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International Journal of Nursing Practice 2013; 19: 8187

RESEARCH PAPER

Evaluation of nursing documentation on


patient hygienic care
Nurcan Kksal Inan RN
Nurse Educator, Suphan cad. Merkez, IMKB Van Anadolu Saglk Meslek Lisesi, Van, Turkey

Leyla Din RN PhD


Associated Professor, Nursing Department, Faculty of Health Sciences, Hacettepe University, Ankara, Turkey

Accepted for publication April 2012


Inan NK, Din L. International Journal of Nursing Practice 2013; 19: 8187
Evaluation of nursing documentation on patient hygienic care
This study was conducted to evaluate nursing documentation on patient hygienic care and to analyze the consistency
between actual care given by nurses and that of documented in nursing record. Data were collected from 85 nurses
employed at critical care units, on whom 255 sets of observations were performed through a structured participant
observation form, which could be used to record the observation episodes and to audit nursing records. Results indicated
that the most frequent performed hygienic care was oral care, perianal care, hand washing and bed bathing. The
consistency between actual patient hygienic care and its documentation was 77.6%. The quality of nursing records was
poor and inadequate to reflect individualized nursing care. Results suggest that more emphasis is needed in nursing practice
and nursing education on the quality of record keeping in nursing to increase its evidential value.
Key words: hygiene, nursing care, nursing documentation, patients, record keeping.

INTRODUCTION
The nursing process is a rational and systematic problemsolving approach used as a scientific framework to organize individualized nursing care by identifying, preventing
or treating actual or potential health problems through the
phases of assessment, diagnosis, planning, implementation and evaluation. The nursing process is an ongoing
process as the evaluation phase requires reassessment of
the patient and documentation on whether the caring
needs of patient have been met or not. Documentation is
a vital component of all phases of nursing process.1,2

Correspondence: Leyla Din, Hacettepe Universitesi, Saglik Bilimleri


Fakultesi, Hemsirelik Bolumu, Shhiye 06100 Ankara, Turkey. Email:
leylad@hacettepe.edu.tr
doi:10.1111/ijn.12030

Documentation is any written or electronically generated information about a client that describes the care or
service provided to that client. Health records might be
paper documents or electronic documents, such as electronic medical records, faxes, e-mails, audio or video
tapes and images.3
Documentation is a professional and legal responsibility
of nurses. Nursing documentation serves for ensuring
continuity of care through communication, for the evaluation of the quality, efficiency and effectiveness of patient
care, and for providing evidence for legal, ethical, financial or qualityassurance purposes and research. Documentation also provides the database for planning future
health care, and contributes to nursing education and
knowledge base.36
At critical care environments, such as intensive care
units and emergency departments, nursing deals with
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82

life-threatening problems that require continuous assessment and intense therapeutic measures and interventions.
Failure to document any aspects of assessment and therapeutic procedures might threaten the continuity of care
and patient safety. Therefore, nursing documentation is
essential for ethical nursing practice and for protection of
patients rights.6
In order to be used as evidences for legal, professional,
ethical and financial purposes, the quality of documents is
important. Documentation should be comprehensive,
complete, accurate, factual, concise, timely and representative of professional observations and assessments.
Records should identify the person who provided or
documented the care.13,7 However, previous studies have
demonstrated that nursing documentation is inadequate,
incomplete or inappropriate.810 In a meta-synthesis study
of 14 qualitative research reports, Krkkinen et al.10
showed that individualized patient care is not visible in
nurses documentation of care, and ethical questions concerning the substance of nursing care documentation are
not discussed. Studies carried out in Turkey also indicated
that nursing documentation includes only records on
assessment of vital signs and administration of medications, but individualized patient care is not visible in
nurses documentation.1113
The provision of patient hygiene is one of the most
frequently performed individualized nursing care activities, which is usually decided by the sole judgement of the
caring nurse. It is generally performed at critical care units
such as intensive care units or neurology clinics where
patients are mechanically ventilated or confined in bed
due to life-threatening problems. Patient hygiene is associated with many benefits including removal of bacteria
and perspiration from the skin, reducing risk of infection,
stimulation of blood circulation, providing comfort and
relaxation and improving the patients self-image and
emotional well-being. It also provides nurse the opportunity to interact with the patient and assess the patients
medical condition and physical state. Furthermore, the
provision of patient hygienic care is one of the visible
nursing care activities if documented. However, few
studies have demonstrated that hygienic care activities of
nurses are also poorly documented.11,13 The lack of proper
and/or poor documentation in nursing can negatively
impact patient care and can impede the effectiveness,
quality and visibility of nursing work. There is a lack of
empirical data specifically on nursing documentation of
patient hygienic care. Thus, this study aims to contribute
2013 Wiley Publishing Asia Pty Ltd

NK Inan and L Din

to the debate about nursing records by reflecting the


nurses record keeping practices on patient hygienic care.
In particular, the aims were:
1. To describe the frequency patient hygienic care activities of nurses at the patients bedside of critically care
units.
2. To analyze the consistency between actual care given
by nurses and that of documented in nursing record.
3. To evaluate the quality of nurses general record
keeping practices.

METHODS
This descriptive study combined a structured observational study with an audit of nursing records. We adopted
a descriptive, observational design because our main aim
was to describe the actual patient hygienic care activities
and record keeping practices of nurses, rather than
exploring from the perspectives of participants or retrospectively auditing the existing records.

Study settings
The study was conducted at six intensive care units;
including coronary care unit, thorax and cardiovascular
intensive care unit, medical care intensive unit, neonatal
intensive care unit, neurosurgical intensive care unit, and
postanaesthesia care unit; and neurological clinic and
thorax and lung disease clinic of a large urban universityaffiliated teaching hospital in I zmir, Turkey. The hospital
has a total of 950 bed capacity, and 560 nurses were
employed. Critically care units were selected as study
settings because nurses spent most of their time on direct
nursing care in all critical care units and patient hygienic
care was practiced more frequently, which could be particularly informative with respect to this study.
At the time when the study was conducted, the hospital
did not use electronic documentation, but standard paperbased patient files or nursing data forms were used for
documentation.

Sample
The target population for this study was nurses working at
critical care units where patients are at most in need for
hygienic care. A convenience sample of 98 nurses was
drawn from the study settings, of whom 73 were
employed at intensive care units, 10 nurses at thorax and
lung disease clinic and 15 nurses at the neurology clinic.
Thirteen nurses who were working at coronary care unit

Nurses record keeping practices

were excluded from the study sample because they had


been included for the pilot study. Thus our sampling
included 85 nurses.

Preliminary investigation
A preliminary investigation has been conducted through
the unstructured observation of 10 volunteered nurses at
medical care unit of Hacettepe University Hospital,
Ankara, for 1 month. The physical structure of medical
care unit and the work schedules of nurses were similar to
those of study settings. The aims of this preliminary investigation was to develop first draft of data collection form
by identifying the frequencies of hygienic care activities
performed by one nurse per day, the amount of time
spent on per hygienic care and determining their record
keeping practices.
During this preliminary investigation, we identified
that nursing documentation included standard forms,
which requires charting among a list of numerous nursing
activities mostly about the vital signs, food and fluid intake
and outputs, medical treatment schedule and hygienic
care of patients. Several scales were also used for assessment of pain and conscious state of patients, for example,
Numeric Pain Rating Scale and Glasgow Coma Scale.
Patient hygienic care were performed during the day
time, and the frequency of patient hygienic care activities
provided by one nurse within a day was one to three with
an amount of 15 min to 1 h depending on the kind of
hygienic care. Although nursing documentation was recognized as an important professional task, the intensity of
nurses daily work and the acuity of patients impeded
complete, accurate and regular record keeping.

Instrument and pilot study


Following the preliminary investigation, we developed an
instrument that consisted of questions about nurses
demographics and a structured observation form, which
could be used both to record the observed patient hygienic care activity and to audit nursing records of patient
hygienic care.
The format of the participant observation form
included a definitive list of patient hygienic care that
should be observed and predefined categories that contain
the name of hygienic care, equipment or agents used in
care, the date and time, name and signature of the nurse
who provided the care and the outcome of care or patient
reaction. Each category could be checked and rated in
terms of completeness, accurateness and timeliness of the

83

record by auditing of patient charts with nursing data. The


face validity of structured participant observation form
was undertaken by three experts from nursing education,
and the form was revised based on their suggestions. We
were unable to examine psychometric properties of the
instrument; rather than assigning numeric values or scores
to observed behaviours, data from the observation form
was analyzed by using frequency counts and percentages.
In order to test the questionnaire and structured observation form, a pilot field test was carried out in March
2005 through the observation of 13 participants who were
working at a coronary care unit of a teaching hospital
in I zmir. The structure of the nurses working schedule
encompassed two shifts that cover the day (8.00 am to
8.00 pm) and night (8.00 pm to 8.00 am). However,
because patient hygienic care was usually performed at
any time during the daytime, the observation schedule
included continuous monitoring from 8.00 am to 8.00
pm. Following this pilot study, necessary improvements
has been made on the structured observation form, and
the observation schedule was finalized.

Data collection
Data collection was implemented between the dates of 30
March and 30 July 2005 through 255 observation episodes
of 85 nurses. Each nurse was continuously observed by
one researcher without any interference from 8.00 am to
8.00 pm until the completion of three patient hygienic
care activities. Each observed patient hygienic care was
recorded immediately in the structured observation
form, and then the nursing record was examined for predefined record keeping criteria. Upon completion of each
observation period, each nurse was asked to fill out the
questionnaire.

Ethical considerations
Written permission for this study was obtained from
the Medical Directories of Hacettepe University Adult
Hospital, Ankara, and Dokuz Eylul University Hospital.
Nurses were informed about the aims of the study and that
their patient hygienic care activities will be observed.
Written informed consent was obtained from all nurses
and the confidentiality and anonymity of participants were
ensured.

Data analysis
The SPSS version 13.00 for Windows (SPSS Inc, Chicago,
USA), was used for data entry and statistical analysis.
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84

NK Inan and L Din

Descriptive statistics were performed for data analysis,


and the association between demographic variables and
recorded activities were calculated using Fisher exact chisquare test. P-values under 0.05 were considered to be
statistically significant.

RESULTS
Table 1 shows the demographic characteristics of the study
participants. The age of about 49.4% of the participants,
Table 1 Demographic characteristics of nurses (n = 85)
Demographics
Age groups
2226
2731
32
Education level/graduation
Vocational health school
Associates degree
Baccalaureate degree
Clinical experience (in years)
15
610
11
Experience at critical care unit (in years)
15
610
11

36
42
7

42.4
49.4
8.2

11
22
52

12.9
25.9
61.2

42
39
4

49.4
45.9
4.7

59
22
4

69.4
25.9
4.7

ranged from 27 to 31 years, 42.4% ranged from 22 to 26


years and the remaining was above the age of 32 years. They
had different levels of nursing education, including baccalaureate degree (60.0 %), associates degree (25.9 %) and
diploma from vocational health school. Approximately
half (49.4) of the participants had a clinical and or intensive
care experience for up to 5 years, and most participants
(69.4%) were working at the same clinic for 15 years.
About 28.2% of participants were working at postanaesthesia care unit, 10.6% were working at thorax and lung
disease clinic, whereas the nurse staffing of other intensive
care units and clinics were equivalent with a number of 13
for each unit. Most participants (62.4%) were working full
time in day shift from 8.00 am to 8.00 pm.
Figure 1 shows the frequency and documentation of
observed patient hygienic care activities of nurses. A total
of 85 nurses were observed on whom 255 sets of observations were performed. Oral care (n = 64) was the most
frequently recorded observation followed by the names of
other patient hygienic care activities including perianal
care, face, hand, foot care and eye care and bed bathing.
Most of the observed patient hygienic care activities
(77.6%) were recorded, of those majority included foot
care (90%), perianal care (90%), bed bathing (88.2%)
and oral care (87.5). Ear care could not be observed
during this study, and three observations on dressing the
patient were not recorded. Most of undocumented
patient hygienic care activities included nose care
(63.6%), eye care (42.8%) and face care despite which
had been performed.

100
90
80
70

60
50
40

90
87.5
66.7

88.2

83.3

83.3

57.2

30
20

36.4

10
0
Oral care
(n = 64)

Perianalgenital care
(n = 40)

Face care
(n = 42)

Hand care
(n = 24)

Foot care
(n = 20)

Eye care
(n = 28)

Complete bed
bath (n = 17)

Hair care
(n = 6)

Figure 1. Documentation of observed patient hygienic care. () Documented (77.6%); ( ) Undocumented.

2013 Wiley Publishing Asia Pty Ltd

Nose care
(n = 11)

Dressing
(n = 3)

100
100
100
100
100
100
100
100
100
56
36
28
20
18
16
15
5
4
100
100
100
100
100
100
100
100
100
56
36
28
20
18
16
15
5
4
100
100
100
100
100
100
100
100
100
56
36
28
20
18
16
15
5
4
73.2
66.7
64.3
75
72.2
37.5
66.7
60
25
41
24
18
15
13
6
10
3
1
26.8
33.3
35.7
25
27.7
62.5
33.3
40
75
15
12
10
5
5
10
5
2
3
100
100
100
100
100
100
100
100
100
56
36
28
20
18
16
15
5
4
94.6
100
100
100
100
100
100
100
100
53
36
28
20
18
16
15
5
4
5.3

indicates incomplete records.

100
100
100
100
100
100
100
100
100
56
36
28
20
18
16
15
5
4
56
36
28
20
18
16
15
5
4
Oral care
Perianal care
Face care
Hand care
Foot care
Eye care
Complete bed bathing
Hair care
Nose care

%
n
%
n
%
n
%
n
%
n
%
n
%
n
%
n

Not documented
Unsigned
Complete
Incomplete
Complete

Not documented

Complete

Correct

Incorrect

Nurse name
Time
Date
Equipment/cleansing agents
Name of hygienic procedure
Total
Documented patient
hygienic care

DISCUSSION
This study was carried out to describe the frequency of
patient hygienic care activities and to evaluate its documentation through 255 observations and auditing the

Table 2 Record keeping qualities of documented patient hygienic care activities (n = 198)

Table 2 shows some of record keeping qualities of


documented patient hygienic care activities. On standardized nursing documentation forms, the names of hygienic
care activities, and nurse who provided care were
recorded completely. However, the names of nurses were
recorded without signature, and none of patient hygienic
care activities included any information about the view or
reaction of the patient to the care provided, and except
for a small percentage of oral care (5.3), none of the
documented activities included the equipment and cleansing agents used during the hygienic care, despite which the
majority of patient hygienic care were performed with
soap or liquid soap and a basin of water.
During observations, the majority of oral care was performed by aspirating or irrigating the mouth or using foam
swabs and oral rinsing agents either 0.9% normal saline or
diluted sodium bicarbonate instead of toothbrush and
toothpaste. None of the oral risen agents were recorded
by participants. The time of most hygienic care activities
were also incomplete or inaccurate.
Of those 198 documented observations, only 37
included handwritten nursing notes. Thus, although we
did not show the data about the quality of nursing notes
on the table, observation results indicated that most of
the nursing notes were readable, but inconsistent and
inadequate for reflecting nursing care and psychosocial
support, any change in the condition of the patient and
patients response to treatment or care. Nursing notes
were also not written in a logical and sequential manner.
Although not included in structured observation form,
during this study, we also audited patient charts and
nursing notes for nursing care plans. However, despite
the fact that nursing directory emphasized the importance
of nursing process and the study settings incorporated
standardized nursing care plans, none of the nurses used
standard nursing care plans or made an individualistic
nursing care plan for their patients.
Statistical analysis indicated that the frequency of documentation among nurses who were working up to 5 years
were higher than other years of clinical experience (P <
0.05). There was no association between the documentation and nurses demographical variables (P > 0.05).

85

Patients response

Nurses record keeping practices

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86

NK Inan and L Din

nursing records of 85 nurses, who were working at


intensive care units, thorax and lung disease clinic and
neurology clinic.

Limitations of this study


Before discussing the main results of this study, several
methodological limitations should be mentioned. A major
limitation concerned with the non-random convenient
sampling technique used in this study, whereby only
nurses who had been working at critical care units were
recruited. Because the sample is not representative of all
practicing nurses, the generalizability of our results is
limited. Second limitation was lack of psychometric
assessment of the structured participant observation form
used in this study. Although the observation form was
prepared after a preliminary investigation and the face
validity was established by consulting with experts and
pretesting before data collection, we did not examine the
psychometric characteristics of the observation form. Key
concepts of psychometric assessment, the validity and
reliability, are not properties of the instrument, but are
related to the interpretation of scores.14 As we did not
obtain scores from observations, we cannot comment on
validity and reliability of our results. However, the results
of observational studies are, by their very nature, impossible to repeat because of various factors that might change
over time and influence repeatability. These could include
institutional policies, heavy workload, inadequate supply
of nurses as well as patient-related factors such as the
severity of illness and need for hygienic care. Third limitation was related to observational method. Observation
was time consuming and complex with respect to data
collection and analysis. In addition, nurses were continuously observed at critically care units, a work environment equipped with numerous sophisticated machines
and a stressful work context with increased acuity and
complexity of patients who needed constant attention.
Therefore, during the initial period of observations,
most nurses were uncomfortable, some of them tried to
provide good hygienic care for their patients and record in
detail, but this appeared to be reduced through use of
second and third observations. Although over time all
nurses became accustomed to the experience, it is possible that nurses tend to behave as the observer would like
it, and some nurses might have performed and recorded
more hygienic care than they did previously. Fourth limitation was related to auditing the nursing records to detect
the quality of documentation. Although numerous audit
2013 Wiley Publishing Asia Pty Ltd

tools have been developed,1617 none of these tools were


specific to audit patient hygienic activities. Thus, in this
study, we recorded the audited qualities of documentation on structured observation form. A more comprehensive, systematic auditing tool specific to patient hygienic
care provided by nurses would provide more accurate and
objective data. However, as the first study is specific to
patient hygienic care activities of nurses at critical care
units, this study contributes to empirical nursing literature on nursing documentation through use of observation, which had the advantage of obtaining factual data on
what nurses actually do for provision of patients hygienic
care rather than what they report or want to say.

Discussion of main results


In this study, oral care was the most frequently performed
hygienic care followed by the names of perianal care,
hand, foot, eye care and bed bathing. This result is valuable for patient care because providing hygienic care for
patients is among the fundamental nursing activities, and
patients at critical care units are at most in need as many
of them were not able to maintain personal hygiene and
prone to oral and skin problems due to their medical and
physical conditions.
Our results on audited records indicated that although
some of the patient hygienic cares were undocumented
despite which they had been performed by nurses, the
consistency between nursing hygienic care and its documentation was 77.6%. This finding is incongruent with
the previous studies reporting that patient hygienic care
activities of nurses were less widely recorded,1113 but
consistent with the results of a qualitative study of
Penaforte and Martins,18 who showed that hygiene care
activities are present in the shift change reports. The
observational study of De Marinis et al.19 showed that
nursing records reported 37% of the assessments and 45%
of the interventions. In their study, the consistency
between nursing activities and their documentation was
only 40%. Despite the fact that we also found a significant
proportion of inconsistency (22.6%) between the actual
patient hygienic care performed by nurses and its documentation, this study highlighted the visibility of patient
hygienic care activities of nurses on nursing records.
However, the qualities of nursing records were poor in
terms of completeness, correctness and timeliness, and
were inadequate to reflect an individualized nursing
care and patients involvement in their care. This
result support previous studies reporting that nursing

Nurses record keeping practices

documentation is inadequate,6 inconsistent and invisible


for individualized patient care.10 In a retrospective study,
Setz and Innocenzo20 showed that majority of nursing
documentation was acceptable (64.7%), but only 8.7% of
nursing documentation was of good quality.
Poor documentation undermines patient care and
threatens the safety of patients, in particular at intensive
care units where most patients are critically ill. Inadequate
and poor quality nursing records cannot be used as a tool
for facilitating communication; promoting the quality and
continuity of nursing care and meeting professional and
legal standards. Therefore, more emphasis is needed for
the importance of documentation and record keeping
qualities in nursing practice, nursing education and
continuing education of nurses.

CONCLUSION
This study indicated that most of patient hygienic care
performed by nurses was recorded, but the inconsistency
between performed activities and those of recorded, and
the poor quality of documentation requires attention of
clinical nurses, nurse managers and educators. Further
studies across a larger sample using well-developed auditing and observation tools with good psychometric characteristics specific to identify nurses activities on patient
hygienic care are needed to investigate the nurses record
keeping practice.

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