看護とケアのジャーナル

Usefulness of Nursing Documentations in Multi-professional Collaboration and Information Exchange in Finland

Abstract

Anne Kuusisto, Pirkko Nykänen and Johanna Kaipio

Background: Efficient collaboration and information exchange among care givers is essential during patient´s hospital period for the high quality and safety of patient care. Nursing documentation plays important part in effective collaboration and information exchange. One prerequisite for efficient and productive multidisciplinary collaboration is the nursing documentation when it is in appropriate format and easily accessible. In Finland, nursing documents are produced, stored and represented with a nursing documentation system (NDS), which is part of an electronic health record (EHR). The nursing model applied is based on a nursing process, a nationally defined nursing core data set and the Finnish Care Classification (FinCC). Research design and method: This study is a part of the research where we evaluated the feasibility and usability of the structured nursing documentation model and four widely used NDSs. One perspective in evaluation was the study of the usefulness of the nursing model and NDSs in multi-professional collaboration and information exchange. The materials were collected with thematic interviews with seven physicians and 20 nurses in spring 2010 in the clinical contexts of primary, specialized and private health care. Results: Nursing documentation model and NDSs supported poorly electronic multi-professional care and information exchange. Physicians found nursing documentations difficult to access and to understand. Information was documented as small, separate items and thus a comprehensive picture of the patient’s situation was not present. Collaborative care aspects were either not supported. The nursing model used could not be utilized by the physicians and NDSs did not take into account the needs of those physicians who require information on patient care provided by nurses. Conclusion: Experiences from our study could be used by other hospitals, care givers and countries for better design of nursing documentation. In the future, better utilization of information requires that the nursing documentation model and NDSs are designed to support not just documentation but also information exchange and multi-professional collaboration.