Quantitative investigation results
Overall, 2972 patients were included, i.e., 699, 717, 784, and 772 in the study years, respectively (Table 1). Overall, 249 patients had 272 HAI corresponding to a prevalence of patients with any HAI of 8.4% (Annex Table 2). Of these, 116 (47%) patients matched our inclusion criteria and encountered 21 CAUTI (18%), 7 CLABSI (6%), 10 VAP (9%), and 78 SSI (67%).
We found conclusive documentation to IP standards for CAUTI, CLABSI, VAP, SSI, and overall in 29/104 (28%), 29/151 (19%), 46/122 (38%), 328/931 (35%), and 432/1308 (33%) cases, respectively; proof of adherence in 27/104 (26%), 26/151 (17%), 46/122 (38%), 261/931 (28%), and 360/1308 (28%) cases, respectively; proof of NON-adherence in 2/104 (2%), 3/151 (2%), 0/122 (0%), 67/931 (7%), and 72/1308 (6%) cases, respectively (Figure 1 – Figure 4). The number of standard items with ≥75% documentation was for CAUTI, CLABSI, VAP, SSI, and overall, one (20%), three (13%), three (23%), four (27%), 11 (20%), respectively (Figure 1 – Figure 4).
Qualitative inquiry results
Saturation was reached with 19 interviewees; eight nurses (eight female), 11 physicians (five female); nine from floor ward (seven female), three from ICU (three female), one from intermediate care unit (one female), and six from operating room (two female). Of the 67 inductive codes, 40 were allocated to the TPB dimension Attitude with 148 coded interviewee statements (snippets), four to Subjective Norm with 78 snippets, and 23 to Perceived Behavioural Control with 491 snippets.
According to the TPB, an individual's Attitude towards an action is the product of various positive or negative behavioural beliefs about what results from a given action, while the Attitude represents an antecedent of the Intention to act, i.e., to document in our case . We found the following Attitudes towards documentation.
Documentation is meant to guarantee the continuity of care in the case of patient handovers between physicians or care teams.
“Each therapeutic decision should be noted in a way so that if the treating physician falls ill the next day, one can understand why something has been changed.” (Male resident, floor ward)
Documentation can also serve as a reminder for themselves or for their colleagues.
"To remember why the patient has one [invasive device]." (Male resident, floor ward)
"[To] remind yourself, oh what did I [do] again yesterday on this patient and then you can read up. For your own history, but also for night shifts." (Female resident, floor ward)
Some healthcare providers consider documentation as a safeguard against legal consequences.
"In this profession you have one foot in prison, (laughs) by now." (Female resident, floor ward)
However, on the contrary, the fear of negative (legal) consequences was also a reason to abstain from documentation, in order to avoid evidence of one's own misconduct.
"In the case of a secondary infection, you don't want the report to say that you made the operating field unsterile, but then continued to work anyway. Then you dig your own grave." (Male resident, floor ward)
Other reasons against documentation were repetitions, which seem to weaken the motivation to document a medical procedure in writing.
“If the indication [for a urinary catheterization] leads to a prescription for several days, the re-evaluation will not be documented every day. For example, it is clear that the prostate volume will not get so small in one day that it would allow us to take the catheter out.” (Female resident, floor ward)
Finally, a perceived lack of relevance was the most frequent answer to the question why a certain action should or should not be documented.
"I think it's unnecessary. Not only because of the time, but simply because it (pause 3 seconds) makes no sense." (Female resident, floor ward)
In general, healthcare providers said they do not document the course of an action but limit themselves to documenting the result.
"It's really just like when the process is done, the result where you write it down. You don't write down the workflow." (Female nurse, floor ward)
Human behaviour is considerably influenced by the perceived judgement of one’s actions by subjectively important others. As a physician resident points out, a “laissez-faire attitude of superiors” can impair the necessary discipline to document.
Professional pride seems to positively influence the quality of documentation.
“The documentation by nurses is a picture of our care - concise, using technical terms, precise.” (Female nurse, floor ward)
Interestingly, even the design of digital interfaces can transport the message that documentation is necessary and expected.
“If it is visible [on the screen] and one can only select it by a click it will be used because it suggests that it could have a legal relevance.” (Female resident, operating room)
On the other hand, young residents in particular wonder what the senior physician will think of them if they go into too much detail in their account of procedures.
"The one who co-signs the report would probably delete it if I had documented it." (Male resident, floor ward)
The decision not to document is apparently governed by the assumption that a medical procedure is carried out according to an established ‘standard’. Only deviations from the norm would be noted.
“Hand hygiene and all these things that are, like, self-evident are not documented. Except if something goes wrong, the patient touches the wound, then yes.” (Female nurse, floor ward)
"It would make sense to document when you have deviated from the internal standard and give a reason why." (Female resident, operating room)
Especially actions that appear to be self-evident in the eyes of the community are not documented.
“I see this [hand hygiene] as something personal, and so, very self-evident.” (Male resident, operating room)
Perceived Behavioural Control
The third antecedent of the Intention to Act in the TPB reflects the control one has over one’s capability to execute planned actions. This includes both, perceived but also real barriers and facilitators to execution.
The time needed for documentation depends on the design of the documentation process. Many interviewees expressed their frustration with bad information technology interfaces, or their ideas and desire for better systems, especially through automatization.
"I would document much more if I had voice recognition software." (Female resident, floor ward)
Time restraints count among the most frequently cited barriers to go and write a procedure down.
"Lack of time is of course the biggest obstacle." (Female resident, ICU)
The lack of consistent digitalization was often criticized in the context of documentation.
“The results of an electronic arterial blood pressure measurement have to be noted on a paper slip and from there, they have again to be typed into the [EMR] system by hand.” (Female nurse, floor ward)
“Many different documentation systems lead to you forgetting it and it is very cumbersome.” (Female nurse, floor ward)
A noisy work environment can jeopardize work in general but also interfere with the quality of documentation.
“Too many people in one room, I cannot concentrate!” (Female nurse, floor ward)