Effects of nursing record education focused on legal aspects at small and medium sized hospitals

Article information

J Korean Acad Soc Nurs Educ. 2021;27(2):152-162

Publication date (electronic) : 2021 May 31

doi : https://doi.org/10.5977/jkasne.2021.27.2.152

Taehee Do¹⁾, Heejung Kim^2),

¹⁾ Graduate student, Daegu Catholic University

²⁾ Associate Professor, College of Nursing·Institute of Nursing Science, Daegu Catholic University

Address reprint requests to: Kim, Heejung College of Nursing, Daegu Catholic University, 33 Duryugongwon-ro 17-gil, Nam-gu, Daegu, 42472, Republic of Korea Tel: +82-53-650-4830 Fax: +82-53-650-4392 E-mail: cholong98@cu.ac.kr

*This manuscript was adapted from a master’s thesis by Taehee Do from Daegu Catholic University in Daegu, Korea

Received 2021 March 11; Revised 2021 May 6; Accepted 2021 May 7.

Abstract

Introduction

Nursing records provide an account of the care and treatment given to a patient, providing a way to monitor progress and develop clinical histories. They allow for continuity of care by facilitating treatment and support [1]. They are an official communication tool for medical staff and an integral part of patient care, providing evidence of care for patients [2]. Nursing records are also used as basic data for healthcare policymaking, statistical analysis, research, education, and insurance claims [3]. Therefore, nurses are responsible for maintaining accurate records of the care they provide and are accountable if information is incomplete and inaccurate [4].

As electronic medical records are becoming more widely used, nursing records are also transitioning from paper to electronic formats. The expansion of electronic nursing records (ENRs) promotes better quality, completeness, and accuracy. Furthermore, electronic nursing records have allowed nurses to spend more time nursing patients since less time is required to write nursing records [2]. On the other hand, a study criticized that ENRs often fail to reflect individual patients’ personal nursing care because the records contain repetitive, standardized text. This threatens patient safety, revealing the negative side of ENRs [2,5]. Lee [6] reported that nursing records’ accuracy in ENRs was only 61.9%. Kang [7] found that while 94.9% of ENRs contained information about patients’ conditions and status, only 65.3% recorded nursing services provided to patients.

The obstacles to writing nursing records are having several patients to care for and excessive workload. Nurses generally tend to neglect writing nursing records as they prioritize providing direct nursing care [6,8]. A study identified that obstacles to writing nursing records were lack of knowledge about nursing record, lack of awareness on the importance of nursing records, and difficulty in describing patients’ internal conditions [9]. Medical staff cannot communicate effectively without proper nursing records, and poor communication can negatively affect patient care. Therefore, nurses must ensure that their documentation meets high standards and must record treatment decisions and plans, nursing services provided, and patient’s response to treatment [10,11].

Nurses vary in their level of knowledge about nursing records. However, systemic education on nursing record for nurse has been insufficient [12]. Nursing students receive theoretical education at college, with little hands-on instruction; most of nurses learn only how to use their hospitals’ ENR system during orientation in South Korea [13]. Only 15.8% of clinical nurses in South Korea receive nursing-record education at hospital and do not receive sufficient hands-on or in-service training. Especially, fewer still receive sufficient education on the legal aspects of nursing records despite the educational demand for it was increasing [14].

Record keeping is an essential part of nursing practice with clinical and legal significance [4]. The importance of nursing records as legal documents is growing. The number of medical disputes increased by 67% on average from 2015 to 2019 [15]. Accordingly, the number of nursing-related medical disputes has also increased with the expanding roles and responsibilities of nurses. Therefore, it is imperative that nurses recognize and respond to nursing errors, understand their legal obligations and responsibilities, and keep complete and accurate records of all nursing activities.

In 2016, 34.2% of all nurses in South Korea worked in small or medium hospitals [16]. The incidence of medical disputes in small and medium hospitals was 54.1%, twice the incidence in tertiary hospitals (19.7%) [17]. However, the nursing record performance of nurses in small and medium hospitals was lower than in tertiary hospitals [17]. Despite the higher educational need of nurses in small and medium hospitals with regard to nursing records than those in large hospitals, education for nurses in small and medium hospitals is not efficiently provided due to the lack of dedicated educators [18]. Therefore, nursing record education focused legal aspect is essential to ensure better quality of nursing care and protect nurses from legal disputes.

Most studies on nursing record have been conducted on nurses in large hospitals. While several studies have measured nurses’ level of knowledge on nursing records [12,13], a little research has been done on effects of nursing record education with nurses, especially education programs focused on the legal aspects of nursing records in small and medium hospitals [14,19]. This study examined the effects of a nursing-record education program focused on the legal aspect of nursing record among nurses in small and medium hospitals in South Korea and aimed to provide basic data to develop nursing-record education program.

Methods

Development and Application of Nursing-Record Education Program

To develop and education program on nursing record, we began by reviewing articles published in the last ten years, searching PubMed, CINAHL, the Korea Education and Research Information Service (KERIS), and the National Digital Science Library (NDSL). To determine our target group’s educational needs, we conducted a preliminary investigation among 30 nurses working in small or medium hospitals in South Korea. The preliminary investigation revealed a high need for education on how to write nursing records and case-based education, particularly concerning documentation of doctors’ orders and noncompliance, patients’ reason for noncompliance, cases of defending medical malpractice, and nurse colleague’s carelessness, and nursing records time. Through the preliminary investigation, the educational need for nursing records from a legal aspect of view was confirmed. The education program was developed by reviewing the literature on nursing records, standards of the Hospital Accreditation Program, and by reflecting the preliminary investigation results. Our education program’s major topics included nursing-record guidelines and instructions and medico-legal case studies related to nursing records. The education program was reviewed by two directors of nursing departments, two head nurses with over 10 years of work experience in small- and medium-sized hospitals, and two professors from nursing college. The program was revised based on their feedback. The education program was a two-hour intensive workshop with reference to Kim’s research results [22]. The workshop was conducted by researcher. The program consisted of lecture with PowerPoint presentation, discussions, interactive activities, and practical sessions. The researcher conducted the educational program once at each of the two hospitals, 16 participants per session. The participants received a hand out to enhance the information taught in the program. Team-based learning was carried out in groups of four to carry out tasks during education. Team-based learning was conducted to how to write related nursing record after outlining the medico-legal case. Table 1 summarizes the program’s educational content.

Table 1

The Contents of Nursing Education Program

Results

General Characteristics of Participants

The 62 nurses participating were assigned to either the experimental (n=32) or the control (n=30) group. Among them, 38.7% were aged 26–30, 54.8% had a bachelor’s degree, 25.8% were married, 53.2% had worked for 1–5 years, and 27.4% had worked for 5 years or more. Only 20 of the 62 nurses (32.3%) had experience with education on nursing records. The experimental group did not statistically differ from the control group in general characteristics (Table 2).

Table 2

Homogeneity of General Characteristics between Two Groups (N=62)

Preliminary Test of Homogeneity on Outcome Variables

The preliminary test for homogeneity in the dependent variables for the control and experimental groups revealed the following. The nursing-record knowledge score was 53.09±5.83 in the experimental group and 50.90±6.09 in the control group. The nursing-record performance scores were 3.39±0.34 in the experimental group and 3.21±0.39 in the control group. The nursing-record behavior scores were 3.97±0.34 in the experimental group and 3.83±0.30 in the control group. The test of homogeneity between the experimental and control groups showed no significant differences (t=1.45, p=.153; t=1.96, p=.054; t=1.73, p=.089) (Table 3).

Table 3

Homogeneity of Dependent Variables between Two Groups (N=62)

The Comparison of Nursing Record Knowledge, Nursing Record Performance, and Nursing Record Behavior between Two Groups

Table 4 shows the mean values for nursing-record knowledge, performance, and behavior from the pretest and posttest. The experimental group’s knowledge scores increased from 53.09±5.83 to 59.44±3.14 after the education program. The control group’s scores increased slightly from 50.90±6.09 to 54.17±6.14. The difference between the two groups was statistically significant (t=2.43, p=.019).

Table 4

The Comparison of Nursing Record Knowledge, Nursing Record Performance, and Nursing Record Behavior between Two Groups (N=62)

The experimental group’s performance scores increased from 3.39±0.34 to 3.56±0.26. The control group’s scores dropped slightly from 3.21±0.39 to 3.20±0.48. The difference between the two groups was statistically significant (t=2.19, p=.033).

The experimental group’s behavior scores increased from 3.97±0.34 to 4.21±0.42 after the education program. The control group’s scores increased slightly from 3.83±0.30 to 3.84±0.30. The difference between the two groups was statistically significant (t=2.42, p=.018).

Changes of Nursing Record Knowledge, Nursing Record Performance and Nursing Record Behavior in Experimental Group

Table 5 shows the changes in the experimental group’s scores after the education. The experimental group’s scores in all areas improved after education. In the knowledge section, the correct answer rate for Do’s increased from 0.89±0.10 to 0.98±0.40 (t=5.48, p=.001), and the correct answer rate for Don’ts increased from 0.70±0.11 to 0.80±0.08 (t=4.95, p=.001).

Table 5

Changes of Nursing Record Knowledge, Nursing Record Performance, and Nursing Record Behavior in Experimental Group (N=32)

In the performance section, the most significant improvement was for “Record consistently in connection with the nursing process and records of previous workers,” from 3.28±0.73 to 3.63±0.49 (t=2.78, p=.009). The second was the item “Commit the results of physical assessment to an admission note” increased significantly from 3.39±0.50 to 3.71±0.46 (t=3.10, p=.004).

In the behavior section, the most significant improvement was for “Record the doctor’s call and communication during the call” from 3.75±0.84 to 4.41±0.61 (t=4.98, p=.001). The second was the item “Do not record negative views about patients” increased significantly from 3.97±0.74 to 4.56±0.56 (t=4.44, p=.001).

Discussion

This study was conducted to evaluate the effects of a nursing record education program on nurses’ knowledge and performance on nursing records in small and medium hospitals in South Korea.

32.3% of the participants had received education on nursing records at their hospitals. This result was similar to the findings of Goo [23], who measured knowledge level about nursing records of clinical nurses in general hospital and clinic and found that 32.2% had previously received education on nursing records. Both Goo’s study [23] and this study, where the participants were nurses in small and medium-sized hospitals, showed that the subjects did not have much educational experience in nursing records. Lee et al. [12] reported that over 70% of nurses in large hospitals received education on nursing records, meaning that nurses who work at small- and medium-sized hospitals have fewer opportunities to receive education on nursing records compared with those who work in large hospitals.

The experimental group that received nursing record education scored higher on the knowledge of nursing records compared with the control group that did not receive the education. This result was consistent with both studies of Kim & Yi [19] and Kim et al. [24] that nurses’ nursing record knowledge improved after an educational intervention. The experimental group’s correct answer rate for Do’s section of nursing record increased from 0.89 to 0.98, and its correct answer rate for Don’ts increased from 0.70 to 0.80. This result was consistent with the finding of Kim et al. [24] which showed improvements of 0.86 to 0.90 and 0.75 to 0.90, respectively. In this study, nursing-record knowledge did not improve as much as it did in other studies. This seems to be due to insufficient education hours. Therefore, it will be necessary to choose the educational environment, methods, and sufficient hours considering the target audience.

It has been shown that there is a lack of knowledge about the legal aspects of nursing records. This result was consistent with the finding of Lee et al. that only 70% of nurses correctly answered questions on the same items [12]. Kim [14] reported that nurses lacked awareness about medico-legal disputes and attributed to be due to lack of proper education on nursing records’ legal aspects. Several studies have examined the importance of nursing records. Kim & Yi [19] found the benefits of nursing-record education focused on the legal aspects, as did the study of Kim et al. [24] that 83.3% of nurses said that nursing-record education focusing on the legal aspects is necessary. Nursing-record education should include medical law, which is frequently revised, and information about trial cases related to nursing malpractice incidents. An online education program on the legal aspects of nursing records could effectively help educate nurses, including those at small and medium hospitals who have fewer opportunities for education while also providing them sufficient time to study [25].

The experimental group scored higher on nursing-record performance than the control group. This was consistent with the study of Linch et al. [26] reported that the quality of nursing records among nurses in the coronary care unit increased after an educational intervention. Our experimental group’s nursing-record performance scores increased from 3.39 to 3.56 out of 4. Although different assessment tools were used, this increase was higher than the 62% reported by Lee [6] and similar to the 82% reported by Kang [7]. The reasons for this result are not clear; however, it seems to be attributed to the fact that the participant’s hospitals manage nursing records according to hospital accreditation standards [17].

In more detail, the experimental group’s performance scores for five performances-related items improved after education. However, the scores did not improve for the items on recording the nursing process and the results of nursing interventions. Establishing an appropriate nursing process can improve the quality of nursing records and increase communication between medical staff, consequently bringing positive outcomes for patients [26]. However, ENRs use standardized terminologies about nursing diagnoses and interventions that do not always sufficiently describe patients’ situations and nursing processes [27]. It is necessary to update the ENR database on diagnoses and interventions regularly to improve their nursing record performance.

The experimental group’s nursing-record behavior scores increased more significant than those of the control group, this result was consistent with Kim’s study [22] showing that nurses’ nursing record behavior in large hospitals improved after an educational intervention. But, some legally sensitive items did not improve significantly after the intervention such as: “Management of your own ID related to nursing record”. These items are very sensitive parts from a legal perspective. There have been many legal suits related to cases in which the nurse did not record the nursing care for his or her conduct. From a legal standpoint, the nurse who treated the patient is recognized as the recorder of the medical record, so the nursing record must be completed by that nurse only. This result suggests the need for additional training about legal aspects of nursing records.

In the study results, there were items that were not performed even though the knowledge score was high. Kim & Yi [19] reported similar results when they compared general hospital nurses’ post-education improvements in nursing record knowledge and performance. Kang [7] reported that nurses recorded only 52% of the nursing activities that they performed. Similarly, Mykkänen et al. [28] found that some nurses did not record their nursing activities—although they knew it was mandatory—citing reasons such as lack of time, overload, and nurse’s tendency to prioritizing direct nursing care over record keeping. From a legal standpoint, undocumented nursing care is considered as never having been given. Therefore, nurses must be regularly educated to grow more aware of how important it is to record comprehensively and accurately recording all nursing activities. Monitoring their recording should be routine to ensure compliance. Nurses must realize that maintaining nursing records is an integral part of nursing care that allows medical staff to precisely understand patients’ conditions [8,29].

Based on these results, more effective education strategies and programs must be developed to raise the awareness about the importance of nursing records and improve nurses’ performance as well as knowledge to writing nursing records. New nurses who receive nursing-record education perform better at record keeping than those who do not [17]. This suggests that it would be a more efficient way to include how to write nursing record for new employee’s education. It was also found that nurses’ performance increased when both lectures and hands-on training were provided. Thus, hands-on training on writing nursing records in various clinical situations, in addition to regular lectures, will effectively enhance nurses’ knowledge and performance to writing nursing records. Additionally, to increase the quality of nursing records and maintain the improved quality, consistent monitoring and repeated education on nursing records at the nursing department level are necessary.

A study reported that education on topics nurses consider important or are interested was highly effective in maintaining nurses’ performance for a long time [30]. In a sense, nursing record education in the legal aspect can prepare for unexpected legal disputes in the nursing field, and it is necessary to emphasize the importance of nursing record in the legal aspect, especially for nurses at small and medium sized hospitals relatively many medical litigation. Additionally, to increase and maintain nursing-record quality requires consistent monitoring and continuing education at the department level.

In this study, we found that nursing-record education improved nurses’ knowledge and performance in writing nursing records in small and medium sized hospitals in South Korea. In particular, it was found that the legal aspect of nursing records should be more important and education on them is necessary. In addition, this result is especially meaningful in that it objectively assessed the effect of the education program by using third-party evaluation instead of self-reported questionnaires.

The study has various limitations: The recruitment of participants was only from two hospitals, the results could not be inferred to all nurses. In addition, the post-test was conducted only once, the lasting effect could not be confirmed. Further research may track longer periods to validate measurement results.

Conclusion

In this study, nurses’ nursing record knowledge, performance, and behavior improved significantly after nursing record education. Based on this result, nursing record education is an effective intervention to improve nurses’ knowledge and performance to writing nursing records in small- and medium sized hospitals. We suggest the development of a systematic and standardized education program on nursing records included its legal aspect for nurses in small- and medium sized hospitals. The results would be helpful as basic data for developing a nursing record education program for nurses in small and medium sized hospitals.

Supplementary materials

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