Introducing standardised care plans as a new recording tool in municipal health care

Abstract

Aims and Objectives To explore how nurses use standardised care plans as a new recording tool in municipal health care, and to identify their thoughts and opinions. Background In spite of being an important information source for nurses, care plans have repeatedly been found unsatisfactory. Structuring and coding information through standardised care plans is expected to raise the quality of recorded information, improve overviews, support evidence‐based practice and facilitate data aggregation. Previous research on this topic has mostly focused on the hospital setting. There is a lack of knowledge on how standardised care plans are used as a recording tool in the municipal healthcare setting. Design An exploratory design with a qualitative approach using three qualitative methods of data collection. The study complied with the Consolidated Criteria for Reporting Qualitative Research. Methods Empirical data were collected in three Norwegian municipalities through participant observation and individual interviews with 17 registered nurses. In addition, we collected nursing records from 20 electronic patient records. Results Use of standardised care plans was influenced by the nurses' consideration of their benefits. Partial implementation created an opportunity for nonuse. There was no consensus regarding how much information to include, and the standardised care plans could become both short and generic, and long and comprehensive. The themes “balancing between the old and the new care planning system,” “considering the usefulness of standardised care plans as a source of information” and “balancing between overview and detail” reflect these findings. Conclusions Nurses' use of standardised care plans was influenced by the plans' partial implementation, their views on usefulness and their personal views on the detail required in a care plan. Relevance to Clinical Practice The structuring of nursing records is a fast‐growing trend in health care. This study gives valuable information for those attempting to implement such structures in municipal health care.

Facilitating the Implementation of Standardized Care Plans in Municipal Healthcare

“…Traditionally, making care plans has been an individual task, resulting in large discrepancies in outcome, where individual nurses have had different views of which interventions best suit the patients' needs, and their knowledge and self-efficacy regarding SCP use have varied greatly. 19 The findings of this study suggest the need for collaboration between co-workers in developing care plans to possibly reduce insecurity and contribute to a more uniform understanding of how to use SCPs. Previous studies on care planning have tended to focus on inter-professional collaboration, rather than collaboration within a more homogenous group of healthcare workers within a setting.…”

“…Both municipalities had SCPs implemented in their EHR system and had previously engaged in identifying challenges regarding use of SCPs. 19 In both municipalities, all healthcare workers providing nursing care, for example, RNs, auxiliary nurses, and nursing assistants, were expected to read and record progress notes in the care plan. Constructing the care plans was however a task that in some settings was restricted to RNs, whereas in other settings, it was a task for auxiliary nurses as well.…”

“… 19 , 20 On the professional level, challenges include unfamiliarity with standardized terminology, 20 struggles regarding standard nursing statements not covering diverse patient conditions, 21 and a lack of consensus on how standardized structures should be used. 19 Organizational challenges include lack of training, 22 lack of managerial support, 4 , 23 multiple information systems in use, 1 and information systems not supporting nurses' workflow. 4 , 13 Although they may describe the benefits and challenges associated with the implementation of structuring nursing records, few studies provide possible practical solutions to allow the structures to become an integrated part of nurses' information practice.…”

“… 27 – 30 As a means to enhance quality of the records, SCPs were implemented in Norwegian municipal healthcare, but there have been issues with integrating them into clinical practice. 19 …”

Nurses’ Experiences of Documenting the Mental Health of Older Patients in Long-Term Care

“…Standardized terminologies are expected to improve the accuracy of nursing documentation (De Groot et al, 2019; Törnvall & Jansson, 2017), and the Norwegian Directorate of eHealth (2018) recommends the use of the International Classification for Nursing Practice (ICNP®) (ICN, n.d.). The implementation of ICNP in Norway has only just began, and standardized care plans used as a recording tool is piloted in the municipal healthcare setting (Østensen et al, 2020).…”