The Lived Experiences of Nurses in the Documentation Process in the Clinical Practice

This paper explores the lived experiences of nurses in the documentation process in clinical practice, aiming to clarify how they perceive, manage, and give meaning to documentation within busy hospital settings by highlighting both its essential role and the tensions it creates between patient care, workload, and professional accountability. Using a descriptive phenomenological design and Colaizzi’s method applied to in‑depth, semi‑structured interviews with staff nurses from special units in a tertiary government hospital, the study systematically transformed rich first‑person accounts into themes that reflect the core structure of nurses’ documentation experiences. The findings show that nurses regard documentation as indispensable for patient safety, continuity of care, communication within the healthcare team, and legal protection, yet experience it as time‑consuming, burdensome, and often in competition with direct bedside care, responding to heavy workloads and high patient acuity by prioritizing immediate care and safety while using practical strategies such as near‑real‑time charting, workflow organization, and structured formats to cope with documentation demands. The research is limited to one institution and a specific group of nurses, so the results are context‑bound rather than statistically generalizable, but they carry important implications for policy and practice, suggesting that documentation systems, standards, and staffing patterns should be redesigned to better align with real clinical workflows and to protect both record quality and nurse well‑being. The paper’s original value lies in offering a phenomenological, context‑specific understanding of documentation as a lived experience rather than as a purely technical task, illuminating how documentation embodies ethical responsibility, clinical judgment, and emotional labor, and thereby contributing nuanced insight to nursing scholarship and efforts to improve documentation practices.