Nurses’ care planning and documentation processes in electronic health records of patients living with dementia

Abstract

Background: Communication and coordination of patient information are central to achieving continuity and safety for patients in health services. Electronic health records (EHRs) are utilized in large parts of the world, including Norway, in daily clinical practice to plan and document healthcare. As the workload and transition of patients increase in health services, including in nursing homes, nurses and other healthcare professionals increasingly rely on patient information from the EHR to support their daily planning and management of high-quality nursing care for patients. In dementia care, the need to plan and document patient information in a safe and secure way is important for patient safety and a person-centered approach and follow-up of the patient. Little is known about the care planning and documentation process of nurses in long-term dementia care settings.

Aim: The overall aim was to gain knowledge and understanding of the care planning and documentation processes of nurses in EHRs in the dementia nursing home setting.

Methods: A qualitative descriptive design was utilized in this PhD project. Multiple approaches to elicit the perspectives and experiences of nurses were chosen to understand their everyday world of planning and documenting nursing care in the dementia care setting. The project comprises three substudies. In Substudy 1, a retrospective chart review was conducted utilizing content analysis with a deductive approach to describe the content and comprehensiveness of the nursing documentation of patients living with dementia in Norwegian nursing homes. The content was described in relation to person-centered care (PCC) and the nursing process (NP). Comprehensiveness was measured with the Comprehensiveness In Nursing Documentation (CIND) scale. In Substudy 2, a think-aloud (TA) study was conducted utilizing a stepwise verbal protocol analysis to explore and describe nurse’s clinical reasoning during care planning and documentation of nursing in the EHR of patients living in special dementia care units in Norwegian nursing homes. In Substudy 3, a one-on-one interview study was conducted utilizing a semi-structured interview guide. Following a deductive orientation, reflexive thematic analysis was utilized to generate patterns of shared views and meanings among the participants.