Evaluating an intensive ward-based writing coach programme to improve nursing documentation: lessons learned.

Aim: This study aimed to develop a ward-based writing coach programme to improve the quality of patient information in nursing documentation.

Background: Omissions in the patient information make nursing notes an unreliable source for care planning. Strategies to improve the quality of nursing documentation have been unsuccessful. An education programme, with one-to-one coaching in the clinical environment, was tested.

Method: A concurrent mixed methods approach including a pre-post test intervention and control design for the quantitative component combined with a qualitative approach using a focus group (eight nurses) was used. Healthcare records for 87 patients (intervention) (46 pre and 41 post) and 88 patients (control) (51 pre and 37 post) were reviewed using the Nursing and Midwifery Content Audit Tool for quality nursing documentation. Sixteen nurses from two intervention wards participated in an introductory workshop with 2 weeks of coaching. No intervention was given to the control ward.

Results: No significant differences were found between the wards across the 14 criteria representing quality documentation; most criteria were present in 75% or more of the records. Improvements were demonstrated in both the intervention and comparison units. Themes identified from the focus groups included the impact these changes had on nurses and patients, perceived difficulties with nursing documentation, medicolegal aspects and the attributes of an effective writing coach.

Conclusion: Writing coaching is a supportive approach to improving nursing documentation. Also, regular auditing prompts nurses to improve nursing documentation. Further research using larger sample sizes can further confirm or refute these findings.