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Rodríguez-Suárez CA, Hernández-De Luis MN. Evaluation of the appropriateness of nursing case studies using the CARE checklist. ENFERMERIA CLINICA (ENGLISH EDITION) 2024:S2445-1479(24)00069-9. [PMID: 39032784 DOI: 10.1016/j.enfcle.2024.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 04/04/2024] [Indexed: 07/23/2024]
Abstract
Case report is a narrative description of the problem of one or several patients. The CARE checklist (CAse REport) is the consensus document for reporting clinical case reports and through adaptations to the different CARE disciplines is used to define standards for authors in scientific journals; however, the specificity of the nursing process makes it difficult to adjust nursing case reports to CARE. The aim was to analyze the publications of clinical cases with a nursing perspective in scientific journals, as well as the quality standards and evaluation systems used. Few journals reviewed agreed to publish nursing case reports or stated standards for authors to adjust to CARE. Preliminary results indicated average or poor adherence to CARE, with the most reported elements being: Keywords, patient information and introduction. Adherence was lower for the elements: Timeline, therapeutic intervention, follow-up and outcomes, and patient perspective. The characteristics of the nursing process implies a low adherence to CARE, so it is necessary to unify criteria to guide researchers, authors, reviewers and editors of scientific journals, as well as to improve the rigor and quality of the reports. Currently, there are no specific guidelines for reporting clinical case reports with a nursing perspective available. These normative gaps could be solved by developing a CARE extension adapted to the methodological characteristics of the nursing process.
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Affiliation(s)
- Claudio Alberto Rodríguez-Suárez
- Departamento de Enfermería, Universidad de Las Palmas de Gran Canaria, Canary Islands, Spain; Unidad de apoyo a la investigación del Complejo Hospitalario Universitario Insular Materno-Infantil de Gran Canaria, Servicio Canario de la Salud, Canary Islands, Spain.
| | - María Naira Hernández-De Luis
- Centro de Salud El Doctoral, Gerencia de Atención Primaria de Gran Canaria, Servicio Canario de la Salud, Canary Islands, Spain
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Shelley D, Davis D, Bail K, Heland R, Paterson C. Oncology Nurses' Experiences of Using Health Information Systems in the Delivery of Cancer Care in a Range of Care Settings: A Systematic Integrative Review. Semin Oncol Nurs 2024; 40:151579. [PMID: 38402020 DOI: 10.1016/j.soncn.2023.151579] [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: 05/15/2023] [Revised: 12/19/2023] [Accepted: 12/30/2023] [Indexed: 02/26/2024]
Abstract
OBJECTIVES This systematic review aimed to identify oncology nurses' experiences of using health information systems (HIS) in the delivery of cancer care. DATA SOURCES The electronic databases searched included CINAHL, MEDLINE (EBSCO host), SCOPUS, Web of Science Core Collection, Google Scholar, OVID, and ProQuest Central (using advanced search strategy) and hand searching of reference lists of the included articles and relevant systematic reviews. Studies published in English language were examined. CONCLUSION Twenty-six studies were included. Three themes emerged: (1) the transparency and application of the nursing process within HIS, (2) HIS enhancing and facilitating communication between nurses and patients, and (3) the impact of HIS on the elements of person-centered care. Nurses' experiences with HIS were overall positive. However, digital systems do not fully capture all elements of the nursing processes; this was confirmed in this review, through the nurses' lens. Most studies used HIS for symptom reporting and monitoring within non-inpatient settings and largely biomedical and lack insight into the person-centeredness and overall holistic care. IMPLICATIONS FOR NURSING PRACTICE There are evidently varied views of HIS adoption across the globe. HIS can improve health-related quality of life and symptom burden, including self-reporting of symptoms among patients. However, there is a need for ongoing high-quality research, and clearer reporting than is evident in the current 26 studies, to fully understand the impact of HIS within the nursing processes and patient outcomes across all specialty cancer fields.
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Affiliation(s)
- Delilah Shelley
- PhD Candidate-Nursing, Faculty of Health, University of Canberra, Canberra, Australia.
| | - Deborah Davis
- Professor of Midwifery, Faculty of Health, University of Canberra, Canberra, Australia
| | - Kasia Bail
- Associate Professor of Nursing and Midwifery, Faculty of Health, University of Canberra, Canberra, Australia
| | - Rebecca Heland
- Chief Nursing & Midwifery Information Officer, ACT Health Directorate, ACT Health, Canberra, Australia
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3
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Cocchieri A, Cesare M, Anderson G, Zega M, Damiani G, D'agostino F. Effectiveness of the Primary Nursing Model on nursing documentation accuracy: A quasi-experimental study. J Clin Nurs 2023; 32:1251-1261. [PMID: 35253297 DOI: 10.1111/jocn.16282] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 02/18/2022] [Accepted: 02/22/2022] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To analyse the Primary Nursing Model's effect on nursing documentation accuracy. BACKGROUND The Primary Nursing is widely implemented since it has been considered as the ideal model of care delivery based on the relationship between the nurse and patient. However, previous research has not examined the relationship between Primary Nursing and nursing documentation accuracy. DESIGN A pretest-posttest-follow-up design was used. METHODS The study was conducted from August 2018 to February 2020 in eight surgical and medical wards in an Italian university hospital. The Primary Nursing was implemented in four wards (study group), while in the other four, the Team Nursing was practised (control group). Nursing documentation accuracy was evaluated through the D-Catch instrument. From the eight wards, 120 nursing documentations were selected randomly for each time point (pre-test, post-test and follow-up) and in each group. Altogether, 720 nursing documents were assessed. The study adhered to the TREND checklist. RESULTS The Primary Nursing and Team Nursing Models exhibited significant differences in mean scores for documentation accuracy: assessment on admission, nursing diagnosis, nursing intervention and patient outcome accuracy. No differences between the two groups were found for record structure accuracy and legibility between the posttest and follow-up. CONCLUSION Primary Nursing exerts an overall positive effect on nursing documentation accuracy and persists over time. RELEVANCE TO CLINICAL PRACTICE The benefits from Primary Nursing implementation included better-documented patient outcomes. The use of Primary Nursing linked with the use of the nursing process allowed for a more individualised and problem-solving approach. Nurse managers should consider the implementation of Primary Nursing to improve care quality.
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Affiliation(s)
- Antonello Cocchieri
- Section of Hygiene, Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Manuele Cesare
- Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Gloria Anderson
- Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Maurizio Zega
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Gianfranco Damiani
- Section of Hygiene, Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Fabio D'agostino
- Saint Camillus International, University of Health Sciences, Rome, Italy
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4
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Curtis K, Fry M, Kourouche S, Kennedy B, Considine J, Alkhouri H, Lam M, McPhail SM, Aggar C, Hughes J, Murphy M, Dinh M, Shaban R. Implementation evaluation of an evidence-based emergency nursing framework (HIRAID): study protocol for a step-wedge randomised control trial. BMJ Open 2023; 13:e067022. [PMID: 36653054 PMCID: PMC9853264 DOI: 10.1136/bmjopen-2022-067022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Poor patient assessment results in undetected clinical deterioration. Yet, there is no standardised assessment framework for >29 000 Australian emergency nurses. To reduce clinical variation and increase safety and quality of initial emergency nursing care, the evidence-based emergency nursing framework HIRAID (History, Identify Red flags, Assessment, Interventions, Diagnostics, communication and reassessment) was developed and piloted. This paper presents the rationale and protocol for a multicentre clinical trial of HIRAID. METHODS AND ANALYSIS Using an effectiveness-implementation hybrid design, the study incorporates a stepped-wedge cluster randomised controlled trial of HIRAID at 31 emergency departments (EDs) in New South Wales, Victoria and Queensland. The primary outcomes are incidence of inpatient deterioration related to ED care, time to analgesia, patient satisfaction and medical satisfaction with nursing clinical handover (effectiveness). Strategies that optimise HIRAID uptake (implementation) and implementation fidelity will be determined to assess if HIRAID was implemented as intended at all sites. ETHICS AND DISSEMINATION Ethics has been approved for NSW sites through Greater Western Human Research Ethics Committee (2020/ETH02164), and for Victoria and Queensland sites through Royal Brisbane & Woman's Hospital Human Research Ethics Committee (2021/QRBW/80026). The final phase of the study will integrate the findings in a toolkit for national rollout. A dissemination, communications (variety of platforms) and upscaling strategy will be designed and actioned with the organisations that influence state and national level health policy and emergency nurse education, including the Australian Commission for Quality and Safety in Health Care. Scaling up of findings could be achieved by embedding HIRAID into national transition to nursing programmes, 'business as usual' ED training schedules and university curricula. TRIAL REGISTRATION NUMBER ACTRN12621001456842.
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Affiliation(s)
- Kate Curtis
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
| | - Margaret Fry
- Faculty of Health, University of Technology Sydney, Broadway, New South Wales, Australia
- Emergency and Critical Care, Northern Sydney Local Health District, Saint Leonards, New South Wales, Australia
| | - Sarah Kourouche
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Belinda Kennedy
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Julie Considine
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, & Institute for Health Transformation, Deakin University, Burwood, Victoria, Australia
- Eastern Health Foundation, Box Hill, Victoria, Australia
| | - Hatem Alkhouri
- Emergency Care Institute, NSW Agency for Clinical Innovation, North Ryde, New South Wales, Australia
| | - Mary Lam
- Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
| | - Steven M McPhail
- Australian Centre for Health Service Innovation and School of Public Health & Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Christina Aggar
- Northern New South Wales Local Health Network, Lismore, New South Wales, Australia
| | - James Hughes
- Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- School of Nursing, Queensland University of Technology, Kelvin Grove, Queensland, Australia
| | - M Murphy
- Western Sydney Local Health District, Wentworthville, New South Wales, Australia
| | - Michael Dinh
- Department of Emergency, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Ramon Shaban
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Marie Bashir Institute for Infectious Diseases & Biosecurity, University of Sydney, Sydney, New South Wales, Australia
- Department of Infection Control, Western Sydney Local Health District, Westmead, New South Wales, Australia
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5
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Nool I, Tupits M, Parm L, Hõrrak E, Ojasoo M. The quality of nursing documentation and standardized nursing diagnoses in the children's hospital electronic nursing records. Int J Nurs Knowl 2023; 34:4-12. [PMID: 35343084 DOI: 10.1111/2047-3095.12363] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/24/2022] [Indexed: 01/11/2023]
Abstract
AIM The aim of the paper is to compare the quality of nursing documentation in the Children's Hospital before and after the NANDA-I nursing diagnoses training. METHODS Research employed the interventional study design, and pre-post study design. Before and after the NANDA-I nursing diagnoses training, 50 nursing records were analyzed in the interventional pre-post study, using D-Catch instrument. RESULTS The most often documented problem-centered nursing diagnosis before training was anxiety and after the training, hyperthermia. The most common risk diagnoses before and after the training was risk of infection. Before the training, one health promotion diagnosis was determined in the nursing records, and after the training the number increased to four. The highest value was given to readability of the nursing documentation both before and after the training. The lowest score before the training was given to the quality determiners of the accurate nursing diagnoses and after the training given to the determiners of the results' quantity. The sum score of documenting the nursing interventions was the most inconsistent before the training and after the training. The most consistent was the readability of the nursing records before and after the training. Statistically significant differences in the improvement of quality were revealed in all areas except for the readability of the nursing documentation and the quantity of nursing assessment. CONCLUSIONS The results of the study revealed that following the training, the quality of nursing documentation improved, the wording of the nursing diagnoses improved, and the number of accurate nursing diagnoses had increased. IMPLICATIONS FOR NURSING PRACTICE Results of the research provide an overview of the importance of the training in improving the quality of nursing documentation and aid the educators in planning the trainings, focusing more on the challenges in the documentation.
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Affiliation(s)
- Irma Nool
- Senior Lecturer at the Chair of Nursing, Tallinn Health Care College, Tallinn, Estonia
| | - Mare Tupits
- Senior Lecturer at the Chair of Nursing, Tallinn Health Care College, Tallinn, Estonia
| | - Lily Parm
- Senior Lecturer at the Chair of Nursing, Tallinn Health Care College, Tallinn, Estonia
| | - Eha Hõrrak
- Junior Lecturer at the Chair of Nursing, Tallinn Health Care College, Tallinn, Estonia
| | - Merle Ojasoo
- Associate Professor at the Chair of Nursing, Tallinn Health Care College, Tallinn, Estonia
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6
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Klingshirn H, Gerken L, Hofmann K, Heuschmann PU, Haas K, Schutzmeier M, Brandstetter L, Wurmb T, Kippnich M, Reuschenbach B. [Complexity of outpatient intensive care for ventilated people: Cross-mapping into the standardised NNN-taxonomy]. Pflege 2022; 36:259-268. [PMID: 36325985 DOI: 10.1024/1012-5302/a000919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
Complexity of outpatient intensive care for ventilated people: Cross-mapping into the standardised NNN-taxonomy Abstract. Background: In Germany, free text is the preferred method for recording the nursing process in outpatient intensive care, although classification systems could enable a more precise description. Research question: How is nursing care for people with outpatient ventilation represented by the NNN-taxonomy and what are the recommendations for nursing practice? Methods: A qualitative "multiple case" design was applied. Using deductive content analysis (data sources: nursing documentation and secondary analysis of interviews with affected persons), several cases, both individually and across all cases were linked to the NNN-taxonomy (cross-mapping). Results: In total, the nursing documentation of 16 invasively ventilated persons with a mean age of 58.4 years (SD = 16.3) was analysed. Seven persons additionally contributed interview data. Documentation was mainly based on the "Strukturmodell" (14/16) with a moderate to high accuracy (D-Catch Score: 16.6; SD = 4.1). Cross-mapping resulted in 4016 codes: 618 nursing diagnoses, 1956 interventions and 1442 outcomes. Documentation was strongly measure-oriented, not very person-centred and with a lack of differentiation between diagnosis and intervention. Conclusions: To improve nursing practice, a person-centred attitude and the ability to differentiate between nursing diagnoses, interventions and outcomes should be promoted.
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Affiliation(s)
- Hanna Klingshirn
- Katholische Stiftungshochschule München, University of Applied Sciences, München, Deutschland
| | - Laura Gerken
- Katholische Stiftungshochschule München, University of Applied Sciences, München, Deutschland
| | - Katharina Hofmann
- Katholische Stiftungshochschule München, University of Applied Sciences, München, Deutschland
| | - Peter Ulrich Heuschmann
- Institut für Klinische Epidemiologie und Biometrie, Julius-Maximilians-Universität Würzburg, Deutschland
- Zentrale für Klinische Studien Würzburg, Universitätsklinikum Würzburg, Deutschland
- Deutsches Zentrum für Herzinsuffizienz (DZHI), Universität Würzburg, Deutschland
| | - Kirsten Haas
- Institut für Klinische Epidemiologie und Biometrie, Julius-Maximilians-Universität Würzburg, Deutschland
| | - Martha Schutzmeier
- Institut für Klinische Epidemiologie und Biometrie, Julius-Maximilians-Universität Würzburg, Deutschland
| | - Lilly Brandstetter
- Institut für Klinische Epidemiologie und Biometrie, Julius-Maximilians-Universität Würzburg, Deutschland
| | - Thomas Wurmb
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Sektion Notfall- und Katastrophenmedizin, Universitätsklinikum Würzburg, Deutschland
| | - Maximilian Kippnich
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Sektion Notfall- und Katastrophenmedizin, Universitätsklinikum Würzburg, Deutschland
| | - Bernd Reuschenbach
- Katholische Stiftungshochschule München, University of Applied Sciences, München, Deutschland
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7
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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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8
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Munroe B, Curtis K, Fry M, Shaban RZ, Moules P, Elphick TL, Ruperto K, Couttie T, Considine J. Increasing accuracy in documentation through the application of a structured emergency nursing framework: A multisite quasi-experimental study. J Clin Nurs 2021; 31:2874-2885. [PMID: 34791742 DOI: 10.1111/jocn.16115] [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: 08/02/2021] [Revised: 09/30/2021] [Accepted: 10/16/2021] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To determine if the use of an emergency nursing framework improves the accuracy of clinical documentation. BACKGROUND Accurate clinical documentation is a nursing professional responsibility essential for high-quality and safe patient care. The use of the emergency nursing framework "HIRAID" (History, Identify Red flags, Assessment, Interventions, Diagnostics, reassessment and communication) improves emergency nursing care by reducing treatment delays and improving escalation of clinical deterioration. The effect of HIRAID on the accuracy of nursing documentation is unknown. DESIGN A quasi-experimental pre-post study was conducted and the report was guided by the strengthening the reporting of observational studies in epidemiology (STROBE) checklist. METHODS HIRAID was implemented in four regional/rural Australian emergency departments (ED) using a range of behaviour change strategies. The blinded electronic healthcare records of 120 patients with a presenting problem of shortness of breath, abdominal pain or fever were reviewed. Quantity measures of completeness and qualitative measures of completeness and linguistic correctness of documentation adapted from the D-Catch tool were used to assess accuracy. Differences between pre-post groups were analysed using Wilcoxon rank-sum and two-sample t-tests for continuous variables. Pearson's Chi-square and Fisher exact tests were used for the categorical data. RESULTS The number of records containing the essential assessment components of emergency care increased significantly from pre- to post-implementation of HIRAID. This overall improvement was demonstrated in both paediatric and adult populations and for all presentation types. Both the quantitative and qualitative measures of documentation on patient history and physical assessment findings improved significantly. CONCLUSION Use of HIRAID improves the accuracy of clinical documentation of the patient history and physical assessment in both adult and paediatric populations. RELEVANCE TO CLINICAL PRACTICE The emergency nursing framework "HIRAID" is recommended for use in clinical practice to increase the documentation accuracy performed by emergency nurses.
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Affiliation(s)
- Belinda Munroe
- Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia.,Illawarra Health and Medical Research Institute, Building 32 University of Wollongong, Wollongong, NSW, Australia
| | - Kate Curtis
- Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia.,Illawarra Health and Medical Research Institute, Building 32 University of Wollongong, Wollongong, NSW, Australia.,Susan Wakil School of Nursing, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia.,George Institute for Global Health, University of NSW, Newtown, NSW, Australia.,Faculty of Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Margaret Fry
- Susan Wakil School of Nursing, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia.,University of Technology Sydney School of Nursing and Midwifery, Sydney, NSW, Australia.,Northern Sydney Local Health District, St Leonards, NSW, Australia.,New South Wales Biocontainment Centre, Western Sydney Local Health District and New South Wales Health, Sydney, NSW, Australia
| | - Ramon Z Shaban
- Susan Wakil School of Nursing, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia.,New South Wales Biocontainment Centre, Western Sydney Local Health District and New South Wales Health, Sydney, NSW, Australia.,Sydney Institute for Infectious Diseases, University of Sydney, Camperdown, NSW, Australia.,Division of Infectious Diseases and Sexual Health, Westmead Hospital and Western Sydney Local Health District, Westmead, NSW, Australia
| | - Peter Moules
- Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
| | - Tiana-Lee Elphick
- Susan Wakil School of Nursing, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia.,Research Central, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
| | - Kate Ruperto
- Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
| | - Tracey Couttie
- Division of Kids and Families, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
| | - Julie Considine
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute of Health Transformation, Deakin University, Geelong, Vic., Australia.,Centre for Quality and Patient Safety Research - Eastern Health Partnership, Box Hill, Vic., Australia
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9
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Azevedo OAD, Cruz DDALMD. Quality indicators of the nursing process documentation in clinical practice. Rev Bras Enferm 2021; 74:e20201355. [PMID: 34320097 DOI: 10.1590/0034-7167-2020-1355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/05/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES to propose quality indicators for clinical nursing documentation. METHODS methodological study in which literature review guided the composition of an instrument for evaluating nursing documentation. Two independent professionals evaluated 204 medical records of adult patients. The analysis of this assessment generated quality indicators for clinical nursing documentation. Inter-rater agreement was analyzed by Cohen's kappa. RESULTS the bibliographic review, analysis by experts and pre-test resulted in 88 evaluation items distributed in seven topics; in 88.5% of the items, inter-rater agreement between strong and almost perfect (k=0.61-1.0) was observed. Analysis of the evaluations generated a global indicator and seven partial indicators of documentation quality. Compliance in the two services ranged between 62.3% and 93.4%. The global indicator showed a 2.1% difference between services. CONCLUSIONS seven quality indicators of clinical nursing documentation and their method of application in hospital records have been proposed.
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Moldskred PS, Snibsøer AK, Espehaug B. Improving the quality of nursing documentation at a residential care home: a clinical audit. BMC Nurs 2021; 20:103. [PMID: 34154606 PMCID: PMC8215798 DOI: 10.1186/s12912-021-00629-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 06/09/2021] [Indexed: 11/21/2022] Open
Abstract
Background Quality in nursing documentation holds promise to increase patient safety and quality of care. While high-quality nursing documentation implies a comprehensive documentation of the nursing process, nursing records do not always adhere to these documentation criteria. The aim of this quality improvement project was to assess the quality of electronic nursing records in a residential care home using a standardized audit tool and, if necessary, implement a tailored strategy to improve documentation practice. Methods A criteria-based clinical audit was performed in a residential care home in Norway. Quantitative criteria in the N-Catch II audit instrument was used to give an assessment of electronic nursing records on the following: nursing assessment on admission, nursing diagnoses, aims for nursing care, nursing interventions, and evaluation/progress reports. Each criterium was scored on a 0–3 point scale, with standard (complete documentation) coinciding with the highest score. A retrospective audit was conducted on 38 patient records from January to March 2018, followed by the development and execution of an implementation strategy tailored to local barriers. A re-audit was performed on 38 patient records from March to June 2019. Results None of the investigated patient records at audit fulfilled standards for recommended nursing documentation practice. Mean scores at audit varied from 0.4 (95 % confidence interval 0.3–0.6) for “aims for nursing care” to 1.1 (0.9–1.3) for “nursing diagnoses”. After implementation of a tailored multifaceted intervention strategy, an improvement (p < 0.001) was noted for all criteria except for “evaluation/progress reports” (p = 0.6). The improvement did not lead to standards being met at re-audit, where mean scores varied from 0.9 (0.8–1.1) for “evaluation/progress reports” to 1.9 (1.5–2.2) for “nursing assessment on admission”. Conclusions A criteria-based clinical audit with multifaceted tailored interventions that addresses determinants of practice may improve the quality of nursing documentation, but further cycles of the clinical audit process are needed before standards are met and focus can be shifted to sustainment of knowledge use.
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Affiliation(s)
- Preben Søvik Moldskred
- Luranetunet Care Centre, Solstrandvegen 39, 5200, Os, Norway. .,Centre for Evidence-Based Practice, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Postbox 7030, 5020, Bergen, Norway.
| | - Anne Kristin Snibsøer
- Centre for Evidence-Based Practice, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Postbox 7030, 5020, Bergen, Norway.,Department of Health and Caring Sciences, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Postbox 7030, 5020, Bergen, Norway
| | - Birgitte Espehaug
- Centre for Evidence-Based Practice, Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Postbox 7030, 5020, Bergen, Norway
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Martin K, Ricciardelli R. A Qualitative Review of What Forensic Mental Health Nurses Include in Their Documentation. Can J Nurs Res 2021; 54:134-143. [PMID: 34024163 DOI: 10.1177/08445621211018061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Documentation of mental health care is a critical component of nursing practice. Despite being identified as playing a critical role, researchers continue to question the quality of nursing documentation and missing and/or inaccurate information. PURPOSE Our aim is to explore the content of nursing documentation among mental health nurses providing care to forensic inpatients. METHODS Using a constructed semi-grounded emergent theme approach for data analysis, we reviewed the types of activities, subjects, and interactions described within nursing notes and identified themes of the content. RESULTS Our results demonstrate that nursing documentation could be categorized into one of seven themes: interactions, food, activities, sleep, mental health, physical health and hygiene. These areas were not consistent with the recommendations from nursing bodies in Canada, specifically the areas of assessment, planning, implementation, and evaluation. Furthermore, missing in the nursing notes is context. CONCLUSIONS The discussion highlights the importance of nursing documentation within the context of best practice, bias, and the impact on patient care. We also discuss missing information (context, clinical relevance, and case conceptualization), and suggest that nurses are not injecting this expertise in patient notes. Clinical implications for documentation practices are presented in relation to education and reflective practice.
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Affiliation(s)
- Krystle Martin
- Research & Academics Department, Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada.,Faculties of Health Science and Social Science and Humanities, Ontario Tech University, Oshawa, ON, Canada
| | - Rosemary Ricciardelli
- Research & Academics Department, Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada.,Department of Sociology, Memorial University of Newfoundland, St. John's, NL, Canada
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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: 5] [Impact Index Per Article: 1.7] [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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Kasamatsu TM, Nottingham SL, Eberman LE, Neil ER, Welch Bacon CE. Patient Care Documentation in the Secondary School Setting: Unique Challenges and Needs. J Athl Train 2020; 55:1089-1097. [PMID: 32966580 DOI: 10.4085/1062-6050-0406.19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Athletic trainers (ATs) recognize patient care documentation as an important part of clinical practice. However, ATs using 1 electronic medical record (EMR) platform reported low accountability and lack of time as barriers to documentation. Whether ATs using paper, other EMRs, or a combined paper-electronic system exhibit similar behaviors or experience similar challenges is unclear. OBJECTIVE To explore ATs' documentation behaviors and perceived challenges while using various systems to document patient care in the secondary school setting. DESIGN Qualitative study. SETTING Individual telephone interviews. PATIENTS OR OTHER PARTICIPANTS Twenty ATs (12 women, 8 men; age = 38 ± 14 years; clinical experience = 15 ± 13 years; from National Athletic Trainers' Association Districts 2, 3, 6, 7, 8, 9, and 10) were recruited via purposeful and snowball-sampling techniques. DATA COLLECTION AND ANALYSIS Two investigators conducted semistructured interviews, which were audio recorded and transcribed verbatim. Following the consensual qualitative research tradition, 3 researchers independently coded transcripts in 4 rounds using a codebook to confirm codes, themes, and data saturation. Multiple researchers, member checking, and peer reviewing were the methods used to triangulate data and enhance trustworthiness. RESULTS The secondary school setting was central to 3 themes. The ATs identified challenges to documentation, including lack of time due to high patient volume and multiple providers or locations where care was provided. Oftentimes, these challenges affected their documentation behaviors, including the process of and criteria for whether to document or not, content documented, and location and timing of documentation. To enhance patient care documentation, ATs described the need for more professional development, including resources or specific guidelines and viewing how documentation has been used to improve clinical practice. CONCLUSIONS Challenges particular to the secondary school setting affected ATs' documentation behaviors, regardless of the system used to document care. Targeted professional development is needed to promote best practices in patient care documentation.
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Martin K, Ricciardelli R, Dror I. How forensic mental health nurses' perspectives of their patients can bias healthcare: A qualitative review of nursing documentation. J Clin Nurs 2020; 29:2482-2494. [PMID: 32242997 DOI: 10.1111/jocn.15264] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 02/12/2020] [Accepted: 03/12/2020] [Indexed: 01/05/2023]
Abstract
AIMS AND OBJECTIVES Our aim was to examine the notes produced by nurses, paying specific attention to the style in which these notes are written and observing whether there are concerns of distortions and biases. BACKGROUND Clinicians are responsible to document and record accurately. However, nurses' attitudes towards their patients can influence the quality of care they provide their patients and this inevitably impacts their perceptions and judgments, with implications to patients' care, treatment, and recovery. Negative attitudes or bias can cascade to other care providers and professionals. DESIGN This study used a retrospective chart review design and qualitative exploration of documentation using an emergent theme analysis. METHODS We examined the notes taken by 55 mental health nurses working with inpatients in the forensic services department at a psychiatric hospital. The study complies with the SRQR Checklist (Appendix S1) published in 2014. RESULTS The results highlight some evidence of nurses' empathic responses to patients, but suggest that most nurses have a style of writing that much of the time includes themes that are negative in nature to discount, pathologise, or paternalise their patients. CONCLUSIONS When reviewing the documentation of nurses in this study, it is easy to see how they can influence and bias the perspective of other staff. Such bias cascade and bias snowball have been shown in many domains, and in the context of nursing it can bias the type of care provided, the assessments made and the decisions formed by other professionals. RELEVANCE TO CLINICAL PRACTICE Given the critical role documentation plays in healthcare, our results indicate that efforts to improve documentation made by mental health nurses are needed and specifically, attention needs to be given to the writing styles of the notation.
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Affiliation(s)
- Krystle Martin
- Ontario Shores Centre for Mental Health Sciences, Whitby, Ontario, Canada.,Ontario Tech University, Oshawa, Ontario, Canada
| | - Rosemary Ricciardelli
- Ontario Shores Centre for Mental Health Sciences, Whitby, Ontario, Canada.,Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Itiel Dror
- University College London (UCL), London, UK
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Abstract
Background: Most nursing records in Taiwan have been computerized, resulting in a large amount of unstructured text data. The quality of these records has rarely been discussed. Purpose: This study used a text mining method to analyze the quality of a nursing record system to establish an auditing model and associated tools for nursing records, with the ultimate objective of improving the quality of electronic nursing records. Methods: This study utilized a retrospective method to collect the electronic nursing records of 6,277 patients who had been discharged from the internal medicine departments of a medical center in northern Taiwan from January to June 2014. SAS Enterprise Guide Version 6.1 and SAS Text Miner Version 13.2 software were used to perform text mining. Nursing experts were invited to examine the electronic nursing records. The text mining results were compared against a benchmark that was developed by the experts, and the efficiency of SAS Text Miner was examined using the criteria of specificity, sensitivity, and accuracy. Results: In this study, 27,356 nurse-formulated events were used in the analysis. The results of the nurse-formulated events showed an 8.08% similar error with system-formulated events, 29.72% were identified as necessary and appropriate names, 17.53% were retained, 10.15% involved error event names, and 34.52% were not classified. In this study, the sensitivity of SAS text mining in the training (testing) data set was 96% (95%), and the specificity and accuracy were both 99% (99%). Conclusions: The results of this study show that text mining is an effective approach to auditing the quality of electronic nursing records. SAS Text Miner software was shown to identify inappropriate nursing record content quickly and efficiently. Furthermore, the results of this study may be included in in-service education teaching materials to promote the writing of better nursing records to improve the quality of electronic nursing records.
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D’Agostino F, Zeffiro V, Cocchieri A, Vanalli M, Ausili D, Vellone E, Zega M, Alvaro R. Impact of an Electronic Nursing Documentation System on the Nursing Process Accuracy. METHODOLOGIES AND INTELLIGENT SYSTEMS FOR TECHNOLOGY ENHANCED LEARNING, 8TH INTERNATIONAL CONFERENCE 2019. [DOI: 10.1007/978-3-319-98872-6_29] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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17
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Qualität der pflegerischen Dokumentation und Auswirkungen auf die pflegerische Praxis – ein integratives Review. ACTA ACUST UNITED AC 2018. [DOI: 10.1007/s16024-018-0316-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Šerková D, Marečková J. CREATION AND VALIDATION OF Q-DIO, AN INSTRUMENT FOR RATING THE QUALITY OF NURSING DOCUMENTATION - LITERATURE REVIEW. CENTRAL EUROPEAN JOURNAL OF NURSING AND MIDWIFERY 2018. [DOI: 10.15452/cejnm.2018.09.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Tuinman A, de Greef MHG, Krijnen WP, Paans W, Roodbol PF. Accuracy of documentation in the nursing care plan in long-term institutional care. Geriatr Nurs 2017; 38:578-583. [PMID: 28552204 DOI: 10.1016/j.gerinurse.2017.04.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 04/20/2017] [Accepted: 04/24/2017] [Indexed: 11/19/2022]
Abstract
Nursing staff working in long-term institutional care attend to residents with an increasing number of severe physical and cognitive limitations. To exchange information about the health status of these residents, accurate nursing documentation is important to ensure the safety of residents. This study examined the accuracy of nursing documentation in 197 care plans of five long-term institutional care facilities. Based on the phases of the nursing process, the D-Catch instrument measures the accuracy of the content and coherence of documentation. Inadequacies were especially found in the description of residents' care needs and stated nursing diagnoses as well as in progress and outcome reports. In somatic and psycho-geriatric units, higher accuracy scores were determined compared with residential care units. Investments in resources (e.g., time), reasoning skills of nursing staff, and implementation of professional standards in accordance with legal requirements may be needed to enhance the quality of nursing documentation.
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Affiliation(s)
- Astrid Tuinman
- Hanze University of Applied Sciences Groningen, School of Nursing, Groningen, The Netherlands.
| | - Mathieu H G de Greef
- University of Groningen and University Medical Center Groningen, Department Human Movement Sciences, Groningen, The Netherlands
| | - Wim P Krijnen
- Hanze University of Applied Sciences Groningen, Research Group Healthy Ageing, Allied Health Care and Nursing, Groningen, The Netherlands
| | - Wolter Paans
- Hanze University of Applied Sciences Groningen, Research Group Nursing Diagnostics, Groningen, The Netherlands
| | - Petrie F Roodbol
- University of Groningen and University Medical Center Groningen, Department of Health Psychology, Groningen, The Netherlands
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An Internationally Consented Standard for Nursing Process-Clinical Decision Support Systems in Electronic Health Records. Comput Inform Nurs 2017; 34:493-502. [PMID: 27414705 DOI: 10.1097/cin.0000000000000277] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Nurses are accountable to apply the nursing process, which is key for patient care: It is a problem-solving process providing the structure for care plans and documentation. The state-of-the art nursing process is based on classifications that contain standardized concepts, and therefore, it is named Advanced Nursing Process. It contains valid assessments, nursing diagnoses, interventions, and nursing-sensitive patient outcomes. Electronic decision support systems can assist nurses to apply the Advanced Nursing Process. However, nursing decision support systems are missing, and no "gold standard" is available. The study aim is to develop a valid Nursing Process-Clinical Decision Support System Standard to guide future developments of clinical decision support systems. In a multistep approach, a Nursing Process-Clinical Decision Support System Standard with 28 criteria was developed. After pilot testing (N = 29 nurses), the criteria were reduced to 25. The Nursing Process-Clinical Decision Support System Standard was then presented to eight internationally known experts, who performed qualitative interviews according to Mayring. Fourteen categories demonstrate expert consensus on the Nursing Process-Clinical Decision Support System Standard and its content validity. All experts agreed the Advanced Nursing Process should be the centerpiece for the Nursing Process-Clinical Decision Support System and should suggest research-based, predefined nursing diagnoses and correct linkages between diagnoses, evidence-based interventions, and patient outcomes.
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Hinton JE, Mays MZ, Hagler D, Randolph P, Brooks R, DeFalco N, Kastenbaum B, Miller K. Testing Nursing Competence: Validity and Reliability of the Nursing Performance Profile. J Nurs Meas 2017; 25:431-458. [DOI: 10.1891/1061-3749.25.3.431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background and Purpose: There is growing evidence that simulation testing is appropriate for assessing nursing competence. We compiled evidence on the validity and reliability of the Nursing Performance Profile (NPP) method for assessing competence. Methods: Participants (N = 67) each completed 3 high-fidelity simulation tests; raters (N = 31) scored the videotaped tests using a 41-item competency rating instrument. Results: The test identified areas of practice breakdown and distinguished among subgroups differing in age, education, and simulation experience. Supervisor assessments were positively correlated, r = .31. Self-assessments were uncorrelated, r = .07. Inter-rater agreement ranged from 93% to 100%. Test–retest reliability ranged from r = .57 to .69. Conclusions: The NPP can be used to assess competence and make decisions supporting public safety.
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Nøst TH, Frigstad SA, André B. Impact of an education intervention on nursing diagnoses in free-text format in electronic health records: A pretest–posttest study in a medical department at a university hospital. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/2057158516668081] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Discussions on how nursing documentation should be carried out have been ongoing for the last decade. In this study, free-text format for nursing diagnoses was introduced to nursing staff at a university hospital in Norway. The aim of the study was to investigate the impact of an education intervention introducing nursing diagnoses in a free-text format following a problem-etiology-symptom structure. A pretest–posttest design was performed to assess changes in quality and quantity in the nursing documentation using the audit instrument N-Catch II. Several elements in the nursing documentation had statistically significant changes; the largest was found for quantity in nursing diagnoses. Education interventions aimed to improve nurses’ documentation in the electronic health record may have an effect on more complete and accurate nursing documentation. The presented education intervention showed a significant impact of more accurate nursing diagnoses and significant improvements in nursing documentation.
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Affiliation(s)
- Torunn Hatlen Nøst
- Department of Nursing Science, NTNU Norwegian University of Science and Technology, Trondheim, Norway
- NTNU Center for Health Promotion Research, Norwegian University of Science and Technology, Trondheim, Norway
| | - Sigrun Aasen Frigstad
- Department of Nursing Science, NTNU Norwegian University of Science and Technology, Trondheim, Norway
| | - Beate André
- Department of Nursing Science, NTNU Norwegian University of Science and Technology, Trondheim, Norway
- NTNU Center for Health Promotion Research, Norwegian University of Science and Technology, Trondheim, Norway
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D'Agostino F, Barbaranelli C, Paans W, Belsito R, Juarez Vela R, Alvaro R, Vellone E. Psychometric Evaluation of the D-Catch, an Instrument to Measure the Accuracy of Nursing Documentation. Int J Nurs Knowl 2015; 28:145-152. [DOI: 10.1111/2047-3095.12125] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Fabio D'Agostino
- Department of Biomedicine and Prevention; University of Rome Tor Vergata; Rome Italy
| | | | - Wolter Paans
- Research Group in Nursing Diagnostics; Hanze University of Applied Sciences; Groningen The Netherlands
| | | | | | - Rosaria Alvaro
- Department of Biomedicine and Prevention; University of Rome Tor Vergata; Rome Italy
| | - Ercole Vellone
- Department of Biomedicine and Prevention; University of Rome Tor Vergata; Rome Italy
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Blekken LE, Nakrem S, Gjeilo KH, Norton C, Mørkved S, Vinsnes AG. Feasibility, acceptability, and adherence of two educational programs for care staff concerning nursing home patients' fecal incontinence: a pilot study preceding a cluster-randomized controlled trial. Implement Sci 2015; 10:72. [PMID: 26002520 PMCID: PMC4450463 DOI: 10.1186/s13012-015-0263-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 05/15/2015] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Fecal incontinence has a high prevalence in the nursing home population which cannot be explained by co-morbidity or anatomic and physiological changes of aging alone. Our hypothesis is that fecal incontinence can be prevented, cured, or ameliorated by offering care staff knowledge of best practice. However, it is not clear which educational model is most effective. To assess the effect of two educational programs for care staff, we planned a three armed cluster-randomized controlled trial. There is a lack of research reporting effects of interventions targeting improved continence care processes in older patients. Thus, to improve the quality of the planned trial, we decided to carry out a pilot study to investigate the feasibility of the planned design, the interventions (educational programs) and the outcome measures, and to enable a power calculation. This paper reports the results from the pilot study. METHODS Three nursing homes, representing each arm of the planned trial, were recruited. Criteria for assessing success of feasibility were pre-specified. Methods, outcome measures, acceptability, and adherence of the components of the intervention were evaluated by descriptive statistical analyses and qualitative content analysis of one focus group interview (n = 7) and four individual interviews. RESULTS The main study is feasible with one major and some minor modifications. Due to challenges with recruitment and indications supporting the assumption that a single intervention with one workshop is not sufficient as an implementation strategy, the main study will be reduced to two arms: a multifaceted education intervention and control. The components of the multifaceted intervention seemed to work well together and need only minor modification. Important barriers to consider were sub-optimal use of skill-mix, problems of communicating important assessments and care plans, and isolated nurses with an indistinct nurse identity. CONCLUSIONS Overall, the main study is feasible. The pedagogical approach needs to consider the identified barriers. Thus, it is essential to empower nurses in their professional role, to facilitate clinical reasoning and critical thinking among care staff, and to facilitate processes to enable care staff to find, report, and utilize information in the electronic patient record. TRIAL REGISTRATION ClinicalTrials.gov: NCT01939821.
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Affiliation(s)
| | - Sigrid Nakrem
- Faculty of Nursing, Sør-Trøndelag University College, Trondheim, Norway.
| | - Kari Hanne Gjeilo
- Department of Cardiothoracic Surgery, Department of Cardiology and National Competence Centre for Complex Symptom Disorders, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
- Department of Circulation and Medical Imaging, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Christine Norton
- Faculty of Nursing and Midwifery, King's College London, 57 Waterloo Road, London, SE1 8WA, UK.
| | - Siv Mørkved
- Department of Public Health and General Practice, Norwegian University of Science and Technology, Trondheim, Norway.
- Clinical Service, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
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Implementation of Free Text Format Nursing Diagnoses at a University Hospital's Medical Department. Exploring Nurses' and Nursing Students' Experiences on Use and Usefulness. A Qualitative Study. Nurs Res Pract 2015; 2015:179275. [PMID: 26075091 PMCID: PMC4444573 DOI: 10.1155/2015/179275] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/23/2015] [Indexed: 11/30/2022] Open
Abstract
Background. Nursing documentation has long traditions and represents core element of nursing, but the documentation is often criticized of being incomplete. Nursing diagnoses are an important research topic in nursing in terms of quality of nursing assessment, interventions, and outcome in addition to facilitating communication and continuity. Aim. The aim of this study was to explore the nurses' and nursing students' experiences after implementing free text format nursing diagnoses in a medical department. Method. The study design included educational intervention of free text nursing diagnoses. Data was collected through five focus group interviews with 18 nurses and 6 students as informants. The data was analyzed using qualitative content analysis. Results. The informants describe positive experiences concerning free text format nursing diagnoses' use and usefulness; it promotes reflection and discussion and is described as a useful tool in the diagnostic process, though it was challenging to find the diagnosis' appropriate formulation. Conclusion. Our findings indicate a valid usability of free text format nursing diagnoses as it promotes the diagnostic process. The use seems to enhance critical thinking and may serve as valuable preparation towards an implementation of standardized nursing diagnoses. Use and support of key personnel seem valuable in an implementation process.
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Blekken LE, Vinsnes AG, Gjeilo KH, Mørkved S, Salvesen Ø, Norton C, Nakrem S. Effect of a multifaceted educational program for care staff concerning fecal incontinence in nursing home patients: study protocol of a cluster randomized controlled trial. Trials 2015; 16:69. [PMID: 25887238 PMCID: PMC4349711 DOI: 10.1186/s13063-015-0595-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 02/09/2015] [Indexed: 11/17/2022] Open
Abstract
Background Fecal incontinence has a high prevalence in the older population, which cannot be explained by comorbidity or the anatomical or psychological changes of aging alone. Fecal incontinence leads to a high economic burden to the healthcare system and is an important cause of institutionalization. In addition, fecal incontinence is associated with shame, social isolation and reduced quality of life. The importance of identifying treatable causes in the frail elderly is strongly emphasized. It is recommended that an assessment of fecal incontinence should be implemented as part of an evaluation of older patients. Although there is a substantial evidence base to guide choice of implementation activities targeting healthcare professionals, little implementation research has focused on the care of older people nor involved care processes or care personnel. This study is based on the assumption that fecal incontinence among nursing home patients can be prevented, cured or ameliorated by offering care staff knowledge of best practice through a multifaceted educational program. The primary objective is to test the hypothesis that a multifaceted educational program for nursing home care staff on assessment and treatment of fecal incontinence reduces patients’ frequency of fecal incontinence. Methods/design The study is a two-armed, parallel cluster-randomized controlled trial. Primary outcome is the frequency of fecal incontinence among patients. Sample size calculations resulted in a need for a total sample of 240 patients. Twenty nursing home units in one city in Norway will be recruited and allocated to intervention or control by an independent statistician using computer-generated tables. The intervention is a multifaceted educational program. Units in the control arm will provide care as usual. The intervention period is 3 months. Data will be collected at baseline, 3, and 6 months. Data will be analyzed using mixed effect models with the cluster treated as a random effect. Discussion This study is the first randomized controlled trial specifically focusing on this neglected area. The result of the study will give evidence for best practice for continence care in nursing homes, and organizational advice concerning implementation strategies. Trial registration ClinicalTrials.gov: NCT02183740, registered June 2014.
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Affiliation(s)
- Lene Elisabeth Blekken
- Faculty of Nursing, Sør-Trøndelag University College (HiST), Postbox 2320, 7004, Trondheim, Norway.
| | - Anne Guttormsen Vinsnes
- Faculty of Nursing, Sør-Trøndelag University College (HiST), Postbox 2320, 7004, Trondheim, Norway.
| | - Kari Hanne Gjeilo
- Department of Cardiothoracic Surgery, Department of Cardiology and National Competence Centre for Complex Symptom Disorders, St. Olavs Hospital, Trondheim University Hospital, Postbox 3250, 7006, Trondheim, Norway. .,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology (NTNU), 7491, Trondheim, Norway.
| | - Siv Mørkved
- Department of Public Health and General Practice, Norwegian University of Science and Technology (NTNU), 7491, Trondheim, Norway. .,Clinical Service, St Olavs Hospital, Trondheim University Hospital, Postbox 3250, 7006, Trondheim, Norway.
| | - Øyvind Salvesen
- Department of Cancer Research and molecular Medicine, Norwegian University of Science and Technology (NTNU), 7491, Trondheim, Norway.
| | - Christine Norton
- Faculty of Nursing and Midwifery, King' College London, 57 Waterloo Road, London, SE1 8WA, UK.
| | - Sigrid Nakrem
- Faculty of Nursing, Sør-Trøndelag University College (HiST), Postbox 2320, 7004, Trondheim, Norway.
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Paans W, Müller-Staub M. Patients' Care Needs: Documentation Analysis in General Hospitals. Int J Nurs Knowl 2014; 26:178-86. [DOI: 10.1111/2047-3095.12063] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Wolter Paans
- Research and Innovation Group in Nursing Diagnostics; Hanze University of Applied Sciences; Groningen the Netherlands
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Instefjord MH, Aasekjær K, Espehaug B, Graverholt B. Assessment of quality in psychiatric nursing documentation - a clinical audit. BMC Nurs 2014; 13:32. [PMID: 25349532 PMCID: PMC4207848 DOI: 10.1186/1472-6955-13-32] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 10/03/2014] [Indexed: 11/24/2022] Open
Abstract
Background Quality in nursing documentation facilitates continuity of care and patient safety. Lack of communication between healthcare providers is associated with errors and adverse events. Shortcomings are identified in nursing documentation in several clinical specialties, but very little is known about the quality of how nurses document in the field of psychiatry. Therefore, the aim of this study was to assess the quality of the written nursing documentation in a psychiatric hospital. Method A cross-sectional, retrospective patient record review was conducted using the N-Catch audit instrument. In 2011 the nursing documentation from 21 persons admitted to a psychiatric department from September to December 2010 was assessed. The N-Catch instrument was used to audit the record structure, admission notes, nursing care plans, progress and outcome reports, discharge notes and information about the patients’ personal details. The items of N-Catch were scored for quantity and/or quality (0–3 points). Results The item ‘quantity of progress and evaluation notes’ had the lowest score: in 86% of the records progress and outcome were evaluated only sporadically. The items ‘the patients’ personal details’ and ‘quantity of record structure’ had the highest scores: respectively 100% and 71% of the records achieved the highest score of these items. Conclusions Deficiencies in nursing documentation identified in other clinical specialties also apply to the clinical field of psychiatry. The quality of electronic written nursing documentation in psychiatric nursing needs improvements to ensure continuity and patient safety. This study shows the importance of the existence of a validated tool, readily available to assess local levels of nursing documentation quality.
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Affiliation(s)
| | - Katrine Aasekjær
- Centre for Evidence-Based Practice, Bergen University College, Bergen, Norway
| | - Birgitte Espehaug
- Centre for Evidence-Based Practice, Bergen University College, Bergen, Norway
| | - Birgitte Graverholt
- Centre for Evidence-Based Practice, Bergen University College, Bergen, Norway
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Wang N, Björvell C, Hailey D, Yu P. Development of the Quality of Australian Nursing Documentation in Aged Care (QANDAC) instrument to assess paper-based and electronic resident records. Australas J Ageing 2013; 33:E18-24. [DOI: 10.1111/ajag.12072] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ning Wang
- University of Wollongong; Wollongong New South Wales Australia
| | - Catrin Björvell
- University of Wollongong; Wollongong New South Wales Australia
| | - David Hailey
- University of Wollongong; Wollongong New South Wales Australia
| | - Ping Yu
- University of Wollongong; Wollongong New South Wales Australia
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Broderick MC, Coffey A. Person-centred care in nursing documentation. Int J Older People Nurs 2012; 8:309-18. [PMID: 23216647 DOI: 10.1111/opn.12012] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Accepted: 09/11/2012] [Indexed: 10/27/2022]
Abstract
AIMS AND OBJECTIVES To explore nursing documentation in long-term care, to determine whether it reflected a person-centred approach to care and to describe aspects of PCC as they appeared in nursing records. BACKGROUND Documentation is an essential part of nursing. It provides evidence that care has been carried out and contains important information to enhance the quality and continuity of care. Person-centred care (PCC) is an approach to care that is underpinned by mutual respect and the development of a therapeutic relationship between the patient and nurse. It is a core principle in standards for residential care settings for older people and is beneficial for both patients and staff (International Practice Development in Nursing and Healthcare, Chichester, Blackwell, 2008 and The Implementation of a Model of Person-Centred Practice in Older Person Settings, Dublin, Health Service Executive, 2010a). However, the literature suggests a lack of person-centredness within nursing documentation (International Journal of Older People Nursing 2, 2007, 263 and The Implementation of a Model of Person-Centred Practice in Older Person Settings, Dublin, Health Service Executive, 2010a). METHOD A qualitative descriptive study using the PCN framework (Person-centred Nursing; Theory and Practice, Oxford, Wiley-Blackwell, 2010) as the context through which nursing assessments and care plans were explored. RESULTS Findings indicated that many nursing records were incomplete, and information regarding psychosocial aspects of care was infrequent. There was evidence that nurses engaged with residents and worked with their beliefs and values. However, nursing documentation was not completed in consultation with the patient, and there was little to suggest that patients were involved in decisions relating to their care. IMPLICATIONS FOR PRACTICE The structure of nursing documentation can be a major obstacle to the recording of PCC and appropriate care planning. Documentation that is focused on the 'person' will contribute to a more meaningful relationship between nurses and residents.
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Paans W, Sermeus W, Nieweg RMB, Krijnen WP, van der Schans CP. Do knowledge, knowledge sources and reasoning skills affect the accuracy of nursing diagnoses? a randomised study. BMC Nurs 2012; 11:11. [PMID: 22852577 PMCID: PMC3447681 DOI: 10.1186/1472-6955-11-11] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 08/01/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This paper reports a study about the effect of knowledge sources, such as handbooks, an assessment format and a predefined record structure for diagnostic documentation, as well as the influence of knowledge, disposition toward critical thinking and reasoning skills, on the accuracy of nursing diagnoses.Knowledge sources can support nurses in deriving diagnoses. A nurse's disposition toward critical thinking and reasoning skills is also thought to influence the accuracy of his or her nursing diagnoses. METHOD A randomised factorial design was used in 2008-2009 to determine the effect of knowledge sources. We used the following instruments to assess the influence of ready knowledge, disposition, and reasoning skills on the accuracy of diagnoses: (1) a knowledge inventory, (2) the California Critical Thinking Disposition Inventory, and (3) the Health Science Reasoning Test. Nurses (n = 249) were randomly assigned to one of four factorial groups, and were instructed to derive diagnoses based on an assessment interview with a simulated patient/actor. RESULTS The use of a predefined record structure resulted in a significantly higher accuracy of nursing diagnoses. A regression analysis reveals that almost half of the variance in the accuracy of diagnoses is explained by the use of a predefined record structure, a nurse's age and the reasoning skills of `deduction' and `analysis'. CONCLUSIONS Improving nurses' dispositions toward critical thinking and reasoning skills, and the use of a predefined record structure, improves accuracy of nursing diagnoses.
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Affiliation(s)
- Wolter Paans
- Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences, post-box 3109, 9701 DC, Groningen, the Netherlands
- School of Public Health, Faculty of Medicine, Centre for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium
| | - Walter Sermeus
- School of Public Health, Faculty of Medicine, Centre for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium
| | - Roos MB Nieweg
- Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences, post-box 3109, 9701 DC, Groningen, the Netherlands
| | - Wim P Krijnen
- Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences, post-box 3109, 9701 DC, Groningen, the Netherlands
| | - Cees P van der Schans
- Research and Innovation Group in Health Care and Nursing, Hanze University of Applied Sciences, post-box 3109, 9701 DC, Groningen, the Netherlands
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Wang N, Hailey D, Yu P. Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review. J Adv Nurs 2011; 67:1858-75. [PMID: 21466578 DOI: 10.1111/j.1365-2648.2011.05634.x] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS This paper reports a review that identified and synthesized nursing documentation audit studies, with a focus on exploring audit approaches, identifying audit instruments and describing the quality status of nursing documentation. INTRODUCTION Quality nursing documentation promotes effective communication between caregivers, which facilitates continuity and individuality of care. The quality of nursing documentation has been measured by using various audit instruments, which reflected variations in the perception of documentation quality among researchers across countries and settings. DATA SOURCES Searches were made of seven electronic databases. The keywords 'nursing documentation', 'audit', 'evaluation', 'quality', both singly and in combination, were used to identify articles published in English between 2000 and 2010. REVIEW METHODS A mixed-method systematic review of quantitative and qualitative studies concerning nursing documentation audit and reports of audit instrument development was undertaken. Relevant data were extracted and a narrative synthesis was conducted. RESULTS Seventy-seven publications were included. Audit approaches focused on three natural dimensions of nursing documentation: structure or format, process and content. Numerous audit instruments were identified and their psychometric properties were described. Flaws of nursing documentation were identified and the effects of study interventions on its quality. CONCLUSION Research should pay more attention to the accuracy of nursing documentation, factors leading to variation in practice and flaws in documentation quality and the effects of these on nursing practice and patient outcomes, and the evaluation of quality measurement.
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Affiliation(s)
- Ning Wang
- Health Informatics Research Lab, School of Information and Technology, Faculty of Informatics, University of Wollongong, New South Wales, Australia
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Paans W, Sermeus W, Nieweg RMB, van der Schans CP. Prevalence of accurate nursing documentation in patient records. J Adv Nurs 2010; 66:2481-9. [PMID: 20735494 DOI: 10.1111/j.1365-2648.2010.05433.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM This paper is a report of a study conducted to describe the accuracy of nursing documentation in patient records in hospitals. Background. Accurate nursing documentation enables nurses to systematically review the nursing process and to evaluate the quality of care. Assessing nurses' reports in patient records can be helpful for improving the accuracy of nursing documentation. METHOD In 2007-2008, we screened patient records (n = 341) from 35 wards in 10 hospitals in the Netherlands. The D-Catch instrument was used to quantify the accuracy of the (1) record structure, (2) admission data, (3) nursing diagnosis, (4) nursing interventions, (5) progress and outcome evaluations and (6) legibility of nursing reports. Items 2-5 were measured as a sum score of quantity criteria (1-4) and quality criteria (1-4), whereas Items 1 and 6 were measured on a 4-point Likert scale that addressed only quality criteria. FINDINGS The domain 'accuracy of the interventions' had the lowest accuracy scores: 95% of the records revealed a scale score not higher than 5. However, the domain 'admission' had the highest scores: 80% of the records revealed a scale score over 5. CONCLUSION Effective documentation systems that support nurses in linking diagnoses, interventions and progress and outcome evaluations could be helpful. To improve the accuracy of the documentation, further research is needed on what factors influence nursing documentation. Comparable outcomes from other studies indicate that applying our study findings to international contexts might support the development of universal criteria for accurate nursing documentation.
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Affiliation(s)
- Wolter Paans
- Research and Innovation Group in Health Care and Nursing, Hanze Universityof Applied Sciences, Groningen, The Netherlands and Catholic University Leuven, Belgium.
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