PubMed1997
Before a general, nursing documentation model was implemented in one health care region of the Stockholm County Council the opinions which district nurses and nurses at the primary health care centers (PHCCs) had of nursing documentation were investigated. 164 nurses (94%) at all the 22 PHCCs within the region answered a questionnaire in October, 1995. The study showed that the nurses in general were dissatisfied with their own, as well as with their colleagues, nursing documentation. The lack of a common, patient-record model for nursing documentation was considered the greatest obstacle, followed by lack of time and lack of knowledge. Most of the nurses believed that patient records which clearly included all parts of the nursing process would promote patient care. However, according to the nurses themselves, less than one-fifth of them recorded nursing history and nursing outcomes for all or most of their patients. One-third of the nurses reported that documented planned nursing interventions, about one-fourth nursing status and about half of them implemented nursing interventions for all or most of their patients. The nurses said that nursing diagnoses, goals and epicrises were rarely documented. There was no significant correlation between the nurses' ages and their opinions of nursing documentation. Nurses who had completed their education after 1985 were more positive to further education in nursing documentation and to computerised patient records, and confirmed more than others that patient records which included the entire nursing process model would promote patient care. Nurses who worked only at PHCCs were more satisfied with their own documentation as well as with that at their centres and were more positive to computer support than district nurses. Nurses at PHCCs were less in favour of education in nursing documentation, compared with nurses working in home health care and child care. The nurses who were not satisfied with their own nursing documentation were not satisfied with their colleagues' documentation either, but they were positive to further nursing education. More than others, they were of the opinion that better patient care follows from patient records which include the entire nursing process model. The study shows the need for education and continuous support aimed at nurses within the primary health care system regarding nursing documentation.