It is against this background that nurses must prioritise and at times ration elements of ... recorded evidence that this is not always seen as a priority action.
Documentation. Priority in practice: an analysis of the literature. Authors: Sandra Richardson & Polly Grainger Sandra Richardson BA, RGON, Dip Soc Sci, Dip Heal Sci (PG), Dip Tert Teach, PhD Candidate Nurse Researcher Emergency Medicine Research Group Christchurch Hospital Polly Grainger RN, DipHE (adult studies), RCompN, MN (Clinical) Nurse Coordinator - Clinical Projects Emergency Department Christchurch Hospital
Emergency Nurse New Zealand | Summer 2011 | P 8Abstract: Background: Nursing documentation enables continuity of patient care while meeting legal and professional standards. Despite an understanding of the role and importance of record keeping, examples of inadequate and inappropriate nursing documentation remain and this may be linked to a failure to assign an appropriate priority to these tasks.
Aim: This paper reviews literature relating to nursing documentation. The analysis was conducted with the following aims: (1) identify the scope of current literature related to nursing documentation, (2) identify discourses around prioritisation of documentation as a nursing activity and (3) to consider the implications associated with a failure to prioritise documentation.
Methods: A systematic style review of literature was undertaken, utilising CINAHL, Medline, AMED, PsycInfo and Cochrane databases. Elements of thematic and discourse analysis were utilised in the review of the literature. Findings: Literature identified fell into the following broad categories: documentation purpose, documentation practice, technological developments in documentation, documentation as professional practice, documentation as professional burden and documentation as protection.
Conclusions: Despite acknowledgment of the legal, ethical and professional significance of documentation in nursing practice, there remains evidence of low prioritisation of documentation activities. For this to be addressed there needs to be additional research to identify beliefs, attitudes and perceptions underpinning this aspect of nursing practice.
Key words: documentation, prioritisation of care, professional practice
Introduction Nursing as a profession is facing increasing constraints, including inadequate staffing levels and resources. It is against this background that nurses must prioritise and at times ration elements of their practice. One result is that tasks seen as not involving ‘direct patient care’ may be marginalised. Documentation is one such task, despite its increasing scrutiny by a range of personnel. Nurses are aware of the importance of maintaining effective documentation, but there is anecdotal and recorded evidence that this is not always seen as a priority action. An initial literature review was undertaken to identify beliefs, attitudes and perceptions about documentation. In particular, material was sought relating to the prioritisation and allocation of nursing time and resources to documentation.
Search Method The selection and analysis of literature had the following aims: (1) to identify the scope of current literature related to nursing documentation, (2) to determine the discourses around prioritisation of documentation as a nursing activity and (3) to consider the implications associated with a failure to prioritise documentation. Literature relating to nurses attitudes, perceptions and beliefs was specifically sought. The search strategy utilised a number of existing electronic databases including CINAHL, AMED, Medline, PsycInfo and the Cochrane Database. Material retrieved was limited to ‘English language’ and the time period 1995 to 2010. Broad thematic analysis was applied to identify the key subgroups present. These were identified in terms of the following categories: • documentation purpose • documentation as professional practice • documentation as professional burden • documentation as protection
Documentation Purpose Documentation is acknowledged as crucial in ensuring that quality care is achieved for patients. The ability to pass information between health professionals is an essential element of nursing practice. The growing emphasis on quality assurance and evidence based practice highlights the importance of accurate, effective and timely documentation of patient care. Jefferies, Johnson and Griffiths (2010) define the purpose of documentation as being to: “provide effective communication to the health-care team; provide for a person’s effective continuing care, enable evaluation of a person’s progress and health outcome and retain integrity over time” (p113). Aspects of care particularly vulnerable to the impact of poor quality documentation include patient safety, continuity of care, meeting ethical, legal and quality assurance requirements and providing a professional level of practice (Finn, 1997; Anderson, 2001; Barber, 2001; Frank-Stromborg & Christensen, 2001; Pennels, 2002; Teytelman 2002; Cheevakasemsook, Chapman, Francis, & Davies, 2006; Samuels & Fetzer, 2009). In the United Kingdom (UK) the National Audit Office identified that ‘poorly completed records are a major contributory factor to patient safety incidents’ (2005, p7). There is general consensus within the literature regarding the overall focus and purpose of nursing documentation. Currell and Urquhart (2006) define the nursing record system as a “record of care planned and/or given to individual patients/clients by qualified nurses, or other caregivers … under the direction of a qualified nurse” (p.1). The UK nursing and midwifery regulatory body identifies the role of record keeping in nursing as “…an integral part of nursing and midwifery practice, and is essential to the provision of safe and effective care. It is not an optional extra to be fitted in if circumstances allow…” (Nursing and Midwifery Council [NMC] 2010, p.1). Other outcomes include the demonstration of
professional responsibility and accountability for care provided (Iyer & Camp, 1995; Richmond, 1997; Benbow, 2000; NMC, 2010; Cheevakasemsook et al, 2006; Jeffries et al, 2010). There is a body of knowledge and research which considers the implications of failure to document, (Castledine, 2000; Frank, 2001; Teytelman, 2002, Gooding, 2004), but little specific data examining nurses’ rationale for this deficit in practice (Kerr & Lewis, 2000; Frank-Stromberg & Christensen, 2001). While nurses acknowledge the role and significance of documentation, it appears that this is given a low priority. Existing attitudes to documentation cannot change without understanding the rationale and critical processes that allow for failure to document. Documentation in nursing has been influenced by models of nursing care and the widespread introduction of the nursing process. It has been suggested that some instances of inadequate documentation stem from a lack of understanding of the nursing process, however, research demonstrates that even where nurses have a good understanding of this and are highly motivated to maintain standards of care, documentation still remains inadequate (Kerr & Lewis, 2000). Shepherd (cited in Anderson 2001) discusses the need to incorporate a personalised system of care into the formal nursing care plan, and identifies a conflict between the traditional task oriented documentation and the requirements of the nursing process. She suggests that ‘nurses are using a system of record-keeping that does not match the system of care delivery’ (p.22). Advances in documentation technology, techniques and the application of a wider range of nursing models have seen increasing challenges in regard to nursing documentation. Expectations have emerged around record accessibility, stability and security as well as the need for timely data entry, recording of comprehensive history taking, justification for nursing actions and decisions. There is increasing realisation that information recorded is accessible not only to other health professionals but also individual patients and family / whänau, which can place added strain on nurses.
Documentation as Professional Practice Nursing has been identified at various points in history as a vocation, an occupation and a profession. While there is still debate about the role of nursing, there is no doubt that a strong professionalising agenda exists (Schwirian, 1998). Central and integral elements to any profession include a specific, rigorous education programme, the development of a unique knowledge base, a firm theoretical base, altruistic motivation, autonomy, self regulation accountability and responsibility. It is in the areas of autonomy, accountability and responsibility that the development of specific nursing knowledge that documentation skills are essential. Gough (cited in Barber, 2001), suggests that more writing is required “because of the new structures of accountability, things like performance management, use of guidelines, clinical governance, audit and protocols.” (p.24). Accountability and responsibility are especially evident in the movement towards competency based practice; the need to record, and demonstrate professional practice is essential to support these concepts, which has further contributed to the documentation debate (Scott, 2007). The development of professional autonomy implies a corresponding acceptance of responsibility, on both the personal and the professional practice level. Autonomy is the right to carry out one’s practice without interference, a coveted characteristic of any profession (Walsh, 2000). Schwirian (1998) suggests that the establishment of a nursing knowledge base is essential for autonomy to occur. She states that without a knowledge base, little progress in either autonomy or monopoly of services is likely. However, the knowledge base must not only exist, but it must also be recognized, validated, and valued by nurses, other health professionals, health administrators and the general public (p13). In order for this to occur, nurses must articulate their practice and develop the skills
which show their uniqueness and contribution. The ability to accurately reveal nursing interactions in documentation is essential cornerstone to achieving this. Documentation is a practical means of generating the data needed for the development of nursing knowledge. A number of studies have focussed on nursing compliance with documentation standards. Gartlan et al (2010) explored the accuracy of documentation related to wound care, noting this is recognised as a core best practice component yet much was actually “ad hoc and incomplete” (p 2207). Other studies identified poor correlation between nursing documentation and pain assessment standards (Herd et al, 2009; Motov & Khan, 2009; Samuels & Fetzer, 2009). Failure of nurses to adhere to existing standards of practice and to clearly demonstrate them through documentation can impact on the acceptance of advanced nursing practice opportunities. The tradition of ‘oral knowing’ in nursing continues despite increasing requirements for formal documentation. It has been suggested that dissatisfaction with documenting care has further encouraged nurses to esteem oral communication and devalue written communication (Heartfield,1996). It has been argued that this ‘oral basis’ of nursing culture supports the continued oppression of nursing (Street, 1992) since disempowerment will remain if clinical nurses are unable to document their knowledge and practice for reflection and critique, or challenge the power base of medical and administrative culture and that this further exacerbates nurses’ inarticulacy (Street, 1992; Heartfield, 1996). The oral culture does not facilitate the systematic recording and analysis of nursing practice but the reluctance of clinical nurses to develop the skills necessary to give and receive knowledge through written forms of communication (either electronic or hand-written) restricts their capacity to facilitate change (Street, 1992). There is a general consensus in the literature that nurses struggle to write about ‘the real picture’ of what happens to the patient (Heartfield, 1996; Hardey et al, 2000). Kerr and Lewis (2000) attempted to identify factors that contributed to inadequate documentation by nursing studying behaviour in one unit. They found that nurses still rely heavily on long verbal handovers between shifts rather than a brief bedside handover from the nursing documentation. But there is no guaranteed correlation between skilled at verbal communication and efficient care documentation. For most people accurate factual reporting is not a strong characteristic; when asked to describe in detail a series of events, research shows that most people will report less than half the facts accurately (Nicklin & Dean, 1999). The effect of irregular and insufficient documentation can be misleading, not reflecting the clinical nursing care provided (Austin, 2006; Jeffries et al, 2010). Nurses need to develop the practical skills of effective written communication enabling them to translate the complexities of nursing interactions into a professionally credible medium. Professional care is represented by documentation in terms of both content and appearance. The content of the documentation should not only accurately demonstrate the care that has ocurred, but effectively communicate a patient’s situation and progress (Iyer & Camp, 1995; Pennels, 2001; NMC, 2002). Griffith (2004) comments that the standard of handwriting is a requirement of a nurses duty of care, since if subsequent professionals are unable to read any entries due to illegibility and harm results – then negligence can be considered. Nursing documentation represents a specialised style of communication and forms a key component present of nursing practice. Written communication is not simply ‘writing it down’; it requires both skill and experience. While nurses learn to take responsibility for nursing actions early in their career, this is often in regard to tasks that are predictable and prescribed, initially involving little decision making or critical analysis. In reality, each conversation with a patient is unpredictable and can reveal information that must be analysed and then communicated to other members of the team. Iyer and Camp (1995) concur stating nurses ‘make complex, sophisticated decisions concerning patient care, yet nursing documentation does not always reflect these decision-making
responsibilities’ (p.1). This gives rise to questions about nurses’ prioritisation of care. Is it that nurses fail to see documentation as a patient care activity? Is documentation seen as just ‘paperwork’ left to the end of the shift because of more ‘urgent’ actions? If nursing documentation is not accepted as essential (and relevant) in the direct provision of care, it is inevitably given a low priority in the overall time management plan of the individual nurse.
Documentation as professional burden Opinions regarding the utility of documentation vary with Heartfield (1996) suggesting “it is interpreted by some as the evidence of nursing actions, and dismissed by others as a misrepresentation of nursing care” (p. 98). Savy (1997) cites a nurse’s comment that “documentation is not real work. Real work is not documented” (p12), highlighting the ambiguity around the place of documentation in nursing. Kerr (2009) suggests that nurses often fail to value documentation related activities, seeing them as actions which distract and distance them from the provision of hands on patient care. Documentation is sometimes associated with the wider range of ‘bureaucratic’ tasks associated with nursing. Grainger (2007) found that prioritisation, time limitation and workload pressures due to patient acuity were commonly stated causes for not documenting. The increase in administration and seemingly ‘routine’ paperwork has been linked to higher stress levels in senior nurses (Barber, 2001). The differentiation between what is seen as ‘nursing’ and what is relegated to ‘administrative’ tasks is discussed, with a ward sister quoted as identifying the heavy workload associated with ‘admin’ tasks, stating that this takes on average “an extra eight hours on top of my nursing work” (p.25) (our emphasis). This suggests that while administration and general documentation are recognised as part of the nurses’ role, they are not accorded the status of nursing tasks. Advances in technology and the associated knowledge ‘explosion’ are also linked to increased documentation tasks. There is a general theme within the literature that documentation is ‘timeconsuming’ rather than an appropriate use of nursing time (Scoates, Fishman & McAdam, 1996; Savy, 1997; Barber, 2001, Grainger 2007). In order to take responsibility for the communication of information, it is necessary to understand the implications associated with inadequate or insufficient documentation. It is clearly difficult to take responsibility for what is documented if a nurse’s knowledge base is inadequate. In practice, nurses rarely admit to lack of knowledge - utilising evasion instead (Street, 1992). Attempts to ‘cover up’ knowledge deficit may leave the nurse and patient vulnerable, by not to ensuring adequate provision of cares. Nurses rely on extensive clinical information and specialised knowledge to assess and evaluate the processes and outcomes of their clinical decision-making. As nursing becomes more knowledge intensive, nurses are challenged to effectively manage this increasing body of knowledge (SynderHalpern et al, 2001).
Documentation as protection Nursing education about documentation stresses the need for careful, detailed explanation and rationale for every action used or considered yet simultaneously succinct. Documentation that contains too much information, or information that is irrelevant, is rarely sought or used, yet failure to document significant negative findings can be just as problematic (Street 1992; Glover, 2000; Austin, 2006; Jeffries et al, 2010). If nurses’ communication is for the purpose of influencing the behaviour of the nurse taking over the patient care, then the degree to which that nurse acts is a measure of the success of that communication (Street 1992). In an increasingly risk averse society documentation is required to demonstrate critical thinking and proving intention as well as
evidencing practice intervention to be valued for the protection it offers. Documentation from nurses is the written evidence of nursing practice, communication about patients and patient responses to nursing intervention. The nursing care plan has been proclaimed as a means of providing this communication (Tapp, 1990). At a practical level a plan of care is a communication channel among nurses and is believed to improve the quality of care and ensure the continuity of care. On a larger scale, nursing documentation is supposed to provide information for accreditation, quality control, research, justification of nursing budgets, and to direct, measure and evaluate nursing care. Specific documentation processes have developed that itemise nursing care, often in the form of care plans and pathways. Pennels (2001) argues that any tool expected to fulfil so many purposes is likely to invite contradictions, while Grainger (2007) identifies the potential to trigger resistance and adverse emotional responses within practitioners who may feel constrained in their practice as a result of structured documentation requirements. The demand for nurses to engage in time-consuming documentation has recently been a significant aspect of their work. Purkis (1999) suggests that nurses spend up to 30% of their time documenting care. She sees this as due to the increasingly litigious character of healthcare. It has been noted that nursing notes do not follow the ‘hearsay’ rule in which it is necessary for the author to be present when they are submitted as evidence (Nursing Board of Tasmania, 2003). There is also the adage that if nursing care is not documented, it ‘was not done’ (Glover, 2000) with implications for legal and professional investigations and proceedings. Purkis (1999) suggests that nurses find themselves labouring under the weight of two responsibilities – to account for their practice, and to complete the volume of paperwork through and upon which such accountability takes shape. Foster and Moore (1999) cite examples from the UK, where 70% of all complaints to the Health ombudsmen in 1995 were related to communication, and most of those specifically to record keeping. Furthermore, 56 practitioners were called to account for their practice to the UKCC, regarding failure to keep accurate records, with thirty being removed from the nursing register as a result. In meeting the ethical, legal and moral responsibilities of nursing practice, documentation serves as a benchmark for auditing and standards development. As the general level of public knowledge has grown, this increased understanding has led to greater consumer expectations. While this has the potential to empower patients, it may also clash with the reality of service delivery. It is within this environment that issues of accountability arise, nurses are increasingly finding themselves having to justify their practice. This includes having to provide evidence of actions and also rationale for omission of actions. It is little wonder then that nurses react by either ‘over-’ or ‘under-’ documenting in an effort to demonstrate competent practice. Many are intimidated by the potential consequences of committing comment to paper to produce more than a superficial list of tasks completed. This again reinforces the oral culture within nursing – the nuances of practice are more easily shared through conversations at ‘handover’, as are the personal interpretations and assessments deemed too ‘sensitive’ to commit to paper.
Conclusion: Pertinent, timely and accurate nursing documentation promotes consistency in patient care, and effective communication among nurses and other members of the healthcare team. Documentation is an essential way of effectively communicating change in a patient’s status and often the only evidence nurses have that care has been delivered to a patient is by means of documentation. Despite this, ambivalence to nursing documentation has been detected in current research. The importance of written communication is recognised, but inconsistencies also appear. While the
theoretical benefits associated with excellent documentation are often acknowledged, analysis of actual written communication suggests this is rarely achieved. Nurses continue to deliver the majority of direct patient care. The burdens of documenting the care they deliver and the potential effects on professional practice are significant.
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