Evaluating the introduction of primary nursing: the use of a care plan audit

Abstract

A care plan audit was carried out as part of an action research project involving the introduction of primary nursing. The audit tool was based on the Roper, Logan and Tierney Activities of Living model and the nursing process. The audit showed that few changes in documentation had taken place as a result of the introduction of primary nursing. The volume of communications had increased but much of this was not documented on care plans. Other positive changes as a result of introducing primary nursing were found, and both patients and nurses were aware of these.

The study of nursing documentation complexities

“…The documentation issue exists in the actual content, its forms and procedures used. For example, initially recorded assessments are commonly viewed as incomplete 6,10 or as a poor assessment of the patient on admission. 7 Mostly, nursing records have no nursing diagnoses.…”

“…6,8,9 If nursing diagnoses are identified, the patients' problems that are identified predominantly address physical problems based on medical diagnoses, with few psychosocial needs. [10][11][12][13] Nursing diagnoses are often inaccurate and inconsistent, 14 especially when they are not relevant to the patient's condition, 6 and might lead to inappropriate nursing interventions to achieve patient outcomes. Nursing care plans are not consistently written 11,[15][16][17][18] or are not used for interventions.…”

“…19 Nursing interventions recorded are related to medical rather than nursing problems and rarely include the patient's view: they draw only on the nurses' own judgements as the source for successful self-evaluation. 10 Nurses' notes are often written in a repetitive manner or exclude meaningful data. 20 Also, nursing records often show legal inaccuracies.…”

Information handling in the nursing discharge note

“…Of these systems, only NANDA (completed in the second half of 2003) has been translated into Norwegian. Evaluation of the nurses' documentation in the patient record, paper as well as electronic, has focused on how comprehensively it describes the phases of the nursing process in general (Ehnfors & Smedby 1993, Davis et al 1994, Nordströ m & Gardulf 1996, Webb & Pontin 1997, Briggs & Dean 1998, Stokke & Kalfoss 1999, Nilsson & Willman 2000, Ehrenberg & Birgersson 2003 or in relation to particular patient categories (Ehrenberg et al 2004). The discharge note, however, should contain a summary of the recorded information and should serve as a tool for exchanging valid and relevant patient information when the patient is discharged from hospital (Sosial-og Helsedepartementet 2001).…”

Standardized care plans: experiences of nurses in Taiwan

“…Although Shea (1986) noted that there was no evidence that the presence or absence of care plans had any demonstrable effect on patient care, subsequent studies have been conducted to demonstrate the effect of using care plans from different perspectives, and results are varied (Aidroos, 1991;Webb & Pontin, 1997;Briggs & Dean, 1998;Mason, 1999;Moloney & Maggs, 1999;Kerr & Lewis, 2000). Aidroos (1991) conducted chart reviews and found that the quality of care was judged to be lower when a nursing care plan existed and higher where an existing nursing care plan was not followed.…”