Nursing documentation: non-physical dimensions of end-of-life care in acute wards

Int J Palliat Nurs. 2005 Dec;11(12):632-6. doi: 10.12968/ijpn.2005.11.12.20230.

Abstract

Aim: to explore discrepancies between nurses' knowledge and their documentation of issues of psychosocial, spiritual and cultural aspects of palliative care, evidenced clearly in recent nursing research into end-of-life care in an acute care, teaching hospital.

Design: the study involved a retrospective patient case-note audit of an opportunistic sample of 20 patients deceased recently and interviews of the two nurses most involved in the care of each patient (n=40).

Findings: this research indicates that nurses in acute care settings often recognize, sometimes explore, but infrequently document psychosocial, spiritual and cultural aspects of care.

Conclusion: there is a strong need for: (1) education about both the impact of non-physical dimensions of patients' lives and the effective documentation of these dimensions; and (2) up-grading of documentation tools to better facilitate documentation of non-physical aspects of palliative care.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adaptation, Psychological
  • Adult
  • Culture
  • Documentation*
  • Female
  • Holistic Nursing*
  • Hospital Units / organization & administration*
  • Humans
  • Male
  • Middle Aged
  • Nurse-Patient Relations
  • Nursing Audit*
  • Nursing Records*
  • Palliative Care*
  • Retrospective Studies
  • South Australia
  • Spirituality