Introduction
Education of the surgical patient, or of the patient undergoing operative treatment, is an essential part of the nursing care provided. Health care workers, including nurses, in the Slovak Republic are required by Act No. 576/2004 Coll. on health care, services related to the provision of health care and amendment and supplementation of certain laws, which, among other things, defines nursing practice as including "education of the patient to support, maintain and restore health and provision of information about the required nursing care" (§ 2, para. 15, point c).
In terms of § 1 para. 1(f) of Decree No. 95 of the Ministry of Health of the Slovak Republic of 12 March 2018, which determines the scope of nursing practice performed independently by a nurse based on a doctor's indication and in cooperation with a doctor, and the scope of midwifery practice performed independently by a midwife based on a doctor's indication and in cooperation with a doctor, "a nurse who has professional competence to perform professional tasks, in accordance with nursing standards and in accordance with the medical diagnosis, independently educates a person, family or community on a healthy lifestyle, on regimen measures related to nursing care with emphasis on self-sufficiency of the person."
The nurse's educational activities with the patient should be documented in an educational plan (educational record). The educational plan is a "map" that helps achieve set goals (Mandysová, 2016). The educational plan (record) should include: the level of knowledge/skills at the beginning and at the end of education, educational goals, forms and methods used, educational content, educational aids, educational barriers, education date, educational setting, evaluation of achievement of educational goals, and signatures of nurse and patient (Juřeníková, 2010). This plan is part of both nursing and medical documentation of the patient. "Medical documentation is a set of data about a person's health status, about health care and related services for that person" (Act No. 576/2004 Coll. § 2, para. 6).
Nursing documentation represents "the sum of all written, graphic and other records of the nurse related to the provision of general and specialized nursing care by the nurse or midwife" (Vicáňová In Žiaková et al., 2009). A part of nursing documentation is the educational record containing all necessary data that help preserve continuity of education and allow assessment of educational outcomes (Juřeníková, 2010).
Documentation of the educational process, which is part of a patient's nursing documentation, has informative, technical, qualitative, economic and legal functions (Magerčiaková, 2008).
Research aim
The aim of the survey was to determine the level of data concerning education of surgical patients, or patients undergoing operative therapy, recorded in nursing documentation.
Within the survey, we set the following sub-objectives:
- to determine whether an educational record is part of the patient's nursing documentation,
- to map the level of documentation of specified educational diagnoses,
- to determine whether provided written educational material is recorded in patients' nursing documentation,
- to verify what educational content focus is stated in nursing documentation,
- to determine whether barriers to education are indicated for the specific patient in nursing documentation,
- to determine whether collaboration with supportive persons is documented during education,
- to map whether data in patients' nursing documentation concerning education are in line with current legislation.
Methods and sample
For data collection, a retrospective content analysis of documents focused on nursing documentation in hospitalized patients was used. A total of 74 nursing documentations of surgical patients (23 preoperative; 51 postoperative) from three surgical clinics were analyzed. Documentation was analyzed for 36 women (age: 18 to 85 years, mean age: 47.5 years) and 38 men (age: 18 to 80 years, mean age: 47.7 years). Before conducting the content analysis, eight areas were defined on which the analysis was focused:
- a separate educational record as part of patients' nursing documentation,
- documentation of specified educational diagnoses,
- formulation of educational diagnoses,
- documentation of provided written educational material,
- content focus of patient education stated in nursing documentation,
- barriers to education stated in documentation,
- collaboration with supportive persons during patient education,
- maintenance of educational data in line with valid legislation.
Results
The first area to which the analysis was focused was whether an independent educational record is part of nursing documentation of surgical patients. This record was present in 58 nursing documentations of patients; in contrast, in 16 documentations such a record was not present. In five documentations, patient education was recorded in the nursing daily record, and in 11 patient documentations there was no data on educational activities performed by nurses.
Table 1 Educational record as part of patients' nursing documentation
Another area of analysis was documentation of educational diagnoses established for patients. We found that in one nursing documentation there were 0 to 7 established educational diagnoses. The total number of documented educational diagnoses (summed across all nursing documentations) was 128 diagnoses, with an average of 1.73 educational diagnoses per nursing documentation (calculated across all analyzed documentations). When calculated only for documentations in which established educational diagnoses were stated, the number of educational diagnoses per one documentation was 2.06 diagnoses.
In the analysis of formulation of educational diagnoses, we found that 48 were formulated correctly, whereas a correctly formulated educational diagnosis was considered one stated in accordance with Decree No. 306/2005 Coll. of the Ministry of Health of the Slovak Republic, which sets out the list of nursing diagnoses, namely Lack of knowledge (30 diagnoses) and/or Lack of information (18 diagnoses). In contrast, 80 educational diagnoses were not formulated correctly (they were stated as Education about...).
Table 2 Formulation of educational diagnoses
Documentation of provided written educational material in the records was found in 33 nursing documentations of patients, with printed brochures stated in 17 cases, six patients receiving a leaflet, nine patients receiving a CD, and one patient receiving a book (specifically on diabetes mellitus). In 41 patient documentations no records of written educational material provided by nurses were stated.
Table 3 Documentation of provided written educational material
By analysis focused on the content focus of education stated in nursing documentation, we found that in 63 documentations educational content focus was recorded, the total of all content foci was 128, and in 11 documentations education content was not recorded.
Table 4 Patient education content focus stated in documentation
Records of educational barriers were found in 11 nursing documentations, with hearing impairment being the most frequent barrier in four cases, non-cooperation in three patients, immobility in two patients, disorientation in one case, and language barrier (foreign national) in one case. Records of educational barriers were not stated in 63 patient documentations.
Table 5 Educational barriers stated in patient documentation
Collaboration with patients' supportive persons in education was recorded in documentation of 21 patients; in five of these cases, children (son or daughter), in four patients spouse, in one patient a brother, and in one patient an interpreter was stated. In ten cases, the supportive person was not specified. In 53 nursing documentations of patients, collaboration with supportive persons during education was not stated.
Table 6 Documentation of collaboration with supportive persons
In the analysis of maintenance of educational data in nursing documentation in line with valid legislation, we found that in 63 documentations legislative provisions were followed and the education record included data: date and time, brief description of the procedure and evaluation, educational method, identification of the educated patient, and identification of the nurse who performed and recorded patient education. In 11 analyzed nursing documentations no record of implementation of patient education was present.
Table 7 Maintenance of educational data in line with valid legislation
Discussion
"Medical documentation is a set of written, graphic and other data about a person's health status. It is an inseparable part of the provision of health care. Nursing documentation is also part of medical documentation" (Expert guidance of the Slovak Ministry of Health on maintaining medical documentation No. 07594/2009, Art. II, point 1). The purpose of our survey was to determine the level of data concerning education of surgical patients, or patients undergoing operative therapy, recorded in nursing documentation.
Patient education is the basis for maintaining health, prevention, early recognition of complications, performing self-care and preserving self-sufficiency. Every patient in every health-care facility has the right to education. Implementation of educational documentation is important and allows other health care workers to find out what the patient already knows and which issues need to be clarified further. It also serves as a record that can be relied on if a patient files a complaint alleging harm to health because adequate or any instructions were not provided (Kolektív autorov, 2002).
The first sub-objective was focused on finding out whether a separate educational record is part of the nursing documentation of surgical patients. This record was present in 58 nursing documentations of patients out of a total of 74 documentations. In five documentations, patient education was recorded in the nursing daily note and in 11 patient documentations there were no educational data by the nurse. As Juřeníková (2010) states, nursing documentation should include an educational record that allows and supports continuity of education, informs all members of the multidisciplinary team about the state of education, promotes sustained education, makes education more efficient, allows timely identification of possible problems in education, protects health care staff from criminal prosecution and facilitates evaluation of education. Hinkle, Cheever et al. (2018) note that nurses create an individual educational plan so that it corresponds to the patient's learning requirements.
Through the second research objective, we focused on analyzing the level of documentation of educational diagnoses established for surgical patients. We found that in one nursing documentation 0 to 7 established educational diagnoses were recorded. When calculated only on documentations in which established educational diagnoses were recorded, the number of educational diagnoses per documentation was 2.06 diagnoses. In planning education, the nurse is guided by nursing diagnoses and by prioritizing learning for the patient or their family (Nemcová, 2010). Based on patient assessment and subsequent information, the nurse sets an educational-knowledge diagnosis, which is a specification of patient needs. It is addressing a deficit or modification in knowledge, skills or attitudes (Magurová, Majerníková, 2009). In the analysis of formulation of educational diagnoses, we found that 48 were formulated correctly, whereas a correctly formulated educational diagnosis was one stated in accordance with Decree No. 306/2005 Coll. of the Ministry of Health of the Slovak Republic that sets out the list of nursing diagnoses, namely Lack of knowledge (30 diagnoses) and/or Lack of information (18 diagnoses). By contrast, 80 educational diagnoses were not formulated correctly because only phrases such as "Education on wound care" were stated. Nursing diagnoses concerning patient need for understanding or learning can be formulated as the primary problem, the cause of the problem, or may be part of other nursing diagnoses that require educational interventions (Nemcová, 2010). However, it is questionable whether the decree listing nursing diagnoses is appropriate and correct, because the diagnosis Lack of information is in its essence not an educational diagnosis, since education is not merely providing information or simple teaching about a specific issue (Vondráček et al., 2011).
In line with another objective, we examined documentation of provided written educational material to patients in their nursing documentation. Provided material was stated in 33 nursing documentations, which is less than half of the analyzed patient records. These findings indicate low use of written educational materials in nursing practice or an under-recording of use of these materials. A high-quality written information or educational material can contribute to reduced time intensity of education, thereby reducing nurses' workload (Magerčiaková, 2008).
In the analysis of the educational content focus of the patient stated in nursing documentation, we found that content focus was recorded in 63 documentations, and in 11 documentations education content was not recorded. This fact does not mean that nurses do not provide patient education, but rather that records of carried out educational activities are undervalued. Nursing documentation serves as an information source on individual needs, nursing care goals, the care itself and its outcomes, including documentation of patient education (Jaklová, Kovaříková, 2017). The content focus of provided education should also be included in records of patient education.
Records of educational barriers were also one of our analysis objectives. We found such written evidence in 11 documentations, with the most common barriers being hearing impairment, non-cooperation and immobility of the patient. Records of education barriers were not stated in 63 patient documentations. Mandysová (2016) states that during patient education, a wide range of obstacles that make this process difficult can be identified. Barriers may differ depending on whether they are viewed from the patient’s or the nurse’s perspective. There are also additional objective factors that negatively affect the educational process.
We sought to determine documentation of collaboration with patient support persons during education in line with another objective of the survey. This cooperation was recorded in the documentation of 21 patients. In 53 nursing documentations there was no stated collaboration with patient supporters during education, which may represent an objective finding, but may also mean nurses did not record cooperation with the patient's family during educational activities. Monahan et al. (2007) state that teaching the patient and their family is an integral and important part of nursing care in both preoperative and postoperative periods. The physical and psychological condition of the surgical patient often requires cooperation and engagement of supportive persons in education, also in the context of increasingly shorter hospital stays and more frequent surgical procedures performed in day-surgery settings. Cooperation with the patient’s family is especially important in older patients, who represent a substantial patient group hospitalized on surgical wards in light of demographic changes. In this regard, Škrla, Škrlová (2003) state that education of a senior without family cooperation is almost always doomed to fail.
Mapping whether data in patients' nursing documentation regarding education are in line with valid legislation was also part of our analysis. In this context, we found that in 63 documentations legislative requirements were met and the education record contained data on date and time, brief description of the procedure and evaluation, educational method, identification of the educated patient, and identification of the nurse who performed and recorded the patient education. Eleven analyzed nursing documentations did not contain a record of patient education being performed. Nurses carry out patient education to a significant extent every day. Thorough and accurate education documentation is important for communication and continuity of patient instruction. Insufficient documentation of educational activities undermines this important aspect of nursing care. Nursing documentation should include these data:
- formal (planned) and informal (unplanned) patient education,
- materials and aids used in education (written, visual, verbal, audiovisual and instructional),
- involvement of patient and/or family,
- evaluation of educational goals, verification of patient understanding and learning,
- subsequent educational needs (Documentation Guidelines for Registered Nurses, 2012).
Recording in medical documentation in the Slovak Republic is defined in § 21 of Act No. 574/2004 Z.z., where para. 1 states: "An entry in medical documentation contains: a) date and time of entry, b) method of instruction, content of instruction, refusal of instruction, informed consent, refusal of informed consent and withdrawal of informed consent, c) date and time of providing health care, if different from the date and time of the entry, d) scope of provided health care and services related to providing health care, e) results of other examinations, if they are part of the provided health care for which entry is made, f) identification of the attending health-care worker, g) identification of the person to whom health care was provided."
According to Article V, para. 5 of the MoH professional guideline on maintaining medical documentation in relation to maintaining nursing documentation, "A record of a performed procedure contains: a) date and time, b) a brief description of the procedure and evaluation, c) readable signature of the nurse, midwife or medical assistant."
Conclusion
A nurse should not underestimate the educational process and should prepare for it. In some settings, documentation used for this purpose is the basis for practice (Krátká, 2016). It is appropriate if surgical departments also have an educational record as a form that contributes to simplifying nurses' work and whose workload to complete is balanced by its benefit (Vondráček, Wirthová, 2008). The form also motivates nurses to consistently and responsibly keep records of all educational activities with patients, in line with an responsibly implemented educational process, including documenting educational barriers, collaboration with patient support persons, provision of written educational material, and possibly other important data that can also be valuable to other members of the multidisciplinary team in order to ensure efficiency and continuity of surgical patient education. A form for documenting education should be an integral part of patient nursing documentation. It is inappropriate for responsibility for education and its recording to be separated from care for the patient. If education is understood as something requiring additional work, then achieving desired expectations in patient or family behavior is difficult (Nemcová, 2010). A particularly important aspect of educational records is the legal protection of nurses. It should be clear from each educational record what the patient was instructed about and to what extent.
Author: PhDr. Mgr. Mariana Magerčiaková, PhD., MPH Katolícka univerzita v Ružomberku, Fakulta zdravotníctva, Katedra ošetrovateľstva
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