In 1985, a retrospective chart audit was conducted in a 223-bed teaching nursing home to determine whether nurses documented patient care needs consistently on different nursing forms in the medical record and what nursing diagnoses nurses used. Urinary incontinence was selected as the patient care need. ' The results of this study revealed that documentation of incontinence occurred more frequently on forms employing words or phrases relating to elimination or continence status. Incontinence rarely appeared on the medical problem list. The most frequent patient care needs were recorded in descriptive terms of behavioral problems on the nursing care plans (eg, depression, hoarding, restlessness, manipulative behavior). These behavioral problems, frequently found in nursing home residents, did not fit conveniently under nursing diagnoses as delineated by the Fifth Annual Nursing Diagnosis Conference.
A follow-up study was conducted in late 1987 to determine if the consistency of documentation of incontinence and identification of patient needs on care plans had changed since 1985. The study was also extended to include a collection of information about changes in internal organizational components between November 1985 and September 1987 that may have influenced documentation. The specific components of interest for this study were internal resources, organizational structure, and values orientation and expectations.2
A retrospective chart audit using the 1986 and 1987 medical records of residents admitted to the nursing home prior to June 1986 was performed. This date was selected to minimize the risk of missing data on the 1986 record due to recent admission to the facility. Six nursing, medical, and interdisciplinary forms, as in the study in 1985, were reviewed for documentation of the resident's continence/incontinence status. These forms included the following:
The Nursing Admission Data Sheet is completed by the nurse to provide a data base of the resident's condition at admission. This form provides cue words regarding the resident's bladder elimination but not specifically for incontinence.
The Monthly Nursing Summary is completed by the nurse to provide an assessment of the resident and his/her adjustment to the facility. This form contains cue words for continence/ incontinence as well as open space for comments. In the original study, this form was completed on a weekly basis. In early 1987, a policy was implemented to change the frequency of documentation to a monthly basis.
The Nursing Assistant Record is completed by the nursing assistant assigned to provide direct patient care. The nursing assistant documents all care and services given to the resident according to doctors' orders. This form is completed daily by nursing assistants on each shift.
The Medical Problem List is completed by the physician and/or nurse practitioner regarding the date of onset and resolution of active/chronic and temporary problems. An open format is utilized.
The State Comprehensive Patient Appraisal is a multidisciplinary standardized form completed monthly by health-care professionals; the nurse completes the functional assessment section. The purpose of this form is to provide a standardized assessment of the resident. Information from this form is used in determining state reimbursement for the facility.
The Interdisciplinary Care Plan is reviewed and revised monthly by an interdisciplinary team. An open format is utilized for the identification of problems, goals, approaches, and assessments. A new format for this form was implemented in May 1987.
PERCENTAGE OF TIMES CONTINENCE/ INCONTINENCE WAS DOCUMENTED ON EACH TOOL
There were 89 medical records of residents identified as having been admitted prior to June 1986. Fifty of these records from five nursing units were randomly selected for review.
Data were collected over a 3-month period in the fall of 1987. A chart audit tool had been developed, pilot tested, and revised prior to data collection . The definition of urinary incontinence used was identical to the first study: "a condition in which involuntary loss of urine is a social or hygienic problem and is objectively demonstrable."3 The 1986 medical records were located and reviewed in the medical records department; the 1987 medical records were reviewed on the nursing units.
Chi square and contingency coefficients were calculated to ascertain whether there were significant differences in documentation on the 1986 and 1987 nursing, medical, and interdisciplinary forms. The percentage of continence/ incontinence documentation for each tool in 1985, 1986, and 1987 medical records were computed. The frequency of documentation for the first five active problems on the care plan for 1987 was computed and compared with the five most frequently documented patient care needs in the Petrucci et al study.
Changes in Organizational Components
Information about changes in organizational factors or mechanisms that may have impacted documentation was collected and organized under the headings of internal resources, organizational structure and policies, and values orientation and expectations.
Internal resources were defined by the authors as health-care professionals involved in the supervision and provision of direct patient care. Organizational structure and policies were defined as the decision making hierarchy, mechanisms to change policy, and strategies for implementation of new procedures. Values orientation and expectations were defined as activities within the organization designed to change the valuation of behavior and services. This includes educational programs and inservice classes.
A chronology of professional personnel changes, organizational structure and policy changes, and implementation of educational programs on the incontinence during the period between November 1985 and September 1987 was constructed.
There continued to be a significant difference in the consistency of documentation of continence/incontinence among the five documentation forms in 1986 and 1987 as evidenced by the chi square statistics for each year. The contingency coefficient indicates the strength of the relationship between the different forms and presence of documentation about continence/incontinence. For 1986 and 1987, there was a moderate to strong relationship or association.
As in the Petrucci et al study, data from the nursing admission data sheet were excluded from analysis. Petrucci et al had noted that "patients admitted prior to 1983 had no admission database form; admission data were recorded in a narrative note."1 In the most recent study, all 50 patients had been admitted prior to June 1986; many of the records (36%) were missing this information. However, of those records with existing nursing admission data sheets, 20% of those admitted prior to 1985 and 16% admitted after 1985 had documentation regarding continence status. This finding represents no significant difference from the Rstrucci et al findings in 1985.
Figure 1 presents the percentage of conti nence/i neo ntinence docu men tation on each form of the medical records in 1985, 1986, and 1987. There was 100% documentation of continence status on both the state comprehensive patient appraisal form and monthly nursing summary in 1987. As seen in Figure 1 , the forms completed by professional nurses (the state comprehensive patient appraisal form and the monthly nursing summary for 1986 and 1987) had significantly higher documentation than did the 1986 and 1987 nursing assistant records.
Documentation of incontinence had significantly improved on the 1987 care plans and nursing assistant record when compared with the 1985 care plan and 1985 nursing assistant record. Specific forms were compared with each other for differences in documentation, liiere were significant differences in 1986 documentation about continence/ incontinence when the monthly nursing summary and the state comprehensive patient appraisal form were separately compared with the nursing assistant record. The relationship between the forms and presence of documentation was moderate. There continued to be a significant difference in documentation on these same forms in 1987, although the strength of the relationship was weaker. A significant difference in documentation was found between the medical problem list and the interdisciplinary care plan, where there was a weak to moderate relationship. There was no significant difference in documentation of incontinence on the medical problem list in 1987 when compared with the frequency of documentation in 1985.
There were significant differences in the frequency of documentation of patient care needs on the 1985 care plans and the 1987 care plans (Figure 2). Nutritional problems were the most frequently recorded problems in 1987 as compared with a category entitled "other" in 1985. This category included depression, hoarding, restlessness, wandering, demanding, belligerence, and manipulating.1 Incontinence was identified on 36% of the care plans in 1987 and on 2.5% of the care plans in 1985 (?2=52.876, ? < .001). There were no significant differences in age and sex of residents with care plans for incontinence when compared with residents without care plans for incontinence. However, 56% of the residents with care plans for incontinence had been participants in the protocol on a continence research unit, which was established in 1985 (?2= 12.769, P < .001).
Changes in Organizational Components
An organizational change chronology revealed that many changes occurred in professional personnel, organizational structure and policy, and values orientation and expectations between November 1985 and September 1987 (Table).
FIRST FIVE ACTIVE PROBLEMS ON CARE PLANS
Internal Resources. Since 1985, five nurses with advanced degrees and expertise in gerontological nursing were recruited into administrative and clinical positions throughout the organization. The position of medical director had been filled twice, and one medical director had a strong clinical and research interest in commence. Nurses with advanced degrees in nursing were employed to manage a research unit established in late 1985 for the behavioral management of urinary incontinence.
Organizational Structure, A major change in the organization of the nursing department was underway during the original study; a decentralized form of administration and flattening of the organizational chart was instituted. A new director of nursing began employment after the first study was completed and continued the process of decentralizing the nursing department. The number of head nurses was increased from two to five.
Several policies in the departments of nursing and medicine changed since 1985, including many related to documentation. In May 1986, a new format for the interdisciplinary care plan was adopted. Nursing, medical, social work, activities, dietary, and other appropriate personnel continued participation in collaborative care planning conferences. In 1987, a nursing department policy change was instituted that reduced the frequency of documentation from weekly to monthly on a nursing form that summarized a resident's status (monthly nursing summary). A new history and physical form, admission sheet, and face sheet were also introduced.
Values Expectations and Orientation. After the opening of a continence research unit, urinary incontinence was the topic of several educational programs presented to the management and clinical nursing personnel. Newly employed nursing personnel received information during their orientation program regarding the purpose of a continence research unit established to study urinary incontinence.
ORGANIZATIONAL CHANGES AND OCCURRENCE DATES FROM NOVEMBER 1985 TO SEPTEMBER 1987
The purpose of this follow-up study was to examine the consistency of, and changes in, documentation of urinary incontinence and patient needs on care plans. Because documentation is an integral part of an organization's function and purpose, information was collected about organizational changes that were occurring concurrently with changes in documentation. No causal relationship was intended between the organizational changes and the observed changes in documentation. It also should be noted that the study was limited to one facility and, due to the selection criteria and small sample size , generalization of the findings was limited.
A nursing admission database form using cue words regarding elimination had been implemented in 1984. However, due to the selection criteria and small sample size of the present study, evaluation of the nursing admission database was not possible. The median date of admission to the facility on the records in this study was 1983. Therefore, chart audits of nursing admission data sheets for patients admitted after 1985 would be required to evaluate documentation on this form.
There had been significant improvement in the documentation of incontinence on the state comprehensive patient appraisal and monthly nursing summary. The state comprehensive patient appraisal plays a significant role in reimbursement for the facility. Therefore, improvement of documentation may have an impact on an organization's fiscal performance. However, this issue was not directly addressed by this study. Further investigation is warranted to identify nursing management strategies that are successful in effectively improving documentation to enhance organizational fiscal performance. During the chart reviews, it was noted that the monthly nursing summary was often completed on the same date as the state comprehensive patient appraisal. The increase in improvement on the monthly nursing summary may reflect the influence of streamlining that frequency of^documentation from a weekly to a monthly basis and the convenience to the nurse of completing both forms at the same time.
Documentation on the nursing assistant record showed improvement over die 2 years. A factor that may have influenced this finding was the establishment of a continence research unit in late 1985. This unit was located on one of the nursing units in the facility to study behavioral treatment of incontinence. Specific orders regarding toileting and recording urinary incontinence were on all records of participants in continence research unit protocols. Nursing assistants were required to document all services and care provided on each shift.
Nursing supervision is an important component in work performance of ancillary staff. Between 1985 and 1987, a head nurse was hired for each nursing unit who was responsible for assuring quality patient care, hiring and supervising staff, and making budgetary decisions. Reasons for significant differences in the frequency of documentation between professional nursing forms (monthly nursing summary and state comprehensive patient appraisal), and the nursing assistant record are unclear. It may be related to supervision, staffing and workload patterns, educational preparation, or other factors not addressed in this study.
An open format medical problem list did not show significant changes in documentation of incontinence from the original study. Only 14% of the 1987 records had documentation of incontinence on the medical problem list. A checklist or cue word format may heighten physician awareness to the problem of incontinence. Implementation of organizational mechanisms, such as feedback to individual physicians about the results of chart reviews, that include the medical problem list may increase documentation.
The study also found that there was not consistent fol low- through from identification of incontinence by nurses to the development and evaluation of a care plan by the interdisciplinary team. However, because a new format of the interdisciplinary care plan had been in effect for only 4 months prior to the present study, one must be cautious when interpreting the findings. Followup evaluation of the new care plan format is necessary.
Thirty-eight percent of residents who were identified as incontinent of urine on the 1987 state comprehensive patient appraisal had care plans for urinary incontinence. The majority of the residents with care plans for incontinence (56%) had participated in the protocol of the continence research unit. This unit had intensive staffing to collect data and to implement intervention protocols; intensive staff education; and unique management strategies aimed at changing staff behavior. Staffing resources, education, and management strategies that instruct the staff and reward appropriate staff performance with praise are considered central to a successful continence program.4 Therefore, although several forms showed improvement, documentation of incontinence remained inconsistent among the forms reviewed in this study. The use of cue words and feedback of performance in documentation through chart audits may help improve consistency. Participation in interdisciplinary teams by health-care providers who consistently document continence/ incontinence status could also influence documentation in the interdisciplinary setting.
Improvement of documentation on several forms may have been mediated by changes in organization. Increasing the level of professional staff, especially nurses with advanced degrees (internal resource), implementing structural and policy changes (organizational structure), and providing education (values orientation/expectations) could have influenced the identification of patient care needs through better documentation on important assessment forms.
There had been a consistent infusion of professional nurses into key administrative and clinical positions since 1985. The presence of qualified nursing personnel could have contributed to improvement of documentation on nursing forms. Sufficient numbers of adequately prepared staff members are necessary to implement change within an organization. The Institute of Medicine report on the quality of care in nursing homes stated that, "One of the major factors affecting quality of care and quality of life in nursing homes is the number and quality of nursing staff in relation to the facility's requirements."5
Consideration of organizational factors is helpful to nurses for examining professional practice and administrative, clinical, and educational strategies. Changes in organizational models or care delivery systems should be evaluated in terms of performance of nursing documentation. Recommendations for further research include ongoing studies for specific patient care needs and outcomes during restructuring and organizational change of health-care facilities.
Recommendations for nursing management strategies to improve documentation include periodic communication with the staff regarding documentation policies through written and verbal media; formulation and employment of explicit criteria regarding written documentation during performance appraisal conferences; and distribution of the results of chart audits regarding improvement or decline in documentation to the nursing staff on a regular basis.
- 1. Petrucci K, McCormick K, Scheve A. Documenting patient care needs: Do nurses do it? Journal of Geronlological Nursing. 1987; 13(ll):34-38.
- 2. Kaluzny A, Hernández S.Organization change and innovation. In: Shortell S, Kaluzny A , eds . Health Care Management: A Text in Organization Theory and Behavior. New York: John Wiley & Sons; 1983:348-417.
- 3. Bates P, Bradley W, Glen E. Standardization of terminology of lower urinary tract function. JUrol. 1979; 121:551-554.
- 4. McCormick K, Scheve A, Leahy E. Nursing management in geriatric inpatients. Nurs Clin North Am. 1988; 23(l):231-264.
- 5. Institute of Medicine. Improving the Quality of Care in Nursing Homes. Washington DC: National Academy Press; 1987:101.
ORGANIZATIONAL CHANGES AND OCCURRENCE DATES FROM NOVEMBER 1985 TO SEPTEMBER 1987