RESUMEN
OBJECTIVE: To identify and classify the barriers and facilitators of the individualisation process of the standardised care plan in hospitalisation wards. BACKGROUND: The administration of individualised care is one of the features of the nursing process. Care plans are the structured record of the diagnosis, planning and evaluation stages of the nursing process. Although the creation of standardised care plan has made recording easier, it is still necessary to record the individualisation of the care. It is important to study the elements that influence the individualisation process from the nurses' perspective. DESIGN: Qualitative study with the grounded theory approach developed by Strauss and Corbin. METHODS: Thirty-nine nurses from three hospitals participated by way of theoretical sampling. In-depth interviews were conducted, as well as participant observation, document analysis and focus group discussion. The analysis consisted of open, axial and selective coding until data saturation was reached. EQUATOR guidelines for qualitative research (COREQ) were applied. RESULTS: For both barriers and facilitators, three thematic categories emerged related to organisational, professional and individual aspects. The identified barriers included routines acquired in the wards, the tradition of narrative records, lack of knowledge and limited interest in individualisation. The identified facilitators included holding clinical care sessions, use of standardised care plan and an interface terminology, the nurse's expertise and willingness to individualise. CONCLUSION: The individualisation process of the standardised care plan involves multiple barriers and facilitators, which influence its degree of accuracy. RELEVANCE TO CLINICAL PRACTICE: Implementing strategies at an organisational level, professional level and individual level to improve the way the process is carried out would encourage individualising the standardised care plan in a manner that is consistent with the needs of the patient and family; it would improve the quality of care and patient satisfaction.
Asunto(s)
Enfermería de Cuidados Críticos/organización & administración , Planificación de Atención al Paciente/organización & administración , Adulto , Femenino , Grupos Focales , Teoría Fundamentada , Hospitalización , Humanos , Masculino , Persona de Mediana Edad , Investigación Cualitativa , Adulto JovenRESUMEN
AIMS AND OBJECTIVES: To compare stroke unit staff members' documentation of care in line with evidence-based guidelines pre- and postimplementation of a multi-professional, evidence-based standardised care plan for stroke care in the electronic health record. BACKGROUND: Rapid and effective measures for patients with stroke or suspected stroke can limit the extent of damage; it is imperative that patients be observed, assessed and treated in accordance with evidence-based practice in hospital. DESIGN: Quantitative, comparative. METHODS: Structured retrospective health record reviews were made prior to (n 60) and one and a half years after implementation (n 60) of a multi-professional evidence-based standardised care plan with a quality standard for stroke care in the electronic health record. RESULTS: Significant improvements were found in documentation of assessed vital signs, except for body temperature, Day 1 post compared with preimplementation. Documentation frequency regarding body temperature Day 1 and blood pressure and pulse Day 2 decreased post compared with preimplementation. Improvements were also detected in documented observations of patients' micturition capacity, swallowing capacity and mouth status and the proportion of physiotherapist-documented aid assessments. Observations of blood glucose, mobilisation ability and speech and communication ability were unchanged. CONCLUSIONS: An evidence-based standardised care plan in an electronic health record assists staff in improving documentation of health status assessments during the first days after a stroke diagnosis. RELEVANCE TO CLINICAL PRACTICE: Use of a standardised care plan seems to have the potential to help staff adhere to evidence-based patient care and, thereby, to increase patient safety.