Exploring multilevel determinants of nursing documentation quality in suicide care: A qualitative Study in Iranian hospitals.

Abstract

High-quality nursing documentation is crucial for patient safety, continuity of care, and legal accountability, particularly in suicide-related care. Despite its importance, documentation practices in such sensitive contexts are influenced by multiple interacting factors. This study aimed to explore the determinants of high-quality nursing documentation in suicide cases from the perspectives of nurses and clinical supervisors in Iran. A qualitative study using conventional content analysis was conducted in 2024 across multiple hospitals in Iran. Purposive sampling with maximum variation was used to recruit 25 participants, including registered nurses, head nurses, and clinical supervisors involved in suicide care. Maximum variation was ensured across hospital types (general hospitals with emergency departments and specialized psychiatric units), clinical roles, years of experience, and geographical regions. Data were collected through in-depth, semi-structured interviews, transcribed verbatim, and analyzed following Graneheim and Lundman's approach. MAXQDA 2022 software was used for data management. Trustworthiness was ensured using Lincoln and Guba's criteria. Analysis revealed eight main interrelated themes encompassing organizational, professional, interpersonal, and systemic determinants of nursing documentation quality. These included Work Environment and Organizational Support, Professional Knowledge and Competence, Training and Continuing Education, Communication and Collaboration, Staffing and Workload Balance, Motivation and Accountability, Use of Technology and Resources, and Supervision and Feedback. Together, these factors acted as both facilitators and barriers, shaping the accuracy, completeness, and consistency of nursing documentation in suicide- related care. Beyond common documentation factors, the findings highlighted suicide-specific challenges, including the need for precise recording of fluctuating suicide risk, documentation of sensitive patient disclosures, ethical tensions between confidentiality and safety, and the impact of high-stress, time-critical decision-making on documentation accuracy. The findings indicate that improving documentation requires a multifaceted approach that strengthens professional capacity, fosters supportive organizational cultures, optimizes workload and resources, leverages appropriate technologies, and ensures constructive supervision. Particularly in suicide care, where documentation has critical clinical and legal implications, targeted strategies are needed to support accurate recording of risk, patient behavior, and interdisciplinary decision-making. Addressing these determinants through targeted training, supportive organizational policies, adequate staffing, and structured supervision can enhance patient safety, continuity of care, and the effectiveness of suicide prevention efforts.