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Björvell C, Jansson I, Busck-Håkans V, Karlsson I. Creating Subsets of International Classification for Nursing Practice Precoordinated Concepts: Diagnoses/Outcomes and Interventions Categorized Into Areas of Nursing Practice. Comput Inform Nurs 2024; 42:21-26. [PMID: 37607702 DOI: 10.1097/cin.0000000000001072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
The International Classification for Nursing Practice is a comprehensive terminology representing the domain of nursing practice. A categorization of the diagnoses/outcomes and interventions may further increase the usefulness of the terminology in clinical practice. The aim of this study was to categorize the precoordinated concepts of the International Classification for Nursing Practice into subsets for nursing diagnoses/outcomes and interventions using the structure of an established documentation model. The aim was also to investigate the distribution of the precoordinated concepts of the International Classification for Nursing Practice across the different areas of nursing practice. The method was a descriptive content analysis using a deductive approach. The VIPS model was used as a theoretical framework for categorization. The results showed that all the precoordinated concepts of the International Classification for Nursing Practice could be categorized according to the keywords in the VIPS model. It also revealed the parts of nursing practice covered by the concepts of the International Classification for Nursing Practice as well as the parts that needed to be added to the International Classification for Nursing Practice. This has not been identified in earlier subsets as they covered only one specific area of nursing.
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Affiliation(s)
- Catrin Björvell
- Author Affiliations: Department of Informatics and Care Systems, Karolinska University Hospital (Dr Björvell); and Department of Neurobiology, Care Sciences and Society, Karolinska Institutet (Dr Björvell), Solna; Institute of Health and Care Science, Sahlgrenska Academy, University of Gothenburg (Dr Jansson); Swedish eHealth Agency, Stockholm (Ms Busck-Håkans); and Department of Health Sciences, Faculty of Health, Science, and Technology, Karlstad University, Karlstad (Dr Karlsson), Sweden
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2
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Kinnunen UM, Kuusisto A, Koponen S, Ahonen O, Kaihlanen AM, Hassinen T, Vehko T. Nurses' Informatics Competency Assessment of Health Information System Usage: A Cross-sectional Survey. Comput Inform Nurs 2023; 41:869-876. [PMID: 37931302 PMCID: PMC10662616 DOI: 10.1097/cin.0000000000001026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Nurses' informatics competencies are nurses' professional requirements to guarantee the quality of patient care and affect nurses' use of health information systems. The purpose of this survey was to describe nurses' perceptions of their informatics competencies regarding health information system usage. A previously tested web-based questionnaire with multiple-choice questions was sent to nurses whose e-mail address was available through three Finnish Nursing Associations (N = 58 276). A total of 3610 nurses working in Finland responded. Both descriptive and explanatory statistics were used to analyze the data. The three dependent variables "nursing documentation," "digital environment," and "ethics and data protection" were formulated from the data. Nurses' overall informatics competency was good. The "ethics and data protection" competency score was higher than that of "nursing documentation" or "digital environment." Recently graduated nurses and nurses working in outpatient care, virtual hospital, examination, or operation had highest "digital environment" competency score. Health information system experience was associated with "nursing documentation." Nurses are highly qualified health information systems users. However, the competency requirements generated by rapidly expanding digitalization have challenged nurses. It is important to increase educational programs for nurses of how to use digital devices, and how to support patients to use digital services.
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Esteban-Sepúlveda S, Giró-Formatger D, Hernández-García AF, Serratosa-Cruzado S, Moreno-Leyva M, Terradas-Robledo R, Lacueva-Pérez L. Info-NAS: A Computer Program for the Calculation of Intensive Care Unit Nurse Workload. Comput Inform Nurs 2023; 41:825-832. [PMID: 36912356 DOI: 10.1097/cin.0000000000001012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
The purpose of this study was to design an algorithm that allows automatic calculation of nursing workload in intensive care units, based on the Nursing Activities Score scale, through a computer program. Three methodological steps were used: (1) Delphi method (group of experts); (2) identification of the correspondence: Nursing Activities Score items-variables in the EHR, namely, standardized terminology, laboratory values, and prescriptions; and (3) weighting of variables independently by a group of experts. Finally, the algorithm of the computer program was tested. The results showed an algorithm that calculates the nursing workload in an ICU. The calculation is objective and automatic through the EHRs. This study shows the feasibility of the algorithm as a rapid and objective strategy to quantify adequate nurse staffing in intensive care units. Moreover, it provides nurses with a practical resource for the correct completion of records and is thus an incentive to maintain or improve their quality.
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Affiliation(s)
- Silvia Esteban-Sepúlveda
- Author Affiliations: Methodology, Quality and Nursing Research Department, Consorci Parc de Salut MAR de Barcelona (Drs Esteban-Sepúlveda and Terradas-Robledo, Ms Giró-Formatger, Ms Hernández-García, Mr Serratosa-Cruzado, and Ms Lacueva-Pérez); and Departament d'Infermeria Fonamental i Medicoquirúrgica, Escola d'Infermeria, Universitat de Barcelona (Dr Esteban-Sepúlveda)
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Ronquillo CE, Dahinten VS, Bungay V, Currie LM. Differing Effects of Implementation Leadership Characteristics on Nurses' Use of mHealth Technologies in Clinical Practice: Cross-Sectional Survey Study. JMIR Nurs 2023; 6:e44435. [PMID: 37624628 PMCID: PMC10492171 DOI: 10.2196/44435] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 06/22/2023] [Accepted: 07/21/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Leadership has been consistently identified as an important factor in shaping the uptake and use of mobile health (mHealth) technologies in nursing; however, the nature and scope of leadership remain poorly delineated. This lack of detail about what leadership entails limits the practical actions that can be taken by leaders to optimize the implementation and use of mHealth technologies among nurses working clinically. OBJECTIVE This study aimed to examine the effects of first-level leaders' implementation leadership characteristics on nurses' intention to use and actual use of mHealth technologies in practice while controlling for nurses' individual characteristics and the voluntariness of use, perceived usefulness, and perceived ease of use of mHealth technologies. METHODS A cross-sectional exploratory correlational survey study of registered nurses in Canada (n=288) was conducted between January 1, 2018, and June 30, 2018. Nurses were eligible to participate if they provided direct care in any setting and used employer-provided mHealth technologies in clinical practice. Hierarchical multiple regression analyses were conducted for the 2 outcome variables: intention to use and actual use. RESULTS The implementation leadership characteristics of first-level leaders influenced nurses' intention to use and actual use of mHealth technologies, with 2 moderating effects found. The final model for intention to use included the interaction term for implementation leadership characteristics and education, explaining 47% of the variance in nurses' intention to use mHealth in clinical practice (F10,228=20.14; P<.001). An examination of interaction plots found that implementation leadership characteristics had a greater influence on the intention to use mHealth technologies among nurses with a registered nurse diploma or a bachelor of nursing degree than among nurses with a graduate degree or other advanced education. For actual use, implementation leadership characteristics had a significant influence on the actual use of mHealth over and above the control variables (nurses' demographic characteristics, previous experience with mHealth, and voluntariness) and other known predictors (perceived usefulness and perceived ease of use) in the model without the implementation leadership × age interaction term (β=.22; P=.001) and in the final model that included the implementation leadership × age interaction term (β=-.53; P=.03). The final model explained 40% of the variance in nurses' actual use of mHealth in their work (F10,228=15.18; P<.001). An examination of interaction plots found that, for older nurses, implementation leadership characteristics had less of an influence on their actual use of mHealth technologies. CONCLUSIONS Leaders responsible for the implementation of mHealth technologies need to assess and consider their implementation leadership behaviors because these play a role in influencing nurses' use of mHealth technologies. The education level and age of nurses may be important factors to consider because different groups may require different approaches to optimize their use of mHealth technologies in clinical practice.
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Affiliation(s)
| | - V Susan Dahinten
- School of Nursing, The University of British Columbia Vancouver, Vancouver, BC, Canada
| | - Vicky Bungay
- School of Nursing, The University of British Columbia Vancouver, Vancouver, BC, Canada
| | - Leanne M Currie
- School of Nursing, The University of British Columbia Vancouver, Vancouver, BC, Canada
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Original Research: Practice Variations in Documenting Neurologic Examinations in Non-Neuroscience ICUs. Am J Nurs 2023; 123:24-30. [PMID: 36546384 DOI: 10.1097/01.naj.0000905564.83124.2d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND In critical care units, the neurologic examination (neuro exam) is used to detect changes in neurologic function. Serial neuro exams are a hallmark of monitoring in neuroscience ICUs. But less is known about neuro exams that are performed in non-neuroscience ICUs. This knowledge gap likely contributes to the insufficient guidance on what constitutes an adequate neuro exam for patients admitted to a non-neuroscience ICU. PURPOSE The study purpose was to explore existing practices for documenting neuro exams in ICUs that don't routinely admit patients with a primary neurologic injury. METHODS A single-center, prospective, observational study examined documented neuro exams performed in medical, surgical, and cardiovascular ICUs. A comprehensive neuro exam assesses seven domains that can be divided into 20 components. In this study, each component was scored as present (documentation was found) or absent (documentation was not found); a domain was scored as present if one or more of its components had been documented. RESULTS There were 1,482 assessments documented on 120 patients over a one-week period. A majority of patients were male (56%), White (71%), non-Hispanic (77%), and over 60 years of age (50%). Overall, assessments of the domains of consciousness, injury severity, and cranial nerve function were documented 80% of the time or more. Assessments of the domains of pain, motor function, and sensory function were documented less than 60% of the time, and that of speech less than 5% of the time. Statistically significant differences in documentation were found between the medical, surgical, and cardiovascular ICUs for the domains of speech, cranial nerve function, and pain. There were no significant differences in documentation frequency between day and night shift nurses. Documentation practices were significantly different for RNs versus providers. CONCLUSIONS Our findings show that the frequency and specific components of neuro exam documentation vary significantly across nurses, providers, and ICUs. These findings are relevant for nurses and providers and may help to improve guidance for neurologic assessment of patients in non-neurologic ICUs. Further studies exploring variance in documentation practices and their implications for courses of treatment and patient outcomes are warranted.
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Using standardized nursing data for knowledge generation - Ward level analysis of point of care nursing documentation. Int J Med Inform 2022; 167:104879. [PMID: 36179599 DOI: 10.1016/j.ijmedinf.2022.104879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 09/17/2022] [Accepted: 09/19/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Standardized nursing terminology is a prerequisite for describing nursing care processes and generating knowledge for decision-making and management. The structure of the Finnish Care Classification (FinCC) facilitates documentation of nationally agreed core nursing data: nursing diagnoses, interventions, and outcomes. PURPOSE To analyze the use of FinCC to assess patient care needs (nursing diagnoses), care implementations (interventions) and evaluation of the outcomes of nursing care in electronic health records. METHODS AND MATERIALS The descriptive study applied purposeful sampling of nursing data from nursing data repositories in three surgical wards in tertiary and secondary care hospitals. The aggregated, anonymous ward level data from a six-month period was analyzed to show distributions within frequencies and means of component, main and subcategory level use of FinCC in the three hospitals. RESULTS Each of the three levels of the FinCC (component, main and subcategory) were used for recording nursing care. In all hospitals, the three most used diagnosis components covered about one third of the use of all the 17 components. The five most used intervention components cover about one third of the components. The most often used components for diagnoses and interventions were Coordination of care and follow-up care, Pain Management, Activities of daily living and independence and Medication. The prevalence of different components and the main and subcategory level usage for both diagnoses and interventions varied between the hospitals. CONCLUSION Standardized point-of-care nursing data makes patients' daily nursing care transparent. Structured, standardized, and point-of-care nursing data can be utilized to generate new knowledge of nursing care processes and nursing care practice at ward level.
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Gonçalves PDB, Sequeira CADC, Paiva E Silva MATDC, de de Paiva E Silva AA. Developing nursing clinical data models addressing delusion and hallucination with Meleis transitions theory as the theoretical reference model: A focus group study. Perspect Psychiatr Care 2022; 58:894-902. [PMID: 34056711 DOI: 10.1111/ppc.12869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/27/2021] [Accepted: 05/13/2021] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To build the final clinical data models regarding the nursing focuses "Delusion" and "Hallucination" with Meleis transitions theory as the theoretical reference model. DESIGN AND METHODS A qualitative descriptive design was adopted, using two focus groups. FINDINGS The clinical data models obtained by this study recognize a perspective centered on the client's transition, which emphasizes the role of nursing in relation to a client suffering from delusion and hallucination. IMPLICATIONS FOR NURSING PRACTICE These clinical data models may contribute towards improving nursing clinical decision-making and nursing care quality regarding these areas.
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Affiliation(s)
- Patrícia Daniela Barata Gonçalves
- Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal.,B3, Hospital de Magalhães Lemos, Porto, Portugal.,UNIESEP, Escola Superior de Enfermagem do Porto, Porto, Portugal.,NursID, Centro de Investigação em Tecnologias e Serviços de Saúde, Porto, Portugal
| | - Carlos Alberto da Cruz Sequeira
- UNIESEP, Escola Superior de Enfermagem do Porto, Porto, Portugal.,NursID, Centro de Investigação em Tecnologias e Serviços de Saúde, Porto, Portugal
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López M, Fernández-Castro M, Martín-Gil B, Muñoz-Moreno MF, Jiménez JM. Auditing completion of nursing records as an outcome indicator for identifying patients at risk of developing pressure ulcers, falling, and social vulnerability: An observational study. J Nurs Manag 2022; 30:1061-1068. [PMID: 35266605 DOI: 10.1111/jonm.13569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 01/23/2022] [Accepted: 02/20/2022] [Indexed: 11/29/2022]
Abstract
AIM To evaluate the completion of nursing records through scheduled audits to analyse risk outcome indicators. BACKGROUND Nursing records support clinical decision-making and encourage continuity of care, hence the importance of auditing their completion in order to take corrective action where necessary. METHOD This was an observational descriptive study carried out from February to November 2020 with a sample of 1131 electronic health records belonging to patients admitted to COVID-19 hospital units during three observation periods: pre-pandemic, first wave, and second wave. RESULTS A significant reduction in nursing record completion rates was observed between pre-pandemic period and first and second waves: Braden scale 40.97%, 28.02%, and 30.99%; Downton scale: 43.74%, 22.34%, and 33.91%; Gijón scale: 40.12%, 26.23%, and 33.64% (p < 0.001). There was an increase in the number of records completed between the first and second waves following the measures adopted after the quality audit. CONCLUSIONS The use of scheduled audits of nursing records as quality indicators facilitated the detection of areas for improvement, allowing timely corrective actions. IMPLICATIONS FOR NURSING MANAGEMENT Support from nursing managers at health care facilities to implement quality assessment programmes encompassing audits of clinical record completion will encourage the adoption of measures for corrective action.
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Affiliation(s)
- María López
- Nursing Faculty, University de Valladolid, Valladolid, Spain
| | | | - Belén Martín-Gil
- Department of Nursing Care Information Systems, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - María Fe Muñoz-Moreno
- Research Support Unit, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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Kaihlanen AM, Gluschkoff K, Saranto K, Kinnunen UM. The associations of information system's support and nurses' documentation competence with the detection of documentation-related errors: Results from a nationwide survey. Health Informatics J 2021; 27:14604582211054026. [PMID: 34814758 DOI: 10.1177/14604582211054026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The use of information systems and electronic documentation has become a central part of a nurse's work, and it is expected to increase the quality of documentation and patient safety. However, errors related to documentation have been identified as a significant risk for the quality and safety of care. This study examined whether information system's support for documentation and nurses' documentation competence are associated with how frequently nurses detect documentation-related errors that have caused an adverse event. A nationwide survey was conducted in 2020, and a total of 3610 nurses participated. Results from linear regression analyses showed that high documentation support from the information system and high documentation competence were associated with fewer detected documentation-related errors. Nurses with low documentation support from the system and low documentation competence detected the most errors. The results highlight the need to develop electronic health record functions in a way that they better support accurate documentation. Furthermore, organisations should invest in ensuring the documentation skills of nurses and providing appropriate training.
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Affiliation(s)
| | - Kia Gluschkoff
- Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Kaija Saranto
- Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland
| | - Ulla-Mari Kinnunen
- Department of Health and Social Management, University of Eastern Finland, Kuopio, Finland
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Østensen E, Hardiker NR, Hellesø R. Facilitating the Implementation of Standardized Care Plans in Municipal Healthcare. Comput Inform Nurs 2021; 40:104-112. [PMID: 34347643 PMCID: PMC8820770 DOI: 10.1097/cin.0000000000000798] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Standardized care plans have the potential to enhance the quality of nursing records in terms of content and completeness, thereby better supporting workflow, easing the documentation process, facilitating continuity of care, and permitting systematic data gathering to build evidence from practice. Despite these potential benefits, there may be challenges associated with the successful adoption and use of standardized care plans in municipal healthcare information practices. Using a participatory approach, two workshops were conducted with nurses and nursing leaders (n = 11) in two Norwegian municipalities, with the objective of identifying success criteria for the adoption and integration of standardized care plans into practice. Three themes were found to describe the identified success criteria: (1) "facilitating system level support for nurses' workflow"; (2) "engaged individuals creating a culture for using standardized care plans"; and (3) "developing system level safety nets." The findings suggest success criteria that could be useful to address to facilitate the integration of standardized care plans in municipal healthcare information practice and provide useful knowledge for those working with implementation and further development of standardized care plans.
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Martín-Méndez ME, García-Díaz V, Zurrón-Madera P, Fernández-Feito A, Jimeno-Demuth F, Lana A. Evolution of Nursing Workload Indicators Since the Implementation of the Electronic Health Record at a Tertiary Hospital in Spain. Comput Inform Nurs 2021; 39:689-695. [PMID: 34747892 DOI: 10.1097/cin.0000000000000759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Nurses can be overwhelmed by the growing need for documentation derived from the implantation of electronic health records. The objective was to describe the evolution of nursing workload since the implementation of the EHR. We performed a longitudinal study of global workload indicators over a 5-year period at a referral hospital in Spain since introduction of the EHR (2014). Clinical activity records of each nurse were monitored using audit logs of their accesses to EHRs. During the study period, the number of EHR sessions, the number of EHR sessions in which a nursing order was changed, and the time needed to complete each session significantly increased. The number of mouse clicks and keystrokes and the time required to complete each nursing order decreased. Documentation of the following nursing tasks increased: administration of medication, peripheral vascular catheters, urinary catheters, pressure ulcers, nursing assessment forms, and pre-surgical verification. In conclusion, since the implementation of the EHR, an increase in the workload of nursing professionals-estimated through indirect indicators-has been observed due to greater documentation.
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Affiliation(s)
- María E Martín-Méndez
- Author Affiliations: Department of Medicine, School of Medicine and Health Sciences, University of Oviedo (Ms Martín-Méndez and Drs Zurrón-Madera, Fernández-Feito, and Lana); Health Care Service of Asturias, Central University Hospital of Asturias (Drs García-Díaz and Jimeno-Demuth); Healthcare Research Area, Health Research Institute of Asturias (ISPA) (Drs García-Díaz, Zurrón-Madera, Fernández-Feito, Jimeno-Demuth, and Lana); and Health Care Service of Asturias (Spain), Mental Health Center of La Corredoria (Dr Zurrón-Madera), Oviedo, Spain
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Choi J, Bove LA, Tarte V, Choi WJ. Impact of Simulated Electronic Health Records on Informatics Competency of Students in Informatics Course. Healthc Inform Res 2021; 27:67-72. [PMID: 33611878 PMCID: PMC7921572 DOI: 10.4258/hir.2021.27.1.67] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/24/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Nursing has embraced online education to increase its workforce while providing flexible advanced education to nurse professionals. Faculty use virtual simulation and other adaptive learning technologies to enhance learning efficiency and student outcomes in online courses. The purpose of this study was to assess the impact of simulated Electronic Health Records (EHRs) on informatics competency in a graduate online informatics course. METHODS A two-group independent measures study design was adopted to assess students' perception of a simulated EHR while comparing differences in informatics competencies between an intervention group and a control group. A simulated EHR assignment was provided to students in the intervention group, and a paper assignment was provided to those in the control group. The informatics competency of the students was measured using the Self-Assessment of Informatics Competency Scale for Health Professionals (SICS). RESULTS Students who were enrolled in a family nurse practitioner program in fall of 2019 participated in this study (n = 39). The students expressed positive perceptions of a simulated EHR experience. The SICS results indicated that students in the intervention (simulated EHR) group showed higher informatics competency than those in the control group. CONCLUSIONS The positive results of this study support incorporating simulated EHR exercises in online courses. Higher informatics competency in the intervention group implies that the use of simulated EHR facilitated learning of complicated informatics concepts.
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Affiliation(s)
- Jeeyae Choi
- School of Nursing, College of Health and Human Services, University of North Carolina Wilmington, Wilmington, NC, USA
| | - Lisa Anne Bove
- School of Nursing, College of Health and Human Services, University of North Carolina Wilmington, Wilmington, NC, USA
| | - Valerie Tarte
- School of Nursing, College of Health and Human Services, University of North Carolina Wilmington, Wilmington, NC, USA
| | - Woo Jung Choi
- Transform Alliance for Health Clinic, Newton, MA, USA
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Queirós C, Silva MATCP, Cruz I, Cardoso A, Morais EJ. Nursing diagnoses focused on universal self-care requisites. Int Nurs Rev 2021; 68:328-340. [PMID: 33539567 DOI: 10.1111/inr.12654] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 12/01/2020] [Accepted: 12/08/2020] [Indexed: 01/10/2023]
Abstract
AIMS (1) To identify and analyse diagnoses documented by nurses in Portugal within the scope of universal self-care requisites; (2) to determine the main problems with nursing diagnoses syntaxes for semantic interoperability purposes; and (3) to suggest unified nursing diagnoses syntaxes within the scope of universal self-care requisites. BACKGROUND/INTRODUCTION Ageing societies and the increase in chronic diseases have led to significant concern regarding individuals' dependence to ensure self-care. ICNP is widely used by Portuguese nurses in electronic health records for documentation of nursing diagnoses and interventions. METHODS A qualitative study using inductive content analysis and focus group: 1. nursing e-documentation content analysis and 2. focus group to explore implicit criteria or insights from content analysis results. RESULTS From a corpus of analysis with 1793 nursing diagnoses, 432 nursing diagnoses centred on universal self-care requisites emerged from the content analysis. One hundred ten nursing diagnoses resulted from the application of new encoding criteria that emerged after a focus group meeting. CONCLUSION Results reveal that nursing diagnoses related to universal self-care requisites can emphasize the impairment or potentialities of the individuals performing self-care. It also shows a lack of consensus on nominating the nursing diagnoses of people with a deficit in universal self-care requisites, resulting in different diagnoses to express the same needs. IMPLICATIONS FOR NURSING PRACTICE Representation of most relevant nursing diagnoses within the scope of universal self-care requisites. IMPLICATIONS FOR HEALTH POLICY Incorporating standardized language into electronic health records is not enough for improving quality and continuity of care and semantic interoperability achievement. Electronic health records need to work with a nursing ontology in the backend to meet these requirements.
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Affiliation(s)
- Carmen Queirós
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal.,CIDESI: ICN-Accredited Centre for Information Systems and ICNP® Research and Development, Nursing School of Porto, Porto, Portugal.,Health Sciences Research Unit: Nursing (UICISA: E), Coimbra Nursing School (ESEnfC), Coimbra, Portugal.,Department of Ortho-physiatry, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Maria Antónia Taveira Cruz Paiva Silva
- CIDESI: ICN-Accredited Centre for Information Systems and ICNP® Research and Development, Nursing School of Porto, Porto, Portugal.,Nursing School of Porto, Porto, Portugal
| | - Inês Cruz
- Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal.,CIDESI: ICN-Accredited Centre for Information Systems and ICNP® Research and Development, Nursing School of Porto, Porto, Portugal.,Nursing School of Porto, Porto, Portugal
| | - Alexandrina Cardoso
- CIDESI: ICN-Accredited Centre for Information Systems and ICNP® Research and Development, Nursing School of Porto, Porto, Portugal.,Nursing School of Porto, Porto, Portugal
| | - Ernesto J Morais
- CIDESI: ICN-Accredited Centre for Information Systems and ICNP® Research and Development, Nursing School of Porto, Porto, Portugal.,Nursing School of Porto, Porto, Portugal
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Early recognition of surgical patients with sepsis: Contribution of nursing records. Appl Nurs Res 2020; 57:151352. [PMID: 32896443 DOI: 10.1016/j.apnr.2020.151352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 07/05/2020] [Accepted: 08/23/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This study aimed to analyze the contribution of nursing records to the early identification and management of sepsis in surgical patients at a university hospital. METHOD This is a study with a quantitative, retrospective, descriptive, and correlational design. Data collection was performed through hospital information systems in the first semester of 2017 with the approval of the research ethics committee. We included 28 patients who met the inclusion criteria of the study. RESULTS The analysis of the content of the records evidenced the development of the first signs of systemic inflammatory response syndrome (SIRS) and organ dysfunction until the fifth day of hospitalization in 19 patients (67.8%). Confirmation or hypothesis of sepsis diagnosis occurred until the 10th day of hospitalization in 15 patients (53.5%). The analysis of the content of the records showed that the first signs of SIRS were predominantly identified in the electronic patient monitoring system in 26 cases (92.9%), whereas the first signs of organ dysfunction were described in the nursing staff records in 24 patients (85.7%). CONCLUSION The results confirm the importance of the quality of nursing records for risk identification, early recognition, and proper management of sepsis in surgical patients, aiming at achieving greater effectiveness in the management of healthcare processes.
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Ameel M, Leino H, Kontio R, van Achterberg T, Junttila K. Using the Nursing Interventions Classification to identify nursing interventions in free‐text nursing documentation in adult psychiatric outpatient care setting. J Clin Nurs 2020; 29:3435-3444. [DOI: 10.1111/jocn.15382] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 05/05/2020] [Accepted: 06/05/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Maria Ameel
- Helsinki University Hospital Helsinki Finland
- Department of Nursing Science University of Turku Turku Finland
- University of Helsinki Helsinki Finland
| | - Hanna Leino
- Helsinki University Hospital Helsinki Finland
- University of Helsinki Helsinki Finland
| | - Raija Kontio
- Helsinki University Hospital Helsinki Finland
- Department of Nursing Science University of Turku Turku Finland
- University of Helsinki Helsinki Finland
| | - Theo van Achterberg
- Department of Public Health and Primary Care Academic Centre for Nursing and Midwifery KU Leuven Leuven Belgium
| | - Kristiina Junttila
- Helsinki University Hospital Helsinki Finland
- Department of Nursing Science University of Turku Turku Finland
- University of Helsinki Helsinki Finland
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