'It's all about ticks': A secondary qualitative analysis of nurse perspectives about documentation audit

Aim: To understand how nurses talk about documentation audit in relation to their professional role.Background: Nursing documentation in health services is often audited as an indicator of nursing care and patient outcomes. There are few studies exploring the nurses' perspectives on this common process.Design: Secondary qualitative thematic analysis.Methods: Qualitative focus groups (n = 94 nurses) were conducted in nine diverse clinical areas of an Australian metropolitan health service for a service evaluation focussed on comprehensive care planning in 2020. Secondary qualitative analysis of the large data set using reflexive thematic analysis focussed specifically on the nurse experience of audit, as there was the significant emphasis by participants and was outside the scope of the primary study.Results: Nurses': (1) value quality improvement but need to feel involved in the cycle of change, (2) highlight that 'failed audit' does not equal failed care, (3) describe the tension between audited documentation being just bureaucratic and building constructive nursing workflows, (4) value building rapport (with nurses, patients) but this often contrasted with requirements (organizational, legal and audit) and additionally, (5) describe that the focus on completion of documentation for audit creates unintended and undesirable consequences.Conclusion: Documentation audit, while well-intended and historically useful, has unintended negative consequences on patients, nurses and workflows.Impact: Accreditation systems rely on care being auditable, but when individual legal, organizational and professional standards are implemented via documentation forms and systems, the nursing burden is impacted at the point of care for patients, and risks both incomplete cares for patients and incomplete documentation.No Patient or Public Contribution: Patients participated in the primary study on comprehensive care assessment by nurses but did not make any comments about documentation audit.

Automated summary

This study aims to understand how nurses discuss documentation audit in relation to their professional role. The research findings indicate that nurses have concerns and reflections about the process of documentation audit and raise questions about its effectiveness. The study suggests that documentation audit has unintended negative consequences on patients, nurses, and workflows.