Recording Care – The Challenge Ulster University 13 th January 2016

Recording [nursing and midwifery] Care What’s the point?

The quality of a registrants record keeping is a reflection of the standard of their professional practice. Good record keeping is a mark of a skilled and safe practitioner, while careless or incomplete record keeping often highlights wider problems with that individual's practice.’ (NMC 2007) NMC Fitness to Practice Hearings Failure to Maintain Adequate records 07/08: 10.37% 08/09: 8.53% 09/10: 9.57% 10/11: 4% 11/12: 8.9% (n=4250)

‘ In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison....’ Florence Nightingale 1863

‘Mrs Harry denies a series of charges dating between 1998 and 2006 and related to alleged failures to ensure adequate nursing staffing levels and appropriate standards of record keeping, hygiene and cleanliness, administration of medication, provision of nutrition and fluids and patient dignity.’

January 2009 Purpose Meeting Literature Review: Factors Influencing Quality of Registrant Record Keeping The Value and Purpose of Record Keeping Audit Information Recorded Competence to Record Professional Supervision Patient Awareness/ Inclusion Issues Related to Time

What it’s not.....

What it is.....

Aim: To implement an agreed Regional HSC Nursing Document, and improvement methodologies, tools and resources developed during the RRKI to facilitate improvement in the standard of nurse record keeping in Northern Ireland and to promote a culture which supports person-centred record keeping practices.

Facilitated within HSC Trusts ( 5 Secondment Band 7 Professional Officers – one in each Trust) Strand 1: Piloting a new Regional Person Centred Nursing Assessment and Plan of Care (RPCNAPC) Document and development of standards for nursing and midwifery record keeping practice Strand 2: Implementing the Recording Care tools and resources

Paula Boyle SHSCT Jane Patterson SEHSCT Sandra Hogg WHSCT Siobhan Shannon NHSCT Sonya McVeigh BHSCT Angela Drury NIPEC (Lead Officer)

Recording Care

Recording Care at the Bedside

Changing Practice Time and Effort Work-based Activities Focus on Person-centred Practice Learning Integrated into Practice Encouraging Teams

Final report Standards for Nursing and Midwifery Record Keeping Practice Regional person-centred nursing assessment and plan of care document Improved record keeping practice - 30% increase in audit scores Outcomes

Ongoing Work System of accountability to regionally monitor standards of nurse record keeping practice Endoscopy Day Case Record Under 24 hour stay record Health Care Support Worker Practice Regional Abbreviations policy (sep project) Children’s Record & improvement cycles Learning Disabilities Record and improvement cycles Care planning Key Performance Indicator development

Ongoing Work Review of NOAT Review of web resources Review of Record Keeping Guidance Links to revalidation

What next?

Nursing Component: The Challenge

How did we get to where we are? Continuous Recording Care audit cycles demonstrated that compliance targets for care planning were unmet against the indicators within the NIPEC Online Audit Tool (NOAT) each reporting quarter.

Approach ….. Meeting November 2014 informed by: improvement work over the previous two years a literature review piloting of a new model of care planning in two trusts.

Literature Review Literature review presented the following findings: No new care planning models uncovered Effective care plans demonstrated involvement of patients and families Need to continuously reflect and review the standard of care plans

Team effectiveness and communication improved through multi-professional formats Organisational investment required Core skills relevant to planning care should be clearly defined and addressed within practice areas. Literature Review

August/ September 2014 Pilots Pilots reaffirmed previous findings Nurses lacked required skills to record planned nursing care appropriately exemplified by repeated failure to: link identified need to plan of care record evaluations linked the plan of care record outcomes linked to the plan of care and identified need

Agreement Nov 2014 Protocols/standard operating procedures for evidence based care not used Clear description of the patient’s journey reflecting patient involvement Clear description of evaluation of the care planned against assessed need to an agreed goal of nursing care Consideration of new technologies and utility for e-records.

Care Planning Summit 12 th January 2015 and March WG Meeting Protocols/standard operating procedures should not be used within plans of care Nursing standards for care processes which can be referred to within each clinical setting Care Plans should represent a clear description of the patient’s journey through a service Involvement of the patient should be clearly articulated within the record

Daily assessment should be evidenced against ADLs and needs recorded as they arise – i.e. nurses should not be recording potential needs but actual needs as they arise Recording care should be at the bedside of the patient or as close to the point of care delivery Handover should be driven by the plans of care

Evaluation should be set against care planned against assessed need The goal of care is presented in the care planned The skills of nurses to engage in a new process should be addressed along with a system of change management

Presentation to EDoNs 24 th April Acknowledgement of problem Acceptance of principles Goal orientated care NHSCT approach presented

Meetings June, July and August 2015 Debate and discussion about current approaches Front-line staff, Assistant Directors of Nursing, lead nurses, HEIs and NIPEC Agreement of a way forward and pilot process Outlining of pilot process

PACE P – PERSON CENTRED A – ASSESSMENT C – PLAN OF CARE E – EVALUATION

Process Pilot during 31 st August 2015 – 18 th September wards in each Trust – 1 x medical, 1 x surgical and 1 x care of the older person. 2 people on each ward had their care plans recorded in the pilot format.

Governance Consistency Workshop 25 th August 2015 ADNs responsible for operational management of the pilot. NIPEC officers acted as a support to the ward champions and Trusts, where required. Documents used for pilot purposes all clearly stated Trust Nursing Practice Pilot 2015 at least once per single loose piece of paper. Any format of document might be used – uni or multi-professional.

Evaluation AUDIT – USING NOAT FOCUS GROUP This exercise explored in the opinion of the champions: What worked well What didn’t work well The experience of implementing change – barriers and enablers What future support might be required for a wider roll out

Findings Audit 40% improvement in care planning section of NOAT Focus Groups Evidence of person centred/ family centred approach Increased contemporaneous record keeping Increased effectiveness in communication Clear picture of the person’s journey through a service Accountability and professionalism increased Ownership

What next? Presented to CNO/EDoN meeting Agreement for formal pilot Agreement for facilitation to enable Evaluation – link to HEIs, IHI and Person- centred Practice framework (McCormack and McCance, 2010)

And finally…..

People at the Centre Nothing about me without me.....