An analysis of nursing documentation as a reflection of actual nurse work

An analysis of nursing documentation as a reflection of actual nurse work

Jane Terese Brooks

Objectives

This independent study offering is designed for nurses and other health care professionals regarding nursing documentation and strategies to better articulate nursing care and practice. The multiple choice examination that follows is designed to test your achievement of the following educational objectives. After studying this offering, you will be able to:

1. Identify barriers to effective nursing documentation in acute care environments.

2. Differentiate between verbal and written communication of clinical nursing knowledge and practice.

3. Describe nurses’ perceptions of the purpose and worth of their narrative notes in relation to the complexity and context in which nurses work.

4. Determine whether nurses document so as to influence nursing practice and theory development.

Nursing documentation continues to draw criticism from professional, community, and regulatory organizations because of incomplete, substandard charting practices (Howse & Bailey, 1992; Parker & Gardner, 1992; Renfroe, O’Sullivan, & McGee, 1990; Tapp, 1990). Documentation is a fundamental nursing responsibility with professional, legal, and financial ramifications. Charting systems have, however, been consolidated to minimize the amount of irrelevant data and time spent in documentation. There is a concern that nurses may be less able or willing to document in ways that reflect the holistic nature of their practice and work. Further, questions arise as to whether the clinical record is the best medium for an accurate account for nursing’s activities and holistic concerns. The purpose of this article is to describe a pilot study that explained nurses’ perceptions of the functions and values of documentation and barriers to the process. The results have practice, legal, professional, and financial implications for nurses and health care delivery systems.

Perspectives on Nursing Documentation

Much has been written on the content and shortcomings of nursing documentation. Documentation has evolved into a nursing practice strategy to monitor and influence health care outcomes. Still, barriers to effective documentation have been noted in acute care environments. Three studies have specifically investigated these barriers.

Renfroe and associates (1990) reported on the relationship between nurses’ attitudes, subjective norms (or the influence of others), and behavioral intentions toward documentation. Gathering data on 108 nurses from three different southern hospitals, the researchers concluded that subjective norms rather than attitudes have the greatest effect on a nurses’ intention to document optimally. They recommended communication of high ideals and expectations to the staff nurse from important others as ways to enhance optimal documentation (Renfroe et al., 1990).

Tapp (1990) studied the degree to which nurses value documentation, including inhibitors and facilitators to this process. She interviewed 14 nurses from a western VA facility and found that redundant forms and imprecise language contributed to poor documentation. This research concluded that nurses lack a distinct professional identity and language as demonstrated by the inconsistent and devalued documented evidence of their care.

Howse and Bailey (1992) interviewed four nurses from four different Canadian hospitals. Most importantly they identified cognitive and psychosocial factors, for example, poor self-confidence, writing skills, group normative structures regarding charting, and difficulty articulating the specifics of nursing practice as barriers to documentation. They argued that, while simplifying the process, streamlined methods of documentation may reduce the expression of clinical judgment and reasoning to automated rituals.

Nurses have yet to define how best to discover and articulate their clinical focus, concerns, and actions. Their actions are typically described as compassionate, committed, and caring, yet these attributes are often difficult to recognize in the nursing documentation. Problems associated with written communication may be a consequence of the lack of correlation between nursing practice and expectations for documentation. O’Brien and Pearson (1993) emphasized the importance of nurses’ oral literacy in communicating the essence of nursing practice. They found that verbal exchange was used to explain and enhance holistic practice or the “how to” nurse. Verbal accounts of patient care situations were far richer than the recorded data. O’Brien and Pearson (1993) went as far as to say that much of what nurses do can only be transmitted orally. Rules and policies that govern documentation guard against exposing the daily risk and uncertainty of nursing. Yet this protective barrier may inhibit the discovery of knowledge embedded in clinical nursing.

There is a growing body of literature that differentiates between nurses’ verbal and written communication. Various factors have contributed to nurses’ pervasive oral culture. The hospital unit is designed to achieve close working relationships where nurses can frequently discuss and reflect upon clinical choices both internally and with other disciplines. They successfully interact with patients, callers, visitors, and colleagues verbally. (In analyzing unwritten nursing knowledge, O’Brien and Pearson [1993] discuss the integral roles experience and reflection play in updating and validating clinical practice. However, the experiential knowledge of caring has been largely ignored or viewed as inconsequential by today’s health care system.) These authors contend that the verbal exchange should be recognized as a legitimate approach to communicating nursing knowledge because it is impossible to completely capture the art of nursing in writing. Nevertheless, nurse experts generally agree that attempts should be made to clarify and track the essential aspects of nursing practice in the clinical record.

To remain a viable health care provider, nurses are being asked to identify and enhance their clinical activities. Since staff nurses often equate charting with a chore that pulls them away from direct patient care (Kerr, 1992), nursing administrators have attempted to maintain standards while streamlining the charting process. Common goals of contemporary documentation systems have been to shorten narrative sections, flag information for better retrieval, facilitate easy tracking of a patient’s progress, and improve care outcomes (Eggland, 1993; Guido, 1993; Kerr, 1992). Yet, attempts to streamline the clinical record have not necessarily corrected known problems or eliminated nurses’ dissatisfaction with this task (Davis, Billings, & Ryland, 1994; Edelstein, 1990; Howse & Bailey, 1992; Renfroe et al., 1990; Street, 1992). Edelstein (1990) encouraged nursing leaders to address nurses’ negative attitudes toward documentation as well as simplify charting formats to improve charting behaviors. While hospitals using new documentation systems report temporary improvement, few have demonstrated improved documentation over long periods of time.

Davis and associates (1994) examined the content of the nurses’ notes and nurses’ attitudes toward documentation in a British hospital 3 to 4 years after implementing a nursing process-based charting format to determine whether nurses were able to document individualized patient care. Findings indicated that assessments emphasized biomedical rather than psychosocial concerns, problems were broadly stated making it difficult to individualize the plan of care, interventions lacked specificity and patient participation, and the effectiveness of interventions was rarely evaluated. The researchers questioned whether most nurses possessed the degree of autonomy and accountability necessary to determine detailed patient goals or be concerned with long-term outcomes. They concluded that documentation may not be an accurate indicator of good practice and recommended programs to facilitate documentation of the nursing process.

This review of the literature suggests that problems associated with nursing documentation are related to the purpose and worth of nurses’ notes. Do nurses use the clinical record to express their activities and concerns, achieve patient outcomes, or fulfill hospital requirements? Benner (1984) draws attention to the complexity and context in which nurses work and the range of knowledge required to make effective clinical decisions and judgments by identifying and describing nursing competencies. While recognizing that practice is not easily translated into writing, Benner still encourages nurses to articulate their clinical learning so as to influence nursing practice and theory development. This work provides a theoretical framework from which to examine and improve hospital-based nursing documentation. She demonstrates that nurses integrate and organize knowledge differently by functioning at various proficiency levels, but there are gaps in knowledge as to whether these differences are noticeable in documentation. The purpose of this pilot study was to investigate nurses’ perceptions of the function and value of documentation and barriers to this process.

The Pilot Study: Setting and Sample

Using a multiple cases method, seven staff nurses from a 248-bed regional health care facility in Massachusetts were interviewed and their nurses’ notes examined to determine whether nursing documentation is used as a vehicle for communicating clinical issues and knowledge. The subjects were asked to discuss factors that influence charting behavior, what was considered important to document as compared with what was actually documented, and barriers to this process. They were asked to consider the difference between actual “nurse work” and the documented data.

All of the nurse subjects were using FOCUS charting. FOCUS charting integrates narrative notes with the plan of care and records relevant patient information in a systematic, accessible fashion (Gryfinski & Lampe, 1990). Table 1 provides demographic data about each participant. Various educational backgrounds and shifts were represented. Six of the seven had critical care experience.

Table 1.

Demographic Data of the Participants

Years & Years at

Experience Present

Subject Nursing Education Facility

#1 26 yrs Diploma 10 yrs

ER & ICU

#2 20 yrs

ICU & Diploma 15 yrs

Med/Surg,

#3 24 yrs

ICU & BSN 22 yrs

Med/Surg

#4 11 yrs

ICU, CCU & BSN 3 yrs

Med/Surg

#5 6 yrs

ICU & Associate 5 yrs

Med/Surg Degree

#6 8 yrs

Med/Surg & Associate 8 yrs

ICU Degree

#7 4 yrs Associate 7 yrs

Med/Surg Degree

# of Patients

Subject Cared for Shift

#1 5 12 noon

to 5 pm

#2 4 3 pm to 11 pm

#3 4 7 am to 3 pm

#4 5 7 pm to 7 am

#5 4 7 am to 3 pm

#6 1 3 am to 11 pm

#7 7 11 am to 7 am

Procedure

Participants were interviewed immediately following their shift. Interviews were tape-recorded and transcribed verbatim by the investigator. Participants began by describing a significant nursing issue or issues for one of the patients they had cared for that day. The nurses’ notes for that particular patient were then retrieved and read, and the subjects were encouraged to comment and reflect upon any discrepancies between verbal and written accounts of nursing issues.

Instrument

A questionnaire was developed to guide data collection (see Table 2). Open-ended questions were generated from a review of the literature and in consultation with a nurse expert. They were pre-tested on a nurse participant not included in the study. The questions posed to the subjects focused on nurses’ communication about clinical care, reasoning, and decision-making. Their comments were compared to documentation charted in the nurses’ notes found in the medical record.

Table 2. Questionnaire for Pilot Study

1. Tell me about your nursing background: your education and where you worked?

2. How many years have you been practicing nursing?

3. How many patients did you care for today?

4. Now I’d like to talk specifically about your assignment. Think about one patient you cared for today:

a) What were your primary nursing issues?

b) What things mainly occupied your time and thoughts with this patient? (might be the same)

c) So in one sentence, what would you say was a key nursing issue today for this patient?

5. Since you said that *** was a key issue of the day, how did you document or communicate this?

6. Is there any part of this issue that might be important to convey in writing and if so for who?

7. Can you think back over charting on this patient? What factors influenced your thinking (what governs your decision) on deciding what to write?

Please read the narrative notes you wrote for this patient today.

8. How do you think your notes influence tracking movement toward the nursing goals in the care plan?

9. Is there anything that you wanted to say but couldn’t/didn’t? Why? And how did you pass this information on?

10. When you document, who do you think reads your notes and what do they look for?

11. Do you think documentation is valuable? If so to whom and for what?

12. If indeed we believe documentation to be valuable, what are the barriers preventing you from documenting the way you want to?

13. Do you think that nursing documentation is an accurate reflection of nursing work done that shift?

14. What did you talk about in change of shift report and how does it differ from what you write in your notes? Why?

Data Analysis

Common themes. The data were categorized according to content and were identified and ranked according to frequency. Some themes were quite obvious, while others were more subtle yet still quite distinct and powerful. Interview responses were coded into the following seven theme categories for the purpose of content analysis. The most frequently mentioned barriers to documentation are listed in Table 3.

Table 3. Barriers to Nursing Documentation

Extrinsic Barriers

1. Workload demands.

2. Cumbersome charting format.

3. Protocol and unit expectations,

Intrinsic Barriers

1. Inability to capture and monitor behaviors or nonphysical concerns in writing.

2. Norms seemed to favor the communication of mundane or routine aspects of care.

3. A lack of confidence in expressing clinical judgments and decisions.

1. Valuing documentation. All participants stated that they valued documentation yet most expressed a certain hopelessness and futility about the utility of nurses’ notes. Indications of this attitude were evident in such comments as: “My nurses’ notes were probably ineffective;” “A lot of things that we write are really not that important. I think a lot of times, you are just going through repeating things that have been said the shift before.”

Though nurses’ notes were said to be written for other nurses, four of the seven subjects said they did “not routinely” read the notes unless they had “a question.”

2. Barriers to documentation. Extrinsic barriers describe the external influences of a nurses’ charting behavior such as “heavy patient load, insufficient staffing,” or cumbersome charting formats. Six of the nurses said thay had spent “a lot of time” with the patient being discussed. Interestingly only two nurses said their documentation that day had suffered because of a lack of time, and that given more time, they probably would have documented more on the nursing issues they discussed. Other comments suggested that format and protocol enhanced redundancy. “It’s like skin warm and dry, VSS, no c/o pain…all the time.”

Intrinsic barriers defined as inherent or internal influences upon behavior were more complex and difficult to identify. Nurses implied that they had neither the language nor motivation to write about behaviors or nonphysical concerns in the clinical record. Charting norms appeared to focus on objective, system assessments as reflected in comments such as, “I don’t know when I’ve ever seen a note by a nurse address death and dying, we don’t address spiritual issues, we don’t address loneliness and isolation, a million things never show up in FOCUS charting.”

3. Congruency between nursing issues discussed and objective documentation. This powerful theme focused on the discrepancies between nurses’ perceptions of significant events and their documentation. When discussing nursing issues, the subjects focused on (a) salient patient issues, (b) their interpretation of the situation, and (c) decisions and evaluation of nurse-generated strategies. Documentation did not support or describe these central aspects of how nurses interpreted the situations or their care strategies.

Discrepancies between articulated nursing concerns and the documented data are illustrated by comparing the verbal account of these issues with the nurses’ notes:

* Subject 1 emphasized that her primary concern had been determining whether her patient’s “confusion was new or old.” Her notes read: “Examined by nurse practitioner. Labs done. Pt awake and alert, awaiting disposition.”

* Subject 2 concentrated on her patient’s “anxiety. He needed a lot of preoperative teaching, a lot of time talking things out,” because “he’s really only had 2 days to prepare for this major surgery.” She stated “I probably didn’t document it very well actually, the time I took.” Her notes focused exclusively and in great detail on operating room preparation; in particular bowel preparation.

* Subject 3 described her patient as angry, anxious, and “very paranoid.” (My patient) “went on and on for a long time about how they were so mean to her in radiation therapy.” And yet her notes do not allude to this:

8:00: LOC – patient awakened

for VS, alert and oriented.

Comfort – denies any persistent

pain.

GI – ABD puffy, soft, mild

upper ABD tenderness on

palpation. + bowel

sounds. Patient denies

nausea.

Resp – lungs clear.

Fluid Balance – bilat pedal

edema persists. IV site in

tact.

1330: GI – taking only small

amounts of food and liquids.

No complaints of

nausea today.

LOC – napping more today.

Comfort – seems to be

more comfortable today.

Similar discrepancies were found with the remaining subjects. The nurses indicated that they were primarily focused on problems ranging from anxiety and frustration to building a functional relationship with their patients, yet documentation primarily reflected physical systems assessments with no reference to these concerns.

4. Purpose of documentation. Six of the nurses stated that they wrote nurses’ notes primarily for other nurses to help them generally know what’s happened to that patient during the day. The emphasis on a physical or systems assessment was prevalent throughout the interview documentation even when patients were described as “stable.” Five of the seven subjects emphasized the legal ramifications of their notes.

5. Interpretation of the situation. This aspect of nursing described the subjects’ perceptions of patient situations, such as: “he needs aggressive rehab, he needs time to talk things out, she needs to know they’re not trying to be mean to her at radiation therapy, I just tried to maintain him on an even keel.” This information can be quite subjective and was often based upon experiential or intuitive judgment.

6. Nurse-generated strategies. Nurse-generated strategies were based upon the nurses’ interpretation of the situation. They consisted of guidelines and techniques to caring for specific patients such as “he needs a lot of preoperative teaching,” or “you have to spend a lot of time with her saying, `well I think it’s OK Liz, don’t worry.'” Though fairly confident with their interpretation of the situation and nurse-generated strategies, the subjects usually opted to pass this type of information along verbally during the change of shift report.

7. Various modes of communication. Participants freely discussed their intuitive judgments, patient’s emotions, and contextual aspects of care. At best documentation of expert practice is described in terms of scientific, technical, or organizational strategies with little reference to the connection and concern described by Benner (1984) as the primacy of caring. As one nurse said, “I don’t see us documenting a lot of the things that we do and care about, that we talk about it in report.” Most of the nurses were surprised by the incongruence between what they said was important and their documentation. Six of the subjects insisted that they “really should have written something” or more about these issues.

Results

This pilot study was designed to explore nursing documentation and barriers to this process. Practice theory literature and the nursing interviews provide information about how nurses translate what they know into what they do and finally communicate what has been done and needs to be done. Study findings suggest that nurses do not clearly document their knowledge and practice issues. Content of the nurses’ notes was not valued by the subjects in spite of having a supposedly user-friendly charting format and sophisticated documentation aids such as flow sheets, graphic records, and computer-generated care plans. Though they developed a compassionate understanding of patient issues and realistic care strategies, these issues and strategies were not documented. Behavioral issues that were considered of utmost importance to nurses, such as patient confusion, anxiety related to surgery, and the frustration of not being able to talk, were not noted but rather communicated verbally to other care providers. Management decisions relating to patient care such as patient-nurse collaboration were also absent from the documentation. Practice was generally charted in terms of scientific, technical, or organizational strategies, with little reference to the connection and concern so often associated with nursing care. This could imply that nurses’ notes were not capturing nurses’ holistic concerns.

Nurses’ notes maintained a predominately medical focus and seemed to follow the hospital routine of a concise assessment of the patient using a body system approach. It is unclear whether professional nursing is isolated in a medically dominated system that may not perceive nursing issues as valuable or noteworthy. Pertinent nursing issues so easily discussed were probably not documented because the charting format did not provide the appropriate cues from which to draw this information. The subjects suggested that it was simply too difficult or pointless to document on behavioral or perceptual concerns. This apparent discounting of the nonphysical aspects of patient care could merely represent bad habits and charting norms. Yet, by not routinely documenting the most effective way to manage specific patients, these strategies constantly needed to be redeveloped and tested by subsequent nurses caring for the patient. They questioned whether there was an effective way to document expert or superior nursing care while demonstrating that care is safe and appropriate.

Nurses’ notes provide an opportunity to demonstrate practice, and yet the subjects in the study were not using documentation for this purpose. The most significant barriers to documentation appeared to be charting formats that did not adequately present nurses’ interpretation of the situation and care strategies, and a lack of confidence or inability to express clinical judgments and decisions. The benefits of documenting opinion and subjective data did not seem to outweigh the risks, and therefore the nurses in the study documented very little about nursing issues and patient concerns. They were careful to document facts that would not provoke questions or criticism. Documentation in the clinical record was not perceived as the place to share and integrate new knowledge but rather as a defense and justification of nursing actions.

Implications

Since updated documentation formats change more than improve nurses’ charting performance, a critical component of this project was to compare nursing practice to documentation. Current vested or conflicting interests resulting from the multiple purposes of documentation may indeed be a big part of the inconsistencies and omissions that were identified. Staff nurses may be motivated to improve charting performance if criteria to determine the content of nursing documentation were under professional control. When nurses believe their notes are ineffective, not read, a waste of time, or don’t say anything, they lose interest in documenting their clinical knowledge, and thereby minimize their contributions to health care.

Since nursing documentation did not adequately reflect actual work done that shift, nurses should evaluate methods for communicating clinical practice and knowledge in relation to care outcomes. Written as well as verbal exchanges should be used to convey and preserve subjective or “hunch” data. To better understand problems associated with nursing documentation, this research was a first step in attempting to investigate how nurses progress from ideas about nursing, to nursing actions and observations, to the decision of what to record, and finally to actual charting. One must consider other available options for communicating nursing knowledge, such as the change of shift report where nurses seem to freely discuss their initial assessment data, hunches, and clinical judgments. The permanent record does not appear to currently facilitate such expression.

Benner’s work supports the notion that nurses do good work and positively influence practice outcomes. Benner (1984) emphasizes the importance of developing a philosophy of nursing or belief system and language that closely links theory and knowledge to clinical practice. Since clinical nursing focuses on the holistic needs of the patient, it should be represented in the documentation. Street (1992) insists that written language should describe both the objective and subjective aspects of clinical practice. These authors recognize nurses’ ability to influence patient outcomes and take risks based upon sound clinical judgments. Street (1992) believes that nurses have unwittingly contributed to their oppression and devalued their knowledge and practice by perpetuating their “oral culture” rather than carefully recording their clinical learning (p. 1).

Nurses are now faced with the challenge of communicating nursing knowledge and care strategies within case managed systems. For nurses to remain viable health care providers, they will need to clearly and succinctly present their unique approach to patient care in the clinical record. Nurses are now being encouraged to collaborate with physicians and other disciplines in integrative documentation systems. They will need to evaluate methods for communicating clinical practice and knowledge in relation to care outcomes. For instance, a professional progress note could be developed and used by both the case manager and/or caregiver. Entering data may depend more upon events or stages of care than current shift or daily requirements. Sophisticated nursing knowledge and intuitive judgments are positively affecting patient outcomes and influencing the actions of other health care providers. Therefore nurses should confidently document their professional knowledge and clinical insights. Solutions to improving the content of nurses’ notes will depend on a clearer understanding of problems associated with documentation so that strategies to better articulate nursing care and practice can be achieved. The results of this pilot study indicate that nursing documentation and practices warrant comprehensive examination and refinement.

References

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing. Menlo Park, CA: Addison-Wesley Publishing Co.

Davis, B.D., Billings, J.R., & Ryland, R.K. (1994). Evaluation of nursing process documentation. Journal of Advanced Nursing, 19(5), 960-968.

Edelstein, J. (1990). A study of nursing documentation. Nursing Management, 21(11), 40-46.

Eggland, E.T. (1993). Nursing documentation resource guide. Frederick, MD: Aspen Publishers, Inc.

Guido, G.W. (1993). Trends in documentation. Medical Surgical Nursing Quarterly, 1(4), 87-95.

Gryfinski, J.J., & Lampe, S.S. (1990). Implementing FOCUS charting: Process and critique. Clinical Nurse Specialist, 4(4), 201-205.

Kerr, S.D. (1992). A comparison of four nursing documentation systems. Journal of Nursing Staff Development, 8(1), 2631.

Howse, E., & Bailey, J. (1992). Resistance to documentation – a nursing research issue. International Journal of Nursing Studies, 29(4), 371-380.

O’Brien, D., & Pearson, A. (1993). Unwritten knowledge in nursing: Consider the spoken as well as the written word. Scholarly Inquiry for Nursing Practice: An International Journal, 7(2), 111-124.

Parker, J., & Gardner, G. (1992). The silence and the silencing of the nurse’s voice: A reading of patient progress notes. The Australian Journal of Advanced Nursing, 9(2), 3-9.

Renfroe, D.H., O’Sullivan, P.S., & McGee, G.W. (1990). The relationship of attitude, subjective norm, and behavioral intent to the documentation behavior of nurses. Scholarly Inquiry for Nursing Practice, 4(1), 47-59.

Street, A.F. (1992). Inside nursing: A critical ethnography of clinical nursing practice. New York: State University of New York Press.

Tapp, R. A. (1990). Inhibitors and facilitators to documentation of nursing practice. Western Journal of Nursing Research, 12(2), 229-240.

Jane Terese Brooks, MSN, RN, is Staff RN, ICU, Cape Cod Hospital, Hyannis, MA.

COPYRIGHT 1998 Jannetti Publications, Inc.

COPYRIGHT 2007 Gale Group