Improving documentation using a nursing model

Abstract

Background. The present investigation is part of a study where the Registered Nurses on three hospital wards received a 2 year intervention programme on nursing documentation in accordance with a keyword structure based on the nursing process. Aim. To describe the Registered Nurses' perceptions of and attitudes towards the effects of the intervention, and to generate hypotheses for further research. Method. Focus group discussions were used to collect data, with a qualitative content analysis method for the processing of the data. Findings. The most interesting finding in these group discussions was the statements made by participants that the structured way of documenting nursing care made them think more, and think in a different way about their work with their patients. Two types of role changing were reported; from a medical technical focus to a more nursing expertise orientation and from a 'hands on clinician' to more of an administrator and secretary. Conclusion. A number of issues debated among the participants in this study could be seen as organizational matters and lead to the important issue of multidisciplinary and organizational work when implementing innovations within nursing.