Exploring strategies to improve documentation of nursing notes in hospitals globally: An integrative review

Abstract

Documentation of nursing notes is the main communication mechanism for nurses and the multidisciplinary teams in healthcare, hence its quality is crucial in decision-making. Despite the technological advances in medical information systems, documentation of nursing notes remains a challenge. This study aimed to examine strategies to improve documentation of nursing notes in hospital worldwide. An integrative review was conducted. The search string was developed by the authors with the help of a librarian. The inclusion criteria were articles between 2010–2024. The exclusion criteria were articles written in other languages other than English. The authors and a librarian accessed databases for this review in MEDLINE, CINAHL with full text, academic search ultimate, APA PsycInfo, ERIC, E journals, CAB abstracts, Africa-wide information, and Education Source. A total of 52 articles were selected and included. Most studies were predominantly from, Australia, United states of America, South Africa, Brazil and United Kingdom. There is a paucity of studies that address strategies to improve nursing documentation especially from Low and middle income countries(LMICs). The study revealed that the factors that facilitate improvement in the documentation of nursing notes include interventions at the organisational, unit, and healthcare provider levels. A total four themes were identified in the study these included: 1. organizational-level support, through policy 2. clinical training unit support, through training 3. unit-level support through leadership and 4. nurse documentation practices through structure and standardization. Conclusion: Improving nursing documentation within healthcare organizations requires coordinated interventions that create enabling environments that adapt these approaches to improve nursing documentation.

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