Nurses' experiences of and opinions about using standardised care plans in electronic health records--a questionnaire study.

AIM

The aim of the present study was to investigate nurses' opinions about using standardised care plans in electronic health record and quality standards for clinical practice.

BACKGROUND

Following introduction of an electronic health record, use of standardised care plans and quality standards has increased among nurses at two hospitals in Sweden. Understanding nurses' opinions is important to continued development in this area. There are few previous studies on nurses' opinions about standardised care plans.

DESIGN

Survey.

METHOD

The study was quantitative, descriptive and based on a questionnaire. The questionnaire included items on nurses' knowledge of and opinions about standardised care plans and quality standards.

RESULTS

The majority of the nurses were of the opinion that standardised care plans increase their ability to provide the same high-quality basic care for all patients. They also thought that a common standardised care plan across several professions would improve conditions for provision of high-quality care. The majority of the nurses also felt that the quality standards are a prerequisite of maintaining standardised care plans of high quality. There was no consensus on whether standardised care plans increase the risk of failing to notice patients' individual problems. Most agreed that standardised care plans decrease documentation time as well as redundant documentation. The study showed that training is needed to teach nurses how to use standardised care plans in care provision.

CONCLUSIONS

The nurses in the study had positive attitudes towards use of standardised care plans and felt that they could facilitate nursing practice.

RELEVANCE TO CLINICAL PRACTICE

Use of standardised care plans can improve nursing documentation and facilitate work for nurses. Moreover, it can support nurses in their use of evidence-based nursing methods. The present study shows that nurses have positive attitudes, which could facilitate continued use of standardised care plans.