Академический Документы
Профессиональный Документы
Культура Документы
Correspondence: B J Ö
ORVELL C., WREDLING R. & THORELL-EKSTRAND I. (2003) Journal of
Catrin Björvell, Advanced Nursing 43(4), 402–410
Division of Nursing Research, Improving documentation using a nursing model
Borgmästarvillan,
Background. The present investigation is part of a study where the Registered
Karolinska Hospital,
Nurses on three hospital wards received a 2 year intervention programme on nur-
S-171 76 Stockholm,
Sweden. sing documentation in accordance with a keyword structure based on the nursing
E-mail: catrin.bjorvell@medks.ki.se 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 multidiscipli-
nary and organizational work when implementing innovations within nursing.
According to the Theory of Reasoned Action (Ajzen & information is documented as running notes without struc-
Fishbein 1980) people’s intentions to behave in certain ways ture or keywords and primarily describes the medical care
are determined by their attitudes towards the behaviour and ordered by the physician.
the subjective norm or their perceptions of social pressure to The present investigation is part of a study (Björvell et al.
behave or not behave in a particular way. Groenman et al. 2002) in which RNs on three hospital wards received a 2 year
(1992) describe attitude as an enduring cluster of beliefs, intervention programme on nursing documentation in
feelings and behavioural tendencies relating to any person, accordance with the VIPS model. This model is designed to
object or issue. People will have positive or negative feelings structure nursing documentation systematically and consists
or emotions about a person, object or issue. These feelings of two levels of keywords: the first level accords with the
and beliefs will influence the behaviour directed at the person nursing process (Yura & Walsh, 1988) and the second level
or object. Norms and values also play an important part in with specific keywords for history, status and interventions
the concept of attitude. (Figure 1). VIPS is an acronym formed from the Swedish
In the light of these definitions a change in behaviour, words for well-being, integrity, prevention and security and
in this case nursing documentation behaviour, needs to start the model aims at producing a problem-based nursing care
with a change in attitude towards documentation. Lewin plan and a discharge note to guarantee legal compliance. It is
(1973) calls this first stage in a changing process in which used in both electronic and paper-based patient records. The
attitudes and habits are addressed the unfreezing stage and model has been tested and validated, as described elsewhere
deems this to be decisive of whether or not the change will (Ehnfors et al. 1991, 1996, 2002).
last. Bridges (1996) states that individual, psychological The intervention programme comprised six parts:
change is the most difficult and time consuming part; he calls (1) theoretical training in groups, (2) individual supervision
this the transition part and describes it as including a first in clinical practice, (3) conference days and evening seminars,
stage of ‘ending’, letting go of old habits and roles in order to (4) training and support of two change agents from each
accept new ones. ward, (5) support and advice to head nurses regarding
The tradition among RNs in Sweden is to document organizational changes necessary to facilitate nursing docu-
the given care retrospectively, rather than documenting the mentation and (6) development of new forms and standard
prospective planning of nursing care. By tradition, the care plans, as described elsewhere.
Figure 1 Flowchart of the VIPS model for nursing documentation. From Ehnfors et al. (2002), reproduced with permission.
2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(4), 402–410 403
C. Björvell et al.
404 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(4), 402–410
Experience before and throughout the nursing career Intervention for nursing documentation
Changing roles
Increasing awareness
A process of transition within the individual regarding their
Statements about a new way of thinking occurred repeatedly
perception of the meaningfulness of documentation and their
in two of the groups. This changed thinking was in relation
approach to the patient was mentioned by two participants in
to patient assessments, with participants describing how
two different groups. They described themselves as having
they used a more structured and thorough approach when
felt strong resistance both towards documentation and to-
assessing or communicating with patients. A deepened
wards a less medically-oriented way of thinking about the
understanding of the patient’s specific situation regarding
patient, but said that this had changed during the 2 years of
nutrition, pain, cognitive or communicative status was
the intervention programme. They now described themselves
described. Patients’ needs were reported as being more
as being more clear about their nursing perspective. One said:
precisely described, and hence more visible and leading to more
specific nursing interventions. They described how they were …it has been a long process and I finally have begun to grow into it. I
forced to think more about the specifics and how to name them had never said that I was an expert in nursing, never ever. No, I was a
correctly. As two of the participating RNs in different groups medical technical expert. I was trained that way, that’s the way it was
put it: and it has been a big process. I thought that I would lose so much, I
actually thought that it [nursing] had less value. I was not trained to
I believe I think more as a whole. Before you just did your job, so to
be a nursing expert. Now I can actually say I am [a nursing expert].
speak, without thinking so much actually, but now you have to think
(Group 2)
about what you do, so that you can write it down…I think one thing
comes with the other. (Group 1) On the other hand, in two of the groups some participants
discussed the RN’s professional role as being transformed
…I also think that I have become much more clear about what it is
into more of a secretary, ward clerk and medical social
that I do, you know. What kind of interventions I do…and I think in
worker rather than a nurse:
a different way, you simply have to think it through more carefully
before you write it down. That’s what I think. Nursing becomes more I think, today when you sit and document so much, you feel like you’re
visible, what you do with the patients. (Group 2) more of a secretary. When I compare to when I started as an RN and
the picture today, then I feel that I have been pushed further and further
Structuring into the nursing station instead of being with the patients. (Group 3)
There seemed to be agreement among participants that
Frustration was voiced about increased paperwork, with
documentation was necessary for patients’ safety. Although it
comments that this affected direct patient care in a negative
was clearly stated that the new way of documentation took
way. Some participants said that RNs had in a sense lost their
more time, a couple of RNs also mentioned that structured
2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(4), 402–410 405
C. Björvell et al.
It increases safety, I think, because I have not relied on my It’s a higher stress level because it [the documentation] is hanging
colleague to give me a complete report, I have read it myself. Then, over you. I have to document before I go home, so I do it after work
of course, it has to be correctly documented, but this [reading] puts hours. (Group 3)
more pressure on us to do so. (Group 2)
Later in the discussion participants in the same group argued
that this had little to do with the nursing documentation, but
Organizational issues was instead an effect of the increased workload:
This category deals with aspects of the work environment – A lot of this, I’m sure depends on the workload on the ward, I
physical as well as psychological. mean…I don’t think we can blame it on the VIPS. (Group 3)
406 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(4), 402–410
Experience before and throughout the nursing career Intervention for nursing documentation
It’s not just the fault of the VIPS, it’s the patient clientele that are so not getting enough help from RNs with the patients, which
very much sicker…and then the fact that we don’t get replacements if was said to give RNs feelings of guilt.
someone is absent. (Group 3) Some participants, in one group in particular, saw that
there was a change in attitude among nursing assistants about
Mostly, the increased patient turnover rate with increased
nursing documentation, in that they had become more
administrative work for admission and discharge was
positive and that they themselves used the documentation
debated, and the fact that the increased workload was
to read about patient care at shift change:
not matched by an increase in staffing. However, other
types of administrative work were also mentioned, such as The nursing assistants have become more positive [towards RNs’
recording of patient costs and number of hospital days per documentation]. They understand it, but at the same time they think
patient. that it takes too much time. But I don’t think that anyone, not to our
knowledge, thinks it [RNs’ documentation] is unnecessary or wrong.
(Group 2)
Acquired skills
The response from the medical profession was described as
This category includes statements about having adequate or
varied. One group spoke of positive reinforcement, support
inadequate skills in how to document nursing care, and about
and respect regarding their documentation. They knew that
having or not having access to measures to improve know-
the physicians read and used the information in the nursing
ledge, e.g. documentation consultants or peer review sessions.
records and made positive remarks about it:
Participants described increased self-assurance about their
knowledge of nursing documentation, and they were aware We had a female physician who said that you get the best information
that they had more knowledge about documentation than from the nurses’ papers. I think you have their respect. One of the
other RNs, even than those who had received the new nursing physicians said ‘I read your papers anyway’. (Group 2)
education who had supposedly learned about VIPS during
Participants in the other two groups reported lack of support,
their training.
and hierarchical attitudes with lack of respect or indifference.
Nursing diagnoses was mentioned in all three groups, and
Two different kinds of negative reactions from physicians
discussed at length in two, as the most difficult part of the
were described. One was a sense of frustration because
documentation and how they lacked sufficient training in
physicians could not find the information that they were
this. It was also the formulation of nursing diagnoses that
looking for in the nursing documentation and another was
was said to be the part of the documentation that required the
lack of respect by ridiculing RNs for their documentation as
most time to think and reflect.
if it was childish:
Participants in each group stated that they needed more
supervision by experts and more peer review to further There has been no support from the physicians; even the department
develop their skills. manager sits down and asks what we are pottering about with, as if
we were writing down a recipe or something…They think that it’s
some kind of playground. (Group 1)
Responses and reactions of others
These negative remarks were said to come only from
This category concerns reflections about the reactions and
physicians in their own wards, and not from visiting
behaviour of physicians, nursing assistants and other health
physicians – consultants or physicians on call – who instead
staff in relation to RNs’ new way of documenting nursing
praised and complemented the nursing documentation on
care.
these wards. RNs thought it was unfortunate that their own
All three groups discussed at length the reactions of nursing
physicians could not appreciate their work, when other
assistants and physicians, whereas responses from other health
physicians could.
professionals – physical therapists, occupational therapists,
medical social workers – were only mentioned sporadically.
Reactions from nursing assistants to nursing documenta- Discussion
tion in general were often described as negative and partic-
This study explored a group of RNs’ reflections on their
ipants felt that they lacked understanding and support. They
experiences of nursing documentation using the VIPS model
discussed reasons for this behaviour, one being that nursing
in clinical practice within the framework of a training
assistants did not have the knowledge to understand the RN’s
programme.
job. Another explanation was that it was a reaction towards
2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(4), 402–410 407
C. Björvell et al.
The most interesting finding in these group discussions was Another aspect of this phenomenon is described by Schön
statements made by participants that the structured way of (1991) when he talks about reflection-in-action as an
documenting nursing care made them think more and think important way for the practitioner to learn and develop
in a different way about their work with patients. This has, as professionally.
far as we know, not been described in earlier research on this Two kinds of change in professional role were mentioned.
topic, and needs to be further investigated. One described in a negative way was the increase in
Two types of role change for the RNs were reported: from administrative work that had transformed the RN into a
a medical technical focus to a more nursing expertise secretary rather than a nurse. The other was described in a
orientation, and from a ‘hands-on clinician’ to more of an positive way and was more of a mental transition from
administrator and secretary. working with a medical–technical focus to a more clear focus
The strengths and weaknesses of the study should be on nursing. This is interesting, since the RNs working in
acknowledged. One strength to be pointed out is participants’ Sweden today are divided into two different paradigms. Those
high level of knowledge on the topic of implications of who were educated in a vocational system were trained to
nursing documentation in clinical practice that was discussed. view themselves as medical technicians, while RNs educated
Another strength of the methodology in this study is that it later in a university system are educated to a much greater
has both validated earlier findings (Björvell et al. 2003) and extent to be nursing care professionals. The same aspect was
generated new knowledge. expressed by some of the RNs interviewed in a study by Öhlén
Our purpose when using focus group interviews was to and Segesten (1998). They suggest that the development of a
illuminate phenomena or topics perceived by the participants nursing language and documentation of individual patient
that need further investigation. The participating RNs were care plans were factors influencing the change in the nursing
guaranteed anonymity in relation to the research team, and images. Benner et al. (1996) stated that only by verbalizing
so the moderators of the focus groups and the person who specific nursing knowledge will it be clear even to nurses
transcribed the audiotaped discussions were not part of the themselves what they are doing and how they are doing it.
research team. The advantage of this was that participants The fact that the focus group discussions were held in 1995
were able to speak freely. However, it may be seen as may be seen as a limitation, and a follow-up study is planned.
disadvantageous that it was not possible in the analysis to However, we argue that the results are likely to be represen-
distinguish whether one statement was made by a number of tative of today’s nurses, as very little has changed among RNs
different people or if one person repeated the same statement. in Sweden with regard to attitudes towards nursing docu-
Homogeneity with regard to workplace was chosen for the mentation (Ehrenberg 2001), and a large majority of clinical
focus groups, which could be seen as a limitation as it may nurses working today were educated in the vocational system
have influenced the discussions as a result of pre-existing as opposed to the university system.
relationships between the participants (Krueger 1994, Lack of time was reported as a major issue in this study
Morgan 1997). On the other hand it may also be seen as a as it has been in many previous studies concerning nursing
strength that they felt at ease with each other, leading to more documentation (Tapp 1990, Howse & Bailey 1992, Ehnfors
open discussion (Morgan 1996). 1993, Törnkvist et al. 1997, Ehrenberg 2001). However,
As mentioned earlier, participants commented that they not having time to document was not an option for these
were ‘thinking more’ and in a different way in relation to RNs as they had agreed to participate in the documentation
their work with patients and in relation to their own role intervention study (Björvell et al. 2002). Instead, some of
as RNs. Ong’s (1982) research into the history of linguis- them commented that they did not have time for direct
tics describes the consequences when cultures move from patient care any more, and partly blamed the nursing
the spoken to the written word. In modern society, we tend documentation activities for this. On the other hand, it was
to give higher validity to the written text than to the clearly stated that nursing documentation was only one in a
spoken. To formulate the written word, he states, sharpens group of increasing administrative tasks, which are well
the analysis as the written word is far more demanding known to be the result of general changes in the health care
to be understood without gestures, intonations and imme- sector because of cost cutting and reorganizations (Social-
diate clarifications. Each possible interpretation must be styrelsen 2000, Kajermo Nilsson et al. 2001, Needleman
considered, and this imposed reflection is an activity that et al. 2002). Previous studies (Degerhammar & Wade 1991;
increases the consciousness. This may also be seen in a Prescott et al. 1991; Lundgren & Segesten 2001) also
wider context where RNs need to voice patient care to show that it is not a new phenomenon, that RNs spend
the public and to politicians (Buresh & Gordon 2000). a diminishing amount of time on direct patient care.
408 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(4), 402–410
Experience before and throughout the nursing career Intervention for nursing documentation
2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(4), 402–410 409
C. Björvell et al.
Cowley S. (1995) Professional development and change in a learning Krueger R. (1994) Focus Groups. A Practical Guide for Applied
organisation. Journal of Advanced Nursing 21, 965–974. Research, 2nd edn. Sage Publications Inc., Thousand Oaks.
Degerhammar M. & Wade B. (1991) The introduction of a new Lewin K. (1973) Group Dynamics and Social Change in Social
system of care delivery into a surgical ward in Sweden. Interna- Change: Sources, Patterns and Consequences (Etzioni A. & Etzioni
tional Journal of Nursing Studies 28, 325–336. E., eds), Basic Books, New York.
Donaldson N. & Rutledge D. (1998) Expediting the harvest and Lundgren S. & Segesten K. (2001) Nurses’ use of time in a medical-
transfer of knowledge for practice in nursing: catalyst for a journal. surgical ward with all-RN staff. Journal of Nursing Management
Online Journal of Clinical Innovations 1, 1–25. 9, 13–20.
Ehnfors M. (1993) Nursing documentation practice at 153 hospital Morgan D.L. (1996) Focus groups. Annual Records Sociology 22,
wards in Sweden as described by nurses. Scandinavian Journal of 153–185.
Caring Sciences 7, 201–207. Morgan D. (1997) Focus Groups as Qualitative Research. Sage
Ehnfors, M., Thorell-Ekstrand, I. & Ehrenberg A. (1991) Towards Publications Inc., Newbury Park.
basic nursing information in patient records. Vard i Norden 21, Needleman J., Buerhaus P., Mattke S., Stewart M. & Zelevinsky K.
12–31. (2002) Nurse-staffing levels and the quality of care in hospitals.
Ehnfors M., Ehrenberg A. & Thorell-Ekstrand I. (1997) The VIPS New England Journal of Medicine 343, 1715–1722.
model – implementation and validity in different areas of nursing Öhlén J. & Segesten K. (1998) The professional identity of the nurse:
care. Studies in Health Technology Informatics 46, 408–410. concept analysis and development. Journal of Advanced Nursing
Ehnfors M., Ehrenberg A. & Thorell-Ekstrand I. (2002) The devel- 28, 720–727.
opment and use of the VIPS-model in the Nordic countries. In Ong W.J. (1982) Orality and Literacy. The Technologizing of the
ACENDIO 2002 (Oud N., ed.), Proceedings of the special con- Word. Methusen Routledge Ltd, London.
ference of the Association of Common European Nursing Diag- Open Code, ver. 2.1 (2001) UMDAC and Epidemiology. Depart-
noses, Interventions and Outcomes, Vienna, Austria, pp. 139–168. ment of Public Health and Clinical Medicine at University of
Ehrenberg A. (2001) Nurses’ perceptions concerning patient records Umeå, Umeå, Sweden.
in Swedish nursing homes. Vard i Norden 21, 9–14. Prescott P., Phillips C., Ryan J. & Thompson K. (1991) Changing
Ehrenberg A., Ehnfors, M. & Thorell-Ekstrand, I. (1996) Nursing how nurses spend their time. Image: Journal of Nursing Scholar-
documentation in patient records: experience of the use of the ship 23, 23–28.
VIPS-model. Journal of Advanced Nursing 24, 853–867. Renfoe D.H., O’Sullivan P.S. & McGee, G.W. (1990). The
Giorgi A. (1989) Some theoretical and practical issues regarding the relationship of attitude, subjective norm and behavioural intent to
psychological phenomenological method. Saybrook Review 7, 71–85. the documentation behaviour of nurses. Scholarly Inquiry for
Groenman N.H., Slevin O.D’A. & Buckenham M.A. (1992) Social Nursing Practice An International Journal 4, 47–60.
and Behavioural Sciences for Nurses. Campion Press Ltd, Edin- Sandelowski M. (1998) Writing a good read: strategies for re-pre-
burgh. senting qualitative data. Research in Nursing and Health 21, 375–
Howse E. & Bailey J. (1992) Resistance to documentation – a nursing 382.
research issue. International Journal of Nursing Studies 29, 371–380. Schön D. (1991) The Reflective Practitioner. How Professionals
Jerlock M. & Segesten K. (1994) Att dokumentera omvårdnaden – Think in Action. Ashgate Publishing Ltd, Avebury.
svårigheter och motstånd (To document nursing care – difficulties Socialstyrelsen. (2000) Omfattningen av administration i vården
and resistance). Sjukskötersketidningen 2, 43–48. (In Swedish) (The Extent of Administrative Tasks in Healthcare). Swedish
Kajermo Nilsson K., Nordström G., Krusebrant Å. & Björvell H. National Board of Health and Welfare, Stockholm, Sweden.
(1998) Barriers to and facilitators of research utilization, as Tapp A. (1990) Inhibitors and facilitators to documentation of nur-
perceived by a group of registered nurses in Sweden. Journal of sing practice. Western Journal of Nursing Research 12, 229–240.
Advanced Nursing 27, 798–807. Tydén T. (1993) Knowledge Interplay. User-Oriented Research
Kajermo Nilsson K., Nordström G., Krusebrant Å. & Lützén K. Dissemination Through Synthesis Pedagogics. Doctoral Thesis.
(2001) Nurses experiences of research utilization within the fra- Acta Universitatis Upsaliensis, Uppsala, Sweden.
mework of an educational programme. Journal of Clinical Nursing Törnkvist L., Gardulf A. & Strender L. (1997) The opinions of
10, 671–681. nursing documentation held by district nurses and by nurses at
Kihlgren M. & Thorsén H. (1996) Violation of the patient’s integrity, primary health care centres. Vard i Norden 17, 18–25.
seen by staff in long term care. Scandinavian Journal of Caring Yura H. & Walsh M. (1988) The Nursing Process. Assessing, Plan-
Sciences 10, 103–107. ning, Implementing, Evaluating, 5th edn. Appleton & Lange,
Kitzinger J. (1995) Introducing focus groups. BMJ 311, 299–302. Norwalk, USA.
410 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(4), 402–410