Developing care plan documentation: an action research project

Journal of Nursing Management, 1995,3,193-199

Developing care plan documentation: an action research project

Introduction

Nursing documentation provides the principle source of information about patient care (Gropper 1988) and forms the pivotal point of the delivery system (Costello & Summers 1985). It therefore reflects the competence and caring abilities of the nurse (Feutz-Harter 1989) and its development may be a source of dynamism and creativity (Christie 1993).

Reflecting the importance associated with effective documentation an extensive audit of the existing manual care planning system within one general hospital was undertaken before attempting to introduce a computerized system. The audit report suggested that care planning was not being carried out to an acceptable standard. Particular areas of concern included identification of problems and documentation of progress and evaluation. The decision was therefore made to concentrate on developing skills in relation to these areas before considering the introduction of computerization.

A project group was subsequently established consisting of a resource management co-ordinator, two senior nurses, two nurse teachers, and two ward sisters. The research and development manager from the College of Nursing was later co-opted. The membership of the group reflected the view that any potential change in nursing depends on a co-ordinated approach involving management, teachers and clinical staff working together on a project over a substantial period of time.

The resulting collaboration between education, service and management made it possible for a significant element of research to be included in the development process and contribute towards promoting a reflective and lasting improvement in patient care documentation.

After an initial meeting of the project group, three different clinical areas were selected to explore reasons for the deficiencies that had been identified in the audit.

Staff at all levels were consulted using unstructured interviews. The results showed little understanding of care planning, and much criticism of the current documentation. Changing the nursing documentation was now seen to involve more than minor amendments to the paper work.

Review of the literature: care plans, their history, purpose etc.

Traditionally, docuimentation has been seen as a means of communicating information and organizing and evaluating care for the nurse (Shea 1984) and also as an educational tool for the student (White 1993). Administratively it can allow resources to be secured and distributed appropriately (Shea 1984) in part through identifying the need for skilled care (Gropper 1988).

As nurses become increasingly autonomous and accountable for their practice, the legal power of documentation has a crucial role to play in the defence of specific actions [Sklar 1984) and also as a record of what has occurred ;and what has not (Edelstein 1990).

The literature suggests that effective documentation may enhance qualily care by improving communication (Summers & Costello 1985). This is supported by current research findings that show a correlation between care plans and positive patient outcomes such as reduced stay (Black et af. 1989), which illustrates that documentation cannot be divorced from its use in practice. Costello and Summers (1985) suggest that the effectiveness of a good care plan may be measured by the frequency with which they are read and used.

However, much of the literature presents a negative picture of the perceived value and use of care plans in practice. Sutcliffe (1990) suggests that care plans are superfluous, contain obvious information, and are

0 1995 Blackwell Science Ltd 193

A. McElroy, V. Corben and K. Mcleish Developing care plan documentation

time-consuming to complete (Edelstein 1990) , which adds to the pressure of work and stress, and reduces time to care. Documentation of care planning is seen as a punishment and a chore imposed by administrators (Sutcliffe 1990). The literature further suggests that care plans are viewed as unimportant, are not valued (Fox Ungar, Newel1 & Guilbalt 1989), and rarely developed or followed (Costello & Summers 1985).

If a literature review of care planning documentation suggests it is at present undervalued and inappropriate; but that it may also correlate positively with improved patient outcomes; what does it suggest are the problems? Shea (1984) identifies the problems as relating to the nurse, the environment and the tool.

Several authors, e.g. Gropper and Sutcliffe (1985) and Edelstein (1990) suggest the main cause for the lack of recognition of the value of effective documentation relates to a lack of understanding of the central issues involved, such as the principles of nursing philosophies and models and their relationship to care planning. Nurses need to understand this before they can begin to plan care (Wright 1990).

There appears to be resentment amongst some nursing staff concerning models and their relevance to nursing (Frissell 1988). Copers (1986), however, suggests that further development of understanding and knowledge would reduce this resentment, especially if it was under- stood that the models are there to be adapted to the individual situation. With this foundation to practice, care planning can be logically and sensitively developed.

The introduction of the nursing process using a top-down approach within a brief period of time and with minimal education (De la Cuesta 1983) again results in devalued documentation and a lack of understanding. This is reflected in care plans being physically oriented, and nurses being unable to identify patients’ problems (Hunt & Marks-Moran 1986). In addition, care plans are often poorly written and medically orientated (Shea 1986). In relation to evaluation, a study by Challoner and Drummond (1992) revealed a lack of quality in written daily interventions and a lack of awareness of the need for an accompanying measurable component.

Historically, document design has also caused difficulties in relation to short-stay patients, specialized and unpredictable events (Shea 1986). Lack of understanding of care planning and difficulties with documentation design may have led to positive attitudes towards standard care plans as identified by Nicholls and Barstow (1980). They suggest that these reduce the amount of thought and time required as they are largely pre-written.

Another important reason for the inappropriate use of documentation is related to the negative attitudes and

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perceived lack of support from nurse managers (Nicholls & Barstow 1980; Shea 1986). Shea (1986) suggests that confusion about responsibility and accountability for the documentation, coupled with managers failure to recog- nize the time required to document properly (Edelstein 1990) , prevents nurses valuing documentation of care.

Unit structure and staff attitudes also have an important influence on the use of documentation (Nicholls & Barstow 1980), especially that of the ward sister (Yassin & Watkins 1993). Peer pressure and the influence of others directly affects the written content of documentation (Renfrow et al. 1993).

The literature also suggests some strategies for improvement. Effectiveness of documentation depends on being able to change attitudes and beliefs of nurses, including managers (Renfrow et al. 1990), before behaviour can be changed. Gropper (1988) suggests a direct correlation between understanding of related issues and quality of documentation. The development of a more positive approach towards the practice of care planning and its documentation therefore, depends on effective education and management support (Schmidt et al. 1990).

Researching and developing care plans

The review of the literature reinforced the importance of effective documentation and confirmed the need for relatively substantial educational input which would enable ward ‘teams’ to develop increased understanding and a collective consciousness. Meaningful change in nursing documentation can require a radical review of attitudes and values associated with care planning and the process of nursing. The successful introduction of new documentation, therefore, constitutes a substantive exercise in change management.

Wright (1989: p. 6) defines change as ‘an attempt to alter or replace existing knowledge, skills, attitudes, norms and styles of individual groups’.

Chinn, Benne and Bennis (1976) describe three strategy approaches to change, one of which is referred to as ‘normative re-educative’ which places a high emphasis on ownership and participation. This suggests that those required to use an innovation, should be intimately involved in its development and implementation. Ottaway (1976) emphasizes that change should begin with the ‘doers’ who must participate fully in the change process.

He suggests that ‘top-down’ approaches often result in temporary change only, and highlights the need for a continuous cycle of education and change if new skills and knowledge are to be internalized. These principles are consistent with the main tenets of action research,

0 1995 Blackwell Science Ltd, Journal of Nursing Management, 3. 193-1 99

Journal of Nursing Management

and it was decided that in order to ensure a systematic approach to evaluation and development, an action research approach should be adopted.

As a method, this provides a way of carrying out research and working on solving practical problems at the same time (Webb 1989). Nolan and Grant (1993) describe action research as a cyclical process involving a number of stages including diagnosing a problem area, developing a plan of action, implementing the plan, and evaluating its effectiveness so that lessons learnt can be used to re-examine the original problem. Researchers and participants work together to analyse the situation they wish to change.

Various methods are used for data collection, and it is generally accepted that a specific method is not required (Whyte 1992). Whyte explains how action research allows exploration and creativity regarding models and methods used.

Holter and Schwartz-Barcott (1993) describe three main approaches to action research. The mutual collaboration approach was regarded as best suited to this particular study. With this model, the researchers and practitioners come together to identify potential problems, their underlying causes, and possible solutions. As an outcome of dialogue, the researcher and the practitioner arrive at a new common understanding of the problem and its causes, and mutually plan for initiating a change process.

In adopting this approach, we acknowledge that implementation of the desired changes would need to occur within what Schon (1987) refers to as the ‘swampy lowlands’ of reality and that, therefore, research must come down from the ‘firm high ground’ of theory. The problems identified in the original audit must be addressed in the context of the‘ dynamic and complex social environments in which nursing interventions actually occur.

Development activities

In acknowledging these principles a study day was planned to involve as many staff as possible from two pilot wards; one medical and one surgical. Management support was demonstrated by informal attendance during the day, and in maintaining ward cover for the time concerned. The aim of the study day was to develop understanding of philosophies, models and the nursing process, prior to exploring the application of these issues to the design of new documentation. During the day, the group was divided into two focus groups each comprising all the members of one ward team.

Focus groups are a valuable tool both for collecting

data and managing the change process. They are not a free wheeling conversation among group members, but have a clearly identifiable agenda (Kreugar 1989). They are a non-directive, (qualitative research method in which group members influence each other by responding to ideas and comments in the discussion. Focus group theory acknowledges that we are a product of our environment, and are influenced by the people with whom we interact. The intent is to produce qualitative data that provides insights into the at1 itudes, perceptions and opinions of participants. They are not intended to develop a consensus, but can generatle a collective consciousness.

The data are primarily obtained through open-ended questions where respondents are able to choose the manner in which they respond, and also from observations during the group cliscussion. Basch (1987) , states that subjects tend to disclose more about themselves to people who resemble them in various ways than to people who differ from them. The rule for selecting focus group participants is therefore commonality, not diversity.

The participants were highly motivated and appreciat- ive of the opportunity to be actively involved. Both teachers and participants were struck by the degree of commonality between two clinically different areas. For example, both independently identified a need for a more flexible assessment sheet and suggested the idea of short and long-stay documentation.

The workshop resulted in both pilot wards writing their own action plans with one ward designing a short- stay and the other a long-stay document. Once these forms had been designed the decision was made to pilot the forms in six areas, which were chosen on the recommendation of the senior nurses.

Individual contact with the ward sisters in these areas was made by the project co-ordinator who had established their general willingness to participate.

This initial contact was followed up by a presentation to each ward explaining the background to the project; bringing them up-to-date and providing an opportunity to clarify any queries. In keeping with the research focus of the project, all ward staff were asked to complete questionnaires at this point concerning their views on care planning. The questionnaire had been used in other local studies following its original design by Pellatt (1993).

A copy of the questionnaire, and details of the responses, is detailed in the Appendix. The intention is to repeat the process at a future date once new documentation is well established to assess the impact of the process on beliefs and attitudes towards care planning. In general terms, the data presented a rather confused picture and in many cases the number of nurses agreeing and disagreeing with a particular statement is very

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similar. This tends to support the impression gained from the focus group discussions that there is no common understanding amongst nurses regarding the purpose and utility of care planning.

The ward staff were then asked to select two nominees whose role was to act as a link between the working group and their ward staff. They were invited to attend a half-day workshop which provided a shortened version of the full study day; introduced them to the new documentation and gave them an opportunity to discuss their role.

The nominees were issued with notebooks for ward staff to record questions and comments concerning the documentation and the contact numbers of the project team as a source of support. At the nominees’ request a mid-point review was arranged. Link teachers from the pilot areas were invited to a presentation and contacted individually to discuss their role in supporting the project.

The pilot study commenced 3 weeks later. The co-ordinator and a nurse teacher regularly visited all the areas involved to address issues arising from the notebooks and to help resolve problems relating to the

I understanding and use of the forms. The mid-point review was used to provide an oppor-

tunity for the nominees to discuss their views on’ the new documentation, their role as nominees and to collect data.

Evaluation and data analysis

The process of formally evaluating the new documentation and the implementation process involved three separate data collection activities: ward note books, nominee focus groups and audit of the documentation.

The audit tool was designed in response to issues raised by the nominees and from an initial evaluation of a small sample of completed documents. The tool focused primarily on document design as distinct from the underlying process. The combined data were analysed under the headings: assessment, planning, evaluation and communication as used in the audit tool.

Assessment

Two main issues were highlighted by this analysis-the role of nursing models and the process of assessment. The importance of guidelines related to the model being used was unanimous. Initially there was some preference for a structured assessment, but this preference had diminished by the end of the pilot study, suggesting that staff had developed a greater working knowledge of the model used.

From the audit it became apparent that there was no explicit use of any model on the short-stay forms and only 50% use with the long-stay documentation. Both reflected a physical bias which raises a question about understanding of the model even when explicitly used.

The information on the short-stay forms was medically orientated, whereas the long-stay documents reflected a nursing orientation. This may be related to the brief nature of information on the short-stay forms.

The process of assessment appeared to be a problem both in a general sense and more specifically in relation to the use of the forms. This was illustrated by nurses’ difficulty with using a blank sheet for assessment, and with their requests for including assessment data on the biographical sheet. On a positive note the flexibility of the blank assessment form was generally appreciated and there was a consensus ,that this helped to reduce the amount of writing that was necessary.

By the end of the pilot study it was no longer being highlighted as a problem by the nominees. In addition, some nominees stated that their assessment skills had improved during the study.

Planning

The key issue of core care plans was continually highlighted in relation to care planning. Initially, there was a purely practical problem in incorporating the core care plans into the new documentation. Once this problem was overcome they were used in approximately 50% of forms audited.

The positive influence of core care plans was reinforced by the majority of participants at the nominees focus group. Skills in planning care were seen to have improved during the pilot study by some of the nominees. However, there was an acknowledgement that there were still shortcomings in the documentation of care planning.

Evaluation

A key problem with the evaluation sheet was related to the amount of space available. The ward books and mid- point review demonstrated the need for more space for formative and detailed summative evaluation. This remained unresolved at the focus group review and was identified by one nominee as being ‘one of the biggest problems’.

The accountability log was viewed positively at the mid-point review and the audit identified it as being well used both on the long- and short-stay forms. One area identified problems in completing the log when only one trained nurse was on duty. The level of understanding of

196 0 1995 Blackwell Science Ltd, Journal of Nursing Management. 3, 193-1 99


evaluation was reflected in the generally appropriate information written on the evaluation sheet and adap- tations to meet patient need further supported this. An example being the use of 2-day instead of 7-day evaluation sheets for clients with rapidly changing conditions.

In the majority of long-stay forms the evaluation entries were linked to the appropriate problem, however, this was not the case with the short stay-forms. The design of the long-stay documentation may have encouraged this linkage.

Initially, nurses in some areas were ticking the evaluation columns, but this was quickly recognized as being an inadequate record as it was difficult to be sure of the exact meaning of a tick! Even when nurses were writing in the evaluation columns, concern was expressed about finding necessary information when dealing with com- plaints. This was highlighted in the ward books and raised again during the focus group discussion.

Communication

After some initial confusion about its purpose, the communication sheet was generally well liked and appropriately used. Its use varied slightly from area to area, for example, whether or not it was used by other members of the multi-disciplinary team. Lack of space was occasionally a problem. At the focus group discussion it was mentioned that this sheet was sometimes being used as a continuation for longer evaluation entries. It may be that these last two factors are connected.

General comments

Although the forms were not universally liked, they appeared to stimulate thought and discussion concerning care planning. The pilot study provided a forum for developing not only the documentation but also the relevant skills required by the individual. In addition to the observations already made, these developments were illustrated by the constructive and practical suggestions from the nominees at both mid-point and final reviews.

Ward sister’s group discussion

Research has demonstrated that the ward manager is the key figure in ward organization and the delivery of care (Pembrey 1980; Lathlean & Famish 1984). Yassin and Watkins (1983) also highlight the relationship between the ward sister’s attitude to the care planning process and its perceived value by other members of the ward team. With this in mind ward sisters from the pilot areas were invited to form a separate focus group. This discussion

was intended to provide a forum for examining their attitudes towards the project, and general issues relating to care planning.

In general there was agreement that time was a major issue in care planning with pressure of work acting as a deterrent to good (care plans. The group agreed that quality of care planning was higher in some areas than others. Reasons cited included the proportion of trained staff and their level of understanding of the care planning process. There was a distinct lack of consensus within the group regarding the relevance of nursing models and theory.

The group felt that ownership of the new documentation and its implementation had not been achieved at ‘grass roots’ level, other than in the two areas actually involved in document design and that this was an important issue. The fact that the documentation had been developed by clinical colleagues did not automatically ensure ownership.

Conclusions from the project

It is clear from the study that a return to the original documentation is not regarded as a viable option by any of the wards invo1vc:d in the pilot study.

The study highlighted a lack of collective consciousness amongst nurses regarding the purpose and utility of the care planning process. Since there was a desire to continue to meet to discuss care planning, an on-going forum, facilitated by nurse teachers, was established for the discussion of issues relating to the care planning process and documentation. This level of continued involvement and commitment may reflect that the initial identification of need had been their own.

There was a clear consensus amongst the wards involved in the project, that given the extent of movement of patients and staff between clinical areas, there should be a degree of commonality in documentation across the site. Combined with this, however, is a recognition that individual wards have specific requirements and that local ownership is an important issue. The new documentation is therefore being used as a basis for development allowing flexibility for local modification.

There was undoubtedly a need to agree criteria for document design and all aspects of care planning. A care plan development group was therefore, set up to agree these criteria, monitor future developments and act as a resource. This is likely to involve a ward by ward programme including educational input to increase understanding of the care planning process linked with practical assistance in resolving specific issues relating to care planning on individual wards.

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The terms of reference agreed by the development group reflects the view that quality nursing care must be reflected in quality documentation, and that this percep- tion will have to be nurtured and developed until fully integrated into the nurse’s professional culture. Undoubtedly, one of the key lessons learnt during the lifetime of the project has been that close collaboration between managers, education specialists and ward-based clinical teams is a powerful combination in the implementation of change.

It is clear that the project is merely the beginning of an ongoing process of development. It seems that having been given the opportunity to be involved in changing their own practice, the nurses have been inspired to move forward with new ideas and enthusiasm. It is therefore hypothesized that as a educational process firmly rooted in practice this project represents a model to used for future developments in other areas.

Appendix

Respondents = 85 qualified nurses (registered or enrolled nurses) attitudes to care plans.

Strongly Strongly Do not Disagree Strongly agree disagree know disagree

1

2 3 4 5

6

7

8

9 10 11 12 13 14 15 16 17 18 19 20 21

Care plans have been forced on ward nurses by academics and teachers. Care plans are important for medico-legal reasons. Nurses often criticize colleagues care plans. Most have the same problems needing the same care. Care plans should be abandoned and another method of documentation found. Nurses should be spending their time caring for patients, not writing care plans. It is possible to design care plan documentation that all nurses will be happy to use. Every nurse has the power and authority to make decisions about nursing interventions. Care plans improve patient care. Care plans involve too much paper work. Care plans allow patient involvement in decision-making. Care plans are a waste of time. Care plans improve communication between nurses. I find it difficult to identify problems. I find it easy to set goals. No one reads care plans. I always have time to update care plans. Care plans are too long winded. Most nurses are able to write good care plans. Care plans are good in theory, but do not work in practice. The teachinglpreparation I had to enable me to use care plans was adequate.

5

26 10 3 8

14

19

18

1 19 1

3 1 1

10 1 9 1

10 4

-

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Developing care plan documentation: an action research project