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Evaluation of documented nursing care plans by the use of

nursing-sensitive outcome indicatorsjep_1233 611..618

Inger Jansson RN,1 Ewa Pilhammar-Andersson PhD2 and Anna Forsberg PhD3

1Doctoral Student, School of Social and Health Sciences, Halmstad University, Halmstad and Institute of Health and Care Sciences, The

Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden2Professor, Institute of Health and Care Sciences, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden3Senior Lecturer, Institute of Health and Care Sciences, The Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden

Keywords

care plans, empirical research report,

nursing diagnosis, outcome, stroke

Correspondence

Inger Jansson

School of Social and Health Sciences

HOS

Halmstad University

Box 823

SE-301 18 Halmstad

Sweden

E-mail: [email protected]

Accepted for publication: 24 March 2009

doi:10.1111/j.1365-2753.2009.01233.x

Abstract

Rationale and aim There is a lack of evidence that nursing care plans affect patientoutcomes. The aim of the present study was to evaluate whether documented nursing care

plans affect patient outcomes by the use of nursing-sensitive outcome indicators.Method A retrospective, cross-sectional design with patients surveyed at time of dischargefrom two hospital units for patients with stroke and after 23 weeks at home. The controlunit (A) did not employ care plans. The intervention unit (B) used care plans on a dailybasis. Outcome was measured by the National Stroke Registerand the two questionnaires:Quality of patients perspective and Euroquol five dimensions. Data were collected overa 5-month period (October 2007February 2008).Results In total, 87 patients were included in the study. Patient characteristics in the twogroups at admission and the health-related quality of life 2 to 3 weeks after discharge weresimilar. The patients from unit B were more satisfied with individual care ( P = 0.03) andparticipation (P = 0.007). Unit B also had a shorter length of stay (P = 0.004).Conclusions The effects of documented care plans are difficult to evaluate from a patientperspective, as many factors can improve the outcome. However, documentation of careplans is a prerequisite for measuring the quality and outcome of the care provided. Thissmall study indicates that documented care plans may affect patient satisfaction regardingindividual care, participation and length of hospital stay.

Introduction

According to an extensive literature review [1] focusing on studiesof nursing diagnosis and nursing care, there is a lack of evidencethat documented nursing care plans affect patient outcomes.However, the review revealed that the documentation of nursing

diagnoses improved the quality of documented patient assess-ments and identification of commonly occurring diagnoseswithin similar settings. Escalating health care costs along with apopulation increasingly consisting of old people demand cost-effectiveness and quality of care in the health care system. Thismeans that professionals need to employ interventions that lead tothe best outcome in order to ensure effective use of resources.Nurses are educated to make clinical judgments about an individu-als response to actual and potential health problems/life pro-cesses, state the expected outcome of nursing care and formulate aplan for nursing care interventions. However, the part of thenursing process that includes nursing diagnosis, outcome and

interventions as set out in a care plan is seldom documented inclinical settings [2,3]. The documentation of nursing care can beseen as an indicator of quality, as its ultimate aim is that it shouldserve as a tool to achieve high-quality care as well as guaranteeingcontinuity and safety during hospitalization in addition to facili-tating the use of evidence-based care [4].

According to a study by Bjrvell et al. [5], documentation ofnursing diagnoses obliges nurses to focus on nursing care. After anintervention, the nurses found that a structured way of document-ing nursing care made them change from focusing on medicaltechnical aspects to a greater emphasis on nursing competence.Axelsson et al. [6] also found that nurses perceived that document-ing nursing diagnoses helped them to view the patient as an indi-vidual as well as a whole human being, increased their awarenessof nursing practice and had a positive influence on their profes-sional role. The study concluded that nurses were motivated todocument nursing diagnoses by the wish to more deeply analysethe patients nursing needs. From the above, it can be concluded

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2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice 16 (2010) 611618 611


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that the documentation of care plans has an impact on the qualityof care, although there is a lack of evidence as to its outcome froma patient perspective.

Background

Internationally, six prerequisites have been defined as essential for

high-quality care: knowledge-based and adapted to its purpose,safe, patient focused, efficient, equal and provided within a rea-sonable timeframe [7].

Nursing-sensitive outcome indicators (NSOI) are described bythe American Nurses Association (ANA) as focusing on howpatients, and their conditions, are affected by their interaction withnursing staff [8, p. viii]. A literature review [9] stated that theoutcomes generally considered as sensitive to nursing care can beclassified into the following four NSOI groups: Functional, whichincludes physical and psychosocial functioning in addition to self-care abilities, Clinical, which comprises symptom control or man-agement, Perceptual, which includes satisfaction with nursingcare and with care outcome and Safety, which consists of adverse

incidents and complications, such as thrombosis, falls, bleedingand infection. As a result of an inventory of NSOI, the Interna-tional Council of Nursing (ICN) [10] added the NSOI group use ofhealth care, comprising the following three indicators: length ofhospital stay because of increased morbidity, unplanned emer-gency department visits and hospital re-admission.

Nursing-sensitive outcome indicators have been used in differ-ent studies to measure the effect of nursing care. Following anextensive literature review on the state of the art in the area ofstaffing and patient safety, Blegen [11] stated that patient safetyassociated with nursing care is most visible in hospital inpatientunits. The most frequent NSOI in the review linked to staffing waspneumonia, followed by failure to save life, urinary tract infec-tions, mortality as well as falls and injuries such as pressure ulcers.

Other NSOI that were found to be linked to staffing were length ofstay (LOS), postoperative infections and thrombosis. NSOI werealso used in a quality project by ANA, the aim of which was toexamine patient care outcomes in acute care hospitals in Califor-nia. ANA performed a pilot study to assess the feasibility ofmeasuring NSOI [12], after which they started to develop theCalifornia Nursing Outcomes Coalition (calNOC) database [13].The data include hospital nurse staffing, patient days, patient falls,pressure ulcers and restraint prevalence, registered nurse educationand patient satisfaction with nursing care. Additional indicatorsunder development include standardized nursing assessment anddocumentation of patients activities of daily living (ADL) inaddition to measurement of nursing-sensitive medication errors.

Johnson et al. [14] also describe the development of a tool forreporting clinical nursing data, The nursing quality indicatorreport, divided into four sections: human resources, patient satis-faction, infection control and clinical nursing indicators such asfalls, pressure ulcers, nursing documentation and medical errors.Quality work based on the results from the data has led to areduction in the number of patient falls, improved nursing docu-mentation and fewer medication errors [14].

In order to develop the quality of care and adopt a moreevidence-based approach, it is necessary for nurses to employ theoverview of knowledge that is available in the national guidelinesand compilations of evidence in their respective countries, for

example The Cochrane Collaboration [15]. In Sweden, theNational Board of Health and Welfare [7] states that systematicquality work should be pursued in order to satisfy the demands ofpatient safety, patient satisfaction and cost-effectiveness. Nationalguidelines should form the basis for the development of institu-tional practice guidelines that describe responsibility, goals,guiding principles, routines and treatment procedures. As a final

step, it should be possible to follow the care process for eachindividual patient by means of the documentation. This means thatnurses documentation of standard or individual care plans shouldproceed from a description of the patients care needs, problems orrisks in the form of a care diagnosis, as well as stating interven-tions and expected outcome. These parts of the care plan can eitherbe written in the authors own words, which is usual in Sweden orin standardized language such as that employed for diagnosis;North American Nursing Diagnosis Association (NANDA), inter-ventions; nursing interventions classifications (NIC) and outcome;nursing outcome classification (NOC) [16].

The aim of the present study was to evaluate whether docu-mented nursing care plans affect patient outcomes by the use of

NSOI.

Method

Design

The retrospective, cross-sectional design took the form of a studywith patients surveyed at the time of discharge from the stroke unitand 23 weeks after going home. The study compared two hospitalunits treating patients with stroke at two different hospitals locatedina rural part ofSweden.Althoughthe patients atthe two units werenot matched, the inclusion criteria were identical, and the medicalcare, as well as routines and conditions in the two settings, was assimilar as possible. The control unit (A) did not document care

plans. The intervention unit (B) documented all steps of the nursingprocess including nursing care plans. In this study nursing careplans mean either a standardized care plan defined by Carpenito[17] as a printed plan that describes the nursing care to be providedfora patient, familyor a group, or a individualized care plan definedas a written plan following the steps of nursing process describingthe nursing care to be provided for the individual patient. In unit Bboth these types of care plans were used as a daily routine.

Settings

We selected two hospitals in order to find a ward that did notdocument care plans (unit A) and one that did so (unit B), because

of the fact that our inquiries have shown that nurses within thesame hospital clinic work in a similar manner. The two hospitalswere located within the same council area, which means that theywere subject to the same political control and allocation ofresources. The only difference was that unit A carried out allrehabilitation interventions within the ward, while unit B sentpatients requiring a longer period of care to a specific rehabilita-tion department in the hospital. Details about staff and routineswere provided by a specialist clinical nurse in each unit. The unitswere based on stroke teams comprising doctors, physiotherapistsand occupational therapists who worked with the patients on adaily basis. The teams also included a speech therapist, social

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welfare officer and psychologist, while a dietician and dentalhygienist were included when required.

Unit A had developed institutional practice guidelines forstroke, a local adaptation of the national care guidelines, but nomonitoring took place of whether these guidelines were applied onthe basis of each patients needs, as no individual or standardizedcare plans were documented in the patient records. The electronic

nursing documentation system in place at the unit only made itpossible to document the assessment, as there was no space inwhich to document individual or standardized care plans.

In unit B individual care plans were documented, usuallyincluding: ADL activities, movement disabilities, nutrition, socialplanning, pain and ulcers. Standardized care plans were preparedin relation to knowledge, risk of falls, nutrition, enteral probe,social planning and activities which could be included in theindividual patients record, when necessary. In this unit the aboveinformation was documented manually, which made it possible forthe nurses to document both individual care plans and standardizedcare plans. The nursing diagnosis, outcome and interventions werewritten without a specific format; thus, no classification system

such as NANDA, NIC or NOC was used. Relevant data regardingthe two hospital units are presented in Table 1.

Participants

Patients with suspected stroke were admitted to the two partici-pating units. When the diagnosis of stroke (trombosis or bleeding)was confirmed, the patients were entered into the National StrokeRegister (NSR) [18]. During the study period, a total of 231patients at the two units were registered in the NSR. Inclusioncriteria were: patients admitted to the unit and diagnosed as suf-fering from stroke during the study period. Exclusion criteria

were: children younger than 16 years, death during the hospitalstay, a hospital stay of less than 24 hours, inability to understandthe Swedish language and a health condition that made participa-tion inappropriate (assessed by the nurse in charge). The two mainreasons for exclusion were cognitive failure and death. A total of87 patients, 55 men and 32 women, were consecutively included.A questionnaire was sent to the patients home address 2 to 3

weeks after discharge, which was completed and returned by atotal of 65 participants, 41 men and 24 women (See Fig. 1). Nopower calculation was performed, as it was regarded as a smallstudy aimed at investigating the possibility of evaluating whetherthe documentation of care plans has an impact on patient outcomesand, if so, which measurement instruments are relevant.

Data collection

A nurse in each ward was selected to be responsible for obtainingconsent from the patients who agreed to participate in the study as

Table 1 Data pertaining to the two hospital units

Unit A Unit B

Standardized care plans No Yes

Individualized care plans No Yes

Patients 29 25

Staff Day Evening Day Evening

Stroke nurse, weekdays 1 1

Nurses, weekdays 4 3 4 3

Nurses, weekend 3 3 3 3

Assistant nurses, weekdays 5 3 5 3

Assistant nurses, weekend 3 3 3 3

Admitted with diagnosed stroke, units A and B

N= 231

Exclusion criteria


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well as for registering them, which took place during the periodOctober 2007February 2008.

Each NSOI group was measured as follows:Functional NSOI was studied by means of the Euroquol five

dimensions (EQ-5D). EQ-5D was chosen for measuring health-related quality of life (HRQOL). It is a standardized, non-disease-specific instrument, which provides a simple descriptive profile of

a persons HRQOL. The questionnaire includes five dimensions ofhealth: mobility, self-care, usual activities, pain/discomfort andanxiety/depression. Each dimension comprises three levels: noproblems, moderate problems and severe problems [19].

Clinical and perceptual NSOI was measured by the Quality ofpatients perspective (QPP) instrument. The QPP was chosen inorder to assess patients self-reported satisfaction with care. Eachquestion is evaluated by the respondent in two ways, the first beinga factual assessment, perceived reality, and the second an estima-tion of its subjective importance based on a 4-point Likert-typescale. The instrument was designed to be analysed by item as wellas to be combined into a score [20].

Thirteen questions were selected from the basic instrument in

order to measure satisfaction with nursing care; one question aboutpain control, one pertaining to the general atmosphere on the ward,two on the subject of education and information, three on theopportunity for participation in the care as well as whether indi-vidual care was provided, two about physical needs and four aboutthe encounter with the nurses.

Safety NSOIinvolved data from the NSR [18] about unexpectedcomplications, that is, pneumonia, thrombosis and fractures thatcould be caused by falls. Data from this register also included thepatients status before the stroke and at time of admission as wellas LOS in hospital.

Use of health care NSOI was measured by additional questionsabout any follow-up visits and re-admissions in the weeks follow-ing the patients return home.

The NSR [18] was filled in by the nurse at the time of thepatients discharge to the home. The postal questionnaire com-prised the EQ-5D and QPP instruments in addition to questionsabout use of health care, all of which were adjusted to the medicalcondition of stroke or cerebral bleeding and considered easy toanswer. The questionnaire was sent to the patients 2 to 3 weeksafter discharge (Fig. 1).

Ethical considerations

Permission to carry out the study was granted by a Regional EthicsCommittee.

The participants were provided with verbal and written infor-

mation, after which the nurse obtained their informed writtenconsent. Participation was voluntary and the informants were toldthat they could withdraw from the study at any time. Confidenti-ality was guaranteed.

Data analysis

The data were mainly at a nominal and ordinal level in order togenerate descriptive statistics or require non-parametric analyses.The MannWhitney U-test was employed to analyse differences inthe QPP and EQ-5D between two unpaired groups (units A and B).In order to compare two sets of nominal data, that is, age, sex and

use of health care, the chi-squared distribution was tested. Statis-tical significance was considered when P < 0.05.

Validity and reliability

The QPP has been tested and found to have satisfactory validityand reliability, with Cronbachs alpha values of 0.690.93 [21].

The EQ-5D is a validated, standardized instrument that has beenemployed in many studies for the clinical and economic evaluationof health care [19]. The QPP has been used by Muntlin et al. [22],who stated that many of the identified areas are related to nursingcare. To our knowledge, it has not been tested before whether theeffect of documentation on NSOI can be measured by means ofthese instruments.

Results

Participant characteristics

Most of the participants from the two units were fully consciouswhen admitted to hospital. There were no differences in terms ofage, sex or physical functioning prior to the stroke. The partici-pants characteristics are presented in Table 2.

Functional NSOI

There were no differences between the two units in HRQOL 2 to 3weeks after discharge.While on the whole the participants reportedno problems in the areas of mobility and self-care, a number ofpatients experienced moderate problems related to usual activitiessuch as work, household chores,family andleisure activities as wellas pain/discomfort and anxiety/depression (Table 3).

Clinical and Perceptual NSOI

The patients in both units reported satisfaction with nursing care bymeans of a four point scale from 1 (do not agree at all) to 4 (fullyagree). They alsohad the opportunity to tick not applicable, whichmeans that the number of patients who answered each questionvaries, as these responses were not included. The patients from unitB reported a higher level of satisfaction: I had good opportunity toparticipate in decision that applied to my care ( P = 0.007) (ques-tion 8) and My care was determined by my own requests andneedsrather than the staffs procedures (P = 0.03) (question 9).

No differences were observed in the patients assessment of thesubjective importance of the different questions (Table 4).

Safety NSOI

Unexpected complications during the hospital stay such as theoccurrence of fractures, thromboses and pneumonia were mea-sured. The prevalence in unit A was one fracture and one case ofpneumonia, while there were no reports of any complications inunit B. The low level of complications means that no differencescan be measured between the units.

Use of health care NSOI

The LOS differed between the two units, with unit B havingsignificantly shorter care times (P = 0.004). The number of visits




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Table 2 Participant characteristics, data

from the National Stroke RegisterUnit A Unit B

Participants 52 35

Male 63% (n = 33) 63% (n = 22)

Female 37% (n = 19) 37% (n = 13)

Age, mean value 74 years 74 years

Diagnosis: bleeding 4% (n = 2) 14% (n = 5)

Diagnosis: infarction 96% (n =

50) 86% (n =

30)Degree of consciousness on admission

RLS 1 fully awake 96% (n = 50) 100% (n = 35)

RLS 23 partly unconscious 2% (n = 1)

RLS 48 unconscious 0% (n = 0)

Type of residence before the illness

Own home 92% (n = 48) 89% (n = 31)

Own home with home-help service 2% (n = 1) 11% (n = 4)

Municipal special housing 6% (n = 3) (n = 0)

Mobility before the illness

Fully mobile 96% (n = 50) 100% (n = 35)

Fully mobile indoors 2% (n = 1) (n = 0)

Required assistance with mobility (n = 0) (n = 0)

Toilet visits before the illness

Managed visits to the toilet without assistance 98% (n = 51) 100% (n = 35)

Req ui red assistance with visits to the toil et 2% (n=

1) (n=

0)Dressing before the illness

Managed without assistance 98% (n = 51) 100% (n = 35)

Required assistance 2% (n = 1) (n = 0)

No statistical differences were found between the two units.

Table 3 Euroquol five dimensions, health-related quality of life

Dimensions

Unit A Unit B

Pn No problems

Moderate

problems

Severe

problems n No problems

Moderate

problems

Severe

problems

Mobility 34 7 1% (n = 24) 26% (n = 9) 3% (n = 1) 28 64% (n = 18) 36% (n = 10) 0 0.511

Self-care 34 76% (n = 26) 20% (n = 7) 3% (n = 1) 28 82% (n = 23) 18% (n = 5) 0 0.623Usual activities 32 50% (n = 16) 37% (n = 12) 12% (n = 4) 28 50% (n = 14) 50% (n = 14) 0 0.133

Pain/discomfort 33 27% (n = 9) 67% (n = 22) 6% (n = 2) 27 48% (n = 13) 52% (n = 14) 0 0.139

Anxiety/dep ressio n 3 2 50 % (n = 17) 41% (n = 13) 6% (n = 2) 28 61% (n = 179) 39% (n = 11) 0 0.385

Table 4 Quality of care from the patient perspective

Quality of care, perceived reality

Statement

Unit A Unit B

Pn M SD n M SD

1. I received useful information on how examinations and treatments would take place 34 3.38 0.74 29 3.41 0.73 0.87

2. I recei ve d u se ful in formatio n o n sel f-care; ho w I shou ld take care of myse lf 28 2 .82 1 .0 9 2 6 3.35 0.94 0.06

3. The nurses and assistant nurses seemed to understand how I experienced my situation 35 3.66 0.68 27 3.67 0.62 0.87

4. The nurses and assistant nurses were respectful towards me 32 3.72 0.58 27 3.7 0.61 0.96

5. The nurses and assistant nurses showed commitment; cared about me 30 3.83 0.38 28 3.71 0.6 0.57

6. I received effective pain relief 18 3.28 0.89 9 3.44 1.01 0.47

7. I talked to the nurses in private when I wanted to 21 3 0.95 17 3.24 0.97 0.34

8. I had good opportunity to participate in decision that a pplied to my care 26 2.65 0.94 24 3.38 0.88 0.007

9. My care was determined by my own requests and needs rather than the staffs procedures 31 3.1 0.7 27 3.48 0.75 0.03

10. My relatives and friends were treated well 32 3.63 0.71 25 3.56 0.82 0.8

11. There was a pleasant atmosphere on the ward 34 3.44 0.79 29 3.59 0.63 0.52

12. I received food and drink that I like 34 3.38 0.78 29 3.55 0.87 0.21

1 3. I received the b est p ossi bl e p hysi cal care , e.g. h el p with m y p erso nal h yg ie ne 20 3 .1 0 .9 1 1 8 3.39 0.85 0.27

Bold values are statistically significant.

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to the outpatient clinic or hospital within the first 23 weeks after

discharge did not differ in terms of scheduled or emergency visits(Table 5).

Discussion

Study limitations

In this study we wished to investigate whether or not nursing carebased on a structured method of documenting care plans affectspatient outcomes. Two questions emerged at the start of theplanning of the study: which variables are useful for measuringpatient-related effects? Is it possible to measure whether the docu-mentation of care plans affects patient outcomes? Because of thefact that we did not know which variables might be affected by the

documentation of care plans, we decided to measure as manyNSOI as possible based on existing documentation in the StrokeRegister, in addition to the questions asked in the questionnaires.We chose to send the questionnaires to the patients 2 to 3 weeksafter their discharge to the home, as it was assumed that by thenthey had had time to digest their experiences and were no longer ina state of dependence vis vis the health care professionals. Alonger period was assumed to constitute a greater risk of theemergence of new nursing problems that were not an issue whenthe care planning was performed at the hospital. This interval cannevertheless have led to patients forgetting a great deal of howthey experienced the care. We only obtained information aboutHRQOL at that particular point in time. It might have been of

greater interest to explore HRQOL at the moment of discharge tothe home since the measure of HRQOL then presumably had beenmore related to the care and hospital stay. Further, HRQOL athome might be affected by the fact that it was good to be backhome. We could also have employed a more sensitive instrumentfor measuring ADL, as in the study by Glasson et al. [23] wherethe Bartels ADL-index was used to evaluate a new care model.Nevertheless, a remaining problem is the difficulty in determiningwhich interventions had an effect on the results.

We are aware of the difficulties of drawing conclusions from astudy comparing two different sites using and not using docu-mented care plans, because, although efforts have been made to

ensure that they are otherwise as similar as possible, any number

of factors could contribute to any observed differences. However,we argue that studies of these kinds are needed to further explorethe value of care plans and the impact of NSOI, in spite of themany difficulties. One notable difference between the units wasthat unit A had patients staying for long-term rehabilitation.When excluding the few patients who had stayed for long-termrehabilitation, the difference in LOS was still significant. Accord-ing to a review by Blegen [11], the aim of previous studies wasoften to explore whether the number of registered nurses at theunit has an impact on the NSOI. In our study, although strive forequal conditions in the two ward, unit A had four more beds thatcould mean in general a heavier workload at this unit. However,we have made the assumption that four more patients might notaffect quality of care to the amount that it has an impact on

NSOI and instead have drawn a very cautious conclusion thatother factors such as working methods also may have influencedthe outcome. While we know that in unit B the nurses workingmethod involved documenting all the steps in the nursingprocess, we do not know whether the nurses in unit A workedalong those lines, although they did not actually document theprocedure. We also have no knowledge pertaining to the qualityof the documentation produced by unit B. A previous study [24]revealed that nursing diagnoses are often non-specific and inac-curately formulated, leading to inappropriate nursing goals andinadequately defined nursing interventions. The nurses in unit Bwho documented care plans did not employ the classificationsystem for diagnosis, outcome and interventions. A previous

study [25] demonstrated that the implementation of the classifi-cation systems NANDA, NIC and NOC led to a higher quality ofnursing diagnosis documentation as well as etiology-specificnursing interventions and outcomes. Nevertheless, studies [5,6]have revealed that even when the steps are documented withouta specific format, nurses exhibit a higher level of nursing exper-tise orientation; thus, for this reason, we wished to investigatewhether the documentation of care plans has an impact onNSOI.

The NSOI recognized by the literature can also be influenced bymany other factors, for example, the organization of care in termsof structure and available resources, the work of other professional

Table 5 Use of health caren Unit A n Unit B P

LOS, average 52 12.46 days 35 6.26 days 0.004

Planned follow-up visits

Hospital 34 12% (n = 4) 26 27% (n = 7) n.s.

Outpatient clinic 34 44% (n = 15) 26 31% (n = 8) n.s.

Emergency visits

Hospital 33 15% (n = 5) 26 8% (n = 2) n.s.Outpatient clinic 33 18% (n = 6) 26 4% (n = 1) n.s.

Discharged to

Own home 52 75% (n = 39) 33 70% (n = 23) n.s.

Own home with rehabilitation 52 6% (n = 3) 33 10% (n = 3) n.s.

Municipal accommodation 52 10% (n = 5) 33 0 n.s.

52 6% (n = 3) 33 0 n.s.

Municipal accommodation with

rehabilitation/geriatric rehabilitation

52 4% (n = 2) 33 (21% n = 7) n.s.

LOS, length of stay; n.s., not significant.




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categories, the well-being of patients and their family members,previous experiences of care, etc.

In order to minimize the risk of organizational changes in theunits, we wished the data collection period to be as short aspossible, which contributed to the small number of participants.Nevertheless, certain measurable differences emerged between theunits, which may have been more obvious had the study been

conducted with a larger number of participants. Another limitationmay be the fact that patients who perhaps have the greatest need ofcare planning, that is, those with a very poor health status, wereexcluded from this study because of cognitive failure, which meantthat they were unable to give their informed consent and completethe questionnaire. More patients in unit B had assistance from anext of kin when filling in the questionnaires than in unit A, whichmight reflect the fact that patients in unit B were in a worsecondition. However, when comparing data from the NSR, thisassumption was not confirmed. Finally, it is difficult to tell whetheror not the answers from unit B reflect opinions from the next of kinto a greater extent than in unit A.

Discussion of findings

Functional NSOI

Usual activities pain/discomfort and anxiety/depression during the23 weeks following discharge constituted problems for thepatients in both groups. According to a previous study [1], pain isthe most common nursing diagnosis, and participating nurses fromunit B stated that they often produced individual care plans on thisbasis. Despite this, no difference was found between the units inthis respect. Nor did the question in the QPP pertaining to painreveal any differences in how patients perceived the pain reliefmedication received during their hospital stay. With regard to

activities, the participating nurses from unit B stated that theydocumented both individual and standardized care plans.However, despite this, we were unable to observe any differencesin this area, which may be due to the care plans having no effect onnursing care, that the study population was too small or that theinstrument employed was not sensitive enough.

Clinical and perceptual NSOI

A study by Wilde Larsson et al. [26] revealed that the patientsperception of the quality of care is influenced by his or her level ofHRQOL. The fact that the HRQOL as measured by the EQ-5D wasidentical at the two units strengthens the result of the instrument

that measures quality from a patient perspective (QPP).In Axelssons study [6], the nurses perceived that nursing diag-nosis clarified the patients individual needs. In our results morepatients in unit B stated: My care was carried out in accordancewith my own requests and needs rather than staff procedures,which may indicate that the patients cared for in unit B wherenursing diagnoses were employed, also perceived that the care wasguided by their individual needs to a higher degree than in unit A,where nursing diagnoses were not used. A previous study [24]revealed that nursing diagnoses do not always agree with thepatients perception of his or her problem and needs, althoughthe present study indicates that such diagnoses lead to more

individualized care compared with cases where they are notemployed.

Earlier studies [27,28] demonstrated that patients do not per-ceive themselves as involved in the care that they receive in theward and prefer to play a passive role. In this present study we donot know how the answer is in this specific question.

The fact that more patients in unit B reported that: I was given

a good opportunity to participate in decisions that applied to mycare could be an indication that care plans allow patients tobecome more involved in their care. In further studies it might beinteresting also to review the nursing documentation regardingboth quality and quantity of recorded nursing interventions.

According to the ICNs code of ethics for nurses [29], respectfor human rights, including cultural rights, the right to life andchoice, to dignity and to be treated with respect is inherent innursing. The nurses in both units appear to have succeeded incommunicating this attitude to the patients, as the latter were verysatisfied at being treated with respect and at the nurses payingthem attention. This aspect of nursing thus functioned satisfacto-rily, irrespective of whether or not care plans were documented.

Safety NSOI

The patients who participated in the study suffered few complica-tions during their time in hospital in the form of fractures, throm-boses and pneumonia. It would have been interesting to measurewhether the incidence of these complications was greater amongthe most seriously ill patients with the largest care need who wereexcluded from the present study. As the nurses in unit B docu-mented care plans pertaining to the risk of falls as well as toactivities where the possible outcome could be fractures or throm-boses, it would be interesting to measure these indicators in alarger study where differences might occur because of the use of

care plans. It would also have been interesting to measure theincidence of falls and pneumonia at the units, the latter being themost common NSOI according to Blegen [11].

Use of health care NSOI

The large difference in length of hospital stay is noteworthy.Although unit B, in which care plans were documented, had sig-nificantly shorter care times, it is not possible to infer that this isdue to structured nursing care based on care plans. An explanationmay be the fact that the patients in unit A also remained in the wardfor long-term rehabilitation, while the patients in unit B weretransferred to a rehabilitation department if their need for rehabili-

tation was estimated to be extensive.A major problem described in studies measuring NSOI [11,13]is to ensure that nurses employ the correct documentation in rela-tion to the various indicators. Blegen [11] states that we needstandardized data of patient outcomes in order to conduct morerigorous studies than in the past. Muller-Staub [2] concludes thatstandardized terms in the documentation make it easier to measurethe quality of nursing. Nursing documentation can be seen as oneform of NSOI [4] and this becomes particularly obvious when wetry to measure the effect of something that is not clearly docu-mented. Care plans could result in improved quality of care as wellas constitute a measure of high-quality care.

I. Jansson et al. Evaluation of documented nursing care plans

2009 The Authors. Journal compilation 2009 Blackwell Publishing Ltd 617


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Conclusions

It is difficult to evaluate whether documented care plans affectpatient outcomes, as there are many other factors that have animpact. Nevertheless, the present small study revealed that patientswho were cared for on the basis of documented care plans per-ceived not only that the care was more individual, that they had a

greater opportunity to participate in decision making, but also thatthe use of care plans had no influence on patients experiencedHRQOL, prevalence of unexpected complications or use of healthcare after hospital discharge.

We were unable to establish whether care plans affect patientoutcome but conclude that nurses need to document care planscomprising nursing diagnosis, interventions and outcome in orderto be able to measure the quality of the nursing care provided. Theuse of standardized terms in this documentation would furtherfacilitate the measurement of quality of care. A larger study inves-tigating how documentation affects patient outcome could, in con-junction with an intervention comprising the implementation ofdocumentation of diagnosis, interventions and outcome, also

measure NSOI both before and after the implementation.

Acknowledgements

This study was performed by valuable assistance from one clinicalnurse specialist at each stroke unit as well as from Kalle Svenssonand Tina Rinaldo at Improve IT, Halmstad. We also gratefullyacknowledge Assistant Professor Jos Ferraz Nunes for adviceregarding the design and Assistant Professor Monika FagevikOlsn for advice regarding statistical analysis.

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