing records quality scores for being present/absent in workshops, but impact of overlapping these two interventions cannot be accurately differentiated.

In conclusion, implementing clinical governance as a model for improving the quality of health services can improve quality of nursing documentation. Although, this improvement in quality than before the implementation of clinical governance is significant but yet quality of nursing documentation is undesirable and multiple efforts are required to improve it. Evaluating how to offer the nursing services and nursing care simultaneous with recording and use of nursing process can cause to improve the quality of nursing documentation. Further studies are necessary to reveal the impact of these suggestions on quality of nursing documentation.

ACKNOWLEDGEMENTS:

The authors thank the nurses and personnel of the medical record archives of Bahonar Hospital for their contribution to our data collection.

CONFLICT OF INTEREST AND FUNDING:

There is no conflict of interest to be declared. The authors received no financial support for the research and publication of this article.

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Table 2. Quality of nursing documentation before and after Clinical Governance
	Before Clinical Governance (Mean ± SD)	After Clinical Governance (Mean±SD)	Test statistic
Nursing documentation Quality score	1.62 ± 0.16	1.66 ± 0.14	t = -2.52 p value = 0.01
Structure	2.31 ± 0.21	2.36 ± 0.19	T = -2.29 p value = 0.02
Content	1.06 ± 0.22	1.10 ± 0.22	T = -1.47 p value = 0.14