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ABSTRACT
Objective: The objective of this study was to explore residents' perception of time they spend on clinical data and
patient care.
Methods: A cross-sectional study, utilizing a validated questionnaire was conducted in July 2019 at the King Fahad
Armed Forces Hospital, Jeddah after gaining ethical approval. Link to the online survey designed on Google forms
was shared through Facebook, WhatsApp, and Email. The questionnaire consisted of 21 items to assess different
variables like direct patient care, documentation requirements, and complete patient interaction.
Results: Out of 150 participants, the response rate was 111 (74%). Of 111 participants, regarding clinical
documentation, 105 (95%) felt that it has become excessive, and 93 (84%) agreed that it compromises patient
time. In addition, 87 (78%) residents felt rushed all the time and 82 (74%) said that they are frustrated with data
entry. On the educational value of clinical documentation, 90 (81%) of residents agreed that it has little or no
influence. Furthermore, 92 (83%) agreed that it negatively impacts the time available for teaching other junior
residents.
Conclusion: We conclude that: although residents wish to provide quality care to their patients, many of them felt
that data entry has become excessive and it is negatively affecting their clinical training.
Keywords: Clinical documentation, Patient care, Stress, Residents, Hospital record systems, Teaching and
learning.
1: Pak Red Crescent Medical and Dental College, Kasur, Pakistan.
2: King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia.
Correspondence to: Dr. Faezah Siddiqui, Email: , ORCiD: faeexahsiddiqui8@gmail.com 0000-0003-2583-8064
1 2
Faezah Siddiqui , Ali Awais Malik .
INTRODUCTION
Both residents and physicians frequently complain
1
about the time wasted on data entry. This is a common
complaint highlighted in multiple studies e.g. a survey
of 2000 Austrian hospital physicians indicated a
downward trend in job satisfaction compared to earlier
2
years. Another similar study summarized the fact that
53% of the physicians felt burnt out at some point and
52%of them considered the excessive documentation as
3
one of the main reasons.
Modern information technologies (IT) are introduced in
healthcare to ensure patient safety and facilitate
communication amongst medical professionals. But,
due to the growing mass of clinical data with no
foreseeable decline in the future, many residents do not
have time to perform what would be most useful for
their patients. Residents are the primary link to
healthcare as the patient comes first to their contact. In
a recent study on residents, faculty members showed
their concern about resident education due to limited
ORIGINAL ARTICLE
JDUHS
clinical exposure. However, the residents felt the need
to reorganize their clinical training in terms of
supervised content and quality rather than quantity of
4
duty hours. Long duty hours, clinical rotations,
examinations and data entry further leads to burnout in
5,6
residents as they have to do so many things at once.
Another concern is the educational value that the data
7
has for the residents.
Thus, we intend to explore residents' perception of
time they spend on clinical data and patient care. It is
hypothesized that the descriptive information acquired
through this study will provide insight into how
residents view their residency training program in
terms of learning and satisfacti on and help in
identif y ing so m e of t h e mai n issues that a r e
compromising patient care.
METHODS
This cross-sectional study was conducted in July 2019 at
the King Fahad Armed Forces Hospital, Jeddah which is
a 410 bed hospital. After gaining approval from the
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creative commons.
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Juggling Between Paperwork and Patient Care: How Residents View Their
Time Division in Clinical Training?
http://doi.org/10.36570/jduhs.2020.2.974
60 J Dow Univ Health Sci 2020, Vol. 14 (2): 60-65
physicians into ordered data as follows for analysis: 0%
to 20% = 1; 21% to 40% = 2; 41% to 60% = 3; 61% to 80% = 4; 81%
to 100% = 5. Additionally, Likert rating scale data were
changed to numeric data as follows: strongly agree = 5;
agree = 4; neither agree nor disagree = 3; disagree = 2;
strongly disagree = 1.
RESULTS
The overall response rate was 111 (74%) out of 150
participants filled in the online questionnaire. Of 111
respondents, 57 (51%) were females and 54 (49%) were
males. The average age of residents was 29 years. Most
of the residents belonged to first-year 52 (47%) followed
by second-year 28 (25%), fourth-year 18 (16%) and third-
year 13(12%). Majority of residents who responded were
from the medical department 39 (36%), followed by
surgery 34 (32%), Gynecology and Obstetrics 21(19%),
Pediatrics 8 (7%), ENT 4 (3%), Radiology 3 (2%), and
Anesthesiology 2 (1%).
On electronic medical record, 65 (59%) of residents
thought it negatively impacts direct patient care, 28
(25%) indicated that it positively impacts direct patient
care while 18 (16%) mentioned it has no impact on direct
patient care or time available for patients.
On the educational value of clinical documenta-tion, 90
(81%) of residents agreed that it has little or no
influence. A high agreement on paperwork and patient
care was observed. (Table 1) Residents’ perception
about time spent on direct patient care and related
activities and residents' response on the amount of
time spent and ideal time on direct patient care and
documentation requirements are shown in table 2 &
Figure 1.
“Research Committee” of King Fahad Armed Forces
Hospital Institutional Review Board (IRB; study
no.0800-12), a pilot study was done. A group of six
residents representing all medical departments were
approached to address any issue related to “item
language and its understanding'' and ''time took to
complete the questionnaire''.
An approximate of 211 residents at the hospital, from
year 1 to year 5 formed the target population. A sample
size of 150 residents was calculated through OpenEpi
online software, using a confidence interval of 95% and
margin of error of 5%. The source of data was a reliable
and validated 21-item Questionnaire developed in 2013
by Waren Alpert Medical School of Brown University. In
Waren Alpert Medical School of Brown University who
developed the questionnaire, the sample size was 1515
residents in 24 specialties.⁸ The residents were briefed
on the purpose of the study. They were assured of
confidentiality and had an option of refusal to
participate in the study. A checklist for giving consent as
“I agree” or “I do not agree” was created in the Google
form. Participants can only go to the next section after
giving consent.
Link to an online survey designed on Google forms was
shared through Facebook, WhatsApp and Email.
The Questionnaire was designed to identify three
components.
1. Time duration spent on patient care and clinical
documentation by physicians.
2. Record training level and practice information of
participants details, and
3. Analyze particip ants' und erstandings of the
obligatory clinical documentation.
Majority of questions applied a 5 point Likert rating
scale; ordered responses were also collected. Direct
patient care was defined as the amount of time directly
spent on a patient's history, physical examination,
cou n sel i ng, and tre a tme n t b y th e ph y sic i an.
Documentation requirements included all written or
electronic patient's documents, including notes,
problem lists, medication reconciliation, disability
forms, r eports o r test results, and di s c harge
paperwork. And lastly, complete patient interaction
was summarized as the total time devoted to patient
care, inclusive of direct patient care and related clinical
documenta-tion.
Data were collected at one point of time through the
Likert Scale (continuous scale) and analyzed through
(SPSS) version 25. Descriptive analysis included
frequency distribution, percentages, mean, and
standard deviation.
We converted the percentage of time spent by
Siddiqui et al. Paperwork and Patient Care
61
J Dow Univ Health Sci 2020, Vol. 14 (2): 60-65
Figure 1: Residents’ response on amount of time spent and
ideal time on Direct Patient Care and Documentation
Requirements
Avereage time spent
0
0.5
1
1.5
2
2.5
3
3.5
Ideal amount
of time for
direct patient
care during a
complete
patient
interaction
Amount of
time spend on
direct patient
care by
residents
Ideal amount
of time spend
filling
documents
(electronic or
paper)
Amount of
time spend on
filling
documents
(electronic or
paper)
DISCUSSION
Residents committed to caring for patients never
signed up for a career in clinical documentation. Still,
clinical documentation is an important component of
patient care. Globally, a great deal of attention has been
focused on the matter; many are questioning whether
this is the best use of residents' training and ability?
While also wasting the patient's time, as they came for
the residents' medical expertise, not their data
expertise.⁹ One might have thought that applying
technology can reduce the time due to the streamlining
of data through an electronic health record (EHR). But
in reality, the residents and attending physicians may
end up spending 3 times more on electronic health
records. Another issue that cannot be ignored is the
increased risk of negligent behavior by doctors due to
,
the failure to review clinical documents entirely.¹⁰ ¹¹ This
research shows insight into how residents view their
residency training program in terms of learning and
satisfaction. In our setting in Saudi Arabia, healthcare is
provided by the Kingdom, and as such the insurance
companies are not involved. Regardless, lots of data
entry is required to keep the hospital records in terms of
admissions, treatment, management, and follow up.
In add i tion, the rising cost of healthcare also
Table 1: Level of Agreement on Paperwork and Patient care
Strongly
Disagree=1
n (%)
Disagree=2
n (%)
Neutral=3
n (%)
Agree=4
n (%)
Strongly
Agree=5
n (%)
Motivation of quality care 0 (0) 0 (0) 0 (0) 23 (21) 88 (79)
Excessive paperwork 0 (0) 0 (0) 7 (6) 52 (47) 52 (47)
Time with patients restricted 0 (0) 6 (5) 12 (11) 41 (37) 52 (47)
Decreased overall patient care 0 (0) 23 (21) 11 (10) 36 (32) 41 (37)
Could provide better care with
less documentation requirements
0 (0) 12 (11) 6 (5) 70 (63) 23 (21)
Feel rushed 0 (0) 6 (5) (16) 52 (47) 36 (32)
Feel frustrated 0 (0) 6 (5) 23 (21) 41 (37) 41 (37)
,
demands short hospital stays and legal regulations. ¹²¹³
This furthers the demand for timely, high-quality and
patient-oriented documentation to be done by the
attending residents. ¹⁴
In our study, many of the residents felt that data entry
has become excessive and that it is negatively affecting
their clinical training. They believe that they can provide
quality care if they are able to spend more time with
their patients. These findings are similar to a study done
in the University of Wisconsin, USA which reported
primary care physicians spending practically 6 hours
every day on electronic health records.¹⁵ Another study
wa s done in Austria on eighty ph ysicians als o
highlighted the same issue where 27% of their time was
committed to clinical and administrative documenta-
tion². In addition, various studies have brought
attention to this issue where physicians were identified
as spending almost 25% to 60% percent of their daily
,
time on documentation. ¹⁶ ¹⁷
Sinsky et al. found that physicians spend 43% of their
time entering and abstracting information from
medical data, and 29% on direct patient care.¹⁷ In
addition, another study noted that only 55% of
physicians' time was spent on face to face patient
interaction while the remaining 45% was devoted to
Table 2: Residents’ perception about time spent on direct patient care and related activities
Perception of Residents Percentage of time spent in duty hours
Clinical documentation which can improve patient care. 36.8
Actual time spent on direct patient care 47.4
Ideal time for direct patient care 68.4
Patients expectation from you on complete patient care 63.2
Ideal time to be spent on clinical documentation 31.6
Siddiqui et al. Paperwork and Patient Care
62 J Dow Univ Health Sci 2020, Vol. 14 (2): 60-65
Specific measures can be adopted by the hospital
administration to help residents with data entry and
patient care. Hospital electronic record systems need
to become user friendly and residents need to be
trained on how to operate them. Hiring clerical and
administrative support for residents can also amend
the situation. ³¹
Although our study has identified an important issue
related to excessive data entry, it also has few
limitations in its design which should be taken into
consideration for future research. Firstly, due to the
small sample size, a response bias is feared which might
have missed the perceptions of some of the residents. It
may also be a possibility that residents underestimated
or overestimated the amount of time they spent on
data entry. Secondly, our study only provides a glance
into that of the residents' views and not the hospital
administration due to its cross-sectional design. Further
research with longitudinal design to gain better insight
into the thoughts of the hospital administration can be
enlightening. Thirdly, since the study was conducted in
a single institute, its scope was limited to King Fahad
Armed Forces Hospital.
CONCLUSION
Although residents wish to provide quality care to their
patients, time management is an obstacle. They believe
that they can provide quality care if they are able to
spend more time with their patients. Specific measures,
such as turning record systems user friendly and hiring
clerical and administrative support, should be adopted
by the hospital administration to assist residents with
data entry and patient care.
ETHICAL APPROVAL: The study protocol was approved by
the Research Committee of King Fahad Armed Forces
Hospital, Jeddah, Saudi Arabia.
AUTHORS' CONTRIBUTION: FS: Conceived, designed and did
data collection, analysis & manuscript writing. AAM: did
manuscript editing and final approval of manuscript after
review.
CONFLICT OF INTEREST: The authors have no conflict of
interest to declare.
FUNDING: The authors did not receive any financial support
for the research and publication.
Received: June 11, 2020
Accepted: August 24, 2020
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