Aims and objectives: To explore nursing documentation in long-term care, to determine whether it reflected a person-centred approach to care and to describe aspects of PCC as they appeared in nursing records.
Background: Documentation is an essential part of nursing. It provides evidence that care has been carried out and contains important information to enhance the quality and continuity of care. Person-centred care (PCC) is an approach to care that is underpinned by mutual respect and the development of a therapeutic relationship between the patient and nurse. It is a core principle in standards for residential care settings for older people and is beneficial for both patients and staff (International Practice Development in Nursing and Healthcare, Chichester, Blackwell, 2008 and The Implementation of a Model of Person-Centred Practice in Older Person Settings, Dublin, Health Service Executive, 2010a). However, the literature suggests a lack of person-centredness within nursing documentation (International Journal of Older People Nursing 2, 2007, 263 and The Implementation of a Model of Person-Centred Practice in Older Person Settings, Dublin, Health Service Executive, 2010a).
Method: A qualitative descriptive study using the PCN framework (Person-centred Nursing; Theory and Practice, Oxford, Wiley-Blackwell, 2010) as the context through which nursing assessments and care plans were explored.
Results: Findings indicated that many nursing records were incomplete, and information regarding psychosocial aspects of care was infrequent. There was evidence that nurses engaged with residents and worked with their beliefs and values. However, nursing documentation was not completed in consultation with the patient, and there was little to suggest that patients were involved in decisions relating to their care.
Implications for practice: The structure of nursing documentation can be a major obstacle to the recording of PCC and appropriate care planning. Documentation that is focused on the 'person' will contribute to a more meaningful relationship between nurses and residents.
Keywords: documentation; nursing; older people; person-centred practice; residential care.
© 2012 Blackwell Publishing Ltd.