Exploratory Study of Documented Psychosocial Nursing Interventions within the Palliative Care Setting

Further research is needed to better understand issues related to the provision of psychosocial care at end-of-life (EOL). Nursing documentation provides an effective strategy for assessing quality of care. The objective was to assess the quality of documentation processes for EOL care and to identify the degree to which a process-based approach was utilized. A case study qualitative design was applied through a retrospective chart review of the Powerchart documentation database. The process-based framework set out in the Nursing Role Effectiveness Model (NREM) and a modified version of the Quality of Documentation of Nursing Diagnoses, Interventions and Outcomes (Q-DIO) instrument were utilized to guide data collection and analysis. The majority of nursing documentation was of poor quality and statistically significant differences were noted between Q-DIO subsections. This study showed that nurses working in a palliative care setting vary in their ability to complete accurate high quality documentation of psychosocial care.