Eva Törnvall

Nursing documentation for communicating and evaluating care.

AIMS To investigate the utility of electronic nursing documentation by exploring to what extent and for what purpose general practitioners use nursing documentation and to what extent and in which cases care unit managers use nursing documentation for quality development of care. BACKGROUND As health care includes multidisciplinary activities, communication about the care given is essential. To assure delivery of good and safe care, quality development is necessary. The main tool available for communication and quality development is the patient record. In many studies, nursing documentation has been found to be inadequate for this purpose. DESIGN This study had a cross-sectional descriptive design. METHODS Data were collected by postal questionnaires, one to the general practitioners (n = 544) and one to care unit managers (n = 82) in primary health care. Data were analysed by descriptive statistical and qualitative content analysis. RESULTS The general practitioners usually used the nursing record as the foremost source of information for treatment follow-up. The results, however, point out weaknesses and shortcomings in the nursing records, such as difficulties in finding important information because of a huge amount of routine notes. The care unit managers generally (74%) used the record for statistical purposes, while only half of them used it to evaluate care. CONCLUSION Nursing records need more clarity and need to be more prominent regarding specific nursing information to fulfil their purpose of transferring information and to constitute a base for quality development of care. RELEVANCE TO CLINICAL PRACTICE The results of this study can provide a part of a basis upon which a multi-professional patient record could be developed and which could also function as an alarm to managers at different levels to prioritize the development of nursing documentation.

Swedish Diabetes Register, a tool for quality development in primary health care.

Introduction In Sweden, quality indicators in health care have been the basis for developing National Quality Registers. The Swedish National Diabetes Register (NDR) - one of the largest diabetes registers globally - was introduced in primary health care (PHC) in the county of Östergötland by an implementation project, 2002-2005. Aim The aim of the present paper was to investigate, by using the results of the NDR, whether the registration led to sustained outcomes of medical results of diabetes care in PHC in the county during the period 2005-2009. Method HbA1c, blood pressure (BP), albuminuria and low-density lipoprotein-cholesterol were registered online in the NDR. In 2005 and 2006, goal achievement for HbA1c was measured and compared between PHC centres (PHCC) within the county. In 2007, achievements to national goals were compared between the PHCCs within the county and with those Swedish counties that had attained a sufficiently high registration rate. In 2008 and 2009, the average county results were compared with the corresponding national average measurements for all 21 Swedish counties combined. Result In 2005, a clear improvement trend for HbA1c and BP was shown within the county. In 2007-2009, goal achievements in the county studied were slightly better than the other counties measured and the country as a whole in almost every comparison. Discussion The present study has shown association between medical results and registration in the NDR. As the project was primarily a quality improvement work, the results have continuously influenced the development of diabetes care. Both the health professions and the county council now have - in the NDR - an effective and rapid method for evaluation and follow-up of diabetes care. The systematic documentation, followed by comparisons and analyses, create ideas for care improvements.

The Swedish National Diabetes Register in clinical practice and evaluation in primary health care

Aim The purpose of this project is to describe the use of the Swedish National Diabetes Register (NDR) in clinical practice in a Swedish county and to specifically monitor the diabetes care routines at two separate primary health-care centres (PHCC) with a special focus on older patients. BACKGROUND According to Swedish law, all health-care units have to maintain a system for quality evaluation and improvement. As the NDR holds the most important quality indicators, implementation of the NDR in primary care was carried out by an implementation project in 2002-2005. METHODS Initially, a digital questionnaire about NDR routines was sent to all PHCC. Statistics about hemoglobin adult 1c (HbA1c) and blood pressure (BP) was presented for the diabetes teams at two centres who were also interviewed. The responses became the basis for a focus group interview with both teams together, with data subject to content analysis. Findings The study showed that reporting to the NDR has become a compulsory routine in primary care. The diabetes nurse specialist was responsible for the practical management of the register and used the NDR for continuous monitoring of the patients. Most centres used the NDRs statistics for evaluation and analyses annually. The diabetes nurse adapted the visits to the patients wishes and general condition. Only in terms of target values for HbA1c and BP did they accept slightly higher values for the older patients. Since the NDR was implemented, the registration rate has remained at 75% and has not increased. The reason given was that patients with diabetes living in nursing homes are checked up by the municipal nurse who does not use the NDR. However, the risk of omitting older patients in the NDR could be considerably decreased if data could be transferred from the electronic patient record.

Double documentation in electronic health records

Documentation in the patient record must be systematic and rigorous. However, each health care profession documents parts of the electronic health record (EHR) separately. This system can lead to double documentation. The aim of the study was to describe the amount of double documentation in health records for in-patients. A retrospective descriptive review of 30 records for in-patients diagnosed with hip fracture was conducted. Double documentation occurred on all records reviewed during the stay in hospital and in or between all professions reviewed. In total, 822 instances of double documentation were found. The EHRs available today are not designed to monitor processes. Instead, they follow each health profession, which can lead to double documentation. It would be desirable to develop an EHR from a process perspective and not a record per profession.

Education to Increase Skills in Research Methods among Clinicians in Health Care

Introduction: The aim of this study was to evaluate participants’ and managers’ experience of the design and content of an education programme. The Knowledge to Action (KTA) framework was applied to identify the steps of knowledge creation and action in the education programme. Methods: Data were collected from 18 participants representing two groups: participants in the intervention and supervisors and managers. Two focus groups took place: two with participants in the intervention (4 and 3 in each) and one with eleven managers. Results: All steps in the KTA framework were identified and discussed from several aspects. The importance of selecting projects that were relevant and added value in their clinics was mentioned by all participants. The participants also mentioned that after the education, they had further understanding and increased skills in how to be active and perform continuous improvement projects. The step in the KTA process regarding how to adapt knowledge to local context was not discussed explicitly by the participants or managers. Discussion: Education in research methods and performing improvement projects to develop the clinic creates a more positive attitude to working with continuous improvement. The participant’s self-esteem and knowledge increased regarding how to work with improvements. It is important to have the manager’s support to perform a project. Emphasis was on knowledge inquiry and synthesis and presenting the results with or without possible solutions. The participants and managers talked about barriers and knowledge use more generally and at an organizational level. This means that the participants did not gain the last bit of knowledge needed to put the action into practice. This implies that the problem regarding lack of implementation skills in health care might remain.

Preliminary Evidence for the Usefulness of Standardized Nursing Terminologies in Different Fields of Application: A Literature Review.

PURPOSE To examine the effects of using standardized terminologies in nursing. METHODS A systematic literature research was conducted in June 2015 going back to January 2007. A modified narrative synthesis was used as the structure for the analysis. RESULTS Twenty-three articles were included. Three themes were identified: enable evaluation of nursing-sensitive outcome indicators, enable calculation of resource consumption, and characterize nursing care. CONCLUSIONS The studies included in the analysis described evidence for usefulness rather than effect. In all the studies, standardized nursing terminology was found to be essential for measuring, clarifying, and understanding nursing care. IMPLICATIONS FOR NURSING PRACTICE The use of standardized terminologies could be advantageous. However, there are shortcomings in nursing documentation and the use of standardized nursing terminologies that obstruct evaluation of nursing care.