Comparing Nurses and Head Nurses Perspectives on the Factors Behind the Quality of Nursing Documentation

Background: Nursing documentation has significant roles in giving coherence to teamwork, making effective use of healthcare providers knowledge, improving care quality, maintaining care continuity, and identifying changes in patients conditions. However, studies show its poor quality. Objectives: This study compared nurses and head nurses perspectives on the factors behind the quality of nursing documentation. Methods: This descriptivecorrelational study was conducted in 2017 in Valiasr (PBUH) Hospital, Birjand, Iran. Accordingly, 140 eligible nurses and all 15 headnurses in the hospital were recruited to the study through simple random sampling and census, respectively. They filled out a researchermade 26item questionnaire about factors behind the quality of nursing documentation. Because of the nonnormal distribution of the study variables, the MannWhitney U, KruskalWallis, and Friedman tests were used for data analysis. The level of significance was set at less than 0.05. Results: Head nurses did not significantly differ from nurses respecting the mean scores of personal, managerial, and organizational factors behind the documentation quality (P 0.05). The highestscored factors were organizational factors. Conclusions: Organizational factors are the most important factors behind the quality of nursing documentation. Thus, adequate nurse staffing and avoidance from assigning nonnursing responsibilities to nurses are recommended to improve the quality of nursing documentation.