The development of nursing document control procedures: a process of organisational change

There were two distinct aims of this research study; firstly, to gain a greater understanding of nursing documentation practice, and, secondly, to study the management of change within a health care setting. The importance of creating high quality nursing documents for the purposes of recording patient care is well emphasised within the published work of key health care figures, such as the Nursing and Midwifery Council (2010) and the Health Service Ombudsman (2006); however the necessary guidance to achieve such high quality documents appears to be lacking. Previous studies have been inconclusive in diagnosing the root causes of nursing documentation issues, and consequently, recommendations for improvement have largely involved the redesign of a single document, which have often failed to address the underlying problem. Collectively, the inconsistencies within the literature marked the need to undertake further research, in order to thoroughly investigate nursing documentation practice and to better understand the organisational and cultural barriers to the successful implementation of change within the NHS.

The research took a case study approach which involved an investigation of nursing documentation practice and organisational change within a single organisational setting. A two phase methodology was developed in order to collect sufficient levels of data to form research findings. Firstly, an analysis of 161 documents provided a degree of quantitative data to gain a greater understanding of the standard of nursing documents in use within the case study organisation. This was followed by eleven semi-structured interviews and a focus group in addition to the use of a diary log, kept by the researcher, to record key observations over a two year period.

The main findings provided evidence of a lack of formalised procedure for the development and management of nursing documentation within the case study organisation. Authors of nursing documents did not always see their role as „educators‟, however a number of nurses interviewed within the purposes of the research voiced concerns in relation to a lack of understanding, and, when tested, gave differing responses and interpretations as to the meaning of some of the assessments contained within key nursing documents.

Whilst an improvement model was developed to address some of the issues encountered throughout the research, strong messages emerge in relation to the successful management and implementation of change within a health care setting. A perceived cynicism of change in addition to the entrenchment of routines and procedures were key defence mechanisms used by the nursing workforce.