‘Paper care not patient care’: Nurse and patient experiences of comprehensive risk assessment and care plan documentation in hospital

AIMS AND OBJECTIVES: To explore organisation‐wide experiences of person‐centred care and risk assessment practices using existing healthcare organisation documentation. BACKGROUND: There is increasing emphasis on multidimensional risk assessments during hospital admission. However, little is known about how nurses use multidimensional assessment documentation in clinical practice to address preventable harms and optimise person‐centred care. DESIGN: A qualitative descriptive study reported according to COREQ. METHODS: Metropolitan tertiary hospital and rehabilitation hospital servicing a population of 550,000. A sample of 111 participants (12 patients, 4 family members/carers, 94 nurses and 1 allied health professional) from a range of wards/clinical locations. Semi‐structured interviews and focus groups were conducted at two time points. The audio recording was transcribed, and an inductive thematic analysis was used to provide insight from multiple perspectives. RESULTS: Three main themes emerged: (1) ‘What works well in practice’ included: efficiency in the structure of the documentation; the Introduction, Situation, Background Assessment, Recommendation (ISBAR) framework and prompting for clinical decision‐making were valued by nurses; and direct patient care is always prioritised. (2) ‘What does not work well in practice’: obtaining the patient's signature on daily care plans; multidisciplinary (MDT) involvement; duplication of paperwork and person‐centred goals are not well‐captured in care plan documentation. (3) ‘Experience of care’; satisfaction of person‐centred care; communication in the MDT was important, but sometimes insufficient; patients had variable involvement in their daily care plan; and inadequate integration of care between MDT team which negatively impacted patients. CONCLUSIONS: Efficient and streamlined documentation systems should herald feedback from nurses to address their clinical workflow needs and can support, and capture, their decision‐making that enables partnership with patients to improve the individualisation of care provision. RELEVANCE TO CLINICAL PRACTICE: The integration of effective MDT involvement in clinical documentation was problematic and resulted in unmet supportive care from the patient's perspective.