Eva Törnvall1, Lis Karin Wahren, Susan Wilhelmsson. 1. Department of Social and Welfare Studies, Faculty of Health Sciences, University of Linköping, Campus Norköping, SE 60174 Norrköping, Sweden. evato@isv.liu.se
Abstract
AIM: The aim was to implement and evaluate a standardised nursing record, using patients with leg ulcer as an example, regarding the content of the nursing record and district nurses' experiences of documentation. METHOD: This was a prospective, stratified and randomised intervention study, with one intervention group and one control group. A standardised nursing wound care record was designed and implemented in the electronic patient record in the intervention group for a period of 3 months. Pre- and post-intervention audits of nursing records [n=102 and n=92, respectively] were carried out and 126 district nurses answeredquestionnaires pre-intervention and 83 post-intervention. RESULT: The standardised nursing wound care record led to more informative, comprehensive and knowledge-intensive documentation according to the audit and district nurses' opinions. Furthermore, the district nurses' self-reported knowledge of nursing documentation increased in the intervention group. When the standardised nursing wound care record was not used, the documentation was mostly incomplete with a lack of nursing relevance. There were no differences in the district nurses' experiences of documentation in general between the two groups. CONCLUSION: Using the standardised nursing wound care record improved nursing documentation meeting legal demands, which should increase the safety of patient. There was however a discrepancy between the nurses stated knowledge and how they carried out the documentation. Regular in-service training together with use of evidence based standardised nursing records, as a link to clinical reasoning about nursing care, could be ways effecting change.
RCT Entities:
AIM: The aim was to implement and evaluate a standardised nursing record, using patients with leg ulcer as an example, regarding the content of the nursing record and district nurses' experiences of documentation. METHOD: This was a prospective, stratified and randomised intervention study, with one intervention group and one control group. A standardised nursing wound care record was designed and implemented in the electronic patient record in the intervention group for a period of 3 months. Pre- and post-intervention audits of nursing records [n=102 and n=92, respectively] were carried out and 126 district nurses answered questionnaires pre-intervention and 83 post-intervention. RESULT: The standardised nursing wound care record led to more informative, comprehensive and knowledge-intensive documentation according to the audit and district nurses' opinions. Furthermore, the district nurses' self-reported knowledge of nursing documentation increased in the intervention group. When the standardised nursing wound care record was not used, the documentation was mostly incomplete with a lack of nursing relevance. There were no differences in the district nurses' experiences of documentation in general between the two groups. CONCLUSION: Using the standardised nursing wound care record improved nursing documentation meeting legal demands, which should increase the safety of patient. There was however a discrepancy between the nurses stated knowledge and how they carried out the documentation. Regular in-service training together with use of evidence based standardised nursing records, as a link to clinical reasoning about nursing care, could be ways effecting change.
Authors: Diane Doran; Nancy Lefebre; Linda O'Brien-Pallas; Carole A Estabrook; Peggy White; Jennifer Carryer; Winnie Sun; Gan Qian; Yu Qing Chris Bai; Mingyang Li Journal: Worldviews Evid Based Nurs Date: 2014-08-05 Impact factor: 2.931