The effect of a VIPS implementation programme on nurses' knowledge and attitudes towards documentation

The Copenhagen University Hospital decided to adhere to the standards of the Joint Commission of International Accreditation in 2000. These standards require systematic assessment of patient care needs and include the use of written nursing care plans. In order to meet these standards, the hospital management decided to introduce the Swedish VIPS model, which is a model designed to structure nursing documentation (VIPS is an acronym for well‐being, integrity, prevention and safety). The present study explores the nurses’ knowledge and attitudes towards documentation and addresses the research questions: (a) what are the nurses’ attitudes towards documentation of nursing care? and (b) do nurses have sufficient knowledge of the documentation system to systematically document their patient assessment and clinical decisions? The research design was prospective, comparative, and quasi‐experimental (nonrandomized), including a study group (n = 72) and a control group (n = 57). A questionnaire was used to compare nurses’ self‐evaluated attitudes towards documentation, and a multiple‐choice test was given in order to assess nurses’ knowledge of the documentation system. The study group participated in a special implementation programme (response rate 82%), while the control group attended the regular 3‐day documentation course at the hospital (response rate 79%). The study showed that the two groups responded similarly, but the nurses in the study group were significantly stronger in their conviction that they had the knowledge to make care plans and that they routinely made them. The study group demonstrated slightly less motivation than the control group, while the two groups shared a positive attitude towards nursing documentation. The study group did consistently better on the knowledge tests. The findings show that the implementation programme had a positive impact on nursing documentation, and that the VIPS model increased the nurses’ understanding of the nursing process.     

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.     

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.     

Putting policy into practice: pre- and posttests of implementing standardized languages for nursing documentation

Aims and objectives. To describe the change in documentation of the nursing process in all inpatient wards in a 900‐bed university hospital. Major research question was what are the differences between before and after implementation of documentation policy related to the steps of the nursing process? Background. Implementation of standardized languages has been shown to be difficult to accomplish in clinical practice. Patients are the source of data and their conditions, responses and well‐being should be reflected in the nursing record. As such, nursing documentation can create the premises for the development of new knowledge in nursing and the improvement of nursing performance and can provide data and information necessary for nursing researchers to evaluate the quality of interventions and participate in the formulation of healthcare policy. This study is part of longitudinal project to prepare nurses for electronic documentation within the interdisciplinary health record and to improve documentation of nursing using standardized languages. Design and method. A cross‐sectional study design was used: a pretest (n = 355 nursing records) for baseline status of nursing documentation, an intervention and a post‐test (n = 349 nursing records) to obtain data on nursing documentation. The year‐long intervention comprised planned work in groups, and educational and supporting efforts. Results. A statistically significant improvement was found in the use of Functional Health Patterns for documentation of nursing assessment, NANDA for nursing diagnoses and Nursing Interventions Classification for nursing interventions in documentation of daily nursing care for inpatients. Conclusion. At all organizational levels intervention aimed at putting policy regarding documentation into clinical practice considerably improved daily use of standardized nursing languages. Relevance to clinical practice. Nurses need to use standardized language to document patient care data in the electronic health record and to demonstrate contributions to nursing care.     

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

This study was designed to gain information on the quality of nursing care based on the comments in nursing records. The specific aims of the study were to find out if the patients' (i) individual needs are assessed, the goals for nursing care are set, and the nursing interventions are determined; (ii) if the patients' needs are met and (iii) if goal achievement is regularly evaluated by including comments in nursing documents. In addition, the study aimed to describe the up-to-dateness of nursing care plans as well as the frequency of making daily notes. The data were collected on 36 wards of four residential homes. A 30% sample of the nursing documents on each ward was collected (n=332) using the Senior Monitor instrument. The documents studied were mainly nursing care plans and daily note sheets. Seventy-three per cent of the nursing home residents had an up-to-date nursing care plan at the time of data collection. The main results demonstrated that a written statement on the patient's mental ability was lacking in every fourth document although 75% of the patients suffer from at least moderate dementia in Finnish long-term care institutions. Development activities should also be targeted to the documentation of clear and concrete means by which patients' independent functioning is supported. In addition, evaluation was the area that warranted attention and development activities since only every fourth record included information on changes in the patients' functional capability. Although a lot of in-service training has been focused on improving the documentation practices, there is still a need for development. The means by which knowledge is transferred to guide the practice should be carefully considered. Also forms should be developed to meet the special requirements for recording nursing care in long-term care settings.     

Implementation and evaluation of a nursing process support system for long‐term care: a Taiwanese study

Aims. To (1) develop and implement a Nursing Process Support System in Chinese (NPSSC) enabling computerised documentation for nursing home residents, (2) evaluate the efficiency of NPSSC, (3) assess obstacles to the use of the NPSSC and (4) assess nurse users’ satisfaction with the NPSSC. Background. Long‐term care facilities in Taiwan have been slow to computerise resident’s medical records. The development and implementation of a computerised documentation system provides a way to enhance nursing documentation in long‐term care settings and can prevent hazards that result from documentation errors. Design. Quasi‐experimental. Methods. This study used one group pre/post‐test. Five nursing homes in Taiwan were included in the study. Twenty‐seven nurses used the NPSSC to computerise 396 residents’ medical records. Using the NPSSC allowed nurses to enter health assessment data into the computer system, which automatically triggered appropriate nursing diagnoses. The NPSSC included geriatric nursing interventions and the use of alternative Chinese therapies. Results. Obstacles that hindered nurses' use of the NPSSC were identified and possible solutions to overcome these hindering factors were discussed. The use of the NPSSC significantly improved nursing documentation in that resident’s records were organised and consistent and nurses were able to complete a comprehensive care plan within 48 hours. Nurses reported a higher satisfaction in nursing documentation after the implementation of the NPSSC than previously. Conclusions. This study suggested a pathway to develop and implement a computer‐based, user‐friendly nursing documentation system for nursing homes. This study may be used as a template for implementing computerised documentation worldwide. Relevance to clinical practice. Nursing home providers may consider implementing the NPSSC to replace the traditional hand‐written documentation system. An effective use of in‐service programs within the workplace helped ease the transition from hand‐written documentation to the computer‐based NPSSC.     

Issues in nursing documentation and record-keeping practice

Record keeping is an essential part of nursing practice with clinical and legal significance. Good quality record keeping is linked with improvements in patient care, while poor standards of documentation are regarded as contributing to poor quality nursing care. The quality of nursing documentation has consistently been found to be failing to meet recommended standards. This article will provide an overview of the literature on record-keeping practice and examine what makes good quality record keeping and the factors that prevent nurses from achieving good documentation standards. This article will also look at ways that documentation standards can be improved and the impact that accountability has on the record-keeping practices of nurses.     

Electronic nursing documentation in primary health care

The aim of this study was to describe and analyse nursing documentation based on an electronic patient record (EPR) system in primary health care (PHC) with emphasis on the nurses' opinions and what, according to the nursing process and the use of the keywords, the nurses documented. The study was performed in one county council in the south of Sweden and included 42 Primary Health Care Centres (PHCC). It consisted of a survey, an audit of nursing records with the Cat-ch-Ing instrument and calculation of frequencies of keywords used during a 1-year period. For the survey, district nurses received a postal questionnaire. The results from the survey indicated an overall positive tendency concerning the district nurses' opinions on documentation. Lack of in-service training in nursing documentation was noted and requested from the district nurses. All three parts of the study showed that the keywords nursing interventions and status were frequently used while nursing diagnosis and goal were infrequent. From the audit, it was noted that medical status and interventions appeared more often than nursing status. The study demonstrated limitations in the nursing documentation that inhibited the possibility of using it to evaluate the care given. In order to develop the nursing documentation, there is a need for support and education to strengthen the district nurses' professional identity. Involvement from the heads of the PHCC and the manufactures of the EPR system is necessary, in cooperation with the district nurses, to render the nursing documentation suitable for future use in the evaluation and development of care.     

Standardized care plans: experiences of nurses in Taiwan

Background. Nursing care plans have been viewed as structured plans of action for patient care. Studies have investigated the outcomes or effectiveness of using different types of care plans, but have seldom reported nurses’ perceptions of using care plans in daily practice. Aims and objectives. The purpose of this study was to explore nurses’ experiences using a standardized care plan. Design. Nineteen clinical nurses at a teaching hospital in Taiwan were interviewed one‐on‐one and in depth from April to June 2000. Data analysis was based on Miles and Huberman's data reduction, data display, and a conclusion verification process to identify themes and concepts that represented nurses’ experiences using a care plan. Results. The following themes emerged from the interview data: being reminded of care procedures, time‐saving in making care plans, time‐consuming in making shift reports, undesirable content design, and paperwork‐oriented/not patient‐centered. Conclusion. With the considerable amounts of money spent on education and training to meet nurses’ needs, a careful examination of nurses’ experiences in using care plans, should assist in care plan development and lead to observable effects on patient care. Relevance to clinical practice. Nursing documentation reflects nurses’ observations, assessments, and interventions. It is expected that better use of standardized care plans will enhance nurses’ access to appropriate and accurate information in decision‐making, thus improving the charting process and care quality.     

Improved quality and comprehensiveness in nursing documentation of pressure ulcers after implementing an electronic health record in hospital care

Aims. One aim was to compare the quality and comprehensiveness in nursing documentation of pressure ulcers before and after implementation of an electronic health record in a hospital setting. Another aim was to investigate the use of preformulated templates for pressure ulcer recording in the electronic health record. Background. With the possibilities of the electronic health record to provide information and give accurate and reliable feedback to the healthcare organisation, it is of high priority to develop standardised documentation practices for various areas of care (e.g. such as pressure ulcer care). Design. A cross‐sectional retrospective review of health records. Methods. Three departments in a Swedish university hospital participated. In 2002, there were 413 patients, including 59 paper‐based records identified with notes on pressure ulcers and in 2006, 343 patients, including 71 electronic health records with pressure ulcer recording. Recorded data on pressure ulcers were retrospectively reviewed. Results. Significantly more patient records showed notes of pressure ulcer grade (p < 0·001), size (p = 0·004), risk assessment (p = 0·002), nursing history (p = 0·040), nursing diagnoses (p < 0·001), nursing goals (p < 0·001) and nursing outcomes (p = 0·016) in 2006 than in 2002. One third of the recordings used preformulated templates. Conclusions. Although there were significant improvements in pressure ulcer recording after the change to the electronic health record, several deficiencies remained. Due to the short time of our follow‐up after implementation of the electronic health record, we suspect that the quality of recording will improve when nurses become more familiar with the new system. Relevance to clinical practice. Education related to the use of the electronic health record and evidence‐based pressure ulcer prevention should be provided to the nurses. To facilitate documentation, the templates need to be refined to be more user‐friendly.     

Standardized Nursing Diagnoses in an Electronic Health Record: Nursing Survey Results

PURPOSE. A survey was conducted to obtain feedback from registered nurses as end‐users of standardized nursing terminology for care planning in an electronic health record. Revisions to the care plan terminology were completed as part of an evidence‐based project by nurses at one facility. METHODS. The survey was conducted pre‐, post‐, and 2‐year post‐implementation to obtain feedback from the acute care registered nurses (RNs). FINDINGS. Nurses reported a more positive agreement with the changes at 6 months compared with baseline, which generally was found to be sustained in the 2‐year survey. Overall, the standardized terminology provided the nurses greater ease in their selection of nursing diagnoses and interventions in planning patient care, yet their reported satisfaction did not change. The survey identified several problematic areas related to nurses and care planning. Nurses reported less agreement with the statement about the care plans offering them the ability to determine the status of their patient's nursing care needs. They noted less agreement with statements of the care plan offering information on assessment of patient outcomes of nursing care. CONCLUSIONS. The patient plan of care in the electronic record is expected to offer nurses the ability to communicate the needs of the patient and assess outcomes of care. The survey findings indicate weaknesses warranting further exploration to identify changes needed to improve care planning documentation.     

Factors Associated With Nursing Diagnosis Utilization in Canada

PURPOSE. To investigate factors associated with nursing diagnosis utilization.
METHODS. A retrospective chart audit was conducted on four hospital units over a 5-month period and linked to the nurses (N = 65) who participated in a survey on attitudes toward nursing diagnosis.
FINDINGS. Computer-generated nursing care plans resulted in the greatest frequency of nursing diagnosis documentation. Nurses who did not document nursing diagnoses, and nurses employed in hospitals without nursing diagnosis implementation programs, had more positive attitudes toward the value of nursing diagnosis in practice compared with nurses who documented nursing diagnoses and nurses employed in hospitals with implementation programs.
CONCLUSIONS. Nurses have a greater tendency to document nursing diagnoses when institutions have formal educational programs and computer-generated care plans.     

Nursing documentation audit--the effect of a VIPS implementation programme in Denmark

Aim and objectives. The aim of this paper is to present a study describing nurses’ adherence to the VIPS model by evaluating the quality of nursing assessment, and the quantity of completed nursing care plans. Background. Numerous efforts have been made over the years to improve nursing documentation in Denmark. Hospitals have traditionally based nurses’ charting on a rudimentary version of the nursing process and on Virginia Henderson's theory of human needs. In 2002–2004 the Copenhagen University Hospital, Rigshospitalet, introduced the Swedish VIPS model for nursing documentation. VIPS is an acronym for well being, integrity, prevention and safety, all of which are seen as major goals for nursing care. The model organizes nursing data according to a system of keywords, which facilitates storage and retrieval of data. Design and methods. The design in this part of the study was retrospective, wherein 50 journals from each of the departments of cardiology, neurology, oncology and urology were audited annually for three years using the Cat‐ch‐Ing instrument (n = 600). All nursing journals were randomly selected by including the first 50 journals at each site given a specific date. Results. The nursing documentation significantly improved during the course of the study. After the second year the participants used the keywords appropriately and correctly according to the VIPS model. Application of primary nursing increased during the study. Initial, ongoing and discharge patient status improved. The nurses’ familiarity with nursing diagnoses, goals and interventions increased. Conclusions. The structured implementation programme significantly improved nursing documentation, and the simultaneous training of the entire nursing staff shows promise. The VIPS model has prepared the nurses for more complex computerized taxonomies and classification systems in the future by improving the nurses’ analytical skills. Relevance to clinical practice. New strategies for improving nursing documentation have been demonstrated.     

Critical Care nurses' understanding of the NHS Knowledge and Skills Framework. An Interpretative Phenomenological Analysis

Aims: This small‐scale research study aimed to explore Critical Care nurses' understanding of the National Health Service (NHS) Knowledge and Skills Framework (KSF) in relationship to its challenges and their nursing role. Background: The NHS KSF is central to the professional development of nurses in Critical Care and supports the effective delivery of health care in the UK. KSF was implemented in 2004 yet engagement seems lacking with challenges often identified. Design: This qualitative study adopted an Interpretative Phenomenological Analysis framework. Method: Data were collected from five Critical Care nurses using semi‐structured interviews that were transcribed for analysis. Results: Two super‐ordinate themes of ‘engagement’ and ‘theory‐practice gap’ were identified. Six subthemes of ‘fluency’, ‘transparency’, ‘self‐assessment', ‘achieving for whom’, ‘reflection’ and ‘the nursing role’ further explained the super‐ordinate themes. Critical Care nurses demonstrated layers of understanding about KSF. Challenges identified were primarily concerned with complex language, an unclear process and the use of reflective and self‐assessment skills. Conclusions: Two theory‐practice gaps were found. Critical Care nurses understood the principles of KSF but they either did not apply or did not realize they applied these principles. They struggled to relate KSF to Critical Care practice and felt it did not capture the ‘essence’ of their nursing role in Critical Care. Relevance to clinical practice: Recommendations were made for embedding KSF into Critical Care practice, using education and taking a flexible approach to KSF to support the development and care delivery of Critical Care nurses.     

Handling of peripheral intravenous cannulae: effects of evidence-based clinical guidelines

Aim. This study aimed at evaluating the outcome of implemented evidence‐based clinical guidelines by means of surveying the frequency of thrombophlebitis, nurses’ care, handling and documentation of peripheral intravenous cannulae. Background. Peripheral intravenous cannulae are frequently used for vascular access and, thereby, the patients will be exposed to local and systemic infectious complications. Evidence‐based knowledge of how to prevent these complications and how to care for patients with peripheral intravenous cannula is therefore of great importance. Deficient care, handling and documentation of peripheral intravenous cannulae have previously been reported. Design. A cross‐sectional survey was conducted by a group of nurses at three wards at a university hospital before and after the implementation of the evidence‐based guidelines. Method. A structured observation protocol was used to review the frequency of thrombophlebitis, the nurses’ care, handling and the documentation of peripheral intravenous cannulae in the patient's record. Results. A total of 107 and 99 cannulae respectively were observed before and after the implementation of the guidelines. The frequency of peripheral intravenous cannulae without signs of thrombophlebitis increased by 21% (P < 0·01) and the use of cannula size 0·8 mm increased by 22% (P < 0·001). Nurses’ documentation of peripheral intravenous cannula improved significantly (P < 0·001). Conclusion. We conclude that implementation of the guidelines resulted in significant improvements by means of decreased frequency of signs of thrombophlebitis, increased application of smaller cannula size (0·8 mm), as well as of the nurses’ documentation in the patient's record. Relevance to clinical practice. Further efforts to ameliorate care and handling of peripheral intravenous cannulae are needed. This can be done by means of increasing nurses’ knowledge and recurrent quality reviews. Well‐informed patients can also be more involved in the care than is common today.