Professional Documents
Culture Documents
RACHEL LANGDON,
Research Assistant, South Western Sydney Centre for Applied Nursing Research, Liverpool, NSW, Australia,
Professor and Director/Professor of Nursing, South Western Sydney Centre for Applied Nursing Research / School of
Nursing and Midwifery, University of Western Sydney, 3Registered Nurse, Mater Christi Residential Aged Care
Facility, Toormina, NSW, Australia and 4Operational Nurse Manager, Concord Repatriation General Hospital,
Concord, NSW, Australia
Correspondence
Rachel Langdon
SWS Centre for Applied Nursing
Research
Locked Bag 7103
Liverpool BC NSW 1871
Australia
E-mail: rachel.langdon@sswahs.
nsw.gov.au
Introduction
Appropriate screening can identify people at risk of
adverse health outcomes and facilitate timely access to
appropriate comprehensive assessments and care. This
is relevant for all patients but is particularly important
94
Literature review
Documentation by nurses of the practices and care they
undertake is vital in ensuring appropriate and continued
care of patients (Karkkainen & Eriksson 2003, Pearson
2003, Taylor 2003, Jefferies et al. 2010). Nursing
documentation has often been criticized for being
incomplete, leading to inconsistency and the duplication
of care (Taylor 2003). Although nurses believe in the
value of documentation (Tapp 1990, Bjorvell et al.
2003), they often believe they do not have enough time
to write notes, their notes are not read (Bjorvell et al.
2003) and that the actual care they provide is more
important than writing it down (Tapp 1990).
However, the importance of documenting the
assessments and activities nurses carry out has been
realized. Assessment and documentation of the risk
status of patients on admission provides an opportunity
to manage those risks at the earliest opportunity (Carroll 2007). Documenting those assessments ensures high
quality care appropriate to the needs of each individual
patient (Karkkainen & Eriksson 2003, Pearson 2003,
Cheevakasemook et al. 2006, Jefferies et al. 2010),
continuity of care, promotes better patient outcomes
and assists health care professionals to develop and
implement care plans (Cheevakasemook et al. 2006).
Further, managing risk is linked directly to positive
patient outcomes including fewer adverse events such as
falls (Uden et al. 1999), pressure areas (including reddened areas, pressure ulcers or pressure sores) (Gunningberg et al. 2000) and a reduced length of stay
(Bjorvell et al. 2000). The focus of documentation is
also shifted away from the initial assessment and care
activities to a more encompassing view of nursing care
and the recording of these activities (Karkkainen &
Eriksson 2003).
2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2013, 21, 94105
R. Langdon et al.
Method
Design
This study used concurrent mixed methods, both
quantitative and qualitative methodologies. The quantitative component of this study used a retrospective
medical record audit design using an online data collection form based on the APAT. Two focus groups of
nurses who regularly use the form comprised the qualitative component, which provided complementary
findings (Lewis 2011) on how the nurses experienced
comprehensive assessment using the APAT.
Sample
A total of 286 medical records, randomly selected, from
the two participating NCAHS facilities were reviewed:
Coffs Harbour Base Hospital (2005 = 51, 2009 = 50);
Lismore Base Hospital (2005 = 92, 2009 = 93).
As the medical record audit was being conducted at
the two regional health facilities, two focus groups,
representing RNs practising at these facilities, were
conducted in November 2009. A convenience sample of
12 RNs (four from Coffs Harbour Base Hospital and
eight from Lismore Base Hospital), who responded to a
flyer distributed throughout their health facilities, participated in the focus groups. The focus groups were
digitally recorded and verbatim transcripts were produced for analysis.
Table 1
Tools included in the APAT (used in this study)
Confusion assessment method (CAM)
Mini-mental state examination
The Northern Hospital Modified STRATIFY
Malnutrition screening tool
Substance use history (as per NSW DOH Policy PD 2007_091 Nursing & Midwifery
Management of Drug & Alcohol Issues in the Delivery of Health Care)
Discharge risk screen (as per NSW DOH Policy PD 2007_092: Discharge Planning
Responsive Standards)
Assessment tools for delirium, cognitive impairment, and mental health were developed by
clinical staff based on their clinical knowledge and available evidence
96
Data analysis
Data analysis involved both quantitative and qualitative
techniques. Quantitative data were analysed using the
Statistical Package for Social Sciences (SPSS) Version 19
for Windows (IBM SPSS Inc., Chicago, IL, USA). Chisquare statistics and t-tests were calculated to determine
differences between the two audit times.
Qualitative data from the focus groups were coded
and analysed using QSR NVivo Version 8 (QSR International Pty Ltd, Doncaster, Vic., Australia). An
inductive approach to thematic analysis was undertaken
to determine latent themes within the data (Braun &
Clarke 2006). Initial codes were generated separately for
each focus group. These initial codes were then grouped
into main themes and confirmed for both focus groups.
Results
Medical record audit
Patient demographics
There was no statistically significant difference between
the proportion of records of males and females
2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2013, 21, 94105
(v2 = 1.404, P = 0.236) between the two audits. However, at an average of 10.8 days (SD = 11.4), the length
of stay for patients in 2009 was statistically significantly
longer than those in 2005 (mean = 7.8 days, SD = 7.04,
t = )2.47, P = 0.014). Similarly, the age of patients in
2009 (64.9 years) was statistically significantly higher
than those in 2005 (59.7 years) (t = )2.30, P = 0.022).
However, there was no statistically significant difference in the number of patients whose records were
audited who were older than 65 (2009 = 51%,
2005 = 50.3%, v2 = 0.014, P = 0.906) (see Table 2).
Presenting problem
The most common presenting problem in both 2005
and 2009 related to symptoms or ill-defined conditions, including abdominal pain, vomiting and shortness of breath. Conditions relating to the circulatory
system (CVA, stroke), musculoskeletal (hip and knee
replacements) and digestive system (gastroenteritis,
hernia) were also common presenting problems (see
Table 2).
Completion of major sections
There were statistically significant differences between
2005 and 2009 in a number of major sections completed. Proportionally more 2009 records had fully or
partially completed sections for the falls risk screen
(49.6% compared with 46.2%, v2 = 4.120, P = 0.042),
malnutrition screen (52.2% compared with 31.4%,
v2 = 8.070, P = 0.005), and the mental illness risk
screen (56.1% compared with 20.0%, v2 = 24.641,
P 0.001) when compared with 2005 records.
However, statistically significantly fewer records in
2009 had fully or partially completed sections of
Community Services Prior to Admission (21.2% compared with 45.2%, v2 = 17.062, P 0.001), diet
(41.4% compared with 64.2%, v2 = 11.752, P =
0.001), discharge checklist (30.8% compared with
53.5%, v2 = 15.130, P 0.001), transport arrangements (25.9% compared with 50.4%, v2 = 18.054,
P 0.001) and follow-up appointments (21.0%
compared with 43.7%, v2 = 16.770, P 0.001).
Some of these decreases in completion rates may be due
to the earlier records not having a section relating to
these checklists, thereby rendering a proportion of the
earlier records unable to be included in the analysis.
No statistically significant differences were found in
the number of records at either time period with fully or
partially completed sections for allergies, patients own
medication, complementary therapies, aids / prostheses,
orientation to the ward, discharge risk screen, referrals
made during admission, infection control, physical
97
R. Langdon et al.
2005
2009
Variable
Mean (SD)
Mean (SD)
t (sig)
Age (years)
Length of stay (days)
59.7 (20.0)
7.8 (7.04)
64.9 (18.4)
10.8 (11.4)
)2.30 (0.022)
)2.47 (0.014)
n (%)
n (%)
v2 (sig)
71 (49.7)
72 (50.3)
81 (56.6)
62 (43.4)
1.404 (0.236)
71 (49.7)
72 (50.3)
70 (49.0)
73 (51.0)
0.014 (0.906)
0
16
17
3
(0.00)
(10.81)
(11.49)
(2.03)
2
20
13
3
(1.41)
(14.08)
(9.15)
(2.11)
15
15
11
1
18
4
1
6
1
32
(10.14)
(10.14)
(7.43)
(0.68)
(12.16)
(2.70)
(0.68)
(4.05)
(0.68)
(21.62)
8
14
13
3
16
4
1
8
0
27
(5.63)
(9.86)
(9.15)
(2.11)
(11.27)
(2.82)
(0.70)
(5.63)
(0.00)
(19.01)
Gender
Male
Female
Age group
Under 65
65 or older
Presenting problema
Blood disease
Circulatory system
Digestive system
Endocrine, metabolic, immune
disease
Genitourinary system
Infectious or parasitic disease
Injury or poisoning
Mental disorder
Musculoskeletal or connective tissue
Neoplasms
Nervous system or sense organs
Respiratory system
Skin or subcutaneous tissue
Symptoms, signs, ill-defined
condition
Other health influencing factors
Contact with health services
5 (3.38)
3 (2.03)
Table 2
Demographics and presenting
problem
8 (5.63)
2 (1.41)
Diagnoses coded using the Charlson comorbidity index (Charlson et al. 1987).
Table 3
Completion of major sections
Allergies
Completed/Partially completed
Not completed
Patients own medication
Completed/Partially completed
Not completed
Complementary therapies
Completed/Partially completed
Not completed
Aids/Prostheses
Completed/Partially completed
Not completed
Orientation to the ward
Completed/Partially completed
Not completed
Discharge risk screen
Completed/Partially completed
Not completed
Community services prior to admission
Completed/Partially completed
Not completed
Referrals made during admission
Completed/Partially completed
Not completed
Infection control
Completed/Partially completed
Not completed
Physical assessment
Completed/Partially completed
Not completed
Falls risk screen
Completed/Partially completed
Not completed
Diet
Completed/Partially completed
Not completed
Malnutrition screen
Completed/Partially completed
Not completed
Substance use risk screen
Completed/Partially completed
Not completed
Mental illness risk screen
Completed/Partially completed
Not completed
Delirium risk screen
Completed/Partially completed
Not completed
Cognitive impairment risk screen
Completed/Partially completed
Not completed
Discharge checklist
Completed/Partially completed
Not completed
Community services referral
Completed/Partially completed
Not completed
Transport arrangements
Completed/Partially completed
Not completed
Follow-up appointments
Completed/Partially completed
Not completed
2005 n (%)
2009 n (%)
v2 (sig)
101 (70.6)
42 (29.4)
97 (67.8)
46 (32.2)
0.263 (0.608)
45 (32.6)
93 (67.4)
59 (41.5)
83 (58.5)
2.396 (0.122)
21 (21.9)
75 (78.1)
17 (12.3)
121 (87.7)
3.801 (0.051)
98 (69.0)
44 (31.0)
89 (62.2)
54 (37.8)
1.450 (0.229)
75 (52.8)
67 (47.2)
86 (60.1)
57 (39.9)
1.555 (0.212)
89 (62.7)
53 (37.3)
103 (72.0)
40 (28.0)
2.835 (0.092)
56 (45.2)
68 (54.8)
29 (21.2)
108 (78.8)
17.062 (<0.001)
3 (2.1)
139 (97.9)
8 (5.6)
135 (94.4)
2.328 (0.127)
42 (59.2)
29 (40.8)
81 (58.3)
58 (41.7)
0.015 (0.902)
93 (65.5)
49 (34.5)
100 (69.9)
43 (30.1)
0.642 (0.423)
36 (46.2)
42 (53.8)
84 (60.4)
55 (39.6)
4.120 (0.042)
61 (64.2)
34 (35.8)
58 (41.4)
82 (58.6)
11.752 (0.001)
22 (31.4)
48 (68.6)
72 (52.2)
66 (47.8)
8.070 (0.005)
87 (63.0)
51 (37.0)
87 (60.8)
56 (39.2)
0.145 (0.704)
14 (20.0)
56 (80.0)
78 (56.1)
61 (43.9)
24.641 (<0.001)
0 (0.0)
3 (100)
79 (56.8)
60 (43.2)
3.843 (0.050)
0 (0.0)
3 (100)
78 (56.1)
61 (43.9)
3.735 (0.053)
76 (53.5)
66 (46.5)
44 (30.8)
99 (69.2)
15.130 (<0.001)
16 (17.2)
77 (82.8)
21 (14.8)
121 (85.2)
0.247 (0.619)
71 (50.4)
70 (49.6)
37 (25.9)
106 (74.1)
18.054 (<0.001)
62 (43.7)
80 (56.3)
30 (21.0)
113 (79.0)
16.770 (<0.001)
99
R. Langdon et al.
2005 n (%)
Pressure areas present
Yes
0 (0.0)
No
22 (24.4)
Not completed/Not noted
68 (75.6)
Nursing action taken to relieve pressure areas
Yes
13 (14.3)
Risk assessment tool
4
Frequent turning/repositioning
1
Encourage movement/repositioning
3
Jordan Frame/air mattress
0
Monitoring
0
Referral made
0
No
78 (85.7)
Patients total falls risk score
02
21 (21.0)
3 or more
9 (9.0)
Not completed
5 (5.0)
No area on form/Not noted
65 (65.0)
Referrals related to falls
Referral made, documented on P1
0 (0.0)
Referral made, documented in
5 (5.1)
notes but not on P1
Referral is not made
21 (30.4)
Not applicable
69 (70.4)
Not completed
3 (3.1)
Nursing action taken related to falls
Yes
22 (22.9)
Falls assessment tool
2
Physiotherapy/Physiotherapy review
3
Assist as needed (mobilization)
7
General nursing care
1
Bed rails
1
Motor assessment scale (completed
1
by physiotherapist)
Walking aid
3
No
74 (77.1)
Table 4
Pressure areas and falls
2009 n (%)
v2 (sig)
5 (5.0)
33 (33.3)
61 (61.6)
7.168 (0.028)
30 (31.3)
23
15
7
9
2
1
66 (68.8)
7.593 (0.006)
62
20
2
3
(71.6)
(23.0)
(2.3)
(3.4)
0 (0.0)
8 (9.5)
3.881 (0.275)
19 (22.6)
57 (67.9)
0 (0.0)
38 (43.2)
37
13
5
1
1
1
8.580 (0.003)
0
50 (56.8)
Focus groups
Participants in the focus groups were asked a number of
questions about the form including: how important they
considered a comprehensive assessment to be; how they
found the process of completing the form; whether a
full assessment was carried out for each patient; questions they considered mandatory; questions they preferred to avoid; and how the form facilitated the care
and discharge of patients.
The verbatim transcripts of the two focus groups
were read and coded, yielding 334 comments relating to
23 individual codes. From these individual codes, five
main themes emerged relating to: items on the form;
holistic approach to care; why the form was/was not
completed; how the form was completed; and use of the
form and patient outcomes from using the form. Quotes
from the two focus groups are identified as being from
focus group 1 (FG1) or focus group 2 (FG2).
Items on form
The participants were asked what items on the form
they thought should be completed for every patient. The
participants felt the most important items on the new
form related to the discharge risk screen. Although there
was not a consensus, other items were also considered
important, namely the falls risk screen and the pressure
area assessment. Other sections mentioned were substance use, delirium, allergies, infection control and
aids/prostheses brought into hospital.
Improvements to the form were also suggested. The
addition of personal information about the patient was
considered important as participants felt it would
facilitate optimum care and build a positive relationship
with the patient.
when youve got your delirium or your
dementia you can go back to that and talk to them
That will bring them back to normality and
reality [it] makes a difference too in how they
react to you and how you can care for
them.
(FG1)
The addition of a sign-off for each section was also
proposed as the form was often completed by a number
2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2013, 21, 94105
R. Langdon et al.
Discussion
The introduction of the APAT has increased nursing
actions relating to falls and pressure areas and also resulted in increased referrals to other health professionals, for example, physiotherapists and speech
pathologists. The completion rates for some sections of
the APAT increased from 2005 to 2009, namely the
falls risk screen, the malnutrition screen and the mental
illness risk screen.
Overall, the nurses attitude towards the APAT was
positive, with important areas of the form, such as the
falls risk screen and the pressure area assessment more
likely to be completed. The completion of these
assessments has resulted in an increase in referrals and
nursing interventions, highlighting the importance of
documentation as a guide to nursing action (Jefferies
et al. 2010, Johnson et al. 2011). However, sections
facilitating discharge (discharge checklist, transport
arrangements) and long-term care to prevent readmission (follow-up appointments), while completed, were
not done so as diligently.
Although the APAT was perceived by nurses to be
lengthy, they also recognized that having a comprehensive list of screening criteria prompted them to take
action where previously they may not have. As one
participant in the focus groups noted, awareness goes
up with the use of the tool. One of the most promising
outcomes of the introduction of the APAT was the increase in the number of nursing activities undertaken,
especially in relation to the relief of pressure areas and
falls, confirming that nurses are more likely to carry out
preventative activities once patients are identified as
being at risk (Uden et al. 1999, Gunningberg et al.
2000, Jefferies et al. 2010). Similarly, assessment of
2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2013, 21, 94105
R. Langdon et al.
Limitations
Although data were collected for cognitive impairment, delirium, substance abuse and mental health,
the proportion noted as not applicable was high,
making the reporting and interpretation of the data
difficult.
104
Conclusion
Nurses have become more aware of the health care
needs of the patient as a result of the comprehensive
patient assessment they carry out. This has resulted in
an increase in the number of nursing actions taken,
especially in relation to falls and pressure areas. Nurses are also able to take advantage of the non-clinical
information gathered and take a more holistic approach to patient care. Electronic medical records
provide an opportunity to store and retrieve comprehensive nursing assessments that would relieve the
pressure on nurses time and benefit patient health
care.
Acknowledgements
The authors would like to acknowledge Steve Curtis (Lismore
Base Hospital) and Stuart Garland (Coffs Harbour Base
Hospital) for their hard work in data entry, insightful comments about the data entry form, and facilitating the focus
groups at their respective hospitals. The authors would also
like to acknowledge the nurses who volunteered their time to
participate in the focus groups.
Source of funding
Funding for the project was provided by the Clinical
Governance Unit of the North Coast Area Health
Service.
2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2013, 21, 94105
Ethical approval
Ethical clearance was obtained from the South Western
Sydney Area Health Service Human Research Ethics
Committee (CGRH) (09/CGRH/6, CH62/6/2009009)
and the North Coast Area Health Service Research
Governance Unit.
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