Factors related to nursing record time by work shifts

Abstract

This study aimed to clarify factors related to nursing record time. Using the electronic medical record and human resources data of the hospital, data of 2 days were collected regarding nursing record time during daytime and night-time work shifts, nurse and patient attributes and nursing record attributes. Fundamental statistics for each variable and Spearman's rank correlation coefficients for nursing record time and each attribute were calculated. Logistic regression analysis was performed using nursing record time and each attribute as dependent and independent variables, respectively. Mean nursing record times were 93.8±47.8 and 102.9±80.2 min for daytime and night-time work shifts, respectively. No significant correlation was observed between nursing record time and nurse attributes in daytime or night-time work shifts. In daytime work shifts, following factors significantly correlated with the length of nursing record time: score of ≥1 in Item A (severity and medical/nursing requirements) of their patients (OR=1.86, p=.042), score of ≤3.8 in Item B (OR=0.50, p=.041), ≤80% nursing records taken within 60 min after occurrence of an event (OR=0.39, p=.002) and ≤40% patients eligible for a clinical pathway (OR=0.39, p=.002). In night-time work shifts, only the number of nursing records showed significant positive correlation (r=.551, p=.010). These results suggest the importance of using severity and medical/nursing requirements as an index for allocating patients, especially in daytime work shifts; increasing record terminals for taking nursing records timely and using simplified recording formats like clinical pathways.