Perioperative nurses' attitudes toward the use of nursing diagnoses in documentation

Perceptions of Turkish Nursing Students on Nursing Diagnose

Objective: This study aimed to determine how Turkish nursing students’ perceived nursing diagnosis. Methods: This descriptive and cross-sectional study was carried out with 655 nursing students in the Departments of Nursing in the Health Sciences Faculties of two universities, in the Aegean and western Black Sea Region, between 15 February and 5 April 2020. The Students Information Form and Perceptions of Nursing Diagnosis Scale were used for data collection. The independent samples t-test, one-way ANOVA test, and the Mann-Whitney U-test with Bonferroni-correction were used to determine the differences between the groups. Pearson correlation analysis was used to determine the effects of independent variables Results: The mean age of the nursing students was 21.12±1.39; 76.6% of them were female and 36.8% were in the second-year. 53.7% of the nursing students reported that they had difficulty in making nursing diagnoses. The overall Perceptions of Nursing Diagnosis Survey score of the nursing students was found to be 2.46±051. Statistically significant difference was found between Perceptions of Nursing Diagnosis Survey scores in terms of gender (p=0.012), the necessity of nursing diagnosis (p<0.001), and having sufficient knowledge about nursing diagnosis (p=0.019). Conclusions: The findings of this study have revealed that Turkish nursing students’ perceptions of nursing diagnoses are positive. It is important that use effective teaching methods in teaching nursing diagnoses in fundamental nursing education, to give more importance to nursing diagnoses. It is recommended to plan qualitative studies to in-depth examine students’ perceptions with randomized controlled studies involving innovative educational interventions in the future

Reliability, Validity and Empirical Dimensionality of the Minnesota Nurses' Perceptions of Nursing Diagnoses Scale Among Italian Nursing Students

BACKGROUND AND PURPOSE

Perceptions toward nursing diagnosis (ND) may represent core drivers of its adoption within clinical practice. Few studies have investigated perceptions toward ND within nursing academic contexts. The study was conducted to validate the Italian version of the Minnesota Nurses' Perceptions of Nursing Diagnoses (MNPND) scale on a sample of Italian nursing students and explore the psychometric structure of perceptions in a sample drawn from this population.

METHODS

A cross-sectional survey with an online self-administered questionnaire was used. The study used exploratory factor analysis (EFA) and confirmatory factor analysis (CFA).

RESULTS

A three-factorstructure was obtained from parallel analysis and EFA. This was confirmed using CFA; fit statistics: MLRχ² ₍₁₃₂₎ = 230.150, p <. 001; CFI = 0.94; TLI = 0.93; RMSEA = 0.05 [90% CI = 0.041-0.064]; SRMR = 0.056).

CONCLUSIONS

The MNPND scale is a useful instrument to measure nursing students' perceptions of ND.

Nursing Outcomes for Patients with Risk of Perioperative Positioning Injury

PURPOSE

To select and refine the outcomes and indicators of Nursing Outcomes Classification for the diagnosis of risk for perioperative positioning injury.

METHOD

Validation study on expert consensus and refinement through pilot study.

FINDINGS

Eight outcomes and 35 indicators were selected in consensus. After clinical testing was performed, in which 10 patients were assessed at five different times. Eight outcomes and 33 indicators remained in the protocol.

CONCLUSION

This study made it possible to select the most relevant outcomes and indicators to be measured for this diagnosis in clinical practice.

IMPLICATIONS FOR NURSING PRACTICE

Validation studies by consensus and clinical testing are important to promote the accuracy, creating opportunities to legitimize, and improve the concepts of taxonomies.

The documentation practice of perioperative nurses: a literature review

AIMS AND OBJECTIVE

To explore and present the existing knowledge of the documentation practices of perioperative nurses in the operating room.

BACKGROUND

Studies demonstrate that the documentation of nursing care provided is important for the continuity of patient care as well as patient safety. Nurses find that documenting their perioperative services is important to the surgical pathway; however, a number of studies indicate that the documentation practices of perioperative nurses are characterised by subjectivity, randomness and poor quality.

DESIGN

A literature review with a systematic search of scientific material.

METHOD

The content of the studies included was analysed using content analysis as suggested by Krippendorff. The materials were acquired by searching electronic databases. The search was performed for the period 1995-2015 and resulted in 12 studies.

RESULTS

Three general themes were found to be important for perioperative nurses' documentation practices: (1) the documentation tool must be adapted to the clinical practice; (2) nurses document to improve patient safety and protect themselves legally; and (3) traditions and conditions for documentation.

CONCLUSION

Nurses considered documenting their perioperative practices very important. It was of vital importance that the tool used be adapted to the actual clinical practice and to relevant regulations regarding form and content. Nurses' subjective perceptions of and opinions on the effect of documentation influenced their documentation practices, which were widely governed by habits and traditions. Nurses document to safeguard patients against errors but also to protect their own legal status. Nurses also use documentation as proof of their nursing and as 'a window' to gain recognition for their professional practice.

RELEVANCE TO CLINICAL PRACTICE

Our review demonstrates that a focus on the documentation traditions of perioperative nurses combined with training, structure and improved technical tools may facilitate the documentation and thereby improve patient safety.

The non-implementation of the nursing process: reflection based on Deleuze's and Guattari's concepts

The nursing process can contribute to consolidate nursing as a science, as it evidences the systematization of its thinking and its actions, providing visibility to the work that is done. However, national and international studies have reported many difficulties that are faced when implementing it. These difficulties motivated the development of this study, which had the objective of discussing and reflecting on nursing work from a theoretical revision supported by aspects of subjectivity according to Deleuze and Guattari, considering that they may be unconsciously expressed by nurses in their daily professional tasks, resulting in the non-implementation of the nursing process.

Surgery: Between Both Anguish and Joy

Objetivo: describir las categorías que hacen parte de los factores causales de un esquema teórico que emergió durante la investigación: Conviviendo con la ambivalencia en las interacciones de cuidado. Método: cualitativa con enfoque en la teoría fundamentada. Se utilizaron técnicas como la observación, las entrevistas informales y formales a 20 pacientes, 19 auxiliares de enfermería y 8 enfermeras que laboran en diferentes centros quirúrgicos de segundo nivel del Valle de Aburrá. Resultados: se presentan las categorías relacionadas con los sentimientos y las emociones del paciente y del personal de enfermería al ingreso al centro quirúrgico, que hacen parte de los factores causales. Los pacientes desean la normalidad porque sienten molestias no solo físicas sino emocionales, pero también sienten ambivalencia frente al procedimiento quirúrgico. Desde el equipo de enfermería hay una disposición al cuidado porque las enfermeras se identifican en el trabajo para y con seres humanos y se responsabilizan del cuidado del paciente en este periodo. Conclusiones: el equipo de enfermería en cirugía debe estar consciente de la importancia de las dimensiones emocional, social y humana del cuidado y poner especial atención al temor y la ansiedad a los cuales están expuestos los pacientes; por tanto, el cuidado humano en este escenario es vital al ver al otro como un sujeto de atención en su contexto, con sus creencias y valores, aceptándolo tal cual es.

Sistemas de classificação de enfermagem e sua aplicação na assistência: revisão integrativa de literatura

O objetivo deste estudo foi buscar evidências sobre o uso de sistemas de classificação de enfermagem na assistência, por meio de revisão integrativa da literatura. Com a busca nas bases LILACS e PubMed, com as palavras-chave classificação, enfermagem, padronizado, sistema, linguagem, selecionaram-se 38 artigos. Encontraram-se cinco sistemas de classificação principais implementados nos serviços: de diagnósticos de enfermagem (da North American Nursing Diagnosis Association International), intervenções de enfermagem (Nursing Interventions Classification), resultados de enfermagem (Nursing Outcomes Classification), a Classificação Internacional para a Prática de Enfermagem e a Classificação Internacional das Práticas de Enfermagem em Saúde Coletiva. Os artigos abordaram aspectos relacionados à implementação, avaliação, educação continuada e validação de termos relacionados aos sistemas de classificação. Há benefícios para a assistência com a implementação desses sistemas, com melhora da assistência, da qualidade das informações e da organização do serviço.

A meta-study of the essentials of quality nursing documentation

The aim of this study was to synthesize all relevant information about nursing documentation and present the essential aspects of quality nursing documentation. Literature searches, limited to the English language, were conducted on both CINAHL (1982 to week 3, April 2008) and MEDLINE (1996 to April 2008) using the following search terms: attitude, audit, care, culture, documentation, guideline health, in service, legal, liability, medical, nurses, nursing, organizational, patient, personnel, planning practice, quality, records, research and training. One hundred and seventy-one papers were reviewed for their relevance to the clinical question. Twenty-eight articles were read by two researchers. Data informing the clinical question were extracted and categorized into key concepts by an analysis of similarities. The seven major themes (essentials) of quality nursing documentation were identified. This paper has reviewed contemporary literature, research evidence and local policies to identify the seven essential components of quality nursing documentation. Some of the barriers or more controversial aspects of the final policy are described.

An educational strategy for teaching standardized nursing languages

PURPOSE. The aim of this paper is to describe an educational strategy for teaching standardized nursing languages (SNL) used in both the classroom and clinical components of a psychiatric-mental health nursing course at the associate degree level. DATA SOURCES. Data included a review of the relevant literature, teaching experiences, and faculty and student experiences. DATA SYNTHESIS. Enhancing associate degree student nurses' competency regarding diagnosis and interventions is essential to influence positive health outcomes. Use of diagnostic, outcome, and intervention classifications for learning nursing care promotes critical thinking, individualization of nursing care, and students' fluency with SNL. One possible teaching strategy to assist students to learn and use SNL was implemented through the use of a faculty-developed Student Nurse Documentation Packet. CONCLUSIONS. The educational strategy provided students opportunities to enhance their experience with the SNL to plan and document care of individuals experiencing psychiatric-mental health problems. IMPLICATIONS FOR NURSING. The educational strategy used in this program was judged to be successful. Research is needed to provide empirical evidence of the efficacy of this pedagogical strategy for increasing knowledge and enhancing students' competency.

The validation of AORN recommended practices in Finnish perioperative nursing documentation

In Finland, there are no common guidelines or recommended practices for perioperative documentation. Thus, perioperative nursing documentation varies from one operating department to another. To create minimum criteria for nursing documentation in Finland, we conducted an investigation in a university hospital district in 2006. Purposive sampling was used to invite experts in perioperative nursing documentation (N = 42) to serve as a Delphi panel. The final criteria are 120 items, 71% of which are based on the AORN standards and recommended practices. These criteria may be used to educate students and new perioperative personnel and to enhance the quality of nursing practice. To ensure relevance and usability, the criteria should be tested in various perioperative settings with a variety of surgical patients.

Examination of nursing diagnoses used by nursing students and their opinions about nursing diagnoses

PURPOSE

This study was planned as a descriptive study for the purpose of determining what nursing diagnoses are used by nursing students and their opinions about nursing diagnoses.

METHODS

The response rate was 70% (n= 346). Research data about the nursing diagnoses students used and their opinions about them were collected on a semi-structured questionnaire developed by the researchers after reviewing related information in the literature.

FINDINGS

Of the students, 76.9% knew what nursing diagnosis was, but 31.5% had difficulty stating patient care needs as nursing diagnoses.

CONCLUSIONS

The majority of students in this study agreed that nursing diagnoses are a priority subject in the nursing profession, that nursing diagnoses needed to be used on the wards, and that nursing diagnoses needed to be documented in medical records on the wards.

IMPLICATIONS FOR NURSING PRACTICE

It is recommended that nursing diagnoses be given more concentration in the nursing curriculum and that courses about nursing diagnoses be prepared for the purpose of giving students more detailed information.

Enhancing problem solving and nursing diagnosis in year III Bachelor of Nursing students

BACKGROUND

The School of Nursing in which this research was conducted uses a problem based learning approach in clinical nursing courses. Although the skills required for problem solving, and those in nursing care planning, are similar and therefore, support each other in the learning environment, there is limited evidence of the effectiveness of this teaching strategy on problem solving and nursing care planning.

AIM

The aim of this study was to implement a change in the clinical nursing course in the third year of the Bachelor of Nursing (BN) programme and determine if this change improved students' problem solving and care planning.

METHOD

A nine-step problem solving process to deal with problem scenarios was introduced. We hoped that consistent use of this systematic process would improve students' problem solving and care planning skills in the classroom and the clinical area. In order to determine change in problem solving and care planning skills we compared (a) the previous third year student performance on semester I and II assessments with those of the study participants and (b) results at the end of semester I with end of semester II within the study cohort. Findings from these analyses are presented in this paper.

The Impact of a PDA-Assisted Documentation Tutorial on Student Nurses' Attitudes

The purpose of this pretest-posttest study was to determine the effect of a PDA-assisted documentation tutorial on fourth-year student nurses' (n=56) attitudes toward computerized documentation, anticipation to exercise of professional judgment when documenting, and satisfaction with computer technology for documentation. Paired t test showed significant increases in anticipation to use professional nursing judgment and satisfaction with the PDA for documentation. Satisfaction with the PDA for documentation was positively and significantly related to attitudes toward computerized documentation (r=.46, P<.01), and satisfaction with a PDA learning tutorial (r=.46, P<.01). Attitudes toward computerized documentation, length of nursing experience, and satisfaction with the PDA learning tutorial predicted satisfaction with the PDA for documentation. Seventy percent of 213 comments about the value of the PDA were favorable. These findings indicate that the PDA may be a valuable documentation tool for teaching professional nursing judgment and documentation skills to undergraduate nursing students.