Using standardised nursing documentation in a general ward setting

Abstract

Overview of the topic: The nursing report is data generated about a patient to describe the care provided to enhance continuity of care. For the purpose of this study, a nursing report refers to the written form of documentation that is required for handover between different shifts or during a transfer of a patient. The research question: Does standardised vs.non-standardised nurse report writing help to improve patient care planning and nursing care in a general ward setting? The PICO elements: Population - nurses working in a general adult medical-surgical ward; intervention and comparative intervention - structured nursing report with non structured; outcome - improve patient care planning and nursing care. Inclusion/exclusion criteria: Excluded if publication date is before January 2000. Duplicated studies were excluded. The outcome of the search: 9 selected articles- 1 systematic review, 1 RCT, 5 quasi experimental studies and 2 observational studies. A triangulated approach was utilised having a mixture of data collection. The methods of appraisal used: CASP tools were used to appraise systematic review, RCT and observational studies. The TREND cheeklist was utilised to analyse quasi experimental studies. The main results from the evidence: Studies indicated a positive result regarding the introduction of a standardised nursing report. Through nurse involvement and education, proper documentation may be achieved. The main conclusions: The strengths and weaknesses of the study were portrayed. Ethical issues were taken into consideration. Good documentation may lead to improved patient care and planning. The implications and the important recommendations: In Malta, there is a lack of information on proper nurse report writing leading to inconsistent, irrelevant or misunderstood reports. Further research is required through the collection of audits and sampling of patients' records. Different structured formats of documentation needs further review. Education and nurse involvement in the implementation phase is also recommended since a higher compliance rate is evident.