Designing and implementing an electronic nursing record to support compassionate and person-centred nursing practice in an acute hospital using practice development processes

Abstract

Background

The complexity of nursing practice can pose challenges to the development of an e-record that meets all the requirements and standards whilst capturing the essence of the relationship between the nurse and his/her patients.

Aims

1. Describe the process of designing the content of an electronic nursing record (e-record) specific to nursing in an Irish/UK context, using Practice Development (PD) methodology.

2. To share the learning of involving the end-user in the development of a person-centred e-nursing record.

Methods

Evidence-based PD methodologies, principles and evaluation tools were employed to involve end users in the development of a person-centred and evidence-based e-record.

Results

The results are limited to evaluation of the design process and reported using the SQUIRE guidelines for reporting quality improvement. Investing in time to involve end users in the design and implementation phase resulted in satisfaction and adoption of the e-record by nurses.

Conclusions

For nurses to be satisfied with the content and process flow of an e-nursing record it needs to include the relational and non-clinical aspect of nursing practice in addition to the clinical pre-set content. Involving the end user in a meaningful way supports a positive outcome.

Keywords

electronic nursing record nursing documentation: practice development person-centred practice nurse/patient relationship acute hospital

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