Qualitative descriptive study reveals challenges in nursing documentation in an emergency department, suggesting needs for innovation.
Premises and Purpose of the study: In the Emergency Department (ED), characterized by high intensity of care, the nursing documentation, highly relevant in the care pathway, should assume context-specific characteristics. This study aimed to investigate how nurses of an ED of a second level hospital in the Marche region (IT) evaluate nursing documentation, and how they would consider the introduction of innovative clinical care documentation.Materials and Methods: This qualitative descriptive study involved n. 15 nurses from the ED of the Italian hospital, who underwent interviews following the Colaizzi method, until saturation level. The initial question, “What is your opinion about the nursing documentation currently used in the ED and how would you assess the introduction of a new model of nursing record?”, represented the input for the articulation of the rest of the interview.Results: An inappropriate recording of procedures and activities related to the nursing care process, due to the patients’ complexity and to a documental system not suited to a high-intensity care context, has been highlighted. Proposals aimed to overcome the excessive bureaucracy, which hampers the correct compilation of the nursing documentation, have been made.Conclusions: In the ED of the Italian hospital involved in the present study it is fundamental to implement an innovative and appropriate nursing documentation system. Nurses’ awareness of the problem’s relevance and their proposals in this regard, could be the starting points to make relevant changes to the current practice.
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