Documentation and assessments are crucial to following patients’ progress. One action research project radically changed processes to improve patient care
Liz Lees MSc, Dip HSM, BSc, DipN, RGN, is consultant nurse, acute medicine, at Heart of England Foundation Trust, Birmingham.
Lees L (2010) An action research project to improve the quality of nursing documentation on an acute medicine unit. Nursing Times; 106: 37, early online publication.
Background An action research project was undertaken to explore issues underpinning poor quality documentation and how improvement in assessment can be achieved and sustained.
Aim To improve nursing documentation, as well as the quality of nursing assessments and evaluation in an acute medicine unit using an action research approach.
Method Nurses from an acute medicine unit helped develop a new process for assessment documentation. Five pieces of documentation were radically changed and three new pieces developed. During testing, four cycles of action research were completed; as a result, focused interventions were made to the documentation andassessment process to promote improvement in the areas that demonstrated poor completion or compliance. The new documentation was evaluated for degree of completion and compliance with the new process.
Results Documentation, the quality of entries recorded, and compliance improved. Documentation was also more up to date. Staff commitment helped unravel issues underpinning poor completion/compliance to the original documentation and assessment process.
Conclusion Care planning must be taught in pre-registration training as a fundamental principle of care. Understanding issues pertinent to a busy area and designing a process that makes completion of documentation easier means changes can be sustained long after the active stages of action research have been completed.
Keywords Documentation, Quality, Risk assessments, Care planned, Completion, Compliance
- This article has been double-blind peer reviewed
Box 1. The assessment and admission process
- Arrival on ward;
- Observations recorded;
- Drugs administered;
- Admission documentation commenced;
- Activities of daily living assessed;
- Risk assessment booklet completed;
- Care plans selected;
- Initial entry in medical notes made.
Box 2. example of note entries disconnected from care planned
Four care plans were selected: anxiety; sleep; mobility; and discharge planning. The nursing entries made were:
- Assisted to wash and dress;
- Taken soup for lunch;
- OT and physio;
- Complaining of pain in left hip.
Good quality nursing documentation enables transparent and consistent approaches to the planning and delivery of care; it is the cornerstone for professional practice (Gunningberg et al, 2009; Leach, 2008).
This action research project was based in an acute medicine unit (AMU); such clinical areas are responsible for assessing/admitting almost all medical patients who arrive at hospital as an emergency. At Heart of England Foundation Trust, this can be more than 50 admissions a day.
Although local standards for nursing documentation and assessments in the Heart of England AMU are subjected to regular audit, we have experienced continued challenges in upholding the established standards (Nursing and Midwifery Council, 2009; Wong, 2009).
A plethora of literature surrounds nursing documentation (Gunningberg et al, 2009; NMC, 2009; Wong, 2009; Leach, 2008), computerised care planning and reducing paperwork (Tornval and Wilhelmsson, 2008). This action research project adds to this by exploring the issues underpinning poor quality documentation and how improving the assessment process on an AMU was achieved and sustained. These issues are transferable to other clinical areas wishing to examine documentation and the assessment process.
A complex range of issues underpins the constructs of nursing documentation from simple aspects, such as the suitability of its design, to the overall questioning of what nurses need to achieve from documentation of nursing care (NMC, 2009; Tornval and Wilhelmsson, 2008).
AMUs may see documentation maintenance as being of lower priority than other areas because their work concerns patients who have predominantly short hospital stays and whose conditions have high levels of acuity (RCP, 2007). For example, AMU nurses must assess risk, plan and prioritise the delivery of emergency care, and request investigations while coordinating busy shifts without neglecting to complete documentation within a short time frame (usually less than 48 hours) (Abayomi and Hackett, 2004). It is therefore crucial that documentation is designed with the patient’s journey in mind and driven by a desire to achieve good quality relevant documentation (Gunningberg et al, 2009).
This project was initiated by the senior sister who was new to the AMU and had asked for help to improve documentation quality in the clinical area. It was designed and led by the consultant nurse for acute medicine in close collaboration with nurses on the AMU.
The model of documentation on the AMU was a traditional paper based medical record system, where entries were made by all professional disciplines. This meant that, although patients’ records were called “medical records”, they were integrated records where multiprofessional entries
were made in contemporaneous order and the information was shared by all professionals. Multidisciplinary care planning and electronic records or care planning were not practised; the only electronic system covered prescribing and administration of medicines.
To start the action research process, we examined all key areas where nurses documented care: risk assessments; nursing care plans; charts; and entries in the medical notes. This gave us a broad understanding of the issues being experienced.
The key issues were identified as:
- Nursing documentation in medical notes:
- Too much unfocused information;
- Information omitted;
- Tendency to document “that day” rather than “progress and future”.
- Nursing documentation and standards of record keeping:
- Inferior quality of documentation;
- Lack of systematic process for assessment and admission documentation;
- Separation of risk assessment and care planning;
- Lack of continuity evaluation of care planned.
The issues were complex but their effects could be understood – poor documentation masked the potential to demonstrate good communication, evaluation and outcomes of care from the nursing assessments and documentation. The issues fell broadly into four categories:
- The patient assessment and documentation process;
- The inferior quality of documentation;
- The poor quality of risk assessments;
- Inadequate care planning and evaluation.
In addition, the individual stages of the accepted or usual assessment and admission process were identified by the senior and junior sisters with the research facilitator to see if and how the documentation process corresponded to them (Box 1).
After collecting this information the action research to unravel the issues behind the documentation and care planning of the AMU could begin.
Documentation modification at the outset
Immediately before the first action cycle, at the thinking and planning stage, the assessment and documentation process was redesigned. This included producing a pack of better quality documentation aligned with the “usual” process (Box 1). The new process consisted of eight elements:
- Front checklist (indicating what must be completed);
- ABCDE assessment (acuity status examining: airway, breathing, circulation, disability and exposure on admission);
- Nursing activities of living assessment;
- List of care plans (where nurses indicated which ones they had selected);
- Evaluation of care plans (where nurses indicated the ones they had discontinued);
- Patient’s property form;
- Multidisciplinary information sheet (used for discharge planning information);
- The risk assessment booklet. After the redesign, this was a separate document – it was impossible to incorporate it into the pack as it was already a separate booklet of substantial size. It was listed on the front checklist to remind staff to complete it.
The action research approach – observation, fact finding, reflection, dialogue, collaboration, risk, multiple actions, interpretation and transformation (Polit and Beck, 2008; Burns and Grove, 2007; Reed, 2005) – was used to investigate the effect of a series of interventions made by nurses on the documentation and assessment process.
These interventions were called “action steps”. Each was decided in relation to the issues discovered, which were then followed by a complete systematic action cycle following the steps above.
When all aspects of the action cycle had been completed, each cycle was repeated four times over four months to further refine and improve the documentation and assessment process (Reed, 2005).
Qualitative and quantitative methods of data collection were combined. The factfinding sessions included audits from which quantitative was generated; the feedback book let nurses provide anonymous narrative comments producing qualitative data. Workshops enabled the triangulated approach by producing the possibility of three sources of information (Polit and Beck, 2008).
- Individual pieces of documentation: the research facilitator and senior sister carried out factfinding sessions to inspect all documentation for its degree of completion. They noted the extent of completion for each piece, paying specific attention to signatures, dates and times. An audit form was developed, which enabled the same aspects of documentation to be considered for each cycle.
- Evaluation of nursing entries: to ascertain whether day to day evaluation of nursing care had any continuity, specific nursing entries about care on the day of admission were compared with the day to day entries in the medical records on the day of the factfinding. Nursing entries were aligned and compared with the care plans originally selected. To ensure validity of the audit data, entries were inspected, taking into consideration whether any care plans had been discontinued and new ones started.
- End of bed inspection: to further substantiate whether or not the entries were representative of care being carried out, an end of bed inspection was also conducted. This involved taking the patient’s documentation and comparing it with the actual care and patient’s condition.
Three workshops were held to teach staff about risk assessment, care planning and documentation evaluation (NMC, 2009; Leach, 2008; Polit and Beck, 2008; Abayomi and Hackett, 2004). It was not possible to synchronise a workshop with every action research cycle, due to the logistics of selecting different nurses who could attend. The action research approach was explained at the workshops and participation was encouraged. Exercises included how to write and evaluate care plans.
Each member of the registered nursing team was encouraged to feed back about changes to the documentation and process in a book at the nurses’ station during each month that the revised documentation was in place.
Nurses did write some comments, although initially they were reluctant and tended to give the senior sister or research facilitator verbal comments. These were transcribed into the feedback book so a full account of suggestions leading to changes made to the documentation could be traced.
The aim was to involve AMU nurses in progressively solving problem, leading to new actions to eradicate poor completion/quality of documentation (Polit and Beck, 2008). While the nurses were guided by the research facilitator, they were vital to the action research process by engaging and sharing their knowledge of the AMU environment to adapt and improve documentation (Burns and Grove, 2007).
The AMU has five bays, each with six beds, and side rooms. Thirteen sets of patient records were randomly selected for sampling: two from each bay and three from the side rooms.
AMU patients move from the unit within a short time; this meant that, at the time of factfinding, notes were often unavailable, particularly for patients in the active phase of the discharge process. There were also empty beds. It was therefore impossible to sample every set of records.
A graph was produced at the end of each cycle to show which documentation had been fully completed. This was shared with staff via a report on the noticeboard and via junior sisters at monthly ward meetings. The total number of completed documentation sets possible for each cycle was 13.
Action cycle 1 (Fig 1)
After the first month, the best area showing full completion was the selection of care plans from a list included in the pack. The area needing most improvement was the discontinuation of care plans; only one set of documentation had care plans evaluated (n=13 sets).
The documentation consistently failed full completion owing to a lack of names and signatures on individual sheets. End of bed checks revealed that, while risk assessments were being completed in the booklet (seven of 13), the care delivered was not representative of other risk assessments that had taken place. For example, there were often bowel charts at the end of the bed that were not referred to elsewhere in the documentation.
Action cycle 2 (Fig 2)
We decided to reformat the care planning and evaluation document so that links required between “the plans selected” and evaluation required would be obvious.
By the end of the second month, there had been a vast improvement in the front checklist, ABCDE assessment checklist, nursing assessment checklist, risk assessment booklet, property form and multidisciplinary information sheet. One glaring omission was, again, the evaluation of care plans. This was also seen in use of bullet point lists in the notes that bore little relation to care planning on admission.
The process of systematic evaluation of care seemed to break down quite quickly after admission. Inconsistencies appeared immediately in the notes if the process had not been started properly.
Action cycle 3 (Fig 3)
Care planning was addressed in the first workshop to tackle the continuing trend for its discontinuation. As a result, the number of care plans evaluated increased from zero to eight out of 13 sets inspected.
While care planning evaluation improved, there was again a distinct mismatch in the care being delivered at the end of bed inspections. Intravenous infusions, pain charts and wound risk assessments were commonly in place but not mentioned in the care planning notes. This affected the continuity of day to day record keeping, which had deteriorated to a list of bullet points after three days’ stay (Box 2).
Three sets of documentation were virtually blank. We later identified that these had been started by a bank nurse; had these been completed, compliance would have been significantly better with each cycle.
Action cycle 4 (Fig 4)
We decided to include an example of how to evaluate care in the nursing entries as well as repeating the focus on care planning at the next workshop. There were also additions to the documentation on the basis of suggestions in the feedback book.
At the end of this final cycle, we decided to audit as many sets of notes as possible; 27 were available out of a possible 34. There was considerable improvement across all areas of documentation: signatures were on all pages and several sets contained a note to ask relatives if information was “pending”.
After the final cycle, a meeting was held to reflect on the project. Discussion with the senior sister helped to develop a new piece of documentation to assist with the day to day evaluation of care. In the end this was not implemented because we did not want to create more paperwork. Also, the work had become embedded and we did not want to disrupt what had already been completed. However, it was used for teaching sessions to show links within the care planning process, in an attempt to eradicate bullet point lists.
Care planning was not well understood by nurses from overseas, who made up the majority of staff on the AMU. In addition, British nurses said they had “given up” trying to plan care because the process broke down so many times as so few nurses understood it. It also became evident from documentation entries that one nurse in particular consistently failed to evaluate patients’ care plans.
After the workshops, one-to-one teaching was carried out in the clinical environment to emphasise the principles of care planning (Leach, 2008). This meant that nurses on night duty would not be excluded if they could not attend the daytime workshop.
The workshops provided dynamic discussions where issues relating to documentation were raised. The activities of daily living assessment evolved as a direct result of suggestions from these sessions. The discussion enabled a greater understanding of the links and importance of the process. Moreover, it seemed the process would fail if each part was not adequately completed.
Comments showed compliance with the process and a willingness to engage to make documentation easier:
“Needs documentation hole punched please,”
as well as staff trying to make links between nursing charts and nursing assessment:
“Medical early warning scores should be added to the ABCDE assessment,”
“Add: put the patient’s name above theirbed on the front checklist please,” and
“Add wristband as well please.”
Some anxiety about the lack of handover was also evident, together with the realisation that care happens 24 hours a day. Concern regarding inconsistencies in the quality of documentation between nursing staff was evident:
“What do we do if the documentation has not been completed by the admitting person?”
Other comments did not suggest changes to the process or content, but did suggest there had been an improvement:
“I think it is easy to use,” and
“I think it is good.”
Nursing documentation in medical records
The documentation of too much unfocused nursing information made it difficult to find decisive information (Tornval and Wilhelmsson, 2008). For example, requested investigations resulted in the emphasis on decisions and the patient’s progress being masked. Of equal concern was the omission of information, such as a patient’s transfer date and time, acute deterioration, care that had been discontinued and new care that had commenced (Gunningberg et al, 2009).
The most commonly noted omissions, observed from a mismatch between care at the bedside and that documented in medical notes, were IV infusions (commenced a few days into the patient’s stay, when new cannulas were inserted) and problems with bowel function. Often a bowel chart at the end of the bed would be noted, but nothing documented in the integrated medical record to demonstrate the patient’s progress.
Entries in the records were not always up to date, which was representative of what care was being delivered at the bedside; for example, changes to a regimen of care were not represented (NMC, 2009; Wong, 2009).
The care planning process was also a concern; care planned using care planning documentation was not evaluated consistently in the medical records (Leach, 2008). Nurses documented “bullet point lists of functional care/comments”, which were disconnected from the care planned and without a goal (Box 2). It was difficult to establish whether this was because their knowledge of care planning was lacking or the practice of care planning had been eroded through changing documentation practices in the trust.
When initially inspected, documentation was considered to be of poor quality; notes were often misaligned, barely decipherable and photocopied. There was no AMU standard for completing assessments and the overall admission process; this has been rectified (Lees, 2009).
New staff nurses were left to their own devices to decide what assessments to complete; as such, they may never have known the correct core nursing assessments and admission process (Leach, 2008).
Core nursing admission assessments, showing the patient’s baseline condition, were sometimes missing altogether, negating reassessment and the ability to document improvement or deterioration (Leach, 2008).
Furthermore, risk assessments, care plans and nursing charts were kept separately from the medical records, making it difficult for nurses to track patients’ progress during their stay (Wong, 2009). Risk assessments for skin integrity, nutritional status and falls have become “routine” assessments while patients are in hospital (Larvelo et al, 2010).
The lack of care planning shows that it may have been replaced by risk assessments. There is an emphasis on completing elements of a process, with risk assessments being paramount (Abayomi and Hackett, 2004). These may make a patient’s problem explicit but may not make the actions implicit. Once a risk assessment has been completed, the patient is likely to be moved from the AMU to another clinical area; this may prevent AMU nurses’ exposure to the rigours of care planning and evaluation over a sustained period. As a result, they revert to a daily bullet point list, which is disconnected from patients’ progress on goals set day to day in their journey of care (Leach, 2008).
Most wards with a paper based system will use a similar system where risk assessments are kept at the end of the bed; this may adversely affect the comprehensiveness and standards of nursing record keeping (NMC, 2009; Gunningberg et al, 2009; Abayomi and Hackett, 2004).
As the project was based within an AMU, the research facilitator was unable to follow up patients transferred to other clinical areas.
This work could affect all areas of the hospital receiving medical patients; starting the new documentation in AMU means it would automatically be transferred to other areas with patients without prior consultation about the changes being made. It is not clear whether AMU documentation was continued when patients transferred to other areas of the hospital or if new documentation was started.
Bank nurses will adversely affect quality of documentation if they are not trained in the correct assessment and admission process.
Hypothetical questions developed were:
- Have risk assessments replaced the care planning process?
- Do overseas nurses have the knowledge to care plan?
- Does a highly acute fast patient turnover area promote reductionism?
- Do nurses understand how to involve patients in goal setting?
The lack of a systematic process for care planning and documentation led to poor entries in the integrated medical records. Without planning or goals at the outset, care could not be evaluated consistently day by day. Nurses were given poor quality documentation; this has now vastly improved.
Good quality documentation and a clear process whereby nurses were empowered to make changes were critical to the success of this project. Creating the documentation pack made it easier for nurses to complete the process. However, this did not improve documentation care when new patient problems arose. Regular workshops, auditing and the involvement of staff may help to raise the standard of record keeping (NMC, 2009; Reed, 2005).
Although AMU nurses become specialists in undertaking patient assessments and implementing actions, this may cause them to take a reductionist approach (Polit and Beck, 2008), where they “only do what they need to do at the time”.
Also, unless patients are followed up after being transferred from AMU, there are no perceived consequences of poor quality care planning and documentation for staff working on the unit.
Risk assessments must be linked to care that is planned and the care planning process must be reinvigorated as a fundamental taught element of nurse training.
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