Background Rehabilitation nursing lacks a documentation framework representative of nursing’s contribution to rehabilitation outcomes. The Rehab ABC nursing documentation framework (Rehab ABC) was designed to improve the structure and content of rehabilitation nursing documentation. The framework acts as a mental model and memory aid using a basic mnemonic structure. It contains all the items of the Functional Independence Measure (FIMTM) and additional, comprehensive care responsibilities such as nutrition, pressure care, falls management, cognition and continence care.
Aim To evaluate introducing the Rehab ABC with the Normalisation Process Theory (NPT) NoMAD survey using two different implementation processes.
Methods The Rehab ABC was introduced in two independent rehabilitation units using different implementation models of practice development (PD) and quality improvement (QI). The NPT NoMAD survey was used to evaluate four domains of normalisation.
Results The Rehab ABC had become a normalised process in both units, reflecting how well the framework can be embedded using PD or QI. Providing evidence, the Rehab ABC makes sense and is coherent, creating change using local ‘buy-in’ through reflexive participation. Audit results reinforced individual and focus group feedback that the Rehab ABC provides users with a logical and understandable framework that supports multidisciplinary team (MDT) communication.
Conclusion The Rehab ABC provides nurses with a simple sense-making tool to improve documentation and MDT communication. It reflects how rehabilitation nurses integrate functionally focused, comprehensive and goal-oriented rehabilitation in their care. NPT is an easily administered evaluation process that can help guide implementation and gauge the success of the Rehab ABC framework in different clinical contexts.