Introduction The key aim of recording information in patient’s medical records is toimprove the delivery of effective person-centered care; support clinicaldecision-making and to enhance communication between allied healthprofessionals (Zegers, 2011). Nursingstaff play a significant role in the effective management of delivery ofcommunication (Nursing and Midwifery Council, 2015). Nursing documentation is afundamental aspect of patient care, ensuring quality assurance and clarity ofthe care being delivered (Stevenson, 2012).
Currently within the National Health Service (NHS), electronic healthrecords are implemented positively within doctor surgeries, within theradiology and pathology department of hospitals, mental health providers and withinthe community care environment (Slabodkin, 2013). Within Scottish health-boardsnurses and allied health-care professionals within an acute ward settingsdocument on paper-based documents. Problems can occur when obtaining paperbased records and it is considered labour demanding. Additionally, electronicnotes are more legible and easily accessed by health care professionals(Akhu-Zaheya, 2017). Within the wardenvironment, allied health care professionals such as: physiotherapists;occupational therapists; speech and language therapists; addiction teams andsocial workers, will assess an individual and will document in a variety of notes(Charalambous, 2016). However, healthcare workers may not have time toread these notes or know where exactly these assessments have been documented(Pain et al, 2017). Electronic systems would allow all health careprofessionals to examine assessments carried out by all staff to the specificdate and time. Providing an electronicrecord which is shared amongst the multi-disciplinary team which allowsretrievable patient data is viewed as a great advantage to the health caresystem (Chand, 2014).
Furthermore, electronic health care documentation isexpected to reduce redundancy and increase accessibility to latest notes andassessments (Hellesø, 2001). When nursing staffcommunicate with an individual’s relative or next of kin, it is documented on aseparate document. Allied healthcare professionals do not usually access thenursing notes or the relative communication sheets, which can possibly hindercare. Moreover, this reinforces the need for an electronic system which isupdated and accessible to staff. The use of paper-based documentation, could result in drawbacks incommunication including: varying terminologies and jargon; inadequate recordkeeping; using unsuitable abbreviations; unclear writing; illegal modificationof documentation; repetition of information; as well as leaving blank notes inthe wrong section and finally; missing nurses’ signatures within documentation(Jefferies, 2012; Yu, et al, 2013).
Healthcare professionals have a duty of confidentiality to individualsusing the system. Between the years of 2011-2014 there have been 7,255 cases ofNHS data breaches, including cases where clinicians had accessed patient data inappropriately.These risks can be managed in several ways by electronic system audit trails.
This can be used to monitor exploitation and may act as a deterrent (ParliamentUK, 2016). The elimination of handwriting provides more legible and accuratepatient records (Menke et al,2001). Electronic systems also aid in theminimisation of lost or damaged documentation which can occur in paper-basedcharting (Curtis, 2011). The electronic documentation system aids thefacilitation for more effective communication as computer and tablets withinthe hospital setting would be programmed with standardised templates and dropdown menus which would prompt nurses and allied health professionals to recordthe relevant data (Smith, 2005). Effective and clear communication between healthcare professionals isessential for the delivery of safe and person-centred care (Blom et al, 2015).Poor and ineffective communication result in pro-longed hospital stays andinadequate patient care (Judd, 2013). With aims of the introduction of an electronicsystem which all healthcare professionals can access in acute settings willenhance communication. Finally, the successful implementation of the proposedproject would enhance the relationship amongst health care professionals andstrengthen multi-disciplinary team working and care.
Outline and Justification To structure the change proposal Kurt Lewin’s model of change will beused (Lewins, 1947). This model of change offers a regulated approach that canhelp healthcare professionals recognise the need for change, direction throughthe process, and accomplish the anticipated outcome (Bozak, 2003). Lewinstheory (1947) consists of three stages including: unfreeze, change andrefreeze.
The first step of Lewin’s framework (1947), unfreezing, includes theidentification of the current need or issue. Through this initial stage, theremay be feelings of uneasiness, anxiety, and distress among the individualsinvolved. To “unfreeze” the current strategies in place, the leader of thechange must demonstrate and promote to the teams the driving forces for thechange and the goals set. Opinions and attitudes of the multi-disciplinary teamshould be obtained as the various disciplines will be affected by theimplementation of electronic documentation.
The stakeholder analysis is auseful tool to classify and win backing of key and powerful figures within theorganisation (Reyes-Alcázar, 2012). Nursing and allied health managers play asignificant role in promoting the change culture,ensuring staff have positive attitudes for the transition (Mathena, 2002). To successful implement electronic documentation, the powerfulstakeholders must support staff through transition this in turn, positivelyimpacts patient’s quality of care and organisational performance (Phillips,2013). This key step to promoting the first stage of the model, will highlightdriving forces for the implementation of electronic documentation. Thestakeholders must promote the desired goals from the change. Supporting thebelief that an electronic system that can be used by all health professionalswill enable all clinical data to be more secure, accurate and time effective(Bozak, 2003). TheRoyal College of Nursing (2017) affirm the significance of precisedocumentation and state accurate record keeping is essential for the safedelivery of care. Conversely,the legal implications of healthcare documentation; the law abides by if careor treatment are not recorded it can be assumed that it did not happen(Stevens, 2010).
Handwritten notes must be recorded with date, time and asignature of the individual completing the recording (The Nursing and MidwiferyCouncil, 2015). The implementation of electronic records would ensureautomatically accurate time and date is always recorded once the user logs intothe system using their specific identification number and password. Effective collaboration between multi-disciplinary teams has proven to advancepatient outcomes (Reinke,2011).
However, this can only be successful when staff have role clarity andappropriate training (Bosch, 2015). Furthermore, the implementation ofelectronic health data, would be driven by the stakeholder’s provision of adequatetraining for colleagues which potentially would allow staff development ofskills and knowledge. The staff confidence of the delivery training willdiminish any fears or apprehensions to the change. Finally, unfreezing thecurrent use of paper-based documentation would be strengthened by supportivemanagement and positive culture in the acute setting (Hummerston, 2014). The process of implementing the proposed plan is Lewins (1947) secondstage of the model, known as “change” (Sassen, 2009). At this stage, theleaders of the change should highlight the benefits of the change and begin toput the electronic system into practice. Conducting a pilot study within NHS Ayrshireand Arran, one of the smaller Scottish health boards would be more appropriatethan NHS Greater Glasgow and Clyde.
The purpose of the trial is to examine thefeasibility of the electronic health system that is anticipated to be used on agreater scale (Leon, 2011). Continuing education throughout the process isvital alongside avid communication skills for transition (Henly, 2016). Nursesand allied health care teams must meet up regularly with leader to discuss whatis working well at the current time and what needs improved, to enhanceoutcomes of the strategy. Additionally, action plans should be created by eachteam to aid the discussions of any issues as this will encourage leaders andteams to tackle any negative emotions regarding the transition (Visser, 2013).
Theacceptance and successful change from paper-based documentation to anelectronic system will allow staff to proceed into the final stage of theframework. Health care professionals must abide by and consider The United KingdomData Protection Act (1998) throughout this change. The act is in place toprotect individuals against exploitation and mishandling of informationregarding them. The act defines how information should be appropriately managedlegally for those living within the United Kingdom. Breeching the act canresult in dismissal and cessation of contract (Wright, 2002). The use ofelectronic documentation will optimise auditing which will protect citizens forthe safer delivery of care (Yu, 2013). The final stage of Lewins (1947) model is “refreeze”. At this point, anequilibrium is met and evaluation of the system can be commenced.
Evaluationand reflection is critical to promote advancement in the profession and to assessthat all clinical data is professional, accurate and comprehensive (Bagay,2012). Information technologists should continue to educate staff and, new teammembers to ensure of a high standard education of the electronic systems.Training days should be implemented for new software and technology includinguse of tablets and other portable electronic devices. Training days play acritical role within electronic healthcare, they enhance professional’s knowledge;understanding of the system and ensure staff complete documentation accuratelyand efficiently (Lopez, 2017). Transformational leadership is a popular theory used within thehealthcare system. Transformational leadership is defined as a method thatcauses transitions in individuals and, the health and social system. The aim ofthe theory is to generate effective and affirmative change within the team withthe end target aiming to have created assertive leaders (Luzinski, 2011). Additionally, the transformational leadershipprocess encompasses working in an inter professional team with various leaders.
The managers have a clear goal of what they wish to achieve and how theworkplace should function (Robbins, 2007). The change to an electronic systemis the vision of the leader, however, the team can state their opinions andthoughts of the transition throughout the process. This creates a sense ofrecognition and belonging throughout the team which optimises the staffsambition of successfully implementing the desired goals (Bujak, 2005). Finally, leadersmust promote continued professional development (McQueen, 2017). The projectwill require individuals involved to be proactive within their team to beinvolved with training day participation and encouragement within the team tostrive towards the aims through advanced education. The Royal College ofNursing (2017) further develop this by declaring that it is a necessaryrequirement for staff to be up to date in the usage of electronic systems intheir clinical area and employees must be competent of the practice of thesystems.
Evaluation Nursing and allied health professional documentation is a fundamentalindicator of how and when care and treatment was delivered (Wilson, 2012). Assessingthe quality of the implementation of the electronic system will provide insightinto how successful the transition was within the health board. Qualitative research in the form of focus groups where participants areopen to share their opinions and experiences of the project is a way in whichdata will be collected (Gelling, 2015). Aiming to investigate what worked welland what would need improved when implementing this change within other healthboards across Scotland. The focus groups will consist of a member from eachdiscipline and will be conducted two weeks following the introduction of thenew system. Furthermore, quantitative data will be collected in the form ofelectronic anonymous questionnaires.
Questionnaires will be issued to staffafter each training session. The collection of this data will conclude if staffbelieved the training is of adequate standard to safely implement the change.The data collected will conclude the safeness and effectiveness of the systemin regards to, delivery of care. Auditing tools areuseful for the detection of understanding positives and negatives within a service(Shuldham, 2017).
Audits can progressto action plans which are essential for continuation of learning (REF). Auditswill be carried out to safeguard healthcare users that their care is beingdocumented efficiently and accurately. Audits carried out will ensure safety isbeing maximised (Ref).
Significant improvement to recordings within the acutesetting would justify the expansion of the system. Conclusion The introduction of an electronic system replacing paper-baseddocumentation aims to maximise the delivery of care. Ensuring that, nurses andallied health professionals can document in one place electronically which canbe easily accessed within the acute setting provides maximisation of thedelivery of person-centred care. The aim also highlights the importance ofprecise and efficient recordings.
It optimises accuracy of when the document isbeing recorded and, prevents illegibility and illegal modifications ofdocuments.