Nursing documentation in nursing homes - state-of-the-art and implications for quality improvement

A comprehensive picture of using standardized nursing languages in long-term care systems: An integrative review

PURPOSE

This integrative review was conducted to provide a comprehensive picture of the use of standardized nursing languages (SNLs) in long-term care (LTC) systems.

METHODS

A comprehensive search was performed with terminological variants of "standardized terminology" and "long-term care" in eight electronic databases up to December 2021. Eligible studies were further identified by screening the reference lists of publications that met the inclusion criteria. The quality of the included studies was appraised using the Joanna Briggs Institute checklists. The study findings were organized into themes, which represent the focus of the study.

FINDINGS

Eighty-one publications that studied 12 SNLs in 17 countries are presented in this review. The Omaha System, NANDA-I, NIC, and NOC were the most common SNLs. Study foci were classified into five themes: evaluating the applicability of 10 SNLs (n = 22), characterizing nursing care using six SNLs (n = 16), developing core sets and tools based on seven SNLs (n = 15), documenting nursing care by using four SNLs (n = 14), and implementing intervention programs based on six SNLs (n = 14).

CONCLUSIONS AND IMPLICATIONS FOR NURSING

SNLs can be used for various purposes, and the available evidence supports the expansion of their utilization. Further studies should continue to identify gaps in the existing versions of SNLs to reflect the LTC nursing process in multiple societies. Additionally, the successful use of SNLs requires background knowledge of nursing informatics; therefore, preparation should be started in the nursing curriculum and continued in healthcare facilities, including LTC settings. These research findings will assist healthcare managers, researchers, and policymakers in the LTC field in effectively utilizing SNLs.

Restorative Quality Improvement: Novel Application of Six Sigma in a Skilled Nursing Facility

BACKGROUND

Six Sigma is a quality improvement (QI) method used in hospitals, but not typically in nursing homes (NHs), to reduce service variability and expenditures.

LOCAL PROBLEM

The existing QI process for functional maintenance program (FMP) charting/auditing in an urban NH allowed variability and lost revenue.

METHODS

A single-group pre/posttest design with analysis of variance and t-test analysis was used to implement Six Sigma for the FMP process.

INTERVENTION

Phases of Define, Measure, Analyze, Improve, and Control addressed performance objectives of FMP capacity; staff retention; congruence between prescribed, performed, and charted FMPs; and month-end summaries of resident status on FMPs.

RESULTS

With the existing staff, capability was increased by 17 residents ($200 000 revenue) and 90% to 100% charting congruence was achieved. Limited success was attributed to lack of skill diffusion, team communication, manager availability, and project prioritization.

CONCLUSIONS

Six Sigma was moderately successful when applied in a single NH for QI.

Introducing standardised care plans as a new recording tool in municipal health care

AIMS AND OBJECTIVES

To explore how nurses use standardised care plans as a new recording tool in municipal health care, and to identify their thoughts and opinions.

BACKGROUND

In spite of being an important information source for nurses, care plans have repeatedly been found unsatisfactory. Structuring and coding information through standardised care plans is expected to raise the quality of recorded information, improve overviews, support evidence-based practice and facilitate data aggregation. Previous research on this topic has mostly focused on the hospital setting. There is a lack of knowledge on how standardised care plans are used as a recording tool in the municipal healthcare setting.

DESIGN

An exploratory design with a qualitative approach using three qualitative methods of data collection. The study complied with the Consolidated Criteria for Reporting Qualitative Research.

METHODS

Empirical data were collected in three Norwegian municipalities through participant observation and individual interviews with 17 registered nurses. In addition, we collected nursing records from 20 electronic patient records.

RESULTS

Use of standardised care plans was influenced by the nurses' consideration of their benefits. Partial implementation created an opportunity for nonuse. There was no consensus regarding how much information to include, and the standardised care plans could become both short and generic, and long and comprehensive. The themes "balancing between the old and the new care planning system," "considering the usefulness of standardised care plans as a source of information" and "balancing between overview and detail" reflect these findings.

CONCLUSIONS

Nurses' use of standardised care plans was influenced by the plans' partial implementation, their views on usefulness and their personal views on the detail required in a care plan.

RELEVANCE TO CLINICAL PRACTICE

The structuring of nursing records is a fast-growing trend in health care. This study gives valuable information for those attempting to implement such structures in municipal health care.

The contribution of electronic health records to risk management through accreditation of residential aged care homes in Australia

Background

The Australian government has implemented a compulsory aged care accreditation system to guide and monitor the risk management approach in registered residential aged care (RAC) homes. This research assessed the contribution of electronic health records (EHR) to risk management in RAC homes in relation to the extent that aged care accreditation fulfils its role.

Methods

A convenience sample of 5560 aged care accreditation reports published from 2011 to 2018 was manually downloaded from the Accreditation Agency web site. A mixed-method approach of text data mining and manual content analysis was used to identify any significant differences in failure to meet accreditation outcomes among the RAC homes. This took account of whether EHR or paper records were used, year of accreditation, and size and location of the homes.

Results

It appears that aged care accreditation was focused on structure and process, with limited attention to outcome. There was a big variation between homes in their use of measurement indicators to assess accreditation outcomes. No difference was found in outcomes between RAC homes using EHR and those using paper records. Only 3% of the RAC homes were found to have failed some accreditation outcomes. Failure in monitoring mechanism was the key factor for failing many accreditation outcomes. The top five failed outcomes were Human Resource Management, Clinical Care, Information Systems, Medication Management and Behavioural Management.

Conclusions

Sub-optimal outcomes have limited the effectiveness of accreditation in driving and monitoring risk management for care recipient safety in RAC homes. Although EHR is an important structure and process component for RAC services, it made a limited contribution to risk management for accreditation in Australian RAC homes. Either EHR was not effective, or the accreditation process was not robust enough to recognize its influence. Aged care accreditation in Australia needs to develop further outcome-based measures that are supported by robust data infrastructure and clear guidance.

Nurses' information practice in municipal health care-A web-like landscape

AIM

To uncover the characteristics of nurses' information practice in municipal health care and to address how, when and why various pieces of information are produced, shared and managed.

BACKGROUND

Nursing documentation in the electronic patient record has repeatedly been found unsatisfactory. Little is known about how the information practice of nurses in municipal health care actually is borne out. In order to understand why nursing documentation continues to fail at living up to the expected requirements, a better understanding of nurses' information practice is needed.

DESIGN

A qualitative observational field study. The study complied with the Consolidated Criteria for Reporting Qualitative Research.

METHODS

Empirical data were collected in three Norwegian municipalities through participant observations and individual interviews with 17 registered nurses on regular day shifts. The data were analysed through thematic content analysis.

RESULTS

Nurses' information practice in municipal health care can be described as complex. The complexity is reflected in four themes that emerged from the data: (1) web of information sources, (2) knowing the patient and information redundancy, (3) asynchronous information practice and (4) compensatory workarounds.

CONCLUSIONS

The complex and asynchronous nature of nurses' information practice affected both how and when information was produced, recorded and shared. When available systems lacked functions the nurses wanted, they created compensatory workarounds. Although electronic patient record was an important part of their information practice, nurses in long-term care often knew their patients well, which meant that a lot of information about the patients was in their heads, and that searching for information in the electronic patient record sometimes seemed redundant.

RELEVANCE TO CLINICAL PRACTICE

This study provides contextual knowledge that might be valuable (a) in the further development of information systems tailored to meet nurses' information needs and (b) when studying patient safety in relation to nurses' information practice.

The Impact of a Shared Decision-Making Training Program on Dementia Care Planning in Long-Term Care

BACKGROUND

Shared decision-making (SDM) can be a way for staff to adopt international recommendations advocating the involvement of nursing home residents and their family members in care planning and the development of personalized care plans.

OBJECTIVE

The main aim was to analyze the effects of training nursing home staff in the implementation of SDM on agreement of residents' 'life-and-care plans' with the recommendations (primary outcome) and on family caregivers' quality of life and sense of competence, and staff's job satisfaction (secondary outcomes).

METHODS

In the intervention condition, staff attended a training program on the use of SDM with residents and family caregivers in the care planning process. In the control condition, care planning as usual took place. For the primary outcome, in-depth qualitative and quantitative analyses of the care plans were performed. Multivariate Permutation Tests were applied to assess the impact on secondary outcomes.

RESULTS

Forty-nine residents and family caregivers and 34 professionals were involved. Overall, many of the care plans developed during the intervention showed a high level of agreement with the care planning recommendations. Both Italian and Dutch care plans showed improvement in the number of clear problem statements (p < 0.001). In Italy, significant improvements (p < 0.05) were also found regarding specific care objectives, documentation of objectives met, and of residents and families' involvement. No impact was found on secondary outcomes.

CONCLUSION

The involvement of residents and family caregivers in care planning contributed to an improvement of the residents' care plans, but it did not have an effect on family caregivers and staff outcomes.

Long-Term Care Health Care Aides' Perceptions of Decision-Making Processes in Transferring Residents to Acute Care Services

Most transfers of long-term care (LTC) facility residents to the emergency department (ED) via 911 calls are necessary. Avoidable transfers can have adverse effects including increased confusion and dehydration. Around 20% of transfers are perceived to be avoidable or unnecessary, yet decision making around transfers is complex and poorly understood. Using a qualitative-focused ethnographic approach, we examined 20 health care aides' (HCAs) perceptions of decision processes leading to transfer using experiential interview data. Inductive analysis throughout iterative data collection and analysis illuminated how HCAs' familiarity with residents make them vital in initiating care processes. Hierarchical reporting structures influenced HCAs' perceptions of nurse responsiveness to their concerns about resident condition, which influenced communications related to transfers. Communication processes in LTC facilities and the value placed on HCA concerns are inconsistent. There is an urgent need to improve conceptualization of HCA roles and communication structures in LTCs.

'Who's actually gonna read this?' An evaluation of staff experiences of the value of information contained in written care plans in supporting care in three different dementia care settings

WHAT IS KNOWN ON THE SUBJECT?: A written plan is designed to improve communication and co-ordinate care between mental health inpatient wards and community settings. Reports of care plan quality issues and staff and service user dissatisfaction with healthcare bureaucracy have focused on working age mental health or general hospital settings. Little is known about mental health staff perspectives on the value of written care plans in supporting dementia care. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Competing demands on staff time and resources to meet administrative standards for care plans caused a tension with their own professional priorities for supporting care. Mental health staff face difficulties using electronic records alongside other systems of information sharing. Further exploration is needed of the gap between frontline staff values and those of the local organization and managers when supporting good dementia care. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Frontline staff should be involved in designing new information systems including care plans. Care plan documentation needs to be refocused to ensure it is effective in enabling staff to communicate amongst themselves and with others to support people with dementia. Practice-based mentors could be deployed to strengthen good practice in effective information sharing.

ABSTRACT

Background Reports of increased healthcare bureaucracy and concerns over care plan quality have emerged from research and surveys into staff and service user experiences. Little is known of mental health staff perspectives on the value of written care plans in supporting dementia care. Aim To investigate the experiences and views of staff in relation to care planning in dementia services in one National Health Service (NHS) provider Trust in England. Method Grounded Theory methodology was used. A purposive sample of 11 multidisciplinary staff were interviewed across three sites in one NHS Trust. Interviews were transcribed, coded and analysed using the constant comparative method. Findings Five themes were identified and are explored in detail below: (1) Repetition; (2) the impact of electronic records on practice; (3) ambivalence about the value of paperwork; (4) time conflicts; and (5) alternative sources of information to plan care. Discussion Participants perceived that written care plans did not help staff with good practice in planning care or to support dementia care generally. Staff were frustrated by repetitive documentation, inflexible electronic records and conflicting demands on their time. Implications for practice Frontline staff should be involved in designing new information systems including care plans.

Accuracy of documentation in the nursing care plan in long-term institutional care

Nursing staff working in long-term institutional care attend to residents with an increasing number of severe physical and cognitive limitations. To exchange information about the health status of these residents, accurate nursing documentation is important to ensure the safety of residents. This study examined the accuracy of nursing documentation in 197 care plans of five long-term institutional care facilities. Based on the phases of the nursing process, the D-Catch instrument measures the accuracy of the content and coherence of documentation. Inadequacies were especially found in the description of residents' care needs and stated nursing diagnoses as well as in progress and outcome reports. In somatic and psycho-geriatric units, higher accuracy scores were determined compared with residential care units. Investments in resources (e.g., time), reasoning skills of nursing staff, and implementation of professional standards in accordance with legal requirements may be needed to enhance the quality of nursing documentation.

The construction of a subset of ICNP® for patients with dementia: a Delphi consensus and a group interview study

Background

The International Classification for Nursing Practice (ICNP®) 2013 includes over 4000 concepts for global nursing diagnoses, outcomes and interventions and is a large and complex set of standardised nursing concepts and expressions. Nurses may use subsets from the ICNP as concepts and expressions for research, education and clinical practice. The objective of this study was to identify and validate concepts for an ICNP subset to guide observations and documentation of nursing care for patients with dementia.

Method

The process model for developing ICNP subsets was followed, according to the guidelines adopted by the International Council of Nursing (ICN). To identify relevant and useful concepts for the subset, a modified form of the Delphi method was used. Six nurses working in healthcare services in three municipalities in Norway with postgraduate education in geriatric psychiatry and dementia care participated in two Delphi sessions. The participants reviewed and scored the concepts included in the suggested subset and had an opportunity to rewrite them and offer alternatives. To validate the subset after the Delphi study, a group interview was conducted with six other nurses with postgraduate education in geriatric psychiatry and dementia care. The group interview was recorded and transcribed, and summative content analysis was used.

Results

Suitable concepts for an ICNP subset to guide observations and documentation of nursing care for patients with dementia were identified. In total, 301 concepts were identified, including 77 nursing diagnoses, 78 outcomes and 146 nursing interventions. An increased focus on concepts to describe basic psychosocial needs such as identity, comfort, connection, inclusion and engagement was recommended by nurses in the validation process.

Conclusions

Relevant and pre-formulated nursing diagnoses, goals and interventions were identified, which can be used to develop care plans and facilitate accuracy in the documentation of individuals with dementia. The participants believed that it may be difficult to find formulations for all steps of the nursing process. In particular, nursing diagnoses and psychosocial needs are often inadequately documented. The participants highlighted the need for the subset to contain essential information about psychosocial needs and communication.

Assessment of quality in psychiatric nursing documentation - a clinical audit

Background

Quality in nursing documentation facilitates continuity of care and patient safety. Lack of communication between healthcare providers is associated with errors and adverse events. Shortcomings are identified in nursing documentation in several clinical specialties, but very little is known about the quality of how nurses document in the field of psychiatry. Therefore, the aim of this study was to assess the quality of the written nursing documentation in a psychiatric hospital.

Method

A cross-sectional, retrospective patient record review was conducted using the N-Catch audit instrument. In 2011 the nursing documentation from 21 persons admitted to a psychiatric department from September to December 2010 was assessed. The N-Catch instrument was used to audit the record structure, admission notes, nursing care plans, progress and outcome reports, discharge notes and information about the patients’ personal details. The items of N-Catch were scored for quantity and/or quality (0–3 points).

Results

The item ‘quantity of progress and evaluation notes’ had the lowest score: in 86% of the records progress and outcome were evaluated only sporadically. The items ‘the patients’ personal details’ and ‘quantity of record structure’ had the highest scores: respectively 100% and 71% of the records achieved the highest score of these items.

Conclusions

Deficiencies in nursing documentation identified in other clinical specialties also apply to the clinical field of psychiatry. The quality of electronic written nursing documentation in psychiatric nursing needs improvements to ensure continuity and patient safety. This study shows the importance of the existence of a validated tool, readily available to assess local levels of nursing documentation quality.

Standardising assessment instruments and care planning in Ireland

Purpose

– Scoping of instruments in use for assessment of needs and the practices that surround care planning in residential care for older people in Ireland, in the wake of the introduction of national standards. The paper discusses these issues.

Design/methodology/approach

– Survey of care providers using an online/postal questionnaire, developed from the domains of need outlined in the standards.

Findings

– There is wide variation in the use of standardised instruments for assessment. Within some domains, standardised instruments enjoy near universal usage. However, within other domains, standardised instruments are often absent, external professional input and/or guidelines dominate and/or instruments have been adapted in-house. Practices surrounding care planning are largely homogeneous and the preserve of medical professionals.

Research limitations/implications

– This research was confined to the Republic of Ireland, limiting generalisation. The self-selecting nature of participants must also be considered. Further research could include, examining how, over time, the standards are shaping care practice, particularly in relation to interdisciplinary working and person-centred care.

Practical implications

– The non-prescriptive nature of the standards presents a challenge to care providers in selecting appropriate standardised instruments for assessment. In addition, medical dominance of care planning limits the extent to which care plans can enhance the provision of interdisciplinary and person-centred care.

Originality/value

– This paper contributes to a growing literature on standardisation of assessment and care planning, provides a reference point for comparison with other nations and, in an Irish context, addresses an area that has received little attention to-date. As such, it is of interest to practitioners, care providers and regulators.

Evaluation of nursing documentation on patient hygienic care

This study was conducted to evaluate nursing documentation on patient hygienic care and to analyze the consistency between actual care given by nurses and that of documented in nursing record. Data were collected from 85 nurses employed at critical care units, on whom 255 sets of observations were performed through a structured participant observation form, which could be used to record the observation episodes and to audit nursing records. Results indicated that the most frequent performed hygienic care was oral care, perianal care, hand washing and bed bathing. The consistency between actual patient hygienic care and its documentation was 77.6%. The quality of nursing records was poor and inadequate to reflect individualized nursing care. Results suggest that more emphasis is needed in nursing practice and nursing education on the quality of record keeping in nursing to increase its evidential value.

The impact structured patient assessment frameworks have on patient care: an integrative review

AIMS AND OBJECTIVES

To evaluate structured patient assessment frameworks' impact on patient care.

BACKGROUND

Accurate patient assessment is imperative to determine the status and needs of the patient and the delivery of appropriate patient care. Nurses must be highly skilled in conducting timely and accurate patient assessments to overcome environmental obstacles and deliver quality and safe patient care. A structured approach to patient assessment is widely accepted in everyday clinical practice, yet little is known about the impact structured patient assessment frameworks have on patient care.

DESIGN

Integrative review.

METHODS

An electronic database search was conducted using Cumulative Index to Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System, PubMed and ProQuest Dissertations and Theses. The reference sections of textbooks and journal articles on patient assessment were manually searched for further studies. A comprehensive peer review screening process was undertaken. Research studies were selected that evaluated the impact structured patient assessment frameworks have on patient care. Studies were included if frameworks were designed for use by paramedics, nurses or medical practitioners working in prehospital or acute in-hospital settings.

RESULTS

Twelve studies met the inclusion criteria. There were no studies that evaluate the impact of a generic nursing assessment framework on patient care. The use of a structured patient assessment framework improved clinician performance of patient assessment. Limited evidence was found to support other aspects of patient care including documentation, communication, care implementation, patient and clinician satisfaction, and patient outcomes.

CONCLUSION

Structured patient assessment frameworks enhance clinician performance of patient assessment and hold the potential to improve patient care and outcomes; however, further research is required to address these evidence gaps, particularly in nursing.

RELEVANCE TO CLINICAL PRACTICE

Acute care clinicians should consider using structured patient assessment frameworks in clinical practice to enhance their performance of patient assessment.

Evaluation of a Nutrition Care Process-based audit instrument, the Diet-NCP-Audit, for documentation of dietetic care in medical records

Adequate documentation in medical records is important for high-quality health care. Documentation quality is widely studied within nursing, but studies are lacking within dietetic care. The aim of this study was to translate, elaborate and evaluate an audit instrument, based on the four-step Nutrition Care Process model, for documentation of dietetic care in medical records. The audit instrument includes 14 items focused on essential parts of dietetic care and the documentation's clarity and structure. Each item is to be rated 0-1 or 0-2 points, with a maximum total instrument score of 26. A detailed manual was added to facilitate the interpretation and increase the reliability of the instrument. The instrument is based on a similar tool initiated 9 years ago in the United States, which in this study was translated to Swedish and further elaborated. The translated and further elaborated instrument was named Diet-NCP-Audit. Firstly, the content validity of the Diet-NCP-Audit instrument was tested by five experienced dietitians. They rated the relevance and clarity of the included items. After a first rating, minor improvements were made. After the second rating, the Content Validity Indexes were 1.0, and the Clarity Index was 0.98. Secondly, to test the reliability, four dietitians reviewed 20 systematically collected dietetic notes independently using the audit instrument. Before the review, a calibration process was performed. A comparison of the reviews was performed, which resulted in a moderate inter-rater agreement with Krippendorff's α = 0.65-0.67. Grouping the audit results in three levels: lower, medium or higher range, a Krippendorff's α of 0.74 was considered high reliability. Also, an intra-rater reliability test-retest with a 9 weeks interval, performed by one dietitian, showed strong agreement. To conclude, the evaluated audit instrument had high content validity and moderate to high reliability and can be used in auditing documentation of dietetic care.

Nursing Documentation in Long-Term Care Settings

In this study on nursing documentation in long-term care facilities, a set of 9 delirium symptoms was used to evaluate the agreement between symptoms reported by nurses during monthly interviews and those documented in the nursing notes for the same 7-day observation period. Residents aged 65 and above ( N = 280) were assessed monthly over a 6-month period for the presence of delirium and its symptoms using the Confusion Assessment Method. The proportion of symptoms documented in the nursing notes ranged from 1.9% to 53.5%. A trend toward a lower proportion of documented symptoms for higher resident−nurse ratios was observed, although the difference was not statistically significant. Efforts should be made to improve the situation by revisiting the content of academic and clinical training given to nurses in addition to exploring innovative ways to make nursing documentation more efficient and less time-consuming within the current context of nurses’ work overload.

Person-centred care in nursing documentation

AIMS AND OBJECTIVES

To explore nursing documentation in long-term care, to determine whether it reflected a person-centred approach to care and to describe aspects of PCC as they appeared in nursing records.

BACKGROUND

Documentation is an essential part of nursing. It provides evidence that care has been carried out and contains important information to enhance the quality and continuity of care. Person-centred care (PCC) is an approach to care that is underpinned by mutual respect and the development of a therapeutic relationship between the patient and nurse. It is a core principle in standards for residential care settings for older people and is beneficial for both patients and staff (International Practice Development in Nursing and Healthcare, Chichester, Blackwell, 2008 and The Implementation of a Model of Person-Centred Practice in Older Person Settings, Dublin, Health Service Executive, 2010a). However, the literature suggests a lack of person-centredness within nursing documentation (International Journal of Older People Nursing 2, 2007, 263 and The Implementation of a Model of Person-Centred Practice in Older Person Settings, Dublin, Health Service Executive, 2010a).

METHOD

A qualitative descriptive study using the PCN framework (Person-centred Nursing; Theory and Practice, Oxford, Wiley-Blackwell, 2010) as the context through which nursing assessments and care plans were explored.

RESULTS

Findings indicated that many nursing records were incomplete, and information regarding psychosocial aspects of care was infrequent. There was evidence that nurses engaged with residents and worked with their beliefs and values. However, nursing documentation was not completed in consultation with the patient, and there was little to suggest that patients were involved in decisions relating to their care.

IMPLICATIONS FOR PRACTICE

The structure of nursing documentation can be a major obstacle to the recording of PCC and appropriate care planning. Documentation that is focused on the 'person' will contribute to a more meaningful relationship between nurses and residents.

Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review

AIMS

This paper reports a review that identified and synthesized nursing documentation audit studies, with a focus on exploring audit approaches, identifying audit instruments and describing the quality status of nursing documentation.

INTRODUCTION

Quality nursing documentation promotes effective communication between caregivers, which facilitates continuity and individuality of care. The quality of nursing documentation has been measured by using various audit instruments, which reflected variations in the perception of documentation quality among researchers across countries and settings.

DATA SOURCES

Searches were made of seven electronic databases. The keywords 'nursing documentation', 'audit', 'evaluation', 'quality', both singly and in combination, were used to identify articles published in English between 2000 and 2010.

REVIEW METHODS

A mixed-method systematic review of quantitative and qualitative studies concerning nursing documentation audit and reports of audit instrument development was undertaken. Relevant data were extracted and a narrative synthesis was conducted.

RESULTS

Seventy-seven publications were included. Audit approaches focused on three natural dimensions of nursing documentation: structure or format, process and content. Numerous audit instruments were identified and their psychometric properties were described. Flaws of nursing documentation were identified and the effects of study interventions on its quality.

CONCLUSION

Research should pay more attention to the accuracy of nursing documentation, factors leading to variation in practice and flaws in documentation quality and the effects of these on nursing practice and patient outcomes, and the evaluation of quality measurement.

Modeling shared care plans using CONTsys and openEHR to support shared homecare of the elderly

This case report describes how two complementary standards, CONTsys (European Standard EN 13940-1 for continuity of care) and the reference model of openEHR, were applied in modeling a shared care plan for shared homecare based on requirements from the OLD@HOME project. Our study shows that these requirements are matched by CONTsys on a general level. However, certain attributes are not explicit in CONTsys, for example agents responsible for performing planned interventions, and support for monitoring outcome of interventions. We further studied how the care plan conceptual model can be implemented using the openEHR reference model. The study demonstrates the feasibility of developing shared care plans combining a standard concept model, for example CONTsys with an electronic health records (EHR) interoperability specification, that is the openEHR, while highlighting areas that need further exploration. It also explores the reusability of existing clinical archetypes as building blocks of care plans and the modeling of new shared care plan archetypes.

Patient-focused nursing documentation expressed by nurses

AIM

The aim of the study was to investigate what expressions nurses use when documenting patient-focused nursing care in electronic patient records.

BACKGROUND

Much effort has been made in the development of nursing documentation. Many studies have found inadequate reporting, focused more on tasks and treatment than on the patient's voice. Electronic patient record-systems have been introduced, bringing new challenges because of unfamiliarity with computers. Electronic patient records have caused dissatisfaction and frustration, however, some studies show improvement in documentation given enough time and effort. Electronic patient record documentation is an integral part of patient-focused care and thus needs to be investigated.

DESIGN

The study is based on the grounded theory approach, as developed by Strauss and Corbin.

METHODS

Forty electronic patient records were analysed, considering whether nurses' written expressions reflected a patient-focused approach. An inductive qualitative method was used, involving constant comparative analysis, up to axial coding.

RESULTS

Three categories emerged from the data: Patient's voice: the patient has expressed his/her thoughts, which are written by the nurse, Nurse's view: the nurse recounts the patient's own thoughts, state or situation and mutual view in patient-nurse relationship: the documentation describes the patient-nurse relationship.

CONCLUSIONS

This study found that the nursing documentation was patient-focused, to some extent. This is significant because nursing documentation represents much more than simply a record of the continuity of care. Many topics for further studies were presented, e.g., the timing of documentation and the differences between the mode of nursing and the documentation.

RELEVANCE TO CLINICAL PRACTICE

The presented findings may be helpful in the development of nursing documentation in electronic patient records and in nursing practice generally. Highlighting the patient's voice could become an effective tool in nursing and its documentation, saving time and getting clear information for improving the patient's care.

Concept mapping

A person-centred assessment and problem-solving approach is acknowledged widely as the preferred method for managing the behavioural and psychological symptoms of residents with dementia (BPSD). Currently this is not well implemented in residential dementia care. In this paper concept mapping is discussed critically as a process that has the potential to improve the quality of resident care by providing an efficient framework for problem-solving. It facilitates data analysis, a missing link in problem-solving BPSD. Overtime concept mapping may also reduce the burden on individual staff, improve the skills and knowledge of all levels of staff and foster learning organizations. Potential challenges to the implementation and success of the process, which include staff shortages, the need for effective leadership and organizational support, are also addressed.

A new method to assess perceived well-being among elderly people--a feasibility study

BACKGROUND

A simple but countable electronic device has been developed to gain reliable information on elderly patients' perceived well-being. The device has been tested and proven to be technically functional and countable. It was now tested in two care homes for the elderly and two private homes to evaluate if it provided solid information about the well-being of elderly persons. This report illustrates the practical usage of the device and shows its efficiency in gathering solid well-being information from the focus group.

METHODS

The test arrangement was carried out by assigning a group of volunteers (n = 10) in care homes for the elderly for two weeks. The time period was long enough to collect a sufficient amount of information to evaluate the perceived well-being of the test subjects. Perceived well-being was assessed by using a Con-Dis device and by filling out an attached questionnaire - RAI - at the same time. RAI consisted of questions concerning mood, pain and quality of life. A standardised RAVA questionnaire with 12 questions concerning test subject's health was also answered once during the two-week time period by each test subject. After the test period the data obtained by Con-Dis was compared with the findings collected using questionnaires.

RESULTS

A statistically significant correlation was found between perceived well-being (measured by Con-Dis) and questionnaire-based mood (r = 0,66, Pearson Correlation Coefficient) and quality of life (r = 0,68). No statistically significant correlation was found between perceived well-being and pain (r = 0,28). Technical functionality and feasibility of Con-Dis were good during the test period. Some problems arose because the test subjects were elderly and some in poor physical condition.

CONCLUSION

On the basis of the collected results, the Con-Dis device presented information on the test subjects' perceived well-being that appeared to correlate with certain aspects of their health status. The test subjects' mood and quality of life but not pain had a statistically significant association with the perceived well-being level measured by Con-Dis.

Description and students' perceptions of a required geriatric clerkship in postacute rehabilitative care

This article describes medical students' evaluation of a geriatric clerkship in postacute rehabilitative care settings. This was a cross-sectional study of fourth-year medical students who completed a mandatory 2-week rotation at a postacute care facility. Students were provided with three instructional methods: Web-based interactive learning modules; small-group sessions with geriatric faculty; and Geriatric Interdisciplinary Care Summary (GICS), a grid that students used to formulate comprehensive interdisciplinary care plans for their own patients. After the rotation, students evaluated the overall clerkship, patient care activities, and usefulness of the three instructional methods using a 5-point Likert scale (1=poor to 5=excellent) and listed their area of future specialty. Of 156 students who completed the rotation, 117 (75%) completed the evaluation. Thirty (26%) chose specialties providing chronic disease management such as family, internal medicine, and psychiatry; 34 (29%) chose specialties providing primarily procedural services such as surgery, radiology, anesthesiology, pathology, and radiation oncology. Students rated the usefulness of the GICS as good to very good (mean+/-standard deviation 3.3+/-1.0). Similarly, they rated overall clerkship as good to excellent (3.8+/-1.0). Analysis of variance revealed no significant group difference in any of the responses from students with the overall clerkship (F(112, 4)=1.7, P=.20). Students rated the geriatric clerkship favorably and found the multimodal instruction to be useful. Even for students whose career choice was not primary care, geriatrics was a good model for interdisciplinary care training and could serve as a model for other disciplines.

Aged-care nurses' knowledge of nursing documentation: an Australian perspective

AIM

This study investigated registered nurses' knowledge of documentation used in aged-care nursing home facilities in Queensland, Australia.

BACKGROUND

The purpose of nursing documentation is to communicate health information, facilitate quality assurance and research, demonstrate nurses' accountability and, within Australia, to support funding of residents' care. Little is known about the relationship between RNs' knowledge of nursing documentation, the documentation process within residential aged care and the outcomes of the documentation.

DESIGN

Cross-sectional, retrospective design.

METHOD

The study was conducted with a large sample of RNs (n = 360) located in 162 Queensland aged-care facilities. Participants completed a postage-return questionnaire in which they identified factors that influence their knowledge and understanding of documentation.

RESULTS

Participants reported that they have considerable knowledge of nursing documentation. They also indicated that they were most knowledgeable about policies on documentation and writing discharge instructions. However, their knowledge of nursing assessments ranked fifth and they were least knowledgeable about reading reports each shift.

CONCLUSIONS

The modified version of Edelstein's questionnaire provided a valid and reliable instrument for measuring RNs' knowledge of nursing documentation. A factor analysis of the 16 items in the Knowledge scale showed excellent reliability. The data indicated that RNs in aged-care facilities have high levels of knowledge about documentation. Specific recommendations relate to the implementation of comprehensive documentation education programs that reflect the needs of organisations and the level of RNs' skills and knowledge concerning documentation.

RELEVANCE TO CLINICAL PRACTICE

Accurate nursing documentation is relevant to residents' care outcomes and to government funding allocations. Measuring RNs' knowledge of nursing documentation can identify factors that impede and facilitate their documentation of care.

The determination of record-keeping behavior of nurses regarding intravenous fluid treatment: the case of Turkey

Record-keeping is one of the legal and professional responsibilities of nurses. This study aims to determine the record-keeping behavior of nurses regarding intravenous fluid treatment (IVFT). The study was conducted with 150 nurses working in adult clinics of a 936-bed university hospital. The most frequently fulfilled record-keeping behaviors were solution type, total solution amount, and date of treatment. The least frequent fulfilled behaviors were the diagnosis of patients and the time of passage of medication added to the solution. The nurses never recorded type of i.v. fluid treatment, complications, and discontinuation of therapy. According to findings of the study, the record-keeping behavior of nurses regarding IVFT is not at the desired level.

Nurses’ reasoning process during care planning taking pressure ulcer prevention as an example. A think-aloud study

BACKGROUND

Nurses' clinical reasoning is of great importance for the delivery of safe and efficient care. Pressure ulcer prevention allows a variety of aspects within nursing to be viewed.

OBJECTIVE

The aim of this study was to describe both the process and the content of nurses' reasoning during care planning at different nursing homes, using pressure ulcer prevention as an example.

DESIGN

A qualitative research design was chosen.

SETTINGS

Seven different nursing homes within one community were included.

PARTICIPANTS

Eleven registered nurses were interviewed.

METHOD

The methods used were think-aloud technique, protocol analysis and qualitative content analysis. Client simulation illustrating transition was used. The case used for care planning was in three parts covering the transition from hospital until 3 weeks in the nursing home.

RESULT

Most nurses in this study conducted direct and indirect reasoning in a wide range of areas in connection with pressure ulcer prevention. The reasoning focused different parts of the nursing process depending on part of the case. Complex assertations as well as strategies aiming to reduce cognitive strain were rare. Nurses involved in direct nursing care held a broader reasoning than consultant nurses. Both explanations and actions based on older ideas and traditions occurred.

CONCLUSIONS

Reasoning concerning pressure ulcer prevention while care planning was dominated by routine thinking. Knowing the person over a period of time made a more complex reasoning possible. The nurses' experience, knowledge together with how close to the elderly the nurses work seem to be important factors that affect the content of reasoning.

Infrastructural arrangements for integrated care: implementing an electronic nursing plan in a psychogeriatric ward

PURPOSE

The paper contributes to the conceptualisation of "integrated care" in heterogeneous work practices. A dynamic perspective is developed, emphasising how integrated care is malleable, open, and achieved in practice. Furthermore, we explore the role of nursing plans in integrated care practices, underscoring the inherent difficulties of building one common infrastructural system for integrated care.

METHODS

Empirically, we studied the implementation of an electronic nursing plan in a psychiatric ward at the University Hospital of North Norway. We conducted 80 hours of participant observation and 15 interviews.

RESULTS

While the nursing plan was successful as a formal tool among the nurses, it was of limited use in practice where integrated care was carried out. In some instances, the use of the nursing plan even undermined integrated care.

CONCLUSION

Integrated care is not a constant entity, but is much more situated and temporal in character. A new infrastructural system for integrated care should not be envisioned as replacing most of the existing information sources, but rather seen as an extension to the heterogeneous ensemble of existing ones.