Person‐centred care in nursing documentation

Abstract

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.

Person‐centred inpatient care – A quasi‐experimental study in an internal medicine context

“…The need to enhance the visualization of a patient's needs, resources, and wishes – instead of nurses’ tasks – in documentation has been emphasized for some time (Kärkkäinen, Bondas, & Eriksson, ). Such documentation was sparse, but in line with previous studies (Broderick & Coffey, ). The review of medical records indicated an increased awareness among healthcare personnel of assessing patients’ resources.…”

“…As documentation constitutes a part of the model of initiating, integrating, and securing PCC (Ekman, Swedberg, et al., ), a protocol for reviewing person‐centred content in medical records was developed within the scope of this study. The protocol was based on the dimensions and items in an existing framework for reviewing nursing documentation in the care of elders (Broderick & Coffey, ) and further developed by researchers with expertise in PCC and psychometric analysis. The final protocol for review included 10 items divided between three dimensions (Table ).…”

Implementation of the Veder contact method in daily nursing home care for people with dementia: a process analysis according to the RE‐AIM framework

“…To effectively provide person‐centred care, caregivers need information about the background and personal interests of the residents. As found in Broderick and Coffey (), this information was not always available, which was a barrier to successful implementation on two wards. However, in addition to developing more effective ways to retrieve this information, the application of the multi‐faceted VCM training and coaching program, including careful observation of the reactions of the residents, provides valuable insight into their personal interests and preferences.…”

Person‐directed care planning in nursing homes: A scoping review

“…Furthermore, in LTC, many—perhaps most—staff are not trained in communication approaches that might engage residents in care planning (Børøsund, Ruland, Moore, & Ekstedt, 2014; Savundranayagam, 2014). The structure of nursing documentation—especially the tendency for care planning forms to require limited psychosocial detail—is likewise an obstacle (Broderick & Coffey, 2013). …”