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Improving documentation using a nursing model

Catrin Björvell PhD RN
Division of Nursing Research at Karolinska Hospital, Department of Nursing, Karolinska Institutet, Stockholm, Sweden

Regina Wredling PhD RN

Department of Nursing, Karolinska Institutet, Stockholm, Sweden

and Ingrid Thorell-Ekstrand PhD RN

Division of Nursing Research at Karolinska Hospital, The Swedish Red Cross College of Nursing and Health, Stockholm,

Submitted for publication 7 August 2002

Accepted for publication 10 April 2003

Correspondence: B J Ö
Catrin Björvell, Advanced Nursing 43(4), 402–410
Division of Nursing Research, Improving documentation using a nursing model
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: 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.

Keywords: nursing documentation, attitude, focus groups, prerequisites and con-

sequences, VIPS

and lack of knowledge to document the nursing care. Also the

usefulness of the documentation is often mentioned (Bowman
Registered Nurses’ (RNs’) perceptions of facilitating and et al. 1983, Tapp 1990, Howse & Bailey 1992, Ehnfors
inhibiting factors in relation to nursing documentation have 1993, Jerlock & Segesten 1994, Törnkvist et al. 1997, Allen
been described in numerous articles in Sweden and other 1998, Ehrenberg 2001). These studies are all based on
countries. These studies discuss how the organization and structured interviews in small samples or questionnaire
environment influence the RNs’ ability to document. Other studies and the revelation of these factors has not changed
aspects concern reactions by other professionals, lack of time the situation for RNs regarding their documentation.

402  2003 Blackwell Publishing Ltd

Experience before and throughout the nursing career Intervention for nursing documentation

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.

Nursing Nursing Nursing Nursing Nursing Nursing Discharge

history status diagnoses goals interventions outcome notes
-Reason for contact Planned - implemented
- Communication
-Health history - Knowledge/Development
-Current care - Participation
- Breathing/Circulation - Information/Education
experience - Nutrition
-Hypersensitivity - Support
- Elimination - Environment
- Social history - Skin/Tissues
-Support services - General care
- Ulcers/Wounds Advanced care
-Lifestyle - Activity - Training
- Sleep - Observation/
- Pain/Perceptions Monitoring
General - Sexuality/Reproduction
information - Special care
- Psycosocial -Wound care
- Information - Emotions - Drug administration
source - Relationships - Coordination
- Significant other - Spiritual/Cultural -Coordinated care-
- Temporary - Well-being planning
notes - Composite assessment -Discharge planning
- Confidentiality - Medications
- Primary nurse
- Ward round Medical information
/Progress notes - Medical assessment

Flowsheet of the VIPS-model

Ehnfors,Thorell-Ekstrand & Ehrenberg 1997

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.

connected with the study and with extensive knowledge of

The study
implementation of nursing documentation.
Each session was initiated by the moderators explaining
the goal of the discussion and purpose of audiotape record-
The purpose of this study was to describe the RNs’ ing. Three key-topics were used to initiate discussions:
perceptions of and attitudes towards the effects of a 2 year participants’ perception of the change in nursing documen-
comprehensive intervention using the VIPS model for nursing tation on the wards, the effects that this change had had on
documentation, and to generate hypotheses for further their daily work and the attitudes of the RNs and others
research. towards these effects. The sessions were audio-recorded and
later transcribed verbatim by a person not connected with the
study in order to assure anonymity.

Twenty RNs were selected to take part in a focus group

Ethical considerations
discussion. These participants were selected from a group of
34 RNs from three hospital wards – a surgical, a neurolog- The research protocol was approved by the Karolinska
ical and a rehabilitation ward at a university hospital in Institutet Ethical Committee. Participants volunteered to take
Stockholm, Sweden – who had participated in a 2-year part and were assured of anonymity.
intervention programme on nursing documentation using the
VIPS model (Björvell et al. 2002). The selection criterion was
Data analysis
to have participated in the intervention programme for the
full 2 years. Participants’ ages ranged between 28 and 50 The transcribed focus group discussions were analysed using
(median 40) and years of practice as an RN ranged between 4 a qualitative content analysis method (Berg 1998). The texts
and 25 (median 14). Twelve worked on day shifts and eight were read line-by-line and divided into text units that
worked on night shifts, nine worked full-time and 11 worked reflected different aspects of the participating RNs’ experi-
part-time. ences. These text units were coded using terms close to the
original statements and then merged into categories. The text
was read through a second time to make sure that no
Data collection
information pertinent to any of the categories had been
The research purpose demanded a method that would missed. Categorized lists of the sentences were printed out,
encourage unprejudiced discussion among the participants re-read line-by-line twice more, and sentences re-allocated to
about the change in nursing documentation, and therefore a different category when pertinent. This coding process was
focus groups were used (Betrand et al. 1992). performed by the first author (CB). The coding approach used
Krueger (1994) describes focus groups as carefully is named ‘sensitising concepts’, which indicates that the
planned discussions, used to obtain perceptions on a specific researcher is guided by previous experiences and theories,
area of interest in a permissive, non-threatening environ- although no specific hypotheses are used (Blumer 1969,
ment. The purpose is to have group members influence each Sandelowski 1998). As CB had extensive previous knowledge
other by responding to ideas and comments in the discus- of the study area, it was unlikely that she would be able to
sion. This is considered an effective technique for exploring categorize the material in an unbiased way. Therefore, two
the attitudes and needs of staff (Kitzinger 1995) to generate additional people individually read although the categorized
hypotheses for further investigation. The intent of focus lists with coded sentences to see if there was anything in the
groups is not to infer or generalize but to determine the data that contradicted the initial categorization and findings.
range of and provide insights into how people perceive a These people were the third author (ITE), who had know-
situation (Krueger 1994). ledge of the material, and another researcher not connected
The focus group discussions were held in 1995, 5 months with the study and not familiar with this material, but with
after the intervention was concluded to allow time for the experience of focus group analysis (KS). The three researchers
effects to become visible. Each group met once for approxi- discussed the material until a negotiated consensus was
mately 2 hours. The location was a conference room in the reached (Giorgi 1989, Kihlgren & Thorsén 1996).
hospital, away from the actual work places of the partici- The computer program ‘Open Code (2001)’ was used for
pants. The focus group moderators were two RNs not the coding procedure.

404  2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(4), 402–410
Experience before and throughout the nursing career Intervention for nursing documentation

documentation through the VIPS model was time-saving

compared with the formerly used running notes.
Most of the topics that came up were mentioned in all three Increased effectiveness in organizing their jobs was de-
focus groups. The participating RNs’ reflections on their scribed by some of the participants. One participant reflected:
experiences of the 2-year intervention on documenting
When I do my rounds I spend more time talking…talking in a more
nursing care by use of the VIPS model were developed into
structured way…to each patient. I know that later I will be busy
four main categories which are not mutually exclusive, as
documenting, so I need to collect as much information as possible
some of the statements could fit into more than one category:
during this round instead of like I used to, first distribute medications,
• influence on daily practice and professional role,
then go back and then later do another round with blood pressure
• organizational issues,
measures…You co-ordinate the things you have to do with each
• acquired skills,
patient. (Group 1)
• responses and reactions by other professionals.
There were also statements from participating RNs indicating
that they would be reluctant to return to their former way of
Influence on daily practice and professional role
This category encompasses reflections concerning how the
If I was to change jobs and go to another ward, I could never work in
new documentation routines affected direct patient care, the
a ward that didn’t use the VIPS model – that would be completely out
RNs’ conduct in relation to the patient and change in
of the question for me. (Group 3)
professional focus as well as practice routines.

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.

professional bed-side role and become secretaries, spending Interruptions

less time with patients and more time at the nursing station. All three groups reported frustration about constantly being
At the same time someone clarified that this was more an interrupted when trying to document, and never having peace
effect of the general increase in workload and not the new and quiet around them for reflection. They were disturbed by
documentation system. Other participants felt that they now telephone calls, relatives of patients, physicians, nursing
had more information about patients than previously as a assistants and other health professionals. When they returned
consequence of the documentation procedures. Two partic- to resume writing in the patient record after having been
ipants in one group, called here A and B, debated this issue: interrupted, the record may have been taken by someone else.
Even more problematic, the interruption in thought was
A: It is not the patient’s words you get to hear, it’s the nursing
described as time-consuming, as thoughts had to be collected
assistant who tells you that he’s not eating well or whatever…you
all over again:
don’t hear it from the patient anymore, unless you just happen to be
there. You had it more under control before. It may not work to sit down for an hour [to document] – maybe you
need 10 minutes here and 10 minutes there. Then you have to be able
B: I feel quite the contrary, you find out more [about the patient]
to concentrate for those 10 minutes and not be interrupted the whole
now, at least if I compare to when I started as an RN in 1988…You
time. It’s incredibly irritating. There is no peace and quiet. (Group 1)
didn’t write nearly as much, you wrote hardly anything. I know my
patients much better now than I used to. (Group 3)
The issue of time was often mentioned in two of the groups.
Participants stated that documenting took time, both in the
Some participants described how, when the documentation
sense that thinking took time and documentation required a
was good, it was easy to switch between patient groups even
greater amount of thinking, but also in the sense that they
in the middle of a work shift. If an RN was absent in one
now documented more elaborately and this was more time-
group, another RN could easily take over the care of her
patients by reading the record. Good documentation was also
mentioned as increasing the possibility of working flexible Even though you wish it would be the contrary, it does take more
hours, as it made the need to be present at a specific time to time to think it through, to get it right, so to speak. What you write
attend an oral report unnecessary. will be saved [in the record], so you don’t want it to look too crappy,
Changing from oral shift reports to reading the written so you have to think it through. (Group 1)
record was discussed in one group as the most important
effect of the intervention programme. The advantages Workload
described were that it was more objective, that it saved time Participants in one group described conflicts of loyalty and
and that it facilitated taking over patients from another feelings of guilt. An example of this was when nursing
team. However, reservations about this were also stated, assistants had a heavy workload with patients and RNs felt
for example if the record was not well-documented, then a they had to attend to administrative issues, including docu-
written report had great disadvantages. mentation. Another example was when the RN on the out-
Increased safety as a consequence of the documentation going shift left unfinished work for her in-coming colleague,
was mentioned in all three groups and was exemplified by because she had not had the time to complete all her work.
being able to read what had been carried out and what should This sense of loyalty and feelings of guilt often resulted in
be carried out for the patient and not having to rely on overtime work. At first, participants stated that a major
another person’s memory to tell you all you needed to know: reason for this was the increase in nursing documentation:

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
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
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

(1998) as a consequence of nurses practising in groups. This

What is already known about this topic leads to the important consideration of multidisciplinary and
• Facilitating and inhibiting factors in relation to nursing organizational aspects when implementing innovations with-
documentation as perceived by Registered Nurses are in nursing.
organizational and environmental influences, reactions A major implication of this study is that further research is
by other professionals, lack of time, lack of knowledge needed to test the hypotheses generated here, particularly
to document nursing care and the degree of usefulness whether the use of a structured model for documentation
of the documentation. with headings for specific content helps ensure that RNs
• People’s intentions to behave in a certain way are perform patient assessments that are more relevant and
determined by their attitudes towards the behaviour whether it enhances RNs’ ability to reflect about nursing care.
and perceptions of social pressure to behave or not
behave in certain ways.
• A change in behaviour – in this case nursing documen-
tation behaviour – needs to start with a change in The authors are grateful to the Stockholm County Council,
attitude in Registered Nurses themselves, as well as in whose generous grant made this study possible and the Board
other health care professionals. of Research for Health and Caring Sciences, Karolinska
Institutet, Stockholm. The authors also thank Associate
Professor Carol Tishelman for her valuable comments and
What this paper adds directions regarding the qualitative methodology and medical
• Registered Nurses’ ability to reflect about nursing care social worker Karin Säflund for co-assessing the transcribed
may be increased by the use of a structured model for focus group discussions.
documentation with headings for specific nursing con-
• A structured model for documentation with headings
for specific nursing content may initiate a change of role Ajzen I. & Fishbein M. (1980) A theory of reasoned action. In
for the RNs from a medical technical focus to a more Understanding Attitudes and Predicting Social Behaviour (Ajzen I.
& Fishbein M, eds), Prentice Hall, Englewoods Cliffs, NJ.
nursing expertise orientation.
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