Table 4. Types and Consequences of Registration Burdens as Perceived by Nurses and Physicians .
| Types of Registration Burden | Sub-themes | Representative Quotes |
| 1. Number of quality registrations | Time spent on quality registration |
Physician ‘While you have only seen the patient for fifteen minutes, you spend half an hour typing for NICE (Dutch medical ICU registry)’ Nurse ‘It’s more like, time after time, something is added of which you think: Do I need to do this as well?’ Physician ‘I think it is good to register because it enables you to benchmark, but its effects are a bit passé. Right now, people are afraid to let it [registrations] go.’ Physician ‘So you are filling out for 4 different databases, it is almost all the same but you cannot even copy-paste.’ |
| Frequency of registration is too high | ||
| Excessive number of quality registrations | ||
| Constant increase in number of quality indicators | ||
| Overlap and contradictions between demands | ||
| 2. Mandatory registrations | Only registering because it is mandatory |
Nurse ‘Because it is mandatory, but not because it is used.’ Nurse ‘And you are doing it because you want your department to score as high as possible?’ |
| Registration has become a goal in itself | ||
| 3. Unnecessary registrations | Registration not tailored to clinical practice and individual patients |
Nurse ‘Then you have a patient coming for tonsil surgery, a young man of 22 and then you have to screen for malnutrition or have to fill in a pressure ulcers score. Then, I think, really, is this really necessary?’ Nurse ‘I am always telling the patient: this is question time! Because you get a hundred times the same story. At the emergency department, then with us... I just know that lady has told us this 4 times already, and I am supposed to sing the same tune for the fifth time.’ Nurse ‘Even as someone who finds it very easy to register, I still think it’s a waste of time that we are doing it, because nothing is done with it.’ Physician: ‘Measure the pain of everyone, even if they have no pain. That makes me think that the nurse should become a nurse again and learn to think more by feeling and not only by ticking her checklists.’ |
| Asking patients same thing several times | ||
| Registration inputs not used | ||
| Nuance is missing in registration | ||
| Check-marking replaces clinical reasoning | ||
| Unclear goal and benefit of registration | ||
| 4. Registrations lead to no or minimal quality improvements | Limited quality improvement after registrations |
Nurse (complication conference) ‘The translation to practice is missing. How can we convert it into an improvement?’ Physician ‘Improvement is of course very difficult, you often have the feeling that you are putting in 200% effort to reach 10% improvement. We should be very critical as to which things are important enough to fight for and are realistically going to change.’ Physician [incident reporting] ‘Once you start on it, you will be busy for 45 minutes to fill in everything. And then you think ‘It wasn’t that bad anyway.’ And when that is finished, a whole group gathers around this issue.... you lose so much time, and that is even more dangerous for the patient.’ Nurse ‘With many registrations, I sometimes wonder: what is being done with it? You checked a list and it’s done.’ |
| Extensive measures delay the PDCA cycle | ||
| Registration does not identify structural problems | ||
| No meaningful feedback | ||
| Local learning curve (not regional or national) | ||
| 5. Unreasonable registrations | Registration should be done by someone else |
Physician ‘There are a lot of obligatory things about which you think ‘can’t it be done automatically’ [...] I am less good at it compared to the other things that I do, I am unique in those things, so use me for that, that is better for the patient as well.’ Physician [surgical checklist] ‘When you are at the highest level of concentration, because you are about to start, and then you get such a red rag in front your eyes which says stop and I have to say left or right, but I already mentioned that a hundred thousand times, I find it unnecessary.’ Nurse ‘The protocol states that when you are measuring pain and intervene, you have to ask again within half an hour. This is not feasible. When they say ‘I am in pain,’I will prepare morphine. I have to find someone, which costs me ten minutes, and twenty minutes later I have to ask whether the pain has disappeared. You will do that anyway, but you have to register, well, there it goes.’ |
| Registration interferes with clinical practice | ||
| Registration is not feasible in practice | ||
| Timing of the registration | ||
| 6. Quality/reliability of registrations | Quality indicator is not valid or reliable |
Physician ‘Then it’s check-marked on autopilot whereas, if you really need to take action, I don’t think that’s registered properly.’ Nurse ‘When you tick, it does not mean that the patient will also receive proper care.’ Nurse ‘Chronic pains are not identified, those [pain scores] just say nothing.’ |
| Sham registrations: autopilot box-ticking | ||
| Registration does not identify causes of inadequate care | ||
| 7. Inefficiencies in the registration process | Double registrations due to several demands |
Nurse [wound registration] ‘There are several fields in the EHR for this, but they refer to the same quality theme.’ Nurse ‘With the implementation of the EHR, we started registering the fluid balance in the EHR, but that did not work out. It was incomplete and that creates a risk for patients with heart failure. That is why we stopped. Now, we register on paper and then enter it into the EHR. So that’s double.’ Nurse ‘There are so many different tabs. There should be one overview. Because it happens at times, that I am talking with someone, and then I realise, I have already asked the patient this.’ Physician ‘Of course it matters how you deal with it, and how you can use the computer to deliver your care. And I think computers are super boring, or I would have chosen a career in ICT.’ |
| ICT and EHR do not support registration | ||
| Various registration systems are not connected | ||
| Registrations are not automatically uploaded within the EHR | ||
| Inconvenience with the EHR | ||
| 8. Political and/or financial interests | (Commercial) interests of stakeholders |
Physician ‘The power of the insurers and the patient association should decrease. They decide: if you don’t get a pink ribbon [breast cancer care certification], then you cannot buy from [name insurer]. These are all political games.’ Physician ‘When I want to figure something out in my research, I have to pay [name scientific database]. Yes, it is all about the money.’ |
| Consequences for: | Sub-themes | Representative Quotes |
| Patient care and attention for family | Registration during patient care devalues contact and limits time with patients and family |
Nurse ‘Then I consider it more important to call and talk with the patient, rather than filling that out.’ Nurse ‘You stand next to your patient and you’re just looking at the screen. Yes, I can touch type, but, how are you? Yes, the patient does not feel they are being taken seriously.’ |
| Quality of care and continuity | Excessive registration diverts time from quality improvements, innovations and research |
Physician ‘[robot-assisted surgery] is really innovative. Worldwide, we are leading the way. And we want others to see this, but it is all in the evening hours, so it is on top of everything, while it is very important.’ Physician ‘Because I see them [nurses] writing a lot and then, during the consultation, they actually know very little about the patient and I wonder that, with all this writing, there is very little efficiency in what is actually being transferred.’ |
| Check-marking replaces verbal communication | ||
| Motivation of healthcare professionals | Excessive registration is demotivating |
Physician ‘Yes it frustrates me. Yes, it is the only thing that frustrates me all day, filling out these stupid lists all the time.’ Physician ‘Society becomes harsher and more demanding, so you have to write everything down very carefully, because trust is no longer the basis, rather, distrust is […]’ Physician ‘People cover themselves. Just do it because then you can be sure nothing will come from it.’ Physician ‘So I avoid a lot of things that I consider quite pointless. I am also not going to pick a fight with the bus driver, that also seems pointless to me. Then you can pick a fight with anyone.’ Physician ‘I think we are quite harsh on each other here. Part of the stress is due to the thought ‘Oh, I will be discussed during the complication conference.’ And it is not particularly helpful for me to think ‘I will be standing there in front of the meeting and they will all tell me that I didn’t do a good job.’’ Nurse ‘No I don’t let myself be affected by that. Also, because I don’t do half of it.’ |
| Registering out of fear of legal consequences | ||
| Check-marking daily practice creates a feeling of distrust | ||
| Unclear benefit of registration creates a lack of urgency to register | ||
| Accepting registration as part of the job | ||
| Focus on incidents and complications creates a blame-and-shame culture | ||
| Rebellious avoidance of registrations | ||
| Quality of registrations themselves | Excessive registration leads to incomplete, non-valid and unreliable figures | Nurse ‘When I am busy, and I have a night shift, and then there is a quite a laundry list, that really makes me crabby. Because then I think, sometimes I really think: ‘I am not doing it, no I am not!’’ |
Abbreviations: ICU, intensive care unit; NICE, National Intensive Care Registry; PDCA, plan–do–check–act; EHR, electronic health record.