Elisabeth Østensen1, Nicholas Richard Hardiker2, Line Kildal Bragstad3, Ragnhild Hellesø1. 1. University of Oslo, Faculty of Medicine, Institute of Health and Society, Department of Nursing Science, Oslo, Norway. 2. University of Huddersfield, School of Human and Health Sciences, Huddersfield, United Kingdom. 3. University of Oslo, Institute of Health and Society and Research Center for Habilitation and Rehabilitation Services and Models (CHARM), Oslo, Norway.
Abstract
AIMS AND OBJECTIVES: To explore how nurses use standardized care plans as a new recording tool in municipal healthcare, 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 standardized 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 standardized 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 standardized care plans was influenced by the nurses' consideration of their benefits. Partial implementation created an opportunity for non-use. There was no consensus regarding how much information to include, and the standardized 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 standardized care plans as a source of information," and "balancing between overview and detail" reflect these findings. CONCLUSIONS: Nurses' use of standardized 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 healthcare. This study gives valuable information for those attempting to implement such structures in municipal healthcare. This article is protected by copyright. All rights reserved.
AIMS AND OBJECTIVES: To explore how nurses use standardized care plans as a new recording tool in municipal healthcare, 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 standardized 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 standardized 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 standardized care plans was influenced by the nurses' consideration of their benefits. Partial implementation created an opportunity for non-use. There was no consensus regarding how much information to include, and the standardized 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 standardized care plans as a source of information," and "balancing between overview and detail" reflect these findings. CONCLUSIONS: Nurses' use of standardized 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 healthcare. This study gives valuable information for those attempting to implement such structures in municipal healthcare. This article is protected by copyright. All rights reserved.
Entities:
Keywords:
ICNP; care plan; electronic patient records; nursing documentation; standardization
Authors: Alexandra González Aguña; Marta Fernández Batalla; Javier Díaz-Tendero Rodríguez; Juan Antonio Sarrión Bravo; Blanca Gonzalo de Diego; José María Santamaría García Journal: Nurs Open Date: 2021-05-06