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Wang J, Xu Y, Yang Z, Zhang J, Zhang X, Li W, Sun Y, Pan H. Factors Influencing Information Distortion in Electronic Nursing Records: Qualitative Study. J Med Internet Res 2025; 27:e66959. [PMID: 40202777 PMCID: PMC12018866 DOI: 10.2196/66959] [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] [Received: 09/27/2024] [Revised: 01/24/2025] [Accepted: 03/29/2025] [Indexed: 04/10/2025] Open
Abstract
BACKGROUND Information distortion in nursing records poses significant risks to patient safety and impedes the enhancement of care quality. The introduction of information technologies, such as decision support systems and predictive models, expands the possibilities for using health data but also complicates the landscape of information distortion. Only by identifying influencing factors about information distortion can care quality and patient safety be ensured. OBJECTIVE This study aims to explore the factors influencing information distortion in electronic nursing records (ENRs) within the context of China's health care system and provide appropriate recommendations to address these distortions. METHODS This qualitative study used semistructured interviews conducted with 14 nurses from a Class-A tertiary hospital. Participants were primarily asked about their experiences with and observations of information distortion in clinical practice, as well as potential influencing factors and corresponding countermeasures. Data were analyzed using inductive content analysis, which involved initial preparation, line-by-line coding, the creation of categories, and abstraction. RESULTS The analysis identified 4 categories and 10 subcategories: (1) nurse-related factors-skills, awareness, and work habits; (2) patient-related factors-willingness and ability; (3) operational factors-work characteristics and system deficiencies; and (4) organizational factors-management system, organizational climate, and team collaboration. CONCLUSIONS Although some factors influencing information distortion in ENRs are similar to those observed in paper-based records, others are unique to the digital age. As health care continues to embrace digitalization, it is crucial to develop and implement strategies to mitigate information distortion. Regular training and education programs, robust systems and mechanisms, and optimized human resources and organizational practices are strongly recommended.
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Affiliation(s)
- Jianan Wang
- Department of Nursing, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yihong Xu
- Department of Nursing, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhichao Yang
- Department of Nursing, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jie Zhang
- Department of Nursing, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoxiao Zhang
- Department of Nursing, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wen Li
- Department of Nursing, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yushu Sun
- Department of Nursing, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hongying Pan
- Department of Nursing, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Kim M, Kim Y, Choi M. Intensive care unit nurses' experiences of nursing concerns, activities, and documentation on patient deterioration: A focus-group study. Aust Crit Care 2025; 38:101126. [PMID: 39550338 DOI: 10.1016/j.aucc.2024.09.011] [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] [Received: 04/21/2024] [Revised: 09/09/2024] [Accepted: 09/25/2024] [Indexed: 11/18/2024] Open
Abstract
BACKGROUND Although prognosis prediction models using nursing documentation have good predictive performance, the experiences of intensive care unit nurses related to nursing activities and documentation when a patient's condition deteriorates are yet to be explored. OBJECTIVE The aim of this study was to explore nurses' experiences of nursing activities and documentation in intensive care units when a patient's condition deteriorates. METHODS This was a descriptive qualitative study using focus-group interviews with intensive care unit nurses in tertiary or university-affiliated hospitals. In total, 19 registered nurses with at least 1 year of clinical experience in the adult intensive care unit were recruited using a purposive sampling method. Five focus-group interviews were conducted, and the data were analysed through a qualitative content analysis. RESULTS Intensive care unit nurses' experiences with patient deterioration were classified into four main categories-perceived patient deterioration; endeavours to verify nurses' concerns; nursing activities to improve a patient's condition; and optimising documentation practices-which comprised 12 subcategories. Intensive care unit nurses recognise patient deterioration through nursing activities and documentation, and the two processes influence each other. However, nursing activities related to nurses' concerns were mainly handed over verbally rather than documented due to the inflexibility of the available standardised forms and the potential uncertainty of those concerns. CONCLUSIONS The findings reveal how intensive care unit nurses perceive, intervene, and document the condition of a deteriorating patient. Nurses' concerns may be the first sign of a patient's deteriorating condition and are therefore crucial for minimising patient risk. Therefore, efforts to systematically document nurses' concerns may contribute to improving patient outcomes.
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Affiliation(s)
- Mihui Kim
- College of Nursing and Brain Korea 21 FOUR Project, Yonsei University, Seoul, Republic of Korea; Department of Nursing Science, Jeonju University, Jeonju, Republic of Korea
| | - Yesol Kim
- College of Nursing and Brain Korea 21 FOUR Project, Yonsei University, Seoul, Republic of Korea; College of Nursing, Gyeongsang National University, Jinju, Republic of Korea
| | - Mona Choi
- College of Nursing and Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea.
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Fang S, Zhao Y, Gao S, Sun J, Song D, Wu Y, Zhong Q, Sun J. 'Implicit rationing of nursing care processes'-Decision-making in ICU nurses' experiences: A qualitative study. Nurs Crit Care 2025; 30:e13127. [PMID: 39011651 DOI: 10.1111/nicc.13127] [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] [Received: 02/18/2024] [Revised: 06/10/2024] [Accepted: 06/30/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Implicit rationing of nursing care is defined as the withholding of necessary nursing measures for patients because of a lack of nursing resources. However, no studies have explored the experience of decision-making about implicit rationing of nursing care in an intensive care unit (ICU). AIM To explore the process of ICU nurses' decisions and judgement based on the conceptual framework of implicit rationing of nursing care. STUDY DESIGN A qualitative study was undertaken between June 2020 and September 2020. The data collection methods were participative observation and interview. Eighteen ICU nurses participated in interviews. A thematic analysis was performed for the data analysis. RESULTS The following five themes emerged: assessment of the condition and nature of nursing and time taken; strategies for setting personal priorities; plan implementation under mitigation strategy; existing nursing in reality; evaluation of the implementation of implicit rationing care. Nurses choose different strategies during plan implementation. CONCLUSIONS In the absence of explicit guidelines on rationing nursing care, nurses often rely on intuitive and situational decision-making processes for setting priorities. Given the vulnerability of ICU patients and the absence of family caregivers, nurses bear a heightened ethical responsibility to provide care. Establishing a positive nursing culture is essential. It is both reasonable and effective to organize work by accurately quantifying workload, improving staffing levels and optimizing scheduling methods. These themes align with the decision-making process outlined in the conceptual framework and offer fresh perspectives. RELEVANCE TO CLINICAL PRACTICE Nurses have a greater responsibility to provide care in an ethical manner and to increase awareness of the importance of holistic nursing care for the patient, that is to raise awareness of the importance of care that is often missed. Nurses actively adopt strategies to reduce implicit rationing of nursing care, including teamwork, organized nursing, working overtime and ignoring quality. The findings highlight the importance of creating a positive nursing culture that encourages nurses to adopt positive strategies.
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Affiliation(s)
- Shuyan Fang
- School of Nursing, Jilin University, Changchun, China
| | - Yingnan Zhao
- The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Shizheng Gao
- School of Nursing, Jilin University, Changchun, China
| | - Juanjuan Sun
- School of Nursing, Jilin University, Changchun, China
| | - Dongpo Song
- School of Nursing, Jilin University, Changchun, China
| | - Yifan Wu
- School of Nursing, Jilin University, Changchun, China
| | - Qiqing Zhong
- School of Nursing, Jilin University, Changchun, China
| | - Jiao Sun
- School of Nursing, Jilin University, Changchun, China
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Kassahun CW, Endalkachew K, Mekonnen CK, Kassie H. Missed nursing care and associated factors among nurses at University of Gondar Comprehensive Specialized Hospital, Ethiopia, 2022. Sci Rep 2024; 14:25571. [PMID: 39462129 PMCID: PMC11513140 DOI: 10.1038/s41598-024-76325-w] [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] [Received: 07/18/2024] [Accepted: 10/14/2024] [Indexed: 10/28/2024] Open
Abstract
The issue of missed nursing care is a problem that affects the overall quality of nursing care in hospitals around the world. However, there is limited research about it in Ethiopia. This study assessed missed nursing care and factors among nurses. An institutional-based cross-sectional study was conducted among 485 nurses at the University of Gondar Specialized Hospital. The data were collected from May 15 to June 15, 2022 using a self-administered questionnaire. A simple random sampling technique was used to select study participants. The data was entered to EPI DATA version 4.6 and exported to SPSS version 23 for analysis. Descriptive statistics were computed, and a summative score of missed nursing care was calculated. Then, multiple linear regression analysis was used to identify the factors. A P-value of 0.05 was used to declare significant level. In this study, missed nursing care was 62.5% (95% CI 60.98-64.02). Documentation, vital signs assessment, intravenous care, and assessment as per hospital policy and patient education were the most frequently missed nursing care. Being single in marital status (B = -4.609, P = 0.004), adequacy of nursing staff (B = -2.458, P = 0.003), satisfaction with income (B = -8.753, P = 0.007), working in medical unit (B = -5.708, P = 0.002) and working in both day and night shift (B = 1.731, P = 0.027) were statistically associated factors. More than half of the participants missed basic nursing care. Most of the identified factors correlated with missed nursing care negatively. Efforts should be done to enhance communication between health team members, assign a manageable number of patients per nurse, and adjust shifts and units.
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Affiliation(s)
| | - Kidist Endalkachew
- Department of Comprehensive Nursing, School of Nursing, University of Gondar, Gondar, Ethiopia
| | - Chilot Kassa Mekonnen
- Department of Medical Nursing, School of Nursing, University of Gondar, Gondar, Ethiopia
| | - Huluager Kassie
- Department of Medical Nursing, School of Nursing, University of Gondar, Gondar, Ethiopia
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Abere Y, Ayenew YE, Aytenew TM, Erega BB, Yirga GK, Ewunetu M, Andargie A, Bantie B, Belay BM. Magnitude and reasons for missed nursing care among nurses working in South Gondar Zone public hospitals, Amhara regional state, Northcentral Ethiopia: institution-based cross-sectional study. BMC Nurs 2024; 23:765. [PMID: 39420274 PMCID: PMC11488123 DOI: 10.1186/s12912-024-02438-2] [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: 07/22/2024] [Accepted: 10/14/2024] [Indexed: 10/19/2024] Open
Abstract
BACKGROUND Missed nursing care has become a global health concern because of its impact on patient safety and nursing care quality. It is a critical indicator of nursing care quality and adverse patient outcomes. However, data regarding the magnitude and reasons for missed nursing care is limited in the study area. This study aimed to determine the magnitude and reasons for missed nursing care among nurses working in South Gondar zone public hospitals. METHODS An institution-based cross-sectional study design was conducted among nurses working in South Gondar zone public hospitals from December 12, 2023, to January 20, 2024. The data was collected through self-administered MISSCARE survey tools. The collected data were entered into EpiData V.4.2 and then exported to SPSS V.25 for analysis. The statistical significance of the association between outcome variables and independent variables was declared at a P-value less than 5% (0.05) at 95% CI. RESULT The magnitude of missed nursing care in the study area was 51.7% (95% CI: 46.89-55.47%). Medications administered as ordered (69.8%), skin/wound care (69.8%), vital signs assessed as ordered and accordingly (68.8%), and IV/central line site care and assessments according to hospital policy (66.2%) were among the nursing care elements that were frequently missed. Material resource (76.7%), teamwork (69.1%), labor resource (65.5%), and communication (56.3%) were the main reasons for missed nursing care. Inadequate number of staff 2.9 (1.75, 4.75), training (CPD) in nursing care 1.9 (1.16, 3.14), equipment's not available 3.9 (2.16, 6.89), and medication were not available. 4.4 (2.48, 7.76) were associated with missed nursing care. CONCLUSION The proportion of commonly missed nursing care was high. After adjusting for demographic variables, labor resources, material resources, and communication were reasons for commonly missed nursing care. Increasing the number of nurses, investing in nurse training, working on equipment availability, and increasing medication availability could minimize frequent omissions of nursing care.
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Affiliation(s)
- Yirgalem Abere
- Department of Adult Health Nursing, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia.
| | - Yeshiambaw Eshetie Ayenew
- Department of Adult Health Nursing, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Tigabu Munye Aytenew
- Department of Adult Health Nursing, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Besfat Berihun Erega
- Department of Midwifery, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Gebrie Kassaw Yirga
- Department of Adult Health Nursing, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Mengistu Ewunetu
- Department of Adult Health Nursing, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Astewle Andargie
- Department of Adult Health Nursing, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Berihun Bantie
- Department of Adult Health Nursing, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
| | - Bekalu Mekonen Belay
- Department of Adult Health Nursing, College of Health Science, Debre Tabor University, Debre Tabor, Ethiopia
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Mohamed A, Muhammed A. A Study at Wad Madani, Sudan: Are We Documenting Acute Ankle Fractures Effectively? Cureus 2024; 16:e68333. [PMID: 39355070 PMCID: PMC11442187 DOI: 10.7759/cureus.68333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2024] [Indexed: 10/03/2024] Open
Abstract
BACKGROUND Medical records are essential documents that outline a patient's medical history and current health status. It involves maintaining records that include assessments of patient outcomes, care plans, and interventions necessary to meet patient needs. A patient's medical record encompasses details about their condition, as documented by healthcare professionals, including clinical assessments, evaluations, and professional opinions related to the delivery of care. METHODS This retrospective study aimed to evaluate the adequacy of our documentation for acute ankle fractures in accordance with the British Orthopaedic Association Standards for Trauma and Orthopaedics (BOAST) guidelines, encompassing a total of 41 cases. The research was conducted at the Gezira Center for Orthopedic Surgery and Traumatology (GCOST) in Wad Madani, Sudan, from May 12 to July 12, 2022. RESULTS Of the 41 recorded notes for acute ankle fractures, 26 (63.4%) were documented by medical officers and 15 (36.6%) by orthopaedic trainees. Most fractures (25 cases, 61%) occurred in individuals aged 18-40 years, and the gender distribution showed that males accounted for most fractures, with 29 cases (70.7%). Additionally, all patients (100%) had a documented cause of injury. Skin integrity was noted in 38 patients (92.7%). Vascular examination was documented in 18 patients (43.9%), while neurological examination was recorded in 16 patients (39%). CONCLUSION Although the cause of ankle fractures was reported in all patients, the neurovascular examination was insufficiently documented, compromising patient care and failing to meet national standards, as highlighted in our study. We recommend implementing the BOAST guidelines to ensure proper documentation and essential assessments.
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Affiliation(s)
- Ahmed Mohamed
- Department of Orthopaedics, Gezira Centre for Orthopedic Surgery and Traumatology, Wad Madani, SDN
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Ameen S, Shafiq SS, Tanvir KM, Saberin A, Banik G, ANM EK, Ashrafee S, Saha PK, Amena B, Alam HMS, Ahmed S, Khan MN, Nahar S, Talha MTUS, Sarkar SS, Hossain AT, Jabeen S, Shaikh MZH, Al-Mahmud M, AFM AU, Ahmed A, Chisti MJ, Islam MS, Sarkar S, Adnan SD, El Arifeen S, Islam MJ, Rahman AE. Introducing a standardised register for strengthening the inpatient management of newborns and sick children: Implementation research in selected health facilities of Bangladesh. J Glob Health 2024; 14:04086. [PMID: 38751318 PMCID: PMC11097124 DOI: 10.7189/jogh.14.04086] [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: 05/18/2024] Open
Abstract
Background It is imperative to maintain accurate documentation of clinical interventions aimed at enhancing the quality of care for newborns and sick children. The National Newborn Health and IMCI programme of Bangladesh led the development of a standardised register for managing newborns and sick children under five years of age during inpatient care through stakeholder engagement. We aimed to assess the implementation outcomes of the standardised register in the inpatient department. Methods We conducted implementation research in two district hospitals and two sub-district hospitals of Kushtia and Dinajpur districts from November 2022 to January 2023 to assess the implementation outcomes of the standardised register. We assessed the following World Health Organization implementation outcome variables: usability, acceptability, adoption (actual use), fidelity (completeness and accuracy), and utility (quality of care) of the register against preset benchmarks. We collected data through structured interviews with health care providers; participant enrolment; and data extraction from inpatient registers and case record forms. Results The average usability and acceptability scores among health care providers were 73 (standard deviation (SD) = 14) and 82 (SD = 14) out of 100, respectively. The inpatient register recorded 96% (95% confidence interval (CI) = 95-97) of under-five children who were admitted to the inpatient department (adoption - actual use). The proportions of completed data elements in the inpatient register were above the preset benchmark of 70% for all the assessed data elements except 'investigation done' (24%; 95% CI = 23-26) (fidelity - completeness). The percentage agreements between government-appointed nurses posted and study-appointed nurses were above the preset benchmark of 70% for all the reported variables (fidelity - accuracy). The kappa coefficient for the overall level of agreement between these two groups regarding reported variables indicated moderate to substantial agreement. The proportion of newborns with sepsis receiving injectable antibiotics was 62% (95% CI = 47-75) (utility - quality of care). We observed some variability in the completeness and accuracy of the inpatient register by district and facility type. Conclusions The inpatient register was positively received by health care providers, with evaluations of implementation outcome variables showing encouraging results. Our findings could inform evidence-based decision-making on the implementation and scale-up of the inpatient register in Bangladesh, as well as other low- and middle-income countries.
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Affiliation(s)
- Shafiqul Ameen
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sabit Saad Shafiq
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - K M Tanvir
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Ashfia Saberin
- Directorate General of Health Services (DGHS), Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | | | | | - Sabina Ashrafee
- Directorate General of Health Services (DGHS), Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - Palash Kumar Saha
- Directorate General of Health Services (DGHS), Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | | | - Husam Md Shah Alam
- Directorate General of Health Services (DGHS), Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - Sabbir Ahmed
- Projahnmo Research Foundation, Dhaka, Bangladesh
| | | | - Salmun Nahar
- Directorate General of Health Services (DGHS), Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | | | - Sadman Sowmik Sarkar
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Aniqa Tasnim Hossain
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sabrina Jabeen
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Ziaul Haque Shaikh
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Al-Mahmud
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Azim Uddin AFM
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Anisuddin Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammod Jobayer Chisti
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | - Supriya Sarkar
- Directorate General of Health Services (DGHS), Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - Sheikh Daud Adnan
- Directorate General of Health Services (DGHS), Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - Shams El Arifeen
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Jahurul Islam
- Directorate General of Health Services (DGHS), Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - Ahmed Ehsanur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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Tadese M, Endale A, Asegidew W, Tessema SD, Shiferaw WS. Nursing patient record practice and associated factors among nurses working in North Shewa Zone public hospitals, Ethiopia. FRONTIERS IN HEALTH SERVICES 2024; 4:1340252. [PMID: 38390286 PMCID: PMC10883157 DOI: 10.3389/frhs.2024.1340252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 01/22/2024] [Indexed: 02/24/2024]
Abstract
Background Nursing documentation is an essential component of nursing practice and has the potential to improve patient care outcomes. Poor documentation of nursing care activities among nurses has been shown to have negative impacts on healthcare quality. Objective To assess the nursing documentation practice and its associated factors among nurses working in the North Shewa Zone public hospitals, Ethiopia. Method An institution-based cross-sectional study was conducted at the North Shewa Zone public hospitals. A simple random sampling technique was used to select 421 nurses. A pretested, structured, self-administered questionnaire was used to gather the data. Data were entered into Epi Data version 3.1, and SPSS version 25 was used for further analysis. Binary logistic regressions were performed to identify the independent predictors of nursing documentation practice. Adjusted odds ratio was calculated and a p-value less than 0.05 with 95% confidence interval (CI) was considered as statistically significant. Result A total of 421 respondents took part, giving the survey a 100% response rate. The overall good practice of nursing care documentation was 51.1%, 95% CI (46.6, 55.8). In addition, 43.2%, 95% CI (38.5, 48.0) and 35.6%, 95% CI (30.9, 40.1), of nurses had good knowledge of and favorable attitudes toward nursing care documentation. Availability of operational standards for nursing documentation [adjusted odds ratio (AOR) = 1.76; 95% CI: 1.18, 2.64], availability of documenting sheets (AOR = 1.51; 95% CI: 1.01, 2.29), and a monitoring system (AOR = 1.61; 95% CI: 1.07, 2.41) were significantly associated with nursing care documentation practice. Conclusion Nearly half of nursing care was not documented. The practice of nursing care documentation was significantly influenced by the availability of operational standards, documenting sheets, and monitoring systems. To improve the documentation practice, a continuous monitoring system and access to operational standards and documenting sheets are needed.
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Affiliation(s)
- Mesfin Tadese
- Department of Midwifery, School of Nursing and Midwifery, Asrat Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Agizew Endale
- Department of Nursing, Debre Berhan Health Science College, Debre Berhan, Ethiopia
| | - Wondwosen Asegidew
- Department of Public Health, Asrat Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Saba Desta Tessema
- Department of Midwifery, School of Nursing and Midwifery, Asrat Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Wondimeneh Shibabaw Shiferaw
- Department of Nursing, School of Nursing and Midwifery, Asrat Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Molla F, Temesgen WA, Kerie S, Endeshaw D. Nurses' Documentation Practice and Associated Factors in Eight Public Hospitals, Amhara Region, Ethiopia: A Cross-Sectional Study. SAGE Open Nurs 2024; 10:23779608241227403. [PMID: 38268952 PMCID: PMC10807310 DOI: 10.1177/23779608241227403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/12/2023] [Accepted: 01/02/2024] [Indexed: 01/26/2024] Open
Abstract
Background Nursing care documentation, which is the record of nursing care that is planned for and delivered to individual patients, can enhance patient outcomes while advancing the nursing profession. However, its practice and associated factors among Ethiopian nurses are not well investigated. Objective To assess the level of nursing care documentation practice and associated factors among nurses working at public hospitals in Ethiopia. Methods An institutional-based cross-sectional study was conducted from May 1 to 30, 2022. A total of 378 nurses and corresponding charts were randomly selected with a multistage sampling technique. Self-administered structured questionnaires and structured checklists were used to collect data about independent variables and nurses' documentation practice, respectively. Epi Data 4.6 was used for data entry and SPSS version 25 for analysis. Descriptive statistics and binary logistic regression analysis have been employed. The STROBE checklist was used to report the study. Results In this study, 372 nurses participated, and 30.4% (95% confidence interval [CI]: 26%-35%) of them had good nursing care documentation practice. Adequate knowledge about nursing care documentation(adjusted odds ratio [AOR] = 4.16, 95% CI: [2.36-7.33]), favorable attitude toward nursing care documentation (AOR = 3.43, 95% CI: [1.85-6.36]), adequacy of documenting sheets (AOR = 2.02, 95% CI: [1.14-3.59]), adequacy of time (AOR = 3.85, 95% CI: [2.11-7.05]), nurse-to-patient ratio (AOR = 2.78, 95% CI: [1.13-6.84]), and caring patients who had no stress, anxiety, pain, and distress (AOR = 3.56, 95% CI: [1.69-7.52]) were significantly associated with proper nursing care documentation practices. Conclusion Nursing documentation practice was poor in this study compared to the health sector transformation in quality standards due to the identified factors. Improving nurses' knowledge and attitude toward nursing care documentation and increasing access to documentation materials can contribute to improving documentation practice.
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Affiliation(s)
- Fitalew Molla
- Debark Hospital, Amhara Regional Health Bureau, Debark, Ethiopia
| | - Worku Animaw Temesgen
- Department of Adult Health Nursing, School of Health Sciences, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Sitotaw Kerie
- Department of Adult Health Nursing, School of Health Sciences, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Destaw Endeshaw
- Department of Adult Health Nursing, School of Health Sciences, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
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Hardido TG, Kedida BD, Kigongo E. Nursing Documentation Practices and Related Factors in Patient Care in Ethiopia: A Systematic Review and Meta-Analysis. Adv Med 2023; 2023:5565226. [PMID: 37965424 PMCID: PMC10643037 DOI: 10.1155/2023/5565226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/21/2023] [Accepted: 10/28/2023] [Indexed: 11/16/2023] Open
Abstract
Background Ineffective nursing documentation practices have been reported to negatively impact patient outcomes and health professional efficiency. On the prevalence of nurses' documentation practices in Ethiopia, several separate studies have been carried out. However, there is no pooled prevalence of nurses' documentation practice. Therefore, this systematic review and meta-analysis aimed to assess the overall prevalence of nursing care documentation practice and related factors in Ethiopia. Methods and Materials This review only included articles that were published. The main databases were Medline/PubMed, Web of Science, Google Scholar, Scopus, Ethiopian University Repository Online, and the Cochrane Library. Cross-sectional studies that satisfy the criteria and are written in English are included in the review. Using a random effects model, the pooled prevalence of nurses' documentation practices was determined. The funnel plot and the Eggers test were also used to look into publication bias. All statistical analyses were done with STATA version 14. Result This review included nine studies with a total of 2,900 participants. The pooled prevalence of nurses' documentation practice in Ethiopia was 50.01% (95% CI: 42.59 and 57.18; I2 = 93.8%; and P ≤ 0.001). In terms of subgroup analysis, Addis Ababa had the highest prevalence of nurses' documentation practice at 84% (95% CI: 77.18 and 90.82), while Southern Ethiopia had the lowest at 40.00% (95% CI: 38.10 and 44.90). Nursing documentation practices were statistically associated with the availability of nursing documentation formats, adequate nurse-to-patient ratio, motivation, and training. Conclusion This review showed that one in two nurses practiced poor documentation of their daily activities in Ethiopia. Therefore, strict monitoring, evaluation, and supervision of nursing care documentation services are highly recommended for all stakeholders. We strongly recommend improving the identified factors by arranging training for nurses, motivating them, providing adequate documentation formats, and maintaining a nurse-to-patient ratio.
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Michl G, Paterson C, Bail K. 'It's all about ticks': A secondary qualitative analysis of nurse perspectives about documentation audit. J Adv Nurs 2023; 79:3440-3455. [PMID: 37106563 DOI: 10.1111/jan.15685] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 03/02/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023]
Abstract
AIM To understand how nurses talk about documentation audit in relation to their professional role. BACKGROUND Nursing documentation in health services is often audited as an indicator of nursing care and patient outcomes. There are few studies exploring the nurses' perspectives on this common process. DESIGN Secondary qualitative thematic analysis. METHODS Qualitative focus groups (n = 94 nurses) were conducted in nine diverse clinical areas of an Australian metropolitan health service for a service evaluation focussed on comprehensive care planning in 2020. Secondary qualitative analysis of the large data set using reflexive thematic analysis focussed specifically on the nurse experience of audit, as there was the significant emphasis by participants and was outside the scope of the primary study. RESULTS Nurses': (1) value quality improvement but need to feel involved in the cycle of change, (2) highlight that 'failed audit' does not equal failed care, (3) describe the tension between audited documentation being just bureaucratic and building constructive nursing workflows, (4) value building rapport (with nurses, patients) but this often contrasted with requirements (organizational, legal and audit) and additionally, (5) describe that the focus on completion of documentation for audit creates unintended and undesirable consequences. CONCLUSION Documentation audit, while well-intended and historically useful, has unintended negative consequences on patients, nurses and workflows. IMPACT Accreditation systems rely on care being auditable, but when individual legal, organizational and professional standards are implemented via documentation forms and systems, the nursing burden is impacted at the point of care for patients, and risks both incomplete cares for patients and incomplete documentation. NO PATIENT OR PUBLIC CONTRIBUTION Patients participated in the primary study on comprehensive care assessment by nurses but did not make any comments about documentation audit.
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Affiliation(s)
- Gabriella Michl
- School of Nursing, Midwifery and Public Health, University of Canberra, Bruce, Australian Capital Territory, Australia
| | - Catherine Paterson
- School of Nursing, Midwifery and Public Health, University of Canberra, Bruce, Australian Capital Territory, Australia
- Canberra Health Services & ACT Health, SYNERGY Nursing & Midwifery Research Centre, Canberra, Australian Capital Territory, Australia
- Robert Gordon University, Aberdeen, UK
| | - Kasia Bail
- School of Nursing, Midwifery and Public Health, University of Canberra, Bruce, Australian Capital Territory, Australia
- Canberra Health Services & ACT Health, SYNERGY Nursing & Midwifery Research Centre, Canberra, Australian Capital Territory, Australia
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Teshome M, Geda B, Yadeta TA, Mideksa L, Tura MR. Intravenous fluid administration practice among nurses and midwives working in public hospitals of central Ethiopia: A cross-sectional study. Heliyon 2023; 9:e18720. [PMID: 37576315 PMCID: PMC10412755 DOI: 10.1016/j.heliyon.2023.e18720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 07/11/2023] [Accepted: 07/25/2023] [Indexed: 08/15/2023] Open
Abstract
Intravenous fluid administration is the most common invasive procedure widely practiced in hospital settings. Globally, approximately 25 million people receive intravenous fluid therapy. Different factors affect nurse's intravenous fluid administration practices; that it may influences on the patient's outcome, increase morbidity and mortality. Previous study indicates that healthcare providers especially in developing countries have skills gap related to intravenous fluid administration. The purpose of this study was aimed to assess the intravenous fluid administration practices and its associated factors among nurses and midwives working in public hospitals of West Shewa zone, Central Ethiopia. Materials and methods An institution-based cross-sectional study design was employed among 396 nurses and midwives in public hospitals in West Shewa zone, Central Ethiopia, from March 1 to 31, 2019. A Simple random sampling was used to select study participants using structured self-administered questionnaire, and observational checklist. The logistic regression model was used to identify association, and odds ratio was used to test the strength of the associations with outcome variable and predictor variables. Results In this study, 59.3% (95%CI = 54.7%-64.5%) participants was had inadequate intravenous fluid administration practice. Inadequate knowledge (AOR 2.1; CI 95% = 1.36-3.36), being untrained (AOR 1.7; 95% CI = 1.04-2.86), unavailability of supervision (AOR 1.8; CI 95% = 1.14-2.99), and absence of incentives and promotion for nurses and midwives (AOR 2.1; CI 95% = 1.19-3.62) were significantly associated with outcome variable. Conclusion Nearly seven in ten participants in the study setting were inadequate intravenous fluid practice. Inadequate knowledge, training, and absence of supervision by senior staffs, and absence of incentives and promotion for nurses and midwives were the main factors affecting intravenous fluid administration practice. Refresher courses, supervision, incentives and promotions were needed to nurses and midwives for an improvement of the intravenous fluid administration practice.
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Affiliation(s)
- Million Teshome
- Department of Nursing, College of Medicine and Health Sciences, Ambo University, Ethiopia
| | - Biftu Geda
- School of Public Health, College of Health Sciences and Medicine, Haramaya University, Ethiopia
| | - Tesfaye Assebe Yadeta
- School of Nursing and Midwifery, College of Health Sciences and Medicine, Haramaya University, Ethiopia
| | - Lema Mideksa
- Department of Nursing, College of Medicine and Health Sciences, Ambo University, Ethiopia
| | - Meseret Robi Tura
- Department of Nursing, College of Medicine and Health Sciences, Ambo University, Ethiopia
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Dinari F, Bahaadinbeigy K, Bassiri S, Mashouf E, Bastaminejad S, Moulaei K. Benefits, barriers, and facilitators of using speech recognition technology in nursing documentation and reporting: A cross-sectional study. Health Sci Rep 2023; 6:e1330. [PMID: 37313530 PMCID: PMC10259462 DOI: 10.1002/hsr2.1330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/18/2023] [Accepted: 05/31/2023] [Indexed: 06/15/2023] Open
Abstract
Background and Aim Nursing reports are necessary for clinical communication and provide an accurate reflection of nursing assessments, care provided, changes in clinical status, and patient-related information to support the multidisciplinary team to provide individualized care. Nurses always face challenges in recording and documenting nursing reports. Speech recognition systems (SRS), as one of the documentation technologies, can play a potential role in recording medical reports. Therefore, this study seeks to identify the barriers, benefits, and facilitators of utilizing speech recognition technology in nursing reports. Materials and Methods This cross-sectional was conducted through a researcher-made questionnaire in 2022. Invitations were sent to 200 ICU nurses working in the three educational hospitals of Imam Reza (AS), Qaem and Imam Zaman in Mashhad city (Iran), 125 of whom accepted our invitation. Finally, 73 nurses included the study based on inclusion and exclusion criteria. Data analysis was performed using SPSS 22.0. Results According to the nurses, "paperwork reduction" (3.96, ±1.96), "performance improvement" (3.96, ±0.93), and "cost reduction" (3.95, ±1.07) were the most common benefits of using the SRS. "Lack of specialized, technical, and experienced staff to teach nurses how to work with speech recognition systems" (3.59, ±1.18), "insufficient training of nurses" (3.59, ±1.11), and "need to edit and control quality and correct documents" (3.59, ±1.03) were the most common barriers to using SRS. As well as "ability to fully review documentation processes" (3.62, ±1.13), "creation of integrated data in record documentation" (3.58, ±1.15), "possibility of error correction for nurses" (3.51, ±1.16) were the most common facilitators. There was no significant relationship between nurses' demographic information and the benefits, barriers, and facilitators. Conclusions By providing information on the benefits, barriers, and facilitators of using this technology, hospital managers, nursing managers, and information technology managers of healthcare centers can make more informed decisions in selecting and implementing SRS for nursing report documentation. This will help to avoid potential challenges that may reduce the efficiency, effectiveness, and productivity of the systems.
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Affiliation(s)
- Fatemeh Dinari
- Medical Informatics Research Center, Institute for Futures Studies in HealthKerman University of Medical SciencesKermanIran
| | - Kambiz Bahaadinbeigy
- Medical Informatics Research Center, Institute for Futures Studies in HealthKerman University of Medical SciencesKermanIran
| | - Somayyeh Bassiri
- Branch Artificial IntelligentIslamic Azad University MashhadMashhadIran
| | - Esmat Mashouf
- Department of Health Information TechnologyVarastegan Institute for Medical SciencesMashhadIran
| | - Saiyad Bastaminejad
- Department of Genetics, Faculty of ParamedicalIlam University of Medical SciencesIlamIran
| | - Khadijeh Moulaei
- Department of Health Information Technology, Faculty of ParamedicalIlam University of Medical SciencesIlamIran
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Ojo IO, Olaogun AA. Utilisation and Challenges of Standardised Nursing Languages in Nursing Process Booklets in Selected Tertiary Health Institutions in Nigeria. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2023. [DOI: 10.1016/j.ijans.2023.100552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
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Kassie SY, Demsash AW, Chereka AA, Damtie Y. Medical documentation practice and its association with knowledge, attitude, training, and availability of documentation guidelines in Ethiopia, 2022. A systematic review and meta-analysis. INFORMATICS IN MEDICINE UNLOCKED 2023. [DOI: 10.1016/j.imu.2023.101237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023] Open
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Nyelisani M, Makhado L, Luhalima T. A professional nurse’s understanding of quality nursing care in Limpopo province, South Africa. Curationis 2022. [DOI: 10.4102/curationis.v45i1.2322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Abstract
This commentary summarizes the contemporary design and use of surveys or questionnaires in nursing science, particularly in light of recent reporting guidelines to standardize and improve the quality of survey studies in healthcare research. The benefits, risks, and limitations of these types of data collection tools are also briefly discussed.
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Kasaye MD, Beshir MA, Endehabtu BF, Tilahun B, Guadie HA, Awol SM, Kalayou MH, Yilma TM. Medical documentation practice and associated factors among health workers at private hospitals in the Amhara region, Ethiopia 2021. BMC Health Serv Res 2022; 22:465. [PMID: 35397590 PMCID: PMC8994305 DOI: 10.1186/s12913-022-07809-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 03/17/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Medical documentation is an important part of the medical process as it is an essential way of communication within the health care system. However, medical documentation practice in the private sector is not well studied in Ethiopian context. The aim of this study was to assess the practice of medical documentation and its associated factors among health workers at private hospitals in the Amhara region, Ethiopia. Method An institution-based cross-sectional quantitative study supplemented with a qualitative design was conducted among 419 health workers at the private hospitals in the Amhara Region, Ethiopia from March 29 to April 29 /2021. Data were collected using both a self-administered questionnaire and interview guide for quantitative and qualitative respectively. Data were entered using Epi data version 3.1 and analyzed using SPSS version 20. Descriptive statistics, Bi-variable, and multivariable logistic regression analysis were performed. In-depth interviews were conducted using semi-structured questionnaires with eight respondents to explore the challenges related to the practice of medical documentation. Respondent’s response were analyzed using OpenCode version 4.03 thematically. Results Four hundred seven study participants returned the questionnaire. Nearly 50 % (47.2%) health workers had of good medical documentation practice. Health workers who received in-service training on medical documentation AOR = 2.77(95% CI: [1.49,5.14]), good knowledge AOR = 2.28 (95% CI: [1.34,3.89]), favorable attitude AOR = 1.78 (95%CI: [1.06,2.97]), strong motivation AOR = 3.49 (95% CI: [2.10,5.80]), available guide line formats AOR = 3.12 (95% CI: [1.41,6.84]), eHealth literacy AOR = 1.73(95% CI: [1.02,2.96]), younger age AOR = 2.64 (95% CI:[1.27,5.46]) were statistically associated with medical documentation. Conclusion More than half of the medical services provided were not registered. Therefore, it is important to put extra efforts to improve documentation practice by providing planed trainings on standards of documentation to all health workers, creating positive attitudes and enhancing their knowledge by motivating them to develop a culture of information.
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Magnitude of missed nursing care and associated factors in case of North Shewa Zone public Hospitals, Amhara regional state, Ethiopia. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2022. [DOI: 10.1016/j.ijans.2022.100497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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20
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Physicians and nurses documentation practice at the University of Gondar Teaching Hospital, Northwest Ethiopia. INFORMATICS IN MEDICINE UNLOCKED 2022. [DOI: 10.1016/j.imu.2022.101016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Campagna S, Basso I, Vercelli E, Ranfone M, Dal Molin A, Dimonte V, Di Giulio P. Missed Nursing Care in a Sample of High-Dependency Italian Nursing Home Residents: Description of Nursing Care in Action. J Patient Saf 2021; 17:e1840-e1845. [PMID: 32168274 DOI: 10.1097/pts.0000000000000643] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to describe omitted or delayed nursing care (i.e., missed nursing care [MNC]) in a sample of Italian nursing homes (NHs). METHODS Nurses from 50 NHs located in Northern Italy selected the 20 most dependent residents in their care and reported instances of MNC for three to five consecutive shifts. They described the type of MNC, its cause(s), management, recurrence, and severity of possible consequences for the resident. Information on the residents and the NH was also collected. The instances of MNC were classified as potentially avoidable/preventable or not. RESULTS Overall, 266 (85.3%) of 312 nurses participated and 1000 residents were observed during 381 shifts (164 mornings, 164 afternoons, and 53 nights); 101 (38%) nurses reported 223 instances of MNC among 175 residents (17.5%). Ninety-seven omissions and 109 delays occurred during the day shift (56 omissions were delegated to the next shift). The most frequent MNC was drug administration (n = 71, 34.5%). In 24 (44.4%) of 54 instances of delayed drug administration, the delay was less than 30 minutes. Nurses rated approximately 20% of MNC (n = 41) as highly severe because of the discomfort caused to the resident, the clinical impact, or the repetitiveness of the situation. Nurses ascribed almost half of MNC (n = 100, 48.5%) to inadequate staffing, and they categorized 26 (11.6%) instances of MNC as unavoidable. CONCLUSIONS The number of nurse-reported instances of MNC we reported was much lower than that previously collected with available instruments. Most MNC did not impact the comfort and safety of residents. A certain proportion of MNC was unavoidable.
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Affiliation(s)
- Sara Campagna
- From the Department of Public Health and Pediatrics, University of Torino, Torino
| | - Ines Basso
- From the Department of Public Health and Pediatrics, University of Torino, Torino
| | - Elisa Vercelli
- From the Department of Public Health and Pediatrics, University of Torino, Torino
| | - Marco Ranfone
- From the Department of Public Health and Pediatrics, University of Torino, Torino
| | - Alberto Dal Molin
- Department of Translational Medicine, University of Piemonte Orientale, Novara
| | | | - Paola Di Giulio
- From the Department of Public Health and Pediatrics, University of Torino, Torino
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Kołtuniuk A, Witczak I, Młynarska A, Czajor K, Uchmanowicz I. Satisfaction With Life, Satisfaction With Job, and the Level of Care Rationing Among Polish Nurses-A Cross-Sectional Study. Front Psychol 2021; 12:734789. [PMID: 34650492 PMCID: PMC8505674 DOI: 10.3389/fpsyg.2021.734789] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/27/2021] [Indexed: 01/07/2023] Open
Abstract
Background: Rationing of nursing care is a serious issue that has been widely discussed throughout recent years in many countries. The level of satisfaction with life and of satisfaction with job as the nurse-related factors may significantly affect the level of care rationing. Aim: To assess the rationing of nursing care among the Polish nurses and the impact of nurse-related variables, i.e., satisfaction with life and satisfaction with job on the level of nursing care rationing. Materials and Methods: A cross-sectional study was conducted among 529 Polish registered nurses employing in two University Hospitals. Three self-report scales in the Polish version were used in this study, namely, Basel Extent of Rationing of Nursing Care-revised version (BERNCA-R), Satisfaction with Life Scale (SWLS), and Satisfaction with Work Scale (SWWS). Results: The respondents indicated that the most frequently rationed activity is studying the situation of individual patients and care plans at the beginning of the shift. The least frequently rationed activity indicated by the respondents was adequate hand hygiene. The patient-to-nurse ratio and the level of satisfaction with job are significant independent factors affecting the level of care rationing. Conclusions: The assessment of the level of satisfaction with life and identification of factors affecting this assessment will enable reducing the occurrence of care rationing.
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Affiliation(s)
- Aleksandra Kołtuniuk
- Department of Nervous System Diseases, Faculty of Health Sciences, Wroclaw Medical University, Wroclaw, Poland
| | - Izabela Witczak
- Department of Health Care Economics and Quality, Faculty of Health Sciences, Wroclaw Medical University, Wroclaw, Poland
| | - Agnieszka Młynarska
- Department of Gerontology and Geriatric Nursing, School of Health Sciences, Medical University of Silesia, Katowice, Poland
| | - Karolina Czajor
- Department of Ophthalmology, Wroclaw Medical University, Wroclaw, Poland
| | - Izabella Uchmanowicz
- Department of Clinical Nursing, Faculty of Health Sciences, Wroclaw Medical University, Wroclaw, Poland
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Ngusie HS, Shiferaw AM, Bogale AD, Ahmed MH. Health Data Management Practice and Associated Factors Among Health Professionals Working at Public Health Facilities in Resource Limited Settings. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2021; 12:855-862. [PMID: 34393540 PMCID: PMC8357531 DOI: 10.2147/amep.s320769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/21/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Despite the vast amount of resources invested in the development of health information systems, health professionals in developing countries are still suffering from lack of adequate skill to perform health data management activities. There is a lack of sound evidence to overcome health data management challenges in this setting. This study aimed to assess health data management practice and its associated factors among health professionals working at public health facilities in North Wollo Zone, Northeast Ethiopia. METHODS A quantitative cross-sectional study was conducted at public health facilities in North Wollo Zone, Northeast Ethiopia from March 2 to April 15, 2020. A total of 715 health professionalswere selected using a stratified random sampling technique. EpiData version 4.6 and STATA version 15 were used for data entry and analysis, respectively. Descriptive statistics were computed. Multi-variable logistic regression analyses techniques were carried out to show the association between explanatory and outcome variables. Odd ratio at 95% confidence level was used to describe the strength of association. RESULTS A total of 643 health professionals participated in this study. The response rate was 90%. Among them, 56.1% (95% CI: 52.3%-59.9%) demonstrated good data management practice. Working in health center [AOR=1.31 (95% CI: 1.853, 2.003)], having knowledge on data management [AOR=3.74 (95% CI: 2.454, 5.713)], favorable attitude toward data management [AOR=2.64 (95% CI: 1.746, 3.976)], high competency level on data management tasks [AOR=3.12 (95% CI: 1.873, 5.197)], friendliness of data management format [AOR=2.26 (95% CI: 1.478, 3.454)], supervision [AOR=1.78 (95% CI: 1.153, 2.745)] and training [AOR=1.84 (95% CI: 1.115, 3.022)] were significantly associated with good practice of health data management. CONCLUSION Health data management practices of health professionals' were found to be inadequate. Capacity building to enhance health professionals' data management knowledge, attitude and their competency level, providing continuous supportive supervision, designing friendly data management format, providing comprehensive data management training are necessary measures to improve data management practice in this study setting.
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Affiliation(s)
- Habtamu Setegn Ngusie
- Department of Health Informatics, College of Health Science, Mettu University, Mettu, Ethiopia
| | - Atsede Mazengia Shiferaw
- Department of Health Informatics, Institute of Public Health, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Adina Demissie Bogale
- Department of Health Informatics, Institute of Public Health, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
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Ayele S, Gobena T, Birhanu S, Yadeta TA. Attitude Towards Documentation and Its Associated Factors Among Nurses Working in Public Hospitals of Hawassa City Administration, Southern Ethiopia. SAGE Open Nurs 2021; 7:23779608211015363. [PMID: 34104715 PMCID: PMC8150635 DOI: 10.1177/23779608211015363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/17/2021] [Indexed: 11/17/2022] Open
Abstract
Background Nursing documentation is the record of nursing care that has been planned and delivered to individual clients by qualified nurses or under the direction of qualified nurses. Various studies have shown that documentation is still a critical issue in both high- and low-income countries, especially in Sub-Saharan Africa like Ethiopia. However, there is a paucity of data in Ethiopia, the attitude of nurses towards nursing care documentation, particularly in the study setting. Therefore, this study aimed to assess the nurse's attitude towards documentation and associated factors in Hawassa City administration public hospitals, Southern Ethiopia. Methods Institutional based cross-sectional study was conducted among 422 nurses from March 01 to 30, 2020. A simple random sampling technique was applied to select the study participants. Data were collected using a self-administered questionnaire. Statistical package of social science (SPSS) version 20.0 software was used for analysis. The association between the attitude of nurses towards documentation and predictors was determined using multivariable logistic regression analysis. The level of statistical significance was determined at a p-value of less than 0.05. Result Among 413 nurses who participated in the study, 58.8% [95% CI of 54.5% to 63.7%] of them had a favorable attitude towards documentation. Work setting [AOR = 1.94 (95% CI: 1.23-3.05)] and Knowledge [AOR = 3.28 (95% CI: 2.08-5.16)], were significantly associated factors with nurses' attitude towards documentation.Conclusion and Recommendations: More than half of the study participants had a favorable attitude towards documentation. Working unit and knowledge were factors associated with nurse's attitude toward nursing care documentation. Therefore, increasing nurse's knowledge about documentation and managing working units effectively are recommended to increase the nurses' attitude toward documentation.
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Affiliation(s)
- Sisay Ayele
- Department of Nursing, Dilla University, Dilla, Ethiopia
| | - Tesfaye Gobena
- Department of Environmental Health, Haramaya University, Harar, Ethiopia
| | - Simon Birhanu
- School of Nursing and Midwifery, Haramaya University, Harar, Ethiopia
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Tamir T, Geda B, Mengistie B. Documentation Practice and Associated Factors Among Nurses in Harari Regional State and Dire Dawa Administration Governmental Hospitals, Eastern Ethiopia. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2021; 12:453-462. [PMID: 34007235 PMCID: PMC8121277 DOI: 10.2147/amep.s298675] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 04/03/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Nursing documentation is an integral and vital professional nursing practice that refers to the process of recording nursing activities concerned with the care given to individual clients to ensure continual effective, safe, quality, evidence-based, and individualized care. OBJECTIVE To assess documentation practice and identify its associated factors among nurses in six Governmental Hospitals of Harari Regional State and Dire Dawa Administration, Eastern Ethiopia. METHODOLOGY An institutional-based cross-sectional study was conducted among 430 nurses and 421 medical records. Simple random sampling was employed for the selection of nurses and charts after the total sample size had been allocated proportionally for each hospital. Data were collected by using a self-administered questionnaire and review of records, and entered and analyzed by using EpiData version 3.1 and statistical package for social sciences version 20.0, respectively. Logistic regression was used to identify the associated factors. RESULTS In this study, 47.5% of nurses were found to have good nursing documentation practice whereas good nursing documentation practice was found in 38.5% of medical records. Age (AOR, 95% CI 3.54, 1.170-10.8), attitude (AOR, 95% CI 5.66, 3.17-10.11), in-service training (AOR, 95% CI 2.53, 1.477-4.35), nurse to patient ratio (AOR, 95% CI 2.24, 1.24-4.047), motivation (AOR, 95% CI 4.60, 2.721-7.76), and familiarity with standards of nursing documentation (AOR, 95% CI 1.98, 1.137-3.44) were found to have a statistically significant positive association with documentation practice. CONCLUSION Poor documentation practice was due to the identified factors. So, it is better to put further effort toward improving documentation practice through providing training on standards of documentation and enhancing the favorable attitude of nurses toward documentation practice by motivating them regarding documentation activities.
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Affiliation(s)
- Takla Tamir
- Department of Nursing, College of Health and Medical Science, Dilla University, Dilla, Ethiopia
| | - Biftu Geda
- Department of Nursing, College of Health and Medical Science, Haramaya University, Harar, Ethiopia
| | - Bezatu Mengistie
- Department of Public Health, College of Health and Medical Science, Haramaya University, Harar, Ethiopia
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Gathara D, Zosi M, Serem G, Nzinga J, Murphy GAV, Jackson D, Brownie S, English M. Developing metrics for nursing quality of care for low- and middle-income countries: a scoping review linked to stakeholder engagement. HUMAN RESOURCES FOR HEALTH 2020; 18:34. [PMID: 32410633 PMCID: PMC7222310 DOI: 10.1186/s12960-020-00470-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/25/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND The use of appropriate and relevant nurse-sensitive indicators provides an opportunity to demonstrate the unique contributions of nurses to patient outcomes. The aim of this work was to develop relevant metrics to assess the quality of nursing care in low- and middle-income countries (LMICs) where they are scarce. MAIN BODY We conducted a scoping review using EMBASE, CINAHL and MEDLINE databases of studies published in English focused on quality nursing care and with identified measurement methods. Indicators identified were reviewed by a diverse panel of nursing stakeholders in Kenya to develop a contextually appropriate set of nurse-sensitive indicators for Kenyan hospitals specific to the five major inpatient disciplines. We extracted data on study characteristics, nursing indicators reported, location and the tools used. A total of 23 articles quantifying the quality of nursing care services met the inclusion criteria. All studies identified were from high-income countries. Pooled together, 159 indicators were reported in the reviewed studies with 25 identified as the most commonly reported. Through the stakeholder consultative process, 52 nurse-sensitive indicators were recommended for Kenyan hospitals. CONCLUSIONS Although nurse-sensitive indicators are increasingly used in high-income countries to improve quality of care, there is a wide heterogeneity in the way indicators are defined and interpreted. Whilst some indicators were regarded as useful by a Kenyan expert panel, contextual differences prompted them to recommend additional new indicators to improve the evaluations of nursing care provision in Kenyan hospitals and potentially similar LMIC settings. Taken forward through implementation, refinement and adaptation, the proposed indicators could be more standardised and may provide a common base to establish national or regional professional learning networks with the common goal of achieving high-quality care through quality improvement and learning.
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Affiliation(s)
- David Gathara
- KEMRI Wellcome Trust Research Programme, P.O Box 43640 00100, Nairobi, Kenya.
- School of Nursing and Midwifery, Aga Khan University, P.O Box 39340 00623, Nairobi, Kenya.
| | - Mathias Zosi
- Kenya Medical Training College, Kilifi Campus, Nairobi, Kenya
| | - George Serem
- KEMRI Wellcome Trust Research Programme, P.O Box 43640 00100, Nairobi, Kenya
| | - Jacinta Nzinga
- KEMRI Wellcome Trust Research Programme, P.O Box 43640 00100, Nairobi, Kenya
| | | | - Debra Jackson
- School of Nursing & Midwifery, University of Technology, Sydney, Australia
| | - Sharon Brownie
- PRAXIS Forum, Green Templeton College, University of Oxford, Oxford, OX2 6HG, UK
- School of Medicine, Griffith University, Queensland, Australia
| | - Mike English
- KEMRI Wellcome Trust Research Programme, P.O Box 43640 00100, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7FZ, UK
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Uchmanowicz I, Kołtuniuk A, Młynarska A, Łagoda K, Witczak I, Rosińczuk J, Jones T. Polish adaptation and validation of the Perceived Implicit Rationing of Nursing Care (PIRNCA) questionnaire: a cross-sectional validation study. BMJ Open 2020; 10:e031994. [PMID: 32265239 PMCID: PMC7245423 DOI: 10.1136/bmjopen-2019-031994] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To develop a Polish adaptation of the Perceived Implicit Rationing of Nursing Care (PIRNCA)questionnaire. DESIGN Cross-sectional validation study. SETTINGS Nurses working in surgical and cancer wards in Poland. PARTICIPANTS A sample of 513 professionally active nurses was enrolled in the study. INTERVENTION To complete a Polish translation of the full original PIRNCA questionnaire. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was translation and adaptation of the full original PIRNCA tool and its validation to the Polish conditions. The secondary outcome was determination of relationships between sociodemographic variables, nurses' assessment of patient care quality and their overall job satisfaction on the one hand, and PIRNCA scores on the other. RESULTS The respondents' mean score was 1.27 points (SD=0.68) on a scale from 0 to 3. Cronbach's alpha for the entire instrument was 0.957. All items of the questionnaire were found to have a positive item-total correlation. The developed linear regression model showed that nurses' assessment of patient care quality and their overall job satisfaction were independent predictors of PIRNCA scores (p<0.05). 94.15% of nurses reported rationing at least one of the 31 care activities. CONCLUSIONS The present findings indicate a high level of reliability and validity of the translated PIRNCA questionnaire, fully comparable to that of the original. The questionnaire can be used for the assessment of PIRNCA in Polish hospitals.
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Affiliation(s)
| | - Aleksandra Kołtuniuk
- Department of Nervous System Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Agnieszka Młynarska
- Department of Gerontology and Geriatric Nursing, Medical University of Silesia, Katowice, Poland
| | - Katarzyna Łagoda
- Department of Clinical Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Izabela Witczak
- Department of Economics and Quality in Health Care, Wroclaw Medical University, Wroclaw, Poland
| | - Joanna Rosińczuk
- Department of Nervous System Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Terry Jones
- Department of Adult Health and Nursing Systems, Virginia Commonwealth University School of Nursing, Richmond, Virginia, USA
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Leoni‐Scheiber C, Mayer H, Müller‐Staub M. Relationships between the Advanced Nursing Process quality and nurses' and patient' characteristics: A cross-sectional study. Nurs Open 2020; 7:419-429. [PMID: 31871727 PMCID: PMC6917982 DOI: 10.1002/nop2.405] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 10/01/2019] [Indexed: 11/05/2022] Open
Abstract
Aim This study aimed to assess (a) nurses' knowledge and their attitude towards the Advanced Nursing Process-nursing assessment, diagnoses, interventions, outcomes, (b) the quality of the Advanced Nursing Process and (c) relationships with patient characteristics. Design A cross-sectional, descriptive correlational study was performed. Methods Ninety-two registered nurses and ninety nursing records of six hospital wards were included. In January 2016, a knowledge test, a self-assessment tool for measuring nurses' attitude (PND) and the Quality of Diagnoses, Interventions and Outcomes Revised instrument (Q-DIO R) were applied. The correlations between nurses' knowledge, attitude, patient characteristics, organizational factors and the Advanced Nursing Process quality were investigated. Results Nurses demonstrated low levels of knowledge, positive attitudes and an average Advanced Nursing Process quality. Accurate nursing diagnoses were strong and highly significantly related to effective nursing interventions and better nursing-sensitive patient outcomes. A higher proportion of registered nurses was related to better nursing outcomes.
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Affiliation(s)
| | - Hanna Mayer
- Institute of Nursing ScienceUniversity of ViennaViennaAustria
| | - Maria Müller‐Staub
- Lectoraat Nursing DiagnosticsHANZE University GroningenGroningenNetherlands
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Gebeyehu Yazew K, Azagew AW, Yohanes YB. Determinants of the nursing process implementation in Ethiopia: A systematic review and meta-analysis, 2019. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2020. [DOI: 10.1016/j.ijans.2020.100219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Haftu M, Girmay A, Gebremeskel M, Aregawi G, Gebregziabher D, Robles C. Commonly missed nursing cares in the obstetrics and gynecologic wards of Tigray general hospitals; Northern Ethiopia. PLoS One 2019; 14:e0225814. [PMID: 31869340 PMCID: PMC6927650 DOI: 10.1371/journal.pone.0225814] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 11/13/2019] [Indexed: 11/18/2022] Open
Abstract
Background Missed nursing care is considered an error of omission and is defined as any aspect of required patient care that is omitted (either in part or whole) or significantly delayed. Nursing care missed in the perinatal setting can cause negative outcomes and repercussions for the quality and safety of care. This has been reported in multiple settings and countries and is tied to negative maternal outcomes. Preventing missed nursing care requires in-depth research considering the clinical setting. Objective The main aim of the study was to assess commonly missed nursing care elements, reasons, and factors for the omission in the obstetric and gynecologic units of general hospitals in Tigray 2017/18. Methods and materials A cross-sectional study was conducted in eight randomly selected general hospitals in Tigray, Ethiopia. A total of 422 nurses and midwives were selected through simple random sampling using the staff list as a sampling frame. To identify the commonly missed nursing care and related factors, the MISSCARE survey tool was used. Descriptive, bivariate, and multivariate logistic regression analysis was performed to assess potential risk factors of nursing cares omission. Result The study results showed that 299 (74.6%) participants commonly missed at least one nursing care in the perinatal setting. Labor resources 386(96.3%), teamwork 365(91%), material resources 361 (90%) and communication 342 (85.3%) were the reasons identified for commonly missing care. In the multivariate analyses, sex (p-value <0.001), educational level (p-value 0.034), working shift (p-value <0.001) and having an intention to leave the institution (p-value <0.001) showed a significant association with commonly missing care. Conclusion The proportion of commonly missed nursing care was high. After adjusting for demographic variables, labor resources, material resources, and communication were reasons for commonly missed nursing care. Increasing male professional proportion, investing in nurses/midwives training, and harmonizing nursing service administration through appropriate working shift arrangement and timely assessment of professionals’ stability and satisfaction could minimize frequent omission of nursing care.
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Affiliation(s)
- Mebrahtom Haftu
- School of Nursing, College of Health Science, Aksum University, Aksum, Tigray, Ethiopia
- * E-mail:
| | - Alem Girmay
- School of Nursing, College of Health Science, Aksum University, Aksum, Tigray, Ethiopia
| | - Martha Gebremeskel
- School of Nursing, College of Health Science, Mekelle University, Mekelle, Tigray, Ethiopia
| | - Gebrekiros Aregawi
- School of Nursing, College of Health Science, Aksum University, Aksum, Tigray, Ethiopia
| | - Dawit Gebregziabher
- School of Nursing, College of Health Science, Aksum University, Aksum, Tigray, Ethiopia
| | - Carmen Robles
- Midwifery Department, College of Health Science, Mekelle University, Mekelle, Tigray, Ethiopia
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Tasew H, Mariye T, Teklay G. Nursing documentation practice and associated factors among nurses in public hospitals, Tigray, Ethiopia. BMC Res Notes 2019; 12:612. [PMID: 31547843 PMCID: PMC6757410 DOI: 10.1186/s13104-019-4661-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 09/18/2019] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The objective of this study was to investigate documentation practice and factors affecting documentation practice among nurses working in public hospital of Tigray region, Ethiopia. RESULTS In this study, there were 317 participants with 99.7% response rate. The result of this study shows that practice nursing care documentation was inadequate (47.8%). Inadequacy of documenting sheets AOR = 3.271, 95% CI (1.125, 23.704), inadequacy of time AOR = 2.205, 95% CI (1.101, 3.413) and with operational standard of nursing documentation AOR = 2.015, 95% CI (1.205, 3.70) were significantly associated with practice of nursing care documentation. To conclude, more than half of nurses were not documented their nursing care. Employing institutions should provide training on documentation of nursing care to enhance knowledge and create awareness on nurses' documentation to nursing directors and chief executive officer to access adequate documenting supplies besides employing more nurses.
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Affiliation(s)
- Hagos Tasew
- Department Nursing, College of Health Science, Aksum University, Aksum, Ethiopia
| | - Teklewoini Mariye
- Department Nursing, College of Health Science, Aksum University, Aksum, Ethiopia
| | - Girmay Teklay
- Department Nursing, College of Health Science, Aksum University, Aksum, Ethiopia
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Albsoul R, FitzGerald G, Finucane J, Borkoles E. Factors influencing missed nursing care in public hospitals in Australia: An exploratory mixed methods study. Int J Health Plann Manage 2019; 34:e1820-e1832. [PMID: 31448478 DOI: 10.1002/hpm.2898] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 08/14/2019] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Missed nursing care (MNC) is a significant health care issue that impacts on the quality of health care and patient safety. It refers to delayed or omitted aspects of nursing care (totally or partially). MNC is an under-researched area in the Australian health care context. OBJECTIVE This research sought to further explore the MNC phenomenon in the context of an acute care hospital and to identify its common elements and the factors influencing its occurrence. DESIGN A convergent parallel mixed methods design was employed involving secondary analysis of routinely collected hospital data and a survey of 44 nursing staff using the MISSCARE survey instrument. The two sources of data were converged to address the objective. FINDINGS The study found that the most common elements of missed nursing care include failure of patient ambulation, emotional support for patients and/or family, and the provision of full documentation. These elements are consistent with previous international studies conducted in acute care hospital settings. This study identified that local context impacting on MNC was also important and included interruptions to workflow, "perceived" lack of management support, poor handover, and communication breakdown between the nursing team and medical staff. CONCLUSION Consideration of the local health care context is foundational in understanding the MNC phenomenon. The findings of this research may help nursing managers mitigate the possible effects of MNC and therefore improve patient safety in their acute care environment. Additional multisite studies are required to further explore factors associated with MNC in both general and local contexts.
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Affiliation(s)
- Rania Albsoul
- School of Public Health and Social Work and Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Gerard FitzGerald
- School of Public Health and Social Work and Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Julie Finucane
- School of Public Health and Social Work and Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Erika Borkoles
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
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Leoni‐Scheiber C, Mayer H, Müller‐Staub M. Measuring the effects of guided clinical reasoning on the Advanced Nursing Process quality, on nurses' knowledge and attitude: Study protocol. Nurs Open 2019; 6:1269-1280. [PMID: 31367454 PMCID: PMC6650691 DOI: 10.1002/nop2.299] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 03/12/2019] [Accepted: 04/29/2019] [Indexed: 11/23/2022] Open
Abstract
AIM This article is a report of a study protocol designed to examine the effects of guided clinical reasoning on the quality of the Advanced Nursing Process-the evidence-based version of the traditional nursing process. It aims to describe the theoretical framework-Kirkpatrick's evaluation model, the key concepts and the instruments for the planned study. DESIGN A complex experimental intervention study using data and method triangulation is proposed. METHODS Registered Nurses (N = 92), nursing records (N = 180) and 24 patients will be included. Nurses' knowledge and attitude will be evaluated by questionnaires/tests, their clinical performance by observations. Patients' perspective will be addressed by qualitative interviews and patient records by using the instrument Quality of Diagnoses, Interventions and Outcomes revised (Q-DIO R). DISCUSSION Kirkpatrick's model (including quantitative and qualitative methods) is providing evaluations from different perspectives on the quality of the Advanced Nursing Process and on intervention effects.
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Affiliation(s)
| | - Hanna Mayer
- Institute of Nursing ScienceUniversity ViennaViennaAustria
| | - Maria Müller‐Staub
- Lectoraat Nursing DiagnosticsHanze University GroningenGroningenthe Netherlands
- City Hospital WaidZurichSwitzerland
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Bei-Lei L, Yong-Xia M, Fa-Yang M, Zhen-Xiang Z, Qin C, Ming-Ming S, Yuan-Yuan F. Current status and nurses' perceptions of the electronic tabular nursing records in Henan, China. J Nurs Manag 2018; 27:616-624. [PMID: 30267617 DOI: 10.1111/jonm.12720] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 09/23/2018] [Accepted: 09/25/2018] [Indexed: 11/29/2022]
Abstract
AIMS To survey the types of Electronic Nursing Records used and to explore nurses' perceptions in the hospitals in Henan Province, China. BACKGROUND There are few studies about status of electronic nursing documents from nurses' view. METHOD A cross-sectional study of 3,586 nurses using a web-based questionnaire was conducted. RESULTS Approximately 98% of the nurses were college graduates or had higher degrees, with 46% of the nurses managed more than nine beds per nurse each day. About 27% spent more than two hours daily writing records with a further 38% spending between 1 and 2 hr. However, only 52% realized professional nursing records should be archived and fewer than 80% knew the importance and significance of preserving fundamental nursing records. CONCLUSION Although nurses' educational level in Henan is high, the younger age of them (i.e., less experience) and heavy workload may lead to inferior quality of ENR. Nurses' awareness of the importance and legal significance of documents needs improvement. IMPLICATION FOR NURSING MANAGEMENT Our results may provide detailed evidence of the time consuming as well as nurses' knowledge of, abilities in, and opinions about record-keeping in developed countries and bring potential clinical implications for the nursing managers worldwide.
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Affiliation(s)
- Lin Bei-Lei
- Nursing School of Zhengzhou University, Zhengzhou City, China
| | - Mei Yong-Xia
- Nursing School of Zhengzhou University, Zhengzhou City, China
| | - Ma Fa-Yang
- Hormel Cancer Institute, Zhengzhou City, China
| | | | - Chen Qin
- Nursing School of Zhengzhou University, Zhengzhou City, China
| | | | - Fan Yuan-Yuan
- Nursing School of Zhengzhou University, Zhengzhou City, China
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A Comparison of Electronic Medical Record Data to Paper Records in Antiretroviral Therapy Clinic in Ethiopia: What is affecting the Quality of the Data? Online J Public Health Inform 2018; 10:e212. [PMID: 30349630 PMCID: PMC6194098 DOI: 10.5210/ojphi.v10i2.8309] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Anti-Retroviral Therapy (ART) care is a lifelong treatment, which needs
accurate and reliable data collected for long period of time. Poor quality
of medical records data remains a challenge and is directly related to the
quality of care of patients. To improve this, there is an increasing trend
to implement electronic medical record (EMR) in hospitals. However, there is
little evidence on the impact of EMR on the quality of health data in low-
resource setting hospitals like Ethiopia. This comparative study aims to
fill this evidence gap by assessing the completeness and reliability of
paper-based and electronic medical records and explore the challenges of
ensuring data quality at the Anti-Retroviral Therapy (ART) clinic at the
University of Gondar Referral Hospital in Northwest Ethiopia. Methods An institution-based comparative cross-sectional study, supplemented with a
qualitative approach was conducted from February 1 to March 30, 2017 at the
ART clinic of the University of Gondar Hospital. A total of 250 medical
records having both electronic and paper-based versions were collected and
assessed. A national ART registration form which consists of 40 ART data
elements was used as a checklist to assess completeness and reliability
dimensions of data quality on medical records of patients on HIV care. Kappa
statistics were computed to describe the level of data agreement between
paper-based and electronic records across patient characteristics. In-depth
interviews were conducted using semi-structured questionnaires with ten key
informants to explore the challenges related with the quality of medical
records. Responses of the key informant interviews were analyzed using
thematic analysis. Results The overall completeness of medical records was 78% with 95% CI (70.8% -
85.1%) in paper-based and 76% with 95%CI (67.8% - 83.2%) EMR. The data
reliability measured in Kappa statistics shows strong agreements on the
socio-demographic data such as educational status 0.93 (0.891, 0.963), WHO
staging 0.86 (0.808, 0.906); general appearance 0.83 (0.755, 0.892) and
patient referral record 0.87 (0.795, 0.932). The major challenges hindering
good data quality was the current side by side dual data documentation
practice (the need to document both on the paper and the EMR for a single
record), patient overload and low data documentation practice of health
workers. Conclusion The overall completeness of ART medical records was still slightly better in
paper-based records than EMR. The main reason affecting the EMR data quality
was the current dual documentation practice both on the paper and electronic
for each patient in the hospital and the high load of patients in the
clinic. The hospital management need to decide to use either the paper or
the electronic system and build the capacity of health workers to improve
data quality in the hospital.
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