Art & science | education and practice
Do emergency nurse practitioners provide adequate documentation? Anna Neary asks whether attending a specialist training course affects the ability of staff to document their findings for patients at a minor injury unit Correspondence [email protected] Anna Neary is a senior lecturer and programme leader in advanced practice at the University of the West of England, and an emergency nurse practitioner at North Bristol NHS Trust emergency department Date submitted April 28 2014 Date accepted June 10 2014
Abstract Documentation in healthcare services is important but often lacks detail. This article describes a pilot study of whether staff who have completed an emergency nurse practitioner course provide more detail in their patient assessments. Post-course audits demonstrate that standards of documentation had been maintained or had improved in some areas, but had declined in others. Keywords Education, documentation, emergency nurse practice
Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines en.rcnpublishing.com
THE AIM of clinical documentation is to describe patients’ care needs, communicate them to other healthcare professionals, and provide records of the clinical decisions made during patients’ episodes of care. Emergency nurse practitioners (ENPs) should have the skills, confidence and knowledge to document information about their patients accurately. In this context, documentation is not an optional extra but a crucial aspect of ENPs’ duty of care to patients (Merry and McCall 2004). The Department of Health (DH) (2010) position statement on advanced practice states that nurses undertaking ENP programmes should be proficient in four areas of care, namely clinical practice, leadership and collaboration, improving quality, and self-development. The statement also calls for individual performance reviews and robust clinical supervision, which implies that too much of the responsibility for continuing practice development lies with staff and not enough with their employing organisations. In the author’s experience, the skills nurses need to document their assessments and thereby
34 July 2014 | Volume 22 | Number 4
ensure safe practice cannot be learnt in university settings but must be acquired in practice. In this context, there is much guidance on the amount of detail required in patient records (National Audit Office 2005, DH 2006, Nursing and Midwifery Council (NMC) 2010), but there is no gold standard of practice. Many organisations provide proformas that guide staff through the documentation process while letting them decide how much detail to include. While there is evidence that comprehensive documentation can take too much time and take nurses away from patients, greater detail can help ensure patient safety (Committee on the Work Environment for Nurses and Patient Safety 2004). Meanwhile, if there is evidence that poor documentation and practice has led to negligence, medico-legal action can be taken against the staff concerned, so written patient information must be clear, accurate, objective and sufficiently detailed (Pyrek 2009). In 2011, the author conducted a review of the literature on documentation by nurses and allied health professionals. She searched the AMED, British Nursing Index, and CINAHL and CINAHL plus, Cochrane, EBSCO, Medline and Ovid databases using combinations of the search terms ‘documentation’ and ‘record keeping’; ‘advanced practice’, ‘nurse consultant’, ‘nurse practitioners’; ‘education of advanced roles’ and ‘minor injury units’. Results were restricted to articles published in English between 1999 and 2011, and the author conducted a second search in 2012 for updated evidence. Several studies of the accuracy of nurses’ written entries and its relationship with nurses’ levels of education (Daskein et al 2009, Saranto and Kinnunen 2009, Paans et al 2010, Wang et al 2011). EMERGENCY NURSE
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Almost all demonstrate that there are problems with the standard of nursing documentation and that concerns about nursing documentation are international (Hansebo et al 1999, Daskein et al 2009, Wang et al 2011). In a comparative study of documentation in nursing home wards in Sweden, Hansebo et al (1999) found that the standard of documentation improved after staff had been trained to use a specific assessment tool. Ten years later, in a literature review of how nurses in the US record their activities, Frank-Stromborg et al (2001) found that many nurses did not understand the documentation process. Standards of documentation can be improved, however, through education involving repetition of documentation (Ehrenberg et al 1996). Two studies, by Hogan (2004) and Daskein et al (2009), concern nurses’ knowledge and understanding of documentation. While Daskein et al (2009) show that, in general, nurses have a good understanding of documentation, Hogan (2004) found that much of what they write is of poor quality. Taken together, the studies suggest that many nurses cannot apply their knowledge. There are few studies of how to evaluate standards of documentation specifically among nurse practitioners. However, in a comparative study, Cooper et al (2000) found that standards of documentation among ENPs were higher than those among senior house officers. In the author’s experience, many nursing and clinical practitioners who have recently entered the profession find documentation daunting. As the author’s literature review demonstrates, if ENPs had the appropriate education, they would know what aspects of their patient assessments to include and what to exclude. However, such education is not specifically required by ENPs in the UK.
Study The author undertook a study of standards of documentation among ENPs before and after they had completed a relevant course at University of the West of England (UWE), Bristol, to assess whether there is a link between the quality of written documentation and education. The course covers documentation about specific areas of assessment but does not cover documentation as a subject in itself The author’s study had a modified interrupted time series design (Macnee and McCabe 2008), in which measurements are taken at different times, in this case before and after participants had completed a course. Its ten participants were randomly selected from eight minor injury units (MIUs) in a single primary care trust in England. EMERGENCY NURSE
All were registered nurses who had practised in one of the MIUs since they were student ENPs. A group of experienced ENPs who had studied at UWE had developed an audit tool based on national and local policies (NMC 2010, NHS England 2011, NHS Litigation Authority 2013), criteria from a university that provides a recognised ENP course (UWE 2010) and Wimpenny’s (2002) biomedical model. To test the tool’s validity, the author piloted it with ten nurses and refined accordingly. The audit tool is divided into eight sections, of which seven cover different aspects of documentation: ■■ Mandatory: divided into 67 areas covering, for example, documentation of patient demographics, whether they had given consent to treatment and whether their tetanus immunisation status had been documented. ■■ Cardiovascular: six areas, including documentation of swelling and bruising, heart sounds and pulses. ■■ Respiratory: seven areas, including documentation of respiratory rate, chest expansion and breath sounds. ■■ Abdominal: seven areas, including documentation of percussion and bowel sounds. ■■ Head, neck, skin, ears, nose and throat (HNSENT): 19 areas, including documentation of hearing ability and lymph nodes. ■■ Neurological: ten areas, including documentation of gait and reflexes. ■■ Musculoskeletal: 30 areas, including documentation of the spine, shoulder, hand and wrist. In the eighth section the author made an assessment of the overall quality of each participant’s documentation by assessing whether, given the same evidence, the author would make the same conclusions. If she would, the participant concerned was awarded 100%; if she would not, the participant was awarded 0%. This assessment is named the ‘Bolitho test’ after it was made during a court case involving an allegation of medical negligence (Segen 2012). The study was regarded as a service evaluation, and ethical approval was sought from UWE in accordance with research governance and ethics guidance (UWE 2010). Confidentiality and anonymity were ensured, and data were stored safely in a locked cupboard or on a password‑protected computer. The author read and assessed whether the documentation included sufficient detail in each section. She then marked the standard of documentation for each section by ticking July 2014 | Volume 22 | Number 4 35
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Art & science | education and practice
Pre-course 1
2
3 4 5 6 7 8 9 10 Individual study participants
one of four boxes marked ‘good’, ‘satisfactory’, ‘poor’ and, if assessments were unnecessary, ‘not applicable’ on a scorecard. Each participant’s scores were added up and converted into percentages, and each percentage was given a colour: red, amber or green (RAG). Scores below 46% are regarded as low quality and represented as red, those between 46% and 79% are regarded as average and represented as amber, and those above 79% are regarded as high quality and represented as green.
Results Mandatory section Pre-course results show that, overall, 69% of documentation was of good quality, or in the green zone; 8% was of average quality, or in the amber zone; and 11% was of poor quality, or in the red zone (Figure 1). When the ten participants’ standards of documentation in specific areas were assessed, they scored 86% for documenting concerns about child protection, which put them in the green zone. Among their scores in the amber zone, writing drugs in capital letters scored 67%, writing practitioners’ names clearly scored 60% and 36 July 2014 | Volume 22 | Number 4
Quality High Average Poor
Percentage
100 90 80 70 60 50 40 30 20 10 0
Overall quality of documentation on respiratory assessments
100 90 80 70 60 50 40 30 20 10 0
Quality of study participants’ documentation on respiratory assessments Post-course
Figure 4
Pre-course Post-course Results
Pre-course
Quality of participants’ documentation on mandatory health assessments
Percentage
100 90 80 70 60 50 40 30 20 10 0
Post-course Pre-course Results
Post-course
Figure 2
Figure 3
Quality High Average Poor Not applicable
Percentage
100 90 80 70 60 50 40 30 20 10 0
Overall quality of documentation on mandatory health assessments
Percentage
Figure 1
1
2
3 4 5 6 7 8 9 10 Individual study participants
documenting diagnosis after tests scored 50%; among scores in the red zone, documenting tetanus immunisation status scored 44 % and documenting whether patients had given consent scored 20%. Post-course results show that, overall, 52% of documentation was in the green zone, 26% was in the amber zone and 22% was in the red zone. When participants’ standards of documentation in specific areas were assessed, the overall score for documenting concerns about vulnerable older patients, at 56%, was found to be the only one in the amber zone. Among scores in the red zone, documenting child-protection concerns scored 33%, writing the words ‘left’ and ‘right’ in full scored 20%, documenting details of next of kin scored 10% and documenting drug prescriptions scored 0%. Comparison of the two data sets suggests that completion of the ENP course led to a 17 percentage-point reduction in green-zone scores, an 18 percentage-point increase in amber-zone scores, and an 11 percentage-point increase in red-zone scores. Individual participants’ scores in the mandatory section were comparable with RAG data scores, with only three, namely those of participants 6, EMERGENCY NURSE
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8 and 9, increasing after participants had attended the ENP course (Figure 2). Cardiovascular section Pre-course results show that no ENPs documented assessments in this section and post-course results show that only two documented heart sounds. Consequently, 100% of pre- and post-course documentation was in the red zone. Respiratory section Pre-course results show that, overall, 33% of documentation was in the amber zone and 67% in the red zone (Figure 3). Among scores in the amber zone, documenting breath sounds scored 57%; among scores in the red zone, documenting respiratory rate scored 29%, documenting oxygen saturation scored 19%, documenting chest expansion scored 14%, and documenting percussion and tenderness each scored 0%. Post-course results indicate that, after ENPs had completed the course, the standard of their documentation improved. Overall, 67% of documentation was in the amber zone and 33% in the red zone.
Quality of study participants’ documentation on abdominal assessments
Pre-course
Percentage
100 90 80 70 60 50 40 30 20 10 0
Post-course Pre-course Results
Post-course
Figure 6
HNSENT section Pre-course results show that, overall, 22% of scores were in the green zone, 11% in the amber zone and 67% in the red zone (Figure 7). Of those in the green zone, documenting inspection and palpation of the pinna and canal each scored 80%. In the amber zone, documenting inspection of the throat scored 60%. In the red zone, documenting inspection of the mouth and lymph nodes each scored 40%; documenting inspection of the skin and assessment of tenderness each scored 20%; and documenting hearing status and inspection of the nose each scored 0%.
Quality High Average Poor
Percentage
100 90 80 70 60 50 40 30 20 10 0
Overall quality of documentation on abdominal assessments
1
2
EMERGENCY NURSE
3 4 5 6 7 8 Individual participants
9 10
Abdominal section Pre-course results show that, overall, scores for all areas were in the red zone (Figure 5). Scores for documenting scars, tenderness, and liver, kidney and spleen function were each 33%; the score for documenting bowel sounds was 17%; and the scores for documenting percussion and rectal examination results were each 0%. Post-course results show all scores remained in the red zone, except those for documenting tenderness (88%) and bowel sounds (50%). Comparison of the scores shows that more criteria were documented post-course. Three participants’ scores increased, two from 0% to 40% and one from 0% to 60%. Two participants’ scores decreased, from 80% to 20% and from 40% to 20% (Figure 6).
Figure 7 100 90 80 70 60 50 40 30 20 10 0
Overall quality of documentation on head, neck, skin, ear, nose and throat assessments Quality High Average Poor
Percentage
Figure 5
Among scores in the amber zone, documenting breath sounds, oxygen saturation and respiratory rate each scored 75%, while documenting chest expansion scored 50%. The score for documenting percussion rose to 25% but that for documenting tenderness remained at 0%. There was an increase in the individual scores of five participants, and no increase in one individual’s score (Figure 4).
Post-course Pre-course Results July 2014 | Volume 22 | Number 4 37
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Art & science | education and practice
2
3 4 5 6 7 8 Individual participants
9 10
Overall quality of documentation on neurological assessments Quality High Average Poor
Percentage
100 90 80 70 60 50 40 30 20 10 0
1
Post-course Pre-course Results
Post-course results show that, overall, 44% of scores were in the amber zone and 56% of scores were in the red zone. Of those in the amber zone, documenting inspection of the canal and tenderness each scored 67%; documenting inspection of the pinna and skin each scored 50%. Of those in the red zone, documenting inspection of the throat scored 33%; documenting inspection of the lymph nodes, mouth and nose each scored 17%; and documenting hearing status scored 0%. Comparison of results suggests an increase in the amber zone, but a decrease in the green zone, which indicates that post-course results were worse than pre-course results. Results for individuals show an increase in three participants’ scores but a decrease in three other participants’ scores (Figure 8). Neurological section Pre-course results show that, overall, 50% of scores were in the amber zone and 50% in the red zone (Figure 9). Of those in the amber zone, documenting cranial nerve function and Glasgow Coma Score (GCS) score each scored 67%; and documenting power ability, reflexes and muscle tone each scored 50%. 38 July 2014 | Volume 22 | Number 4
Pre-course
Percentage
100 90 80 70 60 50 40 30 20 10 0
Post-course
Figure 10 Quality of study participants’ documentation on neurological assessments
1
2
3 4 5 6 7 8 Individual participants
9 10
Figure 11 Overall quality of documentation on musculoskeletal assessments 100 90 80 70 60 50 40 30 20 10 0
Quality High Average Poor Not applicable
Percentage
Figure 9
Pre-course
Percentage
100 90 80 70 60 50 40 30 20 10 0
Quality of documentation on head, neck, skin, ear, nose and throat assessments Post-course
Figure 8
Pre-course Post-course Results
Of those in the red zone, documenting sensation scored 33%; documenting arm drift and Romberg’s test of proprioception, vestibular function and vision (Khasnis and Gokula 2003) scored 17%; and documenting balance and gait, and mental ability scored 0%. Post-course results showed that documenting GCS score scored 38%; documenting cranial nerve function scored 25%; documenting balance and gait, muscle tone, reflexes and sensation each scored 13%; and documenting arm drift, mental ability, power and Romberg’s test each scored 0% Comparison of results indicates a 100% decline in standards, from average to below average. Some individuals’ scores increased, however. For example, one participant’s score increased from 25% to 42%, and those of two others increased from 0% to 25%. On the other hand, one participant’s score decreased from 67% to 0%, another’s from 42% to 8%, and another’s from 67% to 8% (Figure 10). Musculoskeletal section Pre-course results show that, overall, 30% of scores were in the amber zone, 61% of scores were in the green zone and 9% were not applicable (Figure 11). EMERGENCY NURSE
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Of those in the green zone, documenting spine movement, and documenting the results of hand, knee and shoulder examinations, each scored 100%. Of those in the amber zone, documenting the results of toe examination scored 75%; documenting the results of foot examination, and the look and feel of the spine, each scored 67%; and documenting the results of ankle, elbow, hip and wrist examinations each scored 50%. Post-course results show that all scores were in the green zone. Scores for all forms of documentation were 100% except that for the look and feel of the spine, which was 80%. Comparison of results indicates a 40% increase in scores from average to good quality. One participant’s score increased from 20% to 60%, another’s from 60% to 83%, and another’s from 83% to 87%. The other seven participants maintained 100% scores (Figure 12). Bolitho test section The pre-course score was 70% and the post-course score was 100% (Figure 13), which indicates an increase of 30% from average to a high quality standard. Figure 12 Quality of study participants’ documentation on musculoskeletal assessments
2
3 4 5 6 7 8 Individual participants
9 10
Figure 13 Overall quality of documentation Quality High Average Poor
Percentage
100 90 80 70 60 50 40 30 20 10 0
Post-course Pre-course Results
EMERGENCY NURSE
This study is limited by its small sample size, the use of a single study centre, the audit tool design and the data collection method, so its results cannot be generalised to all levels of advanced practice. Nevertheless, the results can be used to inform the development of advanced practice. The study’s findings indicate that there were post-course improvements in documentation of respiratory and musculo-skeletal assessments. Over recent years, practice in MIUs has become a specialised field with its own educational programmes (Purcell 2010). Much of this work involves musculoskeletal injuries, which may explain why participants in the study tended to excel in this area. In the Bothilo test section, scores either improved or remained the same. However, data also show that standards of documentation of assessments, specifically cardiovascular, abdominal and HNSENT assessments had not improved or had dropped after the staff involved had completed the ENP course.
This study examines the effects of a university ENP programme on participants’ documentation practice using data from retrospective audits. The results demonstrate improvements in the standards of documentation of respiratory and musculoskeletal assessments, but it is difficult to determine whether this improvement is due to participants’ new knowledge. Meanwhile, the standard of documentation of cardiovascular, neurological and HNSENT assessments remained the same or declined in standard following completion of the course. Figure 14 Changes in the quality of study participants’ documentation against number of assessment sections documented Number of assessment types
Post-course 1
Discussion
Conclusion
Pre-course
Percentage
100 90 80 70 60 50 40 30 20 10 0
Changes in individual study participants’ scores are shown in Figure 14.
8-
Quality increased No change in quality Quality decreased No examination made
76543210
1
2
3
4 5 6 7 Individual participants
8
9
10
July 2014 | Volume 22 | Number 4 39
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Art & science | education and practice Like doctors, ENPs undertake physical examinations, and this change in practice must be reflected in their documentation. The ability to document clinical assessments cannot be developed simply by attending a university course, but requires years of experience. In addition, strategies are needed to ensure that ENPs acquire the skills they need. Above all, education plans should be implemented to increase ENPs’ standards of examination and documentation. The audit tool described in this article is reviewed annually by a group of experienced
ENPs and consultant nurses, who have decided to alter the tool so that it can be used to monitor the standard of documentation in specific areas of care in more detail. It is expected that findings from these more detailed audits will prompt clinical leads to devise tailored staff‑training programmes to address poor documentation in these areas. Meanwhile, the reasons why patients attend MIUs should be monitored to ensure that ENPs always have the skills they need to manage them.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
References Committee on the Work Environment for Nurses and Patient Safety (2004) Keeping Patients Safe: Transforming the Work Environment for Nurses. National Academies Press, Washington DC. Cooper M, Kinn S, Ibbotson T et al (2000) Emergency nurse practitioner’s documentation: development of an audit tool. Emergency Nurse. 8, 5, 34-39. Daskein R, Moyle W, Creedy D (2009) Aged-care nurses’ knowledge of nursing documentation: an Australian perspective. Journal of Clinical Nursing. doi: 10.1111/j.1365-2702.2008.02670.x Department of Health (2006) Records Management: NHS Code of Practice. DH, London. Department of Health (2010) Advanced Level Nursing: A Position Statement. DH, London. Ehrenberg A, Ehnfors M, Thorell-Ekstrand I (1996) Nursing documentation in patient records: experience of the use of the
40 July 2014 | Volume 22 | Number 4
VIPS model. Journal of Advanced Nursing. 24, 4, 853-867. Frank-Stromborg M, Christensen A, Elmhurst D (2001) Nursing documentation: not done or, worse, done the wrong way. Part 1. Oncology Nursing Forum. 28, 4, 697-702. Hansebo G, Kihlgren M, Ljunggren G (1999) Review of nursing documentation in nursing home wards: changes after intervention for individualized care. Journal of Advanced Nursing. 29, 6, 1462-1473. Hogan W (2004) Review of Pricing Arrangementsin Residental Aged Care. Department of Health and Ageing, Canberra ACT. Khasnis A, Gokula R (2003) Romberg’s test. Journal of Postgraduate Medicine. 49, 2, 169-172. Macnee C, McCabe S (2008) Understanding Nursing Research: Reading and Using Research in Evidence Based Practice. Second edition. Lippincott Williams and Wilkins, London.
Merry A, McCall A (2004) Errors, Medicine and the Law. Cambridge University Press, Cambridge. National Audit Office (2005) A Safer Place for Patients: Learning to Improve Patient Safety. NAO, London. NHS England (2011) NHS Care Record Guarantee. tinyurl.com/llea9x7 (Last accessed: June 19 2014.) NHS Litigation Authority (2013) NHSLA Risk Management Handbook 2012/13. tinyurl.com/ndnugeb (Last accessed: June 19 2014.) Nursing and Midwifery Council (2010) Record Keeping: Guidance for Nurses and Midwives. NMC, London. Paans W, Sermeus W, Roos M et al (2010) Prevalence of accurate nursing documentation in patient records. Journal of Advanced Nursing. 66, 11, 2481-2489. Purcell D (2010) Minor Injuries: A Clinical Guide. Churchill Livingstone, New York NY.
Pyrek K (2009) Forensic Nursing. CRC Press, Washington DC. Saranto K, Kinnunen U (2009) Evaluating nursing documentation: research designs and methods: systematic review. Journal of Advanced Nursing. 65, 3, 464-476. Segen J (2012) The Dictionary of Modern Medicine: A Sourcebook of Currently Used Medical Expressions, Jargon and Technical Terms. CRC Press, Boca Raton FL. University of the West of England (2010) Research Ethics in the Faculty of Business and Law. tinyurl.com/l72vucb (Last accessed: June 19 2014.) Wang N, Hailey D, Yu P (2011) Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review. Journal of Advanced Nursing. 67, 9, 1858-1875. Wimpenny P (2002) The meaning of models of nursing to practising nurses. Journal of Advanced Nursing. 40, 3, 346-354.
EMERGENCY NURSE
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Do emergency nurse practitioners provide adequate documentation? Anna Neary asks whether attending a specialist training course affects the ability of staff to document their findings for patients at a minor injury unit Correspondence [email protected] Anna Neary is a senior lecturer and programme leader in advanced practice at the University of the West of England, and an emergency nurse practitioner at North Bristol NHS Trust emergency department Date submitted April 28 2014 Date accepted June 10 2014
Abstract Documentation in healthcare services is important but often lacks detail. This article describes a pilot study of whether staff who have completed an emergency nurse practitioner course provide more detail in their patient assessments. Post-course audits demonstrate that standards of documentation had been maintained or had improved in some areas, but had declined in others. Keywords Education, documentation, emergency nurse practice
Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines en.rcnpublishing.com
THE AIM of clinical documentation is to describe patients’ care needs, communicate them to other healthcare professionals, and provide records of the clinical decisions made during patients’ episodes of care. Emergency nurse practitioners (ENPs) should have the skills, confidence and knowledge to document information about their patients accurately. In this context, documentation is not an optional extra but a crucial aspect of ENPs’ duty of care to patients (Merry and McCall 2004). The Department of Health (DH) (2010) position statement on advanced practice states that nurses undertaking ENP programmes should be proficient in four areas of care, namely clinical practice, leadership and collaboration, improving quality, and self-development. The statement also calls for individual performance reviews and robust clinical supervision, which implies that too much of the responsibility for continuing practice development lies with staff and not enough with their employing organisations. In the author’s experience, the skills nurses need to document their assessments and thereby
34 July 2014 | Volume 22 | Number 4
ensure safe practice cannot be learnt in university settings but must be acquired in practice. In this context, there is much guidance on the amount of detail required in patient records (National Audit Office 2005, DH 2006, Nursing and Midwifery Council (NMC) 2010), but there is no gold standard of practice. Many organisations provide proformas that guide staff through the documentation process while letting them decide how much detail to include. While there is evidence that comprehensive documentation can take too much time and take nurses away from patients, greater detail can help ensure patient safety (Committee on the Work Environment for Nurses and Patient Safety 2004). Meanwhile, if there is evidence that poor documentation and practice has led to negligence, medico-legal action can be taken against the staff concerned, so written patient information must be clear, accurate, objective and sufficiently detailed (Pyrek 2009). In 2011, the author conducted a review of the literature on documentation by nurses and allied health professionals. She searched the AMED, British Nursing Index, and CINAHL and CINAHL plus, Cochrane, EBSCO, Medline and Ovid databases using combinations of the search terms ‘documentation’ and ‘record keeping’; ‘advanced practice’, ‘nurse consultant’, ‘nurse practitioners’; ‘education of advanced roles’ and ‘minor injury units’. Results were restricted to articles published in English between 1999 and 2011, and the author conducted a second search in 2012 for updated evidence. Several studies of the accuracy of nurses’ written entries and its relationship with nurses’ levels of education (Daskein et al 2009, Saranto and Kinnunen 2009, Paans et al 2010, Wang et al 2011). EMERGENCY NURSE
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Almost all demonstrate that there are problems with the standard of nursing documentation and that concerns about nursing documentation are international (Hansebo et al 1999, Daskein et al 2009, Wang et al 2011). In a comparative study of documentation in nursing home wards in Sweden, Hansebo et al (1999) found that the standard of documentation improved after staff had been trained to use a specific assessment tool. Ten years later, in a literature review of how nurses in the US record their activities, Frank-Stromborg et al (2001) found that many nurses did not understand the documentation process. Standards of documentation can be improved, however, through education involving repetition of documentation (Ehrenberg et al 1996). Two studies, by Hogan (2004) and Daskein et al (2009), concern nurses’ knowledge and understanding of documentation. While Daskein et al (2009) show that, in general, nurses have a good understanding of documentation, Hogan (2004) found that much of what they write is of poor quality. Taken together, the studies suggest that many nurses cannot apply their knowledge. There are few studies of how to evaluate standards of documentation specifically among nurse practitioners. However, in a comparative study, Cooper et al (2000) found that standards of documentation among ENPs were higher than those among senior house officers. In the author’s experience, many nursing and clinical practitioners who have recently entered the profession find documentation daunting. As the author’s literature review demonstrates, if ENPs had the appropriate education, they would know what aspects of their patient assessments to include and what to exclude. However, such education is not specifically required by ENPs in the UK.
Study The author undertook a study of standards of documentation among ENPs before and after they had completed a relevant course at University of the West of England (UWE), Bristol, to assess whether there is a link between the quality of written documentation and education. The course covers documentation about specific areas of assessment but does not cover documentation as a subject in itself The author’s study had a modified interrupted time series design (Macnee and McCabe 2008), in which measurements are taken at different times, in this case before and after participants had completed a course. Its ten participants were randomly selected from eight minor injury units (MIUs) in a single primary care trust in England. EMERGENCY NURSE
All were registered nurses who had practised in one of the MIUs since they were student ENPs. A group of experienced ENPs who had studied at UWE had developed an audit tool based on national and local policies (NMC 2010, NHS England 2011, NHS Litigation Authority 2013), criteria from a university that provides a recognised ENP course (UWE 2010) and Wimpenny’s (2002) biomedical model. To test the tool’s validity, the author piloted it with ten nurses and refined accordingly. The audit tool is divided into eight sections, of which seven cover different aspects of documentation: ■■ Mandatory: divided into 67 areas covering, for example, documentation of patient demographics, whether they had given consent to treatment and whether their tetanus immunisation status had been documented. ■■ Cardiovascular: six areas, including documentation of swelling and bruising, heart sounds and pulses. ■■ Respiratory: seven areas, including documentation of respiratory rate, chest expansion and breath sounds. ■■ Abdominal: seven areas, including documentation of percussion and bowel sounds. ■■ Head, neck, skin, ears, nose and throat (HNSENT): 19 areas, including documentation of hearing ability and lymph nodes. ■■ Neurological: ten areas, including documentation of gait and reflexes. ■■ Musculoskeletal: 30 areas, including documentation of the spine, shoulder, hand and wrist. In the eighth section the author made an assessment of the overall quality of each participant’s documentation by assessing whether, given the same evidence, the author would make the same conclusions. If she would, the participant concerned was awarded 100%; if she would not, the participant was awarded 0%. This assessment is named the ‘Bolitho test’ after it was made during a court case involving an allegation of medical negligence (Segen 2012). The study was regarded as a service evaluation, and ethical approval was sought from UWE in accordance with research governance and ethics guidance (UWE 2010). Confidentiality and anonymity were ensured, and data were stored safely in a locked cupboard or on a password‑protected computer. The author read and assessed whether the documentation included sufficient detail in each section. She then marked the standard of documentation for each section by ticking July 2014 | Volume 22 | Number 4 35
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Art & science | education and practice
Pre-course 1
2
3 4 5 6 7 8 9 10 Individual study participants
one of four boxes marked ‘good’, ‘satisfactory’, ‘poor’ and, if assessments were unnecessary, ‘not applicable’ on a scorecard. Each participant’s scores were added up and converted into percentages, and each percentage was given a colour: red, amber or green (RAG). Scores below 46% are regarded as low quality and represented as red, those between 46% and 79% are regarded as average and represented as amber, and those above 79% are regarded as high quality and represented as green.
Results Mandatory section Pre-course results show that, overall, 69% of documentation was of good quality, or in the green zone; 8% was of average quality, or in the amber zone; and 11% was of poor quality, or in the red zone (Figure 1). When the ten participants’ standards of documentation in specific areas were assessed, they scored 86% for documenting concerns about child protection, which put them in the green zone. Among their scores in the amber zone, writing drugs in capital letters scored 67%, writing practitioners’ names clearly scored 60% and 36 July 2014 | Volume 22 | Number 4
Quality High Average Poor
Percentage
100 90 80 70 60 50 40 30 20 10 0
Overall quality of documentation on respiratory assessments
100 90 80 70 60 50 40 30 20 10 0
Quality of study participants’ documentation on respiratory assessments Post-course
Figure 4
Pre-course Post-course Results
Pre-course
Quality of participants’ documentation on mandatory health assessments
Percentage
100 90 80 70 60 50 40 30 20 10 0
Post-course Pre-course Results
Post-course
Figure 2
Figure 3
Quality High Average Poor Not applicable
Percentage
100 90 80 70 60 50 40 30 20 10 0
Overall quality of documentation on mandatory health assessments
Percentage
Figure 1
1
2
3 4 5 6 7 8 9 10 Individual study participants
documenting diagnosis after tests scored 50%; among scores in the red zone, documenting tetanus immunisation status scored 44 % and documenting whether patients had given consent scored 20%. Post-course results show that, overall, 52% of documentation was in the green zone, 26% was in the amber zone and 22% was in the red zone. When participants’ standards of documentation in specific areas were assessed, the overall score for documenting concerns about vulnerable older patients, at 56%, was found to be the only one in the amber zone. Among scores in the red zone, documenting child-protection concerns scored 33%, writing the words ‘left’ and ‘right’ in full scored 20%, documenting details of next of kin scored 10% and documenting drug prescriptions scored 0%. Comparison of the two data sets suggests that completion of the ENP course led to a 17 percentage-point reduction in green-zone scores, an 18 percentage-point increase in amber-zone scores, and an 11 percentage-point increase in red-zone scores. Individual participants’ scores in the mandatory section were comparable with RAG data scores, with only three, namely those of participants 6, EMERGENCY NURSE
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8 and 9, increasing after participants had attended the ENP course (Figure 2). Cardiovascular section Pre-course results show that no ENPs documented assessments in this section and post-course results show that only two documented heart sounds. Consequently, 100% of pre- and post-course documentation was in the red zone. Respiratory section Pre-course results show that, overall, 33% of documentation was in the amber zone and 67% in the red zone (Figure 3). Among scores in the amber zone, documenting breath sounds scored 57%; among scores in the red zone, documenting respiratory rate scored 29%, documenting oxygen saturation scored 19%, documenting chest expansion scored 14%, and documenting percussion and tenderness each scored 0%. Post-course results indicate that, after ENPs had completed the course, the standard of their documentation improved. Overall, 67% of documentation was in the amber zone and 33% in the red zone.
Quality of study participants’ documentation on abdominal assessments
Pre-course
Percentage
100 90 80 70 60 50 40 30 20 10 0
Post-course Pre-course Results
Post-course
Figure 6
HNSENT section Pre-course results show that, overall, 22% of scores were in the green zone, 11% in the amber zone and 67% in the red zone (Figure 7). Of those in the green zone, documenting inspection and palpation of the pinna and canal each scored 80%. In the amber zone, documenting inspection of the throat scored 60%. In the red zone, documenting inspection of the mouth and lymph nodes each scored 40%; documenting inspection of the skin and assessment of tenderness each scored 20%; and documenting hearing status and inspection of the nose each scored 0%.
Quality High Average Poor
Percentage
100 90 80 70 60 50 40 30 20 10 0
Overall quality of documentation on abdominal assessments
1
2
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3 4 5 6 7 8 Individual participants
9 10
Abdominal section Pre-course results show that, overall, scores for all areas were in the red zone (Figure 5). Scores for documenting scars, tenderness, and liver, kidney and spleen function were each 33%; the score for documenting bowel sounds was 17%; and the scores for documenting percussion and rectal examination results were each 0%. Post-course results show all scores remained in the red zone, except those for documenting tenderness (88%) and bowel sounds (50%). Comparison of the scores shows that more criteria were documented post-course. Three participants’ scores increased, two from 0% to 40% and one from 0% to 60%. Two participants’ scores decreased, from 80% to 20% and from 40% to 20% (Figure 6).
Figure 7 100 90 80 70 60 50 40 30 20 10 0
Overall quality of documentation on head, neck, skin, ear, nose and throat assessments Quality High Average Poor
Percentage
Figure 5
Among scores in the amber zone, documenting breath sounds, oxygen saturation and respiratory rate each scored 75%, while documenting chest expansion scored 50%. The score for documenting percussion rose to 25% but that for documenting tenderness remained at 0%. There was an increase in the individual scores of five participants, and no increase in one individual’s score (Figure 4).
Post-course Pre-course Results July 2014 | Volume 22 | Number 4 37
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Art & science | education and practice
2
3 4 5 6 7 8 Individual participants
9 10
Overall quality of documentation on neurological assessments Quality High Average Poor
Percentage
100 90 80 70 60 50 40 30 20 10 0
1
Post-course Pre-course Results
Post-course results show that, overall, 44% of scores were in the amber zone and 56% of scores were in the red zone. Of those in the amber zone, documenting inspection of the canal and tenderness each scored 67%; documenting inspection of the pinna and skin each scored 50%. Of those in the red zone, documenting inspection of the throat scored 33%; documenting inspection of the lymph nodes, mouth and nose each scored 17%; and documenting hearing status scored 0%. Comparison of results suggests an increase in the amber zone, but a decrease in the green zone, which indicates that post-course results were worse than pre-course results. Results for individuals show an increase in three participants’ scores but a decrease in three other participants’ scores (Figure 8). Neurological section Pre-course results show that, overall, 50% of scores were in the amber zone and 50% in the red zone (Figure 9). Of those in the amber zone, documenting cranial nerve function and Glasgow Coma Score (GCS) score each scored 67%; and documenting power ability, reflexes and muscle tone each scored 50%. 38 July 2014 | Volume 22 | Number 4
Pre-course
Percentage
100 90 80 70 60 50 40 30 20 10 0
Post-course
Figure 10 Quality of study participants’ documentation on neurological assessments
1
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3 4 5 6 7 8 Individual participants
9 10
Figure 11 Overall quality of documentation on musculoskeletal assessments 100 90 80 70 60 50 40 30 20 10 0
Quality High Average Poor Not applicable
Percentage
Figure 9
Pre-course
Percentage
100 90 80 70 60 50 40 30 20 10 0
Quality of documentation on head, neck, skin, ear, nose and throat assessments Post-course
Figure 8
Pre-course Post-course Results
Of those in the red zone, documenting sensation scored 33%; documenting arm drift and Romberg’s test of proprioception, vestibular function and vision (Khasnis and Gokula 2003) scored 17%; and documenting balance and gait, and mental ability scored 0%. Post-course results showed that documenting GCS score scored 38%; documenting cranial nerve function scored 25%; documenting balance and gait, muscle tone, reflexes and sensation each scored 13%; and documenting arm drift, mental ability, power and Romberg’s test each scored 0% Comparison of results indicates a 100% decline in standards, from average to below average. Some individuals’ scores increased, however. For example, one participant’s score increased from 25% to 42%, and those of two others increased from 0% to 25%. On the other hand, one participant’s score decreased from 67% to 0%, another’s from 42% to 8%, and another’s from 67% to 8% (Figure 10). Musculoskeletal section Pre-course results show that, overall, 30% of scores were in the amber zone, 61% of scores were in the green zone and 9% were not applicable (Figure 11). EMERGENCY NURSE
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Of those in the green zone, documenting spine movement, and documenting the results of hand, knee and shoulder examinations, each scored 100%. Of those in the amber zone, documenting the results of toe examination scored 75%; documenting the results of foot examination, and the look and feel of the spine, each scored 67%; and documenting the results of ankle, elbow, hip and wrist examinations each scored 50%. Post-course results show that all scores were in the green zone. Scores for all forms of documentation were 100% except that for the look and feel of the spine, which was 80%. Comparison of results indicates a 40% increase in scores from average to good quality. One participant’s score increased from 20% to 60%, another’s from 60% to 83%, and another’s from 83% to 87%. The other seven participants maintained 100% scores (Figure 12). Bolitho test section The pre-course score was 70% and the post-course score was 100% (Figure 13), which indicates an increase of 30% from average to a high quality standard. Figure 12 Quality of study participants’ documentation on musculoskeletal assessments
2
3 4 5 6 7 8 Individual participants
9 10
Figure 13 Overall quality of documentation Quality High Average Poor
Percentage
100 90 80 70 60 50 40 30 20 10 0
Post-course Pre-course Results
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This study is limited by its small sample size, the use of a single study centre, the audit tool design and the data collection method, so its results cannot be generalised to all levels of advanced practice. Nevertheless, the results can be used to inform the development of advanced practice. The study’s findings indicate that there were post-course improvements in documentation of respiratory and musculo-skeletal assessments. Over recent years, practice in MIUs has become a specialised field with its own educational programmes (Purcell 2010). Much of this work involves musculoskeletal injuries, which may explain why participants in the study tended to excel in this area. In the Bothilo test section, scores either improved or remained the same. However, data also show that standards of documentation of assessments, specifically cardiovascular, abdominal and HNSENT assessments had not improved or had dropped after the staff involved had completed the ENP course.
This study examines the effects of a university ENP programme on participants’ documentation practice using data from retrospective audits. The results demonstrate improvements in the standards of documentation of respiratory and musculoskeletal assessments, but it is difficult to determine whether this improvement is due to participants’ new knowledge. Meanwhile, the standard of documentation of cardiovascular, neurological and HNSENT assessments remained the same or declined in standard following completion of the course. Figure 14 Changes in the quality of study participants’ documentation against number of assessment sections documented Number of assessment types
Post-course 1
Discussion
Conclusion
Pre-course
Percentage
100 90 80 70 60 50 40 30 20 10 0
Changes in individual study participants’ scores are shown in Figure 14.
8-
Quality increased No change in quality Quality decreased No examination made
76543210
1
2
3
4 5 6 7 Individual participants
8
9
10
July 2014 | Volume 22 | Number 4 39
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Art & science | education and practice Like doctors, ENPs undertake physical examinations, and this change in practice must be reflected in their documentation. The ability to document clinical assessments cannot be developed simply by attending a university course, but requires years of experience. In addition, strategies are needed to ensure that ENPs acquire the skills they need. Above all, education plans should be implemented to increase ENPs’ standards of examination and documentation. The audit tool described in this article is reviewed annually by a group of experienced
ENPs and consultant nurses, who have decided to alter the tool so that it can be used to monitor the standard of documentation in specific areas of care in more detail. It is expected that findings from these more detailed audits will prompt clinical leads to devise tailored staff‑training programmes to address poor documentation in these areas. Meanwhile, the reasons why patients attend MIUs should be monitored to ensure that ENPs always have the skills they need to manage them.
Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared
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Pyrek K (2009) Forensic Nursing. CRC Press, Washington DC. Saranto K, Kinnunen U (2009) Evaluating nursing documentation: research designs and methods: systematic review. Journal of Advanced Nursing. 65, 3, 464-476. Segen J (2012) The Dictionary of Modern Medicine: A Sourcebook of Currently Used Medical Expressions, Jargon and Technical Terms. CRC Press, Boca Raton FL. University of the West of England (2010) Research Ethics in the Faculty of Business and Law. tinyurl.com/l72vucb (Last accessed: June 19 2014.) Wang N, Hailey D, Yu P (2011) Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review. Journal of Advanced Nursing. 67, 9, 1858-1875. Wimpenny P (2002) The meaning of models of nursing to practising nurses. Journal of Advanced Nursing. 40, 3, 346-354.
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