Recording Care – The Nursing Challenge Angela Reed, Senior Professional Officer Michelle Burke, Professional Officer

‘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.’

What it’s not.....

What it is..... Practice!

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

Recording Care 2009 - 2016 2009 2010 2011 2012/13 2014 2015 2016

& ‘s “It ain’t what you do it’s the way that you do it, and that’s what get results…” X X

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

Partnership with Practice How? Time and Effort Partnership with Practice Work-based learning Improvement demonstrated in Practice Encouraging and engaging with teams

Outcomes 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 in-patient record Review of NOAT Review of Record Keeping Guidance and Standards

Ongoing Work Children’s improvement cycles Learning Disabilities record and improvement cycles Care planning Key Performance Indicator development Review of web resources Links to revalidation

Audit Tool: Short NOAT

Audit Tool: NOAT

Short NOAT

Audit Tool: NOAT

Quarterly Quality Focus

Learning

Learning Regional Sign-up Leadership (Executive Nurse to Champion – CNO commission) Facilitation Listen to the frontline Clear goals Accountability Tenacity and Enthusiasm Value and mark achievement (Never give up)

How did we get here? 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 so far….. Information meeting November 2014 Care planning summit January 2015 Meeting Strand 1 March 2015 Presentation to EDoNs/CNO / CE NIPEC April 2015 Review of NHSCT approach May 2015 ERG meetings June, July and August 2015 Pilot Aug Sept 2015

Approach so far….. Evaluation presented to EDoNs/CNO / CE NIPEC November 2015 Funding agreed for facilitation Jan 2016 Pilot Feb/April 2016 Evaluation May/June Meeting EDoNs/CNO/ CE NIPEC July 2016

PACE PERSON ASSESSMENT PLAN OF CARE EVALUATION

PACE

Pilot and Evaluation 3 wards selected in each HSC Trust Children's ward BHSCT Mix of experience using PACE Baseline evaluation data 8 week pilot across all records Midway evaluation review End of pilot evaluation

Evaluation Tools Agreed at Steering Group Directed by frontline staff Resources developed Training provided Learning from the pilot

Evaluation Tools Service delivery: Improved satisfaction response in relation to nursing care Methods of data collection: Patient  satisfaction surveys Patient experience: Evidence of greater inclusion Evidence of participation in care processes Evidence of better communication NOAT audit Patient  surveys Observations in practice Nursing care outcomes:  Improved nursing care planning Benefits for staff: Evidence of greater expressed autonomy Time spent recording nursing care Time spent with the patient recording nursing care Evidence of reported improved professionalism Evidence of reported greater job satisfaction Focus group Time in Motion Study  

Agreement – Once for NI

Spread Plan

Resources www.nipec.hscni.net