Nursing Records Go Digital: A Case Study

“It’s changed how I work because everything is in one place; you never lose a bit of paper and you don’t have to run around the wards looking for something.” – Staff Nurse

In April 2021, the Welsh Nursing Care Record (WNCR) went live across a number of Welsh health boards and trusts. 

It allows nurses in adult inpatient settings (where a patient has to stay in hospital for one or more nights), to complete an online assessment form at a patient’s bedside. In a move away from paper-based form filling, the aim is to save time, improve accuracy, and minimise duplication.

The team leading our digital landscape review met the team behind the WNCR to find out more.

How did the project come about? What problem were you trying to solve  

The impetus for this project arose from understanding the needs of nurses across Wales. Research with this group found that the paper-based forms they had to complete were time consuming and complex – to the extent that they were often not completed in full.  

This was supported by a Healthcare Inspectorate Wales’ annual review from 2014-15 which highlighted the need for the audit and improvement of current nursing tools such as the documentation system.  

What was the opportunity? 

Development of E-forms was already an area of priority for Welsh Government and more recently the NHS Wales Informatics Service (NWIS) and Digital Health and Care Wales (DHCW). A bid was in progress for the Efficiency Through Technology Fund (ETTF) and the WNCR team supported this by providing evidence of the significant benefits which could be realised through standardising nursing forms and shifting from paper documentation to a digital alternative.

This evidence was based on engagement with health boards and trusts to see what documentation already existed, how clinical teams (including nurses) were using current systems, their limitations and the benefits which could be realised through standardisation and digitisation. 

How did you conduct user research?  

The WNCR project team conducted user research with both nurses and technical teams. They held three engagement events with nurses and multi-disciplinary teams across North, Central, and South Wales, where they mapped the user journey of the nurses to understand how the current inpatient assessment worked and to identify where the metaphorical pain points were for them. They received feedback on what nurses needed and wanted from a digital solution. Nurses who couldn’t attend these sessions were able to feed in their experience via an online survey.  

Alongside these events, sessions were run with technical teams across healthboards and trusts and a survey was distributed to gauge views on how the WNCR could be used more broadly.  

The project was also brought to the national technical working group to ensure any digital solution was endorsed by the technical experts. 

In total, over 100 visits were paid to health boards, trusts, individual specialists, clinicians, multidisciplinary teams and patient groups.  

As a minimum viable product (MVP), the team initially focussed on the adult inpatient assessment form and key risk assessments – the forms that nurses complete when a patient arrives on a ward. They worked to standardise this across Welsh health boards and trusts. This brought the additional benefit for agency and student nurses who often move between health boards and trusts. 

Following standardisation, the form was built on an online platform, enabling nurses to complete the assessment on a mobile device or handheld tablet and receive real time notifications about additional checks or assessments which might need to be completed.  

WNCR Tech Team

How did you manage the rollout across healthboards and trusts?  

The rollout across health boards and trusts kicked off with a pilot scheme in early 2020 in every health board across Wales. The MVP of the adult inpatient assessment form was tested – we kept it simple in order to get as much user feedback as possible.  

Essential to enabling the rollout of the live service have been the nursing informatics leads – new roles established in 2018 which connect technical teams to nurses at each of the health boards and trusts. The nursing informatics leads ensure that nurses’ voices and needs are heard by the teams developing and iterating the platform which has been key to it meeting the needs of nurses and ultimately the success of the platform.  

These roles didn’t exist in the NHS in Wales prior to this project and the WNCR team have influenced the design of courses (from certificate to masters level), for digital skills in health and care across Wales. 60 students will be starting the masters programme at the University of Wales, Trinity St Davids this month which will help ensure a pipeline of talent for future roles.  

WNCR Clinical Team

What feedback have you received on the service? 

The response from nurses who have used the platform has been positive.  

67% have reported that they prefer to use the WNCR platform instead of the paper based equivalent. 68% agree that it has had a positive effect on their work; that they feel more confident about forms being completed, that they can be completed more quickly, and that they are easy to access, meaning they can go back into the record to get more accurate information, improving the quality of care that patients receive.  

“It’s changed how I work because everything is in one place; you never lose a bit of paper and you don’t have to run around the wards looking for something.” – Staff Nurse 

“If I can use it, anybody can use it. I am getting very old now. It saves me a lot of time.” – Staff Nurse 

“It’s better to capture all the information with the patients so you can go through everything in one go, so it definitely saves time and I think it’s better for patient care because it means we can spend more time with them than completing paperwork.” – Staff Nurse 

The benefits of using the WNCR have also been felt by other staff. It has made life easier for ward receptionists and clinical coders, as well as other providers of care such as physiotherapists and occupational therapists, who can access patient information at a glance, without having to travel across departments to access paper-based records.  

What are your next steps?

1. Further roll out  

Immediate next steps are to work with the outstanding health boards and trusts to implement the WNCR. The aim is to have brought all inpatient wards across all health boards and trusts online by the end of 2022/23, with the service considered business as usual by March 2023. 

2. More standardisation of forms  

The number of forms which are standardised and available digitally will also be scaled up. Currently only the adult inpatient assessment form and key risk assessments are standardised, and there are 17 documents in the next phase including the Bristol Stool Chart, the food chart, and mouth care.

3. Continue to improve the platform  

There is a process of continuous feedback which doesn’t stop just because the service is live. The WNCR team will continue to collect feedback and subsequently use it to iterate and improve the platform. This will include feedback from users and patients with a question about the WNCR included in the annual all Wales patient satisfaction survey.  

Alongside this continuous improvement, a funded Master of Research (MRes) scholar will explore the benefits and impact of the service at a strategic, ward and patient level. 

4. Link in with other projects across Wales 

Lastly, an important next step will be to continue promoting the WNCR and coordinating with other projects in health and care; including linking in with the DHCW’s vision of a single patient record and common information standards and working with the national data resource programme to achieve the ambition for increased data flow between all health care systems, with data to be inputted once and shared to the relevant teams as needed, to support better decision-making and better quality of care for patients.  

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