Table 2 The process of developing the concept of unprofessional documentation

“I gave the patient’s gavage on a wrong volume, but I did not document it, because I would have been reprimanded.” (Participant 4, master’s degree, clinical nurse)

“If I talk about the error in the implementation, it will be a legal headache, so I will not inform anyone.” (P20. master’s degree, clinical nurse)

“I gave the wrong medicine to the patient and told the supervisor; he would inform everyone and raise my eyebrows. After that, I did not mention any of the errors in the implementation of orders.” (P19, master’s degree, clinical nurse).

“The depressed patient died while we wrote in the report that the orders were implemented, and the patient was fine. The patient’s mother complained, we all destroyed the previous reports together and wrote the patient’s reports from the moment of arrival in such a way that the patient was in a bad mood and did not take medications, because of those new reports we were all acquitted.” (P18, master’s degree, clinical nurse).

“The head of the department said that it was important that I write my report completely and according to instructions so that there was no legal trouble, and it did not matter if the work of the patient was not done, we also had to write unrealistic sometimes.” (13, master’s degree, clinical nurse).

“Due to being busy, I often implement medical orders and my colleagues write the report or vice versa.” (P7, master’s degree, clinical nurse).

“Often, after checking the doctor’s orders, I write the report so that it is in accordance with orders and then implement them.” (P13, bachelor’s degree, clinical nurse)

“I referred the wrong patient for ultrasound, then I realized that I made a mistake, I quickly referred the original patient for ultrasound, but I did not document it.” (P3, bachelor’s degree, clinical nurse).

“At the end of the morning shift, I realized that I did not change the patient’s dressing. I asked my evening shift colleague to secretly change it and mark the morning shift on the label.” (P19, bachelor’s degree, clinical nurse).

Failure to record improper performance due to the fear of reprimand.

Failure to inform others about an error in implementing the order due to the fear of legal trouble.

Concealment of error in the order implementation due to the supervisor’s revealing behavior.

The cooperation of nurses in hiding errors to prevent legal trouble for all.

Pressure by the head nurse to complete the recording to avoid legal trouble.

Documenting the report of the implementation of orders by another nurse.

Recording before action.

Follow up on the implementation of the forgotten order without documentation.

Error correction by colleagues without documentation.

Hiding incorrect implementation of orders.

Untruth documentation and separation of the registrar from the agent.

Pursuing error correction without documentation.

Unprofessional documentation