Journal of Nursing Management, 2013, 21, 112120

Health-care professionals documentation of wellbeing in

patients following open heart surgery: a content analysis of
medical records
ANN-KRISTIN KARLSSON

PhD

, EVY LIDELL

PhD

2,3

and MATS JOHANSSON

PhD

Medical Social Worker, Department of Internal Medicine, Hospital Varberg, Varberg, 2Associate Professor,
School of Social and Health Sciences, Halmstad University, Halmstad, 3Member of Nurse, Fellow of European
Society of Cardiology (NFESC), and 4Cardiologist, Department of General Medicine, Vastra Vall, Varberg, Sweden

Correspondence
Ann-Kristin Karlsson
Department of Rehabilitation
Kuratorsmottagning 1D
Varberg Hospital
432 81 Varberg
Sweden
E-mail: ann-kristin.karlsson@
regionhalland.se

KARLSSON A.-K., LIDELL E. & JOHANSSON M.

(2013) Journal of Nursing Management

21, 112120.
Health-care professionals documentation of wellbeing in patients
following open heart surgery: a content analysis of medical records
Aim To explore health-care professionals documentation of patient wellbeing in
the first five months after open heart surgery.
Background Open heart surgery (coronary artery bypass grafting or heart valve
replacement) is an intervention aimed at relief of symptoms and increased
wellbeing. It is a complex procedure with deep experiences encompassing
physiological, psychological and social aspects. Health-care professionals
documentation of expressions of decreased wellbeing related to open heart
surgery is an important basis for decisions and for the understanding of patients
overall health situation.
Method Eighty medical records were examined by means of qualitative and
quantitative methods in order to explore documentation of patient wellbeing at
four points in time. The analysis was performed by content analysis and
descriptive statistics.
Results Documentation of physical wellbeing was dominant on all occasions,
while psychological wellbeing was moderately well documented and social
aspects of wellbeing were rarely documented.
Conclusion The medical records did not adequately reflect the complexity of
undergoing open heart surgery. Hence the holistic approach was not confirmed in
health-care professionals documentation.
Implications for nursing management Managers need to support and work for a
patient-centred approach in cardiac care, resulting in patient documentation that
reflects patient wellbeing as a whole.
Keywords: documentation, healthcare professionals, open heart surgery, wellbeing
Accepted for publication: 15 June 2012

Introduction
Open heart surgery (OHS) by means of coronary
artery bypass grafting or heart valve replacement is a
112

common intervention aimed at relief of symptoms and

increasing wellbeing in conjunction with improved
prognosis (Falcoz et al. 2003, Herlitz et al. 2005). In
Sweden, 4530 such operations were performed in
DOI: 10.1111/j.1365-2834.2012.01458.x
2012 Blackwell Publishing Ltd

Wellbeing in patients following open heart surgery

2010 (Swedeheart 2010). Open heart surgery is a

complex experience involving physiological, psychological and social aspects of wellbeing (Karlsson et al.
2005, Hawkes et al. 2006, Okkonen & Vanhanen
2006, Tolmie et al. 2006). Okkonen and Vanhanen
(2006) reported that poor family support is associated
with more symptoms of depression, anxiety and hopelessness 6 months after coronary bypass graft surgery.
They also found more depressive symptoms as well as
chest pain in patients living alone. Thus it is important
to be aware that recovery after OHS is far more than
survival and that successful reorientation to everyday
life depends on various factors. Karlsson et al. (2010)
reported from focus group discussions that healthcare
professionals (HCPs) described OHS as a life event
characterised by vulnerability and insecurity that
threatened patients wellbeing. The HCPs perceptions
comprised bodily and emotional signs captured by
means of direct communication with patients,
although intuitive understanding was also employed.
The concept of wellbeing has been defined from different perspectives. It has commonly been described as
health and quality of life as well as an aspect of health
(Sarvimaki 2006). In 1946 the World Health Organization defined health as a state of complete physical,
mental and social wellbeing and not merely the
absence of disease or infirmity (World Health Organization 1946). According to Sarvimaki (2006), the concept of wellbeing may be perceived as both a unifying
concept and a characteristic of health and quality of
life. Although wellbeing is a holistic concept, it can
still be conceptualised in empirical research as physical, psychological, social and spiritual but must be
viewed as a whole on a philosophical level in order to
achieve a deeper understanding (Sarvimaki 2006).
Documentation of expressions of decreased wellbeing perceived by HCPs in their communication with
patients is an important piece of the puzzle, as it
forms a basis both for decisions and for understanding
the patients overall health situation (Adamsen & Tewes 2000, Langewitz et al. 2009). However, previous
research on health-care documentation has not
revealed whose reality patient records reflect. A Danish study in which patient interviews, record analysis
as well as focus group interviews with staff were conducted found that nurses knew more about patients
problems than was documented and that only 31% of
the problems experienced and communicated by
patients were included in the records (Adamsen &
Tewes 2000). One explanation offered was that
assistant nurses had knowledge about the patients
circumstances but no tradition of documenting such
2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2013, 21, 112120

information. Based on videotaped patient consultations, Langewitz et al. (2009) reported that physicians
documented little about psychosocial circumstances
even when patients revealed such information. It was
assumed that the physicians themselves judged what
was relevant, as there was no evidence that physicians
sought feedback from patients on whether or not they
were satisfied with the way in which their information
had been documented. This corresponds to the statement that in the records, the patients description of
experienced symptoms is less important than measurable signs (Swedberg 2010). According to Swedberg
(2010), this reflects the lack of a patient-centred
approach to health care. Laitinen et al. (2010) also
concluded that although nurses documentation was
generally relevant, it was only partially patient-centred. This leads to questions about whether medical
records reflect the complexity of undergoing OHS.
There is limited research on documentation prepared
by HCPs as a multi-professional group in a cardiac
care context. Therefore, the aim of this study was to
explore HCPs documentation of patient wellbeing in
the first 5 months after OHS.

Method
Study design, sample and data collection
The study is a retrospective medical record review
performed with both qualitative and quantitative
methods. The Research Ethics Committee, Sahlgrenska
Academy, University of Gothenburg, Gothenburg,
Sweden, approved the study in 2008 in the form of an
addendum to previous ethical approvals (T653-08 Ad
408-01, S566-03). Eighty records of patients
O
recruited for another study reported elsewhere, who
underwent OHS during the period January 2002 to
October 2003 (Table 1) were examined in order to
explore documentation of patient wellbeing performed
by physicians, nurses, physiotherapists and medical
social workers. The study comprises documentation at
four points in time: the hospital stay after surgery,
two planned cheque-up visits (5 weeks and 5 months
after surgery in accordance with the ordinary routines
after OHS) and various contacts with the hospital during the 5 months after surgery, including rehospitalisation, and phone calls as well as planned meetings with
the medical social worker.
The electronic record system employed at the hospital was based on keywords in order to make it easy to
read and find information. A prefix in the form of a
character (for example N for nurse) was tailored to
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A.-K. Karlsson et al.

Table 1
Characteristics of patients who underwent open heart surgery
(n = 80)
Characteristic
Age (years mean, range)
Male gender (number,%)
Married or cohabiting (number,%)
Retired or semi-retired (number,%)
Working full or part time (number,%)
Surgery
Coronary artery bypass grafting (number,%)
Heart valve replacement (number,%)
Surgical complications (number,%)
History
Smoking (number,%)
Myocardial infarction (number,%)
Hypertension (number,%)
Diabetes (number,%)
Stroke (number,%)

64
67
66
56
27

(4075)
(84)
(82)
(70)
(34)

78 (98)
6 (8)
21 (28)
11
40
45
11
5

(14)
(50)
(56)
(14)
(6)

CABG, Surgical complications: artrial fibrillation, re-operation for

bleeding, pneumonia or renal failure.

each keyword defining the category of the professional

who had prepared the documentation. For some keywords the professionals could use standard phrases
while others had a free text function. The different
professionals wrote consecutively in the same record
and had access to each others notes. However, the
extent to which the HCPs read and were influenced
by each others documentation is unknown. Cardiac
care at the hospital was dominated by the medical
perspective on patient health and wellbeing.

Data analysis
Hard copies of the records were used as a basis for
the review. The analysis was performed by means of a
directed content analysis comprising two steps: a qualitative analysis and a quantitative analysis (Hsieh &
Shannon 2005). This mixed method design was used
in order to expand and enrich understanding of the
results (Morse & Niehaus 2009).

The qualitative analysis framework

The content analysis was based on Sarvimaki and
Stenbock-Hults (1989) model of patient health
dimensions. According to Sarvimaki and StenbockHult (1989), from a holistic perspective, patients
express themselves in five dimensions. The first is the
biophysiological, comprising various systems such as
breathing, blood circulation and reproduction, which
preserve life processes. Physical illness disturbs and
threatens such life processes. The second dimension is
114

the emotional, in which affections, emotions and

mood are expressed. Individuals can react differently
to the same situation: one may react with anger and
another with fear. The third dimension is intellectual
and comprises individuals perceptions of themselves
as well as their own and other peoples needs and feelings. Intellectual functions are important for a persons ability to solve problems and make decisions.
The fourth dimension is spiritual/existential and comprises a persons norms, ideals and values. It is not
necessarily synonymous with a belief in a God. It can
also be expressed in the form of relationships with
other people as well as with nature. The final dimension is socio-cultural, where a person expresses the self
as part of a social and cultural context. Many human
needs can only be fulfilled in the interaction with
other people. Through such interplay individuals
develop their own norms and ideas. After defining the
dimensions, Sarvimaki and Stenbock-Hult (1989)
combined dimensions 24 and labelled them the psychological dimension (Table 2). Care based on a
holistic perspective takes all dimensions of life (biophysical, psychological and socio cultural) into consideration and is characterised by an awareness of the
importance of their interaction.

Data analysis process

The analysis started with two of the authors (A-KK
and EL) independently reading the records, after
which they marked and coded meaning units of relevance for the purpose of the study. The first author
compared the results. Consensus was high throughout
the analysis and only a few amendments were made
as a result of discussion between the authors. The
coded meaning units were initially sorted under Sarvimaki and Stenbock-Hults (1989) model of patient
health dimensions. During the analysis process we
identified information in which physical and psychological values were intertwined, and thus decided to
include a mixed category labelled the physicalpsychological dimension in the original model. The
coded meaning units in each record were labelled separately under the study-ID of each participant in a
Microsoft Access database and sorted into developed
subcategories under the following categories: the physical dimension, the physicalpsychological dimension,
the psychological dimension and the social dimension.
The labelled material was then exported to a Microsoft Excel file in order to obtain an overview of the
data on a group level and conduct the analysis. The
results were discussed and evaluated in the research
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Journal of Nursing Management, 2013, 21, 112120

Wellbeing in patients following open heart surgery

Table 2
Model of health dimensions by Sarvimaki and Stenbock-Hult
(1989)
Dimensions

Definitions

The bio physiological dimension

Comprises various
systems that preserve
life processes

The psychological dimension

The emotional dimension
The intellectual dimension

The spiritualexistential
dimension
The socio-cultural dimension

Comprises affections,
emotions and mood
Comprises individuals
perceptions of
themselves as well as
own and other
peoples needs and
feelings
Comprises a persons
norms, ideals and
values
Comprises a persons
expressions of the
self as part of a
social and cultural
context

group, consisting of different professional categories

(medical social worker, nurse and physician) with
many years experience of patients with cardiac diseases. Finally, the results were described and illustrated by citations from the medical records.

The quantitative analysis

The categories and subcategories were used to quantify the data from the medical records. The Excel file
included the participants study ID, which made it
possible to calculate percentages and quantitatively
describe the documentation over time.

Results
The qualitative content of the physical, physical
psychological, psychological and social dimension categories is described below. The quantitative results are
presented numerically in Table 3 and discussed at the
end of this section.

examination 5 weeks later. Documented in-hospital

activities took the form of short comments such as
walking around the ward and has taken a shower,
while after discharge the focus was on physical training and pursuit of interests. One example was Feeling
well after surgery and has started working a bit in the
garden. Experiences poorer physical condition after
the heart attack and surgery. In the subcategory A
general feeling of being ill, being ill, in the form of
fever, shivering and faintness, was documented and
could be expressed as feeling both warm and cold but
not shivering, no fever. Such notes occurred during
the hospital stay after surgery and in connection with
additional contacts. The documentation of breathing
concerned the occurrence of shortness of breath and
coughing. The notes were in the form of short comments like troubled by cough and phlegm. Such notes
were rare at the final visit after surgery. Documentation of appetite, bowel movement and micturition
was also short and connected with the hospital stay
and additional contacts. The subcategory Symptoms
of discomfort contained information about various
expressions of discomfort such as feeling sick and
unsteady, palpitations, numbness or clicking in the
chest and was documented during the whole OHS
process. Two examples are: She sometimes has a feeling of discomfort, of tingling on the left side of her
chest in connection with irritation or embarrassment,
A short while after getting up he felt dizzy and
unsteady and went quickly back to bed. Documentation about the status of wound healing occurred frequently during the hospital stay as well as at the visit
5 weeks after surgery. The notes took the form of
short, standard phrases such as sternum and wounds
without objections. Pain in the form of angina as
well as pain located in the chest or elsewhere also
received much attention on all occasions. No angina,
Great problem with pain in the breastbone after
bypass surgery. The last subcategory Swelling
contained notes about the presence of swelling (mostly
legs) such as swollen lower leg and foot, which
decreases in the evening. Such notes were associated
with the hospital stay and the first visit after
discharge.

The physical dimension

This dimension, supported by nine subcategories, was
the most comprehensive, irrespective of the documentation time.
Ability to be active was the first subcategory.
The patients ability to be active was of interest, especially during the hospital stay after surgery and at
2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2013, 21, 112120

The physicalpsychological dimension

This mixed category contained information of an
intertwined and complex nature, which implies that
physical and psychological processes interacted and
influenced the conditions described. Four subcategories were formulated.
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A.-K. Karlsson et al.

Table 3
Health-care professionals documentation of patient health and wellbeing over time after open heart surgery (n = 80)

Categories

Subcategories

The physical dimension

Ability to be active*
General feeling of
being ill
Breathing
Appetite
Bowel movement,
micturition
Symptom of discomfort
Healing of wounds
Pain
Swelling
Lifestylek
Sleep
Tiredness
Wellbeing**
Mental orientation
Reaction
Mood
Need for care
Challenges in
social lifekk

The physicalpsychological
dimension

The psychological dimension

The social dimension

Hospital stay
after surgery (%)
76 (95)
18 (23)

44 (55)
2 (3)

9 (12)
1 (1)

15 (18)
16 (20)

46 (58)
17 (21)
39 (44)

30 (38)
1 (1)
6 (8)

3 (4)
0 (0)
2 (3)

15 (19)
16 (20)
9 (11)

34
78
74
15
6
29
26
65
39
18
13
2
3

18
65
51
10
24
8
8
59
1
6
13
0
2

(43)
(98)
(93)
(19)
(8)
(36)
(33)
(81)
(41)
(23)
(16)
(3)
(4)

(23)
(81)
(64)
(13)
(30)
(9)
(9)
(74)
(1)
(8)
(16)
(0)
(3)

Examination
5 months
after surgery (%)

Additional
contact during
the 5 months
after surgery (%)

Examination
5 weeks
after surgery (%)

17
2
27
0
27
1
3
62
3
3
7
0
0

(21)
(3)
(34)
(0)
(34)
(1)
(4)
(78)
(4)
(4)
(9)
(0)
(0)

25
17
28
7
5
15
11
20
7
12
10
2
3

(31)
(21)
(35)
(9)
(6)
(19)
(14)
(25)
(9)
(15)
(13)
(3)
(4)

*Activities of daily life, physical training and pursuit of interests; fever, shivering and faintness; shortness of breath and coughing; feeling
sick and unsteady, palpitations, numbness clicking in the chest; angina, pain located in the chest or elsewhere; keating habits, weight,
smoking and alcohol use; **used as an overall concept; awareness of themself, time and place, remembering and concentration; yearning, tearfulness, unhappiness, irritability and existential thoughts; depressed mood, anxiety and listlessness; the need for home-help
service; kkresponsibility for children or an ill relative, communication problems in the relationship with family members, lack of capacity for
social activities.

The first subcategory was Lifestyle, which

described documented communication about eating
habits, weight, smoking and alcohol use and was associated with the check-up visits. This documentation
reflected a dialogue between a patient and a HCP,
sometimes initiated by the patient as in the following
comment: The patient describes problems with daily
alcohol consumption and asks for help to stop. In
another example, the dialogue led to important information for the understanding of a measurable sign:
Considerable weight loss during recent months. The
patient is recently divorced and has sole responsibility
for six children. Documentation on sleep occurred
most frequently during the hospital stay after surgery
and in connection with additional contacts. There
were short notes such as has slept well and sometimes notes expressing disagreement such as The
patient himself feels that he has slept badly, but it
looks as if he has had a peaceful night. Tiredness
was in focus, especially during the hospital stay after
surgery, usually formulated as feeling tired and
exhausted. The presence of wellbeing was frequently
documented during the whole OHS process. It was
116

used as an overall concept, sometimes documented as

a result of a dialogue The patient says that she is feeling well but mostly as a short comment such as
being well.

The psychological dimension

This dimension was described by three subcategories.
The first sub-category was Mental orientation and
contained notes about the extent of patients awareness of their own person, time and place, difficulties
remembering or concentrating on things. One example
was The patient is a bit confused at times. Such documentation was associated with the hospital stay after
surgery. The second subcategory comprised documentation about different reactions and was most frequently found during the hospital stay and in
connection with additional contacts, and described
patients yearning for relatives, tearfulness, unhappiness, irritability and existential thoughts: The patient
is dealing with existential thoughts and uncertainty
about what he will be able to do in terms of work in
the future. The third subcategory, Mood, contained
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Journal of Nursing Management, 2013, 21, 112120

Wellbeing in patients following open heart surgery

notes about the presence of depressed mood, anxiety

and listlessness. This documentation was found to a
limited extent on all occasions. Two examples were:
Feeling anxious and depressed, wants to get in touch
with the medical social worker and After surgery
he has periodically felt depressed and has difficulty
controlling his temper.

The social dimension

This category, comprising two subcategories, was the
least informative, irrespective of documentation time
in the OHS process.
The sub-category Need for care contained notes
about the need for the home help service, mostly on
the part of patients living alone. The patient is worried about how he will manage when he returns home.
He wants to have the home help service. The subcategory Challenges in social life described difficulties
upon returning home because of responsibility for
children or an ill relative, communication problems in
the relationship with family members and/or lack of
capacity for social activities: The patient expresses
the need to stay in hospital for a few more days
because his wife is seriously ill.
The quantitative results indicate that HCPs
focused on different aspects of patient health and
wellbeing during the OHS process. During the hospital stay after surgery, wounds (98%), pain (93%),
activity and breathing (58%) were documented to
a great extent, while the other subcategories in
the physical dimension were sometimes documented
as checked by HCPs and sometimes not. In the
physicalpsychological dimension, sleep and tiredness
were moderately documented while wellbeing
occurred frequently (81, 74, 78, 25%, respectively)
at all four points in time. Mental orientation was
the most frequently documented of the psychological
aspects during the hospital stay (41%). Notes about
mood remained at a fairly constant level on all four
occasions (16, 16, 9 and 13%), as did social
aspects. At the examination 5 weeks after surgery,
the notes indicate that wounds (81%), pain (64%)
and activity (55%) were still in focus but that lifestyle questions also had priority (30%). Five months
after surgery the decreased frequency of notes indicates that most physical problems were over, with
the exception of pain (34%) and various experiences
of discomfort (21%). Lifestyle aspects (34%) were
then in focus. Notes related to additional contacts
during the 5 months after surgery reflected much the
same problems as on the first occasion.
2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2013, 21, 112120

Discussion
This study reveals that the health dimension model (Sarvimaki & Stenbock-Hult 1989) was suitable for describing documentation on patient wellbeing in connection
with OHS when the combined category the physical
psychological dimension was added. The analysis visualised an obvious imbalance between the different dimensions. Documentation of physical wellbeing dominated
at all points in time, while psychological wellbeing was
moderately documented and social aspects of wellbeing
were rarely documented. The focus on physical status in
connection with OHS may appear natural as well as
expected; nevertheless, such an imbalance between the
dimensions is inconsistent with a holistic perspective on
health and can have a negative impact on the outcome
for the patients. Decreased psychological wellbeing was,
for example, revealed in a previous study on the same
study population as in the current study, in the form of
mild to moderate depressed mood (the Montgomery
sberg Depression Self rating Scale  730) in 52% of
A
the patients at 5 weeks, and/or at 5 months as well as
3 years after OHS (Karlsson et al. 2008).
The repeated reading of the patient records generated
reflections about linguistic style and how to understand
the terms used, as well as the preferential right of interpretation. The electronic record system employed at the
hospital was based on keywords in order to make it
easy to find and read information. Nevertheless, the use
and interpretation of the keywords varied remarkably
within as well as between professional groups. Written
information is taken for granted despite the fact that it
can be interpreted in various ways according to differences in perspective and conceptualization among cooperating HCPs (Mead & Bower 2000). One example
from the material studied is the documentation of wellbeing. It was frequently used in comments such as feeling well, going home or not feeling quite well but
without further explanation. In addition to uncertainty
about whether such documentation reflects the patients
wellbeing as a whole or only a limited aspect of it, this
telegraphic style in the form of uncompleted sentences
makes it unclear whether the opinion documented is
that of the patient or the HCP. Although there were
also good examples of documentation that clearly built
on a dialogue between patient and HCP, it was often
impossible to distinguish the patients voice in the
form of expressed feelings, thoughts and experiences.
The same kind of linguistic vagueness has been reported
in previous studies (Tornvall et al. 2004, Laitinen et al.
2010). Such vagueness cannot be eliminated by using standardised terms. According to Adamsen and Tewes (2000),
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A.-K. Karlsson et al.

such terms will not ensure improved quality of documentation. The patient perspective must also be included here.
As mentioned above, the psychological aspects of
OHS were moderately documented, although it is well
known that depressive symptoms are associated with
increased risk of mortality and new cardiac events as
well as lower physical and emotional functioning,
adherence to prescribed medication and life-style recommendations (Doering et al. 2005, Mallik et al.
2005, Rumsfeld & Ho 2005, Wellenius et al. 2008).
It has been argued that HCPs in somatic care have difficulties recognising such symptoms because of a lack
of experience (Rumsfeld & Ho 2005, Ziegelstein et al.
2005). The present study was unable to verify this
assumption, although it was observed that when a
HCP had documented depressive symptoms, this information was repeated in other HCPs documentation
without obvious consideration. Karlsson et al. (2010)
reported that HCPs found it easier to recognise anxiety than depressed mood after OHS. In the present
study we emphasise the complex interplay between
body and psyche by adding a mixed category the
physicalpsychological dimension. A weight problem,
for example, has to be understood as something more
than a measurable physical problem. To resolve it,
one also has to focus on its psychological dimension
by means of emotional and intellectual reasoning.
Documentation of social circumstances was sparse,
which corresponds with the findings reported by Laitinen et al. (2010). In contrast to Laitinen et al. (2010),
the present study only reported communicated social
circumstances and not passive comments about
patients having visits, as the latter add little information about the relationship with relatives and their
ability to be supportive. The importance of social support and family relationships for patient wellbeing in
connection with OHS (e.g. occurrence of chest pain
and depressed mood) has been recognised for many
years (Karlsson et al. 1999, Okkonen & Vanhanen
2006). There must be an explanation for the paucity of
documentation other than the patients short hospital
stay after surgery and the high workload on the wards.
The most plausible answer seems to be that, as long as
holistic thinking is not the main approach of HCPs,
there will be a gap between knowing and doing,
research and practise  and patients will pay the price.
The quantitative result raises questions about why
documentation about, for example, sleep, bowel
movement, tiredness and breathing does not occur
routinely in all records during the hospital stay after
surgery. Were such aspects of wellbeing discussed with
all patients but only noted by some HCPs when there
118

was a problem? Was for example tiredness taken for

granted because of the circumstances and thus not
noted? These questions cannot be answered by this
study but point to the need for change. In a study
about nursing documentation, different influencing
factors were identified. Some were personal, such as
limited competence and motivation, while others were
organisational, including inadequate audit, supervision
and staff development (Cheevakasemsook et al. 2006).
It can be assumed that other groups of HCPs are
struggling with similar problems and hence, practising
HCPs, as well as health-care managers, have an
important role in developing documentation to ensure
that it is well-written, clear, adequate and safe.

Limitations
This study focused on HCPs documentation of wellbeing in patients following OHS. Both qualitative and
quantitative methods were employed in order to better
understand the phenomenon. The independent reading
and coding performed by two of the researchers
strengthens the trustworthiness of the study, and the
reasonableness of the results was evaluated by the
interdisciplinary research group. However, one limitation might be our decision to analyse the HCPs documentation as a whole, thus perhaps overlooking
interesting differences between professional categories.
However, in this study the main interest was the documentation of wellbeing per se, irrespective of profession. Another limitation is that a record review cannot
fully reflect the care provided, or the character of the
complex interplay between a patient and an HCP.
Nevertheless, a record review both directly and indirectly reflects much of the HCPs approach to and perspectives on patient health and wellbeing. Finally, the
currency of the data might be questioned. This study
ends our research on this study population, and
9 years have passed since the recruitment was finished.
However, very little has changed in cardiac care when
it comes to documentation of patient wellbeing as a
multi-dimensional concept, which justifies the study
and strengthens the urgency of its message.

Conclusion
The documentation in the medical records did not
adequately reflect the complexity of undergoing OHS.
The HCPs documented physical, psychological and
social aspects of wellbeing in patients in connection with
OHS, where physical aspects were clearly dominant.
Hence, holistic thinking, which is associated with
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Journal of Nursing Management, 2013, 21, 112120

Wellbeing in patients following open heart surgery

patient-centred care, was not evident in the HCPs

documentation.

Implications for nursing management

The study underlines the need for HCPs to clarify
their own opinions on patient health as well as
patients experiences in their documentation. Medical
record systems should be organised so that the sharing
of documentation among HCPs is facilitated, as each
profession has unique information about the patients
health and wellbeing. The present study can inspire
interprofessional discussions about the meaning of
commonly used terms and concepts to achieve better
understanding, increased patient outcome and safer
care. One example of a desirable amendment of documentation in cardiac care is the inclusion of keywords
aimed at documentation of information containing
intertwined physical and psychological values. The
current study reveals the need for deeper understanding among HCPs of the complexity of the reasons for
decreased patient wellbeing in the form of different
signs and symptoms after OHS. One way to achieve
such change is for HCPs to consciously practise
patient-centred techniques (echoing, mirroring, waiting and summarising) in their communication with
patients. Such techniques have been associated with
increased patient utterances containing crucial information (Langewitz et al. 2009). Nursing managers as
well as other health leaders need to support and
work for a patient-centred approach in cardiac care.
Because of to their caring perspective, nursing managers would be the most appropriate professional category to lead patient documentation development work
so that it reflects patient wellbeing as a whole.

Sources of funding
The Research board at Varberg Hospital, Varberg,
supported the study.

Ethical approval
The Research Ethics Committee, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
T653-08 Ad 408-01, S566-03.

Acknowledgements
We thank Folke Karlsson at FK Data for building and maintaining the data base. This study was supported by the
Research board at Varberg Hospital.
2012 Blackwell Publishing Ltd
Journal of Nursing Management, 2013, 21, 112120

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2012 Blackwell Publishing Ltd

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