Qualitative Study to Investigate the Process of Nursing Documentation Regarding the Transfer or Omission of Information in an Intensive Care Unit

Background: The nursing documentation in all aspects of promoting continuous improvement and ensuring the quality of health services. But the nursing documentation is not something immutable, has limitations as far as the staff of the department, and the broader health system that impede the observance. Aim: To investigate the documentation of nursing process in nursing shift change, in relation to the transfer or omission of information in an Intensive Care Unit (ICU). Method: This qualitative study was conducted during the months June-July 2014 in ICU of the Greek region University Hospital. The research population consisted of all nurses Higher Education in ICU under study, while the method for sample selection was intentional sampling (purposive sampling), under which selected 16 nurses. The collection of data related to the recording of information transferred between nurses on the morning shift change (7–3). As sampling was selected as non-structured observation (unstructured observation) written and oral briefings using notes written by the researchers themselves and transcript of oral reasons. Data analysis was done by researchers following the method of content analysis and the phenomenological approach parallel. Results: In the clinical setting conducted the study, expressed varying attitudes towards importance of nursing documentation and there were differences in the ways of perception, process compliance and management among nurses. Excessive workload and lack of social and personal life because of this, and the deluge of information are some of the reasons that affect the transfer of information relating to patients. Moreover, its own climate between nurses helps to transfer data, but several are information between staff not reported because they are given. Conclusions: Presented variations as to how to conduct the nursing documentation, that the effectiveness and limitations subject personnel and the health system as a whole.