The routine documentation of nursing care is an everyday part of nursing practice, which provides a permanent record of the care given to a patient and the patient’s response to that care. The NMC (2002) states that good record-keeping:
VOL: 99, ISSUE: 10, PAGE NO: 36
Maggie Tarling, MSc, BSc, RGN, is integrated care pathways coordinator at University Hospital, Lewisham
Paul Lambirth, RGN, is ward manager surgery;Therese Mackey, RGN, is ward manager medicine;Michelle Predki, RGN, is ward manager surgery;Grace Stevenson, RGN, is ward manager medicine for the elderly;Sally Votier, RGN, is senior sister A&E;Marcia Skeete, RGN, is ward manager orthopaedics; all at University Hospital Lewisham
The routine documentation of nursing care is an everyday part of nursing practice, which provides a permanent record of the care given to a patient and the patient’s response to that care.
The NMC (2002) states that good record-keeping:
- Promotes high standards of care;
- Is important as a means of communication within the interprofessional team;
- Is able to detect changes in the patient’s condition at an early stage;
- Acts as a record of the care delivered to patients.
The NMC also stipulates that the record is made at the time of care, is written legibly, is clear and unambiguous, is accurate, and serves the best interests of the patient. It is increasingly recognised that, in practice, the nursing record does not fulfil its expectation as a communication tool and record of care. Currell et al (2000) found little evidence that nursing record systems have any direct link to patient outcomes. Moloney and Maggs (1999) argued that ‘record-keeping and care planning is retrospective and remote from the patient.’
The assessment tool
Gloucestershire Royal NHS Trust has developed a nursing assessment tool (2000), the Gloucester patient profile (GPP), which has several reported advantages over traditional nursing records (Hodgson and Haswell, 1999):
- Greater reliability;
- More cost effective in paper and nursing time;
- Gives a flow chart showing a patient’s status at a glance;
- Shows trends over time;
- Has increased user satisfaction;
- Has a common language that promotes multidisciplinary working.
The GPP requires nurses to assess patients in several dimensions, including: general well-being, activities of daily living, breathing, gut function, wounds and Waterlow (pressure ulcer) assessment. It is presented in a grid format with a colour code for each dimension. Green means that the patient is fully independent and requires no nursing intervention or support. Amber means the patient is deemed to have a potential problem requiring some nursing intervention. The details of the problem and what nursing intervention is carried out is documented on a continuation sheet. An assessment in the red section means the patient is deemed to be fully dependent requiring full nursing intervention and nursing care. This should then trigger a nursing care plan.
The patient is assessed on these dimensions once every shift, that is in the morning, evening and night. It produces a graphical representation of the patient’s dependency and gives a picture of progress over time. The GPP does not assess non-physical aspects of care such as psychological or social needs, but these are documented within the continuation sheets. The GPP was formally evaluated in several clinical areas, which previously had little uniformity in nursing records, for example unified elderly care records, casualty cards, various pre-printed assessment care plans and the ‘kardex’ system.
A before and after evaluation compared:
- The volume of paperwork used in the nursing record;
- The time taken to complete the record;
- The place where nurses completed the record;
- Nurses’ satisfaction and perceptions of the record.
After approval from the local research ethics committee, six clinical areas participated in the evaluation: two acute surgical wards, a care of the elderly ward, an acute medical ward, an ear, nose and throat ward and the emergency referral unit of the A&E department. Non-participant observation was carried out on two randomly selected shifts in each area to observe where nursing records were completed and how much time was taken. After the initial observation an education programme on the use of the GPP was carried out in each clinical area. The GPP was then introduced into practice and the observations were repeated after three to four months.
The ward managers in each area supported the change and were, therefore, excluded from the evaluations. Nominal group evaluations (Carney et al, 1996; Jones and Hunter, 1995); were carried out in each area to assess nurses’ attitudes to the record before and after the introduction of the new patient profile. Groups of nurses from each ward area were asked to list the positive and negative aspects of the nursing record individually and then to agree a list in small groups. This information was collated into a list of positive and negative aspects for the whole group. Individuals allocated a total of 10 points (five for the positive and five for the negative) to the lists to give a weighting to the aspects the nurses felt were most important. A chi squared analysis was performed on the pooled evaluations. A percentage was also calculated for items given a score by nurses.
The writing of a total of 170 records was observed - 102 pre-implementation and 68 post-implementation of the GPP. There was a statistically significant difference in the mean time taken to complete a nursing record and the mean number of pages used in the nursing record before and after the introduction of the profile (Box 1). The GPP took longer to complete but used less paper than the traditional method. There was also a statistically significant difference in the place where nurses completed the nursing record (2=6.68, p<0.5).
Before implementation only 23 per cent of nurses completed the record at patients’ bedsides, while afterwards 51 per cent of nurses did so. More nurses also involved the patient with the GPP. A total of 51 nurses participated in the group evaluations, rating the GPP slightly more positively than traditional record-keeping. However, this was not statistically significant (2=0.90, p>0.05). Overall there were more negative comments regarding traditional nursing records and more positive comments for the GPP (Boxes 2 and 3).
The GPP took two minutes longer to complete on average than the traditional records, but saved on the amount of paperwork used in the nursing record. There was a significant change in the way nurses wrote the records. More nurses completed their nursing assessment and record-keeping by the patient’s bedside and also involved the patient and relatives in the record-keeping process with the GPP. Nurses evaluated the GPP more positively than traditional records. Nurses felt the GPP provided the ability to see the patient’s condition at a glance and that it was easy to use. Although it took longer to complete, some nurses felt the GPP was less time consuming.
The use of colour coding was evaluated positively and was seen as a useful guide to nursing intervention. Nurses also commented that the Waterlow assessment was used more frequently with the new system. The main negative comment - that it was too easy for staff just to copy the previous entry - has many implications. An inaccurate record may compromise nursing care as potential and actual nursing problems could be missed. There may also be potential medico-legal implications. It is difficult to identify the reason staff do this. It could be an educational issue caused by a nurse not understanding the GPP or having problems with nursing assessment and intervention. There may also be performance issues with staff who do not use it properly. However, the GPP makes it obvious when a nurse has not completed it properly. This issue highlights the importance of monitoring and also presents a challenge for managers to ensure that staff are practising at the expected standard.
Other negative comments about the new profile illustrated difficulties nurses encountered with its use. They felt that some areas of the tool were open to different interpretations. The ambiguity is due to the diversity of patients requiring nursing care. Each ward area will need to agree and attribute different meanings to the dimensions; for example the assessment of stairs has a totally different meaning for orthopaedic patients than it does for general surgery patients. Some ward areas felt that completing the new documentation on a shift basis was too frequent. It was found that the GPP did not work very well in the ENT ward because of the high turnover of patients, many of whom were day surgery patients. But it was felt that the GPP would work well for patients who are in hospital for longer periods. Although the assessment tool does not cover non-physical aspects of nursing care, patients’ psychological and social needs were still assessed and documented. These aspects of nursing care do not lend themselves to the grid-format design of the GPP.
Conclusion and recommendations
The assessment tool has several advantages: it reduced the amount of paperwork and involved patients and their relatives in the process of nursing assessment and record-keeping. However, the GPP took longer to complete, but in light of the increase in patient involvement this might be time well spent.
The GPP was evaluated more positively than the traditional record, but in light of the negative comments, the following recommendations should be considered:
- Nurses need to be thoroughly trained in its use;
- Ward areas need to consider frequency of assessment;
- There needs to be a common, agreed interpretation for particular patient groups;
- Managers should ensure that there is an ongoing mechanism in each ward area to monitor the use of GPPs;
- Careful consideration needs to be given to the management of staff-performance issues raised by this evaluation;
- Other professional groups and patients should be involved in any further evaluation of its usefulness.