A nurse is caring for a client who had a recent stroke. prior to transferring

Information work is a critical part of the medical endeavor. Strauss and Corbin note that trajectory work, as they view medical care, requires information flow before and after each task or task sequence to maintain continuity of care. Tasks are not isolated but are intertwined and build on one another to achieve patient goals. Nurses bear a large burden in both managing and implementing the interdisciplinary team’s plan for the patient, as well as documenting the care and progress toward goals. As a result, nurses spend considerable amounts of time doing information work. There are several genres of nursing documentation studies: those that examine recordkeeping practices as a whole, those that examine issues relating to the documentation (time, content, completeness), and comparative evaluations of different types of changes in the documentation regime including automation versus paper. Taken together, these provide both detailed and broad knowledge of nurses’ recordkeeping practices and highlight the reasons why any change (manual or computerized) is so difficult to integrate into nursing practice.

General Recordkeeping Practices of Nurses

Nursing documentation covers a wide variety of issues, topics, and systems. Researchers, practitioners, and hospital administrators view recordkeeping as an important element leading to continuity of care, safety, quality care, and compliance. Studies, however, reveal surprisingly little evidence of the linkage between recordkeeping and these outcomes. The literature features multiple exhortations and case studies aimed at improving nurses’ recordkeeping in general or for specific diagnoses.,

The literature also reveals the tensions surrounding nursing documentation. These include: the amount of time spent documenting; the number of errors in the records;,, the need for legal accountability; the desire to make nursing work visible; and the necessity of making nursing notes understandable to the other disciplines., For the purposes of this review, we confine ourselves to discussions of either manual or automated nursing systems of documenting patient care, primarily in hospitals. As we have found, while there are good and well-designed individual studies, the different methodologies, populations studied, and variables analyzed have led to little generalizability across the research, making comparisons between them impossible.

There are several literature reviews of nursing documentation systems. Urquhart and Currell completed the most systematic and comprehensive review, examining the literature through 2004. They focus on nursing record systems as variations in the systems effect nursing practice and patient outcomes. Currell and Urquhart conclude that nurses experience tensions between patient care needs and hospital management-promoted documentation rules. They also found that the studies show both mixed responses to new systems and inconclusive links between the nursing documentation system used and its impact on patient care. Also noted was the lack of standardization among systems.

In a more targeted literature review, Langowski examined the relationship between quality health care, particularly safety, and point-of-care online nursing documentation systems. Unlike Currell and Urquhart, Langowski found that overall documentation quality improved with an online electronic health record (EHR). The measures used, however, varied between the studies, and documentation impact on quality was assessed through evaluating the presence of certain types of information and the frequency of data entry. The accuracy of the information was not evaluated. Nurses’ satisfaction with documentation systems has also been used as a measure of quality though the relationship between satisfaction and documentation is never clearly delineated. The variation in the definition and measures used for evaluating quality is characteristic of this literature.

The final review was carried out by Karkkainen, Bondas, and Eriksson. They conducted a metasynthesis of 14 qualitative research reports to determine how well individualized patient care was represented in nursing documentation. Karkkainen and coworkers identified three themes in the literature reflecting the tensions in the record: demands of the organization, nurses’ attitudes and duties, and the patient’s involvement in care. This mirrors the findings of Currell and Urquhart. In conclusion, Karkkainen, Bondas, and Eriksson argue that individualized patient care is not visible in nursing documentation, and that current methods used to standardize communication in the records (forms with check-off lists) contribute to this gap. In another work, Karkkainen and Eriksson note that, although standardized forms of documentation can enhance concise and directed information, poorly designed forms may enhance document content but do little to support patient-centric care. The challenge is to design systems that are patient focused but also reap the benefits of standardization in terms of more accurate, precise, and up-to-date information transfer among all members of the interdisciplinary team.

Several single studies provide additional insight into nursing recordkeeping practices. Allen examined nurses’ views of the nursing record and its routine usage in practice. Using observations and interviews, Allen found that nurses were ambivalent towards the records, both seeing them as a symbol of the place of nurses in the clinical arena, but also reporting that the records are too heavily structured by management, a finding echoed throughout the literature (e.g. Lee and colleagues). As a consequence, Allen points to the practice of nurses developing shadow documentation systems (informal nursing records and ward diaries) that help nurses maintain a high-level overview of the patient’s care on one’s shift.

In another qualitative study, Hardey and colleagues observed nurses in five acute elderly care wards at a district general hospital in the south of England. They argue that “scraps,” individualized information systems, contained a unique combination of personal and professional knowledge and changed dynamically in response to patient care on a shift. The main source of information in the scraps was information conveyed during the nurse handover. This finding suggests that scraps provide information not found in the patient record. Instead the scraps contain the summarized or synthesized version of the patient’s story that includes only the information the nurse feels is needed to carry out care effectively on one’s shift.

Ngin picks up on the idea of information work as discussed by Strauss and Corbin and provides an in-depth analysis of nurses’ retrieval, interpretation, documentation, and passing of information. She, too, found that nurses relied less on the formal forms of documentation in the medical record and the care plan than on informal sources; her subjects preferred getting information directly from other nurses who had first-hand, observational knowledge of patients or from summary documentation, such as in Kardexes or personal notes. Ngin quoted nurses as saying, “The Kardex is a ‘living document’ which nurses have dubbed the Bible of nursing care. On the other hand, nurses tend to regard care plans as ‘just a requirement’” (p. 81). Ngin also differentiates between coordination of care (which she saw as the role of the Kardex, various worksheets, and more personalized information systems) and continuity of care (which she viewed as sustained by handovers).

In combination, these reviews and studies indicate that nursing documentation in the medical record does not meet the espoused purpose of being a communication tool that supports the continuity, quality, and safety of care. The evidence presented in this section also points to several conditions that perpetuate misunderstanding of nursing work and the means to track it. First, there is wide variation in recordkeeping practices between units and between health care organizations. Second, nurses heavily utilize shadow recordkeeping systems to aid in immediate patient care activities and decisions. Finally, there is an overwhelmingly negative attitude toward formal recordkeeping—either outright hostility or the view that documentation is “just a requirement.”

Representativeness and Completeness of the Content

In several more targeted studies, the central issues of concern were how well the records reflected the care given and accuracy of the patient’s condition. Tornvall and colleagues audited EHR records and found that reports of medical status and interventions were more prevalent than nursing status. The authors concluded that nursing documentation was limited and inadequate for evaluating the actual care given. Ehrenberg and Ehnfors’ triangulation between data from a chart review and interviews of nurses revealed little agreement between the records and the care nurses reported as having given. The researchers went so far as to state in their findings (p. 303) that “there are serious limitations in using the patient records as a data source for care delivery or for quality assessment and evaluation of care.”

Another set of studies examined the completeness of nursing documentation; these typically utilized chart review and audit as a methodology. The issue of completeness is important; Croke cites failure to document as one of the six top reasons that nurses face malpractice suits. In terms of overall completeness, Stokke and Kalfoss found many gaps in nursing documentation in Norway. Care plans, goals, diagnoses, planned interventions, and projected outcomes were absent between 18 percent and 45 percent of the time. Taylor found that many of the care plans reviewed did not convey the specific information necessary to carry out the required procedure. One third of the nurses in this study mentioned accessing written documentation but did not express any preference for care plans.

Other completeness studies have evaluated the impact of the form type and content required. In a controlled clinical trial utilizing a chart review method, Sterling analyzed wound assessment documents from three different units. While more of the important details of wound assessment were recorded when using a wound assessment chart, missing information was found for both charting methods (conditions) in the study. In another controlled clinical trial with home care nurses, Tornkvist and colleagues administered an educational intervention focusing on pain management. Their findings indicated that several statistically significant improvements in care were achieved after the introduction of the pain-advisers in the study units. Most pertinent to this chapter, the nurses’ satisfaction with their written documentation on pain increased with the addition of several new types of assessments used for charting pain.

While computerization has been referred to as a cure for incomplete records, the evidence on this is also mixed. Larrabee and colleagues found that completeness increases over time after system implementation, with expected gains not being realized until 1 year after implementation. Care planning systems are also not immune from problems with the completeness of documentation. While Bjorvell and colleagues reported increased completeness of documentation, particularly in the proportion of discharge planning notes, Griffiths and Hutchings’ audit of records from home health care nurses found initial nursing assessments poorly documented, affecting later care.

The studies in this section indicate two things. Completeness of a record may have an impact on the quality of care, but only if it reflects completeness of the right content. Echoed again here is that document focus, rather than the patient-centric nature of the medical record, does little to support shared understanding by clinicians of care and the communication needed to ensure the continuity, quality, and safety of care. The typical content and format of documentation—and its lack of accessibility—have also resulted in document-centric rather than patient-centric records.

Time Spent Documenting

Time spent documenting patient care is generally not regarded by nurses as being patient care, even though there is a Nursing Intervention Classification (NIC) term for it. Studies focused on time indicate that nurses spend a significant amount of time recordkeeping. In the most comprehensive literature review on time, Poissant and colleagues reviewed 11 studies examining documentation time before and after moving from a manual to an online system. Of these studies, six reported a time savings when using a computer. There was up to a 25 percent savings by nurses charting with bedside systems. Three studies reported increased time, particularly in the one study that employed handheld computers. However, of the three studies that assessed nurses’ efficiency by using the patient as the sampling unit, the results were negative—more time was spent on documentation per patient after system implementation, with increases ranging from 7.7 percent to 128 percent. The authors propose that time efficiencies are gained by standardized forms in systems, although some systems require more information to be documented.

Other studies have exposed the overall documentation burden carried by nurses. Hardey and colleagues found that recordkeeping was given lower status and priority than was direct patient care. It was also viewed as excessively time consuming. Nurses regularly copied data from the medical record and other documents to create personal records that guided their activities. Korst and colleagues conducted a work-sampling study over a 14-day period. Out of 2,160 observations, the average percent of time nurses spent on documentation was 15.8 percent; 10.6 percent for entry on paper records and 5.2 percent on the computer. The percentage of time spent on documentation was independently associated with day versus night shifts (19.2 percent vs. 12.4 percent, respectively). Time of day is also a factor in retrieving information.

The series of studies in this section indirectly expose the cost implications of maintaining medical records that offer little assistance to clinicians in the provision of patient-centric care. Moreover, maintaining medical records that bring little clinical value not only wastes nurses’ time but also limits the time available to engage in value-added care activities. The cost implications alone justify a call-to-action to redesign documentation systems so that they are patient-centric and aligned with intended purposes.

Studies That Focus on Improving Documentation

Deficiencies in the nursing record, such as problems with accurately representing the patient, the time-consuming nature of recording, and the completeness of the record, have led to a series of interventions aimed at improving nursing documentation. The impetus for changing nursing documentation has come from several sources: hospital management, the nurses themselves, and nursing researchers. Compliance with legal mandates, paperwork reduction campaigns, and meeting professional standards are also common reasons for changing recordkeeping regimes.

The changes made to the documentation process to reach these goals vary broadly. Much of this literature is characterized by contradictory case studies. Scharf reported a case study of one hospital that simplified a set of complex forms to enable nurses to spend more time caring for patients while still meeting the Joint Commission’s documentation requirements. Another case study involved a change from a preprinted form to a free-text, handwritten care plan for each patient. The studies reviewed include examples of those focused on understanding users’ needs (through assessing attitudes and opinions) and those focused on implementing and evaluating interventions designed to improve documentation.

Dillon and colleagues conducted a survey to assess nurses’ readiness to adopt a new EHR. Their findings indicated that nurses had a positive overall attitude, although nurse age was a significant factor in determining nurses' attitudes regarding the EHR. Nurses were concerned, though, about the impact of the new EHR on quality health care delivery. In closing Dillon and coworkers noted that “these results clearly show that the nurses have real concerns about the new impending computer system and that the new system may be risky and might remove the human component of what they do” (p. 144). For example, a comment made by one nurse reflected the concerns of many, “I just don't want the system problems to interfere with patient care.” One of her colleagues also commented, “I'm nervous about it [the impending system implementation]—hoping that it will not slow down my productivity—or be too time-consuming” (p.144).

Other studies have used educational interventions designed to improve documentation alone or documentation and care. Karkkainen and Eriksson completed a pre- and postintervention study, which involved an educational intervention to have nurses apply a theory of caring science to the care plans, to promote a more patient-focused documentation. Chart audit was done pre- and postintervention, and questionnaires assessed nurses’ attitudes about this theory-based recording method. The major change observed was more attention by nurses to patient views and increased recording of these in the plan.

Studies of computerized charting and care planning systems usually provide some measure for nurses’ satisfaction. Two surveys of nurses’ attitudes toward computerization are important to note. Axford and Carter’s study on how nurses believed computer technology impacted their practice is important in this regard. Their survey asked about resource consumption, nursing work practices, and professional and patient outcomes. Their findings indicated that nurses did not think technology would have a negative impact on practice. This was true for both those knowledgeable about computers and those less familiar with them— although the strength of this belief did vary, with experts feeling more strongly.

Other researchers have examined the effects of computers on nursing documentation directly. Nahm and Poston did a quasi-experimental, modified time series study that measured the effects of the nursing module of a point-of-care clinical information system on nursing documentation and patient satisfaction. Data were collected before implementation, and after implementation at 6-, 12-, and 18-month intervals. Compliance with items applicable to nursing documentation in the JCAHO Closed Medical Review Tool was used to assess the quality of nursing documentation. Nahm and Poston found a statistically significant increase in the quality of nursing documentation after system implementation and a reduction in the variability of charting. Most importantly, charting compliance increased and continued at the 12- and 18-month time points after initiation of the new system. This indicates that change is incremental, and that longitudinal studies are critical to assess the impact of computer systems.

The body of the literature reviewed in this section provides evidence indicating that well-constructed interventions, such as education and revising formats (automation and forms), can enhance documentation and improve patient care. The evidence also suggests that there is a time-related pattern to user satisfaction, perceptions of value, and achievement of desired documentation outcomes following the implementation of new computer information systems. Nonetheless, the findings must be interpreted with caution due to wide variation of the settings examined, interventions applied, and methods of evaluation. As with all of the literature in this area, the main limitation is lack of generalizability, due primarily to the wide variation of documentation practices within and across organizations.

Nurse Care Planning and Plans

In health care organizations, the EHR, oral reports, handoffs, conferences, and health information technologies (HIT) are intended to facilitate information flow. In particular, the JCAHO specifically conceptualizes the care planning process as the structuring framework for coordinating communication that will result in safe and effective care. The Essentials of Baccalaureate Education for Professional Nursing Practice, drafted by the accrediting body the American Association of Colleges of Nursing, lists several core competencies that directly relate to the nurse’s care planning process including the ability to “…diagnose, plan, deliver, and evaluate quality care” (p. 11), “use appropriate technologies in the process of assessing and monitoring patients” (p. 14), “apply health care technologies to maximize optimal outcomes for patients” (p. 16), and “develop a comprehensive plan of care…” (p.16). Although there appears to be clear value to effective care planning and the process of communicating the plan, evidence of this in the literature lacks specificity.

The patient care planning literature encompasses a wide variety of concepts, studies, and interventions. The main subdivisions of patient care planning in the literature are advance care planning (care at the end of life), case management (working with the entire medical team and associated professionals), and critical pathways or protocols for treating specific diseases. As defined, these categories are all potential conceptual matches and should encompass nurse-related care planning and plans. The majority of the care planning literature, however, is disease-oriented or medically focused, with little attention to the actual judgments and actions nurses take in carrying out the interdisciplinary plan at the point of care. Nor does this literature evaluate the impact of nursing care on patient outcomes. We believe the following illustrates the content of literature related to nurse care planning and plans.

Several studies have been done focusing on the introduction of the Scandinavian VIPS (well being, integrity, prevention, safety) model into care planning. Ehrenberg and Enfors performed a stratified, randomized controlled trial using chart audit and interviews. They reported that their study group that received a new form and educational intervention exhibited increased completeness and correctness of documented information, although there were still some areas in which the control group documented better than the study group.

Care plan findings from Mason’s qualitative study indicated that care plans were not thought to adequately represent the patient, and consequently were not used in the planning or evaluation of care. Observations conducted as part of this study confirmed that the major guides to practice were report, direct observation of the patient, and bedside charts. In these clinical units, the care plan was viewed as actually discouraging thinking, because the standardized formats hindered individualized care by operating as check-off lists that discouraged nurses from engaging in mindful care planning. In one unit, however, the care plans were successfully integrated with practice. Nurses’ attitudes toward care plans in this unit were generally positive and the plans were used to aid in explanation and communication, and to guide practice. In this unit, care plans were kept at the bedside. The success of nurses’ adoption of the care plans was attributed to the fact that they were perceived as clinically driven, more representative of the patient’s condition, and there was a sense of local ownership.

Smith and colleagues studied the implementation of a computerized care planning and documentation system, using the NIC and nursing outcomes classification (NOC) framework. Data were collected through questionnaires, observations, and chart audits both before and after computer implementation. Post implementation data revealed that the nurses’ attitudes toward computers were more negative and charting time was unchanged; however, chart audits revealed improvement in the completeness of the nursing record.

In research where the intervention has focused on changing the care planning process, findings have shown that patient outcomes can be improved. Implementation of a care pathway for post surgical patients, to streamline nursing care of postoperative colon resection patients, resulted in a statistically significant shorter length of stay. In another controlled study, From and colleagues found that new care planning forms, as opposed to a narrative written in the medical record, could be associated with earlier recognition of patient problems, a shorter length of stay, and a higher accuracy in planning the discharge time.

Other studies have reported finding previously noted problems in the care planning practices. Research on the effects of the NANDA International, Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC) terminologies in the care planning process has also shown mixed results. Scherb found that nursing care did make a difference in patient outcomes. However, because the method of data capture, it was impossible to identify the nursing diagnoses and interventions that contributed to the positive patient outcomes.

In a related study, Lillibridge found that when nurses were asked to list the type of data they would normally collect using specific examination techniques, 23 percent provided nursing assessment details. It can be argued that if nurses were provided with an explicit nursing framework (and language) to document and communicate about their care that nurses and the interdisciplinary team members would more readily understand the importance and impact of nursing care and patient outcomes. Others have also found that the care plans typically do not reflect actual nursing practice.,

Even when care planning interventions are similar, as in the case of the introduction of the Scandinavian VIPS method for nursing documentation, results vary among studies. Studies by Darmer and colleagues show both more methodological rigor and more positive results. This controlled, longitudinal study introduced the VIPS care planning model to nurses on eight units (four study and control units, respectively). The intervention consisted of different educational interventions prior to utilizing the VIPS care planning model. Data included surveys of nurses’ attitudes towards documentation and their knowledge of the new regime. Nurses in the study group had more confidence in their ability to create good care plans and did better than the control group on the knowledge tests. Overall, the nurses in the study by Darmer and coworkers were more positively predisposed towards documentation than those in another VIPS study, by Björvell and colleagues.

The Björvell and colleagues study also featured a VIPS intervention and results overall were positive. There was a statistically significant score increase in quantity (P values for the quantity variables ranged from P < 0.0001 – 0.0003) as well as quality of the nursing documentation (P values of the quality variables ranged from P < 0.0001 – 0.0002). In a followup study, Darmer and colleagues reviewed 600 charts utilizing the VIPS model at four sites using a standardized audit tool. They found that nursing documentation significantly improved during the course of the study (P = .00001). After the second year, the participants used the keywords appropriately and correctly according to the VIPS model. Overall, this structured implementation program significantly improved nursing documentation.

Implementing a new care planning system without sufficient cultural, educational, and organizational support has been identified as leading to problems. Educational interventions, in particular, are a major focus in the literature. Hansebo and colleagues found that although care planning documentation increased after an educational intervention, the level of assessment was low. The authors concluded that educational interventions were needed to improve clinical judgment.

Lee also identified major educational issues associated with the implementation of computerized documentation systems. He argues that launching a care planning system alone, without knowledge of the diagnoses or how to use the care plans in clinical decisionmaking, limits their utility. For Lee and colleagues, the new system also increased nursing workload, primarily due to a lack of computers, and competition for terminals with other professionals and students. In the end, the nurses found the care plan lacking in three aspects: (1) content, primarily the inability to individualize patient care; (2) poor system function; and (3) lack of system integration with the other information technology systems. In another article, Lee and Chang report on an interview-based evaluation of this system. In this latter study, the nurses interviewed saw the new system as paperwork and not patient-oriented.

The quality of and implementation strategy for care planning systems has impeded adoption as much as the actual care plan within the system. Ammenwerth and colleagues found that planning and documentation of tasks (P = .004) and report writing (P = .019) required significantly more time with the computer based system than with the paper based system. For the care planning module, no statistically significant difference between the study and control groups was seen due to the limited number of items. At the conclusion of Ammenwerth and colleagues’ study, seven nurses (58 percent) agreed that the PIK software application saved time for care planning, but only three agreed that PIK saved time for documentation of tasks or for report writing. The majority of nurses agreed that with PIK, nursing documentation is more complete (10 nurses), legibility is better (9 nurses), and that the quality of documentation is better (8 nurses). However, Ammenwerth and colleagues did not tie these findings to patient outcomes or changes in nursing practice. The conclusion that the introduction of a care planning system alone, without supporting organizational change, will not work is also supported by Spranzo’s work.

In summary, the nurse care planning literature indicates several things. First, when thought goes into the care planning process, better patient outcomes are possible. Second, altering the care planning process has thus far been done in an ad hoc manner and most of the evidence is from case studies. Individualized approaches have been implemented in specific settings. Their replicability across patient care settings, even from acute care to stepdown units within one hospital, has not been tested. While supporting the continuity of care on an individual unit is good, the larger issue of increasing continuity of care across time and space (across units and health care settings) needs to be addressed if patients are to receive truly holistic care. Third, current approaches to care planning have focused primarily on the care planning document itself. While some studies, have changed the care planning process, the focus has been the actual plan. Finally, when the care planning process has been computerized, there appear to be substantial system problems resulting from a lack of nursing input into the module’s design and functionality. Lack of nursing input has contributed to the failure of the nurses in these studies to embrace care planning and, at times, even to be able to judge whether a different care planning approach would result in better patient outcomes.

Towards an Interdisciplinary Plan of Care

Given the problems in developing a care planning system that works well for just nurses, it is clear why creating comprehensive systems that support interdisciplinary plans is that much more complicated. This is particularly true if Gage’s conception of interdisciplinary teams is utilized. He defines multidisciplinary teams as those in which consultation is a series of individual consultations, where interpretation is made independently by members of the medical team. On the other hand, interdisciplinary care planning occurs when the team collaboratively synthesizes the information and reaches consensus around treatment and goals for the patient. Much of the literature falls short of Gage’s ideal and what is categorized as interdisciplinary care planning should more appropriately be viewed as case management.

The majority of articles on interdisciplinary care planning focus either on case management or clinical pathways. These emanate from specialties and areas that traditionally have had closer ties among a variety of professionals (doctors, nurses, social workers) to manage a patient’s condition. Typical among the case management genre are case studies of interdisciplinary care planning in nursing homes or for the elderly. The clinical pathways articles focus on a specialty or specific unit, such as acute care. In one qualitative study of an interdisciplinary discharge planning process, Atwal found that many parts of the discharge process were regularly ignored and assessments were not done collaboratively. Nurses mentioned lack of time as the biggest barrier to interdisciplinary collaboration. Interdisciplinary care planning and the resulting plan can bring value to patients and enrich all disciplines; however, in its current iteration the vision proposed by Gage has not yet become a reality.