Introducing Standardized Care Plans as a New Recording Tool in Municipal Healthcare

Elisabeth Ostensen, Nicholas Hardiker, Line K. Bragstad, Ragnhild Helleso

Research output: Contribution to journalArticle

Abstract

Aims and Objectives: To explore how nurses use standardized care plans as a new recording tool in municipal healthcare, and to identify their thoughts and opinions.

Background: In spite of being an important information source for nurses, care plans have repeatedly been found unsatisfactory. Structuring and coding information through standardized care plans, is expected to raise the quality of recorded information, improve overviews, support evidence-based practice, and facilitate data aggregation. Previous research on this topic has mostly focused on the hospital setting. There is a lack of knowledge on how standardized care plans are used as a recording tool in the municipal healthcare setting.

Design; An exploratory design with a qualitative approach using three qualitative methods of data collection. The study complied with the Consolidated Criteria for Reporting Qualitative Research.

Methods; Empirical data were collected in three Norwegian municipalities through participant observation and individual interviews with 17 registered nurses. In addition, we collected nursing records from 20 electronic patient records.

Results: Use of standardized care plans was influenced by the nurses’ consideration of their benefits. Partial implementation created an opportunity for non-use. There was no consensus regarding how much information to include, and the standardized care plans could become both short and generic, and long and comprehensive. The themes “balancing between the old and the new care planning system,” “considering the usefulness of standardized care plans as a source of information,” and “balancing between overview and detail” reflect these findings.

Conclusions: Nurses’ use of standardized care plans was influenced by the plans’ partial implementation, their views on usefulness, and their personal views on the detail required in a care plan. Relevance to Clinical Practice: The structuring of nursing records is a fast-growing trend in healthcare. This study gives valuable information for those attempting to implement such structures in municipal healthcare.
Original languageEnglish
Number of pages12
JournalJournal of Clinical Nursing
Early online date29 May 2020
DOIs
Publication statusE-pub ahead of print - 29 May 2020

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