Review Article
Volume 2 Issue 10 - 2020
Individualization Process of the Standardized Care Plan through an Electronic Health Record. A Qualitative Study
Mònica Castellà-Creus1*, Maria-Eulàlia Juvé-Udina2, Maribel González-Samartino3 and Pilar Delgado-Hito4
1Deputy Director of Nursing, Hospital Universitari Germans Trias i Pujol, Catalan Institute of Health, Badalona, Catalonia, Spain
2Assistant professor, Department of Fundamental Care and Medical-Surgical Nursing. Faculty of Medicine and Health Sciences, University of Barcelona, L’Hospitalet de Llobregat, Catalonia, Spain
3Unit Nurse Manager, Hospital Universitari de Bellvitge, Department of Health Information Systems, Catalan Institute of Health, L’Hospitalet de Llobregat, Catalonia, Spain
4Director and Professor, Department of Fundamental Care and Medical-Surgical Nursing. Faculty of Medicine and Health Sciences, University of Barcelona, L’Hospitalet de Llobregat, Catalonia, Spain
*Corresponding Author: Mònica Castellà-Creus, Deputy Director of Nursing, Hospital Universitari Germans Trias i Pujol, Catalan Institute of Health, Badalona, Catalonia, Spain .
Received: October 01, 2020; Published: November 07, 2020




Abstract

Introduction: Understanding the method used by nurses in the individualization process of the Standardized Care Plan is essential to improve the delivery of nursing care and be more competent to know what patients need.

Aim: To describe the stages of the Standardized Care Plan individualization process used by nurses in acute hospitalization wards.

Method: A qualitative study in accordance with Strauss and Corbin’s Grounded Theory was undertaken. Theoretical sampling with maximum variation was used to select nurses from adult units in three hospitals. In-depth individual interviews, participant observation and a focus group discussion were employed to obtain data. Constant comparison was used for analysis. Open, axial and selective coding were performed until data saturation was reached.

Results: Thirty-nine nurses participated between in-depth individual interviews and a focus group. Additionally, the researchers carried out 65 hours of participant observation. The analysis allowed the emergence of a core category: “adapting the standard to patient’s needs” that describes the meaning of the Standardized Care Plan individualization process given by nurses. In addition, three thematic categories were also identified: “clinical reasoning”, “individualization attributes” and “instrumental procedure”. Clinical reasoning enables the nurse to decide the appropriate Standardized Care Plan according to the reason for admission and then adjust its elements according to the patient’s comprehensive assessment. Individualization attributes describes some characteristics of this process like the prioritization of the life-threatening diagnoses and willingness to involve the patient and family. Finally, this individualization process also includes an instrumental procedure that is used to reflect the individualization record in the Electronic Health Record.

Conclusion: All of these steps are necessary in order to deliver and record a delivery of care that takes into account the needs and preferences of the patient and their family through an individualized care plan.

Keywords: Electronic Health Records; Nursing Care Plans; Nursing Process; Nursing Records; Qualitative Research

References

  1. Alfaro-LeFevre R. “Applying Nursing Process. Promoting collaborative care”. Philadelphia, PA: Lippincott Williams and Wilkins (2009).
  2. Bokhour BG., et al. “How can healthcare organizations implement patient-centered care? Examining a large-scale cultural transformation”. BMC Health Services Research1 (2018): 168.
  3. Juvé-Udina ME. “Evaluación inductiva de la estructura de una terminología enfermera de interfase: conceptualización del proceso enfermero”. [“Inductive evaluation of the structure of a nursing interface terminology: conceptualization of the nursing process”]. Nursing (Spanish ed.) 7 (2012): 62-66.
  4. Juvé-Udina ME. “Plans de cures estandarditzats per a malalts hospitalitzats. [Standardized care plans for inpatients]”. Barcelona, Catalonia: Generalitat de Catalunya, Departament de Salut, Institut Català de la Salut (2013).
  5. Ballantyne H. “Developing nursing care plans”. Nursing Standard26 (2016): 51-60.
  6. Jakobsson J and Wann-Hansson C. “Nurses' perceptions of working according to standardized care plans: a questionnaire study”. Scandinavian Journal of Caring Sciences4 (2013): 945-952.
  7. Pöder U., et al. “Implementation of a multi-professional standardized care plan in electronic health records for the care of stroke patients”. Journal of Nursing Management6 (2011): 810-819.
  8. Svensson S., et al. “Development and implementation of a standardized care plan for carotid endarterectomy”. Journal of Vascular Nursing2 (2012): 44-53.
  9. Juvé-Udina ME. “Evaluación de la validez de una terminología enfermera de interfase”. [“Validity evaluation of an interface nursing terminology”] PhD diss., Universitat de Barcelona (2012).
  10. Carpenito LH. “Nursing Diagnoses. Application to Clinical Practice”. Philadelphia, PA: Wolters Kluwer (2016).
  11. Thoroddsen A., et al. “Content and completeness of care plans after implementation of standardized nursing terminologies and computerized records”. Computers, Informatics, Nursing10 (2011): 599-607.
  12. Törnvall E and Jansson I. “Preliminary Evidence for the Usefulness of Standardized Nursing Terminologies in Different Fields of Application: A Literature Review”. International Journal of Nursing Knowledge2 (2017): 109-119.
  13. American Nurses Association. “Nursing: Scope and Standards of Practice”. Silver Spring, MD: ANA (2015).
  14. Juvé-Udina ME. “What patients' problems do nurses e-chart? Longitudinal study to evaluate the usability of an interface terminology”. International Journal of Nursing Studies12 (2013): 1698-1710.
  15. González-Samartino., et al. “Accuracy and completeness of records of adverse events through interface terminology”. Revista da Escola de Enfermagem USP 52 (2018): e03306.
  16. Juvé-Udina ME. “ATIC®. Una terminología enfermera de interfase (II)”. [“ATIC®. A nursing interface terminology (II)”]. Revista ROL de Enfermería5 (2012): 368-375.
  17. Juvé-Udina ME. “Salud, entorno y enfermería. Fundamentos teóricos y metodológicos para el desarrollo y la validación de una Terminología Enfermera de interfase (III)”. [“Health, environment and nursing. Philosophical and theoretical foundations for the development and validation of a nursing interface terminology. Part III”]. Revista ROL de Enfermería6 (2012): 409-416.
  18. Akhu-Zaheya L., et al. “Quality of nursing documentation: Paper-based health records versus electronic-based health records”. Journal of Clinical Nursing34 (2018): e578-e589.
  19. Rouleau G., et al. “Impact of Information and Communication Technologies on Nursing Care: Results of an Overview of Systematic Reviews”. Journal of Medical Internet Research4 (2017): e122.
  20. Ammenwerth E., et al. “Nursing process documentation systems in clinical routine--prerequisites and experiences”. International Journal of Medical Informatics 2-3 (2001):187-200.
  21. Mayilvaganan V. “Steps in individualizing a standardized care plan”. Nursing Journal of India2 (2002): 33-35.
  22. Castellà-Creus M., et al. “Proceso de individualización de un plan de cuidados estandarizado mediante un sistema de información. Caso clínico: ictus”. [“Individualization process of the standardized care plan through an electronic health record. Clinical case: ictus”]. Nursing9 (2011): 60-66.
  23. Desai S., et al. “A review for development of concise nursing care plan (CNCP)”. International Journal of Advances in Nursing Management 4 (2019): 371-377.
  24. Strauss A and Corbin J. “Bases de la investigación cualitativa: técnicas y procedimientos para desarrollar la teoría fundamentada” [“Qualitative research basis: techniques and procedures to develop a grounded theory”]. Medellín: Universidad de Antioquía (2002).
  25. Tong A., et al. “Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups”. International Journal of Qualitative Health Care6 (2007): 349-357.
  26. Guba EG and Lincoln YS. “Paradigmatic controversies, contradictions, and emerging confluences”. In Denzin NK, Lincoln YS (Editions.), The sage handbook of qualitative research. London: SAGE Publications (2000).
  27. Rettke H., et al. “Using reflexive thinking to establish rigour in qualitative research”. Nursing Research6 (2018): 490-497.
  28. Olsson PT., et al. “Standardized care plans in Swedish health care: their quality and the extent to which they are used”. Scandinavian Journal of Caring Sciences4 (2009): 820-825.
  29. Thoroddsen A., et al. “Content and completeness of care plans after implementation of standardized nursing terminologies and computerized records”. Computers, Informatics, Nursing10 (2011): 599-607.
  30. Castellà-Creus Mònica., et al. “Barriers and facilitators involved in standardised care plan individualisation process in acute hospitalisation wards: A grounded theory approach”. Journal of Clinical Nursing 28 (2019): 4606-4620.
  31. Náfrádi L., et al. “Is patient empowerment the key to promote adherence? A systematic review of the relationship between self-efficacy, health locus of control and medication adherence”. PLoS One10 (2017): e0186458.
  32. Bravo P., et al. “Conceptualising patient empowerment: a mixed methods study”. BMC Health Services Research 15 (2015): 252.
  33. Risling T., et al. “Evaluating Patient Empowerment in Association With eHealth Technology: Scoping Review”. Journal of Medical Internet Research9 (2017): e329.
  34. Andersen IC., et al. “Patients' and their family members' experiences of participation in care following an acute exacerbation in chronic obstructive pulmonary disease: A phenomenological-hermeneutic study”. Journal of Clinical Nursing23-24 (2017): 4877-4889.
  35. Mackie BR., et al. “Acute care nurses' views on family participation and collaboration in fundamental care”. Journal of Clinical Nursing 11-12 (2018): 2346-2359.
  36. Ramós-Garzón X. “Reflexiones sobre el proceso de Enfermería. Desafío para estudiantes, docentes y profesionales de la práctica clínica” [“Reflections on the Nursing Process. Challenge for students, teachers and professionals of clinical practice”]. Metas de Enfermería 20 (2017): 75-78.
  37. Juvé-Udina ME. “Capacidad discriminante del diagnóstico enfermero principal con el uso de la terminología ATIC: estimación ponderal preliminar”. [“Discriminant capability of the main nursing diagnosis using the ATIC terminology: Preliminary weight estimation”]. ENE Revista de Enfermería 11.3 (2017).
  38. Yu P., et al. “Unintended adverse consequences of introducing electronic health records in residential aged care homes”. International Journal of Medical Informatics9 (2013): 772-788.
  39. Lima AF and de Oliveira Melo T. “Percepção de enfermeiros em relação à implementação da informatização da documentação clínica de enfermagem” [“Nurses' perception regarding the implementation of computer-based clinical nursing documentation”]. Revista da Escola de Enfermagem USP1 (2012): 175-183.
Citation: Monica Castella-Creus., et al. “Individualization Process of the Standardized Care Plan through an Electronic Health Record. A Qualitative Study”. EC Nursing and Healthcare 2.12 (2020): 09-20.

PubMed Indexed Article


EC Pharmacology and Toxicology
LC-UV-MS and MS/MS Characterize Glutathione Reactivity with Different Isomers (2,2' and 2,4' vs. 4,4') of Methylene Diphenyl-Diisocyanate.

PMID: 31143884 [PubMed]

PMCID: PMC6536005


EC Pharmacology and Toxicology
Alzheimer's Pathogenesis, Metal-Mediated Redox Stress, and Potential Nanotheranostics.

PMID: 31565701 [PubMed]

PMCID: PMC6764777


EC Neurology
Differences in Rate of Cognitive Decline and Caregiver Burden between Alzheimer's Disease and Vascular Dementia: a Retrospective Study.

PMID: 27747317 [PubMed]

PMCID: PMC5065347


EC Pharmacology and Toxicology
Will Blockchain Technology Transform Healthcare and Biomedical Sciences?

PMID: 31460519 [PubMed]

PMCID: PMC6711478


EC Pharmacology and Toxicology
Is it a Prime Time for AI-powered Virtual Drug Screening?

PMID: 30215059 [PubMed]

PMCID: PMC6133253


EC Psychology and Psychiatry
Analysis of Evidence for the Combination of Pro-dopamine Regulator (KB220PAM) and Naltrexone to Prevent Opioid Use Disorder Relapse.

PMID: 30417173 [PubMed]

PMCID: PMC6226033


EC Anaesthesia
Arrest Under Anesthesia - What was the Culprit? A Case Report.

PMID: 30264037 [PubMed]

PMCID: PMC6155992


EC Orthopaedics
Distraction Implantation. A New Technique in Total Joint Arthroplasty and Direct Skeletal Attachment.

PMID: 30198026 [PubMed]

PMCID: PMC6124505


EC Pulmonology and Respiratory Medicine
Prevalence and factors associated with self-reported chronic obstructive pulmonary disease among adults aged 40-79: the National Health and Nutrition Examination Survey (NHANES) 2007-2012.

PMID: 30294723 [PubMed]

PMCID: PMC6169793


EC Dental Science
Important Dental Fiber-Reinforced Composite Molding Compound Breakthroughs

PMID: 29285526 [PubMed]

PMCID: PMC5743211


EC Microbiology
Prevalence of Intestinal Parasites Among HIV Infected and HIV Uninfected Patients Treated at the 1o De Maio Health Centre in Maputo, Mozambique

PMID: 29911204 [PubMed]

PMCID: PMC5999047


EC Microbiology
Macrophages and the Viral Dissemination Super Highway

PMID: 26949751 [PubMed]

PMCID: PMC4774560


EC Microbiology
The Microbiome, Antibiotics, and Health of the Pediatric Population.

PMID: 27390782 [PubMed]

PMCID: PMC4933318


EC Microbiology
Reactive Oxygen Species in HIV Infection

PMID: 28580453 [PubMed]

PMCID: PMC5450819


EC Microbiology
A Review of the CD4 T Cell Contribution to Lung Infection, Inflammation and Repair with a Focus on Wheeze and Asthma in the Pediatric Population

PMID: 26280024 [PubMed]

PMCID: PMC4533840


EC Neurology
Identifying Key Symptoms Differentiating Myalgic Encephalomyelitis and Chronic Fatigue Syndrome from Multiple Sclerosis

PMID: 28066845 [PubMed]

PMCID: PMC5214344


EC Pharmacology and Toxicology
Paradigm Shift is the Normal State of Pharmacology

PMID: 28936490 [PubMed]

PMCID: PMC5604476


EC Neurology
Examining those Meeting IOM Criteria Versus IOM Plus Fibromyalgia

PMID: 28713879 [PubMed]

PMCID: PMC5510658


EC Neurology
Unilateral Frontosphenoid Craniosynostosis: Case Report and a Review of the Literature

PMID: 28133641 [PubMed]

PMCID: PMC5267489


EC Ophthalmology
OCT-Angiography for Non-Invasive Monitoring of Neuronal and Vascular Structure in Mouse Retina: Implication for Characterization of Retinal Neurovascular Coupling

PMID: 29333536 [PubMed]

PMCID: PMC5766278


EC Neurology
Longer Duration of Downslope Treadmill Walking Induces Depression of H-Reflexes Measured during Standing and Walking.

PMID: 31032493 [PubMed]

PMCID: PMC6483108


EC Microbiology
Onchocerciasis in Mozambique: An Unknown Condition for Health Professionals.

PMID: 30957099 [PubMed]

PMCID: PMC6448571


EC Nutrition
Food Insecurity among Households with and without Podoconiosis in East and West Gojjam, Ethiopia.

PMID: 30101228 [PubMed]

PMCID: PMC6086333


EC Ophthalmology
REVIEW. +2 to +3 D. Reading Glasses to Prevent Myopia.

PMID: 31080964 [PubMed]

PMCID: PMC6508883


EC Gynaecology
Biomechanical Mapping of the Female Pelvic Floor: Uterine Prolapse Versus Normal Conditions.

PMID: 31093608 [PubMed]

PMCID: PMC6513001


EC Dental Science
Fiber-Reinforced Composites: A Breakthrough in Practical Clinical Applications with Advanced Wear Resistance for Dental Materials.

PMID: 31552397 [PubMed]

PMCID: PMC6758937


EC Microbiology
Neurocysticercosis in Child Bearing Women: An Overlooked Condition in Mozambique and a Potentially Missed Diagnosis in Women Presenting with Eclampsia.

PMID: 31681909 [PubMed]

PMCID: PMC6824723


EC Microbiology
Molecular Detection of Leptospira spp. in Rodents Trapped in the Mozambique Island City, Nampula Province, Mozambique.

PMID: 31681910 [PubMed]

PMCID: PMC6824726


EC Neurology
Endoplasmic Reticulum-Mitochondrial Cross-Talk in Neurodegenerative and Eye Diseases.

PMID: 31528859 [PubMed]

PMCID: PMC6746603


EC Psychology and Psychiatry
Can Chronic Consumption of Caffeine by Increasing D2/D3 Receptors Offer Benefit to Carriers of the DRD2 A1 Allele in Cocaine Abuse?

PMID: 31276119 [PubMed]

PMCID: PMC6604646


EC Anaesthesia
Real Time Locating Systems and sustainability of Perioperative Efficiency of Anesthesiologists.

PMID: 31406965 [PubMed]

PMCID: PMC6690616


EC Pharmacology and Toxicology
A Pilot STEM Curriculum Designed to Teach High School Students Concepts in Biochemical Engineering and Pharmacology.

PMID: 31517314 [PubMed]

PMCID: PMC6741290


EC Pharmacology and Toxicology
Toxic Mechanisms Underlying Motor Activity Changes Induced by a Mixture of Lead, Arsenic and Manganese.

PMID: 31633124 [PubMed]

PMCID: PMC6800226


EC Neurology
Research Volunteers' Attitudes Toward Chronic Fatigue Syndrome and Myalgic Encephalomyelitis.

PMID: 29662969 [PubMed]

PMCID: PMC5898812


EC Pharmacology and Toxicology
Hyperbaric Oxygen Therapy for Alzheimer's Disease.

PMID: 30215058 [PubMed]

PMCID: PMC6133268


News and Events


April Issue Release

We always feel pleasure to share our updates with you all. Here, notifying you that we have successfully released the April issue of respective journals and the latest articles can be viewed on the current issue pages.

Submission Deadline for upcoming Issue

Ecronicon delightfully welcomes all the authors around the globe for effective collaboration with an article submission for the upcoming issue of respective journals. Submissions are accepted on/before April 26, 2021.

Certificate of Publication

Ecronicon honors with a "Publication Certificate" to the corresponding author by including the names of co-authors as a token of appreciation for publishing the work with our respective journals.

Best Article of the Issue

Editors of respective journals will always be very much interested in electing one Best Article after each issue release. The authors of the selected article will be honored with a "Best Article of the Issue" certificate.

Certifying for Review

Ecronicon certifies the Editors for their first review done towards the assigned article of the respective journals.

Latest Articles

The latest articles will be updated immediately on the articles in press page of the respective journals.

Immediate Assistance

The prime motto of this team is to clarify all the queries without any delay or hesitation to avoid the inconvenience. For immediate assistance on your queries please don't hesitate to drop an email to editor@ecronicon.uk