Society is in the midst of an information explosion. The search for knowledge occurs in everyone's life, both unconsciously and consciously, as particular data to solve a problem or make a decision is sought out. Gathering the right information in an efficient manner and storing it so it can be accessed and manipulated as required are fundamental to an organization achieving its goals.
Health care and the practice of nursing are currently also information intensive industries (Conrick & Foster, 1993; Shamian, Nagle, Oc Hannah, 1992; Silva Oc Aderholdt, 1992). Nurses no longer "just provide care." They are responsible for creating, processing, and distributing information. There are those who believe the collection of data has become a goal in itself, forcing substantial amounts of data collection on to nurses, where the result does little to enhance or in any way affect patient care (Dennis, Sweeney, Macdonald, & Morse, 1993; Silva & Aderholdt, 1992; Sinclair, 1991). It was predicted in the 1960s that the introduction of computers would improve the efficiency of performing certain tasks and allow nurses more time for direct patient care (Conley, 1961, cited in Shamian et al., 1992). As Shamian et al. (1992) report, this has not proven to be the case.
The purpose of this article is to outline the issues related to the documentation of clinical information in aged care institutions in New South Wales (NSW) (Australia). Documentation is defined as the transfer of clinical information through written form. It encompasses all types of written notes, such as admission and assessment forms, observation charting, progress notes, wound and elimination charting, medication records, discharge notes, and more administrative tasks like stock re-ordering and rostering.
AUSTRALIA'S UNIQUE DOCUMENTATION PRACTICES
Long-term care nursing in Australia has particular aspects that make documentation practices somewhat "unique." Not the least of these is that the funding sources for longterm care services define documentation parameters. Unlike acute care hospitals, nursing homes and extended care facilities are funded by the Federal (Commonwealth) government through the Department of Health and Ageing, which inspects and audits facilities for competence and achievement of patient (resident) care outcomes. Verification for funding claims is drawn from clinical records documenting residents' care.
The Aged Care Reform Package implemented by the Federal Government in October 1997 introduced a new classification scale in residential aged care, the Resident Classification Scale (RCS), determined on the basis of patient records (Commonwealth of Australia, 1997). On this basis, operators are paid a per-resident, per-day rate for all care and services. The prescriptive, lengthy documentation and subsequent validation requirements of the Commonwealth funding model mean, in the absence of substantial documentation, appropriate funding may not be provided. As a consequence, nursing and personal care services may not be adequately funded. Furthermore, nursing home proprietors no longer have to prove the money they receive has been spent on nursing care, so the excessive emphasis on documentation described earlier does not necessarily translate into more funds for resident care ("Documentation in Aged Care," 1997).
Quality documentation is, therefore, crucial not only to nurses' professional duty of care but also to the funding process. Finding a balance between the time required for documentation activities and the time to actually perform nursing duties with the residents has, at times, posed an impossible task for long-term care nurses ("Documentation in Aged Care," 1997).
Apart from the difficulties and problems associated with training nurses in the new charting requirements, documentation has been reported as excessive. It has been estimated that nurses spend 15% to 25% of their work time on documentation (Moody Sc Snyder, 1995; Wyatt, 1995). Documentation has been cited as a common reason for overtime (Moody & Snyder, 1995). Some proprietors are said to employ specific (non-RN) staff with little or no direct clinical contact just to complete the required documentation ("Documentation in Aged Care," 1997). In contrast, documentation undertaken in acute and rehabilitation settings, funded by the State Government, aims to contribute to individual patient care rather than to determine levels of funding.
Aside from funding, other reasons exist why nursing documentation in long-term care institutions is important. First, by the nature of these institutions, and the limited capitel directed to this practice area, it may be one of the last domains to implement computerized documentation. Second, given the acuity of current patients, any compromise in the amount of nursing time for direct care is to be avoided. It is widely acknowledged that documentation is perceived to take time away from nursing care (Howse & Bailey, 1992; Miller & Pastorino, 1990). Nowhere is this more noteworthy than in long-term care settings where patients tend to have the most complex health care needs (Palmer & Short, 1994). Because of cost constraints, skill mix is diverse and biased toward those who are less highly educated.
Finally, and perhaps most importantly, much of nursing work is unseen. Parker and Gardner (1991) contend that much of nursing practice is invisible from the official, or legal, hospital record, referring to it as the "silence" of nurses' voices. The only "visible" part may be nurses' documented accounts of patient care. However, many health care providers (including many nurses themselves) do not see nursing documentation as important ("Documentation in Aged Care," 1997; FoxUnger, Newell, & Guilbault, 1989; Miller & Pastorino, 1990).
Many nurses believe physicians neither value nor read nursing notes (Howse & Bailey, 1992). Nursing documentation, like other documentation, is often lost or discarded after discharge (Mueth, 2000; Weber, 1991) because nursing care plans, time-consuming to produce and crucial to the nursing process, often do not become part of the permanent record. Nurses often prefer verbal to written communication, and feel uneasy about their written ideas being the subject of scrutiny and criticism (Howse & Bailey, 1992).
DOCUMENTATION: NURSES' GROWING RESPONSIBILITY
Nurses have traditionally gathered and will continue to gather and record patient information as a part of care delivery. However, there is currently an acknowledgment that nurses' responsibilities have gone far beyond this. They collect and document information for medical and administrative staff (Meiner, 1999), and collect and input data into computerized clinical information systems, which provide greater access to all data and the resultant analysis (Mueth, 2000). As a consequence, nurses may then spend even more time than before in what may be called documentation, but which may have little to do directly with patient care (Dawe, WarnockMatheron, & Ross, 1993; Pierpont &Thilgen, 1995).
Nursing documentation has grown markedly, both in breadth and in complexity, in the past decade. An analysis of its scope and the time spent in this activity, especially in the Australian context, is sorely missing. Estimates in the United States indicate nurses spend as much as 60% of their time manually documenting or charting, incorporating the various components of the nursing process (Wîndïe, 1994). Other estimates range from 13.7% to 50% (Adler & Icenhour, 1993; Barry & Gibbons, 1990; Hendrickson, Doddato, & Kovner, 1990; Pabst, Scherubel, & Minnick, 1996; Quist, 1992). To overcome the timeconsuming nature of charting, numerous technologies have been developed to streamline the process (Parker, Wells, Buchanan, & Benjamin, 1994):
* Pre-printed flow sheets or care plans.
* Charting by exception.
* Computerized systems.
Currently, there are several factors influencing the need for and time taken in documenting clinical information. First is clinical pathways, a management tool for documenting best practice patterns along a timeline for a particular group of patients, according to illness or condition (Windle, 1994). It is meant to decrease documentation, but often this is not the case. In fact, some Australian acute care hospitals have created a duplicate charting system by adding documentation related to clinical pathways to their existing system. No work on the use of clinical paths in long-term care institutions in Australia has been published.
In addition, changes to policy have led to a need to formulate better ways of performing tasks integral to the nursing domain. For example, early discharge policies that decrease length of stay have resulted in patients in acute settings having a higher acuity for a greater proportion of their stay. Documentation then becomes more critical, because in the short time patients are in the hospital, more procedures may be undertaken.
Older patients (who currently also form a greater proportion of inpatients in acute settings) generally have more complex health needs than other groups. The more detailed and lengthy admission assessment implies nurses are increasingly likely to be undertaking more documentation. It follows that more detailed discharge documentation will be required. It also implies increased nursing workloads. There is evidence that nurses are completing their documentation after their shifts have ended (Pabst, Scherubel, & Minnick, 1996).
New South Wales is experiencing the same nursing shortage (NSW Health Department, 1996) as the rest of the Western world, with specialist nurses in short supply. Patient acuity and throughput are increasing (Ackley, 1999; Green, 1998; "Survey Reveals Early Warning Signs," 1999). Combined with fewer nurses per patient, there is potentially less time for quality documentation and, more importantly, less time for direct care - especially innovative or creative care.
Some could argue that the greatest time-saving measure would be the fully-computerized electronic medical record, which remains elusive even in the United States (Dorenfest, 1999). Computerized clinical information systems may save time documenting in settings such as intensive care (Butler & Bender, 1999) but there is no evidence this is so in aged care institutions. There are others, however, who believe computers have not altered the amount of time spent in documenting (Pierpont & Thilgen, 1995). Comparable work has not been published in Australia.
THE COMPLEX NEEDS OF OLDERADULTS
Ensuring a continuum of care is critical for older adults. Continuity of care depends on adequate documentation and precise, in-depth documentation demonstrating effective provision and coordination of care (Weiler, 1994). Effective care planning is a challenge. There is considerable evidence that care plans rarely reflect the current state of the patient, or present a record reflecting a patient's experiences through the episode of care (Batehup & Evans, 1992). Longterm care has its own approach to documentation because it covers a wide range of specialties and a multiplicity of severe health problems (Palmer & Short, 1994) with a need for an increasingly more complex knowledge base. This is exacerbated by funding peculiarities in Australia.
Research conducted outside Australia has shown that documentation of older adults' needs is inadequate. For example, Collier and Schirm (1992) found, through interviews with U.S. nurses, there were greater interactions between older adults who were hospitalized and their family members than apparent from documentation. The low rate of family involvement reflected in written records apparently understated the extent of family-focused nursing practice. Of the six forms of written records examined in this U.S. study, medical progress notes contained the most information related to family involvement in the care of hospitalized older adults. Documentation of nursing care was found mainly in the interim nursing notes rather than the permanent record.
In another example, Petrucci, McCormick, and Scheve (1987) found a lack of reference to continence status in patients' notes. Similar findings related to residents' food intake have been reported (Pokrywka et al., 1997). A study of the transfer of nursing home residents to hospital emergency departments found many of the patients were transferred with inadequate documentation (Jones, Dwyer, White, & Firman, 1997). Similarly, though more general, Malek and Olivieri (1996) found insufficient documentation and evaluation of pain assessment and relief (in the form of narcotics). They ask how, without an evaluation, the nurse decides on the frequency of narcotic administration or how nurses on the following shift decide the next intervention. According to Malek and Olivieri (1996),
In the end, the only basis that can be used to analyze nurses' clinical decision-making expertise and fulfillment of their professional role is what has been documented (p. 71).
Further compounding these issues is the increased incidence of cognitive impairment for individuals older than age 80 (usually with Alzheimer's disease) which accounts for approximately 80% of dementia cases among older adults in the United States (Weiler, 1994). As a consequence, their ability to communicate (verbally or non-verbally); physical status (e.g., nutritional needs, sleep patterns, continence status); safety needs; and orientation to person, place, and time (Weiler, 1994) are often affected. These patients have multiple, progressive and irreversible cognitive deficits. Charting must reflect needs, assessments, interventions, and events affecting the patient during the period of time a nurse has been providing care.
Legally, the delivery of care requires informed consent to be made explicit. Individuals with dementia do not automatically lose all decision-making capabilities. Charting, therefore, must document the patient's cognitive status, ability to provide informed consent or refusal of care, and safety needs. Gerontological nurses must differentiate between nursing assessments indicating diminished capacity to perform psychomotor or cognitive function and the legal definition of incompetence in making decisions. Legally, patients with Alzheimer's disease may be judged competent, though incapable of adequately assessing their own health status, the importance of treatment questions, their acute or long-term environment, or their own prognosis (Weiler, 1994).
The major issues confronting documentation of clinical activities in long-term care settings in Australia are:
* The proscriptive nature of federal legislation. While documentation continues to be a major criterion by which an extended care facility is evaluated for Commonwealth funding, excessive use of nurses* time will be required to meet documentation needs.
* Non-standard modes of documentation. Most progress notes are multidisciplinary. Some sites use charting by exception, except for one full written note on the day shift, while other sites chart all shifts,
* Problems maintaining continuum of care. Older adults have multiple episodes of ill health and, therefore, have separate files in multiple sites. Duplication and transfer of clinical information by an increased number of clinicians means significant patient information could be lost in the system.
* Staff skill mix. Extended care facilities, which are for the most part privately run facilities, tend to employ less-qualified (often unqualified), and therefore lower paid, personnel to care for their older residents.
* Complexity of care. Older adults tend to have complex health needs, making clear and concise documentation critical to their care.
* Increased numbers of older patients. The proportion of older adults in Australian society is increasing, with projections that the rate for individuals age 80 and older (2% in 1990) will increase to 2.9% in 2001 and 3.6% in 2002 (Palmer & Short, 1994).
* Increased numbers of patients with dementia. More patients with dementia means more time required to involve patients in their care.
* Non-computerization. Most nursing documentation in this state is still undertaken manually and is likely to be so for some time given the current government's reluctance (or inability) to commit the necessary capital expenditure (NSW Clinical Systems Reference Group, 1996).
Documentation and the transfer of clinical knowledge in long-term care settings outside Australia are fraught with problems and issues that need to be addressed. The same is true within Australia, although a confounding variable here is the imperative to document, given the nexus with funding. Nevertheless, at a time when residents in long-term care facilities are increasingly sicker and more frail and in need of the expert care of nurses at the bedside, nurses cannot be constrained by a documentation system that purports to have been streamlined ("Documentation in Aged Care, "1997).
Clinical pathways, if implemented as a full documentation system, should reduce the amount of documentation required in the acute older adult care setting. However, patients, especially older adults with multiple and complex health needs, rarely fit into predetermined treatment tracks. Such pathways have limited use in long-term care institutions.
The current health care climate requires nurse managers to maintain the quality and quantity of services provided to patients with everdecreasing operational budgets. State government "productivity cuts" achieved during the past 3 years were nothing more than horizontal budget cuts. Staff members are expected to work harder and smarter with fewer resources. Many nurse executives have dealt with the problem through changes to skill mix rather than work redesign, which engenders its own set of questions about documentation.
Work redesign (i.e., the process of analyzing current work activities and redesigning them to decrease duplication and overlap) has the potential to decrease hospital costs by increasing nursing productivity. In addition, and more importantly, work redesign could free valuable time for the "caring" aspects of nursing - the ones valued more highly by patients (Duffield & Lumby, 1994). With nursing shortages again on the horizon, research assessing the level of documentation activities is opportune. Equally noteworthy is the need to determine whether the volume and complexity of the documentation requirements are reflected in measurable quality outcomes of patient care.
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