Improving the use of the nursing process: the impact of charting methodology developed from King's conceptual framework on the use of the nursing process

Abstract

The purpose of this study was to assess the effects of changing a nursing documentation system, developed from King's Conceptual Framework, on the use of the nursing process. The null hypothesis was that there would be no significant increase in the reflection of the use of the nursing process on the nursing care plan or nurses' notes, as a result of using a nursing documentation system developed using King's Conceptual Framework (1981). The design involved the development of a questionnaire that was used to review health records pre and post implementation of a documentation system developed based on King's Conceptual Framework and Theory of Goal Attainment (1981). A Record Completeness Score was obtained from some of the questions. The null hypothesis was rejected. The results of the study have implications for nursing administration and the evaluation of nursing practice. If the use of a documentation system developed from a conceptual framework increases the reflection of the nursing process on the patient's health record, nursing will have the means to measure patient outcomes/goal attainment. All health care organizations and levels of government are focusing on methods to monitor and control the health-care dollar. In order for nursing to clearly determine the costs associated with nursing care, measurement of patient outcomes/goal attainment will need to be possible. In order to measure patient outcomes/goals attainment nurses will need to be able to collect data on their practice. It will be critical that nursing have a documentation system in place which facilitates the reflection of the nursing process within a theoretical framework.