Nursing Documentation Burden: A Critical Problem to Solve
In late 2021, our institution, like so many others, was experiencing significant staffing shortages and nursing burnout. Despite dedicated recruitment measures, we still struggled with staffing on a daily basis, so we began to look for other ways to reduce factors contributing to the burnout of our front-line staff. We were in a challenging situation and looking for a solution. Our nurses suggested that we look at their electronic documentation burden.
The U.S. Surgeon General’s Advisory on Building a Thriving Health Workforce: Addressing Health Worker Burnout indicates that nurses spend, on average, about 40% of their shift performing documentation. This is a huge amount - almost half of every shift. Documentation burden is not benign. Time spent in documentation has an inverse relationship to time available for direct patient care; meaning, the more time the nurse spends on documentation, the less time is available for patient care.
For nurses, documentation burden leads to:
- Decreased job satisfaction
- Increased burnout
- Increased cognitive load
- Less time for necessary self-care, such as eating, drinking and bathroom breaks
For patients, healthcare worker burnout causes:
- Increased risk of medical errors
- Increased hospital-acquired infections
- Decreased patient satisfaction
After reading this report, we knew that addressing documentation burden in our facility was not optional, and our Mission POSSIBLE initiative was born.
Mission POSSIBLE is our institution’s task force focused on reducing documentation burden and increasing documentation efficiency. Over the last 24 months, we have worked to reduce documentation burden in a phased approach, relying heavily on feedback from our front-line staff and data to guide decisions. We have learned the importance of establishing guiding principles for documentation elements from other institutions who are also working on this issue. By evaluating current and future documentation elements against our guiding principles, we have removed more than 748 groups, rows and options from our nursing flowsheets in a 24-month period.
Our current phase of the project will reduce the number of documentation rows by more than 50% for lines, drains and airways documentation. We have reduced time spent on documentation by 15% for ICU nurses and 22% for med-surg nurses, which when applied to all units across our system has netted an annual increase of 30,000 hours available for direct patient care.
If you have not started this work in your institution, I urge you to begin. Nationally, multiple efforts are underway to support the Surgeon General's recommendation to “reduce burdensome administrative paperwork.” National solution strategies are already in progress, including burden reduction programs such as the Patients Over Paperwork initiative by the Centers for Medicare & Medicaid Services and The Joint Commission’s recent removal of more than 168 accreditation requirements. Additionally, the 25x5 symposium provided valuable guidance for institutions and payors on strategies to reduce documentation burden. The 25x5 symposium includes a challenge to all institutions to reduce their documentation burden by 75% by 2025. This is an ambitious but achievable goal with a dedicated team.
When you begin this work at your institution, we recommend the following key actions for success:
- Use an interdisciplinary approach. Assemble a team that includes members of informatics, regulatory/risk, nursing leaders and front-line staff from all affected care areas. The roles of each member are different but critical to identify what documentation is required, how the documentation is used by the institution, and how the end users experience performing the documentation. You need all parties to make the project successful.
- Establish guiding principles. Create rules that guide how you will make decisions about what stays and what goes in the electronic medical record (EMR). We took most of our guiding principles from the University of Colorado’s Project Joy work and revised them as needed for our institution. Guiding principles are critical to getting the team on the mental model to make decisions. This should be your team’s first step.
- Eliminate redundancy. As you review your EMR, you will find areas where nurses document the same thing in multiple places. Eliminate these issues by determining the most logical or most user-friendly location to document an element and eliminate the others.
- Understand regulatory requirements. So many of our burdensome documentation elements were thought to be regulatory requirements. However, through the engagement of our regulatory team, we discovered that they, in fact, were not required. Focus on only keeping elements that enhance the care of patients.
- Eliminate unnecessary clicks. Every click counts. Be steadfast in your pursuit to eliminate unnecessary clicks and scrolling for your teams. What may seem like only one extra click or row adds up to the cumulative experience of the end user. Always look for ways to eliminate extra seconds spent on documentation.
- Investigate your options. EMR technology has come a long way. Functions such as macros, rows from orders, cascading rows, voice to text, smart notes. and copy and paste are all potential resources to address documentation burden.
- Protect the health, safety and well-being of healthcare workers and patients above all else.
Use Your Bold Voice
I believe that all nurses should have the ability to influence and refine the elements of nursing documentation. Nurses at the front lines are uniquely qualified to identify areas of redundancy and non-value-added documentation. Nurses in more administrative and supportive roles have an obligation to address documentation burden to improve the quality of healthcare and the mental health of workers. The reduction of documentation burden is everyone’s responsibility. Start now!
What task would you take away from nurse documentation?