Experience of electronic nursing documentation in a hospital setting: A qualitative study

26^th World Congress on Nursing Care

May 21-23, 2018 Osaka, Japan

Lee Khuan, Muhamad Hanafiah Juni and Norafisyah Makhdzir

University Putra Malaysia, Malaysia

Scientific Tracks Abstracts: J Nurs Care

Abstract :

Introduction: Electronic health records have evolved to meet the demands of the health care environment and to improve quality of patient care in hospitals. The purpose of transforming the conventional paper-based documentation to a more efficient electronic system is in tandem with the vision of the World Health Organization to improve handover communication. Only a few studies have investigated nurse's response to electronic documentation in Malaysia. Aim: To understand the nurse's experience of electronic documentation and its influence on nurse's daily job in a ward. Method: This study is based on a qualitative research design. Ten participants were purposively selected from orthopedic wards in a public hospital in West Malaysia. Participants went through in-depth semi-structured interviews lasting about one hour for two sessions on different dates. Observations during morning or afternoon shifts were also carried out for 20 days. The NVivo 10 package was used and data were analyzed by using a content analysis method. Result: Five main themes were identified: Decreased workload versus increased workload; computer related technical problem compromise electronic documentation process; structured computerized contents good and bad, copy and paste culture; consequences of structured computerized content and copy and paste culture. Conclusion: To improve nurses work efficiency, solutions involving a standard operating and monitoring system on computer (Laptop/PC) used and maintenance must be introduced to all staff in the wards to ensure the quality of electronic documentation, which directly maintain quality of patient care. Nursing supervision and continue nursing education are required to ameliorate negative effects from copy and paste culture and structured computerized content.

Biography :

Lee Khuan has completed her PhD from the University Putra Malaysia. She has 13 year of nursing clinical experience at Ministry of Health Malaysia in various fields including community health nursing, neurosurgical wards and operation theater. She is currently working as a Senior Lecturer at the Department of Nursing and Rehabilitation, Faculty of Medicine and Health Sciences, University Putra Malaysia.
Email:leekhuan@upm.edu.my