Documentation is an important function of professional nursing practise. In spite of numerous improvement efforts globally, inadequate documentation continues to be reported as nurse authors investigate barriers and challenges.
The project aimed to improve nurses’ documentation of their patient assessments at the CURE Children's Hospital of Uganda in order to enhance the quality of nursing practise.
An action research methodology, using repeated cycles of planning, intervention, reflection and modification, was used to establish best practise approaches in this context for improving nurses’ efficacy in documenting assessments in the patient record. The researchers gathered data from chart audits, literature reviews and key informant interviews. Through analysis and critical reflection, these data informed three cycles of systems and practise modifications to improve the quality of documentation.
The initial cycle revealed that staff training alone was insufficient to achieve the project goal. To achieve improved documentation, broader changes were necessary, including building a critical mass of competent staff, redesigned orientation and continuing education, documentation form redesign, changes in nurse skill mix, and continuous leadership support.
Improving nursing documentation involved complex challenges in this setting and demanded multiple approaches. Evidence-based practise was the foundation of changes in systems required to produce visible improvement in practise. The involved role of leadership in these efforts was very important.
Assessment is the first standard of nursing practise (American Nurses Association
In a British study, Rothman
CCHU uses paper-based documentation, with the scientific nursing process as the documentation guiding framework. However, audits of patient records for quality assurance purposes and morbidity and mortality reviews revealed poor documentation of nursing assessments and other pertinent patient care information. Since the majority of nurses employed at the hospital were enrolled nurses with limited experience and little formal training in nursing assessment.
This project aimed to improve the documentation of nursing assessments in the patient record as a step toward improving nursing practise at the hospital.
CCHU: CCHU is a specialist paediatric neurosurgical teaching hospital, located in Mbale, Eastern Uganda. The hospital's focus is treatment of children with hydrocephalus, neural tube defects (including spina bifida), and epilepsy and brain tumours.
During the study period (2008–2012), the hospital had 40 beds (30 ward beds and 10 Intensive Care Unit [ICU] beds). There were, on average, 1230 admissions each year; 1180 of these children were being seen for the first time.
At CCHU the nursing service is led by a nurse manager and an assistant-nurse manager. A charge nurse on each shift is responsible the day-to-day running of each of the ward, ICU and operating room or theatre. The nursing care activities are organised under a total patient care delivery model in which the primary care nurse is responsible for all the care of a group of patients throughout the shift. The hospital employed 34 primary care nurses, the majority of whom were enrolled nurses. Enrolled nurses are registered with the Uganda Nurses and Midwives Council after a three year training programme in general nursing science or comprehensive (nursing & midwifery) nursing science. This level of training requires an Ordinary-level certificate (11 years of schooling) for entry into the training programme. Diploma and baccalaureate nursing training programmes require an Advanced-level certificate (13 years) and graduates are registered nurses.
Uganda: The economic cost of treating children with neurosurgical disease is substantial in developed and low resource countries alike (Rabiu & Adeleye
Baccalaureate nurse training in Uganda started in 1993 (Klopper & Uys
Documentation is reported to take up to 50% of nurses’ time per shift (Gugerty
According to Jefferies, Johnson and Griffiths (
Nurses’ perceptions and attitudes towards documentation impact the quality of how and what they document. Studies in various settings found that whilst nurses consider documentation important for nursing professionalisation, they consider it a burdensome secondary task that takes nurses away from direct patient care (Blair & Smith
The workplace environment can contribute to poor documentation. Heavy workloads, laborious documentation forms, fragmentary language (i.e. documentation language that is not understood beyond the local context), inadequate resources and hospital culture all impact the quality of nurses’ documentation (Prideaux
Given the significance of nursing documentation and the reality of poor documentation practises, it is not surprising that there have been resolute calls and subsequent efforts to improve its quality (Whitcomb
Training nurses to improve knowledge, skills and documentation practises has been a widely used strategy. For example, Jefferies
This project utilised action research and action learning methods. Revans (
Phases of project implementation.
Data from patient records revealed poor documentation of nursing assessments. Informal interviews of nursing leadership (key informants) identified inadequate training as a likely explanation for substandard documentation.
In October 2008 a five-day training workshop for all nurses employed at the hospital was planned and conducted by a multi-disciplinary team involving the hospital anaesthesiologist, medical officers, nurse managers and human resources staff (see
One month following the training, the researchers compared all records of patients admitted and discharged during a one week period.
Whilst training participants displayed improved assessment techniques, the chart audit showed no observable change in documentation practises. Comparison of the 2008 post-training documentation practises and content showed they were very similar to records made by different nursing personnel in 2001–2003. Therefore, training alone was insufficient to change practise.
Reflection on these findings pointed to a cultural component of documentation practise that would need to be addressed to achieve observable change in documentation of nursing assessments. The culture was defined in relation to the values, attitudes, competencies and patterns of behaviour (Feng, Bobay & Weiss
In Phase 1, the researchers identified a cultural component of nursing documentation practise that was a barrier to change and conducted a literature review to gain further understanding of the concept of culture in healthcare. Interviews with nursing staff, and visiting nursing students and professors from the United States provided additional perspective.
Findings guided modifications to the content and organisation of the hospital's traditional two-month orientation programme for newly hired nursing staff (
Topics at orientation.
Sequence | Topic |
---|---|
1 | Nursing as a profession and role development (and rehabilitation nursing). |
2 | Historical perspectives in nursing critical thinking and the nursing process. |
3 | The nursing process. |
4 | Laboratory orientation. |
5 | The nursing health assessment (History & physical assessment/examination). |
6 | Respiratory and cardiovascular system assessment. |
7 | Neurological system and gastrointestinal assessment. |
8 | Psychosocial and spiritual assessment. |
9 | Peri-operative nursing. |
10 | Musculoskeletal system head-to-toe examination? (Putting it together). |
11 | Documentation and care planning. |
12 | The ECG and cardiovascular monitoring. |
13 | Care of a client with hydrocephalous and Spina Bifida. |
14 | Holistic care concepts in rehabilitative nursing. |
15 | Communication and teamwork. |
16 | BLS and PALS and the role of teamwork. |
17 | Medication calculations, administration and emergency drugs. |
18 | CIC and bowel management. |
Topics from the 5-day workshop on documentation were incorporated into the orientation to address identified gaps. The first month of orientation was changed to exclusively classroom-based training with only limited ward time so that the new nurses learned the preferred knowledge and practises prior to exposure to the targeted undesirable practises and cultural norms. The second month of orientation included a mentorship period that socialised the new nurses to the ward, operating room or theatre and ICU environments. During this second month of orientation, the new nurses shadowed full-time employees and were oriented to other hospital departments (e.g. radiology, laboratory and physiotherapy).
Further, the researchers developed a new form to facilitate complete documentation of nursing assessments on admission and discharge. The form prompted documentation of a comprehensive nursing history and physical examination aligned with processes taught during orientation.
Charge nurses on the wards reviewed and commented on the redesigned assessment documentation form.
This second cycle of action research focused on initiating the process of culture change in two areas: professional nursing development – orientation, and systems changes – the redesign of the assessment documentation forms.
The charge nurses indicated that the first draft of the revised documentation form – a ruled paper with headings for complete health assessment – was unduly laborious. The form required much writing and relied on nurses’ recall of what to document. Therefore, the form needed modification before it could be introduced to the wards.
After implementation of the modified orientation programme, but before implementation of the new documentation forms, chart audits revealed improvement in newly hired nurses’ documentation at admission, and on a shift-by-shift basis. However, this change was not sustained; in spite of continual feedback and training, the documentation content and practise of new nursing staff reverted to the established inadequate documentation style.
Reflecting on this, the researchers concluded that the power of the culture was too strong to sustain improvement with new nurses quickly taking on the prevalent practises. It was concluded that the form would need to be easier to use in order to support adoption of the new form and documentation practises.
Phase 2 initiated the process of culture change. The purpose of Phase 3 was to build on the changes that, though not sustained, had been visible. A literature review on culture, quality improvement and change management focused reflection on systems changes as drivers of changes in practise. Necessary systems changes included: (1) redesign testing and implementation of the admission assessment form, (2) change in employment policy, and (3) new focus on creating a healthy working environment based on the American Association of Critical-Care Nurses’ (AACCN) standards (
Learning from the previous phase, the researchers planned to refine the documentation form(s) and modify other systems factors (appropriate staffing and healthy work environment), to achieve sustainable change in documentation practise:
The CCHU nurses’ experiences of providing care to children with neurological illness informed content revisions along with new evidence regarding the follow-up of children with neurological disability. According to Warf, Wright and Kulkarni (
Education level of nurses at the hospital.
Year (January) | Enrolled Nurses | Registered (Diploma) | Registered (BSN) | Total | |||
---|---|---|---|---|---|---|---|
Number | % | Number | % | Number | % | ||
2008 | 23 | 66 | 11 | 31 | 01 | 3 |
|
2009 | 16 | 48.5 | 16 | 48.5 | 01 | 3 |
|
2010 | 18 | 48.6 | 17 | 46 | 02 | 5.4 |
|
2013 | 03 | 9.4 | 28 | 88 | 01 | 2.6 |
|
The nursing department leadership initiated this practise improvement project and the hospital administration was aware of it. Participation by nurses was voluntary. Data was gathered and reported whilst ensuring anonymity and confidentiality.
To achieve sustained improvement in the quality of nurses’ documentation of their assessments required a change in the culture of nursing at CCHU along with modification of systems, continual training, mentorship and strong innovative nursing leadership.
Culture, in relation to patient safety and quality improvement in healthcare, comprises the values, attitudes, competencies and patterns of behaviour of employees (Feng
Organisational culture seems to drive and sustain change in quality improvement efforts by creating a new norm of practise. At the hospital, culture change was achieved through recruiting and socialising new nurses into new ways of thinking, thereby building a critical mass of staff with similar values, beliefs, attitudes and competencies in relation to professional nursing practise (Oliver, Marwell & Teixeira
Early in the project new nurses adopted improved practises, but quickly reverted to the established norm reinforced by the culture. This failure to sustain improvements elucidated a need for ‘systems thinking’ to consolidate the change in documentation practise. According to Waldman and Schargel ( Systems thinking suggests that one can only understand (and subsequently improve) a system by looking at how all the parts interact; focusing on, even optimising, parts in isolation will not optimise final (rather than in process) outcomes. (p. 118)
Therefore, sustained change was made possible when multiple interventions were implemented in concert. These were: (a) redesigned orientation and continual training, (b) standardised documentation forms, (c) recruitment of highly educated nurses and (d) improvement of the work environment.
The creation of a new documentation practise norm required redesigned forms to facilitate efficient comprehensive assessment and documentation. In addition, the form established a new way of thinking and practicing, and demonstrates the significant system changes made at the hospital over a four-year period. The revised documentation form also represents progress towards professionalisation and increasing visibility of nursing through quality documentation (Pearson
Nursing leadership focused on improving nurses’ skills in care planning and clinical reasoning, as well as documentation. The hospital faced a challenge of high nurse turnover, mostly due to nurses going back to school to upgrade from enrolled nursing (EN) to registered nursing (RN, Diploma). This phenomenon is not unique to this setting; it is common to nursing globally with various consequences (Hayes
A nursing practise environment refers to ‘the work settings’ organisational characteristics that either facilitate or constrain professional nursing practice’ (Dubois
The purpose of this project was to improve the documentation of nursing assessments in the patient record, initially through training. However, three cycles of action research revealed that training alone was insufficient. Sustainable practise change required multi-pronged efforts to change organisational culture and modify systems to support rather than hinder, practise change. Successful efforts were based on the best available evidence, including nurses’ experiences in providing care and patients’ experiences of receiving care.
The authors would like to thank and acknowledge the CURE Children's Hospital of Uganda and especially the nursing staff for their willing and enthusiastic participation in the project to improve their practise.
The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.
E.M.O. (CURE Children's Hospital of Uganda) was responsible for project planning, design and implementation and preparation of the manuscript. F.K. (CURE Children's Hospital of Uganda) was responsible for project design and policy and decision making during this period. G.W. (CURE Children's Hospital of Uganda) was involved in Phase 3 implementation. M.C. (University of Cape Town) was responsible for manuscript preparation.
Appendix 1: Nursing admission and discharge record: page 1.
Appendix 1: Nursing admission and discharge record: page 2.
Appendix 1: Nursing admission and discharge record: page 3.