Aim To obtain an overview of existing evidence on quality criteria, instruments, and requirements for nursing documentation. Design Systematic review of systematic reviews. Data sources We systematically searched the databases PubMed and CINAHL for the period 2007–April 2017. We also performed additional searches. Review methods Two reviewers independently selected the reviews using a stepwise procedure, assessed the methodological quality of the selected reviews, and extracted the data using a predefined extraction format. We performed descriptive synthesis. Results Eleven systematic reviews were included. Several quality criteria were described referring to the importance of following the nursing process and using standardized nursing terminologies. In addition, some evidence‐based instruments were described for assessing the quality of nursing documentation, such as the D‐Catch. Furthermore, several requirements for formats and systems of electronic nursing documentation were found that refer to the importance of user‐friendliness and development in consultation with nursing staff. Conclusion Aligning documentation with the nursing process, using standard terminologies, and using user‐friendly formats and systems appear to be important for high‐quality nursing documentation. The lack of evidence‐based quality indicators presents a challenge in the pursuit of high‐quality nursing documentation. Impact There is uncertainty in nursing practice about which criteria have to be met to achieve high‐quality documentation. Aligning documentation with the nursing process, using standard terminologies, and using user‐friendly formats and systems appear to be important. These findings can help nursing staff and care organizations enhance the quality of nursing documentation.

Many western countries are experiencing a substantial shortage of home-care nurses due to the increasing numbers of care-dependent people living at home. In-depth knowledge is needed about what home-care nurses find attractive about their work in order to make recommendations for the recruitment and retention of home-care nursing staff. The aims of this explorative, qualitative study were to gain in-depth knowledge about which aspects home-care nurses find attractive about their work and to explore whether these aspects vary for home-care nurses with different levels of education. Discussions were conducted with six online focus groups in 2016 with a total of 38 Dutch home-care nurses. The transcripts were analysed using the principles of thematic analysis. The findings showed that home-care nurses find it attractive that they are a "linchpin", in the sense of being the leading professional and with the patient as the centre of care. Home-care nurses also find having autonomy attractive: autonomy over decision-making about care, freedom in work scheduling and working in a self-directed team. Variety in patient situations and activities also makes their work attractive. Home-care nurses with a bachelor's degree did not differ much in what they found attractive aspects from those with an associate degree (a nursing qualification after completing senior secondary vocational education). It is concluded that autonomy, variety and being a "linchpin" are the attractive aspects of working in home care. To help recruit and retain home-care nursing staff, these attractive aspects should be emphasised in nursing education and practice, in recruitment programmes and in publicity material. K E Y W O R D Sattractiveness, autonomy, home care, nurses

No abstract

Background Patient participation in nursing documentation has several benefits like including patients’ personal wishes in tailor-made care plans and facilitating shared decision-making. However, the rise of electronic health records may not automatically lead to greater patient participation in nursing documentation. This study aims to gain insight into community nurses’ experiences regarding patient participation in electronic nursing documentation, and to explore the challenges nurses face and the strategies they use for dealing with challenges regarding patient participation in electronic nursing documentation. Methods A qualitative descriptive design was used, based on the principles of reflexive thematic analysis. Nineteen community nurses working in home care and using electronic health records were recruited using purposive sampling. Interviews guided by an interview guide were conducted face-to-face or by phone in 2019. The interviews were inductively analysed in an iterative process of data collection–data analysis–more data collection until data saturation was achieved. The steps of thematic analysis were followed, namely familiarization with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and reporting. Results Community nurses believed patient participation in nursing documentation has to be tailored to each patient. Actual participation depended on the phase of the nursing process that was being documented and was facilitated by patients’ trust in the accuracy of the documentation. Nurses came across challenges in three domains: those related to electronic health records (i.e. technical problems), to work (e.g. time pressure) and to the patients (e.g. the medical condition). Because of these challenges, nurses frequently did the documentation outside the patient’s home. Nurses still tried to achieve patient participation by verbally discussing patients’ views on the nursing care provided and then documenting those views at a later moment. Conclusions Although community nurses consider patient participation in electronic nursing documentation important, they perceive various challenges relating to electronic health records, work and the patients to realize patient participation. In dealing with these challenges, nurses often fall back on verbal communication about the documentation. These insights can help nurses and policy makers improve electronic health records and develop efficient strategies for improving patient participation in electronic nursing documentation.

No abstract