Nursing documentation audit--the effect of a VIPS implementation programme in Denmark.

AIM AND OBJECTIVES: The aim of this paper is to present a study describing nurses' adherence to the VIPS model by evaluating the quality of nursing assessment, and the quantity of completed nursing care plans. BACKGROUND: Numerous efforts have been made over the years to improve nursing documentation in Denmark. Hospitals have traditionally based nurses' charting on a rudimentary version of the nursing process and on Virginia Henderson's theory of human needs. In 2002-2004 the Copenhagen University Hospital, Rigshospitalet, introduced the Swedish VIPS model for nursing documentation. VIPS is an acronym for well being, integrity, prevention and safety, all of which are seen as major goals for nursing care. The model organizes nursing data according to a system of keywords, which facilitates storage and retrieval of data. DESIGN AND METHODS: The design in this part of the study was retrospective, wherein 50 journals from each of the departments of cardiology, neurology, oncology and urology were audited annually for three years using the Cat-ch-Ing instrument (n=600). All nursing journals were randomly selected by including the first 50 journals at each site given a specific date. RESULTS: The nursing documentation significantly improved during the course of the study. After the second year the participants used the keywords appropriately and correctly according to the VIPS model. Application of primary nursing increased during the study. Initial, ongoing and discharge patient status improved. The nurses' familiarity with nursing diagnoses, goals and interventions increased. CONCLUSIONS: The structured implementation programme significantly improved nursing documentation, and the simultaneous training of the entire nursing staff shows promise. The VIPS model has prepared the nurses for more complex computerized taxonomies and classification systems in the future by improving the nurses' analytical skills. Relevance to clinical practice. New strategies for improving nursing documentation have been demonstrated.

The effect of a VIPS implementation programme on nurses' knowledge and attitudes towards documentation.

The Copenhagen University Hospital decided to adhere to the standards of the Joint Commission of International Accreditation in 2000. These standards require systematic assessment of patient care needs and include the use of written nursing care plans. In order to meet these standards, the hospital management decided to introduce the Swedish VIPS model, which is a model designed to structure nursing documentation (VIPS is an acronym for well-being, integrity, prevention and safety). The present study explores the nurses' knowledge and attitudes towards documentation and addresses the research questions: (a) what are the nurses' attitudes towards documentation of nursing care? and (b) do nurses have sufficient knowledge of the documentation system to systematically document their patient assessment and clinical decisions? The research design was prospective, comparative, and quasi-experimental (nonrandomized), including a study group (n=72) and a control group (n=57). A questionnaire was used to compare nurses' self-evaluated attitudes towards documentation, and a multiple-choice test was given in order to assess nurses' knowledge of the documentation system. The study group participated in a special implementation programme (response rate 82%), while the control group attended the regular 3-day documentation course at the hospital (response rate 79%). The study showed that the two groups responded similarly, but the nurses in the study group were significantly stronger in their conviction that they had the knowledge to make care plans and that they routinely made them. The study group demonstrated slightly less motivation than the control group, while the two groups shared a positive attitude towards nursing documentation. The study group did consistently better on the knowledge tests. The findings show that the implementation programme had a positive impact on nursing documentation, and that the VIPS model increased the nurses' understanding of the nursing process.