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[Preferences for everyday living written in the nursing record - An explorative document analysis in various nursing
Mike Rommerskirch-Manietta1, Martina Roes1, Rebecca Palm1
1Deutsches Zentrum für Neurodegenerative Erkrankungen e.V., Department für Pflegewissenschaft, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten.
Abstract:
Preferences for everyday living written in the nursing record - An explorative document analysis in various nursing settings Abstract. Background: In Germany, there was previously no instrument for the systematic recording of preferences for the everyday living of older and people in need of care. Subsequently, in a pilot study, an instrument was translated in a culturally sensitive way (PELI-D), piloted and tested psychometrically. In terms of documentation quality, it is important that the preferences recorded by nursing staff are written down in the nursing record using PELI-D, plausibly based on the nursing process.
Aim:
To find out which preferences, assessed by the nursing staff in the pilot study with the PELI-D, were written down in the nursing record.
Methods:
An exploratory document analysis was carried out. Included were 13 nursing records and five discussion participants from five institutions in three nursing settings. The data were evaluated descriptively and by a structuring content analysis.
Results:
A total of 2% of the preferences, which were assessed with the PELI-D, were found in the nursing records and may be due to the use of PELI-D. Preferences mainly from the categories "interventions" and "biography" were found in the nursing record.
Conclusions:
98% of the preferences assessed with the PELI-D were not written down. This can probably be attributed to the fact that the PELI-D was an "innovation" for the nursing staff. Therefore, the execution of an implementation study seems to be reasonable to improve the plausibility of the captured PELI-D data in the nursing documentation. In the context of this, it is also recommended to analyze how the PELI-D influences nursing processes and contents of the nursing record.
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