Documentation and the transfer of clinical information in two aged care settings.
BACKGROUND
Increasingly, documentation, both formal and informal, is being undertaken by nurses using a range of modalities. In Australia there is a sense that the demand for this in the aged care sector is increasing in line with requirements of funding agencies. However, the scope of this activity and its impact on nursing workload in aged care facilities has not been rigorously investigated. Funding of aged care facilities in the public hospital system in Australia is dependent on documentation of care.


OBJECTIVE
The purpose of this study was to determine the frequency and time of day that documentation and transfer of clinical information activities occurred for nurses of all skill levels in two aged care facilities in New South Wales, Australia.


METHODS
Work sampling of direct care, indirect care, unit-related activities and personal time.


METHODS
Two hospitals with aged care facilities near Sydney, Australia.


METHODS
One hundred and six nurses.


RESULTS
16,395 observations of nursing activities were recorded. The transfer of clinical information between health care professionals comprises a large part of the nurse's working day. It comprised between 37 and 38% in this study, but the time of day in which it took place differed between the two hospitals.


CONCLUSIONS
Documentation needs to be seen as an integral part of care by managers and clinicians. Both would wish to ensure that it is undertaken in the most efficient and effective manner to allow the necessary time for direct care. More detailed understanding may allow clinical unit managers to re-structure the workday in terms of documentation to achieve greater efficiencies or effective use of nursing time.
Pelletier
Dianne
D
Centre for Health Services Management, University of Technology, Sydney, Australia. dianne.pelletier@uts.edu.au
Duffield
Christine
C
Donoghue
Judith
J
D003142:Communication; D004282:Documentation / Q000379:methods*; D005851:Geriatric Nursing / Q000379:methods*; D007722:Health Knowledge, Attitudes, Practice; D006299:Health Services for the Aged / Q000458:organization & administration*; D006748:Hospital Departments / Q000458:organization & administration*; D006801:Humans; D009517:New South Wales; D015401:Nursing Administration Research; D009737:Nursing Records; D009741:Nursing Staff, Hospital / Q000458:organization & administration; D019982:Organizational Case Studies