Nursing and medical documentation on patients’ cultural background

Abstract

To investigate if, and to what extent, nursing and medical documentation in patient records include entries on cultural background. Health care professionals in Sweden may have difficulties in providing satisfactory care, due to lack of knowledge about immigrants' background. According to Swedish law the information needed to guarantee safe care must be specified in the patients' records. It is, therefore, important to investigate what information nurses and physicians document on patients' cultural background. In this descriptive study, archival data concerning older and terminally ill patients were analysed retrospectively. The sample consisted of records from 121 patients > or =65 years at the time of death, who were born abroad and died during the year 1999. Content analysis was used to interrogate data collected from patient records, which related to the patient's cultural background. Entries (sentences or portion of sentences) were identified, coded and categorized using Leininger's Sunrise Model. From the patient records, entries could be related to all the factors in the upper part of the Sunrise Model. Some factors were found in all records, and all factors, except technological factors, could be traced across the patients' records. Information concerning folk/lay care could not be found. The results from this study indicate that nurses' and physicians' documentation in patient records included all factors in the Sunrise Model except technological. The overall impression is that the documentation is partly atomistic and insufficient as cultural assessment. Even if the health care personnel want to reduce the amount of documentation produced, this study highlighted the importance of documentation on cultural factors. To save time the nursing documentation could be based on the Sunrise Model and structured according to the VIPS model.