Journal of Advanced Nursing, 1999, 29(6), 1462±1473 Issues and innovations in nursing practice

Review of nursing documentation in nursing

home wards Ð changes after intervention
for individualized care
GoÈrel Hansebo RNT BSc
Doctoral Student, Department of Clinical Neuroscience and Family Medicine,
Division of Geriatric Medicine, Karolinska Institute, Stockholm, Sweden

Mona Kihlgren RN PhD

Associate Professor, Centre for Caring Sciences, OÈrebro Medical Centre
Hospital, OÈrebro, Sweden

and Gunnar Ljunggren MD PhD

Researcher, Department of Clinical Neuroscience and Family Medicine,
Division of Geriatric Medicine, Karolinska Institute, Stockholm, Sweden

Accepted for publication 20 July 1998

HANSEBO G., KIHLGREN M. & LJUNGGREN G. (1999) Journal of Advanced Nursing

29(6), 1462±1473
Review of nursing documentation in nursing home wards Ð changes after
intervention for individualized care
Using standardized assessment instruments may help staff identify needs,
problems and resources which could be a basis for nursing care, and facilitate
and improve the quality of documentation. The Resident Assessment Instru-
ment/Minimum Data Set (RAI/MDS) especially developed for the care of elderly
people, was used as a basis for individualized and documented nursing care.
This study was carried out to compare nursing documentation in three nursing
home wards in Sweden, before and after a one-year period of supervised
intervention. The review of documentation focused on structure and content in
both nursing care plans and daily notes. The greatest change seen after
intervention was the writing of care plans for the individual patients. Daily
notes increased both in total and within parts of the nursing process used, but
re¯ected mostly temporary situations. Even though the documentation of
nursing care increased the most, it was the theme medical treatment which was
the most extensive overall. A difference was seen between computer-triggered
Resident Assessment Protocol (RAP) items, obtained from the RAI/MDS
assessments, and items in the nursing care plans; the former could be regarded
as a means of quality assurance and of making staff aware of the need for further
discussions. The RAI/MDS instrument seems to be a useful tool for the dynamic
process in nursing care delivered and as a basis for documentation. The
documentation should communicate a patient's situation and progress, and if

Correspondence: GoÈrel Hansebo, Department of Nursing, M98,

Karolinska Institute, Huddinge University Hospital,
S-14186 Huddinge, Sweden. E-mail: gorel.hansebo@cnsf.ki.se

1462 Ó 1999 Blackwell Science Ltd

 Issues and innovations in nursing practice Nursing documentation

staff are to be able to use it in their everyday nursing care activity, it must be
well-structured and freely available. The importance of continuing education
and supervision in nursing documentation for development of a reliable source
of information was con®rmed by the present study.

Keywords: assessment instrument, care planning, documentation,

elderly care, nursing process, supervision

the collaboration of health professionals. Fonteyn &

INTRODUCTION
The registered nurse (RN) has in her function a special
responsibility for the nursing care of the patient, including
documentation as a part of quality assurance (BjoÈrvell
1992). Documentation is an essential and integrated part
of nursing care and cannot be separated from its use in
practice (McElroy et al. 1995). It is a signi®cant part of
nursing information, a tool for communication between
1 caregivers (Morrissey-Ross 1988), and it has been empha-
sized in nursing research and development (Goodman
1992). Staff awareness of the legal obligation for nursing
documentation (In Sweden: SFS 1985 p. 562, SOSFS
2 1993a p. 9, 1993b p. 17, 1993c p. 20) has increased during
recent years and its importance for the safety, continuity
and quality of patient nursing care has been stressed
(Ehrenberg et al. 1996). In spite of this knowledge, the
motivation for RN to carry out nursing documentation in
an appropriate way may sometimes be low. In a study by
Renfroe et al. (1990) it was shown that the attitudes of
others, especially in¯uential people, could affect the
intention to document. Inappropriate documentation
could be related to negative attitudes and a perceived
lack of support from nurse managers (Yassin & Watkins
1993, McElroy et al. 1995). Other reasons for resistance
towards documentation may be that RN themselves do not
see the point of the documentation, nor its value (Edel-
stein 1990), coupled with the complexity of the docu-
mentation system and lack of time for its completion (Ron
& Bar-Tal 1993). Furthermore, factors such as low levels of
con®dence about expressing oneself in writing and dif®-
culty in articulating the nature of nursing practice, may
also in¯uence documentation practices (Howse & Bailey
1992). Parker & Gardiner (1992) stress the tendency to take
much of what staff do for granted, and practices that are
taken for granted are by de®nition invisible and, as a
consequence, not documented.
The nursing process is usually used both in nursing
practice and as a structure for documentation forms.
However, studies show differing opinions about the use of
the process concept. Yura & Walsh (1988) describe the
process as an open model, which permits a dynamic
approach to nursing care. Henderson (1982) argues that
the nursing process ignores the subjective or intuitive
aspects of nursing care and that the process undermines
Cooper (1994) have questioned the usefulness of the
nursing process in written documentation. Sutcliffe (1990)
and Fitzpatrick et al. (1992), having reviewed the litera-
ture, claim that the process is a decision-making or
problem-solving approach to individualized nursing care,
a vehicle for improving its quality. Furthermore, the
process promotes a holistic as well as a scienti®c
approach, and it involves critical thinking and systematic
methods; however, it is only a tool.
3 BjoÈrvell & Emlen (1994) have shown that nursing
documentation in nursing homes has been incomplete
and not possible to use as a basis for individualized care or
in a nursing audit. Nursing records did not adequately
re¯ect patients' situations or the work done by staff.
Furthermore, Hale et al. (1997) have shown that nursing
records were of very limited use as a source of secondary
data when patient outcomes were correlated with nursing
interventions.
Assessment, as the ®rst part of the nursing process, is
very important for care planning. Staff need to be more
aware of the importance of making more speci®c, indi-
vidual assessments as a basis for nursing care (Davis et al.
1994). Sutcliffe (1990) claims that poor assessment leads
to poor care planning and implementation. An assessment
instrument, the Resident Assessment Instrument/Mini-
mum Data Set, RAI/MDS, is a multidimensional instru-
ment specially developed for the care of elderly people
(Morris et al. 1990). The instrument, further described by
Hansebo et al. (1998), has several purposes but the main
one is its use as a basis for individualized care. The
instrument is a tool that gives a comprehensive and
standardized assessment of the patient's physical, psy-
chological and psycho-social status. Using standardized
assessment instruments may help staff to identify needs,
problems and resources which could in¯uence the process
of care planning. An intervention study on implementing
the RAI/MDS was carried out for one year. From answers
to a questionnaire reported earlier from the main study, a
majority of staff who had used the RAI/MDS thought it
could contribute to improving documentation in nursing
care plans and by that the quality of their care delivered
(Hansebo et al. 1998). Thus it seemed important to further
study the nursing documentation before as well as after
the intervention.

Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(6), 1462±1473 1463
G. Hansebo et al.
The purpose of the present study was to compare the
content of nursing care documentation in nursing home
wards before and after one year of intervention with
supervision aimed at individualized and documented care.
THE STUDY
Methods
Intervention wards
The study was carried-out in three nursing home wards at
different locations in Sweden. These wards expressed an
interest in implementing individualized care with the RAI/
MDS tool. They were traditionally staffed, at NH1 with 0á56
per bed, at NH2 with 0á76 per bed and at NH3 with 0á80 per
bed (all excluding night staff). The staff characteristics have
been further described by Hansebo et al. (1998). NH1
housed patients with multidiagnoses, including dementia
disorders. NH2 housed patients with dementia and NH3,
patients with dementia who had disturbing behaviour.
Numbers and characteristics of the patients at the start of the
study are shown in Table 1. Even though some of the
patients died or were discharged and others were admitted
into the nursing home wards during the intervention
period, the characteristics of the patients were similar.
Intervention
The one-year intervention, with the implementation of
individualized and documented care using the RAI/MDS
as a basis, started with changing the ward organization
into caring teams. There were three teams at NH1 and four
teams at both NH2 and NH3. A registered nurse (RN), with
the primary obligation, was the leader and coordinator of a
team of 3±4 enrolled RN or nursing aides. Each caring
team was responsible for a group of 7±8 patients and was
on duty during the day on weekdays. A contact person
was chosen for each patient. This implied a responsibility
for the patient's care from the viewpoint of professional
Table 1 Data on patients of the three groups at the start of the study
NH1, n = 21
Gender: male/female % 17/83
Age: mean (range) 83 (66±97)
Length of stay: days (range) 630 (8±2164)
Mean ADL-sum* (range) 12 (4±18)
CPS level  0±1 24
% 2±3 29
4±6 47
*De®ned from the RAI/MDS as physical function performance, in bed mobility, eating transfer, toilet use with a sum from 4
(independent)±18 (total dependent).
De®ned from the incorporated cognitive performance scale (CPS) in the RAI/MDS as level 0±1 = intact±borderline, level 2±3 = mild
impairment±moderate impairment, level 4±6 = moderately severe impairment±very severe impairment.
1464 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(6), 1462±1473
competence of the contact-person, including participation
in assessment and care planning.
All staff in the three nursing home wards were ®rst
trained in using the RAI/MDS. Each team was then
separately supervised by the ®rst author for two hours
once a month during the intervention year. The nursing
process (assessing, planning, implementing, evaluating)
(Yura & Walsh 1988) provided the pattern of the super-
vision, with RAI/MDS the basis for assessments. Nursing
diagnoses were not used, as staff were unfamiliar with that
concept and therefore did not want to use it. Instead, the
focus was on patient situations, which were described as
patients' problems, needs and resources. One of the
guiding principles of the caring team, when planning for
the individual, was to involve him- or herself, the relatives
and everyone in the caring team. It was seen as important
that knowledge about the patient was in focus and that
everyone in the caring team was familiar with care
planning for the individual. Since the caring team func-
tioned as a team only during the day, it was important that
all staff were informed about what was planned. Docu-
mentation was carried out using the existing documenta-
tion systems of the wards.
Documentation
The three wards used different handwritten documenta-
tion systems, all structured from the nursing process (in
daily notes only: patient situation, implementation and
evaluation). Before the intervention, patients' nursing care
documentation consisted of assessments of only some
patients and handwritten daily notes. After the interven-
tion, the documentation consisted of, in addition to daily
notes, assessments by RAI/MDS and nursing care plans.
The daily notes were reviewed retrospectively from the
month before the intervention. Afterwards, nursing care
plans were reviewed as were daily notes from the month
after the intervention. Only RNs documented nursing care
before the intervention, in contrast to afterwards when
NH2, n = 23 NH3, n = 14
20/80 50/50
81 (69±93) 78 (68±92)
845 (7±5943) 943 (10±4981)
13 (4±18) 9 (4±14)
40 0
8 29
52 71
Issues and innovations in nursing practice
contact-persons participated in the documentation of
nursing care plans.
Ethical considerations
The study was approved by the Regional Research Ethical
Committe of the Karolinska Institute, Stockholm, Sweden
(multicentre study, 94:314).
Data analysis
Daily notes
The nursing documentation was read through several
times to obtain an understanding of the content, and to
see if the documentation followed the form and structure
of the nursing process. A tendency was seen that daily
notes were often written without this consideration. The
®rst part of the analysis was therefore to label the text with
`patient situation', `implementation' and `evaluation',
respectively. The second was to classify the content within
each part of the process. A coding schedule was created for
this classi®cation, based mainly on the RAI/MDS section
titles, items and de®nitions, but supplemented with a few
items (pain, rest/sleep, breathing/circulation) which were
key words from the VIPS (Well-being, Integrity, Prevention
and Security) documentation model, used in many places
in Sweden (Ehnfors et al. 1991). Furthermore, items from
the coding schedule used by FuraÊker & Sandman (1995)
(temperature, medical problems) were added to make it
possible to include the total content of the material.
`Patient situations' dealt with needs and problems as seen
in Table 3. Within `implementations and evaluations' the
themes nursing care, medical treatment, examination/
bandaging and consultations became obvious. Medical
treatment concerned medication given, and examinations
could involve teeth, hearing, vision or X-ray. `Consulta-
tion' concerned phone contact or referral to physician,
dietician, physical or occupational therapist.
Nursing care plans
The nursing care plans were analysed from the nursing
process as structured in the documentation model used by
the wards, i.e. `patient situation' (including needs, prob-
lems and resources), `goal, implementation', and `evalua-
tion'. The same coding scedule as for the daily notes was
used for analysing the content and the same themes were
distinguished. In contrast to the daily notes, it was
possible here to follow the process and it was therefore
easier to analyse.
Statistics
The number of items from the coding schedule, themes
and different parts of the nursing process, were manually
counted in daily notes and nursing care plans, respective-
ly. Triggered Resident Assessment Protocols (RAPs) were
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(6), 1462±1473
Nursing documentation
also manually counted. Mean values were calculated as
number per patient (Tables 2, 4a±d), and the results before
and after the intervention were compared. Changes are
also shown as percentages (Table 2).
Co-assessment
A random sample of 12 out of 57 nursing care plans
together with daily notes from the same patients were
rated independently by a RN after she had been trained in
the coding procedure. To measure agreement between the
RN and the author, the Pearson correlation analysis was
used. The correlations (r) varied between 0á653 and 1á0. A
total of 75% of the correlations had a r-value ³ 0á90 in
nursing care plans and 66% in daily notes.
The Resident Assessment Protocols (RAPs)
In addition to RAI/MDS, the RAI system also consists of
the Resident Assessment Protocols (RAPs) seen in
Table 5. Each RAP speci®es triggering factors that identify
potential problems (Morris et al. 1991). The triggers refer
to information obtained from particular RAI/MDS items or
combinations of items. It is possible that triggered condi-
tions do not give cause for nursing care interventions, but
a triggered condition may require further discussion to
make it possible to con®rm whether a problem actually
exists or not. Even if the RAPs were not used or included
in training during the intervention in the present study, it
became important after the analysis to compare the
documented items in nursing care plans with triggered
RAP items. To obtain RAP triggered items, a computerized
¯ow chart program was used, based on assessment
variables. Owing to the inclusion of the RAP items, the
coding scedule was supplemented with `dehydration',
`psychopharmacological drugs' and `physical restraints',
and other items were separated (communication and
vision, mood and behaviour). Another coding of the
nursing care plans was then made allowing an individual
comparison with triggered RAPs to be made.
RESULTS
In total, there were 361 daily notes on 58 patients during
the month before the intervention and 504 daily notes and
nursing care plans on 57 patients during the month
afterwards.
Daily notes
The daily notes increased by 42% after intervention, and
the documentation as a whole within the daily notes also
increased (Table 2). NH1 showed the greatest change, but
the highest number of daily notes both before and after-
wards was seen in NH2 (Table 2). `Patient situations'
increased by 63%, `implementations' by 61% and `eval-
uations' by 100%. The theme `nursing care' demonstrated
1465
 G. Hansebo et al.

Table 2 Mean value of number of notes, parts of the nursing process and themes per patient, before and after the intervention and changes in the wards, respectively and in total a strong increase, which was most prominent in NH1, but

% change
was however about the same per patient in the three
nursing home wards after the intervention. `Medical

101
101
114
134
111
295

94
88
61
19
63
42
treatment', however, was the biggest theme of all docu-
change mented implementations. It increased after intervention,
except in NH2 where a 26% decrease was seen. As for

2á40
0á16
0á15
0á91
1á18
3á18
0á51
0á23
0á76
1á68
3á16
2á62
`evaluation', about the same increase could be seen as for
`nursing care' and `medical treatment'. Despite the
after

4á79
0á33
0á32
1á82
2á32
8á37
0á89
0á44
4á79
2á25
8á21
8á84

increase in evaluations, it only represented half of the

57

implementations (Table 2). The language was poor and

% change before

did not specify or re¯ect the effect of a certain implemen-

2á39
0á17
0á17
0á91
1á14
5á19
0á38
0á21
Total

4á03
0á57
5á05
6á22

tation. Individual nursing care was seldom re¯ected upon.

58

Table 3 shows documented items within patient situa-

tions. In daily notes, `continence/elimination' and `mood/
behaviour' dominated before as well as after the interven-

202
111
342

77
51
71
56
46

)28
79
36

)52

tion.
change

1á99
0á14
0á15

0á43
)0á08
1á50
3á56
0á36
1á64
1á71
3á65
2á14

Nursing care plans

4á57
0á21
0á21
1á29
2á86
8á56
1á00
0á14
5á21
2á21
8á29
8á14

`Patient situations' (needs, problems and resources) in

after

14

nursing care plans were dominated by `cognition', `com-

munication', `physical function' and `continence/elimina-
% change before

2á58
0á07
0á29
0á86
1á36
5á00
0á64
0á29
3á57
0á50
4á64
6á00
NH3

tion' (Table 3). When comparing the three wards, NH1

14

differed from the others with less items of cognition and

communication (Table 4a). Table 4a shows items within
patient situation, with mean value of 12 per patient and
269
409
209

86
187

60
84
78
13
24
16

)26

NH3 having the highest sum (18).

`Goals' differed between the wards, with the highest
change

number per patient seen in NH1 (Table 4b). They were

2á74
0á21
0á35
1á02
1á16
1á07
0á90
0á46
1á46
1á84

)1á75
1á44

sometimes broadly formulated, and comprised more than

one need, problem or resource. Within `implementations'
5á92
0á56
10á48

0á48
2á24
2á64
9á12
1á12
0á68
5á08
2á24
9á36
after

and `evaluations', nursing care was the dominating theme,

25

and was most prominent in NH3 (Table 4c,d). Sixty-eight

change % change before

per cent of the `implementations' in nursing care plans

3á18
0á35
0á13
1á22
1á48
8á05
0á22
0á22
6á83
0á78
7á52
9á04
NH2

23

including medical treatment were `evaluated', and here

NH3 dominated.
137
120
169
132
222
136
205
500
150
116

21
32

Nursing care plans compared with RAPs

When comparing individually triggered RAPs with the
1á96
0á06
0á03
1á05
0á82
4á86
0á12
0á19
2á65
1á90
6á56 3á94
7á11 3á82

items in a nursing care plan for the patient in question

(n ˆ 57), a disparity was found. Of the RAP items
3á39
0á11
0á17
1á67
1á44
7á05
0á50
0á33
3á94
2á28
after

triggered, 52% were not documented in nursing care

18

plans (Table 5). `Falls', `dehydration', `psychopharmaco-

before

1á43
0á05
0á14
0á62
0á62
2á19
0á38
0á14
1á29
0á38
Number of patient situations 2á62
3á29
NH1

logical drugs' and `physical restraints' were not represent-

21

ed at all. Furthermore, there were items in the nursing care

Number of implementations

plans of an individual, which were not triggered or did not

Investigation/bandaging
Investigation/bandaging

appear in the RAPs (Table 5). This was most obvious in

Number of evaluations
Number of daily notes

`communication', `pressure ulcers', `psychosocial wellbe-

Medical treatment
Medical treatment

ing' and `activities'.

In total, NH3 showed the smallest difference between
Nursing care
Nursing care

Consultings
Consultings

Total mean
Total mean

triggered RAP items and nursing care plans. Also, in

Patients (n)

summary from all nursing care plans, NH3 also showed

the most comprehensive documentation, if goals are
disregarded.

1466 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(6), 1462±1473
Issues and innovations in nursing practice Nursing documentation

Table 3 Documented items within patient situation, in daily notes and nursing care plans in total from the three wards, number (n) and
percent

Daily notes Nursing care plans

Before After After

Patient situation n % n % n %

Cognition 1 0 0 0 102 14
Communication 0 0 0 0 113 16
Physical function 2 1 4 1 173 25
Continence/elimination 67 23 78 17 91 13
Psycho/social wellbeing 2 1 10 2 26 4
Mood/behaviour 75 26 94 20 40 6
Activities 13 4 15 3 39 6
Falls 10 3 15 3 0 0
Nutrition 1 0 18 4 43 6
Oral/dental care 3 1 10 2 11 2
Skin/mucous membrane 23 8 43 9 43 6
Pain 25 9 49 10 5 1
Breathing/circulation 16 5 39 8 3 0
Sleep/rest 42 14 38 8 0 0
Temperature 8 3 24 5 0 0
Night needs 0 0 0 0 14 2
Medical problem 5 2 15 3 0 0
Miscellaneous 0 0 16 3 0 0

Sum 293 100 468 100 703 100

order to see to what extent the different parts were

DISCUSSION
Nursing care documentation in three nursing home wards
was investigated before and after one-year of supervision
using the RAI/MDS (Morris et al. 1990) for the implemen-
tation of individualized and documented care. The main
change after the intervention was that a nursing care plan
was written for all patients, with assessment by the RAI/
MDS as a basis. Dominating items in the nursing care
plans concerned `cognition', `communication', `physical
function' and `continence/elimination'. Daily notes in-
creased, both in total number and within all steps in the
nursing process. The content showed a dominance of
`continence/elimination' and `mood/behaviour' before as
well as after the intervention. The theme `nursing care'
increased the most, but medical treatment was still the
dominating theme in the implementations. Though eval-
uations increased by 100%, they only represented half of
the implementations. Differences were seen between the
three wards, both in nursing care plans and in daily notes.
The nursing documentation reviewed consisted of the
total number of patient records during selected periods,
thereby to enable reliable information about nursing
documentation in the three nursing home wards to be
obtained. One month was seen as an appropriate time
period. The nursing process was used in the analysis in
documented. A coding schedule was developed from
section titles, items and de®nitions in the RAI/MDS and
supplemented with items from coding schedules used by
other researchers. This enabled the inclusion of all mate-
rial from the nursing care plans as well as from the daily
notes. The comparison between documented items from
individual nursing care plans and computerized individ-
ually triggered RAP items, could be seen as a means of
quality assurance. A disparity was found, but triggered
RAPs could be a way to make staff aware of the need for
further discussion about triggered problems or to clarify if
additional assessments were necessary.
It could not be proved by means of a retrospective
analysis of documented nursing care, whether this nurs-
ing care had been delivered or not. It was also dif®cult to
evaluate if the documentation in nursing care plans and
daily notes had been adequate under the prevailing
patient conditions. The review carried out by the ®rst
author was in high agreement with the coassessor, so it
must be considered as reliable. The intervention was
performed in the same way and by the same person (the
®rst author) in the three wards, but because of the
differences between the wards, it seemed important in
the analysis to take into consideration the result from each
ward separately. Generalizations about the ®ndings can

Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(6), 1462±1473 1467
G. Hansebo et al.

Table 4. a. Items within patient situation, number (n) and mean value per patient in nursing care plans, in the wards respectively and
in total. b. Items within goal, number (n) and mean value per patient in nursing care plans, in the wards respectively and in total. c.
Items of nursing care and medical treatment within implementation, number (n) and mean value per patient in nursing care plans, in
the wards respectively and in total. d. Items of nursing care and medical treatment within evaluation, number (n) and mean value per
patient in nursing care plans, in the wards respectively and in total

NH1 NH2 NH3 Total

18 patients 25 patients 14 patients 57 patients

n per pat n per pat n per pat n per pat

(a) Patient situation

Cognition 9 0á5 56 2á2 37 2á6 102 1á8
Communication 12 0á7 58 2á3 43 3á1 113 2á0
Physical function 33 1á8 79 3á2 61 4á4 173 3á0
Continence/elimination 23 1á3 34 1á4 34 2á4 91 1á6
Psycho/social wellbeing 2 0á1 16 0á6 8 0á6 26 0á5
Mood/behaviour 2 0á1 19 0á8 19 1á4 40 0á7
Activities 8 0á4 16 0á6 15 1á1 39 0á7
Nutrition 18 1á0 13 0á5 12 0á9 43 0á8
Oral/dental care 2 0á1 5 0á2 4 0á3 11 0á2
Skin/mucous membrane 24 1á3 13 0á5 6 0á4 43 0á8
Pain 3 0á2 2 0á1 0 0á0 5 0á1
Breathing/circulation 2 0á1 1 0á0 0 0á0 3 0á1
Night needs 1 0á1 0 0á0 13 0á9 14 0á2
Sum 139 7á7 312 12á5 252 18á0 703 12á3
(b) Goal
Cognition 5 0á3 9 0á4 9 0á6 23 0á4
Communication 6 0á3 5 0á2 1 0á1 12 0á2
Physical function 22 1á2 7 0á3 11 0á8 40 0á7
Continence/elimination 23 1á3 3 0á1 4 0á3 30 0á5
Psycho/social wellbeing 2 0á1 3 0á1 2 0á1 7 0á1
Mood/behaviour 2 0á1 0 0á0 7 0á5 9 0á2
Activities 7 0á4 2 0á1 4 0á3 13 0á2
Nutrition 13 0á7 2 0á1 2 0á1 17 0á3
Oral/dental care 2 0á1 0 0á0 1 0á1 3 0á1
Skin/mucous membrane 16 0á9 3 0á1 1 0á1 20 0á4
Pain 2 0á1 1 0á0 0 0á0 3 0á1
Breathing/circulation 2 0á1 1 0á0 0 0á0 3 0á1
Night needs 1 0á1 0 0á0 0 0á0 1 0á0
Sum 103 5á7 36 1á4 42 3á0 181 3á2
(c) Implementation
Nursing care
Cognition 6 0á3 48 1á9 18 1á3 72 1á3
Communication 14 0á8 30 1á2 18 1á3 62 1á1
Physical function 50 2á8 81 3á2 53 3á8 184 3á2
Continence/elimination 32 1á8 33 1á3 35 2á5 100 1á8
Psycho/social wellbeing 3 0á2 15 0á6 7 0á5 25 0á4
Mood/behaviour 3 0á2 6 0á2 13 0á9 22 0á4
Activities 11 0á6 11 0á4 16 1á1 38 0á7
Nutrition 20 1á1 10 0á4 7 0á5 37 0á6
Oral/dental care 2 0á1 5 0á2 2 0á1 9 0á2
Skin/mucous membrane 19 1á1 20 0á8 8 0á6 47 0á8
Pain 4 0á2 3 0á1 0 0á0 7 0á1
Breathing/circulation 2 0á1 1 0á0 0 0á0 3 0á1
Night needs 1 0á1 1 0á0 19 1á4 21 0á4
Sum 167 9á3 264 10á6 196 14á0 627 11á0

1468 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(6), 1462±1473
Issues and innovations in nursing practice Nursing documentation

Table 4 (Continued)

NH1 NH2 NH3 Total

18 patients 25 patients 14 patients 57 patients

n per pat n per pat n per pat n per pat

Medical treatment*
Continence/elimination 16 0á9 11 0á4 13 0á9 40 0á7
Skin/mucous membrane 4 0á2 2 0á1 1 0á1 7 0á1
Pain 1 0á1 0 0á0 0 0á0 1 0á0
Sum 21 1á2 16 0á6 21 1á5 58 1á0
(d) Evaluation
Nursing care
Cognition 5 0á3 27 1á1 18 1á3 50 0á9
Communication 10 0á6 32 1á3 20 1á4 62 1á1
Physical function 31 1á7 49 2á0 28 2á0 108 1á9
Continence/elimination 19 1á1 19 0á8 27 1á9 65 1á1
Psycho/social well being 4 0á2 10 0á4 10 0á7 24 0á4
Mood/behaviour 5 0á3 11 0á4 14 1á0 30 0á5
Activities 7 0á4 10 0á4 12 0á9 29 0á5
Nutrition 16 0á9 13 0á5 8 0á6 37 0á6
Oral/dental care 2 0á1 5 0á2 2 0á1 9 0á2
Skin/mucous membrane 15 0á8 9 0á4 5 0á4 29 0á5
Pain 1 0á1 2 0á1 0 0á0 3 0á1
Breathing/circulation 0 0á0 2 0á1 0 0á0 2 0á0
Night needs 2 0á1 0 0á0 14 1á0 16 0á3
Sum 117 6á5 189 7á6 158 11á3 464 8á1
Medical treatmenty
Continence/elimination 2 0á1 2 0á1 0 0á0 4 0á1
Sum 2 0á1 2 0á1 0 0á0 4 0á1

*No other items within medical treatment were documented.

y
No other items within medical treatment were documented.

not be made with any con®dence. Since the review facilitate a common terminology for the assessment of
consisted of nursing documentation from three locations patients through the de®nition of items. It could be
in Sweden, it probably re¯ects the content of documented helpful for staff in the care of elderly to articulate the
nursing care in Swedish nursing home wards. nature of nursing practice in nursing records, since it
A structured assessment of patients in the three nursing maybe dif®cult to express in writing, small nuances of
home wards was poorly carried out before the interven- change in many patients' conditions (Howse & Bailey
tion, and this is in line with other studies (Sutcliffe 1990, 1992). However, it is important to emphasize the need for
Davis et al. 1994). From another part of the main project de®nitions to be integrated and internalized by staff, thus
Hansebo et al. (1998) reported that the staff of the three making these de®nitions a valid source of data in nursing
wards, in answers to a questionnaire, expressed that using records.
the RAI/MDS made them more aware of the importance of Though psycho-social well being was represented in the
making speci®c individual assessments, and of focusing RAI/MDS in the present study, the documentation did not
patients' needs, problems and resources. This might also verify it as a priority of the delivered nursing care. In
contribute to positive team interaction and facilitate what addition, mood, behaviour and activities were infrequent-
could not be accomplished on an individual basis. This is ly represented in nursing care plans. The need for focus-
corroborated by a study by Edelstein (1990). ing on psycho-social wellbeing as essential for
A common language with properly de®ned terms is comprehensive care quality has been emphasized by
necessary to facilitate the interpretation of documented 4 Heafey et al. (1994). Ron & Bar-Tal (1993) and Davis et al.
nursing care, and thereby to increase the reliability of (1994) held that RN put more emphasis on meeting
documentation (Petrucci et al. 1987, Mortensen 1993, patients' physical needs, saw these as the basic and
Granberg 1994, Hale et al. 1997). The RAI/MDS might obvious needs, and tended to overlook the nonphysical

Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(6), 1462±1473 1469
G. Hansebo et al.

Table 5 Manually documented items in nursing care plans (NCP) (I) and computerized, triggered RAP items (II), equalities (III),
differences (IV) and additionals (V)

Total n = 57

I II III IV V

Nursing care plans NCP RAPs equal % diff % add %

Cognition 42 53 42 79 11 21 0 0
Vision 33 35 22 63 13 37 11 33
Communication 46 14 10 71 4 29 36 78
Physical function 49 39 34 87 5 13 15 31
Continence 48 48 41 85 7 15 7 15
Psychosocial well being 19 20 9 45 11 55 10 53
Mood 14 21 9 43 12 57 5 36
Behaviour 15 24 14 58 10 42 1 7
Activities 26 30 14 47 16 53 12 46
Falls 0 32 0 0 32 100 0 0
Nutrition 18 29 11 38 18 62 7 39
Dehydration 0 13 0 0 13 100 0 0
Dental care 10 34 7 21 27 79 3 30
Pressure ulcers 19 20 5 25 15 75 14 74
Psychopharmacological drugs 0 25 0 0 25 100 0 0
Physical restraints 0 13 0 0 13 100 0 0
Pain 5 0 0 0 0 0 5 100
Breathing/circulation 3 0 0 0 0 0 3 100
Night needs 9 0 0 0 0 0 9 100
Sum 356 450 218 48 232 52 138 39

Equalities = triggered RAPs and items in NCP which were equal.

Differences = triggered RAPs items but not found in NCP.
Additional = items in NCP but not triggered in or found in RAPs.

needs. Henderson (1969) has in many ways provided a `Nursing diagnoses' were not used, as staff were not
model for the nursing profession, and probably in¯uenced familiar with the concept. Several authors have paid
RN in their attitudes towards their patients. Kihlgren et al. attention to nursing diagnoses; the tendency to avoid the
(1992), however, have shown that Henderson's 14 com- adoption of nursing diagnoses (Hogston 1997) and the lack
ponents had a physical orientation bias and therefore in of knowledge which could limit the provision of better
order to cover the content, the components had to be patient care (Sutcliffe 1990), as well as the importance of
supplemented when oral reports were analysed. Items 5 critical re¯ection (LuÈtzeÂn & Tishelman 1996), the impor-
presented in nursing care plans in the present study tance of the education level of staff for the formulation of
probably re¯ect reality in accordance with the activity at nursing diagnoses (Dobrzyn 1995) and the requirement of
the wards; RN in nursing homes are often single-handed high level of intellectual skills (Yura & Walsh 1988,
with few opportunities to cooperate with colleagues. This Carnevali & Thomas 1993). Thus it seemed important not
is perhaps a contributing factor priority being placed on a to confront RN in the three nursing home wards with the
patient's physical needs. The differences between wards concept at the time of the study.
in the priority of content in nursing care plans could The planning of nursing care is linked to evaluation,
perhaps also depend on staff attitudes, their education and it is important to have `goals' for each problem, need
and age (range 21±61) and patients' long periods of stay. or resource. Sutcliffe (1990) revealed in a literature review
NH1 differed from the other wards with less items of that goal setting was highlighted by all authors, and that
cognition and communication within `patient situations' goals had to be clearly written down so that care could be
(Table 4a), even though many patients in this ward were evaluated. In the present study, goals did not correspond
cognitively impaired with regard to their resources of to patient situations. The goals were sometimes formulat-
cognition. Both are of importance when structuring care ed in a broad way and little attempt was made to break
(Kihlgren et al. 1993, Weiler 1994). them down into component parts. This could disclose

1470 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(6), 1462±1473
Issues and innovations in nursing practice
dif®culties for the caring team to formulate goals in
measurable and speci®c terms.
ÔImplementation' of nursing care in daily notes in-
creased most, especially in NH1 (Table 2). This could be
due to the in¯uences from the documentation in nursing
care plans. Daily notes about medical treatment still
dominated after the intervention, even though it decreased
in one ward. In fact, documented medical treatment could
be adequate in relation to patient situations. It could also
be explained by the context of medical dominance.
Documented Ôevaluations' in nursing care plans corre-
sponded in about 70% of documented implementations.
In daily notes, evaluations increased, although they
represented only half of the implementations and did
not always correspond with each other, the language was
poor and did not specify or re¯ect the effect of a certain
implementation. Part of the explanation must take into
account the setting of goals as well as the fact that it is
dif®cult for staff to express evaluations in clear terminol-
ogy. This could be because RN have traditionally used oral
communication instead of documenting their expertise in
writing. This has also been pointed out by Parker &
Gardiner (1992).
Clear daily notes could probably increase the quality of
nursing care since they will the progress of the care
delivered. Even though daily notes increased in our study,
it was dif®cult to see connections between documentation
in nursing care plans and the course in daily notes. In
agreement with Menenberg (1995), daily notes did not
re¯ect implementations based on identi®ed problems,
needs or resources from nursing care plans. It seemed as if
staff did not understand the utility and value of the
nursing process in daily notes.
Nursing care plans compared to RAPs
Falls, dehydration, psychopharmalogical drugs and phys-
ical restraints were not at all represented in the plans
(Table 5). However, these items, were not used as key-
words in nursing care plans because, if they had, they could
have in¯uenced staff attention. It is also important to
emphasize that RAPs appear to be overly sensitive in
triggering problems as a basis for care planning.
Falls could possibly be disregarded due to the fact that
patients were con®ned to wheelchairs. The risk of falls
could also be accounted for under the item `physical
function'. However, in daily notes falls were documented,
which emphasizes the need for consideration of this
problem when patients' care is planned. Triggered RAPs
showed the existence of physical restraint whereas nurs-
ing care plans did not. This probably disclosed a lack of
staff re¯ection. Studies have shown that the use of
physical restraint was closely related to cognitive impair-
ment and physical dependence (Karlsson et al. 1996,
Ljunggren et al. 1997). However, it emphasizes the need
Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(6), 1462±1473
Nursing documentation
to make staff ask themselves why physical restraint is
used in the ®rst place (Karlsson et al. 1998).
Dehydration is a well-known problem among elderly
people and it is important for staff to be alerted when it
occurs (Steen 1996). Dehydration triggered in RAPs could
be seen behind the item of nutrition in nursing care plans.
Psychopharmacological drugs were included in the items
of mood and behaviour and not represented as a special
item (i.e. key word) in nursing care plans. However, due to
the presence in daily notes and the impact these drugs
have on patients' abilities to handle their daily lives, it
would be important for RN to have psychopharamacolog-
ical drugs in focus and to have alternative implementa-
tions when care is planned. In contrast to triggered RAPs,
oral and dental care was relatively seldom recorded in
nursing care plans. The reason could be its perception as a
routine measure, not worth documenting. That dental
status has measurable positive and negative in¯uence on
the lives of older adults is stressed by Strauss & Hunt
(1993). Nordenram et al. (1994) has also emphasized the
need to have oral- and dental care in focus.
There were items in nursing care plans which were not
triggered in the RAPs. These items often concerned
patients' remaining resources or needs for prophylactic
care, which were important for staff to address because of
these patients' vulnerable situations. RAPs seem to be too
problem-orientated, and may be there is a risk that staff
can be in¯uenced not to consider patients'remaining
resources in the care planning.
The nursing process was used as a structure for the
existing documentation models in the three nursing home
wards. Davis et al. (1994) and McElroy et al. (1995) have
stressed that RN have a general lack of understanding of
the purpose and utility of the nursing process. Simmons &
Meadors (1995) maintains that the process in documenta-
tion systems should be used to provide nursing care.
Thus, the supervision in the present study started from the
assumption that the nursing process is a decision-making
and problem-solving method (Sutcliffe 1990, Fitzpatrick
et al. 1992). In addition the supervision had as one of its
aims to make staff understand the utility of the nursing
process.
According to the results of this study, although the
supervision and implementation of the RAI/MDS
improved nursing documentation, it was still not suf®-
cient. Though the instrument could be used to improve
assessments as a basis for planning nursing care, staff
skills and knowledge are necessary for clinical judgement
in determining the appropriate nursing care. However, if
new knowledge is to be internalized, the need for con-
tinuing education and supervision in nursing record
documentation is important, irrespective of the documen-
tation system used (Yassin & Watkins 1993, Bernick &
Richards 1994, FuraÊker & Sandman 1995, McElroy et al.
1995). It is also important to consider the structure of the
1471
 G. Hansebo et al.
documentation system with questions such as: Is it a help
or a hindrance? But it is also important to understand that
nursing records must not be so voluminous that they are
not used in practice.
Professional care is re¯ected by professional documen-
tation, which should not only testify to what has been
done, but should also effectively communicate a patient's
situation and progress, thus saving time for everyone. RN
as leaders must, however, be made aware of their indi-
vidual roles and what is expected from them, since their
attitudes are of importance when the content of care
planning and thus of what is documented is determined.
Acknowledgements
The study was supported by the County Council of
Stockholm and VaÊrdalstiftelsen. The authors are grateful
to Ms Monika Olsson RN for the coassessment of the
analysis of nursing documentation, Mattias O È hman for
È berg BA for
advice on the data analysis and to Per-Arne O
revising the English.
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