Navigating the Complexities of Nursing Documentation When Patients Have Access to the Content: A Qualitative Study

Aim: To explore how Danish registered nurses (RNs) in hospitals experience documenting nursing care in electronic patient records when the content is accessible to patients.

Methods: In a qualitative research design, data were generated in six focus groups conducted in late 2022 and early 2023, comprising 31 RNs employed in inpatient wards at a university hospital in Denmark. Subsequently, qualitative content analysis was applied to the gathered data.

Results: The findings include three themes: (1) weighing one's words, (2) building trust or triggering conflicts and (3) risking loss of knowledge. Together, these three themes illustrate the complexities that RNs navigate when patients have access to the content of nursing documentation.

Conclusion: Patients' access to nursing documentation requires RNs to navigate a complex interplay of factors, including awareness of language-use, influence on the nurse-patient-relative relationships, and the risk of losing essential knowledge. Therefore, although patients' access to nursing documentation can induce a positive change in terms of strengthening the professional focus on documentation, it can also result in changes in documentation practices in ways that may compromise nursing documentation as a working tool.

Implications for the profession and patient care: The findings emphasize an urgent need to explore and discuss how sensitive nursing observations can be shared in a safe and appropriate way when patients have access to the documentation. Furthermore, to prevent misunderstandings and conflicts with patients, it is essential to focus on and prioritize patient involvement in nursing documentation.

Impact: RNs navigate complex practices when patients have direct online access to nursing documentation content. It is crucial to clarify which content nursing documentation should entail and how sensitive nursing observations can be shared in a safe and appropriate way.

Reporting: The COREQ checklist was used for reporting.