Prerequisites and consequences of nursing documentation in patient records as perceived by a group of Registered Nurses.
The issue of nursing documentation and care planning has been discussed in numerous articles, revealing barriers and few facilitators in nursing practice. Few of these articles are scientifically researched and they are often based on small samples. This study aimed to illuminate the factors that Registered Nurses (RNs) in acute care perceived as prerequisites and consequences relevant to their documentation of nursing care when using the VIPS model (VIPS is an acronym formed from the Swedish words for Well-being, Integrity, Prevention and Security). In total 377 RNs divided into two groups (Groups A and B) completed a questionnaire concerning opinions about nursing documentation. Both groups had received a 3-day course on nursing documentation based on the VIPS model. Group A had also participated in a 2-year comprehensive intervention programme. The findings showed that most participants, regardless of group, perceived nursing documentation to be beneficial to them in their daily practice and to increase patient safety, and that use of the VIPS model facilitated documentation of nursing care. The inhibitors, facilitators and consequences of nursing documentation identified here should help both RNs in practice and their leaders to be more attentive to the prerequisites needed to achieve satisfactory nursing documentation in patient records.
Björvell
Catrin
C
Department of Nursing, Division of Nursing Research, Karolinska Hospital, Karolinska Institutet, Stockholm, Sweden. catrin.bjorvell@medks.ki.se
Wredling
Regina
R
Thorell-Ekstrand
Ingrid
I
D000328:Adult; D004282:Documentation; D006801:Humans; D008499:Medical Records; D008875:Middle Aged; D016294:Models, Nursing; D009726:Nurses / Q000523:psychology*; D009731:Nursing Audit; D009732:Nursing Care; D009737:Nursing Records; D011795:Surveys and Questionnaires; D013997:Time Factors