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Abstract

Introduction

High quality nursing documentation and clinical reasoning competence are essential for safe and effective nursing practice, and interprofessional collaboration represents a key care process. This study examined the relationships among nurses’ quality of nursing documentation, interprofessional collaboration, and clinical reasoning competence.

Methods

A cross-sectional, descriptive, correlational, quantitative study was conducted among nurses working in multiple hospitals in Hue, Vietnam. Participants were recruited using convenience sampling. Data were collected from March to July 2025 using online and paper-based questionnaires. The Nurses Clinical Reasoning Scale, Interprofessional Collaboration Scale, and the Student Survey on Writing Nursing Care Plans were used. Descriptive statistics, Pearson correlation, and mediation analyses were performed.

Results

A total of 239 nurses were included in the final analysis. Correlation analysis showed that the quality of nursing documentation was positively associated with interprofessional collaboration (p < 0.001) and clinical reasoning competence (p < 0.001), and interprofessional collaboration was positively correlated with clinical reasoning competence (p < 0.001). Interprofessional collaboration significantly mediated the relationship between quality of nursing documentation and clinical reasoning competence (indirect effect β = 0.02, 95% CI [0.01, 0.04]), accounting for 11.5% of the total effect.

Conclusion

Interprofessional collaboration partially mediated the relationship between quality of nursing documentation and clinical reasoning competence, indicating that high-quality documentation enhances clinical reasoning both directly and indirectly through improved collaborative practice. These findings highlight the importance of strengthening documentation practices and interprofessional collaboration to support nurses’ clinical reasoning competence.

Keywords

nursing documentation interprofessional collaboration clinical reasoning competence nurse

Introduction

Nursing documentation is a fundamental component of professional nursing practice and a key mechanism for ensuring patient safety, care quality, and continuity of care.^1–3 It involves the systematic recording of patient information and nursing care activities across all stages of the nursing process, including assessment, diagnosis, care planning, implementation, and evaluation.³ As a routine clinical practice, nursing documentation provides essential evidence of patient health status and nursing care, thereby improving the clarity, completeness, and consistency of clinical records.⁴ In recent years, implementation of nursing documentation has increasingly incorporated standardized nursing languages, including diagnoses from NANDA International, the Nursing Outcomes Classification, and the Nursing Interventions Classification.^3,5 These standardized terminologies facilitate structured care planning and contribute to improving the quality and consistency of documentation. Through the integration of these standardized terminologies, nursing documentation facilitates efficient information exchange and supports the accurate and systematic recording of patient care.⁶ Beyond its legal and professional functions, nursing documentation promotes effective communication and information flow among interdisciplinary healthcare providers, thereby supporting coordinated, safe, and continuous patient care.⁷ Comprehensive documentation of the nursing process, particularly the capture of nurses’ clinical reasoning, is essential for informed clinical decision making and patient safety.^5,8 High quality documentation further contributes to improved patient outcomes by enhancing clarity, accountability, and consistency in clinical decision making.^3,5

Clinical reasoning competence is essential for effective practice in dynamic healthcare environments, where growing clinical complexity requires nurses to continuously refine their reasoning processes to address evolving patient care demands.^9,10 Clinical reasoning involves a complex cognitive process in which nurses collect and interpret patient information, recognize clinical cues, analyze possible explanations, and make informed decisions regarding patient care.^10,11 Strong clinical reasoning enables nurses to prioritize patient problems, anticipate potential complications, and respond effectively to emerging clinical situations. Empirical evidence indicates that integrating clinical reasoning enhances nursing performance and supports timely, appropriate responses to complex patient situations, thereby improving the quality of care and patient outcomes.^10,12 Moreover, examining clinical reasoning across health professions highlights variation in decision making approaches and underscores its potential to strengthen shared understanding and promote effective interprofessional collaboration.¹³

In complex healthcare environments, effective care delivery requires the involvement of multiple professionals who contribute diverse areas of expertise and clinical perspectives.¹⁴ Through these collaborative interactions, nurses have opportunities to exchange information, consider diverse professional perspectives, and integrate shared knowledge while gathering and analyzing patient information and evaluating its clinical significance, thereby supporting the development of their clinical reasoning.¹⁰ Thus, effective clinical decision making increasingly depends on collaborative practices that enable healthcare providers to integrate diverse knowledge and address the unique and evolving needs of individual patients.¹⁵ A previous study reported that interprofessional collaboration enables nurses to engage in shared decision making and coordinated care, providing access to diverse clinical perspectives that support the development and application of clinical reasoning competence.¹⁶ Through collaborative interactions, nurses are better positioned to synthesize patient information, evaluate clinical priorities, and make sound judgments in complex situations. Consequently, interprofessional collaboration among healthcare providers, particularly nurses, has been consistently associated with improved patient outcomes, enhanced healthcare efficiency, and greater professional satisfaction.^17,18

The Donabedian Model of Healthcare Quality, proposed by Donabedian, provides a systematic framework for evaluating healthcare quality through three interrelated components, including structure, process, and outcomes.¹⁹ In the present study, this model was used as a conceptual framework to explain the relationships among quality of nursing documentation, interprofessional collaboration, and clinical reasoning competence. Within this model, structure refers to the organizational and informational resources that support care delivery, including the quality of nursing documentation practices. Process represents the interactions and communication among healthcare professionals during the provision of care, operationalized in this study as interprofessional collaboration. Outcome reflects the results of these processes, including professional competencies such as nurses’ clinical reasoning. This model provides a theoretical basis for understanding how the quality of nursing documentation influence nurses’ clinical reasoning competence through collaborative processes. Therefore, interprofessional collaboration might function as a mediating mechanism through which the quality of nursing documentation contributes to the development of nurses’ clinical reasoning competence. Therefore, this study was conducted to examine the relationships among quality of nursing documentation, interprofessional collaboration, and clinical reasoning competence. Understanding this relationship is critical for informing educational strategies, clinical practice improvements, and organizational policies aimed at strengthening nursing performance and patient safety.

Methods

Study design and participants

This cross-sectional, descriptive, correlational, and quantitative study was conducted among nurses working across multiple hospitals in Hue, Vietnam. Participants were recruited using convenience sampling. The inclusion criteria were: registered nurses currently working in clinical departments, direct involvement in patient care, at least one year of working experience in the hospital, and willingness to participate in the study. The exclusion criteria included nurses in administrative or managerial positions without direct patient care responsibilities.

Based on the G*Power sample size calculation for Pearson correlation analysis (α = 0.05, power = 0.90, effect size r = 0.30), a minimum of 111 participants was required. To compensate for an anticipated dropout or incomplete response rate of 20%, the target sample size was increased to 133 nurses. A total of 259 nurses were initially recruited for the study. Twenty questionnaires (7.7%) were excluded due to missing or incomplete responses on key study variables. Because the proportion of missing data was relatively small (<10%) and occurred across multiple variables without a systematic pattern, a complete-case analysis approach was adopted. No data imputation was performed. The final analytic sample consisted of 239 participants (92.3% of the initially recruited sample). The final sample size exceeded the minimum required sample size, thereby ensuring adequate statistical power.

Instruments

The self-designed questionnaire was distributed to collect demographic and clinical characteristics of participants in this study.

Clinical reasoning competence was measured using the Nurses’ Clinical Reasoning Scale developed by Liou and colleagues.²⁰ This instrument comprises 15 items rated on a five-point Likert scale and an original version demonstrated strong internal consistency, with a Cronbach’s alpha of 0.92.²⁰ For the present study, the scale was translated from English into Vietnamese using a standardized forward-backward translation procedure.²¹ A pilot test was subsequently conducted with 15 nurses to evaluate the reliability of the translated version. The Vietnamese version demonstrated good internal consistency, with a Cronbach’s alpha of 0.85.

Interprofessional collaboration was assessed using the Interprofessional Collaboration Scale developed by Kenaszchuk and colleagues.²² This self-administered instrument includes 13 items categorized into three domains: communication, accommodation, and isolation. Responses are recorded on a four-point Likert scale, with options ranging from 1 (“strongly disagree”) to 4 (“strongly agree”).²² For the present study, the scale was translated from English into Vietnamese using a standardized forward-backward translation process to ensure linguistic accuracy and conceptual equivalence.²¹ A pilot test was conducted with 15 nurses to evaluate clarity, cultural appropriateness, and reliability of the Vietnamese version. The instrument demonstrated good internal consistency, with a Cronbach’s alpha of 0.82, indicating its suitability for use in the study population.

The quality of nursing documentation was assessed using the Student Survey on Writing Nursing Care Plans developed by Salvador et al., which evaluates the clarity, completeness, and clinical logic of written nursing care plans.²³ The instrument encompasses five dimensions, including data gathering, identifying clients’ problems, formulating sustainable goals, providing appropriate interventions, and recognizing clients’ outcomes which a fundamental component of nursing documentation. Each item is rated on a five-point Likert scale ranging from 1 (poor) to 5 (excellent), yielding a total possible score ranging from 25 to 125, with higher scores indicating better quality of nursing documentation.²³ In the original study, the instrument demonstrated excellent internal consistency, with a Cronbach’s alpha coefficient (α) of 0.935.²³ Although originally developed for students, the instrument required no substantive modification for use with practicing nurses, as it reflects core care planning competencies. A pilot test was conducted with 15 nurses to evaluate the clarity, cultural appropriateness, and reliability of the Vietnamese version of the instrument. Participants were invited to provide feedback regarding item wording, clarity, and relevance to clinical practice. Based on their feedback, minor wording revisions were made to improve comprehension and contextual suitability. In the present study, the tool was subsequently administered to nurses working in a hospital setting, and the overall scale demonstrated good internal consistency, with a Cronbach’s alpha coefficient of 0.89.

Data analysis

Statistical analyses were conducted using SPSS version 24.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics, including means, standard deviations, and frequencies, were used to summarize participant characteristics and study variables. Pearson’s correlation analysis was performed to examine the relationships among key variables. To assess the mediating role of interprofessional collaboration, multiple linear regression analyses were conducted using the PROCESS Macro for SPSS.

Prior to statistical analysis, the dataset was screened for completeness and accuracy. The extent and pattern of missing data were examined. Questionnaires with substantial missing responses on key study variables were excluded from the analysis (n = 20). No statistical imputation procedures were performed because the level of missing data was below the commonly accepted threshold of 10%, minimizing risk of biased parameter estimates. All subsequent analyses were conducted using data from the 239 participants with complete responses.

Ethics statement

This study was approved by the Institutional Ethics Committee of Hue University of Medicine and Pharmacy (Approval No. H2025/061) and conducted in accordance with the Declaration of Helsinki. Participation was voluntary, and written informed consent was obtained from all participants prior to data collection. Confidentiality and anonymity were ensured by removing all identifying information, and data were used solely for research purposes.

Data collection procedure

Data were collected from March to July 2025 using both online and paper-based questionnaires. The online survey was administered via the Google Forms platform and did not collect any identifiable information. Prior to data collection, the researcher met with the chief nurse of each participating hospital to provide an overview of the study. Participants were recruited through head nurses, who disseminated the online survey link to eligible staff via email and Zalo groups, a widely used social networking application in Vietnam. The survey link provided access to the participant information sheet, informed consent form, and questionnaire. For participants who preferred paper-based questionnaires, the principal researcher distributed hard copies and placed secure collection boxes in each unit for the return of completed questionnaires.

Results

Of the 259 nurses who consented and returned questionnaires, 20 were excluded due to incomplete data. A total of 239 participants were included in the final analysis (Table 1). The majority of participants were aged 30–40 years (56.1%), followed by those younger than 30 years (25.1%) and older than 40 years (18.8%). Most respondents were female (84.9%), while males accounted for 15.1%. In terms of educational background, 66.9% held a college degree and 33.1% had a bachelor’s or postgraduate qualification. Regarding work experience, the largest proportion of nurses had 5–10 years of experience (41.6%), followed by 11–15 years (26.8%), more than 15 years (19.5%), and fewer than 5 years (12.1%).

Table 1.

Characteristics of participants (n=239).

	Variable	n	%
Age	<30	60	25.1
	30-40	134	56.1
	>40	45	18.8
Gender	Male	36	15.1
Gender	Female	203	84.9
Educational status	College	160	66.9
Educational status	Bachelor’s degree/Postgraduate	79	33.1
Work experience	<5 years	40	12.1
	5-10 years	85	41.6
	11-15 years	62	26.8
	>15 years	52	19.5
Department	Internal medicine	58	25.5
	Surgery	38	13.4
	Intensive care unit	26	6.7
	Pediatrics	30	8.1
	Other	87	46.3
Employment status	Permanent staff	163	79.2
	Long-term contract	72	18.1
	Short-term/temporary contract	4	2.7
Received training on nursing documentation	Yes	187	95.3
Received training on nursing documentation	No	52	4.7
Type of medical record used	Paper medical records	81	34.2
	Electronic medical records	50	13.4
	Both	108	52.3
Average number of patients cared for per nurse per day	< 5 patients	32	6.7
	5–10 patients	95	49.0
	11–15 patients	51	19.5
	> 15 patients	61	24.8

Participants were drawn from a range of clinical departments, with 25.5% working in internal medicine, 13.4% in surgery, 6.7% in the intensive care unit, and 8.1% in pediatrics, while 46.3% were from other departments. Most nurses were permanent staff (79.2%), with smaller proportions employed on long-term (18.1%) or short-term contracts (2.7%). Nearly all participants reported receiving training on nursing documentation (95.3%). More than half of the nurses used both paper and electronic medical records (52.3%), whereas 34.2% used paper records only and 13.4% used electronic records. In terms of workload, approximately half of the nurses reported caring for 5–10 patients per day (49.0%), while 24.8% cared for more than 15 patients, 19.5% for 11–15 patients, and 6.7% for fewer than five patients.

The mean score for clinical reasoning competence was 57.42 (SD = 5.36), interprofessional collaboration had a mean of 38.02 (SD = 3.79). The mean score for the quality of nursing documentation was 3.02 (SD = 0.53) (Table 2). Correlation analysis showed that clinical reasoning competence was significantly and positively correlated with both interprofessional collaboration (p < 0.001) and the quality of nursing documentation (p <0.001). Additionally, interprofessional collaboration demonstrated a significant positive correlation with the quality of nursing documentation (p < 0.001).

Table 2.

Correlation analysis of clinical reasoning competence, interprofessional collaboration, and quality of nursing documentation (n=239).

Variables	Mean	SD	Quality of nursing documentation	Interprofessional collaboration	Clinical reasoning competence
Quality of nursing documentation	3.02	0.53	1
Interprofessional Collaboration	38.02	3.79	0.27*	1
Clinical reasoning competence	57.42	5.36	0.44*	0.29*	1

Note. * p<0.001.

Before conducting the regression and mediation analyses, the assumptions of linear regression were examined. Visual inspection of histograms and normal probability plots of standardized residuals indicated approximate normality. Homoscedasticity was assessed using scatterplots of standardized residuals against standardized predicted values, which showed no evident pattern or funnel shape, suggesting constant variance of errors. Multicollinearity was evaluated using variance inflation factor and tolerance statistics. All variance inflation factor values were below 2.0, and tolerance values exceeded 0.50, indicating no concerns regarding multicollinearity. These findings support the appropriateness of the regression models used in this study.

As shown in Table 3 and Figure 1, mediation analysis was conducted using Model 4 of the PROCESS macro to examine whether interprofessional collaboration mediated the association between the quality of nursing documentation and nurses’ clinical reasoning competence. The results indicated that the quality of nursing documentation was significantly associated with interprofessional collaboration (β = 0.08, SE = 0.02, t = 3.28, p = 0.001), with a 95% bootstrap confidence interval (CI) ranging from 0.03 to 0.12. Interprofessional collaboration was significantly associated with clinical reasoning competence (β = 0.27, SE = 0.11, t = 2.52, p = 0.01), with a 95% bootstrap CI ranging from 0.06 to 0.48. The total effect analysis demonstrated that the quality of nursing documentation was significantly associated with clinical reasoning competence (β = 0.18, SE = 0.03, t = 5.84, p < 0.001; 95% CI: 0.12–0.24). Direct effect of the quality of nursing documentation on clinical reasoning competence remained statistically significant (β = 0.16, SE = 0.03, t = 5.08, p < 0.001; 95% CI: 0.10–0.22). The indirect effect of quality of nursing documentation on clinical reasoning competence through interprofessional collaboration was statistically significant (β = 0.02, 95% bootstrap CI: 0.01–0.04). The proportion mediated was 11.5%, indicating that interprofessional collaboration partially mediated relationship between quality of nursing documentation and clinical reasoning competence.

Table 3.

Mediation model for quality of nursing documentation and clinical reasoning competence.

Path	β	SE	t	p	Bootstrap 95% (CI)
Path	β	SE	t	p	BootLL CI	BootUL CI
Path a:							R=0.26
Quality of nursing documentation → Interprofessional Collaboration	0.08	0.02	3.28	0.001	0.03	0.12	R² = 0.07, F = 10.77, p = 0.001
Path b:							R=0.43
Interprofessional Collaboration → Clinical reasoning competence	0.27	0.11	2.52	0.01	0.06	0.48	R2 = 0.19, F = 34.06, p < 0.001
Total effect:	0.18	0.03	5.84	<0.001	0.12	0.24	R=0.47
Quality of nursing documentation → Clinical reasoning competence							R² = 0.22, F = 20.82, p <0.001,
							Standardized effect = 0.44 = Medium
Direct effect:
Quality of nursing documentation → Clinical reasoning competence	0.16	0.03	05.08	<0.001	0.10	0.22	Standardized effect = 0.38 = Medium
Indirect effect:
Quality of nursing documentation → Interprofessional Collaboration → Clinical reasoning competence	0.02	0.01	-	-	0.01	0.04	Standardized effect = 0.05 = Small

Proportion mediated (PM)= 11.5%.

Figure 1.

Pathway of interprofessional collaboration in the relationship between quality of nursing documentation and clinical reasoning competence.

Discussion

This study examined the relationships among clinical reasoning competence, interprofessional collaboration, and quality of nursing documentation among clinical nurses working across multiple hospitals. The findings indicate that nurses demonstrated moderate to high levels across all three variables, suggesting that nurses are generally able to apply cognitive decision - making skills, engage in collaborative practices with other healthcare professionals, and maintain acceptable standards of documentation in routine clinical care.

Nurses demonstrated a moderate to high level of clinical reasoning competence, that they were generally able to integrate patient assessment findings, clinical knowledge, and contextual information to support effective clinical decision-making. These findings are broadly consistent with previous research conducted in different healthcare contexts. Noh and Kang (2024) reported a mean clinical reasoning competence score of 59.72 ± 8.01 among Korean oncology nurses.¹² Liu et al. (2025) found that clinical reasoning competence among nurses ranged from 56.24 ± 7.29 to 64.65 ± 6.69.²⁴ In a European context, Notarnicola et al. (2024) reported a higher mean score of 62.98 among Italian registered nurses.²⁵ Although some variation exists across countries and clinical settings, overall findings suggest that nurses generally demonstrate moderate to high levels of clinical reasoning competence. This competence enables nurses to effectively interpret patient conditions, prioritize care needs, and implement appropriate interventions in complex clinical situations. In addition, the relatively high level observed in this study could be related to recent developments in healthcare systems, particularly the increasing adoption of electronic health record systems in many hospitals. In Vietnam, healthcare institutions have increasingly implemented electronic health information systems to improve management of clinical information. In particular, nursing documentation has progressively incorporated standardized nursing languages within the nursing process. Such developments could strengthen the systematic recording of patient care and facilitate clearer communication of nursing assessments, interventions, and outcomes, thereby supporting more informed clinical decision-making in increasingly complex healthcare environments.

Furthermore, digitalization of clinical information has the potential to strengthen interdisciplinary communication and facilitate information sharing among healthcare professionals. When nurses could readily access updated patient information from multiple sources within an electronic system, they might be better positioned to interpret patient conditions and participate more actively in collaborative decision making processes. Electronic records could therefore function as a shared informational platform that supports coordinated care and mutual understanding among members of the healthcare team. However, despite these technological advancements, challenges related to interprofessional collaboration still persist in some healthcare settings. For example, a study conducted at the primary care level by Huyen et al. (2024) reported that healthcare providers from different professional disciplines frequently experienced a “lack of collaborative practice”.²⁶ These findings suggest that structural and organizational barriers, including hierarchical professional relationships, unclear role delineation, and limited opportunities for structured interprofessional communication, continue to hinder effective collaboration.

The present study found that clinical reasoning competence was significantly and positively correlated with both interprofessional collaboration and quality of nursing documentation. In framework of Donabedian model, quality of nursing documentation represents a critical component of care process that structures how clinical information is collected, interpreted, and communicated. High-quality nursing documentation support initial stages of this process by structuring patient information in a systematic and accessible format, thereby facilitating the noticing and interpretation of clinically relevant cues. Consistent with this perspective, previous research has shown that structured documentation systems could enhance nurses’ clinical reasoning by improving the organization and accessibility of patient information during care planning and evaluation.²⁷ Beyond these individual cognitive processes, the findings also suggest that documentation contributes to clinical reasoning through interpersonal mechanism. The mediating role of interprofessional collaboration indicates that well-structured documentation enhance clarity and accessibility of clinical information shared among healthcare professionals. Clear documentation provides a common informational platform that facilitates communication and discussion within interprofessional teams. Through collaborative interpretation of documented patient information, nurses encounter diverse professional perspectives, alternative interpretations of clinical data, and shared problem-solving approaches, which broaden their understanding of patient conditions and support more comprehensive clinical judgments. Evidence suggests that patient documentation serves as a catalyst for interprofessional collaboration, are actively involved in organizing patient care.²⁸ Moreover, interprofessional documentation has been recognized as an effective strategy for strengthening coordination and collaboration within interprofessional care teams.²⁹ From the perspective of Donabedian framework, improving documentation quality might therefore strengthen both the informational infrastructure that supports clinical reasoning and the collaborative processes through which clinical knowledge is exchanged in healthcare teams. These collaborative interactions promote reflective thinking and the integration of multidisciplinary knowledge into clinical decision-making. This finding supports the view that clinical reasoning is a socially situated and context-dependent competency, shaped through professional interactions as well as individual cognitive processes.³⁰

Limitations

This study has several limitations. First, the cross-sectional design limits the ability to establish causal relationships among quality of nursing documentation, interprofessional collaboration, and clinical reasoning competence. Although mediation analysis was used to explore potential pathways, the cross-sectional nature of the data does not permit temporal inference, and the findings should therefore be interpreted as associative rather than causal. Second, all variables were measured using self-administered questionnaires, which might introduce response-related biases such as social desirability bias. The reliance on a single data source may also increase the risk of common method variance, potentially inflating the observed associations among variables. Third, convenience sampling was used to recruit participants from a limited number of healthcare institutions, which may introduce sampling bias and limit the representativeness of the study population. Finally, other organizational and contextual factors not examined in this study also influence nurses’ clinical reasoning competence.

Implications for practice

These findings underscore the need to strengthen nursing documentation practices and interprofessional collaboration to enhance nurses’ clinical reasoning competence. High quality documentation should be recognized as a critical clinical communication tool that supports continuity of care and informed decision making, rather than as a purely administrative task. Healthcare organizations are encouraged to implement standardized documentation systems and provide ongoing training to improve documentation quality. The mediating role of interprofessional collaboration highlights the importance of cultivating collaborative practice environments through structured interdisciplinary communication and shared care planning. Nurse leaders and educators should embed documentation and collaboration competencies into clinical education, mentorship, and performance evaluation. Collectively, these strategies have the potential to strengthen clinical reasoning and promote safer, higher quality patient care.

Conclusions

This study found that the quality of nursing documentation was significantly associated with nurses’ clinical reasoning competence, with interprofessional collaboration mediating a small portion of this relationship. The findings suggest that effective documentation and collaborative team interactions are complementary factors that might support the development of clinical reasoning in nursing practice. Future longitudinal and multi-method research is needed to further clarify the mechanisms linking documentation, collaboration, and clinical reasoning competence.

Footnotes

Acknowledgments

The authors would like to extend their gratitude to all participants who contributed to this study.

ORCID iD

Trang Thi Thuy Ho

Ethical considerations

This study was approved by the Institutional Ethics Committee of Hue University of Medicine and Pharmacy (Approval No. H2025/061) and conducted in accordance with the Declaration of Helsinki.

Consent to participate

Participation was voluntary, and written informed consent was obtained from all participants prior to data collection. Confidentiality and anonymity were ensured by removing all identifying information, and data were used solely for research purposes.

Consent for publication

Not applicable, as all data were anonymized and no identifiable information is included.

Author contributions

TTTH, BDH, Data curation: TTTH, Formal analysis: TTTH, Investigation: TTTH, Methodology: TTTH, BDH, Writing – original draft: TTTH, Writing – review & editing: TTTH, BDH.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

References

Bjerkan

Valderaune

Olsen

. Patient Safety Through Nursing Documentation: Barriers Identified by Healthcare Professionals and Students. Front Comput Sci 2021; 3: 624555. https://doi.org/10.3389/fcomp.2021.624555 Epub ahead of print 1.

Mabunda

Masondo

Mokoena-de Beer

. Nurses’ understanding of quality documentation: A qualitative study in a Mental Health Institution. Curationis 2025; 48: e1–e8. https://doi.org/10.4102/curationis.v48i1.2737

Wahyuni

Nursalam

Dewi

, et al. Electronic nursing documentation for patient safety, quality of nursing care, and documentation: a systematic review. JPMA J Pak Med Assoc 2024; 74: 1669–1677. https://doi.org/10.47391/JPMA.9996

Demsash

Kassie

Dubale

, et al. Health professionals’ routine practice documentation and its associated factors in a resource-limited setting: a cross-sectional study. BMJ Health Care Inform 2023; 30: e100699. https://doi.org/10.1136/bmjhci-2022-100699

Gligor

Rusu

Domnariu

, et al. The quality of nursing diagnoses, interventions, and outcomes in Romanian nursing documentation measured with the Q-DIO: A cross-sectional study. Int J Nurs Knowl 2024; 35: 298–307. https://doi.org/10.1111/2047-3095.12446

Lindsay

Lytle

. Implementing Best Practices to Redesign Workflow and Optimize Nursing Documentation in the Electronic Health Record. Appl Clin Inform 2022; 13: 711–719. https://doi.org/10.1055/a-1868-6431

Muinga

Abejirinde

Paton

, et al. Designing paper‐based records to improve the quality of nursing documentation in hospitals: A scoping review. J Clin Nurs 2021; 30: 56–71. https://doi.org/10.1111/jocn.15545

Bail

Merrick

Bridge

, et al. Documenting patient risk and nursing interventions: record audit. Aust J Adv Nurs; 38: 1. https://doi.org/10.37464/2020.381.167 Epub ahead of print 4 February 2021.

Amin

El-Sayed

AAI

Alsenany

, et al.

How Clinical Reasoning and Decision-Making Competences Influence the Provision of Empathic Care Among Nursing Students?

Teach Learn Nurs 2025; 20: e550–e559. https://doi.org/10.1016/j.teln.2025.01.005

10.

Cunha

LDM

Ventura

Pestana-Santos

, et al. Decision support strategies for bedside nursing clinical reasoning: A scoping review. Int J Nurs Stud Adv 2025; 9: 100393. https://doi.org/10.1016/j.ijnsa.2025.100393

11.

Griffits

Hines

Moloney

. Characteristics and processes of registered nurses’ clinical reasoning and factors relating to the use of clinical reasoning in practice: a scoping review. JBI Evid Synth 2023; 21: 713–743. https://doi.org/10.11124/JBIES-21-00373

12.

Noh

Kang

. The Relationships among communication competence, professional autonomy and clinical reasoning competence in oncology nurses. Nurs Open 2024; 11: e70003. https://doi.org/10.1002/nop2.70003

13.

Huesmann

Sudacka

Durning

, et al. Clinical reasoning: What do nurses, physicians, and students reason about. J Interprof Care 2023; 37: 990–998. https://doi.org/10.1080/13561820.2023.2208605

14.

Zumstein-Shaha

Grace

. Competency frameworks, nursing perspectives, and interdisciplinary collaborations for good patient care: Delineating boundaries. Nurs Philos 2023; 24: e12402. https://doi.org/10.1111/nup.12402

15.

Bouchez

Cagnon

Hamouche

, et al. Interprofessional clinical decision-making process in health: A scoping review. J Adv Nurs 2024; 80: 884–907. https://doi.org/10.1111/jan.15865

16.

Labrague

Al Sabei

Al Rawajfah

, et al. Interprofessional collaboration as a mediator in the relationship between nurse work environment, patient safety outcomes and job satisfaction among nurses. J Nurs Manag 2022; 30: 268–278. https://doi.org/10.1111/jonm.13491

17.

Osman

Mohamud

Hilowle

, et al. Attitudes of Nurses and Physicians Towards Nurse-Physician Interprofessional Collaboration in a Tertiary Hospital in Somalia: Cross-Sectional Study. J Multidiscip Healthc 2025; 18: 2075–2082. https://doi.org/10.2147/JMDH.S511008

18.

Pantha

Jones

Moyo

, et al. Association between the Quantity of Nurse-Doctor Interprofessional Collaboration and in-Patient Mortality: A Systematic Review. Int J Environ Res Public Health 2024; 21: 494. https://doi.org/10.3390/ijerph21040494

19.

Donabedian

. Evaluating the quality of medical care. Milbank Mem Fund Q 1966; 44(Suppl): 166–206.

20.

Liou

S-R

Liu

H-C

Tsai

H-M

, et al. The development and psychometric testing of a theory-based instrument to evaluate nurses’ perception of clinical reasoning competence. J Adv Nurs 2016; 72: 707–717. https://doi.org/10.1111/jan.12831

21.

Cruchinho

López-Franco

Capelas

, et al. Translation, Cross-Cultural Adaptation, and Validation of Measurement Instruments: A Practical Guideline for Novice Researchers. J Multidiscip Healthc 2024; 17: 2701–2728. https://doi.org/10.2147/JMDH.S419714

22.

Kenaszchuk

Reeves

Nicholas

, et al. Validity and reliability of a multiple-group measurement scale for interprofessional collaboration. BMC Health Serv Res 2010; 10: 83. https://doi.org/10.1186/1472-6963-10-83

23.

Salvador

Alqahtani

Sauce

BRJ

, et al. Development of Student Survey on Writing Nursing Care Plan: An exploratory sequential mixed-methods study. J Nurs Manag 2022; 30: O23–O36. https://doi.org/10.1111/jonm.12996

24.

Liu

Sun

Chen

, et al. Comparative study of clinical reasoning competence and self-directed learning competence in nurses across varied years of experience. J Clin Nurs 2025; 34: 836–848. https://doi.org/10.1111/jocn.17051

25.

Notarnicola

Duka

Lommi

, et al. An Observational Cross-Sectional Analysis of the Correlation between Clinical Competencies and Clinical Reasoning among Italian Registered Nurses. Healthc Basel Switz 2024; 12: 1357. https://doi.org/10.3390/healthcare12131357

26.

Huyen

NTT

Tsakitzidis

Tam

, et al. Perceptions and experiences of primary healthcare providers toward interprofessional collaboration in chronic disease management in Hue, Vietnam. J Interprof Care 2024; 38: 52–61. https://doi.org/10.1080/13561820.2023.2227650

27.

Laukvik

Rotegård

Lyngstad

, et al. Registered nurses’ reasoning process during care planning and documentation in the electronic health records: A concurrent think-aloud study. J Clin Nurs 2023; 32: 221–233. https://doi.org/10.1111/jocn.16210

28.

Gudmundsen

Norbye

Dahlgren

, et al. Interprofessional student groups using patient documentation to facilitate interprofessional collaboration in clinical practice – A field study. Nurse Educ Today 2020; 95: 104606. https://doi.org/10.1016/j.nedt.2020.104606

29.

Adamson

Maxwell

Forbes

. Interprofessional guide to documentation in electonic health records. J Interprofessional Educ Pract 2020; 21: 100387. https://doi.org/10.1016/j.xjep.2020.100387

30.

Rencic

Schuwirth

LWT

Gruppen

, et al. Clinical reasoning performance assessment: using situated cognition theory as a conceptual framework. Diagn Berl Ger 2020; 7: 241–249. https://doi.org/10.1515/dx-2019-0051

Quality of nursing documentation and clinical reasoning competence: The mediating role of interprofessional collaboration

Abstract

Introduction

Methods

Results

Conclusion

Keywords

Introduction

Methods

Study design and participants

Instruments

Data analysis

Ethics statement

Data collection procedure

Results

Discussion

Limitations

Implications for practice

Conclusions

Footnotes

Acknowledgments

ORCID iD

Ethical considerations

Consent to participate

Consent for publication

Author contributions

Funding

Declaration of conflicting interests

References