What are the barriers and enablers to using the focus charting format in the hospital setting?

Transcription

1 What are the barriers and enablers to using the focus charting format in the hospital setting? A thesis presented in partial fulfilment of the requirements for the degree of Master of Nursing at the Eastern Institute of Technology Taradale, New Zealand Timothy Dennis Richards 2013

2 Copyright is owned by the Author of the thesis. Permission is given for a copy to be downloaded by an individual for the purpose of research and private study only. The thesis may not be reproduced elsewhere without the permission of the Author.

3 Abstract Introduction Nursing documentation is an important factor in providing safe and effective healthcare to patients. In a review of nursing documentation at a large hospital in New Zealand, it was noted that there was sparse patient focused information and a fragmentation of the nursing process. A Nursing Practice Development (NPD) team set up a project to identify and implement a documentation framework that would encourage critical thinking and provide evidence of the rationale for nursing actions utilising a problem based approach, in order to provide accurate evidence of patient progress. After a comprehensive literature review, the NPD team decided to introduce the focus charting format for nursing documentation. Unfortunately there was limited literature on the effectiveness of such charting formats thus this research was undertaken to fill the gap. Research question/purpose of research The research undertaken for this thesis sought to formally identify, What are the barriers and enablers to using the focus charting format in the hospital setting. Method Both quantitative and qualitative data were collected using an electronic questionnaire on Survey Monkey, a hard copy of the questionnaire and a documentation review. The number of nurses sent the questionnaire was approximately 300. A documentation review was completed on nine wards within the hospital where the focus charting format is used and 45 individual nursing entries were reviewed. Results/findings The response rate from the questionnaire was 48% (n=145). Fifty one per cent of participants believed they had adequate education to successfully use focus charting, however, a common theme from the participants comments that was identified as a barrier to its successful use, was insufficient education and on-going support. Another common theme was different interpretations by nurses about how to use the focus charting format. Some nurses thought lack of time was a barrier whereas others perceived having more time was an enabler. Sixty six per cent of participants believed using the focus format improved the quality of nursing documentation. Significantly (P < 0.05) more positive responses were received from nurses with less than 5 years experience, compared to those with more than 10 years experience regarding adequate focus charting education, focus charting assisting the quality of nursing record, the ease of review, retrieving information and complimenting care plans. ii

4 Conclusions Adequate training of new nurses, regular education of existing nurses and on-going support is an enabling factor in improving and maintaining quality nursing documentation. Barriers to using focus charting are insufficient education and different interpretations on how to use the format. There needs to be a consistent approach with focus charting education and those who teach it to avoid different interpretations. Regular audits of the nursing documentation need to continue; this will help with consistent timely improvements, and maintain a high standard of documentation. iii

5 Contents Contents... 2 Acknowledgments... 4 Chapter One: Introduction... 6 Purpose of research/research question... 8 Chapter summary... 9 Chapter Two: Literature review Chapter summary Chapter Three: Research design and methods The questionnaire The documentation review Ethical considerations Chapter summary Chapter Four: Results Questionnaire Qualitative data Chapter Summary Chapter Five: Discussion Limitations of this research Conclusion Appendices Appendix 1: Focus charting example Appendix 2: Survey Monkey questionnaire Appendix 3: Documentation review tool Appendix 4: Research approval from hospital References Table of Figures Figure 1: Speciality area of respondent to the survey Figure 2: Years of nursing experience of the survey respondents Figure 3: Overall document review scores November Figure 4: Overall document review scores by ward November

6 Table of Tables Table 1: Responses to survey questions expressed as a percentage Table 2: The percentage of positive responses to each question based on years of nursing experience

7 Acknowledgments Throughout my journey along the Master of Nursing pathway I have been supported by numerous people who I wish to acknowledge. Firstly, to my fiancée Pauline, your support along the pathway has enabled me to be very near my goal of achieving a Master of Nursing. You have managed the affairs of our household like a seasoned Chief Executive Officer, ensuring the children s and my life run as smoothly as possible, I cannot thank you enough for your support of me. To my children, Brienna, Georgia, Isaac and Stepson to be Bayley, thank you for keeping the noise down when I was writing my thesis (most of the time), doing your chores and being patient with me when asking for my attention. You are all wonderful children and I hope I have role modelled to you that goals can be achieved in life, no matter what your age, if you are determined to achieve them. To my mother Judy, thank you for listening to me complain about how busy my life is and remaining positive about what I am trying to achieve. Your support throughout my life has made me the man I am today. In memory of my late father Wayne who passed away suddenly on the 28 th May 2010, only a few months after I commenced my Masters pathway. Thank you Dad for being my best friend throughout a difficult time in my life which set me up to successfully continue along the pathway. I know you would be proud of my achievements. To my sisters Juliet and Tracey, thank you for your support of me over the last few years, you were there for me right at the beginning of my journey and I know you will be there when I graduate. To my work colleagues, thank you for all your assistance with my research. Thank you for your feedback on the pilot questionnaire and making available to nurses, hard copies of the questionnaire after the initial electronic survey had a low response rate. A special thanks to Wendy Blair, who encouraged me to recommence post graduate study and for guiding me when choosing my Masters pathway. To all the nurses at the hospital who responded to the questionnaire, thank you as this research would not have been possible if you had not taken the time to complete the questionnaire and write down your comments. To all the lecturers at Eastern Institute of Technology (EIT) who have supported and guided me along the pathway, your encouragement and wisdom has enabled me to maintain the momentum and preserve with my studies. The structure and content of the papers that form the Master of Nursing 4

8 pathway all make sense to me now that I am completing the Masterate of Research paper. I can now say to my colleagues who have recently commenced their Masters pathway, what you are learning now will be relevant and helpful when you commence your research. A special thank you to our initial course coordinator Ruth Crawford who was very supportive and encouraging throughout her time as the coordinator, Ruth helped me believe I could successfully complete this paper. I thank my initial Principal Supervisor Nick Nicol and Associate Supervisor Rachel Forrest for your support and guidance of my thesis. Thank you Rachel, for keeping in touch and being responsive to my questions and provided invaluable feedback on my thesis. Thank you Rachel for ensuring towards the end of the paper I remained supported and guided. Finally, thank you to Elaine Papps who became my Principal Supervisor at a critical time during writing my thesis when Nick resigned from EIT. 5

9 Chapter One: Introduction Nursing documentation is an important factor in providing safe and effective healthcare to patients. The nurse must record patient problems, complaints, assessment data and responses to interventions to ensure patient safety and well-being (Saranto & Kinnunen, 2009). Documentation in New Zealand (NZ) hospitals should also record patient information to provide effective communication to the nurse taking over care of the patient, and provide patient information for the Multi-Disciplinary Team (MDT). Nursing documentation in NZ also evidences the patient record of care provided by the nurse, which includes but is not limited to, observations of vital signs, medications given, patient care plans and care pathways, fluid balance charts, wound charts, assessment findings, interventions and the evaluation of these. Ideally nursing documentation should evidence the nursing process of Assessment, Diagnosis, Plan, Intervention and Evaluation (ADPIE), which is an internationally recognised nursing framework (Alfaro-LeFevre, 2014). The quality of nursing documentation has been a contentious issue internationally and there is no accepted gold standard for measuring the quality and accuracy of this documentation (Paans, Sermeus, Nieweg, & Cp, 2010). Competency 2.3 of the Nursing Council of New Zealand (NCNZ) Competencies for Registered Nurses states that the nurse Ensures documentation is accurate and maintains confidentiality of information (NCNZ, 2012, p21). The indicator for this competency states that the nurse Maintains clear, concise, timely, accurate and current health consumer records within a legal and ethical framework (NCNZ, 2012, p21). In a review of nursing documentation at a hospital in NZ, it was noted that there was sparse patient focused information and a fragmentation of the nursing process (Blair & Smith, 2009). The nursing clinical record for the duty was often an extensive record which meant retrieving specific information related to the patient was time consuming. Traditionally nursing documentation at the hospital where the research was undertaken used a narrative approach recording many activities of the nursing duty within patients clinical notes. One of the weaknesses inherent in narrative documentation is that it is often disorganized and repetitive, and different nurses may address different issues, so a complete picture of the patient may be difficult to ascertain from reading the notes (Lockwood, 2012). It may also be difficult to trace problems, interventions, and outcomes without reading through the entire chart. Narrative documentation should provide a running chronological record of the patient status but this recording often occurs at the end of the duty, which relies on the nurse to recall events accurately and may have been rushed due to time constraints and interruptions. The nurse s 6

10 documentation was often repetitive of information that was also already available elsewhere within the patient s clinical notes. For instance nurses would record patient s vital signs on an observations chart and in the clinical notes, even if the observations were within normal limits. Medications administered and the time they were given would be recorded on the medication chart and in the clinical notes. The practice of repetitive nursing documentation was also evident for other assessments. For example nursing care may have been documented as being completed on the patient s care plan, then this information was recorded again in the patient s progress report, both of which are contained within the patient s clinical notes. In early 2009, a Nursing Practice Development (NPD) team set up a project to identify and implement a documentation framework that aimed to encourage critical thinking and provide evidence of the rationale for nursing actions (Blair & Smith, 2009). This project utilised a problem based approach in order to provide accurate evidence of patient progress. After a review of relevant literature the NPD team decided to introduce the focus charting format in order to improve the quality of nursing documentation (Blair & Smith, 2012). Focus charting was developed in 1981 by a committee of staff nurses at Eital hospital in Minneapolis, out of frustration with the quality of the nursing note and to make the nurse note more valuable (Lampe, 1997). The aim was to make the nursing notes legally sound; reflect the nursing process, provide a concurrent, complete, concise description of the patients status with minimal duplication of information, provide useful communication to MDT members, and offer information in a format that would be easily retrieved for audit and/or research purposes. Since focus charting was introduced in the United States it use has expanded to areas outside acute care and in other clinical disciplines such as mental health (Lampe, 1997). Focus charting is problem orientated documentation whereby the nurse identifies the problems or foci of concern during their assessment of a patient. The focus of concern becomes the key word and is written in the focus column within the patient s clinical notes. Care is then documented under the headings of Data (subjective and objective), Actions and Responses (Williams & Wilkins, 2008). The NPD team adapted the focus charting headings to align with the nursing process of ADPIE. Assessment and diagnosis were to be put under the heading A, and aligned with Data, planning and interventions were put under the heading I and aligned with Actions, and evaluation remained under the heading E and aligned with Responses (Appendix 1). Focus charting is a form of charting by exception. This means that if assessment information is recorded on flow charts, observation charts, care plans, care pathways, or other assessment forms 7

11 then it is not required to be recorded in the patient s progress notes unless there is a focus or problem of concern. Through personal communication, nursing leaders who sponsored and implemented focus charting at the hospital believed it would not only improve the quality of nursing documentation through less repetition and efficient retrieval of specific patient information, but it would provide evidence that the nursing process was being utilised especially the evaluation of nursing interventions. When focus charting was first introduced in the hospital, nurses had the option to use or not use this format until they had received education related to this method of documentation. After approximately one year focus charting was written into the hospitals documentation policy as the format required to be used by nurses when documenting the patient s progress in the clinical notes. Since then, the number of nurses using the focus charting format has been variable, as has the quality of nursing documentation based on audits and findings in the clinical notes. It appears there are some nurses who are able to use the focus charting format successfully while others struggle with the format or choose not to use it at all. The perceived benefits of focus charting seem to have been achieved in some areas of the hospital, though the results appear to be inconsistent. These benefits include less repetition of patient information and more efficient retrieval of information from the nursing record of care (Blair & Smith, 2009). Although there has not been regular audits of focus charting those that have been completed indicate improvements in the quality nursing documentation, however, as previously mentioned these improvements are inconsistent. Anecdotal information from incident reviews at the hospital, which are required when an incident has been reported, suggests that on several occasions when nursing documentation has been reviewed, if the focus format had been used the nurses would have realised they should have acted upon information they had recorded in their patient s clinical notes. Nurses should document acute abnormal findings during assessment then document the intervention initiated, this should be followed by the nurse documenting the evaluation or response of the patient to that intervention (Campos, 2010; Gregory, 2008). Anecdotal evidence suggests the traditionally MDT members at the hospital, especially doctors, did not find nursing documentation easy to read or user friendly and as a result nursing documentation was rarely read by medical teams. This ignoring of the nursing record can often lead to poor communication between MDT members and potential negative patient outcomes (Law, Akroyd, & Burke, 2010). Purpose of research/research question Since the introduction of focus charting at the hospital, barriers and enablers to using focus charting have not been formally identified. No quality data has been gathered to determine if perceived 8

12 benefits are being achieved consistently. There has been no formal information collected from the nurses perspective to indicate whether focus charting has improved the quality of nursing documentation since it was introduced at the hospital. If the barriers and enablers to using focus charting are understood education around its use could be better tailored for new and existing staff. This may in turn improve the quality of nursing documentation which will benefit all nurses, especially those new to the hospital, which may not be familiar with this format, but are never-theless expected to use it. Therefore this research aimed to answer the following question: What are the barriers and enablers to using the focus charting format in a hospital setting? Chapter summary In summary, nursing documentation is critically important but often problematic. In an attempt to resolve documentation issues at a NZ hospital, which traditionally used a narrative approach, the focus charting format was introduced however the benefits have been inconsistent. This inconsistency with focus charting led to the author s research question What are the barriers and enablers to using the focus charting format in a hospital setting. To provide the reader an idea of how this thesis will unfold an explanation of each chapter will follow. Chapter two will look at literature reviewed related to focus charting, other forms of nursing documentation and potential barriers and enablers to their use. Chapter three will discuss the research design and method while ethical considerations related to the research will also therein be mentioned. Chapter four will present the results from the research. Chapter five will discuss the results of the research, limitations, and finally conclusions from the research will be presented. 9

13 Chapter Two: Literature review This chapter provides a review of relevant literature accessed in relation to nursing documentation methods, focus charting and the enablers and barriers to improving the quality of nursing documentation. A literature search was undertaken using of the following databases: CINAHL, New Zealand/Australia Reference Centre, Nursing Reference Centre, Medline, and Google Scholar. Key words included focus charting, documentation, problem orientated documentation, charting by exception, improving nursing documentation, structured documentation and documenting using the nursing process. The literature search revealed textbooks and articles around the concepts of focus charting, but no primary or secondary research was found. Literature related to different documentation methods, the time taken to complete nursing documentation, problems with nursing documentation, and barriers and enablers to improving nursing documentation were located. There was a lack of New Zealand literature related to nursing documentation with the literature for this review stemming from Australia, Canada, Denmark, Iceland, Ireland, Netherlands, Norway, Sweden, Thailand, Turkey, United Kingdom, and the United States of America. Only one study specifically related to the implementation of focus charting was identified. The focus charting format was introduced to a hospital in Pittsburgh, in the United States of America, with the aim to reduce time spent on nursing documentation (Murphy, Beglinger, & Johnson, 1988). The results of the implementation in the Pittsburgh study revealed nursing documentation time over a 24 hour period decreased by 90 minutes. This was estimated as an annual cost savings on nursing time of $437,000, thus there was potential for financial benefits without affecting quality of care (Murphy, et al., 1988). When there are potential financial benefits from improving nursing documentation, it can also have an empowering effect on nurses who actively participate in such quality improvement initiatives (Oldfield, 2007). Björvell, Wredling, and Thorell-Ekstrand (2003) conducted a qualitative study of registered nurses documentation. Their study was conducted two years after three hospitals in Sweden implemented a new format of documentation for nurses called the VIPS model. The acronym VIPS stands for the Swedish terms for wellbeing, integrity, prevention and safety all of which are seen as major goals for nursing (Björvell, et al., 2003). The VIPS model uses a keyword, structured format based on the nursing process, similar to focus charting. Björvell et al. (2003) study revealed a common theme to the anecdotal feedback received from nurses at the hospital, using a structured way of documenting made nurses think more about what they were documenting, and think in a different way about 10

14 their work with patients. Focused topics or key words also served as a common thread to coordinate documentation of patient care (Scoates, Fisherman & McAdam, 1996). Some nurses in the Björvell et al. study felt their role was changing from a medical technician focus to more a nursing expertise orientation when using a structured format based on the nursing process. A study in Denmark by Darmer, Ankersen, Nielsen, Landberger, Lippert, & Egerod, (2006) revealed that using the VIPS model improved the nursing documentation by increasing evidence of the nursing process and facilitating analytical thinking. The use of a structured framework that incorporates the nursing process can assist with improving the quality of nursing documentation (Paans, et al., 2010). Research has demonstrated a structured framework makes the documentation more systematic and comprehensive while evidencing use of the nursing process (Thoroddsen & Ehnfors, 2007). It can also assist nursing with the development and use of the electronic patient record, which appears to be inevitable with developing technology (von Krogh & Nåden, 2008). In Florin, Ehrenberg, Ehnfors, & Björvell (2012), study the VIPs model was compared to another format for MDT documentation, the International Classification of Function, disability and health format (ICF). Results from the comparison demonstrated the VIPS model, which used key words was preferred by nurses to ICF format, which used classifications to describe the patient status (Florin, et al., 2012). The authors also reported core nursing terms and nursing perspectives are missing in the ICF format and the ICF terms can largely be mapped to the key words in the VIPS model (Florin, et al., 2012). In a study conducted in the Netherlands evaluated nursing documentation that used a prestructured format called PES (Paans, et al., 2012). The acronym PES stands for Problem, Etiology and Signs and symptoms, with this format having been taught in nursing education programmes in the Netherland since the mid-1990s (Paans, et al., 2012). Panns et al. concluded that based on the results of this study the PES format has a positive effect on the accuracy of the nursing documentation and improved nurses disposition towards critical thinking thus improving nurses reasoning skills (Paans, et al., 2012). Paans et al. also stated that encouraging nurses use in the PES format, could be a step forward in improving the accuracy of nursing documentation. Further data from Björvell, et al. (2003) study was similar to anecdotal feedback from nurses at the hospital in this study, in that some nurses thought it was more time consuming to document using a structured format. Comparable results appeared from a study in Finland that evaluated four widely used nursing documentation systems that utilised the nursing process, in that nurses felt it increased the documentation workload (Nykänen, et al., 2012). However this contrasts findings of Murphy et al. (1998). 11

15 There have been several studies that report problems with nursing documentation. A mixed method study completed by Cheevakasemsook, Chapman, Francis & Davis (2010), reported that inappropriate charting by nurses was a common problem. A documentation audit was completed on 35 patients clinical notes from acute medical and surgical wards, and a time and motion study of fifteen nurses to observe time spent on documentation. Problems revealed were similar to those at the hospital in which the author undertook the research for this thesis such as inadequate documentation. The Cheevakasemsook et al. study, however, did not reveal the sample selection process, and limitations were not mentioned which could indicate possible bias. The literature search identified other studies which reported that nurses were repetitive with information being recorded within the patients clinical notes, and this consumed patient care time (Paans, et al., 2010). Medications, vital signs, and other assessments were being recorded in several different locations, and this led to the reluctance of some nurses to complete the forms thoroughly (Law, et al., 2010). A study conducted at hospital in Turkey analysed the consistency between hygiene care actually given by nurses and that documented in nursing record, the results revealed that only 77.6% of care was documented (Inan & Dinç, 2013). The authors of this study reported the quality of nursing records was poor and inadequate to reflect individualized nursing care. Their results suggest that more emphasis is needed in nursing practice, and nursing education on the quality of record keeping in order to increase its evidential value (Inan & Dinç, 2013). Lees (2010) and Paans et al. (2010) reported that nursing documentation contained too much unfocused information and lacked a systematic process for assessment and admission documentation; there was also a lack of evaluating planned care. Cheevakasemsook et al. (2010) noted factors that may affect the quality of nursing documentation; one factor they highlighted was no recognition of the significance of nursing documentation by other health professionals. Doctors irregulary read nursing notes and other nursing documentation was disregarded. Nursing documentation was traditionally written at the end of the duty which relied on the nurse s ability to recall events accurately. This in turn meant patient information was not available to MDT members, and nursing notes were often rushed (Lees, 2010). Literature related to improving the quality of nursing documentation also highlighted possible barriers. These barriers include interruptions to nursing time, limited competence and confidence in documentation, inadequate supervision and staff development (Paans, et al., 2010). Lees (2010) noted that casual or relief staff often affected the quality of the nursing documentation if inadequately trained, with this thread appearing as a reoccurring issue in Lees study. A mixed 12

16 method study was conducted in a Australian hospital in order to improve the quality of patient information in nursing documentation (Jefferies, Johnson, Nicholls, Langdon, & Lad, S, 2012). Previous strategies to improve nursing documentation at the hospital had been unsuccessful and omission of patient information continued. An education programme with one-to-one coaching in the clinical environment was tested and the authors reported this as a helpful approach to improving nursing documentation (Jefferies, et al., 2012). A study of nursing documentation in a long term care facility in Canada by Voyer et al. (2013) indicated that nursing documentation under reported patient symptoms such as delirium and confusion, especially when there was an increase in patient to nurse ratio. Authors of this study recommend that efforts should be made to improve nursing documentation by revisiting the content of academic and clinical training given to nurses, in addition to exploring innovative ways to make nursing documentation more efficient and less time-consuming within the current context of nurses work overload (Voyer, et al., 2013). In Denmark the national guidelines for nursing documentation outlines twelve areas in which nurses have to systematically document daily care (Håkonsen, Madsen, Bjerrum, & Pedersen, 2012).This is intended to assist and guide nurses to make a relevant and complete nursing documentation. Auditing is a key factor for improving and maintaining the quality of nursing documentation (Cheevakasemsook, et al., 2006). Jefferies et al. (2012) demonstrated in their study that regular auditing prompts nurses to improve nursing documentation. Nursing documentation can show consistent improvement and be maintained at a high standard with regular audits, and training staff simultaneously rather than using key people has also shown promise as a learning method and implementation strategy for implementing new documentation formats (Darmer, et al., 2006). Adequate training of new nurses and regular education of existing nurses is further identified by Lees (2010) as a factor in improving and maintaining quality nursing documentation. Although none of the literature reviewed was from NZ studies, it revealed similar problems with nursing documentation in New Zealand (Cheevakasemsook, et al., 2006; Lees, 2010; Paans, et al., 2010). The studies conducted by Björvell et al. (2003) Darmer et al. (2006) Panns et al. (2010 & 2012) and Scoates et al. (1996) revealed that benefits of using a keyword, structured approach to documentation and identified potential enablers to the successful introduction of a new documentation format. These studies may be able to be applied to the NZ context as the countries they were conducted in have similar demographics. 13

17 Chapter summary This chapter has discussed literature around the focus charting format. It has identified that there is a gap in the literature in relation to focus charting and highlights the need for this study. Different types of documentation that use a pre-structured format, similar to focus charting, are mentioned. The chapter has discussed studies that report problems with nursing documentation and possible barriers and enablers to improving the quality. The next chapter will discuss the research method and design utilised in this thesis. 14

18 Chapter Three: Research design and methods This chapter will discuss the research design and methods used including the questionnaire tool, participant selection, and the process for documentation review. Ethical issues that are relevant to this study are also identified and discussed. A quantitative approach utilising a survey designed for Likert scale responses with allowances for additional (qualitative) comments was used. This method allows a lot of information to be obtained from a large population in an economical manner (Schneider, Whitehead, Elliott, Lobiondo-Wood, & Haber, 2007). The survey was disseminated to the nurses of the hospital both electronically as a questionnaire on Survey Monkey (Appendix 2) and in hard copy. A documentation review was also undertaken at the hospital being studied. Descriptive statistics were used to describe, organise and summarise the Likert scale data. Crosstabs, Chi-square and z-tests were used to explore associations between years of experience (<5 years, 5-10 years, 10+ years) and whether a response to a question was positive (i.e. agreed or strongly agreed) or negative (i.e. disagreed or strongly disagreed). Neutral responses were removed from the data set for these analyses. For each question that was found to have significant associations using Chi-square, z-tests (using Bonferroni corrections and a significance level of α=0.05) were performed to determine which categories were different from each other. If differences were not able to be detected using z tests then the <5 year and 10+ year categories were selected and a second Chi-square analysis performed comparing these two groups directly. The latter was also done when 0.05 < P < 0.10 for the first Chi-square analysis. A thematic analysis of the comments written by the participants was undertaken and compared to the Likert scale data to reveal possible reasons for them. The questionnaire The questionnaire included an introductory statement about the proposed research, potential benefits of the research for nurses and a statement that anonymity was assured. Consent was implied by participants completing the questionnaire (Rea & Parker, 2012). The questionnaire consisted of 18 closed ended questions related to focus charting that were to be answered using a 5 item Likert scale with responses ranging from strongly agree to strongly disagree. The questionnaire also included the option to record comments so the participants could respond in their own words. The survey was designed to have demographic information presented at the end of the questionnaire rather than on the first page so as to avoid the respondent perceiving the survey as tedious (Bordens & Abbott, 2011). The questionnaire was developed by the author and a pilot test conducted on a small sample group to assess the interpretation of questions. Feedback from this 15

19 group was used to refine some of the questions. It was important to ensure validity and reliability of the questionnaire so the results are believable and dependable, as this forms the basis for further research, practice and theory development (Schneider, et al., 2007). Initially only the link to the electronic questionnaire on Survey Monkey was sent to nurses via their hospital and was resent two weeks later. To accommodate nurses that did not have internet access, hardcopies of the questionnaire were given to the Nurse Educators based in each ward that used focus charting. The Nurse Educators were asked to make the questionnaire available for nurses so that they could participate if they wished. The responses from the hard copies were entered manually by the researcher once they were returned. The documentation review The documentation review was completed on nine wards within the hospital where the focus charting format is used. A review tool initially developed by the NPD team to audit focus charting, was revised by the researcher for the documentation review to determine the percentage of nurses using the focus format and to gain evidence of perceived benefits (Appendix 3). A total of 45 individual nursing entries were reviewed. Ethical considerations Nurses and midwives involved with research using human populations must be mindful of ethical and legal issues and the measures that need to be taken to protect human participants (Schneider, et al., 2007). There are ethical codes and legal regulations to ensure the absence or minimisation of harm, trauma, anxiety and discomfort. There are also internationally agreed ethical principles in research when human participants are involved. These are: respect for autonomy, respect for privacy, respect for justice, beneficence, non-maleficence, respect for human vulnerability and integrity, and respect for cultural diversity (Glickman et al., 2009). Respecting autonomy ensures the research participants have sufficient information about a study to give informed consent. Full disclosure of the study was given in the information section at the beginning of the research survey. The elements of informed consent were considered in the introductory statement for the questionnaire; potential participants were invited to participate and the purpose of the study was discussed, as well as potential benefits of the study. Respect for privacy included informing the participants that confidentiality and anonymity was assured as they could not be identified by completing the questionnaire. Another ethical consideration for this study was the reviewing of clinical notes. There was potential for the author to have discovered information in the clinical notes that ethically they were obligated 16

20 to act on. A discussion with the Director of Nursing (DON) regarding the purpose of the review provided clear direction for the author on this issue. Following the ethical principles of beneficence (doing good) and non-maleficence (doing no harm), if the author did discover information during the documentation review that could potentially harm the patient or put the patient at risk, the author would address their concern with the nurse currently caring for the patient in order to resolve the issue. Consent for the research to be conducted within the hospital was given by the DON and the Nurse Educator Lead, Practice Development (Appendix 4). The author also considered Māori and the importance of The Treaty of Waitangi in the research as part of the ethics application. Although the research is not targeting Māori nurses or the Māori population, all research in NZ is of interest to Māori (Hudson, 2010). The principles of the Treaty, partnership, participation and protection need to be considered throughout research and can be applied to Māori and non-maori. This research was approved by EIT s ethical approval process (Appendix 5). Chapter summary This chapter has discussed the research design and why it was chosen for this research. The questionnaire tool and information provided to the participants has been mentioned as well as participant selection. The process for documentation review process has been presented. Ethical issues that were relevant to this research such as reviewing patient information were identified and guidelines for the research discussed. Maori and the Treaty of Waitangi were also considered in this research. The following chapter provides the results of the research. 17

21 Chapter Four: Results The following chapter discusses the response rate to the questionnaire and the demographics of participants. Quantitative data from each question is presented in Table 1. Demographic groups (Figures 1&2) are analysed and their responses broken down by years of experience tabulated (Table 2). Qualitative data that emerged from participant s comments within the questionnaire are presented as themes that are summarised by individual comments. Results from the documentation review are presented in two graphs (Figures 3&4), one showing overall results for the hospital and another displaying the results from individual wards. Questionnaire The electronic questionnaire on Survey Monkey was initially completed by 60 participants and the resend two weeks later resulted in a further 20 completed surveys, meaning approximately 80 participants from potentially 300 nurses. The author received a further 65 participants from the hard copies sent out, making the total of participants 145 (response rate = 48%). The majority of participants came from medical and surgical areas (88.3%) as shown in Figure 1, with the remainder from Child Health and Rehabilitation. Figure 1: Speciality area of respondent to the survey Of the nurses that completed the survey, 95% were aware that focus charting is the preferred format for nurses to use when recording patient progress in the clinical notes, according to policy, 18

22 Nursing Health Assessment-Care Planning and Evaluation. The focus charting information should use the A, I, and E headings, however, the documentation review revealed that these headings were only used 29% of the time in one ward, which was the lowest user, and 40% of the time in another ward, which was the highest user. The responses for questions 1 through 15 are presented in Table 1. Just over half (51%) of the nurses who responded believed that they had received adequate training to successfully use the focus charting format and 58% of nurses felt confident using focus charting. Conversely, 31% of the nurses who responded did not feel they had adequate training to be able to use focus charting successfully and 21% did not feel confident using the focus charting format. Forty two per cent of the nurses that responded felt that there was insufficient on-going support and education available on the use of the focus charting format, and 13% of the nurses thought the focus charting format was difficult to use. Just over half of the nurses who responded (52%) felt comfortable educating students and new staff members on the use of focus charting. When asked if they felt that focus charting reduced that amount of time spent on documentation, 45% of the nurses agreed or strongly agreed with a similar percentage of nurses (46%) believing that focus charting reduces duplication of patient information. Question 5 (Focus charting reduces the amount of time spent on nursing documentation) and Question 8 (Using the focus charting format increases the amount of time spent on nursing documentation) were intended to be similar in nature but require a different response in order to determine whether the questionnaire was completed honestly and accurately. Of the nurses that responded, 45% agreed or strongly agreed with Question 5 and 45% disagreed or strongly disagreed with Question 8 suggesting that there was high internal reliability for the survey. Of the nurses that responded, 66% felt that the quality of the nursing record of care was assisted by using the focus charting format. Consistent with this, 68% of the nurses surveyed found that reviewing the nursing record of care easier with the use of the focus charting format and 69% found retrieving specific patient information is easy with focus charting. Thirty nine per cent of the nurses who responded believed the current nursing care plans complement focus charting. Similarly, 64% of the nurses surveyed felt that focus charting assists with evidencing the nursing process (ADPIE). However, only 23% believed that the MDT members read the nursing record of care more frequently due to the use of the focus charting format with 41% of nurses selecting neutral for this question. 19

23 Table 1: Responses to survey questions expressed as a percentage Question 1: The education I have received related to using focus charting has been adequate to enable successful use of the format. Strongly agree Agree Neutral Disagree Strongly disagree : There is on-going support and education available on the use of the focus charting format : I feel confident using the focus charting format : The quality of the nursing record of care is assisted by using the focus charting format : Focus charting reduces the amount of time spent on nursing documentation : I find reviewing the nursing record of care easy with the use of the focus charting format : I believe the Multi-Disciplinary Team members read the nursing record of care more frequently due to the use of the focus charting format : Using the focus charting format increases the amount of time spent on nursing documentation : The focus charting format is difficult to use : I feel comfortable educating students and new staff members on the use of focus charting : Focus charting reduces duplication of patient information : Focus charting assists with evidencing the nursing process (ADPIE) : Retrieving specific patient information is easy with focus charting : I complete my focus notes throughout the duty as events occur : The current nursing care plans compliment focus charting

24 Figure 2: Years of nursing experience of the survey respondents. Approximately half of the nurses who responded had ten or more years experience (Figure 2). The responses to each question depending on years of nursing experience (<5 years, 5-10 years, 10+ years) were examined (Table 2). Significantly (P < 0.05) more positive responses were received from nurses with <5 year experience compared to those with more than 10 years experience regarding adequate focus charting education, and focus charting assisting the quality of nursing record, the ease of review, retrieving information and complimenting care plans (Table 2). Greater numbers of those nurses with less than 10 years experience also tended (0.05 < P < 0.10) to feel more confident using focus charting, that it reduced the amount of time on nursing documentation and were more comfortable educating new staff members on how to use focus charting (Table 2). 21

25 Table 2: The percentage of positive responses 1 to each question based on years of nursing experience. Years of Nursing Experience P value 2 Question < (χ 2 ) 1 The education I have received related to using focus charting has been adequate. 2 There is on-going support and education available on the use of the focus charting format a 64.0 ab 52.7 b (31) (25) (55) (24) (24) (50) 3 I feel confident using the focus charting format a b (30) (30) (51) 4 The quality of the nursing record of care is assisted by the using the focus charting format. 5 Focus charting reduces the amount of time spent on nursing documentation. 6 I find reviewing the nursing record of care easy with the use of the focus charting format. 7 I believe MDT members read the nursing record of care more frequently due to use of the focus charting format. 8 Using the focus charting format increases the amount of time spent on nursing documentation a 88.9 ab 67.3 b (32) (27) (55) 64.3 a a (28) (29) (57) 93.5 a b (31) (27) (55) 66.7 a 50.0 ab 26.1 b (18) (16) (46) 20.8 a b (24) (26) (49) 9 The focus charting format is difficult to use a a (30) (22) (53) 10 I feel comfortable educating students and new staff 88.5 a b members on the use of focus charting. (26) (26) (51) 11 Focus charting reduces duplication of patient information ab 75.9 a 43.9 b (27) (29) (57) 12 Focus charting assists with evidencing the nursing process (ADPIE). 13 Retrieving specific patient information is easy with focus charting. 14 I complete my focus notes throughout the duty as events occur (31) (25) (46) 96.9 a b (32) (26) (54) (32) (54) (29) 15 The current nursing care plans compliment focus charting a 75.0 a 40.9 b (24) (24) (44) 1 Positive responses included agreed or strongly agreed. The percentage of positive responses of the total number of response is shown. The bracketed number was the total number of responses for the experience category excluding neutral responses. 2 For each question that was found to have significant associations using χ 2 z-tests (using Bonferroni corrections and a significance level of α=0.05) were performed. Those columns with different superscripts were found to be significantly different from each other. If differences weren t able to be detected using z tests then the <5 year and 10+ year categories were selected and a χ 2 analysis performed comparing the two groups directly thus only two of the numbers will have superscripts. The latter was also done for where the P value for the initial χ 2 was >0.05 but less than

26 Qualitative data The questionnaire was designed to enable participants to provide written comments for each question. From these comments a number of themes emerged, and these were: inadequate education, different interpretations on how to use the focus format, the nursing record of care was easy to read if focus charting is completed properly and education was required for this, medical teams do not read nursing record of care, using the AIE headings was more time consuming, nurses still felt they need to record more information, there is a lack of understanding how to use focus charting so nurses don t related care plans and other assessment documentation to the nursing record of care, and the current care plans are not patient specific. A consistent theme from the comments for question one, which asks if the education was adequate, was there was inadequacy of education. This theme was summed up by the following statements: Barriers- not enough education and resources available to educate all the nursing staffpeople not ready for change Have not received any education on it or been offered any Have not had education on focus charting, and do not believe it is done correctly Had five minutes education years ago and nothing further Different interpretations on how to use focus charting was another theme identified in the comments for question one, and appeared in the comments for other questions. Comments included: I find that focus charting is interpreted differently by individuals There are different opinions on how to do focus charting Everyone has a different opinion on what it should look like Question three asked participants if they felt comfortable using the focus charting format. Although the majority agreed they felt confident using the format, 20.9% disagreed or strongly disagreed. Comments from this question may explain why. I am always afraid I will miss documenting things, and not always use focus charting for my note writing Even the ward leader i.e. CN do not understand FOCUS charting. 23

27 Question four asked if participants felt focusing charting assisted the quality of the nursing record, 65.5% of participants strongly agreed or agreed with this question. Comments included: If focus charting is used appropriately in conjunction with other documentation e.g. care plans and wound assessment forms Focus charting makes it easier to structure report when tired; helps capture important issues when done correctly If used, many staff don t use focus Question five asked participants if focus charting reduced the amount of time spent on nursing documentation. Although 45.1% of participants strongly agreed or agreed with this question, 35% disagreed or strongly disagreed. A theme that appeared from the comments for this question and throughout the questionnaire was related to the insufficient education related to focus charting. Comments included: Because there has been insufficient education and focus charting is not used properly I agree with the headings - but find AIE time consuming If used to its full purpose it probably would, still tempting to write vital signs satis, urine output satis, rather than not write anything "I think there is still an ingrained habit to write about everything due to legalities Question six asked if participants found reviewing the nursing record of care easy with the focus charting format, 68.1% strongly agreed or agreed with this question while themes coming through from comments included the need for education on a focus chart format so it consistently makes reviewing the record of care easy. Only is focus charting used appropriately e.g. what care /interventions was the main focus Sometimes I can find key words which tell me what I want to know but not always. Another theme that emerged for question six was the nursing record of care was easy to review if focus charting is completed properly. Comments supporting this theme include: Makes the notes easier to read and key words assist the reader finding out what they need to know 24

28 It is quicker and clearer to read, however because you only document deviations from the normal plan of care, some vital information about managing the patient could be lost Question seven asked participants if they believed MDT members read the nursing record of care more frequently due to the use of focus charting. A clear theme that arose from the comments for this question was doctors especially do not read the nursing record of care. This theme is summed up by these comments: It is very evident that doctors do not read nursing notes Surgical teams never read the notes I know a lot of medical staff dismiss reading nursing records as considered too long Doctors often make comments in the ward rounds which prove they have not read any nursing notes Only look for bowels or FBC and obs Some MDT members more than others, I don't think it makes a difference. Question eight asked participants if focus charting increased the amount of time spent on nursing documentation, 44.8% of participants disagreed or strongly disagreed with this question though a theme that came through from the comments was, using the AIE headings was time consuming and some nurses felt they were being repetitive with information under different focus headings. Quite time consuming doing A I E format, can be repetitive Sometimes I find when using focus charting I repeat some things in different headings In some cases increases time At the moment both focus charting and report writing is occurring so duplication. For question nine, although 62% disagreed or strongly disagreed that the focus charting format is difficult to use, the recurring theme around insufficient education appeared in the comments. If people were trained/educated better it would work well Has been shown to me different ways with different opinions Difficult to say without being adequately educated on it 25

29 If more training then it would be easier. Question 10 asked if participants felt comfortable educating students and new staff on the use of the focus charting format. The majority (52.4%) strongly agreed or agreed with this question, while themes emerging from comments were that nurses still feel the need to write more information like normal assessment findings. I still write vital signs satis, urine output satis, so am probably not the best educator, it's so hard to get out of the habit I do explain how the focus charting should be written but we as nurses feel we need to know more info.. Another theme that developed was that not all nurses understand the purpose of focus charting and so don t relate nursing care plans and other assessment documentation to the nursing note. Not everyone has the same information about relating NCP, notes and assessment There were 21% of participants who disagreed or strongly disagreed with this statement, again raising the issue of lack of education, how you can feel comfortable educating others if not sure yourself of the correct use of focus charting? Question 11 asked participants if the focus charting reduces duplication of patient information. A recurring theme from the comments for this question and from other questions was that nurses feel the need to document everything that occurs on the duty. In the back of my mind there is always the saying - if it s not written down it s not done What happens if a care plan vanishes? Does that mean you didn t give your patient a wash/continue education regarding procedures etc, this is why I find the format more time consuming The information is often duplicated in the care plan/pathway. Question 13 asked participants if retrieving specific patient information was easy with focus charting. A clear majority (68.7%) agreed with this question and comments supported this result. Makes notes easier to read by finding a specific focus It is easy if recorded under one of the headings If the format has been used 26

30 Not consistently done by all nursing staff. Question 14 asked participants if they complete their focus notes throughout the duty as events occur. The majority of participants disagreed or strongly disagreed (55%) with this question and comments from this question may go some way to explain why. Only if major event e.g., vasovagal, otherwise at end of duty Prefer to- not always possible No time to do that unfortunately On a quiet duty I write notes during the shift if busy it gets left to the end of the shift Notes not always available to do this Question 15 asks participants if the current care plans compliment focus charting. Themes that emerged from the comments for this question included; the current care plans are not patient centred, not specific enough and too generalised. Another theme from comments was participants reported the use of electronic pathways currently used within one area of the hospital did compliment focus charting. I believe that focus charting alongside adequate/effective patient centred care plans is an efficient way of documenting The care plans in current use are not clear or patient centred and so a lot more information is documented in patients clinical notes 27

31 Document review The documentation review revealed that a high percentage of the nursing documentation was of a satisfactory standard but there was sporadic use of the AIE headings and some patient information was still being duplicated (Figure 3 & 4). Eighty two per cent of the focus notes entries where required, this meant the entries where a focus or problem of concern and so it was appropriate to enter them. 120% 100% 80% 60% 40% 100% 82% 96% 96% 91% 78% 20% 40% 38% 29% 0% Figure 3: Overall document review scores November 2012 Figure 4 breaks down the documentation review to individual wards. The wards have been labelled from 1 to 9 to provide anonymity. In regards to meeting the documentation review criteria, ward 5 had the highest percentage and ward 1 the least. 28

32 Ward 9 Ward 8 Ward 7 Ward 6 Ward 5 Ward 4 Ward 3 Ward 2 Ward 1 Any acute changes/significant events are documented as a focus All foci entries in progress notes are required Assessment: A used in progress notes Assessment data are clearly identified for all foci (n/a for evaluative statements) Interventions: I used in progress notes Interventions are recorded for all foci (n/a for evaluative statements) Evaluation: E used in progress notes Evaluative statement written for all foci when applicable. Are ongoing foci in progress notes identified in the nursing care plan 0% 100% 200% 300% 400% 500% 600% 700% 800% 900% Ward 1 Ward 2 Ward 3 Ward 4 Ward 5 Ward 6 Ward 7 Ward 8 Ward 9 100% 100% 100% 100% 100% 100% 100% 100% 100% 80% 60% 80% 100% 60% 100% 80% 100% 80% 0% 80% 60% 20% 100% 20% 60% 20% 0% 100% 100% 100% 60% 100% 100% 100% 100% 100% 0% 80% 60% 0% 100% 20% 60% 20% 0% 100% 80% 100% 80% 100% 100% 100% 100% 100% 0% 40% 60% 20% 80% 20% 20% 20% 0% 80% 80% 100% 80% 80% 100% 100% 100% 100% 60% 60% 80% 60% 100% 60% 100% 80% 100% Figure 4: Overall document review scores by ward November

33 Chapter Summary Results from the questionnaire showed that the majority of participants feel that have had adequate education on focus charting, feel confident using it, and feel comfortable educating others on the format. However, there were still a significant number of participants who felt they have had insufficient education on how to use the format and these negative responses were typically made by nurses with greater than 10 years experience. The majority of participants felt focus charting assisted the quality of the nursing record, reduced duplication of patient information and nursing documentation time was reduced with use of the format. Reviewing the patient record of care and retrieving specific patient information was easy for the majority of participants with focus charting. Most participants agreed focus charting assisted them with evidencing the nursing process. The majority of participants did not complete their focus note throughout the duty with time restraint being a common theme, and the majority strongly agreed or agreed that the current care plans are complimented by focus charting. The documentation review demonstrated the majority of the nursing entries were of a satisfactory standard but there was sporadic use of the AIE headings and some patient information was still being duplicated. The next chapter will comprise discussion about the results from the questionnaire including how education and on-going support on focus charting is a potential enabler to its successful use. The responses from demographic groups will be analysed and possible reasons for the difference mentioned. The results from the documentation review will be deliberated to discover further barriers and enablers to using the focus charting format. Limitations of this research will be discussed followed by conclusions from the research. 30

34 Chapter Five: Discussion Themes from the comments for question one, which asks if the education on focus charting was adequate, were consistent with studies identified in the literature review. Cheevakasemsook et al. (2006), Lees (2010), Panns et al. (2010&2012) identified in their studies that education was key to improving the quality of nursing documentation. Björvell et al. (2003), Darmer et al. (2006) and Jefferies et al. (2012) reported that nursing documentation can show consistent improvement and be maintained at a high standard with regular audits while Darmer et al. reported training staff simultaneously rather than using key people has shown promise as a learning method and implementation strategy for implementing new documentation formats. The majority of nurses received some form of education on focus charting during the initial implementation and currently new nurses to the hospital are introduced to focus charting during their nursing orientation to the organisation, via a one hour presentation. Orientation to a new organisation can be overwhelming for some people with lots of new information presented over a short time frame, so possibly a one hour education session on focus charting during this time may be insufficient to allow its successful use. Literature related to the issue of nursing orientation suggests that preceptors of new nurses play a key role in bridging the gap between classroom orientation and clinical practice (Warren & Denham, 2010). A possible strategy to enable new nurses with using focus charting successfully could be ensuring their preceptors receive adequate education on focus charting, either in the clinical setting or incorporate it into the hospital s preceptorship study day which all potential preceptors are encouraged to attend. Perhaps there are different interpretations or a perception by nurses as to what is seen as education. Since it is nearly five years since focus charting was introduced and the initial education given, it could be possible that the current form of focus charting education at nursing orientation is deficient. On-going support and education on focus charting is possibly an area were there could be an improvement at the hospital as there appears to be sporadic on-going education and in-services for focus charting. Having a neutral option for the question regarding on-going support and education made it difficult to determine if this was a majority response from participants, but there is certainly a significant amount of nurses who believe there is not enough on-going support or education with the use of focus charting. Paans et al., (2010) identified in their study that confidence with completing nursing documentation as a barrier to improving nursing documentation. If nurses do not feel confident using the focus charting format, possibly due to insufficient education, then this would certainly have some effect on the quality of the documentation. 31

35 Previous research has demonstrated the use of a structured framework that incorporates the nursing process can assist with improving the quality of nursing documentation (Paans, et al., 2012; Paans, et al., 2010). A structured framework makes the documentation more systematic and comprehensive while evidencing the nursing process (Thoroddsen & Ehnfors, 2007). Using a structured framework when documenting patient care can also assist nursing with the development and use of a possibly inevitable electronic patient record (von Krogh & Nåden, 2008). Some nurses believed using the focus charting format increased the amount of time spent on nursing documentation. Similar results occurred in the study by Björvell et al. (2003), where nurses thought using a similar, key word structured way of documenting was more time consuming. If nurses do not fully understand the concept of charting by exception and avoiding duplication, then documenting all information from the duty would be very time consuming using the focus charting format. Another theme that came through from the questionnaire was, nurses feeling like they need to write everything that occurs throughout the duty in the nursing record of care due to the legalities. Again this could relate back to the education around focus charting and clinical documentation in general. There is an unwritten rule that circulates around nursing documentation If it is not documented then it did not happen. Although these are wise words, nurses need to remember that observation charts, medication charts, care plans, care pathways, other assessment forms and clinical documentation, all form part of the documentation within the patients clinical notes (NCNZ, 2012; NZNO, 2010). If the record of care is recorded within the clinical notes, and there is not a problem or concern related to these assessments, then it is not required to be duplicated in the nursing record of care when using the focus charting format. One of the key reasons for the development of the focus charting was to provide information in a format that can be easily retrieved for reviewing, auditing and research (Lampe, 1997). Anecdotal evidence suggests that when focus charting is used well, reviewing documentation at the hospital as the result of incidents reports is more efficient, as is retrieving specific patient information. The results from the questionnaire provide evidence that some of the perceived benefits of introducing focus charting have been achieved, this includes assisting the quality of the nursing record, reviewing the nursing record of care is easy, evidencing the nursing process and easy retrieval of specific patient information. Cheevakasemsook et al., (2010) noted many factors that may affect the quality of nursing documentation. One factor they highlighted was that there was no recognition of the significance of nursing documentation by other health professionals, in their study it was reported doctors irregularly read nursing notes and other nursing documentation was disregarded. The high neutral 32

36 response (41.4%) for the question related to this issue may reflect some comments from participants within the questionnaire in that, nurses do not know if MDT members read the nursing notes, this is an area for future research to find out why MDT members, especially medical staff may disregard nursing documentation. Another theme that appeared in the comments from questionnaire may provide one reason as to why doctors do not read the nursing note, because the nursing note is too long. Focus charting was implemented at the hospital studied in an attempt to resolve this issue, it was thought MDT members may find nursing documentation is of more value in this format, thus facilitating communication and ultimately improving patient outcomes. The author believes from their experience and exposure to nursing documentation and as a result from the documentation review, the nursing note in the hospital studied has reduced in length overall with the use of focus charting. Though it was apparent from the documentation review some nurses still write everything that occurs throughout the duty whether or not it is a focus/problem of concern, and even if it is recorded somewhere else within the patient s clinical notes. Although the questionnaire was not sent to MDT members, feedback gathered from MDT members during the pilot of focus charting was positive (Blair & Smith, 2009). Medical consultants feedback included how focus charting made retrieving information from the nursing note easier, other MDT members commented on an improvement in teamwork related to working towards patient care goals. Feedback on the new format from Infection Control supported focus charting as during an outbreak of gastroenteritis at the time, it was noted that there were significant improvements in ease of access to required information. This minimized the time required reviewing the notes, as the information was clear, concise and appeared to be accurately reported. Implementation of this type of documentation in other areas was supported by the Infection Control team (Blair & Smith, 2009). There is possibly a lack of understanding about the focus charting concept by nurses in that all documentation including observation charts, medication charts, care plans, care pathways and other assessment forms can all be considered legal documents in a court of law (Campos, 2010). Law et al. (2010) in their study mentioned how nurses were reluctant to complete forms thoroughly, like care plans for example, due to medications, vital signs and other assessments being recorded in several locations. Patient information being recorded in different locations was a theme that emerged from comments within the questionnaire. This comment sums up those themes: The documents we use have not kept pace with changes to documentation - for examplepatient s weight can be recorded in four places 33

37 This may be a reason why some nurses still record everything in their nursing record due to lack of confidence with the completeness and accuracy of information on other assessments forms such as care plans. The majority of participants believed using the focus charting format assisted with evidencing the nursing process, this response matches findings in a study by Thoroddsen & Ehnfors (2007), who identified that a structured framework makes the documentation more systematic and comprehensive while evidencing the nursing process. Over 68% of participants strongly agreed or agreed that retrieving specific patient information was easy with focus charting. This was one of the perceived benefits of focus charting that appears to have been achieved with its introduction at the hospital, and was supported by feedback from MDT members during the pilot (Blair & Smith, 2009). Previously using the narrative approach and without the keyword heading, the reader may have had to read the majority of the nursing entry to find specific information which could be time consuming and frustrating. The documentation review supported the achievement of this benefit in that auditing and reviewing nursing documentation was easier when focus charting was used. When participants were asked if they completed their focus note throughout the duty as events occurred, 55% disagreed or strongly disagreed while 29% strongly agreed or agreed. Completing the nursing entry into the clinical notes at the end of the duty, rather than chronologically relies on the nurse accurately recalling information. Lees (2010) identifies that this has the potential for information to be inaccurate or omitted. Chronological documentation is recommended in the literature and by the NCNZ (Campos, 2010; NCNZ, 2012). The NCNZ recently revised Code of Conduct for Nurses, states in the guidelines for documentation, Complete records as soon as possible after the event has occurred (NCNZ, 2012 p21). Possible barriers to chronological documentation at the hospital studied have emerged as themes from the comments within the questionnaire. Nurses wrote they did not do chronological documentation because there was not enough time; patients clinical notes were not always available to them due to other MDT members using them, and due to the clinical notes not being kept at the bedside. Not enough time to do this in high acuity high workload ward setting Hard to do as the notes are in the office, not at bedside and not always available to use Some of the participants who wrote comments related to chronological documentation appeared to understand the relevance of it and stated they preferred this method, but wrote there was not enough time to document chronologically due to busy workload. 34

38 The quality of nursing documentation appears to be affected by time pressures that many nurses experience in a variety of clinical environments, present issues include the lack of timely entries. The Nurses Board of South Australia states in their Guidelines for Clinical Documentation that it should be a chronological record of actions and events, and should occur at the time of or as soon as practicable after; the action or event, collaborations, variances to expected outcomes and critical incidents (NBSA, 2006). Chronological documentation is important as it forms the basis of communication between health professionals; informs and is a record of care provided and demonstrates accountability (NBSA, 2006). Another theme reiterated in question 14 was unavailability of the patient s clinical notes to document chronologically, due to colleagues and other MDT members requiring the clinical notes at the same time. The unavailability of the patient s clinical notes when required is a barrier to chronological documentation within the hospital, and frequently occurs during certain times of the day e.g. changeover of nursing staff, doctors rounds and MDT meetings. For nursing documentation to be accurate it must be timely so continuity of care and risk reduction is achieved. This challenge in nursing is also experienced by other MDT members such as physiotherapy and social work. The American Physical Therapy Association (APTA) board of directors identified issues related to improper and deficient documentation in clinical patient care (Delaune & Bemis-Dougherty, 2007). The APTA board directed that a series of tools and resources be developed for members to address concerns regarding physical therapy documentation, this included raising the awareness of documentation issues to physical therapists and educating them on ways to document that satisfy legal requirements (Delaune & Bemis-Dougherty, 2007). Social Workers understanding on the relevance of documentation has evolved over time and the profession has begun to appreciate the importance of documentation for risk management purposes, particularly as a tool to protect patients and to protect practitioners in the event of an ethics complaint or lawsuit (Reamer, 2005). Health care systems rely heavily on MDT documentation to measure patient outcomes, and to identify the need for services and justification for the plan of care. Insufficient or absent documentation can negatively affect communication among MDT members, risk management and most importantly, patient care (Delaune & Bemis-Dougherty, 2007). A future with electronic documentation may be the answer to resolve this issue as the patients clinical record could be accessed from any computer and does not rely on a single hard copy of the clinical record (Häyrinen, Lammintakanen & Saranto, 2010). Care plans not being patient specific or patient centred was a theme that emerged from the comments from question 15 and the documentation review: 35

39 Care plans are not patient specific-too generalised to be of any real value The care plans in current use are not clear or patient centred and so a lot more information is documented in patient clinical notes Specific patient information or on-going foci or problems of concern were not always recorded on the care plan. The care plans used in the majority of the wards are generic and have been developed for use with focus charting. Part of the development process was ensuring that there was enough space on the care plan for nurses to individualise these plans for patients and make them specific, although this was not always occurring. Results of the documentation review revealed that in most areas some care plans were not individualised to the patient and did not include the current focus or problems of concerns. The care plans in current use also require the nurse to record their initial next to cares and interventions outlined on the care plan, as evidence of these being completed on that duty. Several of the care plans reviewed were incomplete or not completed at all for some duties. Basic nursing interventions like pressure area cares, hygiene needs, wound care, nutrition and elimination, need to be recorded as completed. The danger with not recording routine cares in the care plan is, if the nurses is attempting to use a focus charting format where only chart the focus or problem of concern, and the care plan is not completed, then there is no record of these interventions being completed. Nurses should not become complacent with check off assessments or tick boxes, if there is not a systematic approach to care planning poor documentation occurs. Poor documentation makes nurses vulnerable to any litigation should this patients clinical record be involved in an incident review or be brought into dispute (Campos, 2010; Lees, 2010). As identified from the literature, nurses may be reluctant to complete forms like care plans thoroughly due to the information being recorded in several places (Law, et al., 2010). If a nurse has recorded patient information in the nursing record there may be reluctance by a nurse to record the same information in the care plan, even though the care plan may be the most appropriate location for this information. Care plans are necessary in any clinical setting as they provide an emphasis for using the nursing process in a deliberate manner for each patient, and provide the basis for evaluating the effectiveness of nursing interventions (Schultz & Videbeck, 2009). Care plans also allows revisions based on the plan of care and are the only feasible means of effective communication among different members of nursing staff who are on duty at different times, and who may not be familiar with the patient. The care plan provides a central point of information for coordination of care. However care plans are often see as troublesome, time consuming or 36

40 unrelated to the actual care of the patient (Schultz & Videbeck, 2009). A future with electronic documentation including care plans that have forcing functions, that stop progress of completion until certain aspects are finished, may assist with resolving this issue (Newman & Howse, 2007). This statement is supported by comments for question 15 where participants reported the use of electronic pathways currently used within one area of the hospital did compliment focus charting. Having papers based systems for documentation along with electronic documentation does raise issues with regard to effective communication between MDT members. For example the electronic pathways used at the hospital are only accessible to nurses and not utilised by MDT members and could hinder effective communication and cohesive care. There are also future plans in the hospital to make aspects of medical teams documentation electronic via ipads or tablets, so if nursing and other MDT member s documentation is to remain paper based, there is potential for ineffective communication. If the hospital should progress with developing electronic documentation for all MDT members in the future, this transition may be smoother in areas where nurses use focus charting, as research suggest using keywords and a structured format can assist with the development of electronic nursing documentation (von Krogh & Nåden, 2008). When responses from demographic groups where analysed for questions regarding adequate focus charting education, focus charting assisting the quality of nursing record, the ease of review, retrieving information and complimenting care plans, there were significantly more positive responses received from nurses with <5 years nursing experience compared to those with more than 10 years experience (Table 2). The analysis also revealed that nurses with less than 10 years experience tended to feel more confident using focus charting, that it reduced the amount of time spent on nursing documentation and they were more comfortable educating new staff members on focus charting, compared to those nurses with greater than 10 years experience (Table 2). The difference could be due to the <5 years group consisting of relatively new nurses who may have had previous education and experience with focus charting as nursing students on placement within the hospital. Another possible explanation for the different responses between the groups is that the <5 years group could contain a high proportion of recent new graduates who received the initial focus charting education as part of nursing orientation to the hospital. Of interest is Question 11 Focus charting reduces duplication of patient information in that those nurses with 5-10 years experience were more likely to respond positively than those with greater than 10+ years experience while those with <5 years experience were not significantly different from either of the other two categories. Presumably this is because those with the least experience had less information to base their answer on. 37

41 Through the author s experience in educating existing nursing staff, new graduate nurses, and as a clinical lecturer for nursing students, new graduates and nursing students appear to adapt far more readily to using the focus charting format. The easier adaptation to focus charting by students and new graduates may be due to them not having been exposed to, or using any other type of nursing documentation format. A similar result was noted in Panns et al. (2012) study when comparing nursing documentation using the PES structure. The PES structure has been taught in nursing education programs in the Netherlands since the mid-1990s, which may explain why younger nurses in their study had higher accuracy scores for documentation compared to older nurses (Panns et al., 2012). This could also be the reason more positive comments regarding education, on-going support and confidence came from younger nurses (or those with less nursing experience) in the author s research due to previous exposure of focus charting. Panns et al. suggest previous education in the PES structure influenced the accuracy of nursing documentation. More experienced staff who may have been exposed to different types of documentation in the past, or who traditionally wrote a narrative nursing entry, may find the focus format difficult to use and lack confidence educating others, especially if education has not occurred or been insufficient (Cheevakasemsook, et al., 2006; Darmer, et al., 2006). The implication of inadequate education on documentation can have far reaching consequences and could potentially lead to complaints to the Health and Disability Commissioner (HDC). A report from the HDC s office in 2012 examined the complaints made against all DHB s from the period July 2011 to December 2011 (HDC, 2012). Of the 255 complaints made, eight were related to the patients medical record or report and 10% related to communication (HDC, 2012). One case study in particular highlighted insufficient communication between health professionals and recommendations from the HDC to improve communication between health professionals, included clear documentation in the clinical record (HDC, 2012). The documentation review revealed there was still duplication of information. The most common duplication was the reporting of normal observations. Even when observations had remained normal throughout a patient s admission and where there was not a problem or focus of concern, nurses where still reporting them as being stable each duty. The use of the A, I, and E headings was sporadic among nurses and wards. Even though assessment, intervention and evaluation data may have been found by reading the through the nursing entry, it was more time consuming finding this data compared to when the headings were used. Question thirteen asked respondents if retrieving specific patient information is easy with focus charting and over 68% agreed, underlining the benefit of appropriate use of the format. 38

42 It is easy if recorded under one of the headings The results for question thirteen and comments related to this question also highlighted the benefit of using the headings for auditing and researching nursing documentation. When the documentation review was completed those nurses who used the focus charting format with the A, I, E headings, clearly evidence the nursing process. This supports research that suggests structured documentation using a keyword facilitates and improves nurses disposition towards critical thinking (Björvell, et al., 2003, Darmer., et al., 2006; Paans, et al., 2012). From the 45 individual nursing entries reviewed, four entries were recorded by relief nurses who were not permanent nursing staff of the particular wards. The relief nurses focus charting did not include the use of the A, I, E headings, the use of key words where not specific to the focus identified from their assessments, and multiple problems or focuses of concern from the assessment where group under one key word. Although this problem was identified with some permanent nursing staff, it was a consistent theme among relief staff, this was identified in previous documentation reviews by the author and supports Lees (2010) paper that showed the quality of nursing documentation can be affected by casual or relief nurses. Another issue that emerged from the documentation review was incomplete care plans. There were some care plans that had interventions initialled as completed by the nurse who was caring for the patient, for only one or two duties out of the three eight hour duties within a 24 hour period. Although the nurse who did not initial the interventions may have performed them, there was no sign off in the care plan that the interventions had been initiated. This research only goes some way to answering the research question and has identified various gaps in the literature related to focus charting, including barriers and enablers to successfully using the format. This could be addressed by further research in order to discover other barriers and enablers to successful use of the focus charting format. The research does provide some answers as to why some nurses may have difficulties with the format and implications this can have on nursing practice. This research will hopefully assist future nursing education on the format and any hospital or organisations considering implementing focus charting. Limitations of this research In hindsight, the author would not have used a neutral response on the Likert scale for the questionnaire. This is because on average respondents selected neutral 24% of time. It can be argued that most people hold a view on something even if they don t recognise this themselves, therefore it would be fair to force a response (Brace, 2008). It has been demonstrated in other research that not providing a midpoint improved reliability and validity of data (Saris & Gallhofer, 2007). On reflection the author could have included more demographic information in the 39

43 questionnaire e.g. whether the participants had completed any post graduate study. This may have provided further data to explain the difference in responses between the demographic groups analysed in this research. A potential bias with using an electronic questionnaire, such as Survey Monkey, was allowing unlimited responses from one computer. This was required in the hospital setting because of a limited amount of computers available for nurses to use, and could mean that nurses were able to complete the questionnaire more than once. Another potential bias was the author s manual entry of the participant s questionnaire when the hard copies were returned; this could have led to author incorrectly entering data accidentally or intentionally to influence results. A strategy employed to avoid potential author bias and error was the use to a colleague as an independent moderator who checked the accuracy of manually entered data. Conclusion Analyses of the results from the questionnaire and documentation review revealed some reoccurring themes as to what the potential barriers and enablers to using the focus charting format in hospital setting are. Data from the questionnaire and themes from the comments showed that nurses education on the use of the focus charting format was an issue, insufficient education related to focus charting and, a lack of on-going support on use of the format is a barrier to its successful use. This theme is supported by literature that suggests an enabler to successful use of the focus charting format is adequate training of new nurses and regular education of existing nurses as being a factor in improving and maintaining quality nursing documentation (Jefferies, et al., 2012; Lees, 2010; Voyer, et al., 2013). Targeted education and on-going support for nurses may go some way to resolving the issues for those who believed lack of time was a barrier and having more time been an enabler to use the focus charting format. There also needs to be a consistent approach with focus charting education and those who teach it to avoid different interpretations. Better utilisation and individualisation of the nursing care plan and a consistent approach of where assessment data is recorded within the clinical notes may go some way to make nurses feel more confident with using the focus charting format and reduce duplication. Finally, auditing is essential as to sustain the quality nursing documentation therefore regular audits need to continue, this will help with consistent improvements and maintain a high standard of nursing documentation. 40

44 Appendices Appendix 1: Focus charting example Date/Time 09/11/ hours Nursing 1100 hours Nursing Focus/Patient Problem Hip pain related to surgical site Hip pain related to surgical site Patient progress notes A: Patient reports increased R) hip pain. Intensity 3/10 at rest, 5/10 on movement. Dull throbbing ache over suture line. Nil visible redness or swelling noted. Has full range of movement. I: Returned to bed and positioned on unaffected side utilising 30 degree tilt. Codeine phosphate administered as charted. A. Smith A Smith RN E: Patient states pain decreased to 1/10. A. Smith A Smith RN 41

45 Appendix 2: Survey Monkey questionnaire 42

46 43

47 44

48 Appendix 3: Documentation review tool FOCUS CHARTING REVIEW (5 nursing entries from each ward, 9 wards in total)) INDICATORS: The nurse documents major foci of patient concern, recording assessment data, interventions and evaluation of patient outcome. Ward: Date: / / Yes = No = X N/A = N/A Source : Clinical Notes Total Any acute changes/significant events are documented as a focus All foci entries in progress notes are required Assessment: A used in progress notes Assessment data are clearly identified for all foci (n/a for evaluative statements) Interventions: I used in progress notes Interventions are recorded for all foci (n/a for evaluative statements) Evaluation: E used in progress notes Evaluative statement written for all foci when applicable Source: Care PlanCare Care plan Are ongoing foci in progress notes identified in the nursing care plan COMMENTS: Clinical Notes: 45

49 Appendix 4: Research approval from hospital. 46

50 Appendix 5: Research approval from EIT 47

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