What factors affect documentation by midwives? A prospective study assessing relationship between length of shift, workload and quality of note keeping.
OBJECTIVE
The objective of this study was to assess the association between the quality of basic note keeping and partogram documentation with progression of shift and workload on labour ward.


METHODS
This was a prospective observational study.


METHODS
The setting of this study was a labour ward of a teaching district hospital in an inner city London hospital.


METHODS
Intrapartum notes and partograms of 61 consecutive labouring women were assessed for quality of midwifery documentation at the beginning, middle and end of a 12-h shift.


METHODS
The measurements of this study were a basic note-keeping composite score based on validated criteria by the Nursing and Midwifery Record Keeping Guidance 2010 and a partogram completion score based on the National Institute for Clinical Excellence (NICE) Guidelines for Intrapartum Care 2007.


RESULTS
The basic note keeping deteriorated between the middle and the end of the 12-h shift, but it appeared unaffected by workload, with no statistically significant difference between day and night shifts. Partogram documentation was poorer in the middle compared to the beginning of the shift, and there was no statistical difference between day and night shifts. Partogram completion appeared to be influenced by women: midwife ratio as well as progression through a shift.


CONCLUSIONS
The basic note keeping and partogram documentation were best at the beginning of the shift, and fatigue may play a role in poorer documentation towards the middle and the end of the shifts.


CONCLUSIONS
Appropriately scheduled breaks especially during the final third of the shifts may help improve the quality of documentation.
UCL and Royal Free Medical School, London, UK.
S
S
Bailey
UCL and Royal Free Medical School, London, UK.
G
G
Wilson
Department of Obstetrics and Gynaecology, North Middlesex University Hospital, London, UK. Electronic address: waiyoong@nhs.net.
W
W
Yoong
D019985:Benchmarking; D005260:Female; D006801:Humans; D008131:London; D008427:Maternal Health Services / Q000592:standards*; D008880:Midwifery; D009736:Nursing Process; D011247:Pregnancy; D011446:Prospective Studies; D013222:State Medicine; D016526:Workload
Documentation; Fatigue; Midwifery; Note keeping; Partogram