Knowledge Tree

Development and Implementation of Person-Centred Nursing Documentation

Authors:Susan Daly

Abstract Introduction: Irvine et al (2006) assert structured documentation can improve resident care by limiting vague narrative style entries. Nevertheless, in practice the personal and individual aspects of care can only be recorded through a person-centred approach to care planning (Broderick & Coffey 2012, Butterworth 2012, Prideaux 2011). Nurses are therefore challenged to balance the factual, non-speculative principles of good record keeping with a person-centred approach to writing that acknowledges the residents perspective (Butterworth 2012).Short description of change implement: The Kerry Community Hospitals/ Nursing Units undertook a planned, gradual and inclusive process of change that involved the redesign of structured nursing documentation into a nursing care record that facilitated the creation of individualised contemporaneous person-centred care plans.Aim and theory of change: This project aimed to improve the nursing documentation (assessment, care plan and evaluation) used throughout the 6 Kerry Community Hospitals/ Nursing Units as a step towards providing testament to the person-centred care being delivered. The Lewins (1951) force –field analysis change model has been utilised to support successful change.Step 1: Unfreezing (2016)stakeholders are made aware of the need to changeproject team created to steer the innovationMulti-disciplinary team involvedNew document createdExternal review Step 2: Moving (2016/ 2017Experimenting with new ideas – additional projects initiatedCollaborative consultative processInternal and external education for RGNs on creating individualised person-centred care plansResource folders createdPhased introduction of new document Step 3: Refreezing (2017)Reinforcing and integrating the changeMotivation (effective communication & continuing education)Audit & Review – Evaluating the effectiveness of the new documentation in practice Targeted population and stakeholders: Nurses, Clinical Nurse Managers, Directors of Nursing, Area ManagerTimeline: 12 months to create and pilot the documentation and 12 months to implement in all sitesHighlights: (innovation, impact and outcomes) Successful implementation of a new style of nursing documentation that supports a comprehensive biopsychosocial assessment using validated evidence based tools, which support and guide the development of contemporaneous person-centred care plansResidents involvement evident in the care planning and evaluation processPositive feedback from HIQA inspectorIntroduction of- ISBAR record for contacting the doctor- PINCH ME Assessment- AVPU AssessmentComments and sustainability: Regular auditing and evaluation to insure continued success and ensure necessary modifications are addressed.Comments and transferability:Implementation throughout the 6 Kerry Community Hospitals/ Nursing UnitsCreation of 318 person-centred care records176 nurses (including nurse managers) engaged in the changeTransferable to other designated centres for older adultsReferences: 1- Broderick MC, Coffey A. Person-centred care in nursing documentation. International Journal of Older People Nursing. 2012; 8: 309 -318.2- Butterworth C. How to achieve a person-centred writing style in care plans. Nursing Older People. 2012; 24(8): 21-26 3- Irvine K, Tracey M, Scott A, Hyde A, Burtler M, Mac Neala P. Discursive practices in the documentation of patient assessment. Journal of Advanced Nursing. 2006; 53(2): 151 – 9 4- Prideaux A. Issues in nursing documentation and record – keeping practice. British Journal of Nursing. 2011; 20(22): 1450 – 1462.


contemporaneous, person-centred, care plans

How to Cite:

Daly S. Development and Implementation of Person-Centred Nursing Documentation. International Journal of Integrated Care. 2017;17(5):A540.

DOI: on 17th October 2017