Prevalence of accurate nursing documentation in patient records

Evaluation of the appropriateness of nursing case studies using the CARE checklist

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.

Exploration of the Current State of Peripheral Intravenous Catheter Complications and Documentation: A Point Prevalence Study

Peripheral intravenous catheters (PIVCs) are the most commonly used invasive devices in acute care hospitals, with nurses being primarily responsible for the insertion and care of these devices. This point prevalence study aimed to describe current PIVC status and nursing documentation in a large, regional health care system and to explore variables associated with PIVC complications. The study was conducted with adult inpatients. There were 665 PIVCs included in the study. Dressings were clean, dry, and intact in 83% of observations; only 2.7% did not have a transparent dressing. Thirty-one percent of PIVCs were inserted in areas of flexion. Median dwell time was 2.39 days (± 2.36 days), with upper arm sites having the longest dwell time. Overall inter-rater reliability (IRR) for an infiltration or phlebitis score of 0 was high (97.4% and 92%, respectively). However, overall agreement was only 77.16% for infiltration and 40.07% for phlebitis, with significant disagreement as scores increased. Study findings support that there was strong compliance with the Infusion Nurses Society's (INS) Infusion Therapy Standards of Practice vascular access practice recommendations; however, opportunities to improve infiltration/phlebitis assessment and documentation exist.

21st century (clinical) decision support in nursing and allied healthcare. Developing a learning health system: a reasoned design of a theoretical framework

In this paper, we present a framework for developing a Learning Health System (LHS) to provide means to a computerized clinical decision support system for allied healthcare and/or nursing professionals. LHSs are well suited to transform healthcare systems in a mission-oriented approach, and is being adopted by an increasing number of countries. Our theoretical framework provides a blueprint for organizing such a transformation with help of evidence based state of the art methodologies and techniques to eventually optimize personalized health and healthcare. Learning via health information technologies using LHS enables users to learn both individually and collectively, and independent of their location. These developments demand healthcare innovations beyond a disease focused orientation since clinical decision making in allied healthcare and nursing is mainly based on aspects of individuals' functioning, wellbeing and (dis)abilities. Developing LHSs depends heavily on intertwined social and technological innovation, and research and development. Crucial factors may be the transformation of the Internet of Things into the Internet of FAIR data & services. However, Electronic Health Record (EHR) data is in up to 80% unstructured including free text narratives and stored in various inaccessible data warehouses. Enabling the use of data as a driver for learning is challenged by interoperability and reusability.To address technical needs, key enabling technologies are suitable to convert relevant health data into machine actionable data and to develop algorithms for computerized decision support. To enable data conversions, existing classification and terminology systems serve as definition providers for natural language processing through (un)supervised learning.To facilitate clinical reasoning and personalized healthcare using LHSs, the development of personomics and functionomics are useful in allied healthcare and nursing. Developing these omics will be determined via text and data mining. This will focus on the relationships between social, psychological, cultural, behavioral and economic determinants, and human functioning.Furthermore, multiparty collaboration is crucial to develop LHSs, and man-machine interaction studies are required to develop a functional design and prototype. During development, validation and maintenance of the LHS continuous attention for challenges like data-drift, ethical, technical and practical implementation difficulties is required.

Diagnostic accuracy study of the VALENF instrument in hospitalization units for adults: a study protocol

Recently, the VALENF instrument, Nursing Assessment by its acronym in Spanish, was developed as a meta-tool composed of only seven items with a more parsimonious approach for nursing assessment in adult hospitalization units. This meta-tool integrates the assessment of functional capacity, the risk of pressure injuries and the risk of falls. The general objective of this project is to validate the VALENF instrument by studying its diagnostic accuracy against the instruments commonly used in nursing to assess functional capacity, the risk of pressure injuries and the risk of falls. An observational, longitudinal, prospective study is presented, with recruitment and random selection based on admissions to six adult hospitalization units of the Hospital Universitario de La Plana. The study population will be made up of patients hospitalized in these units. The inclusion criteria will be patients over 18 years of age with a nursing assessment within the first 24 h of admission and an expected length of stay greater than 48 h and who sign the informed consent form. The exclusion criteria will be transfers from other units or centers. A sample of 521 participants is estimated as necessary. The evaluation test will be the VALENF instrument, and the reference tests will be the Barthel, Braden and Downton indices. Sociodemographic variables related to the care process and results such as functional loss, falls or pressure injuries will be collected. The evolution of functional capacity, the risk of falls and the risk of pressure injuries will be analyzed. The sensitivity, specificity and positive predictive values of the VALENF instrument will be calculated and compared to those of the usual instruments. A survival analysis will be performed for pressure injuries, falls and patients with functional loss. The VALENF instrument is expected to have at least the same diagnostic validity as the original instruments.Trial registration The study will be retrospectively registered (ISRCTN 17699562, 25/07/2023).

Improving Nursing Assessment in Adult Hospitalization Units: A Secondary Analysis

The main objective of this study was to analyze the impact of a multifaceted strategy to improve the assessment of functional capacity, risk of pressure injuries, and risk of falls at the time of admission of patients in adult hospitalization units. This was a secondary analysis of the VALENF project databases during two periods (October-December 2020, before the strategy, and October-December 2021, after the strategy). The quantity and quality of nursing assessments performed on patients admitted to adult hospitalization units were evaluated using the Barthel index, Braden index, and Downton scale. The number of assessments completed before the implementation of the new strategy was n = 686 (28.01%), versus n = 1445 (58.73%) in 2021 (p < 0.001). The strategy improved the completion of the evaluations of the three instruments from 63.4% (n = 435) to 71.8% (n = 1038) (p < 0.001). There were significant differences depending on the hospitalization unit and the assessment instrument (p < 0.05). The strategy employed was, therefore, successful. The nursing assessments show a substantial improvement in both quantity and quality, representing a noticeable improvement in nursing practice. This study was not registered.

The SITS framework: sustaining innovations in tertiary settings

Background

To date, little attention has focused on what the determinants are and how evidence-based practices (EBPs) are sustained in tertiary settings (i.e., acute care hospitals). Current literature reveals several frameworks designed for implementation of EBPs (0-2 years), yet fewer exist for the sustainment of EBPs (>2 years) in clinical practice. Frameworks containing both phases generally list few determinants for the sustained use phase, but rather state ongoing monitoring or evaluation is necessary. Notably, a recent review identified six constructs and related strategies that facilitate sustainment, however, the pairing of determinants and how best to sustain EBPs in tertiary settings over time remains unclear. The aim of this paper is to present an evidence-informed framework, which incorporates constructs, determinants, and knowledge translation interventions (KTIs) to guide implementation practitioners and researchers in the ongoing use of EBPs over time.

Methods

We combined the results of a systematic review and theory analysis of known sustainability frameworks/models/theories (F/M/Ts) with those from a case study using mixed methods that examined the ongoing use of an organization-wide pain EBP in a tertiary care center (hospital) in Canada. Data sources included peer-reviewed sustainability frameworks (n = 8) related to acute care, semi-structured interviews with nurses at the department (n = 3) and unit (n = 16) level, chart audits (n = 200), and document review (n = 29). We then compared unique framework components to the evolving literature and present main observations.

Results

We present the Sustaining Innovations in Tertiary Settings (SITS) framework which consists of 7 unique constructs, 49 determinants, and 29 related KTIs that influence the sustainability of EBPs in tertiary settings. Three determinants and 8 KTIs had a continuous influence during implementation and sustained use phases. Attention to the level of application and changing conditions over time affecting determinants is required for sustainment. Use of a participatory approach to engage users in designing remedial plans and linking KTIs to target behaviors that incrementally address low adherence rates promotes sustainability.

Conclusions

The SITS framework provides a novel resource to support future practice and research aimed at sustaining EBPs in tertiary settings and improving patient outcomes. Findings confirm the concept of sustainability is a "dynamic ongoing phase".

Nurses' perspectives on shift-to-shift handovers in relation to person-centred nursing home care

AIM

The aim of this study was to gain insight into nurses' perspectives on the shift-to-shift handover in relation to providing Person-centred care (PCC) in nursing homes.

BACKGROUND

PCC is perceived as the gold standard for nursing home care. To preserve the continuity of PCC, an adequate handover during the nurses' shift change is essential. There is, however, little empirical evidence for what constitutes best shift-to-shift nursing handover practices in nursing homes.

DESIGN

An exploratory qualitative descriptive study.

METHODS

Nine nurses were selected purposively and through snowball sampling from five Dutch nursing homes. Semi-structured face-to-face and telephone interviews were conducted. Analysis relied on Braun and Clarke's thematic analysis.

RESULTS

Four main themes were identified related to enabling PCC informed handovers: (1) knowing the resident to be enable to provide PCC was key, (2) the actual handover, (3) additional ways of information transfer and (4) nurses' knowledge of the resident prior to start shift.

CONCLUSION

The shift-to-shift handover is one way that nurses become informed about residents. Knowing the resident is essential to enable PCC. The fundamental underlying question is to what extent nurses have to know the resident in order to enable PCC. Once that level of detail has been established, in-depth research is needed to determine the best method for conveying this information to all nurses. Only then can we start to rethink the role of the shift-to-shift handover in conveying PCC-driven information. No Patient or Public Contribution.

Effectiveness of the Primary Nursing Model on nursing documentation accuracy: A quasi-experimental study

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.

Design and Development of Kardex and Nursing Reports in the Rehabilitation Hospital

Introduction

A nursing rehabilitation Kardex and reports could act as a framework to facilitate and organize rehabilitation programs.

Objectives

This study aimed to design a special Kardex and a structure to rehabilitation nursing reports.

Methods

This study was carried out in two phases consisting of literature review and Delphi method in Rofideh Rehabilitation Hospital, Tehran, Iran. In the first phase, a diverse literature review was done. PubMed, Elsevier, Web of Science, and Google Scholar as a search engine were searched using the keywords of Kardex, "nursing report," "nursing note," "nursing rehabilitation," "nursing Kardex" from 2010 to 2020. After a literature review, the first draft of the Kardex was made. In the next step, using the Delphi method, the initial Kardex was sent to rehabilitation nursing experts in four rounds, and their comments were applied on that.

Results

The rehabilitation nursing Kardex was prepared after four rounds. The Kardex content included "Evaluation of nutritional needs," "Requirements for daily living," "Patients' education," "Examination of bedsores," "Fall prevention," and "communication with rehabilitation departments (physiotherapy, occupational therapy, and speech therapy)."

Conclusion

Rehabilitation Kardex and nursing report sample can be used as a suitable tool to promote patients' independence in rehabilitation centers.

The quality of nursing documentation and standardized nursing diagnoses in the children's hospital electronic nursing records

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.

Development and Validation of a Meta-Instrument for Nursing Assessment in Adult Hospitalization Units (VALENF Instrument) (Part I)

Nursing assessment is the basis for performing interventions that match patient needs, but nurses perceive it as an administrative load. This research aims to develop and validate a meta-instrument that integrates the assessment of functional capacity, risk of pressure ulcers and risk of falling with a more parsimonious approach to nursing assessment in adult hospitalization units. Specifically, this manuscript presents the results of the development of this meta-instrument (VALENF instrument). A cross-sectional study based on recorded data was carried out in a sample of 1352 nursing assessments. Socio-demographic variables and assessments of Barthel, Braden and Downton indices at the time of admission were included. The meta-instrument's development process includes: (i) nominal group; (ii) correlation analysis; (iii) multiple linear regressions models; (iv) reliability analysis. A seven-item solution showed a high predictive capacity with Barthel (R2adj = 0.938), Braden (R2adj = 0.926) and Downton (R2adj = 0.921) indices. Likewise, reliability was significant (p < 0.001) for Barthel (ICC = 0.969; τ-b = 0.850), Braden (ICC = 0.943; τ-b = 0.842) and Downton (ICC = 0.905; κ = 7.17) indices. VALENF instrument has an adequate predictive capacity and reliability to assess the level of functional capacity, risk of pressure injuries and risk of falls.

Sustaining a nursing best practice guideline in an acute care setting over 10 years: A mixed methods case study

Background

To improve patient outcomes many healthcare organizations have undertaken a number of steps to enhance the quality of care, including the use of evidence-based practices (EBPs) such as clinical practice guidelines. However, there is little empirical understanding of the longer-term use of guideline-based practices and how to ensure their ongoing use. The aim of this study was to identify the determinants and knowledge translation interventions (KTIs) influencing ongoing use of selected recommendations of an institutional pain policy and protocol over time from an organizational perspective and 10 years post implementation on two units within an acute care setting.

Methods

We conducted a mixed methods case study guided by the Dynamic Sustainability Framework of an EBP 10 years post implementation. We examined protocol sustainability at the nursing department and unit levels of a multi-site tertiary center in Canada. Data sources included document review (n = 29), chart audits (n = 200), and semi-structured interviews with nurses at the department (n = 3) and unit (n = 16) level.

Results

We identified 32 sustainability determinants and 29 KTIs influencing ongoing use of an EBP in acute care. Three determinants and eight KTIs had a continuous influence in all three time periods: implementation phase (0-2 yrs), sustained phase (>2-10 yrs.), and at the 10-year mark. Implementation of KTIs evolved with the level of application (e.g., department vs. unit) to fit the EBP within the context highlighting the need to focus on determinants influencing ongoing use. Sustainability was associated with continual efforts of monitoring and providing timely feedback regarding adherence to recommendations. KTIs used to embed recommendations into routine practices/processes positively influenced high adherence rates. Use of a participatory approach for implementation and sustainment and linking KTIs designed to incrementally address low adherence rates facilitated sustainment.

Conclusion

This research provides insight into the relationship between implementation and sustainability determinants and related KTIs during implementation and sustained use phases. Unique determinants identified by department and unit nurses reflect their different perspectives toward the innovation based on their respective roles and responsibilities. KTIs fostered changed behaviors and facilitated EBP sustainment in acute care. Findings confirm the concept of sustainability is a dynamic "ongoing process."

The associations of information system's support and nurses' documentation competence with the detection of documentation-related errors: Results from a nationwide survey

The use of information systems and electronic documentation has become a central part of a nurse's work, and it is expected to increase the quality of documentation and patient safety. However, errors related to documentation have been identified as a significant risk for the quality and safety of care. This study examined whether information system's support for documentation and nurses' documentation competence are associated with how frequently nurses detect documentation-related errors that have caused an adverse event. A nationwide survey was conducted in 2020, and a total of 3610 nurses participated. Results from linear regression analyses showed that high documentation support from the information system and high documentation competence were associated with fewer detected documentation-related errors. Nurses with low documentation support from the system and low documentation competence detected the most errors. The results highlight the need to develop electronic health record functions in a way that they better support accurate documentation. Furthermore, organisations should invest in ensuring the documentation skills of nurses and providing appropriate training.

Patterns of communicating care and caring in the intensive care unit

Aim

To explore the perceptions and experiences of nurses in communicating the care and caring in the intensive care unit (ICU).

Design

A focused ethnography.

Methods

This study was conducted in an Australian metropolitan hospital, in which data were gathered from multiple sources: participant observations, document reviews, interviews, and participant's additional written information ‐ over six months (April‐September, 2014). The data were analysed thematically.

Findings

This study addressed inclusively communicating care and caring to patients, families, nurses and other health professionals in ICU. The findings identified main themes concerning the changing patterns of communicating the care and caring in ICU, various patterns of communication used, enablers and barriers of communicating care and caring, and significant issues in communicating care and caring in ICU. Documentation of patients’ psychological and emotional needs, and nurses’ caring behaviours are crucial. These findings need further consideration from all stakeholders.

Attitude Towards Documentation and Its Associated Factors Among Nurses Working in Public Hospitals of Hawassa City Administration, Southern Ethiopia

Background

Nursing documentation is the record of nursing care that has been planned and delivered to individual clients by qualified nurses or under the direction of qualified nurses. Various studies have shown that documentation is still a critical issue in both high- and low-income countries, especially in Sub-Saharan Africa like Ethiopia. However, there is a paucity of data in Ethiopia, the attitude of nurses towards nursing care documentation, particularly in the study setting. Therefore, this study aimed to assess the nurse's attitude towards documentation and associated factors in Hawassa City administration public hospitals, Southern Ethiopia.

Methods

Institutional based cross-sectional study was conducted among 422 nurses from March 01 to 30, 2020. A simple random sampling technique was applied to select the study participants. Data were collected using a self-administered questionnaire. Statistical package of social science (SPSS) version 20.0 software was used for analysis. The association between the attitude of nurses towards documentation and predictors was determined using multivariable logistic regression analysis. The level of statistical significance was determined at a p-value of less than 0.05.

Result

Among 413 nurses who participated in the study, 58.8% [95% CI of 54.5% to 63.7%] of them had a favorable attitude towards documentation. Work setting [AOR = 1.94 (95% CI: 1.23-3.05)] and Knowledge [AOR = 3.28 (95% CI: 2.08-5.16)], were significantly associated factors with nurses' attitude towards documentation.Conclusion and Recommendations: More than half of the study participants had a favorable attitude towards documentation. Working unit and knowledge were factors associated with nurse's attitude toward nursing care documentation. Therefore, increasing nurse's knowledge about documentation and managing working units effectively are recommended to increase the nurses' attitude toward documentation.

Description and Validation of Nursing Diagnosis Using Electronic Documentation: Study Cases in Mother and Child Hospital Indonesia

Background:

A nursing diagnosis is a clinical judgment concerning a human response to a health condition, vulnerability for that response, by an individual, family, group, or community. For the determination of the right nursing diagnosis, a system that guides nurses in implementing care professionally is needed.

Objective:

To describe the nursing diagnosis in mother and child cases validated by using a management nursing information system.

Methods:

This case study used secondary data from 5.294 medical records. Medical records were retrieved from the server, analyzed, and validated by using the mapping model in accordance with the most frequent cases in mothers and children in the hospital. Approximately ten million (10.021) nursing diagnoses were performed by nurses and validated by using a mapping model of medical cases and nursing assessment. The selected medical cases were the five most frequent cases, namely normal delivery, cesarean delivery, healthy newborn, fever, and dengue in children.

Results:

This study yielded the five most frequent nursing diagnoses, namely risk for infection (20.1%), pain (13.37%), anxiety (9.37%), the risk for imbalanced fluid volume (9.36%), and risk for bleeding (9.27%).

Conclusion:

The electronic nursing documentation could help to determine a nursing diagnosis and had been validated for its appropriateness with assessment and the most common cases in mothers and children. Information and system training development are required to carry out the nursing process comprehensively.

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.

Who Are Hospice Patients and What Care Is Provided in Hospices? A Pilot Study

Background:

Hospices provide multidimensional care. In the Netherlands, patients with <3 months estimated life expectancy have access to hospice care. Insight into patients admitted to hospices and the care provided is lacking. In preparation for a national multicenter study, a pilot study was performed.

Objective:

The primary objective was to test the appropriateness of the study procedures and the availability of hospice patient records (HPRs), and patient and care characteristics.

Method:

A cross-sectional pilot study was performed using a descriptive exploratory design. Sixteen hospices were invited to participate, and HPRs from 8 deceased patients per hospice were selected. Data were collected using self-developed electronic case report forms.

Outcomes:

(1). Appropriateness of procedures: availability of HPRs and identified barriers and strategies. (2) Availability of patient and care characteristics in HPRs.

Results:

In total, 104 HPRs of patients from 13 hospices were enrolled. Various types of HPRs were found with different availabilities: nurses’ records were most available (98%) compared to volunteers’ records (62%). Overarching barriers were as follows: ethical issues, lack of knowledge, and lack of communication. Information about the illness was most available (97%), whereas descriptions of experienced symptoms were least available (10%).

Conclusion:

Collecting HPRs is difficult and time-consuming. Specifically, data from separate records of home care nurses and general practitioners were difficult to come by. Patient and care characteristics were alternately present, which led to an extension of data collection in HPRs to 3 time periods. Piloting is essential to adjust study procedures and outcome measures to ensure a feasible national multicenter hospice study.

Predictors of New-Onset Physical Restraint Use in Critically Ill Adults

BACKGROUND

Physical restraints are frequently used for intensive care patients and are associated with substantial morbidity. The effects of common evidence-based critical care interventions on use of physical restraints remain unclear.

OBJECTIVE

To identify independent predictors of new-onset use of physical restraints in critically ill adults.

METHODS

Secondary analysis of a prospective cohort study involving 5 adult intensive care units in a tertiary care medical center in the United States. Use of physical restraints was determined via daily in-person assessments and medical record review. Mixed-effects logistic regression analysis was used to examine factors associated with new-onset use of physical restraints, adjusting for covariates and within-subject correlation among intensive care unit days.

RESULTS

Of 145 patients who were free of physical restraints within 48 hours of intensive care unit admission, 24 (16.6%) had restraints newly applied during their stay. In adjusted models, delirium (odds ratio [OR], 5.09; 95% CI, 1.83-14.14), endotracheal tube presence (OR, 3.47; 95% CI, 1.22-9.86), and benzodiazepine administration (OR, 3.17; 95% CI, 1.28-7.81) significantly increased the odds of next-day use of physical restraints. Tracheostomy was associated with significantly lowered odds of next-day restraint use (OR, 0.13; 95% CI, 0.02-0.73). Compared with patients with a target sedation level, patients who were in a coma (OR, 2.56; 95% CI, 0.80-8.18) or deeply sedated (OR, 2.53; 95% CI, 0.91-7.08) had higher odds of next-day use of physical restraints, and agitated patients (OR, 0.08; 95% CI, 0.00-2.07) were less likely to experience restraint use.

CONCLUSION

Several potentially modifiable risk factors are associated with next-day use of physical restraints.

Structured follow-up of frail home-dwelling older people in primary health care: is there a special need, and could a checklist be of any benefit? A qualitative study of experiences from registered nurses and their leaders

Aim

To identify experiences and opinions about the need for a structured follow-up and to identify potential benefits and barriers to the use of a checklist (Sub Acute Functional decline in the Older people [SAFE]) when caring for frail home-dwelling older people.

Background

The complexity of older peoples’ health situation requires more coordinated health care across health care levels and a better structured follow-up than is currently being offered, especially in the transitional phase between hospital discharge and primary care, but also in more stable phases at home.

Design

This was a qualitative study using focus group interviews.

Methods

Data were collected during six focus group interviews in three districts in a municipality. Nineteen registered nurses (RNs) and seventeen leaders responsible for the follow-up of frail home-dwelling older people participated. Participants were representatives of the RNs in homecare and their leaders.

Results

Our results highlight that although most RNs and their leaders saw a number of significant benefits to conducting a structured assessment and follow-up of frail older people home care recipients, a number of barriers made this difficult to realize on a daily basis.

Conclusion

There is no common perception that a structured follow-up of frail home-dwelling older people in primary health care is an important and contributing factor to better quality of health care. Despite this, most RNs and leaders found that the use of a structured checklist such as SAFE was a benefit to achieving a structured follow-up of the frail older people. We identified several factors of importance to whether a structured follow-up with a checklist is conducted in home care.

Nursing care activities based on documentation

BACKGROUND

Nurses engage in various activities from the time of a patient's admission to his or her discharge from the hospital, helping patients to meet their needs. Each of the activities should be documented properly as authentic and crucial evidence. This study aimed to identify nursing activities in the delivery of nursing care based on the documentation completed.

METHODS

A quantitative design with a retrospective approach was used, in which 240 medical records from Dr. Kariadi Hospital in Semarang, dating from July through September 2016, were obtained and assessed. The records were randomly selected based on the 10 most common medical and surgical diseases and a hospital stay of more than 3 days. The instrument for collecting the data from the patient progress notes used an observations form. The data were analyzed using univariate statistics and needed to be at least 80% of the values for a certain criteria for it to be considered. The results were analyzed to compare the standard of care.

RESULTS

It was revealed that nursing activities in the delivery of nursing care were insufficient. These activities, according the standard of nursing activities, included the assessment of the functional status of decubitus risk (20.8%), biological status (0.4%), formulation of a nursing diagnosis (20.8%), identification of patients' home needs (41.3%), quality of life (66.3%), collaboration intervention in drug administration (60.8%), monitoring of vital signs (23.3%), monitoring of daily living activities (37.5%), mobilization/rehabilitation (37.5%), outcome (46.7%), and resume activities nursing (0.8%).

CONCLUSIONS

Nursing activities are very important within the hospital and must solve the problems that the patient needs. Every nursing activity should produce documentation with critical thinking. If nursing documents are not clear and accurate, inter-professional communication and an evaluation of nursing care cannot be optimal. Nursing activity and documentation should be continuously directed, controlled, and evaluated by a nurse manager. The quality of nursing activities should always be good to increase patient satisfaction, patient safety, and cost-effectiveness.

Improving the quality of nursing documentation in a palliative care setting: a quality improvement initiative

AIM

This paper reports on a quality-improvement project to develop nursing documentation that reflects holistic care within a specialist palliative centre.

BACKGROUND

The World Health Organization definition of palliative care includes impeccable assessment and management of pain and other symptoms. However, existing nursing documentation focuses mainly on the management of physical symptoms, with other aspects of nursing less frequently documented.

METHODS

Supported by a project team and expert panel, cycles of review, action and reflection were used to develop a new palliative nursing documentation. The project was divided into three phases: audits of existing nursing documentation, development of a new palliative nursing care document and audit tool, and pilot implementation and audit of the new nursing documentation.

RESULTS

The new palliative nursing care document demonstrated a higher level of compliance in relation to nursing assessments and a more concise, accurate and comprehensive approach to documenting holistic nursing care and recording of patients' perspective.

CONCLUSIONS

This project has enabled the consistent documentation of holistic nursing care and patients' perspectives; however, continuous education is necessary in order to sustain positive results and ensure that documentation does not become a 'tick box' exercise. Organisational support is required in order to improve documentation systems.

Quality criteria, instruments, and requirements for nursing documentation: A systematic review of systematic reviews

AIM

To obtain an overview of existing evidence on quality criteria, instruments, and requirements for nursing documentation.

DESIGN

Systematic review of systematic reviews.

DATA SOURCES

We systematically searched the databases PubMed and CINAHL for the period 2007-April 2017. We also performed additional searches.

REVIEW METHODS

Two reviewers independently selected the reviews using a stepwise procedure, assessed the methodological quality of the selected reviews, and extracted the data using a predefined extraction format. We performed descriptive synthesis.

RESULTS

Eleven systematic reviews were included. Several quality criteria were described referring to the importance of following the nursing process and using standardized nursing terminologies. In addition, some evidence-based instruments were described for assessing the quality of nursing documentation, such as the D-Catch. Furthermore, several requirements for formats and systems of electronic nursing documentation were found that refer to the importance of user-friendliness and development in consultation with nursing staff.

CONCLUSION

Aligning documentation with the nursing process, using standard terminologies, and using user-friendly formats and systems appear to be important for high-quality nursing documentation. The lack of evidence-based quality indicators presents a challenge in the pursuit of high-quality nursing documentation.

IMPACT

There is uncertainty in nursing practice about which criteria have to be met to achieve high-quality documentation. Aligning documentation with the nursing process, using standard terminologies, and using user-friendly formats and systems appear to be important. These findings can help nursing staff and care organizations enhance the quality of nursing documentation.

Documentation of psychotropic pro re nata medication administration: An evaluation of electronic health records compared with paper charts and verbal reports

AIMS AND OBJECTIVES

To describe the documentation of pro re nata (PRN) medication for anxiety and to compare documentation at two hospitals providing similar psychiatric services, one that used paper charts and another that used an electronic health record (EHR). We also assessed congruence between nursing documentation and verbal reports from staff about the PRN administration process.

BACKGROUND

The ability to accurately document patients' symptoms and the care given is considered a core competency of the nursing profession (Wilkinson, Nursing process and critical thinking, Saddle River, 2007); however, researchers have found poor concordance between nursing notes and verbal reports or observations of events (e.g., Marinis et al., 2010, J Clin Nurs, 19, 1544-1552) and considerable information missing (e.g., Marinis et al., 2010, J Clin Nurs, 19, 1544-1552). Additionally, the administration of PRN medication has consistently been noted to be poorly documented (e.g., Baker et al., 2008, J Clin Nurs, 17, 1122-1131).

DESIGN

The project was a mixed-method, two-phase study that collected data from two sites.

METHODS

In phase 1, nursing documentation of PRN medication administrations was reviewed in patient charts; phase 2 included verbal reports from staff about this practice.

RESULTS

Nurses using EHR documented more information than those using paper charts, including the reason for PRN administration, who initiated the administration, and effectiveness. There were some differences between written and verbal reports, including whether potential side effects were explained to patients prior to PRN administration.

CONCLUSIONS

We continue the calls for attention to be paid to improving the quality of nursing documentation. Our results support the shift to using EHR, yet not relying on this method completely to ensure comprehensiveness of documentation.

RELEVANCE TO CLINICAL PRACTICE

Efforts to address the quality of documentation, particularly for PRN administration, are needed. This could be made through training, using structured report templates and by switching to electronic databases.

CogChamps: impact of a project to educate nurses about delirium and improve the quality of care for hospitalized patients with cognitive impairment

BACKGROUND

Achieving sustainable practice changes to ensure best-practice nursing care in acute hospital environments can be challenging and is not well understood. A multi-faceted practice change intervention was implemented in a large Australian hospital to enhance the capacity of the nursing workforce to provide quality care for older patients with cognitive impairment (CI).

METHODS

Thirty-four experienced Registered Nurses (RNs) became Cognition Champions (CogChamps), and led practice-change initiatives to improve nursing care for older patients (≥65 years) on six wards in one hospital. The CogChamps received comprehensive education about dementia and the identification, prevention, and management of delirium. Over five months, they were supported to develop and implement ward-specific Action Plans designed to change care practices. Nurse-patient interactions were observed and patient charts were audited prior to the implementation of the plans and regularly throughout, using a purpose built Audit/ Observational tool. Data were also collected at a comparable hospital where there were no CogChamps. Data were analyzed for evidence of practice change.

RESULTS

Observational and audit data were collected for 181 patients (average age = 82.5 years) across the two hospitals. All patients had CI and both cohorts had similar behavioral characteristics requiring a high level of care assistance [e.g. 38% displayed evidence of confusion/disorientation and a majority experienced meal-time difficulty (62-70%)]. While nursing practices were generally the same at both hospitals, some differences were evident (e.g. analgesia use was higher at the control hospital). Following implementation of Action Plans, significant increases in nurses' assessments of patients' cognitive functioning (35 to 69%), and administration of analgesia (27 to 48%) were observed at the intervention hospital, although only the improvement in cognitive assessments was maintained at three months follow-up. No other changes in nursing processes were evident.

CONCLUSION

The CogChamps project demonstrates how RN champions were empowered to educate their colleagues about dementia and delirium resulting in a sustained increase in cognitive assessments by ward nurses. Practice improvements were mostly associated with clearly defined Action Plan tasks and goals and where responsibility for task completion was clearly assigned. These elements appear to be important when implementing practice changes.

TRIAL REGISTRATION

Australian Clinical Trials Registration Number: ACTRN 12617000563369 . Retrospectively registered.

Participants' perceptions of an intervention implemented in an Action Research Nursing Documentation Project

AIMS AND OBJECTIVES

The aim of this study is to describe healthcare professionals' experiences and perceptions of an intervention implemented in an action research project conducted to improve nursing documentation practices in four municipalities in Norway.

BACKGROUND

Documentation of individualized patient care is a continuing concern in healthcare services and could impacts the quality and safety of healthcare. Use of electronic systems has made some aspects of documentation more comprehensive, but creation of an individualized care plan remains a pressing issue.

DESIGN

A qualitative descriptive design was used.

METHODS

An action research project was conducted between 2010-2012 to improve the content and quality of nursing documentation in community healthcare services in four municipalities. One year after the project was completed four focus group interviews were conducted with healthcare professionals, one for each involved municipality. Two unit managers were interviewed individually. Qualitative content analysis was used.

RESULTS

Three themes emerged: healthcare professionals perceived competing interest; they experienced that they had to manage complexity and changes; and they highlighted a clear and visible leader as important for success.

CONCLUSIONS

Quality improvement activities are essential. Healthcare professionals experience a complicated situation when electronic health record systems do not support workflow. Further research is recommended to focus on the functionality and user interface of electronic health record systems, and on the role of leadership when implementing changes in clinical practice.

RELEVANCE TO CLINICAL PRACTICE

Stronger cooperation among policymakers, electronic health record system vendors, and healthcare professionals is essential for improving electronic health record systems and documentation practices. Involvement of end-users in these improvements can make a difference in the way the systems are perceived in the clinical workflow.

The Role of Documentation Quality in Anesthesia-Related Closed Claims: A Descriptive Qualitative Study

Clinical documentation is a critical tool in supporting care provided to patients. Sound documentation provides a picture of clinical events that can be used to improve patient care. However, many other uses for clinical documentation are equally important. Such documentation informs clinical decision support tools, creates a legal record of patient care, assists in financial reimbursement of services, and serves as a repository for secondary data analysis. Conversely, poor documentation can impair patient safety and increase malpractice risk exposure by reflecting poor or inaccurate information that ultimately may guide patient care decisions.Through an examination of anesthesia-related closed claims, a descriptive qualitative study emerged, which explored the antecedents and consequences of documentation quality in the claims reviewed. A secondary data analysis utilized a database generated by the American Association of Nurse Anesthetists Foundation closed claim review team. Four major themes emerged from the analysis. Themes 1, 2, and 4 primarily describe how poor documentation quality can have negative consequences for clinicians. The third theme primarily describes how poor documentation quality that can negatively affect patient safety.

From concept to practice, is multidimensional care the leading principle in hospice care? An exploratory mixed method study

BACKGROUND

Hospice care (HC) aims to optimise the quality of life of patients and their families by relief and prevention of multidimensional suffering. The aim of this study is to gain insight into multidimensional care (MC) provided to hospice inpatients by a multiprofessional team (MT) and identify facilitators, to ameliorate multidimensional HC.

METHODS

This exploratory mixed-method study with a sequential quantitative-qualitative design was conducted from January to December 2015. First a quantitative study of 36 patient records (12 hospices, 3 patient records/hospice) was performed. The outcomes were MC, clinical reasoning and assessment tools. Second, MC was qualitatively explored using semistructured focus group interviews with multiprofessional hospice teams. Both methods had equal priority and were integrated during analysis.

RESULTS

The physical dimension was most prevalent in daily care, reflecting the patients' primary expressed priority at admission and the nurses' and physicians' primary focus. The psychological, social and spiritual dimensions were less frequently described. Assessment tools were used systematically by 4/12 hospices. Facilitators identified were interdisciplinary collaboration, implemented methods of clinical reasoning and structures.

CONCLUSIONS

MC is not always verifiable in patient records; however, it is experienced by hospice professionals. The level of MC varied between hospices. The use of assessment tools and a stepped skills approach for spiritual care are recommended and multidimensional assessment tools should be developed. Leadership and commitment of all members of the MT is needed to establish the integration of multidimensional symptom management and interdisciplinary collaboration as preconditions for integrated multidimensional HC.

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

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.

The Status of Nursing Documentation in Slovenia: a Survey

Health documentation is a prerequisite for good and sustainable health and social care. It is especially important for patient involvement and their empowerment. A transition from paper to e-documentation together with the electronic patient record should be based on thorough knowledge of the current state of documentation and its usages. The main objective of this paper was to analyse which documents and work methods of documenting processes within nursing are being used within different environments. Furthermore, what are the main reasons for their discrepancies from theoretical approaches and best practices. The analysis is based on a survey carried out on all three levels of healthcare. The survey questionnaire consisted of 12 questions to which responded 286 nursing teams from community health centres, hospitals and retirement homes in Slovenia. The results point to diversity in documenting as well as lack of interoperability. This is reflected in a great number of different documents. All phases of the nursing process were being documented in only 31.8 % of cases. The main reasons for this can be attributed to work organisation, different definitions of data-set requirements and inadequate knowledge by nurses. Survey results pointed out a need for the renewal of nursing documentation towards a more uniform system based on contemporary health technologies.

An Audit of Nursing Documentation at Three Public Hospitals in Jamaica

PURPOSE

Nursing documentation provides an important indicator of the quality of care provided for hospitalized patients. This study assessed the quality of nursing documentation on medical wards at three hospitals in Jamaica.

METHODS

This cross-sectional study audited a multilevel stratified sample of 245 patient records from three type B hospitals. An audit instrument which assessed nursing documentation of client history, biological data, client assessment, nursing standards, discharge planning, and teaching facilitated data collection. Descriptive statistics were conducted using IBM SPSS, Version 19 (IBM Inc., Armonk, NY, USA).

FINDINGS

Records from three hospitals (Hospital 1, n = 119, 48.6%; Hospital 2, n = 56, 22.9%; Hospital 3, n = 70, 28.6%) were audited. Documented evidence of the patient's chief complaint (81.6%), history of present illness (78.8%), past health (79.2%), and family health (11.0%) were noted; however, less than a third of the dockets audited recorded adequate assessment data (e.g., occupation or living accommodations of patients). The audit noted 90% of records had a physical assessment completed within 24 hr of admission and entries timed, dated, and signed by a nurse. Less than 5% of dockets had evidence of patient teaching, and 13.5% had documented evidence of discharge planning conducted within 72 hr of admission.

CONCLUSIONS

This study highlights the weakness in nursing documentation and the need for increased training and continued monitoring of nursing documentation at the hospitals studied. Additional research regarding the factors that affect nursing documentation practice could prove useful.

CLINICAL RELEVANCE

The study provides valuable information for the development of strategic risk management programs geared at improving the quality of care delivered to clients and presents an opportunity for nurse leaders to implement structured interventions geared at improving nursing documentation in Jamaica. In light of Jamaica's epidemiologic transition of chronic diseases, gaps in nurses' documentation of client assessment, patient teaching, and discharge planning should be addressed with urgency. Patient teaching and discharge planning enable the clients to participate more effectively in their health maintenance process.

A structured framework improves clinical patient assessment and nontechnical skills of early career emergency nurses: a pre-post study using full immersion simulation

AIMS AND OBJECTIVES

The aim of this study was to evaluate the effect of the new evidence-informed nursing assessment framework HIRAID (History, Identify Red flags, Assessment, Interventions, Diagnostics, reassessment and communication) on the quality of patient assessment and fundamental nontechnical skills including communication, decision making, task management and situational awareness.

BACKGROUND

Assessment is a core component of nursing practice and underpins clinical decisions and the safe delivery of patient care. Yet there is no universal or validated system used to teach emergency nurses how to comprehensively assess and care for patients.

DESIGN

A pre-post design was used.

METHODS

The performance of thirty eight emergency nurses from five Australian hospitals was evaluated before and after undertaking education in the application of the HIRAID assessment framework. Video recordings of participant performance in immersive simulations of common presentations to the emergency department were evaluated, as well as participant documentation during the simulations. Paired parametric and nonparametric tests were used to compare changes from pre to postintervention.

RESULTS

From pre to postintervention, participant performance increases were observed in the percentage of patient history elements collected, critical indicators of urgency collected and reported to medical officers, and patient reassessments performed. Participants also demonstrated improvement in each of the four nontechnical skills categories: communication, decision making, task management and situational awareness.

CONCLUSION

The HIRAID assessment framework improves clinical patient assessments performed by emergency nurses and has the potential to enhance patient care.

RELEVANCE TO CLINICAL PRACTICE

HIRAID should be considered for integration into clinical practice to provide nurses with a systematic approach to patient assessment and potentially improve the delivery of safe patient care.

Impact of a multifaceted education program on implementing a pediatric palliative care guideline: a pilot study

BACKGROUND

A national clinical practice guideline for pediatric palliative care was published in 2013. So far there are only few reports available on whether an educational program fosters compliance with such a guideline implementation. We aimed to test the effect of the education program on actual compliance as well as documentation of compliance to the guideline.

METHODS

We performed a prospective study with pre- and post-intervention evaluation on compliance to the guideline of the nurse specialists of a pediatric palliative care team for case management at a children's university hospital. Eleven quality indicators were selected from 192 recommendations from the pediatric palliative care guideline, based on frequency, measurability and relevance. The multifaceted education program included e-learning and an interactive educational meeting. Four e-learning modules addressed 19 patient cases on symptoms, diagnostics and treatment, and a chart-documentation exercise. During the interactive educational meeting patient cases were discussed on how to use the guideline. Documentation of compliance to the guideline in the web-based patient-charts as well as actual compliance to the guideline through weekly web-based parent reports was measured before and after completion of the e-learning.

RESULTS

Eleven quality indicators were selected. The educational program did not result in significant improvement in compliance for any of these indicators. The indicators "treatment of nausea", "pain medications two steps ahead" and "pain medication for 48 h present", measured through parent reports, scored a compliance beyond 80 % before and after e-learning. The remaining indicators measuring compliance, as well as six indicators measuring documentation by chart review, showed a compliance below 80 % before and after e-learning.

CONCLUSIONS

The multifaceted education program did not lead to improvement in documentation of compliance to the guideline. Parent reported outcome revealed better performance and might be the more adequate assessment tool for future studies.

The impact of using electronic patient records on practices of reading and writing

The aim of this study was to investigate the use of electronic patient records in daily practice. In four wards of a large hospital district in Finland, N = 43 patients' care and activities were observed and analysed in terms of the Grounded Theory method. The findings revealed that using electronic patient records created a particular process of writing and reading. Wireless technology enabled simultaneous patient involvement and point-of-care documentation, additionally supporting real-time reading. Remote and retrospective documentation was distant in terms of both space and time. The remoteness caused double documentation, reduced accuracy and less-efficient use of time. 'Non-reading' practices were witnessed in retrospective reading, causing delays in patient care and increase in workload. Similarly, if documentation was insufficient or non-existent, the consequences were found to be detrimental to the patients. The use of an electronic patient record system has a significant impact on patient care. Therefore, it is crucial to develop wireless technology and interdisciplinary collaboration in order to improve and support high-quality patient care.

Nurses' perceptions and attitudes towards documentation in nursing

Introduction: Nursing documentation is essential for ensuring a safe, high-quality and continuous nursing care and research work. By means of documentation nurses communicate with each other, other members of the healthcare team and other care providers. The aim of the present research was to investigate nurses' opinions about the importance of nursing documentation. Methods: For the purposes of the study, a quantitative non-experimental research design was employed. A quota sampling included the nursing employees in ten Slovenian hospitals. The survey was composed of closed-ended questions. The data were collected from June 1, 2012 to March 31, 2013. The response rate was 44.95 %. A total of 592 respondents participated in the research, 47.3 % with secondary education and 52.7 % with completed undergraduate study programme. Chrombach's coefficient alpha was 0.898. Descriptive statistics, Kolmogorov-Smirnov test, Spearman's correlation coefficient, and Mann-Whitney U test were used. Results: Nurses with at least college degree attributed more importance to documentation compared to those with secondary education (p = 0.001). Statistically significant correlation was not established (p = 0.98). However, a negative correlation was identified between the time used for documentation and positive attitude towards documentation (p = 0.04). Discussion and conclusion: Nurses perceive documentation as an important part of their work. They believe that documentation enhances transparency, quality and continuity of care, and patient safety. It would be necessary to identify the differences in practices and perceptions of handovers between nurses and other healthcare providers.

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

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.

Use of Electronic Health-Related Datasets in Nursing and Health-Related Research

Datasets of gigabyte size are common in medical sciences. There is increasing consensus that significant untapped knowledge lies hidden in these large datasets. This review article aims to discuss Electronic Health-Related Datasets (EHRDs) in terms of types, features, advantages, limitations, and possible use in nursing and health-related research. Major scientific databases, MEDLINE, ScienceDirect, and Scopus, were searched for studies or review articles regarding using EHRDs in research. A total number of 442 articles were located. After application of study inclusion criteria, 113 articles were included in the final review. EHRDs were categorized into Electronic Administrative Health-Related Datasets and Electronic Clinical Health-Related Datasets. Subcategories of each major category were identified. EHRDs are invaluable assets for nursing the health-related research. Advanced research skills such as using analytical softwares, advanced statistical procedures, dealing with missing data and missing variables will maximize the efficient utilization of EHRDs in research.

Assessment of quality in psychiatric nursing documentation - a clinical audit

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.

The relationship among evidence-based practice and client dyspnea, pain, falls, and pressure ulcer outcomes in the community setting

Background

There are gaps in knowledge about the extent to which home care nurses’ practice is based on best evidence and whether evidence-based practice impacts patient outcomes.

Aim

The purpose of this study was to investigate the relationship between evidence-based practice and client pain, dyspnea, falls, and pressure ulcer outcomes in the home care setting. Evidence-based practice was defined as nursing interventions based on best practice guidelines.

Methods

The Nursing Role Effectiveness model was used to guide the selection of variables for investigation. Data were collected from administrative records on percent of visits made by Registered Nurses (RN), total number of nursing visits, and consistency of visits by principal nurse. Charts audits were used to collect data on nursing interventions and client outcomes. The sample consisted of 338 nurses from 13 home care offices and 939 de-identified client charts. Hierarchical generalized linear regression approaches were constructed to explore which variables explain variation in client outcomes.

Results

The study found documentation of nursing interventions based on best practice guidelines was positively associated with improvement in dyspnea, pain, falls, and pressure ulcer outcomes. Percent of visits made by an RN and consistency of visits by a principal nurse were not found to be associated with improved client outcomes, but the total number of nursing visits was.

Linking Evidence to Action

Implementation of best practice is associated with improved client outcomes in the home care setting. Future research needs to explore ways to more effectively foster the documentation of evidence-based practice interventions.