Diana Jefferies

A meta-study of the essentials of quality nursing documentation

The aim of this study was to synthesize all relevant information about nursing documentation and present the essential aspects of quality nursing documentation. Literature searches, limited to the English language, were conducted on both CINAHL (1982 to week 3, April 2008) and MEDLINE (1996 to April 2008) using the following search terms: attitude, audit, care, culture, documentation, guideline health, in service, legal, liability, medical, nurses, nursing, organizational, patient, personnel, planning practice, quality, records, research and training. One hundred and seventy-one papers were reviewed for their relevance to the clinical question. Twenty-eight articles were read by two researchers. Data informing the clinical question were extracted and categorized into key concepts by an analysis of similarities. The seven major themes (essentials) of quality nursing documentation were identified. This paper has reviewed contemporary literature, research evidence and local policies to identify the seven essential components of quality nursing documentation. Some of the barriers or more controversial aspects of the final policy are described.

Developing a minimum data set for electronic nursing handover

AIMS AND OBJECTIVES This study presents a minimum data set designed for an electronic system to complement verbal nursing handover. Background.  Poor communication of patient information at handover has been implicated in adverse events with changes to clinical handover being proposed as a solution. This study developed a minimum data set for an electronic patient summary tool. DESIGN; Using an observational design the scope of information being presented by nurses at handover was identified in relation to a generic Nursing Handover Minimum Data Set. METHOD Patient handovers (n = 195) were observed and digitally recorded across diverse specialties. RESULTS Content analysis confirmed the frequent use of the Nursing Handover Minimum Data Set items across all specialties. The use of the items was affected by the patient context and the clinical setting. Aged care patients often had several clinical alerts reported (pressure areas, falls risk). Rapid changes in patient condition in emergency emphasised the need for a focus on observations and presenting problems. Mental health and maternity required further refinement of the items. CONCLUSION The generic Nursing Handover Minimum Data Set can direct nurses to give a comprehensive account of their patients condition and care. The data set needs to be flexible and adaptable to the patient context and setting and complements structured content verbal handover. This minimum data set provides an excellent framework for system development by clinicians, managers and information technologists. Educators can use this tool to teach student nurses, new graduates and experienced staff, about the patient information to be presented at handover. RELEVANCE TO CLINICAL PRACTICE The Nursing Handover Minimum Data Set for electronic nursing handover complements verbal handover and provides a tool to give clinicians access to comprehensive information about all patients within the ward area.

Exploring the structure and organization of information within nursing clinical handovers

Clinical handover is the primary source of patient information for nurses; however, inadequate information transfer compromises patient safety. We investigated the content and organization of information conveyed at 81 handovers. A structure that captures and presents the information transferred at handover emerged: identification of the patient and clinical risks, clinical history/presentation, clinical status, care plan and outcomes/goals of care (ICCCO). This approach covers essential information while allowing for prioritization of information when required. Further research into the impact of ICCCO on patient safety is in progress.Clinical handover is the primary source of patient information for nurses; however, inadequate information transfer compromises patient safety. We investigated the content and organization of information conveyed at 81 handovers. A structure that captures and presents the information transferred at handover emerged: identification of the patient and clinical risks, clinical history/presentation, clinical status, care plan and outcomes/goals of care (ICCCO). This approach covers essential information while allowing for prioritization of information when required. Further research into the impact of ICCCO on patient safety is in progress.

Comparing written and oral approaches to clinical reporting in nursing.

Patient safety is compromised if vital clinical information is not available to all members of the healthcare team. Therefore, it is important to understand the differences between patient information found in nursing documentation and information presented at clinical nursing handover. Content and textual analyses of two data sets were undertaken: one containing 67 examples of nursing documentation and the other containing 195 transcripts of clinical handover to understand the scope and construction of patient information found in each communication system. Clinical handover produced a comprehensive picture of the patient’s condition and care whereas nursing documentation tended to present a series of descriptions of tasks performed by nurses. There is a need to investigate new systems of communication promoting congruence between clinical handover and nursing documentation to ensure that all patient information can be accessed by all interested parties.

Nursing documentation: How meaning is obscured by fragmentary language

This article looks at the effect of using fragmentary language in nursing documentation. Fragmentary language is defined as phrases and abbreviations found in records of nursing care that are understood at the local ward level but would make it difficult for anyone reading the documentation beyond this local level to construct meaning. Sixty-seven entries of nursing documentation were investigated using textual analysis. Each entry was examined to determine how grammatical and linguistic features of the text could impede meaning. Three entries are discussed in detail to demonstrate possible difficulty for readers in understanding the patients condition and care. Education programs that encourage nurses to view their documentation as a crucial aspect of care are recommended. Writing nursing documentation in a manner that allows readers from both within and outside the profession to understand the patients condition and care required is supported. If readers cannot understand what is written in nursing documentation, there is a danger that misinterpretations could lead to clinical errors and adverse events.

A ward-based writing coach program to improve the quality of nursing documentation

A ward-based writing coach program was piloted at a metropolitan hospital in Australia to produce a quality improvement in nursing documentation. This paper describes the education program, which consisted of two writing workshops, each of one-hour duration followed by one-to-one coaching of nurses. This program could be carried out in any clinical area as a part of the regular education program. Nurses are encouraged to view their documentation practices in a critical light to ensure that the documentation is meaningful to readers within or outside the profession. The importance of nursing documentation as a communication tool for all health care professionals is emphasised. Barriers to meaning, such as fragmentary language or the use of unofficial abbreviations, are discussed. Nurses are also encouraged to document the patients condition, care and response to care using defined principles for nursing documentation. This program would be transferrable to any clinical setting looking for a ward-based education program for nursing documentation.

Engaging clinicians in evidence based policy development: the case of nursing documentation.

Abstract A lack of consistent policy direction, revealed by a review of nursing and midwifery documentation, presented researchers with an opportunity to engage clinicians in the process of evidence based policy development. By utilising the framework informed by both practice development and the principles of evidence based practice, clinicians were taken through an education program and a series of activities to develop their skills in discerning how research evidence and other literature can inform policy development. The clinicians’ involvement maximised their investment in the final policy. Clinicians synthesised all the evidence associated with nursing and midwifery documentation and produced a set of seven guiding principles that formed the basis of an area wide policy for nursing and midwifery documentation. The strength of this approach to policy development was that the clinician’s experience ensured that the concerns of the clinicians were included in the policy. Difficulties in completing tasks outside meeting times were highlighted.

Forged by Fire: Margery Kempe's Account of Postnatal Psychosis

The opening sequence of the autobiography, The Book of Margery Kempe, written in approximately 1439, describes an episode of illness after the birth of a first child, which medical historians have identified as postnatal psychosis. Margery however, interpreted her experience of postnatal psychosis in terms of her own worldview, using a Christian paradigm. She was convinced that her recovery was an example of Grace emanating from her special relationship with God which gave her divine knowledge about how to change her life. This led to Margery living a life of remarkable independence for a woman in medieval patriarchal society, as a pilgrim and mystic challenging structures of both marriage and church. By reading Margery’s autobiography through both modern interpretations of postnatal psychosis and her medieval interpretation of illness as a result of sin and recovery as a result of her relationship with God, this article celebrates Margery’s remarkable achievements as she turned towards living a life in the spirit and demanded her independence. Her story demonstrates how the meaning that the person themselves makes of their life threatening illness can lead to emancipation.

Evaluating an intensive ward‐based writing coach programme to improve nursing documentation: lessons learned

AIM This study aimed to develop a ward-based writing coach programme to improve the quality of patient information in nursing documentation. BACKGROUND Omissions in the patient information make nursing notes an unreliable source for care planning. Strategies to improve the quality of nursing documentation have been unsuccessful. An education programme, with one-to-one coaching in the clinical environment, was tested. METHOD A concurrent mixed methods approach including a pre-post test intervention and control design for the quantitative component combined with a qualitative approach using a focus group (eight nurses) was used. Healthcare records for 87 patients (intervention) (46 pre and 41 post) and 88 patients (control) (51 pre and 37 post) were reviewed using the Nursing and Midwifery Content Audit Tool for quality nursing documentation. Sixteen nurses from two intervention wards participated in an introductory workshop with 2 weeks of coaching. No intervention was given to the control ward. RESULTS No significant differences were found between the wards across the 14 criteria representing quality documentation; most criteria were present in 75% or more of the records. Improvements were demonstrated in both the intervention and comparison units. Themes identified from the focus groups included the impact these changes had on nurses and patients, perceived difficulties with nursing documentation, medicolegal aspects and the attributes of an effective writing coach. CONCLUSION Writing coaching is a supportive approach to improving nursing documentation. Also, regular auditing prompts nurses to improve nursing documentation. Further research using larger sample sizes can further confirm or refute these findings.

Challenges in adapting a survey: ensuring cross-cultural equivalence

BACKGROUND The increase in the number of international research studies means more surveys need to be adapted for use in different languages. To obtain valid cross-cultural study results, researchers often use translated surveys. AIM To describe the translation process used, and lessons learned by a bilingual English/Mandarin PhD student and her three English-speaking supervisors when developing and translating an English-language survey for use in a study in Taiwan. DISCUSSION In evaluating the translation process in this study, the three criteria of content equivalence, semantic equivalence and conceptual equivalence are discussed in relation to the challenges these presented to the research team. Some of the ways the team addressed these challenges are also considered. CONCLUSION The time available for the research and the ability of translators need to be assessed when adapting surveys for use in different languages and cultures. Sharing experiences and lessons learned in the translation process was worthwhile, as all members of the research team came away with new knowledge and an understanding of the need to ensure the final version of a translated survey is culturally congruent. IMPLICATIONS FOR PRACTICE To accurately translate a survey into another language, it is essential that one of the researchers be fluent in that language. This guarantees the closest fit of content and semantic and conceptual meaning.