Nurses’ care planning and documentation processes in electronic health records of patients living with dementia

Background: Communication and coordination of patient information are central to achieving continuity and safety for patients in health services. Electronic health records (EHRs) are utilized in large parts of the world, including Norway, in daily clinical practice to plan and document healthcare. As the workload and transition of patients increase in health services, including in nursing homes, nurses and other healthcare professionals increasingly rely on patient information from the EHR to support their daily planning and management of high-quality nursing care for patients. In dementia care, the need to plan and document patient information in a safe and secure way is important for patient safety and a person-centered approach and follow-up of the patient. Little is known about the care planning and documentation process of nurses in long-term dementia care settings. Aim: The overall aim was to gain knowledge and understanding of the care planning and documentation processes of nurses in EHRs in the dementia nursing home setting. Methods: A qualitative descriptive design was utilized in this PhD project. Multiple approaches to elicit the perspectives and experiences of nurses were chosen to understand their everyday world of planning and documenting nursing care in the dementia care setting. The project comprises three substudies. In Substudy 1, a retrospective chart review was conducted utilizing content analysis with a deductive approach to describe the content and comprehensiveness of the nursing documentation of patients living with dementia in Norwegian nursing homes. The content was described in relation to person-centered care (PCC) and the nursing process (NP). Comprehensiveness was measured with the Comprehensiveness In Nursing Documentation (CIND) scale. In Substudy 2, a think-aloud (TA) study was conducted utilizing a stepwise verbal protocol analysis to explore and describe nurse’s clinical reasoning during care planning and documentation of nursing in the EHR of patients living in special dementia care units in Norwegian nursing homes. In Substudy 3, a one-on-one interview study was conducted utilizing a semi-structured interview guide. Following a deductive orientation, reflexive thematic analysis was utilized to generate patterns of shared views and meanings among the participants.publishedVersio

The construction of a subset of ICNP® for patients with dementia: a Delphi consensus and a group interview study

BACKGROUND: The International Classification for Nursing Practice (ICNP®) 2013 includes over 4000 concepts for global nursing diagnoses, outcomes and interventions and is a large and complex set of standardised nursing concepts and expressions. Nurses may use subsets from the ICNP as concepts and expressions for research, education and clinical practice. The objective of this study was to identify and validate concepts for an ICNP subset to guide observations and documentation of nursing care for patients with dementia. METHOD: The process model for developing ICNP subsets was followed, according to the guidelines adopted by the International Council of Nursing (ICN). To identify relevant and useful concepts for the subset, a modified form of the Delphi method was used. Six nurses working in healthcare services in three municipalities in Norway with postgraduate education in geriatric psychiatry and dementia care participated in two Delphi sessions. The participants reviewed and scored the concepts included in the suggested subset and had an opportunity to rewrite them and offer alternatives. To validate the subset after the Delphi study, a group interview was conducted with six other nurses with postgraduate education in geriatric psychiatry and dementia care. The group interview was recorded and transcribed, and summative content analysis was used. RESULTS: Suitable concepts for an ICNP subset to guide observations and documentation of nursing care for patients with dementia were identified. In total, 301 concepts were identified, including 77 nursing diagnoses, 78 outcomes and 146 nursing interventions. An increased focus on concepts to describe basic psychosocial needs such as identity, comfort, connection, inclusion and engagement was recommended by nurses in the validation process. CONCLUSIONS: Relevant and pre-formulated nursing diagnoses, goals and interventions were identified, which can be used to develop care plans and facilitate accuracy in the documentation of individuals with dementia. The participants believed that it may be difficult to find formulations for all steps of the nursing process. In particular, nursing diagnoses and psychosocial needs are often inadequately documented. The participants highlighted the need for the subset to contain essential information about psychosocial needs and communication

Utilizing nursing standards in electronic health records: A descriptive qualitative study

Background The electronic health record (EHR), including standardized structures and languages, represents an important data source for nurses, to continually update their individual and shared perceptual understanding of clinical situations. Registered nurses’ utilization of nursing standards, such as standardized nursing care plans and language in EHRs, has received little attention in the literature. Further research is needed to understand nurses’ care planning and documentation practice. Aims This study aimed to describe the experiences and perceptions of nurses’ EHR documentation practices utilizing standardized nursing care plans including standardized nursing language, in the daily documentation of nursing care for patients living in special dementia-care units in nursing homes in Norway. Methods A descriptive qualitative study was conducted between April and November 2021 among registered nurses working in special dementia care units in Norwegian nursing homes. In-depth interviews were conducted, and data was analyzed utilizing reflexive thematic analysis with a deductive orientation.publishedVersio

Registered nurses’ reasoning process during care planning and documentation in the electronic health records: A concurrent think-aloud study

Aims and objectives: To explore the clinical reasoning process of experienced reg-istered nurses during care planning and documentation of nursing in the electronic health records of residents in long-term dementia care. Background: Clinical reasoning is an essential element in nursing practice. Registered nurses’ clinical reasoning process during the documentation of nursing care in elec-tronic health records has received little attention in nursing literature. Further re-search is needed to understand registered nurses’ clinical reasoning, especially for care planning and documentation of dementia care due to its complexity and a large amount of information collected.Design: A qualitative explorative design was used with a concurrent think-aloud technique.Methods: The transcribed verbalisations were analysed using protocol analysis with referring phrase, assertional and script analyses. Data were collected over ten months in 2019–2020 from 12 registered nurses in three nursing homes offering special de-mentia care. The COREQ checklist for qualitative studies was used.Results: The nurses primarily focused on assessments and interventions during documentation. Most registered nurses used their experience and heuristics when reasoning about the residents’ current health and well- being. They also used logi-cal thinking or followed local practice rules when reasoning about planned or imple-mented interventions.Conclusion: The registered nurses moved back and forth among all the elements in the nursing process. They used a variety of clinical reasoning attributes during care planning and nursing documentation. The most used clinical reasoning attributes were information processing, cognition and inference. The most focused information was planned and implemented interventions.Relevance to clinical practice: Knowledge of the clinical reasoning process of regis-tered nurses during care planning and documentation should be used in developing electronic health record systems that support the workflow of registered nurses and enhance their ability to disseminate relevant information.acceptedVersio

Content and comprehensiveness in the nursing documentation for residents in long-term dementia care: a retrospective chart review.

Background: Insight into and understanding of content and comprehensiveness in nursing documentation is important to secure continuity and high-quality care planning in long-term dementia care. The accuracy of nursing documentation is vital in areas where residents have difculties in communicating needs and preferences. This study described the content and comprehensiveness of nursing documentation for residents living with dementia in nursing homes. Methods: We used a retrospective chart review to describe content and comprehensiveness in the nursing documentation. Person-centered content related to identity, comfort, inclusion, attachment, and occupation was identifed, using an extraction tool derived from person-centered care literature. The fve-point Comprehensiveness in the Nursing Documentation scale was used to describe the comprehensiveness of the nursing documentation in relation to the nursing process. Results: The residents’ life stories were identifed in 16% of the reviewed records. There were variations in the identifed nursing diagnoses related to person-centered information, across all the fve categories. There were variations in comprehensiveness within all fve categories, and inclusion and occupation had the least comprehensive information. Conclusion: Findings from this study highlights challenges in documenting person-centered information in a comprehensive way. To improve nursing documentation of residents living with dementia in nursing homes, nurses need to include residents’ perspectives and experiences in their planning and evaluation of care.publishedVersio

Content and comprehensiveness in the nursing documentation for residents in long-term dementia care: a retrospective chart review.

Background: Insight into and understanding of content and comprehensiveness in nursing documentation is important to secure continuity and high-quality care planning in long-term dementia care. The accuracy of nursing documentation is vital in areas where residents have difculties in communicating needs and preferences. This study described the content and comprehensiveness of nursing documentation for residents living with dementia in nursing homes. Methods: We used a retrospective chart review to describe content and comprehensiveness in the nursing documentation. Person-centered content related to identity, comfort, inclusion, attachment, and occupation was identifed, using an extraction tool derived from person-centered care literature. The fve-point Comprehensiveness in the Nursing Documentation scale was used to describe the comprehensiveness of the nursing documentation in relation to the nursing process. Results: The residents’ life stories were identifed in 16% of the reviewed records. There were variations in the identifed nursing diagnoses related to person-centered information, across all the fve categories. There were variations in comprehensiveness within all fve categories, and inclusion and occupation had the least comprehensive information. Conclusion: Findings from this study highlights challenges in documenting person-centered information in a comprehensive way. To improve nursing documentation of residents living with dementia in nursing homes, nurses need to include residents’ perspectives and experiences in their planning and evaluation of care