Effectiveness of the Primary Nursing Model on nursing documentation accuracy: A quasi-experimental study

Aims and objectives: To analyse the Primary Nursing Model's effect on nursing documentation accuracy. Background: The Primary Nursing is widely implemented since it has been considered as the ideal model of care delivery based on the relationship between the nurse and patient. However, previous research has not examined the relationship between Primary Nursing and nursing documentation accuracy. Design: A pretest-posttest-follow-up design was used. Methods: The study was conducted from August 2018 to February 2020 in eight surgical and medical wards in an Italian university hospital. The Primary Nursing was implemented in four wards (study group), while in the other four, the Team Nursing was practised (control group). Nursing documentation accuracy was evaluated through the D-Catch instrument. From the eight wards, 120 nursing documentations were selected randomly for each time point (pre-test, post-test and follow-up) and in each group. Altogether, 720 nursing documents were assessed. The study adhered to the TREND checklist. Results: The Primary Nursing and Team Nursing Models exhibited significant differences in mean scores for documentation accuracy: assessment on admission, nursing diagnosis, nursing intervention and patient outcome accuracy. No differences between the two groups were found for record structure accuracy and legibility between the posttest and follow-up. Conclusion: Primary Nursing exerts an overall positive effect on nursing documentation accuracy and persists over time. Relevance to clinical practice: The benefits from Primary Nursing implementation included better-documented patient outcomes. The use of Primary Nursing linked with the use of the nursing process allowed for a more individualised and problem-solving approach. Nurse managers should consider the implementation of Primary Nursing to improve care quality.