Relationships of Providers’ Accountability of Nursing Documentations in the Clinical Setting

Documentation demonstrates the unique contribution of nursing to the care of clients. This study investigated the relationships of Providers accountability of nursing documentations in the clinical settings. Judgmental and simple random sampling techniques were used to select documented nursing actions for 264 clients. One research question and four null hypotheses guided the study. The instrument used for data collection was checklist on Nursing documentation in the clinical setting. Descriptive statistics of frequency, means and standard deviation (SD) were used to summarize the variables. Pearson Product Moment correlation was used to answer the research question, while analyses of variance (ANOVA) was adopted in testing the null hypotheses at 0.05 level of significance. The result indicated that significant correlation existed between legal implications of nursing documentation and the core principles of nursing documentation. Significant differences were also observed among providers’ accountability of nursing documentations with regard to promotion of interdisciplinary communication, legal implications of documentation, impacts on quality assurance and nursing science. Keywords— Relationships, Care Providers, Accountability, Nursing documentations, Clinical Setting.


INTRODUCTION
Tools are needed to support the continuous and efficient shared understanding of a patient's care history that simultaneously aids sound intra and inter-disciplinary communication and decision-making about the patient's future care (Joint Commission on the Accreditation of Healthcare Organisations, 2005). Such tools are vital to ensure that continuity, safety and quality of care endure across the multiple handovers made by the many clinicians involved in patient care. Generally, tools are implements held in the hands, which in the healthcare setting refer to documentation. Potter and Perry (2010) describe documentation as anything written or electronically generated that describes the status of a client or the care or services given to that client. Nursing documentation refers to written or electronically generated client information obtained through the nursing process (ARNNL, 2010). Nursing documentation is a vital component of safe, ethical and effective nursing practice regardless of the context of practice or whether the documentation is paper based or electronic, it is an integral part of nursing practice and professional patient care rather than something that takes away from patient care, and it is not optional. According to Potter and Perry (2010), nursing documentation must provide an accurate and honest account of what and when events occurred, as well as identify who provided the care. The documentation should be factual, accurate, complete, current (timely), organized and compliant with standards (Professional and Institutional). Potter and Perry (2010) further stated that these core principles of nursing documentation apply to every type of documentation in every practice setting. Documentation in nursing covers a wide variety of issues, topics and systems (Yocum, 2002;Huffman, 2004, Lindsay et al 2005Johnson et al 2006). Such areas of coverage include all aspects of nursing process, plan of care, admission, transfer, transport, discharge information, client education, risk taking behaviours, incident reports, medication administration, verbal orders, telephone orders, collaboration with other health care professionals, date and time of any event as well as signature and designation of the recorder. The primary purpose of documentation is to facilitate information flow that supports the continuity, quality and safety of care. Potter and Perry (2010) pointed out that data from documentation allow for communications and continuity of care, quality improvement/ assurance and risk management, establish professional accountability, make provision for legal coverage, funding and resource management, and also expand the science of nursing. Potter and Perry (2010) also explained that clear, complete and accurate health records serve many purposes for the clients, families, registered nurses and other health care providers. DeLauna and Ladner (2002) further affirmed that documentation is the professional responsibility of all health care practitioners, and that it provides written evidence of the practitioner's accountability to the client, the institution, the profession and the society. Literature has revealed that the tensions surrounding nursing documentation include the amount of time spent in documenting, the number of errors in the records, the need for legal accountability, the desire to make nursing work visible, and the necessity of making nursing notes understandable to the other disciplines (Spraque and Trapanier 1999; Castledine, 1998;Dimond, 2005;Pearson, 2003). This study therefore intends to examine the relationships of Providers accountability of nursing documentations in the clinical settings.

Research Question.
 To what extent does the legal implications of nursing documentation relate with the core principles of the documentation?.

Hypotheses.  Promotion of interdisciplinary communication does not
significantly differ in the nursing actions documented by the Primary, Secondary and third party providers.  There is no significant difference in the legal implications of the nursing documentations by the primary, secondary and third party providers.  Quality assurance of documented nursing actions does not significantly differ among the primary, secondary and third party providers of the documentation.  The impact of the documented nursing actions on Nursing Science does not significantly differ among the primary, secondary and third party providers of the documentation.

II. MATERIALS AND METHODS Design and Sampling.
The study was a retrospective research design. Judgmental sampling technique was adopted in selecting one Teaching Hospital and one specialist Hospital (tertiary Health Institutions) in Anambra State of Nigeria. Simple random sampling was used to select two General Hospitals (Secondary Health Institutions) and two comprehensive Health Centres (Primary Health Institutions) out of the 24 General Hospitals and 10 comprehensive Health Centres in Anambra State. This was to give all the primary and secondary health institutions equal chance of being selected for the study (Nworgu, 1991).
Nursing documentations on Clients were obtained from three units (medical, surgical and maternity units) of each of the selected health institutions. Other units (e.g. Emergency unit, Out-patient Department, and other special units) were excluded in the study. Documented nursing actions for 96 clients were obtained from the selected tertiary health institutions, 72 were obtained from the secondary health institutions and 96 from the primary health institutions. On the whole nursing documentation for 264 clients were used for the study. Ethical approval were obtained from the six institutions used for the study. Informed consent was also obtained from the clients whose records were used. Confidentiality was ensured by not including the names of the health institutions in the data collection. Alphabetical codes were used to represent the selected health institutions while numerical codes were used for the patients whose records were obtained for the study. Generally, records of nursing documentation done from July -September 2015 were used for the study.

Instrument.
The instrument used for data collection in the study was checklist titled Checklist on Nursing Documentation in the clinical setting (CNDCS). Section A of the instrument provided general information of the health institution (eg level of health institution, clinical specialty, form of documentation, client's clinical diagnosis, documentation of accountability, section B of the instrument was made up of eight sub-sections designed to measure documented nursing actions (eg admissions, transfers, discharges, plan of care, client education, medication, incident reports, vital signs, etc), extent of ensuring core principles in the documentation (eg whether factual, accurate, complete, timely, organized and compliant with standards), ensuring promotion of interdisciplinary communication (eg name(s) of the people involved in the collaboration, date and time of the contact, information provided to or by healthcare provider, responses from healthcare provider, etc), timeliness of the documentation (eg how timely, chronological and frequency), preciseness of the documentation (eg objectivity, unbiased, legibility, clear and concise, etc), Legal implication (eg use of authorized abbreviations, informed consent, advanced directive, etc), impact on quality assurance/ improvement (eg facilitates quality improvement initiative, facilitates risk management, and used to evaluate appropriateness of care), and impact on the science of nursing (eg provides data for nursing/health research, used to assess nursing intervention and client outcomes, etc). The instrument was designed in a 4point scale ranging from 1 to 4 with poor/many omissions having I point, 2 points for fair/incomplete with few omissions, 3 points for good/almost complete, and 4points for very good/complete. The instrument was subjected to reliability test by collecting data from nursing documentations for 15 patients from three levels of health institutions (primary, secondary and tertiary) in another State of Nigeria that was not used for the study. The instrument test/ retest reliability was 0.65.

Data Analysis.
Standard descriptive statistics of frequency, means and standard deviation were used to summarize the variables. Mean score, standard deviation and Pearson Product moment correlation (r) were used to answer the research question while Analysis of variance (ANOVA) was adopted in testing the null hypotheses at 0.01 and 0.05 levels of significance respectively. SPSS version 21 was used in the data analysis.  In table 3, the correlation value (r) for the relation between legal implications of documentation and the core principles was 0.543, and it was significant at 0.01 level.  Table 4 shows that with regard to providers accountability of nursing action documentation, the calculated F-ratio for promotion of interdisciplinary communication was 3.901; for legal implications of documentation, impacts on Quality assurance and nursing science, the F-ratios were 4.480, 0.717 and 2.415 respectively. These results were more than the critical values. Therefore the null hypotheses are rejected. Scheffe Post-Hoc (Akuezuilo and Agu, 2004) test of multiple comparison of mean was used to determine the order of significant differences across the Primary, Secondary and third party providers of accountability.  Table 5 shows that for promotion of interdisciplinary communication, the mean difference of 10.95951 between primary, secondary and third party providers was in favour of the primary providers; also the mean difference of 10.46667 between secondary and third party providers was in favour of secondary provider. For legal implications of documentation, the mean difference of 4.63158 between primary and third party providers was in favour of primary providers, while the mean difference of 5.46667 between secondary and third party providers was in favour of secondary providers.

IV.
DISCUSSION Findings from the study indicate significant correlation (r=0.543) between legal implications and core principles of nursing documentation ( appropriately is a key factor in clinical mishaps and a pivotal issue in many malpractice cases (Springhouse, 1995) because the client's medical record is a legal document, and in the case of a lawsuit the record serves as the description of exactly what happened to a client. Lyer and Camp (1999) noted that in 80% to 85% of malpractice lawsuits involving client care, the medical record is the determining factor in providing proof of significant events. DeLaune and Ladner (2002)  The study revealed significant differences in the providers' accountability of nursing documentation with regard to promotion of interdisciplinary communication, legal implications of documentation, impacts on quality assurance and nursing science (tables 4 and 5). According to Kozier et al (2004), each health care organization has policies about recording and reporting client data, and each nurse is accountable for practicing according to these standards. Agencies also indicate which nursing assessments and interventions that can be recorded by registered nurses (RNs) and which interventions that can be charted by unlicensed personnel (Kozier et al 2004). The role of the nurse varies with the needs of the client, the nurse's credential, and the types of employment setting (Kozier et al, 2004). CRNNS (2012) indicate that legislation and standards of practice of a profession require nurses to document the care they provide demonstrating accountability for their actions and decisions. First hand knowledge means that the professional who is doing the recording is the same individual who provided the care. The RN who has the primary assignment is expected to document the assessment, interventions and clients response noting as necessary the role of other care providers. Third party recordings include documentations by nonprofessionals such as auxiliary staff, designated recorders, client/ family and students (SRNA, 2011). Certainly, proficiency should not be expected from these unlicensed personnel, hence the significant difference observed in this study about the documentations of the primary, secondary and third party providers. CRNNS (2012) pointed out that quality documentation is an integral part of professional RN practice; it reflects the application of nursing knowledge, skills and judgment, the clients' perspective and interdisciplinary communication.

V. CONCLUSION
This study indicates that significant correlation exists between the legal implications of nursing documentation and the core principles of the documentation. It also revealed that quality nursing documentation requires accountability of the professional RN.