Implementation of a documentation model comprising nursing terminologies – theoretical and methodological issues

AIMS: To describe and discuss theoretical and methodological issues of implementation of a nursing services documentation model comprising NANDA nursing diagnoses, Nursing Intervention Classification and Nursing Outcome Classification terminologies. BACKGROUND: The model is developed for electronic patient record and was implemented in a psychiatric hospital on an organizational level and on five test wards in 2001-2005. METHODS: The theory of Rogers guided the process of innovation, whereas the implementation procedure of McCloskey and Bulecheck combined with adult learning principals guided the test site implementation. RESULTS: The test wards managed in different degrees to adopt the model. Two wards succeeded fully, including a ward with high percentage of staff with interdisciplinary background. CONCLUSIONS: Better planning regarding the impact of the organization's innovative aptitude, the innovation strategies and the use of differentiated methods regarding the clinician's individual premises for learning nursing terminologies might have enhanced the adoption to the model. IMPLICATIONS FOR NURSING MANAGEMENT: To better understand the nature of barriers and the importance of careful planning regarding the implementation of electronic patient record elements in nursing care services, focusing on nursing terminologies. Further to indicate how a theory and specific procedure can be used to guide the process of implementation throughout the different levels of management.