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Randomized Controlled Trial
. 2022 Sep;17(5):e12461.
doi: 10.1111/opn.12461. Epub 2022 Apr 8.

Exploring documentation in Person-centred care: A content analysis of care plans

Doris Lydahl  1 , Nicky Britten  2   3 , Axel Wolf  4   5   6 , Öncel Naldemirci  7 , Helen Lloyd  8 , Birgit Heckemann  4   5
Affiliations
Randomized Controlled Trial

Exploring documentation in Person-centred care: A content analysis of care plans

Doris Lydahl et al. Int J Older People Nurs. 2022 Sep.

Abstract

Background: Person-centred care is a growing imperative in healthcare, but the documentation of person-centred care is challenging. According to the Gothenburg Framework of Person-centred Care, care should be documented in continuously revised care plans and based on patients' personally formulated goals and resources to secure a continuous partnership.

Objectives: This study aimed to examine care plans produced within a randomised controlled trial that tested a person-centred care intervention in older people with acute coronary syndrome. Nurses with training in the theory and practice of person-centred care had written the care plans.

Methods: We conducted a secondary analysis of care plans developed in a randomised controlled trial for assessing person-centred care in patients with acute coronary syndrome (Myocardial Infarct [MI] or unstable angina pectoris). The study sample included 84 patients, with three care plans for each patient from inpatient (T1), outpatient (T2) and primary care (T3), that is, a total of 252 care plans. We conducted a descriptive quantitative content analysis of the care plans to examine the reported patients' life-world and medical/health resources and goals.

Results: The analysis illustrates the differences and overlaps between life-world and medical/health goals and resources. The documented goals and resources change over time: life-world goals and resources decreased with time as medical/health goals and resources documentation increased.

Conclusions: This paper illustrates that in the setting of a randomised controlled trial, nurses with training in person-centred care recorded fewer life-world and more medical/health goals over time. Placing life-world goals at the top of the goal hierarchy enables alignment with medical/health goals. Further research should explore whether the goals and resources documented in care plans accurately reflect patients' wishes as they transition along the care chain.

Trial registration: Swedish registry, Researchweb.org, ID NR 65 791.

Keywords: chronic illness; goal setting; person-centred care; qualitative content analsysis; qualitative research.

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Conflict of interest statement

The authors have no conflict of interest to declare.

Figures

FIGURE 1
FIGURE 1
Person‐centred care plan
FIGURE 2
FIGURE 2
Number of documented goals, T1‐T3
FIGURE 3
FIGURE 3
Number of documented resources, T1‐T3
See this image and copyright information in PMC

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