Journal of Gerontological Nursing

Written and Computerized Care Plans

Jeanette M Daly, RN, PhD; Kathleen Buckwalter, RN, PHD, FAAN; Meridean Maas, RN, PHD, FAAN

Abstract

ORGANIZATIONAL PROCESSES AND EFFECT ON PATIENT OUTCOMES

ABSTRACT

The purpose of this study was to determine how use of a standardized nomenclature for nursing diagnosis and intervention statements on the computerized nursing care plan in a long-term care (LTC) facility would affect patient outcomes, as well as organizational processes and outcomes. An experimental design was used to compare the effects of two methods of documentation: Computer care plan and paper care plan. Twenty participants (10 in each group) were randomly assigned to either group. No statistically significant differences were found by group for demographic data.

Repeated measures ANOVA was computed for each of the study variables with type of care plan, written or computerized, as the independent variable. There were no statistically significant differences between participants, group (care plan), within subjects (across time), or interaction (group and time) effects for the dependent variables: Level of care, activities of daily living, perception of pain, cognitive abilities, number of medications, number of bowel medications, number of constipation episodes, weight, percent of meals eaten, and incidence of alteration in skin integrity. There were significantly more nursing interventions and activities on the computerized care plan, although this care plan took longer to develop at each of the three time periods. Results from this study suggest that use of a computerized plan of care increases the number of documented nursing activities and interventions, but further research is warranted to determine if this potential advantage can be translated into improved patient and organizational outcomes in the long-term care setting.

Abstract

ORGANIZATIONAL PROCESSES AND EFFECT ON PATIENT OUTCOMES

ABSTRACT

The purpose of this study was to determine how use of a standardized nomenclature for nursing diagnosis and intervention statements on the computerized nursing care plan in a long-term care (LTC) facility would affect patient outcomes, as well as organizational processes and outcomes. An experimental design was used to compare the effects of two methods of documentation: Computer care plan and paper care plan. Twenty participants (10 in each group) were randomly assigned to either group. No statistically significant differences were found by group for demographic data.

Repeated measures ANOVA was computed for each of the study variables with type of care plan, written or computerized, as the independent variable. There were no statistically significant differences between participants, group (care plan), within subjects (across time), or interaction (group and time) effects for the dependent variables: Level of care, activities of daily living, perception of pain, cognitive abilities, number of medications, number of bowel medications, number of constipation episodes, weight, percent of meals eaten, and incidence of alteration in skin integrity. There were significantly more nursing interventions and activities on the computerized care plan, although this care plan took longer to develop at each of the three time periods. Results from this study suggest that use of a computerized plan of care increases the number of documented nursing activities and interventions, but further research is warranted to determine if this potential advantage can be translated into improved patient and organizational outcomes in the long-term care setting.

In the current health care environment, with its emphasis on cost containment and optimal use of nurses' time, interventions are being scrutinized related to quality of care at minimal cost. Long-term care (LTC) facilities and hospitals must achieve desired outcomes while operating within a complex and rapidly changing environment. Economic and social forces such as rising health care costs, increasing governmental and regulatory policies, an aging population, and information and technology are influencing changes in health care, including nursing practice (National Commission on Nursing Implementation Project, 1989). Increasingly, the changes focus attention on the nurses' documented clinical decisions, diagnoses, interventions, and outcomes achieved (Hildman & Ferguson, 1992; Krall, Chin, Dworkin, Gabriel, & Wong, 1997).

More than a decade ago, the Secretary's National Commission on Nursing (1989) set forth recommendations related to efficient and effective use of nursing resources. Technology, including the use of computerized information systems, was one mechanism to "increase the RN's productivity to improve use of the RN's skills, while providing appropriate documentation of nursing's contribution to the outcomes of care" (Barry & Gibbons, 1990). Information systems were projected to save 1.5 hours of time per nurse per shift, thus making more nursing time available for direct patient care, which, in turn, should improve patient outcomes. Most importantly, the use of computerized clinical planning and decision-making with standardized nomenclature was expected to enhance the quality of nurses' decisions in making nursing diagnoses and selecting interventions to yield optimal patient outcomes.

Further, because it is licensed professional nursing staff who make the clinical judgments necessary for assessment, diagnosis, intervention, and evaluation of desired outcomes, the use of information technology is especially important in LTC where the ratio of assistive non-licensed staff to licensed nursing staff is large. Ideally, information technology should conserve the limited availability and time of RNs and LPNs for the nursing process and documentation so they can devote more time to implementation of patient care. It should also encourage more thorough assessment and documentation of patient problems. With a computerized information system in place, assessment triggers cannot be ignored, and identified problem areas must be addressed through nursing intervention and evaluation. Further, the computerized information system is not viable without standardized languages, which should make care planning more efficient.

Care plans for residents in LTC are mandated by the U.S. Department of Health and Human Services (DHHS) (USDHHS, 1991) and the steps of th nursing process are written as the individual patient's care plan. The DHHS also mandates a quarterly interdisciplinary team meeting for care plan development and continued evaluation. Proper development and documentation of the care plan is an essential but time consuming task, and one that is facilitated by use of standardized language to convey core issues to other health team members (Iowa Intervention Project, 2000).

Problem and Purpose Statement

The purpose of this study was to determine how use of a standardized nomenclature for nursing diagnosis and intervention statements on the computerized nursing care plan in a LTC facility would affect patient outcomes, as well as organizational processes and outcomes. The following null hypotheses were tested: There will be no differences in

* Patient outcomes (e.g., mobility, independence in activities of daily living, cognitive ability, incidence of alteration in skin integrity, perception of pain, bowel function, nutritional status).

* Organizational processes (e.g., number of nursing diagnoses, interventions, activities documented per patient).

* Organizational outcomes (e.g., nursing time to develop and write a care plan) when using a written versus a computerized care plan.

REVIEW OF LITERATURE

Clinical Decision-making

The nursing care plan was used early in the 1900s as a teaching aid for students. Its format has changed over time, but the purpose of providing current up-to-date information for care remains the same (Ackerly, 1939). The literature assumes the written care plan is effective for all types of patients (Johnson, Stone, Larson, & Hromek, 1992). However, Hildman and Ferguson (1992) noted the written care plan is an effective learning tool for nursing students and new graduates, but not necessary for all nurses to provide high quality care. Detennining appropriate nursing diagnoses and nursing intervention labels are regarded as learning exercises for nursing students. For more experienced nurses, the process becomes automatic and documentation of the nursing process is not necessary.

Contradicting the idea that care planning is for novices, Johnson et al. (1992) stated that application of nursing diagnosis and care planning improves the activities of daily living abilities of LTC residents. However, the application must be accurate to be effective. The authors found that a care plan is necessary for providing direction to caregivers and licensed professionals not only must document the care necessary for each LTC resident, but also convey this information to non-licensed staff who will likely implement the interventions.

Computerized Systems and Decision Supports

Documentation by nurses, including the care plan, takes up to 15% of their work time (Miller & Pastorino, 1990). Streamlining documentation can be performed by using pre-printed, standardized plans or computergenerated care plans (Gwozdz & Del Togno-Armanasco, 1992), with problem lists written in plain language so all involved in the care can understand it (Johnston, 1991).

Pease, Guhde, and Guhde (1991) implemented an automated care planning system in their LTC setting, which contained approximately 1,400 statements of problems, goals, and approaches and allowed for individual input of alternatives. Difficulty using the software programs' language was noted. Powell (1989) found that a computerized format facilitated the recording of the care plan, but a software program that uses standardized language and prompts decisions should do more than facilitate documentation.

According to Simpson (1991), any system that requires nurses to access clinical decision support systems and has reminders to fulfill certain tasks, as well as to account for care over time, will change the nature of the profession. Computerized care plan systems that trigger problems from a standardized assessment, proceed with a listing of potential nursing diagnoses, and continue with potential nursing intervention labels and outcomes will provide support for nurses' decisions and improve practice (Powell, 1989). Thus, a computerized approach should provide more complete and accurate identification of nursing diagnoses and interventions.

Standardized Language

Various problems are evident with current care plan documentation, including the fact that multiple terms are used to describe nursing diagnoses, such as patient "needs" or "wants." Confusion also exists when a nursing problem (i.e., not a patient problem), such as the unavailability of a walker, occurs. Ambiguity emerges when common terms such as "nursing order," "approach," or "treatment" are used to describe the same interventions on the care plan.

Non-standardized care plans are often vague related to diagnoses, for example, using the terms "delirium" and "acute confusion" interchangeably. Specifying the nursing diagnosis as an "alteration in thought process" and describing the etiology in standardized form is expected to increase gerontological nurses' choice of the most appropriate nursing intervention. Nursing experience, expanded knowledge, and critical thinking skills are needed to specify diagnoses and etiologies accurately as well as the best treatments to address them.

Care plans using standardized nursing languages that are computerized have the benefits of organizing knowledge, providing knowledge and decision support, and allowing quicker choices because of the logic that is programmed. Thus, more useful diagnoses and prescribed interventions, as well as more helpful instructions for assisting staff, are enabled by the use of standardized languages (Iowa Intervention Project, 2000).

Bulechek and McCloskey (1990) suggest that if uniform terminology was used for care plans, patient outcomes could be enhanced, nursing knowledge advanced, and nursing practice developed. Among other benefits to using standardized nursing languages in nursing practice, education, and research are that they provide a common frame of reference so nurses in different specialty areas and health care settings can communicate better. For example, Impaired Mobility Level IV (totally dependent) means the same thing in pediatrics, rehabilitation units, orthopedic units, or LTC settings. Thus, standardized terminology for nursing diagnoses and interventions should make written communication easier and more efficient, and increase accountability for patient care (Bulechek & McCloskey, 1990).

DEFINITION OF TERMS

For purposes of this study the Written Care Plan was defined as the usual or routine documentation of the nursing process, specifically problems, goals, interventions, and evaluation. Computerized Care Plan was defined as documentation of the nursing process, specifically problems (i.e., North American Nursing Diagnosis Association [NANDA] nursing diagnoses), goals (not standardized), interventions (i.e., Iowa Intervention Project's classification system), and evaluation.

A nursing diagnosis is defined as "a clinical judgment about individual, family, or community responses to actual and potential health problems and life process" (NANDA, 1996). Currently, there are 128 NANDA nursing diagnoses statements. In a comparison of five studies of nursing diagnosis prevalence among older adults and LTC residents, Hardy, Maas, and Akins (1989) found that nursing diagnoses in the NANDA taxonomy reflected the problems of elderly individuals; NANDA standardized language captured those patient responses to illness that nurses treat. Seven nursing diagnoses were most prevalent:

Figure. A model for quality care in the health care system.

Figure. A model for quality care in the health care system.

* Impaired physical mobility.

* Total self -care deficit.

* Alteration in thought processes.

* Impaired skin integrity.

* Alteration in comfort (e.g., pain).

* Alteration in bowel elimination (e.g., constipation).

* Alteration in nutrition (e.g., less than body requirements).

A nursing intervention is defined as "any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes" (Iowa Intervention Project, 1996). These treatments include direct and indirect care interventions that can be nurse-initiated treatments for nursing diagnoses or physician-initiated treatments for medical diagnoses. To date, more than 440 interventions have been identified. Each has a label, definition, and a set of related activities describing the behaviors of the nurse implementing the intervention, and a short list of background readings. Examples of nursing interventions are Bathing, Cast Care, and Emotional Support (Iowa Intervention Project, 2000). The conceptual framework for the study illustrated the relationships between these concepts.

Conceptual Model for Quality Care in the Health Care System

To identify relevant concepts and their interrelationships, a model for quality care in the health care system that included structure, process, and outcomes was used (Figure) (Brett, 1989; Daly, 1993; Donabedian, 1966; Swearengen, 1997). The patient is the nucleus of the model surrounded by the organization fully encased by all factors of society. The model has three dimensions - structure, process, and outcome. The concept of quality of care flows through the three levels of the model (i.e., patient, organization, society) and across the three dimensions. Mechanisms available for documentation of the care plan are structures specific to this study and include both the written and computer-generated care plan. The patient process was the patient's admission to the health center and permanent residence there.

Patient outcome was defined as "a variable patient or family state, condition, or perception responsive to nursing intervention" (Maas, Johnson, & Kraus, 1996). Patient outcomes identified were mobility, independence in activities of daily living, cognitive ability, incidence of alteration in skin integrity, perception of pain, bowel function, and nutritional status.

The outcome variables for this study were organizational processes, patient outcomes, and organizational outcomes. The specific organizational processes identified were the series of actions in the nursing process involved in care plan development and documentation. The results of this process are the list of nursing diagnoses, interventions, and activity statements tabulated for each participant. The organizational outcomes measured were the ñisrsing time to develop and write a care plan. These outcomes were calculated and compared between the two types of care plans.

INSTRUMENTS

Standardized instruments and objective data were used for data collection. The Index of Independence in Activities of Daily Living (IADL) (Katz & Akpom, 1976), Numerical Rating Scale for Pain (Whitaker & Warfield, 1988), and Mini-Mental State Examination (MMSE) are standardized tests with effective psychometric properties used in previous studies (Folstein, Folstein, & McHugh, 1975: Katz & Akpom, 1976). The remaining data were collected from the patients' medical record: level of care (i.e., complete, partial, minimal), total number medications, number of bowel medications, number of constipation episodes, weight, percent of meals eaten, and decubitus and pressure ulcer measurement.

The IADL scale (Katz & Akpom, 1976) reflects profiles of six functions: bathing, dressing, toileting, continence, ambulation, and feeding. Adequacy of these functions are expressed as a grade summarizing the performance. The end result ranges from independent in all six functions to dependent in all six functions with numerical scores ranging from 0 to 6.

The patient outcome "cognitive ability" was measured by the MMSE, which includes 11 questions focusing on the cognitive aspects of mental functions, such as recall, orientation, and calculation (Folstein, Folstein, & McHugh, 1975). Scores range from 0 to 30.

Table

TABLE 1PATIENT OUTCOME RESULTS BY GROUP PER EACH TIME PERIOD

TABLE 1

PATIENT OUTCOME RESULTS BY GROUP PER EACH TIME PERIOD

The patient outcome "pain" was measured by the Numerical Rating Scale for Pain (Whitaker & Warfield, 1988). The degree of pain is indicated by having the participant choose the number that best represents their pain, with 0 as "no pain" and 10 as "pain as bad as it could be.

The incidence of alteration in skin integrity was noted from the patient's Decubitus/Pressure Ulcer Report form. "Yes" indicated there was a skin alteration, otherwise a score of 0 was given for no alteration. Demographic data were collected at admission along with all other study variables. Every month for the following 6 months, all data were collected except the MMSE, care plan data, and time for care plan development, which were collected by the investigator every 3 months after the care plan meeting.

METHODS

An experimental design was used to compare the effects of two methods of documenting clinical decisions and plans on patient outcomes, organizational processes, and outcomes:

* Group I - computer care plan.

* Group II - paper care plan.

Because contamination of participants' care plans was a potential problem with current residents of the health center, each newly admitted resident who met the study's inclusion criteria was asked to participate. Participants were:

* Age 65 or older.

* A permanent resident in the heakh center.

* A resident for at least 7 months.

If residents were discharged from the health center prior to the end of 7 months, they were no longer considered a participant in the study. After consent to participate was received, residents were randomly assigned to group. The study setting was a Continuing Care Retirement Center (CCRC) with a 48-bed health center licensed for skilled and intermediate care.

An IBM (White Plains, NY) compatible computer was in place at the study site and RNs (n = 4) who were computer literate were given an 8hour training session by the Director of Nursing on the new software package for the care plan and minimum data set assessment. Those RNs (n = 4) who were not computer literate were not instructed in use of the computer so the written care plan could be completed in the usual manner. Nurses were assigned a new patient based on their caseloads. Each primary nurse had 3 to 5 residents and developed their care plans at admission and every 3 months thereafter. Data for this study were collected after each care plan completion, which was within 21 days of admission and every 3 months thereafter. Registered nurse turnover was 16% during the study period (Daly, 1 997). Nurses who worked in the CCRC had a mean length of employment stay of 8 years and had a mean age of 46 years. The nurses were all women. There were no significant demographic differences between nurses in the two groups.

Sample

Over a 30-month period, 30 residents moved into the health center and met inclusion criteria. Ten of those residents admitted to the health center started in the study but were later excluded because of death (» = 4) or discharge (n = 6). No one refused to participate in the study.

The remaining 20 participants were randomly assigned to either Group I or Group II, resulting in 10 residents in each group. Their mean age was 86 years with a range of 74 to 97 years. All participants were White, seven were men, and 13 were women. No statistically significant differences were found by group for age, gender, education, and marital status.

Table

TABLE 2NUMBER OF NURSING DIAGNOSES, INTERVENTIONS, ACTIVITIES, AND TIME IN HOURS FOR CARE PLAN BY GROUP

TABLE 2

NUMBER OF NURSING DIAGNOSES, INTERVENTIONS, ACTIVITIES, AND TIME IN HOURS FOR CARE PLAN BY GROUP

LIMITATIONS

The sample size was only 20 participants for two groups. This small sample size may have influenced the lack of differences on the repeated measures analysis.

RESULTS

Patient Outcomes

Patient outcomes are reported for the sample and then listed by group. There were no significant group differences in terms of patient outcomes (Table 1). Repeated measures ANOVA was computed for each of the study variables with type of care plan as the independent variable. There were no statistically significant differences (p > .05) between subjects group (care plan), with subjects (across time), or interaction (group and time) effects for any of the following dependent variables: level of care, ADLs, perception of pain, cognitive abiliues^ number of medications, number of bowel medications, number of constipation episodes, weight, percent of meals eaten, and incidence of alteration in skin integrity.

Organizational Processes

Number of nursing,» diagnoses, interventions, and activities by group are reported in Table 2. A significant main effect for the experimental (computerized) care plan group (the between subjects factor) was observed for two dependent variables - nursing interventions (p = .001) and activities (p = .007) (Table 3 and 4). No interaction effect was noted for group and time (i.e., pattern for nursing interventions and activities over time was consistent across groups). A nonsignificant main effect of time (within subjects factor) was observed (p > .05).

Table

TABLE 3REPEATED MEASURES ANOVA FOR DEPENDENT VARIABLE AND NUMBER OF NURSING INTERVENTIONS

TABLE 3

REPEATED MEASURES ANOVA FOR DEPENDENT VARIABLE AND NUMBER OF NURSING INTERVENTIONS

Table

TABLE 4REPEATED MEASURES ANOVA FOR DEPENDENT VARIABLE AND NUMBER OF NURSING ACTIVITIES

TABLE 4

REPEATED MEASURES ANOVA FOR DEPENDENT VARIABLE AND NUMBER OF NURSING ACTIVITIES

Table

TABLE 5REPEATED MEASURES ANOVA FOR DEPENDENT VARIABLE AND TIME FOR PREPARING CARE PLAN

TABLE 5

REPEATED MEASURES ANOVA FOR DEPENDENT VARIABLE AND TIME FOR PREPARING CARE PLAN

Organizational Outcomes

A complete breakdown of care plan preparation time by group is provided in Table 2. There was considerable variation in the range of preparation time required across the time periods. Repeated measures ANOVA was computed for all preparation time factors. A statistically significant finding for three dependent variables (preparation time [p = .002], other time ip = .003], and total time [p = .000]) was noted for the between-subjects factor. Thus, it took longer at every time period to produce the computerized care plan, although preparation time for the computerized care plans decreased over the three times periods measured.

A significant within-subjects factor (p = .01) was noted for all four time variables (i.e., preparation time, care plan writing time, other time for care plan, total care plan time). No significant interaction effects were observed for group and time (see Tables 5, 6, 7, and 8 for these ANOVA results).

DISCUSSION AND NURSING IMPLICATIONS

The purpose of this study was to examine the effects of two types of care plans - written and computerized - on patient outcomes, organizational outcomes, and processes. Findings are discussed according to these outcomes.

Patient Outcomes

The null hypothesis that there would be no difference in patient outcomes when using a written care plan or computerized care plan was upheld. That is, regardless of how the care plan was written, patient outcomes were not affected. Patients received similar care and outcomes did not change by type of care plan. Standardized language, for the computerized care plan also did not affect patient outcomes. However, the more comprehensive nature of the plan of care suggests that the use of standardized language made the nurses who were writing the care plans aware of all nursing diagnoses and interventions used for their specific patient plan of care (Hawes, et al., 1997).

The patient's plan of care is established based on patient assessment documented on the Minimum Data Set (MDS). If patient outcomes are not affected by the plan of care, other factors may be influencing the quality of care for residents in LTC. Investigation of these factors, as well as the overall value of the care plan, is necessary to determine their effect on patient outcomes. Those factors could include: staffing pattern, length of employment for nursing personnel, administration tolerance of abuse, nurse aid assignment forms, and staff attendance at shift report In addition, future research may expand the list of patient outcomes evaluated, and include a broader range of nurse-sensitive outcomes, as well as those primarily influenced by other disciplines or services such as social work, dietary, and activity therapy.

Organizational Processes

The null hypothesis that there would be no difference in organizational processes when using a written care plan or computerized care plan was not supported. Nursing diagnoses by group were similar with only two to three more nursing diagnoses in the computerized group than the written care plan group. However, nursing interventions and activities were substantially different by group.

Nurses who used the computer wrote Nursing Interventions Classification (NIC) interventions and highlighted each NIC activity relevant to the care plan under preparation; whereas nurses who hand wrote the care plan only listed a few activities. According to data supplied to investigators by the Director of Nursing at the study site, nurses in the written care plan group did not list everything done for the patient, unlike nurses who used the computerized care plan. The NIC activities are comprehensive for each intervention. Thus, only the individualized relevant activities would be trans-, ferred to the nurse aid assignment form. For example, patients may prefer to wear a hospital gown to sleep in rather than their own personal gown.

According to Simpson (1991), a more complete number of nursing diagnoses and recording of nursing interventions are likely to be effected by computerization. This assertion was partially supported by this study, where the average number of nursing interventions and activities (but not diagnoses) documented per patient was significantly greater for the computerized care plan group. Also, having a more thorough care plan should provide all the disciplines (e.g., activities, dietary, social work), as well as the family, with a more comprehensive list of the resident's problems and, thus, the potential opportunity to conduct more relevant interventions for the resident. This assumption requires further testing related to application of the care plan by ancillary care providers and family members.

Table

TABLE 6REPEATED MEASURES ANOVA FOR DEPENDENT VARIABLE AND TIME WRITING CARE PLAN

TABLE 6

REPEATED MEASURES ANOVA FOR DEPENDENT VARIABLE AND TIME WRITING CARE PLAN

Table

TABLE 7REPEATED MEASURES ANOVA FOR DEPENDENT VARIABLE AND OTHER TIME FOR CARE PLAN

TABLE 7

REPEATED MEASURES ANOVA FOR DEPENDENT VARIABLE AND OTHER TIME FOR CARE PLAN

Table

TABLE 8REPEATED MEASURES ANOVA FOR DEPENDENT VARIABLE AND TOTAL CARE PLAN TIME

TABLE 8

REPEATED MEASURES ANOVA FOR DEPENDENT VARIABLE AND TOTAL CARE PLAN TIME

Organizational Outcomes

Study results revealed there was a significant difference in preparation (Table 5) and writing time (Table 6) between the two care plan documentation methods. Use of the computer did not save care plan preparation time or actual writing time. The difference was most pronounced for preparation time, and "other" time (chiefly data gathering for MDS and care plan use), which may reflect lack of staff familiarity with the computer.

As noted earlier, nurses who wrote care plans by hand did not list all interventions or activities pertinent to a particular patient's plan of care. For example, if Impaired Mobility was a nursing diagnosis on the written care plan, the activities listed may be "walk the patient twice daily," and "up in the chair TID." The computerized care plan, on the other hand, would list the intervention "Exercise Therapy: Ambulation and Positioning" and highlight a large number of activities to complete this intervention.

Because nurses who hand wrote the care plan did not include all activities performed for the patient, their writing rime was diminished regardless of the number of the activities completed for residents. That is, although the written plan of care required less time to develop compared to the computerized care plan, it was less comprehensive (Table 2). Tune 1 was the longest total time for both groups and took 7.6 hours for the computerized care plan group. Over time, though, the total time for care plan development decreased and after learning the software program the total care plan time may continue to decline.

This study was completed in a CCRC where each full time nurse on the day or evening shift was expected to carry a caseload of residents, complete MDS assessments, and develop care plans as a primary care nurse would do. This particular institution provided in the work schedule 8-hour shifts for each nurse as necessary to complete their paperwork. For example, in a 1 -month period one nurse may have 8 hours of the scheduled 160 as a "paper day."

This approach is different from other nursing homes that may have one nurse complete the MDS and care plan for all residents, but who is not working on the floor, as were the nurses in this study. The MDS assessment and care planning are time consuming activities, and facilities need to allot appropriate time to complete this work. Moreover, after the paperwork has been completed, additional time and effort must be given to implementation of the appropriate nursing interventions identified.

The Nursing Commission on Nursing Implementation Project (1989) suggested information systems could save 1.5 hours of time per nurse per shift, and the time saved would enhance productivity because nurses could spend more time with patients, resulting in improved outcomes. This study found nurses' care plan preparation and writing time was reduced over time in both the handwritten and computerized groups when a care plan had been developed. Thereafter, less time was spent on that plan of care. In contrast to the National Commission assumption, however, the patient outcomes measured in this study were not effected by this time savings.

CONCLUSION

In comparing residents who had their care plans written or computer generated, results of this study suggest that the computer-generated care plans yielded more nursing interventions (22 versus 9) and activities (235 versus 29). Nurses who prepared the computerized care plan and presented it at the interdisciplinary conference had developed a more thorough care plan than those who had written a care plan by hand. However, the type of care plan, written or computerized, had no impact on patient outcomes, which is the variable of most interest and relevance in terms of improved quality of care.

As noted earlier, care plans are mandated by law for all patients residing in LTC facilities. Annual survey reviews intensively evaluate the written care plan and its follow-through for patient care. Paper compliance is a given, but follow-through by staff is not. Nurses and nursing assistants often do not know what is written for each resident on their individualized plan of care.

In some LTC facilities, a "care plan nurse" writes all the plans, but may not educate the staff on implementing the recommended interventions. Thus, future research in this area should investigate the extent to which activities and interventions listed on the plans of care are actually implemented for each resident, by nurses as well as ancillary (e.g., dietary, social work) staff.

Subsequent studies should also determine if time differences in preparation of written versus computerized care plans diminish as nurses in LTC settings become more "computer capable" and accustomed to using available software packages. The care plan is here to stay and is mandated by law, but results from this study suggest that type of care plan (computerized versus hand written) had no effect on parient care. To be effective, interventions on the care plan need to be conveyed to the frontline staff who, in turn, must implement the interventions in order to affect patient outcomes and provide quality patient care.

Results from this study also suggest use of a computerized plan of care increases the number of documented nursing activities and interventions. Further research is warranted to determine if this potential advantage can be translated into improved patient and organizational outcomes in LTC. Indeed, more detailed and comprehensive plans of care and increased numbers of recommended activities and interventions are only important if they affect, in some meaningful way, the quality of resident care and influence outcomes important to this population.

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TABLE 1

PATIENT OUTCOME RESULTS BY GROUP PER EACH TIME PERIOD

TABLE 2

NUMBER OF NURSING DIAGNOSES, INTERVENTIONS, ACTIVITIES, AND TIME IN HOURS FOR CARE PLAN BY GROUP

TABLE 3

REPEATED MEASURES ANOVA FOR DEPENDENT VARIABLE AND NUMBER OF NURSING INTERVENTIONS

TABLE 4

REPEATED MEASURES ANOVA FOR DEPENDENT VARIABLE AND NUMBER OF NURSING ACTIVITIES

TABLE 5

REPEATED MEASURES ANOVA FOR DEPENDENT VARIABLE AND TIME FOR PREPARING CARE PLAN

TABLE 6

REPEATED MEASURES ANOVA FOR DEPENDENT VARIABLE AND TIME WRITING CARE PLAN

TABLE 7

REPEATED MEASURES ANOVA FOR DEPENDENT VARIABLE AND OTHER TIME FOR CARE PLAN

TABLE 8

REPEATED MEASURES ANOVA FOR DEPENDENT VARIABLE AND TOTAL CARE PLAN TIME

10.3928/0098-9134-20020901-05

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