Barriers to quality nursing documentation at a mental health institution

Abstract

This qualitative study explores the barriers to quality nursing documentation at a mental health institution in South Africa.  Nursing documentation forms a fundamental part of care as it ensures continuity of care and collaboration amongst mental health care providers on the mental health of the persons being treated. Thus, the need to obtain an in-depth understanding of the hindrances mental health nurses face in producing high-quality nursing documents arose. Using in-depth interviews and reflexive thematic analysis, the researchers identified that mental health nurses face challenges such as workforce constrains, resource limitation, leadership and supervision deficits as well as lack of quality assurance mechanisms. Subsequently, suggestions to enhance documentation excellence through capacitation, strategic oversight and standardization of documentation practices were made. The study highlights the importance of ensuring high quality of nursing documentation. Therefore, the findings offer valuable insights applicable to mental health globally, where there are concerns related to the quality of nursing documentation

Keywords: {'name': 'Documentation practices'}, {'name': 'Mental Health Institution'}, {'name': 'Mental Health Nurses'}, {'name': 'Nursing Documentation'}, {'name': 'Nursing Records'}, {'name': 'South Africa'}, {'name': 'Quality'}

Authors & affiliations

Andile Glodin Mokoena-De Beer
Affiliation not supplied

Itumenng George Masondo
Affiliation not supplied

Nkhensani Florence Mabunda
Affiliation not supplied

Deposited references

Supplied references, not a list of publications citing this article.

DOI: 10.19044/esj.2016.v12n3p101

American Nurses Association. (2010). ANA’s Principles for Nursing Documentation: Guidance for Registered Nurses. In Nursing. https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf

DOI: 10.1080/21528586.2024.2349106

DOI: 10.4135/9781071878699

DOI: 10.1016/j.ijans.2019.01.001

DOI: 10.3389/fcomp.2021.624555

DOI: 10.1186/s12912-023-01490-8

DOI: 10.53841/bpsqmip.2022.1.33.46

DOI: 10.1177/23779608221075165

DOI: 10.4102/curationis.v43i1.2041

Chelagat, D., Sum, T., Chebor, A., Kipto, R., & Bundtich, P. (2013). Documentation?: Historical perspectives , purposes , benefits and challenges as faced by nurses. International Journal of Humanities and Social Science, 3(16), 236–240. http://www.ijhssnet.com/journals/Vol_3_No_16_Special_Issue_August_2013/28.pdf

Creswell, J. W., & Poth, C. N. (2025a). Qualitative Inquiry and Research Design: Choosing Among Five Approaches (5th Ed.). Sage.

Creswell, J. W., & Poth, C. N. (2025b). Qualitative Inquiry and Research Design (5th Editio). SAGE Publications, Inc.

DOI: 10.1590/s1980-220x2018003703471

DOI: 10.1136/bmjhci-2022-100699

Denzin, N. (2024). The SAGE Handbook of Qualitative Research (6th Ed.). SAGE Publications, Inc.

DOI: 10.1111/2047-3095.12400

DOI: 10.1177/2333393620960076

Fain, J. A. (2021). Nursing Research: Reading, Understanding, and Applying Nursing Research (6th ed.). FA Davis Company.

Jooste, K. (2017). Leadership in Health Services Management (3rd Ed.). Juta.

Kagee, A., Docrat, S., Freeman, M., Lund, C., Phakathi, S., Shiba, D., & Thom, R. (2022). Mental Health. The South African Health Reforms 2015-2020: The Road Ahead, 178.

DOI: 10.1016/j.ijans.2018.09.002

Khwaji, M. I., Marzook, A., Alrasheedi, H., Alenazi, S. M., Mohammed, H., Alenezi, S., Hulayyil, S., & Alhazmi, B. (2024). The impact of nursing documentation on medical record accuracy and patient outcomesNu. Neuropsychopharmacologia Hungarica, 22(2), 33–38.

DOI: 10.1016/S0140-6736(20)30122-7

DOI: 10.31920/2634-3649/2024/v14n2a2

DOI: 10.2196/preprints.64762

DOI: 10.1186/s12912-021-00629-9

National Department of Health. (2012). Quality Improvement Guide: quality Improvement- the key to providing improved quality care.

DOI: 10.4102/hsag.v28i0.2257

DOI: 10.1155/2024/7392388

Polit, D., & Beck, C. (2021). Nursing Research: Generating and Assessing Evidence for Nursing Practice (11th ed.). Wolters Kluwer.

Republic of South Africa. (2002). Mental Health Care Act No. 17 of 2002. Government Gazette, 44(17), 40. https://www.gov.za/sites/default/files/gcis_document/201409/a17-02.pdf%0Ahttp://www.nsw.gov.au/sites/default/files/Government_Gazette_2_December.pdf#page=15

Republic of South Africa. (2020). The Regulations Regarding the Scope of Practice for Nurses and Midwives. 2020. Goverment Gazette, 43305, 5; 17–18. chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.gov.za/sites/default/files/gcis_document/202005/43305gon521_0.pdf

Roller, M. R., & Lavrakas, P. J. (2015). Applied Qualitative Research Design. Guilford Publications, Inc.

DOI: 10.4236/ojn.2023.137028

DOI: 10.1080/23311886.2020.1838706

DOI: 10.1177/00812463221093525