Review: ‘Gaps,mishaps and overlaps’. Nursing documentation: How does it affect care?

The reviewed study, a small-scale study into nursing documentation in an acute NHS hospital in England, raises serious issues for policy, practice and the wider profession in terms of the effectiveness of existing systems, efficient use of the nursing resource and accountability of individual practitioners. The title ‘gaps, mishaps and overlaps’ is a well-constructed summary of the key findings and has the potential to frame some fundamental questions to shape nurses’ thinking about their professional responsibilities for record keeping (Nursing and Midwifery Council, 2009).

The need for improved communication, care planning and record keeping are regular themes in investigations (Parliamentary and Health Service Ombudsman, 2015; Scottish Public Service Ombudsman, 2016) and inquiries (Francis, 2013) into poor practice. A consistent theme is of a failure of record keeping in terms of them being contemporaneous, accurate and full. The potential link between poor documentation and the quality of care delivery is exemplified in the findings from one Ombudsman’s report into failure of care for a patient with dementia:

It was my opinion that poor record keeping in Mrs A’s case went hand in hand with poor care planning and provision and both were well below reasonable standards. (Scottish Public Service Ombudsman, 2015: 2)

Within this research study the respondents cited a range of examples of failures (‘gaps’ leading to ‘mishaps’) in the documentation that could be seen to have the potential to lead to similar outcomes in terms of safety and standard of care delivery: these included failure to record reason for admission or falls risk, and management of venous access cannulae. As well as raising issues around accountability, the findings also illustrate the challenges for the researcher who identifies examples of poor practice during data collection (particularly when they are potentially known to the participant and are an employee of the study site). The authors address this ethical issue and recognise their professional duty of care as well as preserving the integrity of the research.

The types of ‘overlaps’ in documentation described in the study highlight issues of efficiency of existing systems (in this case paper based) and the impact on the nursing resource. The cited literature on the benefits of electronic patient records (which have the potential for reduction in duplication) is mixed and points to the need for further research, particularly given recent estimates that 70% of nurses in the UK use information and communication technology (ICT) for clinical record keeping (Royal College of Nursing, 2013). Other aspects of ‘overlaps’ centred on the use of pre-printed care plans (and other forms of checklists) which were generated but perhaps not used.

What is of prime importance for this type of research is the resulting local actions, not only in terms of improving the deficiencies in the nursing documentation but in addressing some of the implicit attitudes and behaviours of nurses towards record keeping that emerged in the findings. Questions of accountability and professionalism were threaded throughout the findings and discussion, along with a genuine desire to improve the situation.

A key message in the recommendations for practice in the abstract is that ward nurses need to take greater control of the development of documentation. However, this cannot be done in isolation of wider practice guidelines, organisational policies and the need for integrated systems between acute and primary care. The main solution to care planning appeared to be the development of a ‘bespoke, generic manual’ of core care plans which would mean care could be ‘prescribed’ by reference to specific sections of the manual. Whilst potentially attractive in reducing the need for writing care plans, this type of approach warrants careful critique in terms of person-centred approaches.

Whilst the sample size is small and the results may not be entirely representative (given that healthcare records tend to be specific to individual organisations), the findings of this study are relevant for all types of nursing documentation. Despite an explicit focus on standards for record keeping by the profession, ombudsmen and public inquiries, this study and wider internal audits, inspections and responses to complaints across the UK highlight that poor record keeping remains a challenging issue that has a real potential to contribute towards poor experiences and outcomes of care.