What factors affect documentation by midwives? A prospective study assessing relationship between length of shift, workload and quality of note keeping. Issue 8 (August 2015)

• Record Type: Journal Article
• Authors: Bailey, S.; Wilson, G.; Yoong, W.
• Is Part Of: Midwifery. Volume 31:Issue 8(2015)
• Page Start: 787
• Page End: 792
• Publication Date: 2015-08
• Subjects: Midwifery -- Periodicals; Midwifery -- Periodicals; Sages-femmes -- Périodiques; Midwifery; Periodicals; Electronic journals; 618.2005
• DOI: 10.1016/j.midw.2015.04.001
• Languages: English
• ISSNs: 0266-6138

Abstract

<abstract abstract-type="author" id="ab0005"> <title id="sect0005">Abstract</title> <sec> <title id="sect0010">Objective</title> <p id="sp0050">The objective of this study was to assess the association between the quality of basic note keeping and partogram documentation with progression of shift and workload on labour ward.</p> </sec> <sec> <title id="sect0015">Design</title> <p id="sp0055">This was a prospective observational study.</p> </sec> <sec> <title id="sect0020">Setting</title> <p id="sp0060">The setting of this study was a labour ward of a teaching district hospital in an inner city London hospital.</p> </sec> <sec> <title id="sect0025">Methods</title> <p id="sp0065">Intrapartum notes and partograms of 61 consecutive labouring women were assessed for quality of midwifery documentation at the beginning, middle and end of a 12-h shift.</p> </sec> <sec> <title id="sect0030">Measurements</title> <p id="sp0070">The measurements of this study were a basic note-keeping composite score based on validated criteria by the Nursing and Midwifery Record Keeping Guidance 2010 and a partogram completion score based on the National Institute for Clinical Excellence (NICE) Guidelines for Intrapartum Care 2007.</p> </sec> <sec> <title id="sect0035">Findings</title> <p id="sp0075">The basic note keeping deteriorated between the middle and the end of the 12-h shift, but it appeared unaffected by workload, with no statistically significant difference between day and night shifts. Partogram documentation was poorer in the middle compared to the beginning of the shift, and there was no statistical difference between day and night shifts. Partogram completion appeared to be influenced by women: midwife ratio as well as progression through a shift.</p> </sec> <sec> <title id="sect0040">Key conclusions</title> <p id="sp0080">The basic note keeping and partogram documentation were best at the beginning of the shift, and fatigue may play a role in poorer documentation towards the middle and the end of the shifts.</p> </sec> <sec> <title id="sect0045">Implication for practice</title> <p id="sp0085">Appropriately scheduled breaks especially during the final third of the shifts may help improve the quality of documentation.</p> </sec> </abstract>