NURSING DOCUMENTATION IN HOSPITAL HEALTHCARE: INSIGHTS INTO NURSES’ ATTITUDES AND PERCEPTIONS

Abstract

Introduction: Nursing documentation includes records of nursing interventions throughout the nursing process and ensures continuity and integration of all phases of patient care. Although legally required, nursing documentation in hospitals in Croatia is still not maintained comprehensively. Nurses’ perceptions and attitudes play a key role in ensuring its consistent and complete management.  
Aim: To investigate the attitudes and perceptions of nursing staff with regard to nursing documentation and its importance in hospital practice. 
Materials and Methods: The qualitative study was conducted between 15 May and 3 June 2024 in Zadar General Hospital. Data were collected through semi-structured interviews based on the relevant literature. 
Results: The analysis revealed three main categories. The first category concerned the importance of nursing documentation, which participants recognised as an official and comprehensive patient record, a supplement to other medical records and a means of legal protection for both patients and nurses. The second category included barriers to high-quality documentation, such as lack of time, lack of staff, inadequate electronic equipment, high patient volume and the limitations of the IBIS system. The third category related to the contribution of nursing documentation to patient safety, emphasising a holistic approach that prevents adverse events, protects patients from unsafe practices and enhances nurses’ professional accountability. 
Conclusion: Nurses recognize nursing documentation as essential for care quality, patient safety, and legal protection. Its quality is affected by time and staff shortages, technical limitations, workload, and inadequate adaptation of the electronic system. Nevertheless, high quality documentation supports patient safety through monitoring, information transfer, professional accountability, and prevention of adverse events.