VOL: 103, ISSUE: 6, PAGE NO: 32-33
Kim O?Connor, BSc, RGN, is head of practice development; Therese Earl, RGN, is a professional development nurse; Petra Hancock, BSc, RGN, is a practice facilitator
All at Barking, Havering and Redbridge Hospitals Trust
ABSTRACT O’Connor, K. et al (2007) Introducing improved nursing documentation across a trust. www.nursingtimes.net.
This article describes how staff training and stakeholder engagement were used in a pilot to streamline nursing documentation and ensure its successful roll-out over the four hospitals within Barking, Havering and Redbridge Hospitals Trust. The paper-based documentation has been rolled out across the trust and this will be followed by an electronic version of the system.
Nursing documentation has a high priority in all trusts because analysis of records of care and observations has revealed that use of multiple charts and repetitive recording causes practical and legal problems. Introducing a new system of documentation is not just about changing the design of records. It must also address issues of time management, accountability and planning patient care. A project was undertaken at Barking, Havering and Redbridge Hospitals Trust (BHRT) to streamline nursing documentation acroos the whole trust. The project began with a pilot, which took place on six wards. Its outcomes and recommendations were reviewed and the documentation’s design adjusted to roll out the updated charts to all areas of the hospital.
The aim of the project was to ensure that the documentation for acute adult patients was practical for nursing staff, that it supported planning of patient care, promoted accountability, did not duplicate existing documentation and was an accurate reflection of the care the patient had received. The pilot wards were selected because they were also piloting a supernumerary ward sisters’ project, which meant the sisters were able to support the implementation of the new charts. They played a crucial role in sustaining the project’s impetus, ensuring day-to-day monitoring and ownership of the documentation. They checked the charts daily, reviewed the care plans with the nurses and fed back any changes from the consultants’ ward rounds.
Nursing documentation within BHRT was a concern for senior nurses. Complaints and investigations arising from clinical incidents were leading to indefensible claims because of the lack of thorough documentation and accountability. An internal investigation found the following problems:
- Poor record-keeping;
- Poor planning of care;
- Incomplete admission records;
- Inconsistent/lack of documented care planning;
- Failing systems of communication;
- Ad hoc recording of vital observations;
- Compromised fluid management;
- Lack of reported care evaluation;
- Lack of patient involvement in documentation of care;
- Lack of training documented care planning for student nurses;
- Poor time management.
Each of the trust’s four hospital sites had its own format for nursing documentation. Some had to be completed by hand while others were computerised; some wards retained nursing notes while others embraced unified case notes. Differing fluid balance charts and nursing audit tools also existed.
Many areas had tried to incorporate pre-composed, computerised care plans, which were difficult to apply to individual patient care. These had gradually been abandoned and replaced with inefficient substitutes or nothing at all, thereby compromising documentation even further.
Senior staff concluded that three major issues needed to be addressed:
- Inadequate nursing documentation systemsneeded to be replaced by a new format of record-keeping, using an established nursing model (Roper et al, 2002);
- Poor staff performance in planning and evaluating careneeded to be addressed by instituting a basic approach to planning care where documentation would be completed by hand - this would require documentation and care-planning training within the ward environment;
- Lack of patient involvementneeded to be addressed by nurses planning and documenting care at the bedside, in order to involve the patient in the process.
The project involved a wide range of personnel and the following teams were set up:
- A steering group of senior nursing staff formed to determine an outline of the documentation required. It was disbanded once the draft documentation was finalised;
- The project lead team took responsibility for design, information resources, training, implementation, audit, redesign amendments and reports when management of the project became the responsibility of the practice development team.
- A support team worked under the direction of the practice development team across the trust sites to assist with training and implementation and was most active during the staggered implementation phase between May and July 2005.
Existing internal and external documentation was researched (Wright, 2002), draft documentation charts were designed and fluid management records reviewed (Braden and Bergstrom, 1998; Heaton, 1999; Fisk, 2000; British Association for Parenteral and Enteral Nutrition, 2003; NHS Wales, 2003) as part of the design process.
Particular consideration was given to the accountability of the documenter, clarity, time spent on completion, duplication of information, relevance and ease of use as part of the review of nursing documentation within BHRT. Models of record-keeping within a variety of care settings within BHRT were also reviewed.
The review of external documentation highlighted the Gloucester Patient Profile (GPP, Gloucester Royal NHS Trust, 2000) as a useful model. A visit was arranged first to Lewisham Hospital to evaluate the profile and then to Thurrock Hospital, where GPP was used for a short period to establish patient dependencies as an exercise to review ward establishments.
Research among the steering group concentrated on efficacy of admissions, GPP, care planning, evaluation, patient participation, fluid management, combined notes and nursing tools/algorithms. An algorithm group was set up at this time and is part of the service improvement team’s remit.
Drafting of new charts
The steering group agreed that the BHRT model of record-keeping should be in keeping with The Essence of Care(DH, 2003) and familiar to nursing staff, facilitating the ward-based training that the new documentation would require. It was agreed that Activities of Daily Living(Roper et al, 2002) was the simplest and most effective model to satisfy these criteria.
The following five charts were designed:
- Patient admission record: an A4 card, using tri-fold design, containing confidential information to be retained in ward office folders;
- Patient observation record: an A4 card, using tri-fold design, maintained and stored in patients’ bedside folders;
- Daily patient progress record: an A4 card, using tri-fold design, maintained and stored in patients’ bedside folders;
- Patient plan of care: an A4 card, using tri-fold design, maintained and stored in patients’ bedside folders;
- Fluid balance chart: the new design was piloted initially on two medical wards to determine ease of use and application. This was highly successful and after a few minor adjustments the chart was then piloted on all six identified wards.
Drafts charts were developed by December 2004, with designs finalised by April 2005 in preparation for implementation in May of that year.
We recognised that introduction of new nursing documentation would be difficult to manage due to the trust’s size and differing processes. Staff education was vital and we believed it would be easier to provide and more likely to be understood if delivered within a ward environment. We felt the intimacy of a contained group would enable staff to evaluate the new charts more openly and honestly, providing feedback that would assist with necessary amendments at a later stage. We therefore decided to pilot the project on a small number of wards.
The choice of wards was influenced by an existing scheme, the supernumerary ward sisters’ project taking place on five wards at Oldchurch and King George Hospitals. It was envisaged that these wardmanagers would be in a position to offer more supervision to their staff than the trust’s other sisters. An acute critical admissions unit was also included because it employed two clinical educationalists who could oversee the pilot introduction (Box 1).
Box 1. Six pilot wards
King George Hospital
King George Hospital
King George Hospital
The pilot commenced in May 2005, to coincide with the start of the supernumerary ward sisters’ project. An initial review of progress on each ward took place at six weeks with a final review at five months to finalise any recommended alterations.
From the end of April until mid-May, when the pilot started, a consultation process took place to inform staff about the project. There were three ‘drop-in’ days on each main site, when staff had the opportunity to view prototypes of each chart and discuss the process with members of the practice development team. Suggestions for inclusion and amendments were shared. Additional opportunities to disseminate information included: celebration of nursing day; BHRT Education Forum; a visual display; the information team, matrons’ and ward managers’ meetings; pre-pilot visits to the pilot areas. There were also one-to-one meetings with all staff members and visitors who came into contact with the charts.
Revisions to charts
The following amendments were made to the proposed documentation as a result of the consultation process:
- The patient admission record needed to facilitate the social services referral form, with a capacity for use with fax machines;
- The patient observation record needed adjustments to blood-glucose monitoring, and the observation and pain sections;
- The daily patient progress record needed adjustments to some of the statements, and to include medicines management, wound care, pressure ulcer and patient vulnerability;
- The fluid balance chart needed to show one 24-hour period on one page, inclusion of a plan for the patient of why the fluid chart was needed and what was required of them. This chart was re-named the fluid management chart to emphasise the importance of this aspect of patient care.
In addition, the following supplementary charts were identified as necessary:
- Two supplementary patient observation charts - a neurovascular chart for trauma, head injury, orthopaedic and neurological patients as well as an obstetric observation chart;
- A pressure ulcer management chart and a wound management chart.
A review of trust documentation had to take place in order to fund the charts. In total, 33 forms were removed, with a further 10 to be discontinued once the new charts were fully in circulation. Review of nursing documentation and meetings with the printers enabled us to assess other charts, which prevented duplication.
A variety of training methods were used including ward-based groups, one-to-one individual support, brief seminars and patient involvement using charts and presentations. Initial training was staggered over the wards during six weeks in May and June 2005. Once the documentation arrived, intensive training was provided on one ward per week. Additional support was then available on a drop-in basis or on request from wards. Night and evening sessions were provided to ensure that all staff members were using the documentation.
The project team, support team and ward staff (including matrons) were involved in the training. The ward sisters and matrons would ‘police and check’ the charts and care needed to ensure staff members were given direction on areas of good practice and issues that they needed to remember.
Feedback and support
Many forums were held during the pilot to update staff groups and inform them on areas in which the documentation might be used in the future. Matrons’ and sisters’ meetings together with feedback from the pilot wards were very informative and enabled us to develop the documentation. Nurse education and practice development meetings also raised issues and discussed developments of the pilot.The matrons provided constant constructive feedback and support for the project. They assisted with the ongoing review and questioning of staff members on the documenting and planning of care and gave ad hoc training to students and new or temporary staff members in the absence of the sisters.
Specialist nurses gave assistance with specific training areas including pain, nutrition, diabetes, manual handling and infection control. The nursing directorate secretaries, the support services department and the ward clerks in the pilot areas also gave strong support to the project team. Feedback came from many sources including:
Supernumerary sisters’ meetings;
Specialist nurse forums;
Individual nursing staff members;
All verbal and documented feedback was noted and incorporated into the project and chart redesign.
Before the charts were redesigned the project team liaised with all areas that would be using them. Two stakeholder events were held to give interested parties an opportunity to give their views. There were 54 attendees including nurses from medicine, surgery, gynaecology, neurosciences, intensive therapy units and HDUs as well as specialist nurses from manual handling, pain, nutrition, paediatrics and the chest clinic, and a range of allied health professionals.
The charts were exhibited, then group discussion took place about each area of interest. Comments and concerns were discussed and solutions proposed. Areas that could not be represented at the meetings were contacted by the project team to ensure their views were heard.
This process also stimulated specialties not in the pilot - such as obstetrics and paediatrics - to review their own documentation. Amalgamation of charts has led to increased cost efficiency.
Neurosciences were concerned about how the documentation would work with their computerised care planning. These nurses were computer literate and confident in care planning on the computer system, and have been recommended for piloting the new electronic documentation.
All senior staff members involved were focused and clear on the aims of the pilot. This ensured that they all felt supported through the new documentation process and that the focus was on planning care. The support team gave direction and ensured that any issues that arose were tackled immediately. Feedback from all the pilot sites was constructive and informative and allowed the project team to critically review the documentation, give attention to areas of concern and adjust the designs accordingly (Box 2).
The outcomes reached within the supernumerary sisters’ project were partly due to the implementation of new nursing documentation because it facilitated data collection, discharge processes and the sisters’ role in reviewing and developing a nurse’s ability to assess, plan, implement and evaluate care.
Box2. Impact of pilot on staff members and the project team
Attitudes of the staff
Staff attendance at training sessions
Support from sisters and matrons
Satisfaction with the impact of the documentation on care delivery
Focusing on good documenters
Lack of awareness of the registered nurse’s own accountability when documenting
Knowledge of planning care
Trust geography - five wards were on two sites
Good documenters quickly adapted
Temporary staff and student nurses adapted quickly and liked the charts
Staff did not have to wait for the case notes to be able to document and left their shifts on time
Feedback books were very useful in tackling issues as they occurred
Consultants have expressed a change in staff members’ ability to clearly describe and account for the care their patients had received, especially at weekends
Resistance to documenting care at the bedside and involving patients in the process
Resistance to changing the way nurses document in the notesNurses felt they did not have time to document
Information is now documented immediately and in clearly defined places on the charts. Staff no longer have to stay at the end of the shift due to difficulty accessing the notes. Knowledge of developing patient care plans in preparation for discharge has increased since the pilot began, which has led to earlier discharges within the pilot wards. The nurses’ contact with patients has increased as they are documenting care with the patients. This has increased the nurses’ job satisfaction, while patients have shown less frustration over the care received.
The documentation has facilitated handling of complaints by providing information that the previous documentation did not. The clinical governance department is using it to demonstrate to complainants, the Healthcare Commission, MPs and independent review panels that issues are being addressed and that this is how we are developing our nurses to provide and document the care they give.
A 12-month implementation plan to roll out the documentation began in January 2006, with site-based focus and training within the ward area. The cascade training, resource packs and ward ownership had been cost effective in the pilot, so no additional funding for nursing posts would be needed, providing the supernumerary ward sister project was implemented in all ward areas.
Documentation is only as good as the nurses who complete it and it is important to ensure systems are in place to support managers when accountability issues occur during documentation. Ward teams ensure that all patients have their care documented effectively. This could be facilitated by implementing the supernumerary sister role within the ward areas.
The focus of the pilot was to assess, plan, implement and evaluate care. It was apparent that nurses who trained a long time ago and understood this process found it easy to plan care. Those who had qualified less than five years before, however, found it more difficult, as did those who trained elsewhere in the country or overseas.
All patients are entitled to the same standard of care, so BHRT plans to produce care standards that reflect the way it would like its nurses to work. Initially these could be based on those in the GPP, then broadened to incorporate all clinical skills. This will ensure that whoever delivers care has a benchmark and that managers will have a system of comparison should performance become an issue. BHRT has developed 70 standards of care that correlate with the new documentation. These comply with the model for The Essence of Care(DH, 2003), enabling staff to plan care using common references, which are familiar throughout the trust. The Essence of Care has an important role to play in all the new documentation, which incorporates all activities of daily living into the charts. Care is planned on an entirely individual basis, centring on patients’ perceived needs as well as formal assessments.
The new documentation will increase and emphasise nurses’ awareness of accountability when documenting care, ensuring they understand their responsibility. It will also ensure support systems are in place for managers to use when issues including poor documentation, inadequate planning of care, errors in recording and omissions arise.
The project team has focused on a site-based roll-out programme of the documentation training. As in the pilot, training is ward based and interactive, with a combination of one-to-one and group sessions.
Training is cascaded through matrons, sisters and designated documentation support nurses. The wards take ownership of the implementation of the new documentation due to the desire to change their practice. Training, advice and support is provided by practice development and support teams. A training pack is available for each ward with examples on how to complete the documentation.
Wards are selected and prioritised for the roll-out according to their demonstrating a keen interest in changing their systems or by clinical governance identifying that they need to change their documentation system. To ensure the documentation crosses the specialties and incorporates the patient journey, assessment units, trauma and the day-unit settings need further review to ensure nursing documentation is neither repetitive nor unnecessary.
The documentation has now been reproduced in an electronic format. This complements the Connecting for Health patient record and has the same assessment tools and information requirements as the paper documentation. The paper-based system has been implemented first to ensure nurses are familiar with the process; computer literacy will then be the priority when the electronic system is introduced.
Benefits of the electronic system include:
Instant calculation of patient/ward dependencies, which in turn reflect on management issues;
Effective audit trails;
Continuity of care.
The system is aimed at the wider audience and will be used in conjunction with other modules that are being developed and introduced as part of the interim IT solution for BHRT. Supporting electronic information will be available to all staff members via the trust intranet.
Braden, B., Bergstrom, N.(1998) The Braden Scale for Predicting Pressure Sore Risk. www.bradenscale.com
British Association for Parenteral and Enteral Nutrition(2003) The Malnutrition Advisory Group. Malnutrition Universal Screening Tool (MUST). www.bapen.org.uk
Department of Health(2003) The Essence of Care: Patient focused bench marking for health care practitioners. London: DH.
Fisk, P.(2000) ‘Complex Pain Tool’. Devised with reference to The British Pain Society and the Universal Pain Assessment Tool. Barking Redbridge and Havering Hospitals NHS Trust.
Gloucester Royal NHS Trust(2000) The Gloucester Patient Profile. Development and implementation of an evidenced-based multidisciplinary assessment tool. Gloucester: Gloucester Royal NHS Trust.
Heaton, K.(1999) The Bristol Stool Form Scale In Understanding your Bowels: Family Doctor Series. London: British Medical Association.
NHS Wales(2003) NHS Manual Handling Passport. All Wales Manual Handling Training Passport and Information Scheme. www.wales.nhs.uk/documents/NHS_manual_handling_passpor.pdf
Roper, N. et al(2002) The Elements of Nursing: A Model for Nursing Based on a Model of Living. Edinburgh: Churchill Livingstone.
Wright, K.(2002) The Development of a Multidisciplinary Clinical Record: Changing Culture to Meet the Needs of the EPR. Weston Area Health NHS Trust. http://www.avon.nhs.uk/imtconsortium/publications/RecordKeepingReport.pdf