Improving documentation of patient progress note through role empowerment of head nurse by Orlando theory approach

Abstract

Objective

This study aimed to identify the effect of role empowerment of head nurse by Orlando theory approach on the implementation of progress note documentation.

Method

This study used pilot study approach in which the research process started from developing module of role empowerment of head nurse, implementing of role empowerment of head nurse on in patient ward and then followed by evaluating head nurse competencies through the use of observation sheet and patient progress note. Pre-experiment design with one group pretest–posttest without control was used to evaluate the effectiveness of the intervention, and 115 progress notes were selected through cluster sampling technique which then analyzed by Wilcoxon, Spearman and Kruskal–Wallis test.

Results

There was a significant quality improvement of the implementation of progress note recording following the intervention of head nurses’ role empowerment by Orlando theory approach (p = 0.0001; α = 0.025).

Conclusions

Nurse Staff competencies in documenting progress note were improved significantly through the role empowerment of head nurse by Orlando theory approach. Development of policy, supervision, evaluation, and monitoring by nurse manager are necessary, as well as organizing a workshop on the application of head nurse's role as manager and implementation of progress note documentation.

Introduction

Nursing documentation is a fundamental process of nursing practice in every nursing intervention which contributes to patient well-being and facilitates communication between nurses and other healthcare providers.^1,2 Quality and accuracy of documentation may improve efficiency and professionalism which comply with service standards.^2,3

Nurse manager has the role of educator to motivate other nurses to promote their competencies in nursing documentation.^4,5 Manager's leadership and skill affect directly on nurse performance in providing nursing care which, in turn, affect the patient outcome.⁶ Orlando theory describes that nurse–patient relationship involves mutual interaction which renders it dynamic and collaborative. Nurse validates his perception, idea, or feeling with the patient before selecting an activity.⁷ Laurent stated that Orlando theory elaborated on the dynamic relationship between nurse and patient and involved collective validation between manager and nurse staff. Manager's direction for nurse staff allows for the utmost participation in a dynamic relationship.⁸

Feedback, establishing a dynamic relationship and collaboration is among head nurse's roles which serve as a guide in linking Orlando theory of Dynamic Nurses–Patient Relationship and the role as a head nurse. Intimacy between manager and staff during the teaching process is necessary to promote behavior.⁹ Role empowerment of head nurse by Ida Jean Orlando theory approach has a significant influence on the implementation of progress note documentation.

The preliminary study which was conducted in hospital X revealed that 3 out of 15 progress report note in inpatient wards have a score of 62.5, 7 out of 15 records have a score of 75, and 5 out of 15 records have score of 87.5. Documentation ineffectiveness is resulting from lack of documentation comprehension by a nurse, differences in documentation principles, and inadequate encouragement by head nurse. Therefore, encouragement from the head nurse is necessary for promoting the implementation of documentation which complies with documentation principles.

Method

The study design was a pilot study in which the research process started from developing module of role empowerment of head nurse, implementing of role empowerment of head nurse, and then followed by evaluating head nurse competencies through the use of observation sheet and observation of patient progress note. The evaluation process was performed by using pre-experiment design with one group pretest–posttest without control in which the author only provided intervention for one group without control to examine the effect of intervention o role empowerment of head nurse by Orlando theory approach on the implementation of progress note recording.

The study population was records of patient progress note in hospital X. Total of 115 documents was selected through cluster sampling method, by determining sample size in each cluster with Wilcoxon, Spearman and Kruskal–Wallis test. The study lasted for approximately 6 months, from proposal development in early February to the trial in early July of 2017. Intervention was provided since the pretest by observing patient progress note in a retrospective manner, role of head nurse, conducting role empowerment for head nurses, and then evaluating the role of head nurse following the intervention, and followed by posttest through observation of patient progress note which was filled out by nurse staff involved in the pretest in selected wards. The progress note was observed in a retrospective manner.

The author proposed for ethical clearance to Ethical Committee of Faculty of Nursing of Universitas Indonesia, who later issued the ethical clearance with No. 117/UN2.F12.D/HKP.02.04/2017. The author provided information on every stage of the study to participants. Author complied with principles of research ethics which included obtaining participant's consent before the study, allowing the participant to question any matters concerning the study, and respecting participant's right to refuse and terminate his involvement in the study. Participant's confidentiality was kept in which the data could only be accessed by both author and participant, providing equal treatment, and carefully paying attention to the participant's comfort and risk of intervention throughout the study.

Benefits gained from this study included providing a guide for the head nurse on how to apply for his role as manager and improving nurse staff competencies in the implementation of progress note documentation which complies with documentation principles.

Results

Majority of nurses were female (44 participants 73.3%), diploma nursing graduates (55 participants, 91.7%), and non-government employee (48 participants, 80%). The average nurse age was 28.35 years old with the youngest being 23 years old and the oldest being 46 years old. The average of work experience was 6.57 years with the shortest being 1 year and the longest being 25 years.

Table 1 indicated a significant improvement in head nurse's competencies after the intervention of Orlando theory approach on interpersonal role with average score of (80%) (p = 0.0005; αY= 0.025), informational role with average score of (77.83%) (p = 0.0005; αY= 0.025), and decisional role with average score of (88.57%) (p = 0.0001; α = 0.025) prior to and following the role empowerment. Table 2 demonstrated a significant improvement in documentation after the role empowerment by Orlando theory approach with an average score of (76.76%) (p = 0.0001; α = 0.025). Completeness aspect had average score of (63.4%) (p = 0.0001; α = 0.025) and continuity aspect had average score of (72.7%) (p = 0.0001; αY= 0.025). The result suggested that there was a significant improvement in documentation of patient progress note.

Table 1.

Differences in head nurse competence using the Orlando theory approach at hospital X (n = 15).

Role of the head nurse		Mean	Mean differences	SD	95% CI	p
Professional nursing function and behavior recognition (Interpersonal role))	Before	3.80	2.600	0.561	2.14–3.059	0.0005^*
	After	6.40		0.632
Figurehead role	Before	1.87	0.067	0.35	0.187–0.320	0.282
	After	1.93		0.26
Leader role	Before	0.27	2.333	0.46	1.932–2.734	0.0005^*
	After	2.60		0.51
Laison role	Before	1.67	0.200	0.49	0.029–0.429	0.042
	After	1.87		0.35
Immediate/internal response (Informational role)	Before	1.40	3.267	0.828	2.824–3.709	0.0005^*
	After	4.67		0.617
Monitor role	Before	0.87	1.133	0.35	0.938–1.328	0.0001^*
	After	2.00		0.00
Dissemenator role	Before	0.40	1.266	0.63	0.937–1.595	0.0001^*
	After	1.67		0.49
Spokesperson role	Before	0.13	1.600	0.75	0.455–1.278	0.002^*
	After	1.00		0.36
Discipline of nursing process and improvement (Decisional role)	Before	3.80	2.400	0.676	1.992–2.808	0.0001^*
	After	6.20		0.676
Entrepreneur role	Before	1.00	0.00	0.00	–	0.500
	After	1.00		0.00
Destrubance role	Before	0.27	1.600	0.45	1.319–1.880	0.0001^*
	After	1.87		0.35
Resource allocator role	Before	1.67	0.066	0.49	0.076–0.295	0.159
	After	1.73		0.46
Negotiator role	Before	0.87	0.733	0.35	0.404–1.062	0.001^*
	After	1.60		0.51

*

Significant one tailed α < 0.025.

Table 2.

Implementation of patient progress note documentation before and after strengthening the role of head nurse with Orlando theory approach at hospital X.

Implementation documentation development of integrated patient records		n	Mean	Mean difference	SD	CI 95%	p
Implementation of documentation	Before	115	26.43	5.809	1.352	5.480–6.138	0.0001^*
	After		32.24		1.213
Legal aspects	Before	115	8.99	0.0001	0.093	−0.24–0.24	0.500
	After		8.99		0.093
Completeness	Before	115	7.40	1.957	0.673	1.751–2.165	0.0001^*
	After		9.36		0.850
Continuity	Before	115	10.04	3.861	1.280	3.608–4.114	0.0001^*
	After		13.90		0.675

*

Significant one tailed α < 0.025.

Table 3 revealed that statistically there was no significant yet positive correlation between implementation of progress note documentation, age, and work experience, neither in legal, completeness, nor continuity aspect of documentation (p > 0.05). Table 4 suggested that there was no significant correlation between sex, employment status, and implementation of patient progress note documentation (p > 0.025). There was also no significant correlation between the variable of education and implementation of progress note documentation (p > 0.025), albeit Master degree background had a higher than average score of implementation of progress note documentation than Bachelor of Nursing graduates and diploma graduate nurses’.

Table 3.

Relationship of nurse characteristics (age and work experience) with implementation of patient progress note documentation at hospital X (n = 60).

Variables	Implementation documentation development of integrated patient records	R	R^2	p
Age	Implementation of documentation	0.002*	0.0001	0.362
Work experience		0.034*	0.001	0.241
Age	Legal aspects	0.057	0.003	0.489
Work experience		0.151	0.023	0.121
Age	Completeness	0.126	0.016	0.221
Work experience		0.083	0.007	0.302
Age	Continuity	0.134	0.018	0.070
Work experience		0.103	0.011	0.117

*Significant one tailed α < 0.05.

Table 4.

Differences characteristics (sex, education and employment status) with implementation of patient progress note documentation at hospital X April–May 2017 (n = 60).

Variables	Implementation documentation development of integrated patient records	Implementation of documentation
		n	Mean	SD	p
Sex
Male	Implementation of documentation	16	32.06	1.063	0.285
Female		44	32.23	1.118
Male	Legal aspects	16	9.00	0.001	0.273
Female		44	8.98	0.151
Male	Completeness	16	9.13	0.619	0.144
Female		44	9.36	0.750
Male	Continuity	16	13.94	0.854	0.375
Female		44	13.89	0.722
Education
Diploma	Implementation of documentation	55	32.18	1.090	0.411
Bachelor of Nursing		1	32.00	–
Nurse		4	32.25	0.750
Diploma	Legal aspects	55	8.98	0.135	0.478
Bachelor of Nursing		1	9.00	–
Nurse		4	9.00	0.001
Diploma	Completeness	55	9.29	0.737	0.354
Bachelor of Nursing		1	9.00	–
Nurse		4	9.50	0.577
Diploma	Continuity	55	13.91	0.727	0.498
Bachelor of Nursing		1	14.00	–
Nurse		4	13.75	1.258
Employment status
Non-government employees	Implementation of documentation	48	32.17	1.018	0.284
Contract		12	32.25	1.422
Non-government employees	Legal aspects	48	8.98	0.144	0.309
Contract		12	9.00	0.001
Non-government employees	Completeness	48	9.31	0.689	0.367
Contract		12	9.25	0.866
Non-government employees	Continuity	48	13.88	0.672	0.236
Contract		12	14.00	1.044

*Significant one tailed α < 0.025.

Discussion

Competency of head nurse role with Orlando theory approach

Head nurse's role as manager employed the framework of Orlando theory of The Dynamic Nurse–Patient Relationship: Function, Process, and Principle of Professional Nursing Practice. Head nurse's role as manager was applied for establishing a dynamic relationship between head nurse and nurse staff as a provider of nursing care for the patient. Laurent proposed a dynamic relationship model for manager and leader. A dynamic relationship between manager and staff is essential for the unit's benefit.⁸ Orlando theory defined the significance of the dynamic relationship between nurse and patient as well as involving mutual validation between manager and nurse associate. Manager's direction for nurse staff will result in the full participation in a dynamic relationship.⁸

Valentine developed a concept of nursing leadership for junior nurses based on Orlando theory. Valentine further explained that interaction between manager and junior nurses might develop their basic leadership skills.¹⁰ This study result revealed that head nurse's role as manager for nurse staff was performed maximally and able to establish a dynamic relationship by applying Orlando theory approach for the head nurse and nurse staff as a nursing care provider. Manager's leadership and skill may affect directly on nurse's performance in providing nursing care and patient outcome.^6,11

As a figurehead, the head nurse also serves as a role for nurse staff. One's intimacy with a leader is affected by the similarity of characteristics shared between them which includes age, ethnic, socio-economic, education, and gender.¹² A manager should be able to portray himself as a figurehead in the organization. As a manager, head nurse is also required to play his role as a figure who participates in solving issues in his unit.¹³

In this study, improvement of the manager's interpersonal role was excellent though yet to achieve its optimal level. The fact stated that a good leader is goal-oriented and possessing a common initiative.¹⁴ A good leader should always be consistent with the goal of service and product improvement for the sustainability of organization in a competitive milieu.¹⁵ Effective leadership in the organization may contribute to the better improvement of healthcare provision.¹⁶

An improvement in the liaison role of interpersonal aspect indicated that a head nurse should be capable of maintaining a positive relationship in the provision of nursing care. A head nurse should be able to interact with his colleagues and people outside of the organization.¹⁷ A manager is required to be able to establish a favorable relationship with the staff, deal with conflict, and retain liaison competence between staff and the external party which may promote staff performance and compliance.^18,19 Head nurse's skill in performing his interpersonal role is a competence required to be emulated by all nurses. A nurse manager should be competent in establishing an interpersonal relationship with nurse staff to change their demeanor.²⁰ Miri et al., supported the statement below with his remark that head nurse competencies in interpersonal role included facilitating problem-solving, promoting work motivation and satisfaction, performing staged supervision, improving staff knowledge, and collaborating with departments.¹³

A nurse manager may adopt the immediacy assumption of Orlando theory in which immediate reaction encompasses a combination of how a nurse perceives his idea and feeling toward patient's need accordingly. As a manager, head nurse plays his role as a monitor by controlling and supervising the delivery of nursing care through observation of documentation completed by nurse staff.¹³ A head nurse plays his role as information disseminator by collectively planning and collaborating with nurse staff in presenting reports required for the delivery of nursing care.¹³ As spokesperson in the informational role, head nurse ought to be able to inform all matters concerning the services and collaborate with the nurse manager in establishing hospital policy.¹³

Head nurse's role of information disseminator in the manager area is enacted by providing information for nurse staff that is yet to recognize the culture of the organization. A nurse manager should be able to enact his role as an information disseminator within or outside the organization. High quality of information should be disseminated by a manager. The manager is also required to disseminate information and become a spokesperson in organization environment where he leads.²¹ Furthermore, the manager also should prepare the information before providing it and give a chance to nurse to make a decision.²²

Head nurse is expected to be creative and innovative in creating opportunities for service quality improvement in which he acts as decision maker by developing plans which may bring about progress, being responsible, and able to solve issues by agreeing on the decision he made.²³

The role of entrepreneur demands head nurse to be responsible in devising plans for change which were expected to improve performance in the unit where he leads. As an entrepreneur, the head nurse can promote service quality and develop rules in ward to attain the organization goals.¹³ As an entrepreneur, a manager should initiate changes, identify new ideas, and delegate the responsibility of the idea to another.¹⁷

Head nurse, in enacting his role as decision maker, should be able to deal with all issues in the ward. A manager is required to be competent in resolving all the threats within the organization, taking corrective measures in a dispute, and mediating conflict among the staffs.¹⁷ As a resource allocator, a head nurse determines on how to manage problems occurring on a daily basis. A head nurse executes his role as disturbance handler by observing or preventing troubles from occurring in the ward. The role of resource allocator is enacted through managing and allocating all resources within the organization.¹³

In enacting his role as a negotiator, the head nurse should be able to cooperate and participate in work activities.¹³ The role is associated with the bargaining representative. Head nurse also performs his decisional role by incorporating other sectors to solve the unresolvable issue. The role execution involves superior, other professions, or attending the meeting to resolve the issue. Nurse manager and nurse staff required more participations in deciding the experienced ones.²⁴

This study revealed that there was a significant improvement in the overall implementation of patient progress note documentation, from aspects of legality, completeness, and continuity. Though the legal aspect of documentation in this study did not indicate an improvement, it had the highest implementation score. Documentation should include time, signature, and all parties involved in an intervention.²⁵ The nurse should sign all notations in patient record such as after completing an intervention or taking physician's order.²⁶ Timeliness and appropriateness in documentation were aimed to prevent confusion, inaccuracy, and absence in the medical record.²⁷

In this study, documentation of patient progress note was also examined for its completeness. Documentation should be accurate, complete, and concise in which every correction should be described well and consistent with patient progress.^25,28 Incomplete documentation may pose a risk for patient safety since it may result in ineffective communication among healthcare providers which may delay the treatment.^29,30

Quality of nursing documentation is recognizable through its relevance and continuity in its implementation that also becomes indicators of nursing service quality in the organization. Improvement in effectiveness and efficiency of documentation is attained through promoting quality, completeness, continuity, and decision support system.³¹ Proper nursing documentation has principles that include objectivity, consistency, comprehensiveness, confidentiality and avoiding recording error.²⁸ Nursing documentation plays a pivotal role in organizing health services provided and reflecting many aspects, including nurse's awareness of his role in providing a high-quality health care.³²

Conclusions

There was a significant improvement in head nurse's competencies including interpersonal, informational, and decisional role after the intervention of role empowerment by Orlando theory approach, in which the decisional role had the highest improvement. There was a significant improvement in the implementation of progress note documentation by nurse staff following the intervention of role empowerment of head nurse by Orlando theory approach, including its legal, completeness, and continuity aspect.

The study result revealed that there was no significant correlation between nurse characteristics (age and work experience) and the implementation of patient progress note documentation. There was also no significant correlation between nurse characteristics (sex, education, and employment status) and implementation of patient progress note documentation, though Nurse Master graduates had the highest average score than Bachelor Nursing graduates and diploma graduates.

Efforts in improving implementation of patient progress note documentation require supervision by using observation sheet as a sustainable monitoring and evaluation process from the nurse manager. It also requires a strong commitment of nurse manager to promote knowledge and education of nurse staff in attaining a degree of Bachelor Nursing. Implementation of patient progress note documentation demands time and adaptation process, in which it is necessary for a nurse manager to conduct intensive supervision and provide motivation regularly and continuously.

Funding

This work is supported by Hibah PITTA 2017 funded by DRPM Universitas Indonesia No. 386/UN2.R3.1/HKP.05.00/2017.

Conflict of interests

The authors declare no conflict of interest.