Commentary: Designing and implementing an electronic nursing record to support compassionate and person-centred nursing practice in an acute hospital using practice development processes

This paper highlights an area of nursing practice that is essential in the provision of safe and effective high-quality nursing care: the art of documenting the nursing care given.

Many problems associated with nursing documentation have been reported in the literature and poor standards of documentation have been identified as a contributory factor in the failure to detect deteriorating patients (Kärkkäinen and Eriksson, 2005). A number of practice-based issues have been identified as contributing to poor record keeping. These include time constraints, lack of guidelines, ambivalence about the importance of documentation, limited confidence and competence, and lack of supervision and development (Cheevakasemsook et al., 2006; Hyde et al., 2005).

Too often, nursing documentation focusses on reporting an action related to an activity of daily living, such as eating and drinking, using a description such as ‘small amounts of diet and fluids tolerated’ rather than giving a true picture of the patient at the heart of the care provision. When documenting there is often a lack of consideration of whether anything might be impacting on something like patient appetite, i.e. nausea or pain, or if having small amounts is normal for them.

When reading through examples of nursing documentation, we have to consider whether or not poor documentation of nursing care is indicative of poor quality care given? Or is it that nurses have not been given the tools, or training, to adequately describe their practice? Good nursing care may have been given, but if it is not well described, there may be implications for both the patient and the nurse providing care.

Currently, it would appear that little is known about how nurses are taught to document the care they deliver, and even less is known about which setting for nurse education, university or clinical placement, has most influence upon the knowledge that nursing students gain. If nursing students simply follow potentially poor examples of recording care, then it is hard to see how the practice of documenting care can improve.

Even with the introduction of electronic methods of nursing documentation, there is no guarantee that it will automatically improve the recording of care. As the project reported in the reviewed study highlights, if electronic nursing records are not developed with the direct input of nurses and other healthcare professionals that will use or see them, then they will not be fit for purpose. It may also be argued that there is a place for involving patient groups in the development of electronic records; the structured content of nursing records should be generated based on the experiences and perspectives of all of those to whom the provision of care directly relates.

Examination of nursing documentation also gives us the opportunity to examine more closely what it is that nurses actually do, in addition to consideration of the complexities of describing nursing care delivered. The authors quite rightly identify that the complexity of nursing practice itself poses the greatest challenge when developing an electronic method of recording nursing care.

Any research that can add to the knowledge base in this area will benefit healthcare providers, nursing education institutions and clinical areas, by demonstrating evidence-based methods of developing effective electronic nursing records. This, in turn, will support nurses to develop high quality, effective and time-efficient documentation skills.

Biography

Elizabeth Lumley previously worked as an RGN in Upper GI Surgery. She is currently a research associate; research interests include qualitative research, obesity, improving health, patient experience and nursing documentation.