Care management: agreement between nursing prescriptions and patients' care needs

ABSTRACT Objectives: analyze agreement between nursing prescriptions recorded in medical files and patients' care needs; investigate the correlation between the nurses' professional background and agreement of prescriptions. Method: descriptive study with quantitative and documentary approach conducted in the medical clinic, surgical, and specialized units of a university hospital in the interior of São Paulo, Brazil. The new validated version of a Patient Classification Instrument was used and 380 nursing prescriptions written at the times of hospital admission and discharge were assessed. Results: 75% of the nursing prescriptions items were compatible with the patients' care needs. Only low correlation between nursing prescription agreement and professional background was found. Conclusion: the nursing prescriptions did not fully meet the care needs of patients. The care context and work process should be analyzed to enable more effective prescriptions, while strategies to assess the care needs of patients are recommended.


Introduction
Documentation is an essential practice in nursing, with clinical and legal importance, as well as being a relevant tool of communication among healthcare workers. Nurses are responsible for keeping precise and complete records to ensure the continuity, safety and quality of care delivery (1) .
A Nursing Prescription (NP), which is part of documentation, is an instrument to guide the actions of the staff in the delivery of care to patients (2) . Identifying the care needs of patients is essential in order for nurses to write NP and identify necessary interventions so that individualized quality care is provided (3) . Patient Classification Instruments (PCI) have been used to identify patients' nursing care needs. Thus, a PCI is a tool that enables nurses to plan, implement, and assess the care process (3)(4) .
In practice, difficulties have been reported in regard to the implementation of the nursing process, such as the incomplete or incorrect use when compared to what is taught in nursing schools (5) , deficient knowledge on the part of professionals (6) , and an excessive number of nurses' activities, such as having to manage care, people, and material and physical resources (7) . Work overload limits the time nurses spend with their patients and potentially impedes more efficient assessment.
Prescriptions are performed electronically in some hospitals. Even though this type of recording represents an advancement in nursing care as it standardizes (8) procedures and saves time (9) , its use has generated concerns. One such concern involves the system's copy and past resource, which allows the inclusion of non-valid data that do not transmit the patient's actual situation, which has the potential to affect critical thinking, decision-making and the quality of care (9) .
Unplanned care often results in missed care. Missed care is defined as any aspect of care that is required by patients but is omitted (either in part or in whole) or delayed. Studies report the areas in which care is neglected by the nursing staff (10)(11) and the reasons for such occurrences (11) .
The way in which prescriptions have been distributed among work shifts and the prescriptionto-nurse proportion adopted by some health facilities has been cause for concern. Thus, the identification of failures in the prescription process is essential, as are strategies to promote efficacious care that meet the needs of patients (12) . This study's objective was to answer

Nurse prescribers
Of the 19 nurses participating in the study, 11 were women and eight were men, aged 32 years, on average (sd=7; variation from 24 and 49 years old); with an average professional experience of seven

Nursing prescriptions
The average number of care needs identified per patient ranged from 5.6 (IPD and GO) to 6.7 at time of admission and from 5.0 (medical clinics) to 8.9 (Neurology/orthopedics) at discharge (    (Table 2). Correlation between agreement of nursing prescriptions and the demographic profile of patients, length of hospitalization, and PCI score is presented in Table 3. Values between 0.02 and 0.88 (NP and PCI score) were found.   Considering the total number of items prescribed

Discussion
Patient-centered care, that is, individualized care that ensures the participation of patients in decisionmaking regarding their health/disease situation, is considered to be vital in nursing practice (17) .
To provide a perspective focused on the patients' These findings lead us to reflect on how prescriptions have been used in hospital facilities.
Undoubtedly, its incorporation into the professional routine meant significant improvement in terms of providing quality, individualized, safe, and resultfocused care to patients (20) ; however, there is still a need to investigate the context of care and work process in which such a procedure is implemented to make necessary adjustments.
Some of these difficulties may have influenced this study's results.
Many Brazilian hospital facilities have used electronic nursing documentation and, when properly performed, this favors a practice that enables the frequent review of care plans and the implementation of changes whenever necessary (21) . We noticed in the facility under study, however, that prescriptions from the previous day were copied and care needs were not fully considered or not updated, while prescriptions included procedures that had already been implemented in the units' routines.
The system's resources, such as the ability to copy and paste, favors easy reproducibility of prescriptions so that nurses often fail to use clinical rationale to reassess their patients' care needs. This omission of care influences decision-making and may interfere in the quality of care delivery (9) . Accessing precise information concerning a patient's health status using electronic nursing documentation is highly relevant (22) , but its inappropriate use has been reported by researchers (9,23) .  (24) . Limited time to properly develop NP was also verified in another health care setting (25) . were the most frequently neglected.
The occurrence of so-called missed care has been reported in studies (10)(11) . Nine basic care elements were  (10) . The factors that predict such omissions include the shift worked, number and allocation of personnel, communication within the multidisciplinary team, intensity of workload, and satisfaction of nurses with their current job (11) .
It is believed that the longer nurses monitor a patient, the more efficiently they identify the patient's needs. No statistical significance, however, was found between the agreement of prescriptions written at the time of admission and at discharge, even though patients were discharged on the 17 th day of hospitalization, on average. This reinforces the need to rethink this facility's care organization model.
In addition to attention being paid to factors linked to environment and the way work is performed, the use of assessment strategies can contribute to more effective care planning, minimizing missed care. We recommend the adoption of instruments to make such assessments in order to guide critical thinking when identifying patients' nursing care needs (14,26) . The use of scales to conduct assessments has recently been verified to enable the identification of a larger number of care areas (27) .
It is not yet possible to establish whether nursing care needs that go unsatisfied could be used as an indicator of the quality of nursing care provided in hospitals or what is the best method to ensure that care plans and nursing prescriptions meet all of a patient's care needs (28) .
Even though this study's results have showed weak correlation between the number of NP/nurse and agreement, we believe it is infeasible for a nurse to prescribe for such a large number of patients. The literature does not report the proportion of prescriptions recommended per nurse such that a deeper discussion could be grounded. The indication that nurses' prescriptions do not fully meet the care needs of patients, however, shows that this work organization may not be efficacious and demands managers to take a closer look.
A limiting aspect of this investigation is the fact it was restricted to one hospital facility and did not include all its hospitalization units. Thus, replication of the study is necessary to verify how prescriptions are developed in other settings.

Conclusion
This investigation revealed that nursing prescriptions did not fully meet patients' care needs. Additionally, neither do the time the prescription is written nor the professionals' or the units' characteristics impact level of agreement. Monitoring and analysis of the context in which care is provided and work processes occur is recommended to enable more effective prescriptions, in addition to the use of strategies to assess patients' care needs.