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Morrison-Koechl J, Heckman G, Banerjee A, Keller H. Factors associated with dietitian referrals to support long-term care residents advancing towards the end of life. J Hum Nutr Diet 2024; 37:673-684. [PMID: 38446530 DOI: 10.1111/jhn.13294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Dietitians are central members of the multidisciplinary long-term care (LTC) healthcare team. The overall aim of this current investigation is to gain a better understanding of dietitian involvement in LTC resident's end-of-life care via referrals. METHODS Retrospective chart reviews for 164 deceased residents (mean age = 88.3 ± 7.3; 61% female) in 18 LTC homes in Ontario, Canada, identified dietitian referrals and documented eating challenges recorded over 2-week periods at four time points (i.e., 6 months, 3 months, 1 month and 2 weeks) prior to death. Nutrition care plans at the beginning of these time points were also noted. Logistic mixed effects regression models identified time-varying predictors of dietitian referrals. Bivariate tests identified associations between nutrition orders and dietitian referrals that occurred in the last month of life. RESULTS Nearly three-quarters (73%) of participants had at least one dietitian referral across the four observations. Referrals increased significantly with proximity to death; 45% of residents had a referral documented in the last 2 weeks of life. Dietitian referrals were associated with the number of eating challenges (odds ratio [OR] = 1.42, 95% confidence interval [CI] = 1.27, 1.58). Comfort-focused nutrition care orders were significantly more common when a dietitian was referred (25%) compared with when a dietitian was not referred (12%) in the final month of life (p = 0.04). CONCLUSIONS Our findings suggest that dietitians are involved in end-of-life and comfort-focused nutrition care initiatives, yet they are not engaged consistently for this purpose. This presents a significant opportunity for dietitians to upskill and champion palliative approaches to nutrition care within the multidisciplinary LTC team.
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Affiliation(s)
- Jill Morrison-Koechl
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - George Heckman
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
- School of Public Health Sciences, University of Waterloo, 200 University Avenue West, Waterloo, Ontario, Canada
| | - Albert Banerjee
- Department of Gerontology, St. Thomas University, Fredericton, New Brunswick, Canada
| | - Heather Keller
- Department of Kinesiology and Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
- Schlegel-UW Research Institute for Aging, Waterloo, Ontario, Canada
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Sung S, Kim Y, Kim SH, Jung H. Identification of Predictors for Clinical Deterioration in Patients With COVID-19 via Electronic Nursing Records: Retrospective Observational Study. J Med Internet Res 2024; 26:e53343. [PMID: 38414056 PMCID: PMC10984341 DOI: 10.2196/53343] [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: 10/03/2023] [Revised: 10/26/2023] [Accepted: 02/27/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Few studies have used standardized nursing records with Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) to identify predictors of clinical deterioration. OBJECTIVE This study aims to standardize the nursing documentation records of patients with COVID-19 using SNOMED CT and identify predictive factors of clinical deterioration in patients with COVID-19 via standardized nursing records. METHODS In this study, 57,558 nursing statements from 226 patients with COVID-19 were analyzed. Among these, 45,852 statements were from 207 patients in the stable (control) group and 11,706 from 19 patients in the exacerbated (case) group who were transferred to the intensive care unit within 7 days. The data were collected between December 2019 and June 2022. These nursing statements were standardized using the SNOMED CT International Edition released on November 30, 2022. The 260 unique nursing statements that accounted for the top 90% of 57,558 statements were selected as the mapping source and mapped into SNOMED CT concepts based on their meaning by 2 experts with more than 5 years of SNOMED CT mapping experience. To identify the main features of nursing statements associated with the exacerbation of patient condition, random forest algorithms were used, and optimal hyperparameters were selected for nursing problems or outcomes and nursing procedure-related statements. Additionally, logistic regression analysis was conducted to identify features that determine clinical deterioration in patients with COVID-19. RESULTS All nursing statements were semantically mapped to SNOMED CT concepts for "clinical finding," "situation with explicit context," and "procedure" hierarchies. The interrater reliability of the mapping results was 87.7%. The most important features calculated by random forest were "oxygen saturation below reference range," "dyspnea," "tachypnea," and "cough" in "clinical finding," and "oxygen therapy," "pulse oximetry monitoring," "temperature taking," "notification of physician," and "education about isolation for infection control" in "procedure." Among these, "dyspnea" and "inadequate food diet" in "clinical finding" increased clinical deterioration risk (dyspnea: odds ratio [OR] 5.99, 95% CI 2.25-20.29; inadequate food diet: OR 10.0, 95% CI 2.71-40.84), and "oxygen therapy" and "notification of physician" in "procedure" also increased the risk of clinical deterioration in patients with COVID-19 (oxygen therapy: OR 1.89, 95% CI 1.25-3.05; notification of physician: OR 1.72, 95% CI 1.02-2.97). CONCLUSIONS The study used SNOMED CT to express and standardize nursing statements. Further, it revealed the importance of standardized nursing records as predictive variables for clinical deterioration in patients.
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Affiliation(s)
- Sumi Sung
- Department of Nursing Science, Research Institute of Nursing Science, Chungbuk National University, Cheongju, Chungcheongbuk-do, Republic of Korea
| | - Youlim Kim
- Department of Radiation Oncology, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Su Hwan Kim
- Department of Information Statistics, Gyeongsang National University, Jinju, Gyeongsangnam-do, Republic of Korea
| | - Hyesil Jung
- Department of Nursing, College of Medicine, Inha University, Incheon, Republic of Korea
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Bueno M, Ballantyne M, Campbell‐Yeo M, Estabrooks C, Gibbins S, Harrison D, McNair C, Riahi S, Squires J, Synnes A, Taddio A, Victor C, Yamada J, Stevens B. A longitudinal observational study on the epidemiology of painful procedures and sucrose administration in hospitalized preterm neonates. PAEDIATRIC & NEONATAL PAIN 2024; 6:10-18. [PMID: 38504869 PMCID: PMC10946675 DOI: 10.1002/pne2.12114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 07/25/2023] [Accepted: 08/01/2023] [Indexed: 03/21/2024]
Abstract
Although sucrose is widely administered to hospitalized infants for single painful procedures, total sucrose volume during the entire neonatal intensive care unit (NICU) stay and associated adverse events are unknown. In a longitudinal observation study, we aimed to quantify and contextualize sucrose administration during the NICU stay. Specifically, we investigated the frequency, nature, and severity of painful procedures; proportion of procedures where neonates received sucrose; total volume of sucrose administered for painful procedures; and incidence and type of adverse events. Neonates <32 weeks gestational age at birth and <10 days of life were recruited from four Canadian tertiary NICUs. Daily chart reviews of documented painful procedures, sucrose administration, and any associated adverse events were undertaken. One hundred sixty-eight neonates underwent a total of 9093 skin-breaking procedures (mean 54.1 [±65.2] procedures/neonate or 1.1 [±0.9] procedures/day/neonate) during an average NICU stay of 45.9 (±31.4) days. Pain severity was recorded for 5399/9093 (59.4%) of the painful procedures; the majority (5051 [93.5%]) were heel lances of moderate pain intensity. Sucrose was administered for 7839/9093 (86.2%) of painful procedures. The total average sucrose volume was 5.5 (±5.4) mL/neonate or 0.11 (±0.08) mL/neonate/day. Infants experienced an average of 7.9 (±12.7) minor adverse events associated with pain and/or sucrose administration that resolved without intervention. The total number of painful procedures, sucrose volume, and incidence of adverse events throughout the NICU stay were described addressing an important knowledge gap in neonatal pain. These data provide a baseline for examining the association between total sucrose volume during NICU stay and research on longer-term behavioral and neurodevelopmental outcomes.
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Affiliation(s)
| | - Marilyn Ballantyne
- University of TorontoTorontoOntarioCanada
- Holland Bloorview Kids Rehabilitation HospitalTorontoOntarioCanada
| | - Marsha Campbell‐Yeo
- Dalhousie UniversityHalifaxNova ScotiaCanada
- IWK Health CentreHalifaxNova ScotiaCanada
| | | | | | - Denise Harrison
- University of MelbourneMelbourneVictoriaAustralia
- Murdoch Children's Research InstituteMelbourneVictoriaAustralia
- University of OttawaOttawaOntarioCanada
| | - Carol McNair
- The Hospital for Sick ChildrenTorontoOntarioCanada
| | | | | | - Anne Synnes
- University of British ColumbiaVancouverBritish ColumbiaCanada
| | - Anna Taddio
- The Hospital for Sick ChildrenTorontoOntarioCanada
- University of TorontoTorontoOntarioCanada
| | - Charles Victor
- University of TorontoTorontoOntarioCanada
- The Institute of Health PolicyManagement and EvaluationTorontoOntarioCanada
| | - Janet Yamada
- Toronto Metropolitan UniversityTorontoOntarioCanada
| | - Bonnie Stevens
- The Hospital for Sick ChildrenTorontoOntarioCanada
- University of TorontoTorontoOntarioCanada
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Guanter-Peris L, Alburquerque-Medina E, Solà-Pola M, Pla M. Towards a set of competencies in palliative care nursing in Spain: what's getting in the way of consensus? BMC Palliat Care 2024; 23:41. [PMID: 38350955 PMCID: PMC10865715 DOI: 10.1186/s12904-024-01359-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 01/18/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Spain currently lacks a competency framework for palliative care nursing. Having such a framework would help to advance this field in academic, governmental, and health management contexts. In phase I of a mixed-methods sequential study, we collected quantitative data, proposing 98 competencies to a sample of palliative care nurses. They accepted 62 of them and rejected 36. METHODS Phase II is a qualitative phase in which we used consensus techniques with two modified nominal groups to interpret the quantitative findings with the objective of understanding of why the 36 competencies had been rejected. Twenty nurses from different areas of palliative care (direct care, teaching, management, research) participated. We conducted a thematic analysis using NVivo12 to identify meaning units and group them into larger thematic categories. RESULTS Participants attributed the lack of consensus on the 36 competencies to four main reasons: the rejection of standardised nursing language, the context in which nurses carry out palliative care and other factors that are external to the care itself, the degree of specificity of the proposed competency (too little or too great), and the complexity of nursing care related to the end of life and/or death. CONCLUSIONS Based on the results, we propose reparative actions, such as reformulating the competencies expressed in nursing terminology to describe them as specific behaviours and insisting on the participation of nurses in developing institutional policies and strategies so that competencies related to development, leadership and professional commitment can be implemented. It is essential to promote greater consensus on the definition and levels of nursing intervention according to criteria of complexity and to advocate for adequate training, regulation, and accreditation of palliative care expert practice. Locally, understanding why the 36 competencies were rejected can help Spanish palliative care nurses reach a shared competency framework. More broadly, our consensus methodology and our findings regarding the causes for rejection may be useful to other countries that are in the process of formalising or reviewing their palliative care nursing model.
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Affiliation(s)
- Lourdes Guanter-Peris
- Catalan Institute of Oncology (ICO), Hospital Duran I Reynals, Avinguda de La Gran Via de L'Hospitalet,199-203, 08908, Barcelona, L'Hospitalet de Llobregat, Spain.
| | - Eulàlia Alburquerque-Medina
- Catalan Institute of Oncology (ICO), Hospital Duran I Reynals, Avinguda de La Gran Via de L'Hospitalet,199-203, 08908, Barcelona, L'Hospitalet de Llobregat, Spain
| | - Montserrat Solà-Pola
- Faculty of Nursing, University of Barcelona, S/N Feixa LLarga, Pavelló de Govern 3a Planta, 08907, Barcelona, L'Hospitalet de Llobregat, Spain
| | - Margarida Pla
- Faculty of Nursing, University of Barcelona, S/N Feixa LLarga, Pavelló de Govern 3a Planta, 08907, Barcelona, L'Hospitalet de Llobregat, Spain
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Sung S, Jung H, Kim Y. Exploring Nursing Care for Patients With COVID-19 Using International Classification for Nursing Practice-Based Nursing Records. Comput Inform Nurs 2024; 42:127-135. [PMID: 37579774 DOI: 10.1097/cin.0000000000001048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023]
Abstract
This study explored nursing care topics for patients with the coronavirus disease 2019 admitted to the wards and intensive care units using International Classification for Nursing Practice-based nursing narratives. A total of 256630 nursing statements from 555 adult patients admitted from December 2019 to June 2022 were extracted from the clinical data warehouse. The International Classification for Nursing Practice concepts mapped to 301 unique nursing statements that accounted for the top 90% of all cumulative nursing narratives were used for analysis. The standardized number of nursing statements for each concept was calculated according to the types of nursing care and compared between the two groups. The most documented topics were related to infection; physical symptoms such as sputum, cough, dyspnea, and shivering; and vital signs including blood oxygen saturation and body temperature. Nurses in the intensive care units frequently documented concepts related to the directly monitored and assessed physical signs such as consciousness, pupil reflex, and skin integrity, whereas nurses in wards documented more concepts related to symptoms patients complained. This study showed that the International Classification for Nursing Practice-based nursing records can be used as source of information to identify nursing care for patients with coronavirus disease 19.
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Affiliation(s)
- Sumi Sung
- Author Affiliations: Office of Hospital Information (Dr Sung, and Ms Kim) and Biomedical Research Institute (Dr Sung), Seoul National University Hospital, Seoul; and, Department of Nursing, Inha University, Incheon (Dr Jung), Republic of Korea
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Molla F, Temesgen WA, Kerie S, Endeshaw D. Nurses' Documentation Practice and Associated Factors in Eight Public Hospitals, Amhara Region, Ethiopia: A Cross-Sectional Study. SAGE Open Nurs 2024; 10:23779608241227403. [PMID: 38268952 PMCID: PMC10807310 DOI: 10.1177/23779608241227403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/12/2023] [Accepted: 01/02/2024] [Indexed: 01/26/2024] Open
Abstract
Background Nursing care documentation, which is the record of nursing care that is planned for and delivered to individual patients, can enhance patient outcomes while advancing the nursing profession. However, its practice and associated factors among Ethiopian nurses are not well investigated. Objective To assess the level of nursing care documentation practice and associated factors among nurses working at public hospitals in Ethiopia. Methods An institutional-based cross-sectional study was conducted from May 1 to 30, 2022. A total of 378 nurses and corresponding charts were randomly selected with a multistage sampling technique. Self-administered structured questionnaires and structured checklists were used to collect data about independent variables and nurses' documentation practice, respectively. Epi Data 4.6 was used for data entry and SPSS version 25 for analysis. Descriptive statistics and binary logistic regression analysis have been employed. The STROBE checklist was used to report the study. Results In this study, 372 nurses participated, and 30.4% (95% confidence interval [CI]: 26%-35%) of them had good nursing care documentation practice. Adequate knowledge about nursing care documentation(adjusted odds ratio [AOR] = 4.16, 95% CI: [2.36-7.33]), favorable attitude toward nursing care documentation (AOR = 3.43, 95% CI: [1.85-6.36]), adequacy of documenting sheets (AOR = 2.02, 95% CI: [1.14-3.59]), adequacy of time (AOR = 3.85, 95% CI: [2.11-7.05]), nurse-to-patient ratio (AOR = 2.78, 95% CI: [1.13-6.84]), and caring patients who had no stress, anxiety, pain, and distress (AOR = 3.56, 95% CI: [1.69-7.52]) were significantly associated with proper nursing care documentation practices. Conclusion Nursing documentation practice was poor in this study compared to the health sector transformation in quality standards due to the identified factors. Improving nurses' knowledge and attitude toward nursing care documentation and increasing access to documentation materials can contribute to improving documentation practice.
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Affiliation(s)
- Fitalew Molla
- Debark Hospital, Amhara Regional Health Bureau, Debark, Ethiopia
| | - Worku Animaw Temesgen
- Department of Adult Health Nursing, School of Health Sciences, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Sitotaw Kerie
- Department of Adult Health Nursing, School of Health Sciences, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Destaw Endeshaw
- Department of Adult Health Nursing, School of Health Sciences, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
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Llagostera-Reverter I, Luna-Aleixos D, Valero-Chillerón MJ, Martínez-Gonzálbez R, Mecho-Montoliu G, González-Chordá VM. Improving Nursing Assessment in Adult Hospitalization Units: A Secondary Analysis. NURSING REPORTS 2023; 13:1148-1159. [PMID: 37755342 PMCID: PMC10536114 DOI: 10.3390/nursrep13030099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/12/2023] [Accepted: 08/19/2023] [Indexed: 09/28/2023] Open
Abstract
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.
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Affiliation(s)
- Irene Llagostera-Reverter
- Nursing Research Group (GIENF Code 241), Nursing Department, Universitat Jaume I, 12071 Castellón, Spain; (I.L.-R.); (M.J.V.-C.)
| | - David Luna-Aleixos
- Nursing Research Group (GIENF Code 241), Nursing Department, Universitat Jaume I, 12071 Castellón, Spain; (I.L.-R.); (M.J.V.-C.)
- Hospital Universitario de La Plana, Vila-Real, 12520 Castellón, Spain; (R.M.-G.); (G.M.-M.)
| | - María Jesús Valero-Chillerón
- Nursing Research Group (GIENF Code 241), Nursing Department, Universitat Jaume I, 12071 Castellón, Spain; (I.L.-R.); (M.J.V.-C.)
| | | | - Gema Mecho-Montoliu
- Hospital Universitario de La Plana, Vila-Real, 12520 Castellón, Spain; (R.M.-G.); (G.M.-M.)
| | - Víctor M. González-Chordá
- Nursing Research Group (GIENF Code 241), Nursing Department, Universitat Jaume I, 12071 Castellón, Spain; (I.L.-R.); (M.J.V.-C.)
- Nursing and Healthcare Research Unit (INVESTÉN-ISCIII), Institute of Health Carlos III, 28029 Madrid, Spain
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Moridi A, Abedi P, Iravani M, Khosravi S, Alianmoghaddam N, Maraghi E, Saadati N. Development of a modified physiological birth programme integrated into Iran's health system and its effect on maternal and neonatal outcomes: an embedded mixed-methods study protocol. BMJ Open 2023; 13:e069609. [PMID: 37550027 PMCID: PMC10407369 DOI: 10.1136/bmjopen-2022-069609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 05/09/2023] [Indexed: 08/09/2023] Open
Abstract
INTRODUCTION As recommended by the WHO, promotion of physiological birth is a main strategy to reduce the rate of caesarean section and achieve Sustainable Development Goals. A modified version of the physiological birth programme that may be included into the Iranian healthcare system was developed as a result of this mixed-methods research. METHODS AND ANALYSIS This embedded mixed-methods study had a qualitative phase that was conducted before a clinical trial. This qualitative phase was conducted via semistructured in-depth targeted interviews with the recipients and the providers of physiological birth programme services. Data analysis was performed using a conventional content analysis approach. Then, for designing the intervention, national and international guidelines of physiological birth were reviewed, and a panel of experts was convened using the Delphi method. A randomised controlled trial was used in the second phase of the research to examine the impact of the physiological birth programme's intended intervention on maternal and neonatal outcomes as well as mothers' experiences during labour. It was conducted on 252 eligible pregnant women in two intervention and control groups. Finally, the results of qualitative and quantitative phases contributed to developing a physiological birth programme which can be integrated into the Iranian health system. ETHICS AND DISSEMINATION This study was approved by the Ethics Committee of Ahvaz Jundishapur University of Medical Sciences (IR.AJUMS.REC.1401.050). All participants gave their informed permission. The study's findings will be shared via the publishing of peer-reviewed articles, talks at scientific conferences and meetings with related teams. TRIAL REGISTRATION NUMBER Iranian Registry of Clinical Trials (IRCT20220406054438N1).
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Affiliation(s)
- Azam Moridi
- Department of Midwifery, Reproductive Health Promotion Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran (the Islamic Republic of)
| | - Parvin Abedi
- Department of Midwifery, Reproductive Health Promotion Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran (the Islamic Republic of)
| | - Mina Iravani
- Department of Midwifery, Reproductive Health Promotion Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran (the Islamic Republic of)
| | - Shahla Khosravi
- Department of Community Medicine, Faculty Member of Medicine School, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Narges Alianmoghaddam
- School of Public Health, Massey University College of Health, Palmerston North, New Zealand
| | - Elham Maraghi
- Department of Biostatistics and Epidemiology, Faculty of Public Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran (the Islamic Republic of)
| | - Najmieh Saadati
- Obstetrics and Gynecology, Fertility Infertility and Perinatology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran (the Islamic Republic of)
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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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Zhang W, Huang X, Huang T. Individualized Management of Quality of Care in Orthopedic Nurses Based on Sensitive Indicators. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2023; 2023:1950220. [PMID: 36860796 PMCID: PMC9970706 DOI: 10.1155/2023/1950220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/07/2022] [Accepted: 09/28/2022] [Indexed: 02/22/2023]
Abstract
Background Sensitive indicators of nursing quality focus on the core elements of nursing quality management. Nursing-sensitive quality indicators will play an increasingly important role in the macro and micro management of nursing quality in my country. Objective This study were aimed at formulating the sensitive index management of orthopedic nursing quality based on individual nurses for improvement of the quality of orthopedic nursing. Methods Based on the previous literature, the existing challenges in the early application of the orthopedic nursing quality evaluation index were summarized. Moreover, the management system of the orthopedic nursing quality-sensitive index based on individual nurses was devised and implemented, including monitoring the structure and result indices of individual nurses on duty and sampling the process indicators of patients managed by individual nurses. At the quarter-end, the data analysis was performed and fed back to determine the key points of the changes in the quality of specialized nursing affecting the individual, and the PDCA method was utilized for persistent improvement. The changes of sensitive indices of orthopedic nursing quality before (July-December 2018) and 6 months after implementation (July-December 2019) were compared. Results There were significant differences in other indices (accuracy of limb blood circulation assessment/accuracy of pain assessment/postural care pass rate/accuracy of rehabilitation behavioral training/satisfaction of discharged patients) (P < 0.05). Conclusion The formulation of an individual-based orthopedic nursing quality-sensitive index management system modifies the traditional quality management model, improves the specialized nursing level, contributes to the accurate core competence training of specialized nursing, and improves the quality of specialized nursing of individual nurses. Consequently, there is an overall improvement in the specialized nursing quality of the department, and fine management is attained.
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Affiliation(s)
- Weiling Zhang
- The First Affiliated Hospital, Sun Yat-sen University, China
| | - Xiaomin Huang
- The First Affiliated Hospital, Sun Yat-sen University, China
| | - Tianwen Huang
- The First Affiliated Hospital, Sun Yat-sen University, China
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Kassie SY, Demsash AW, Chereka AA, Damtie Y. Medical documentation practice and its association with knowledge, attitude, training, and availability of documentation guidelines in Ethiopia, 2022. A systematic review and meta-analysis. INFORMATICS IN MEDICINE UNLOCKED 2023. [DOI: 10.1016/j.imu.2023.101237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023] Open
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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: 0] [Impact Index Per Article: 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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Rossi L, Butler S, Coakley A, Flanagan J. Nursing knowledge captured in electronic health records. Int J Nurs Knowl 2023; 34:72-84. [PMID: 35570416 DOI: 10.1111/2047-3095.12365] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 02/26/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE The purpose of this study was to describe the extent to which nursing assessment data was present in the electronic health record and linked to NANDA-I, NIC, and NOC. METHODS This retrospective review used a descriptive approach to examine documentation in the electronic health records (EHR) of 10 hospitalized patients requiring cardiac surgery. A team of experts applied a Delphi consensus-building process to identify the supports and barriers for nursing documentation. FINDINGS Collection of the health history was organized using Gordon's Functional Health Pattern (FHP) Framework. Seventy-five fields were noted for the entry of nursing assessment data of which 65 focused on health history data and 30 documented physical findings and observations. There were no references to the defining characteristics or etiologies with any of the diagnostic labels used. Care plans included the nursing diagnoses, goals of care, and interventions, although there was a lack of clear alignment between the assessment, NANDA-I, NIC, and NOC and the care plan. Progress note documentation addressed significant events in the patient's clinical course; however, these were not nursing problem or diagnosis focused. Four expert reviewers arrived at consensus regarding the supports and challenges impacting nurses' ability to document data depicting nursing's contribution to care using a FHP and standardized nursing language in the EHR. CONCLUSIONS The EHR provides an opportunity to reflect nursing clinical judgment and make nursing care visible. These findings suggest there are challenges to capturing nurse focused data elements in the EHR. IMPLICATIONS FOR NURSING PRACTICE This work has important implications for clinicians, educators, and administrators alike. EHR systems must accurately capture nurses' contribution to patient care to plan for resource allocation and quality care delivery. Ultimately, the development of standardized data sources reflecting the outcomes of nursing care will expand the opportunities to advance nursing knowledge.
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Affiliation(s)
- Laura Rossi
- Simmons University Boston, Massachusetts, USA.,Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shawna Butler
- Massachusetts General Hospital, Boston, Massachusetts, USA.,University of Massachusetts, Boston, Massachusetts, USA
| | | | - Jane Flanagan
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Boston College, Chestnut Hill, Massachusetts, USA
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Al‐Adili L, Boström A, Orrevall Y, Lang NR, Peersen C, Persson I, Thoresen L, Lövestam E. Self‐reported documentation of goals and outcomes of nutrition care – A cross‐sectional survey study of Scandinavian dietitians. Scand J Caring Sci 2022; 37:472-485. [PMID: 36329640 DOI: 10.1111/scs.13131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 10/05/2022] [Accepted: 10/15/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The documentation of goals and outcomes of nutrition care in Electronic Health Records is insufficient making further exploration of this of particular interest. Identifying common features in documentation practice among Scandinavian dietitians might provide information that can support improvement in this area. AIMS To explore the associations between clinical dietitians' self-reported documentation of patients' goals and outcomes and demographic factors, self-reported implementation of the systematic framework the Nutrition Care Process 4th step (NCP) and its associated terminology, and factors associated with the workplace. METHODS Data from a cross-sectional study based on a previously tested web-based survey (INIS) disseminated in 2017 to dietitians in Scandinavia (n = 494) was used. Respondents were recruited through e-mail lists, e-newsletters and social media groups for dietitians. Associations between countries regarding the reported documentation of goals and outcomes, implementation levels of the NCP 4th step, demographic information and factors associated with the workplace were measured through Chi-square test. Associations between dependent- and independent variables were measured through logistic regression analysis. RESULTS Clinically practicing dietitians (n = 347) working in Scandinavia, Sweden (n = 249), Norway (n = 60), Denmark (n = 38), who had completed dietetic education participated. The reported documentation of goals and outcomes from nutrition intervention was highly associated with the reported implementation of NCP 4th step terminology (OR = 5.26; p = 0.009, OR = 3.56; p = 0.003), support from the workplace (OR = 4.0, p < 0.001, OR = 8.89, p < 0.001) and area of practice (OR = 2.02, p = 0.017). Years since completed dietetic training and educational level did not have any significant associations with documentation practice regarding goals and outcomes. CONCLUSION Findings highlight strong associations between the implementation of the NCP 4th step terminology and the documentation of goals and outcomes. Strategies to support dietitians in using standardized terminology and the development of tools for comprehensive documentation of evaluation of goals and outcome are required.
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Affiliation(s)
- Lina Al‐Adili
- Department of Food Studies, Nutrition and Dietetics Uppsala University Uppsala Sweden
| | - Anne‐Marie Boström
- Department of Neurobiology, Care Science and Society Division of Nursing, Karolinska Institutet Huddinge Sweden
- Theme Inflammation and Aging Karolinska University Hospital Huddinge Sweden
- Research and Development Unit Stockholms Sjukhem Stockholm Sweden
- Karolinska Institutet Huddinge Sweden
| | - Ylva Orrevall
- Department of Biosciences and Nutrition Karolinska Institute Stockholm Sweden
- Medical Unit Clinical Nutrition Women's Health and Allied Health Professionals Theme, Karolinska University Hospital Stockholm Sweden
| | - Nanna R. Lang
- Department of Nutrition and Health VIA University College Denmark
| | - Charlotte Peersen
- Department of Unit for Service and Intern Control Department of Service and Quality, Trondheim Municipality Trondheim Norway
| | - Inger Persson
- Department of Statistics Uppsala University Uppsala Sweden
| | - Lene Thoresen
- Cancer Clinic, St. Olavs Hospital Trondheim University Hospital Trondheim Norway
| | - Elin Lövestam
- Department of Food Studies, Nutrition and Dietetics Uppsala University Uppsala Sweden
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15
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Content Validity of the Omaha System Target Terms for Integrative Healthcare Interventions. Res Theory Nurs Pract 2022. [DOI: 10.1891/rtnp-2021-0089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background and Purpose: The objective of this study was to examine the content validity of the Omaha System to represent integrative healthcare (IH) interventions.Methods: A two-step classification procedure was used to validate Omaha System target terms that can represent IH interventions. Target terms were initially sorted based on evidence of use in IH interventions, including systematic reviews published in scientific journals and the Omaha System Guidelines website. Three Omaha System and integrative nursing content experts reviewed and validated target terms based on their definitions. Expert comments were reviewed and addressed, and final decisions were reached by consensus.Results: The content validity of Omaha System target terms was established for 49 of 75 (65.3%) target terms for IH interventions. These 49 targets were employed in 1145 of 1639 (69.9%) interventions in all Omaha System guidelines available online.Implications for Practice: A majority of Omaha System target terms may be used to represent IH interventions. Use of the Omaha System may facilitate efficient, structured, and thorough IH data collection to leverage informatics technology for supporting IH intervention clinical decisions, delivery, evaluation, and knowledge discovery.
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Ebnehoseini Z, Khorasani H, Moharari F, Ebrahimi AR, Boroujerdi M, Jamei F, Mehri MR, Tabesh H. A quantitative study on completeness rate of documentation in psychiatric medical records. Indian J Psychiatry 2022; 64:185-191. [PMID: 35494327 PMCID: PMC9045351 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_495_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 12/12/2021] [Accepted: 02/10/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Mental disorders are one of the leading causes of illness and disability worldwide. According to the World Health Organization (WHO), one in four people in the world will be affected by mental or neurological disorders during their lifetime. Regular evaluation of mental health outcomes plays an important role in making decisions about timely treatment of the patient. Studies show that a medical record does not provide enough information about the diagnosis, current symptoms, psychiatric medications, and side effects of current medications and treatments for ongoing health care. In this study, the completeness of paper-based psychiatric records was investigated. AIM The current study aimed to explore the completeness rate of paper-based psychiatric medical records (PMRs) and to investigate the factors effective on documentation status. SETTING The study was conducted in Ebnesina and Dr. Hejazi Psychiatric Hospital and Education Center. The case hospital is a psychiatric teaching hospital, which has 900 beds. MATERIALS AND METHODS The completeness rate of PMRs was determined using descriptive statistics. Fleiss' Kappa agreement and effective factors on PMRs' documentation status were assessed. RESULTS In total, 83.65% (n = 312) of the PMRs had at least one documentation defect. A significantly higher level of documentation completeness rate between different psychiatric wards was observed. CONCLUSION Based on our results, it is suggested to conduct regular evaluation and provide feedback to the health-care providers, and conduct training courses.
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Affiliation(s)
- Zahra Ebnehoseini
- Department of Medical Informatics, Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hediye Khorasani
- Department of Medical Informatics, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fatemeh Moharari
- Department of Psychiatry, Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Reza Ebrahimi
- Department of Psychiatry, Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Masoumeh Boroujerdi
- Department of Health Information Technology, Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fatemeh Jamei
- Department of Nursing, Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Reza Mehri
- Traditional Medicine Specialist, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hamed Tabesh
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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17
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Zare A, Kermanshahi SMK, Vanaki Z, Memarian R. Promoting Coronary Care Unit (CCU) Head Nurses’ Supervision Performance: Participatory Action Research. SYSTEMIC PRACTICE AND ACTION RESEARCH 2022. [DOI: 10.1007/s11213-021-09567-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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18
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Slyngstad L, Helgheim BI. How Do Different Health Record Systems Affect Home Health Care? A Cross-Sectional Study of Electronic- versus Manual Documentation System. Int J Gen Med 2022; 15:1945-1956. [PMID: 35237067 PMCID: PMC8882660 DOI: 10.2147/ijgm.s346366] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 01/20/2022] [Indexed: 11/23/2022] Open
Abstract
Objective To investigate electronic health record (EHR) systems compared to manual systems (MS) in home health care and how documentation and reporting activities are impacted regarding time use, variation, and accuracy. Methods This is a cross-sectional study of two municipalities (M1 and M2) that use statistical process control charts and interview with caregivers to discuss the issue. Regarding reporting, 309 observations were used for the control charts in M1 and 572 for those in M2. Concerning documentation, 831 observations were used for M1 and 572 for M2. In addition, interviews were conducted with four caregivers from each municipality. Results The municipality with EHR system use 3% of their total time for documentation and 7% for reporting. The municipality with the MS uses 7% of their total time in documentation and 12% for reporting. There is less variation in the charts for the municipality with the EHR system, than for the municipality using an MS. Conclusion The municipality using the EHR system uses less time for documentation and reporting than the other municipality. This is probably due to the standardization of information in M1, and that M2 needs to record documentation twice. The standardization arising from EHR use system may cause less variation in the process than the MS, but less variation might also negatively affect information accuracy. Reduced time for oral reporting also affects information accuracy.
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Affiliation(s)
- Line Slyngstad
- Department of Logistics, Molde University College, Molde, 6410, Norway
- Correspondence: Line Slyngstad, Department of Logistics, Molde University College, Molde, 6410, Norway, Tel +4741621248, Email
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De Groot K, De Veer AJE, Munster AM, Francke AL, Paans W. Nursing documentation and its relationship with perceived nursing workload: a mixed-methods study among community nurses. BMC Nurs 2022; 21:34. [PMID: 35090442 PMCID: PMC8795724 DOI: 10.1186/s12912-022-00811-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 01/13/2022] [Indexed: 11/10/2022] Open
Abstract
Background The time that nurses spent on documentation can be substantial and burdensome. To date it was unknown if documentation activities are related to the workload that nurses perceive. A distinction between clinical documentation and organizational documentation seems relevant. This study aims to gain insight into community nurses’ views on a potential relationship between their clinical and organizational documentation activities and their perceived nursing workload. Methods A convergent mixed-methods design was used. A quantitative survey was completed by 195 Dutch community nurses and a further 28 community nurses participated in qualitative focus groups. For the survey an online questionnaire was used. Descriptive statistics, Wilcoxon signed-ranked tests, Spearman’s rank correlations and Wilcoxon rank-sum tests were used to analyse the survey data. Next, four qualitative focus groups were conducted in an iterative process of data collection - data analysis - more data collection, until data saturation was reached. In the qualitative analysis, the six steps of thematic analysis were followed. Results The majority of the community nurses perceived a high workload due to documentation activities. Although survey data showed that nurses estimated that they spent twice as much time on clinical documentation as on organizational documentation, the workload they perceived from these two types of documentation was comparable. Focus-group participants found organizational documentation particularly redundant. Furthermore, the survey indicated that a perceived high workload was not related to actual time spent on clinical documentation, while actual time spent on organizational documentation was related to the perceived workload. In addition, the survey showed no associations between community nurses’ perceived workload and the user-friendliness of electronic health records. Yet focus-group participants did point towards the impact of limited user-friendliness on their perceived workload. Lastly, there was no association between the perceived workload and whether the nursing process was central in the electronic health records. Conclusions Community nurses often perceive a high workload due to clinical and organizational documentation activities. Decreasing the time nurses have to spend specifically on organizational documentation and improving the user-friendliness and intercommunicability of electronic health records appear to be important ways of reducing the workload that community nurses perceive.
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Muinga N, Abejirinde IOO, Benova L, Paton C, English M, Zweekhorst M. Implementing a comprehensive newborn monitoring chart: Barriers, enablers, and opportunities. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000624. [PMID: 36962452 PMCID: PMC10021603 DOI: 10.1371/journal.pgph.0000624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/20/2022] [Indexed: 11/19/2022]
Abstract
Documenting inpatient care is largely paper-based and it facilitates team communication and future care planning. However, studies show that nursing documentation remains suboptimal especially for newborns, necessitating introduction of standardised paper-based charts. We report on a process of implementing a comprehensive newborn monitoring chart and the perceptions of health workers in a network of hospitals in Kenya. The chart was launched virtually in July 2020 followed by learning meetings with nurses and the research team. This is a qualitative study involving document review, individual in-depth interviews with nurses and paediatricians and a focus group discussion with data clerks. The chart was co-designed by the research team and hospital staff then implemented using a trainer of trainers' model where the nurses-in-charge were trained on how to use the chart and they in turn trained their staff. Training at the hospital was delivered by the nurse-in-charge and/or paediatrician through a combined training with all staff or one-on-one training. The chart was well received with health workers reporting reduced writing, consolidated information, and improved communication as benefits. Implementation was facilitated by individual and team factors, complementary projects, and the removal of old charts. However, challenges arose related to the staff and work environment, inadequate supply of charts, alternative places to document, and inadequate equipment. The participants suggested that future implementation should be accompanied by mentorship or close follow-up, peer experience sharing, training at the hospital and in pre-service institutions and wider stakeholder engagement. Findings show that there are opportunities to improve the implementation process by clarifying roles relating to the filing system, improving the chart supply process, staff induction and specifying a newborn patient file. The chart did not meet the need for supporting documentation of long stay patients presenting an opportunity to explore digital solutions that might provide more flexibility and features.
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Affiliation(s)
- Naomi Muinga
- Athena Institute, VU University Amsterdam, Amsterdam, Netherlands
- KEMRI/Wellcome Trust Research Programme, Nairobi, Kenya
- Department of Public Health, Institute of Tropical Medicine, Sexual and Reproductive Health Group, Antwerp, Belgium
| | - Ibukun-Oluwa Omolade Abejirinde
- Athena Institute, VU University Amsterdam, Amsterdam, Netherlands
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Canada
| | - Lenka Benova
- Department of Public Health, Institute of Tropical Medicine, Sexual and Reproductive Health Group, Antwerp, Belgium
| | - Chris Paton
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, GB, England
- Department of Information Science, University of Otago, Dunedin, New Zealand
| | - Mike English
- KEMRI/Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, GB, England
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Kuha S, Niemelä K, Vähäkangas P, Noro A, Lotvonen S, Kanste O. Quality of care plans in long-term care facilities for the older persons-How well is information from RAI assessments utilised in care planning? Int J Older People Nurs 2021; 17:e12442. [PMID: 34927800 DOI: 10.1111/opn.12442] [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: 02/22/2021] [Revised: 11/02/2021] [Accepted: 12/04/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND In Finland, care plans at long-term care facilities (LTCF) for the older persons should be based on information from Resident Assessment Instrument (RAI) assessments and the principles of structured data. Hence, managers are responsible for ensuring that the RAI system is used to a satisfactory extent, the provided information is used in care planning, and that staff members are competent at composing high-quality care plans. AIM To explore the congruence between first-line managers' assessments of the extent to which care plans include RAI information and separately observed RAI-related contents of care plans. METHODS The study was based on a descriptive, cross-sectional survey of first-line managers (n = 15) from three LTCF organisations and a randomly selected sample of care plans (n = 45) from two LTCF organisations in Finland. Manager responses and analysis of care plans were reviewed at a general level. The data were gathered in 2019 and analysed using statistical methods and content analysis. RESULTS First-line managers' assessments of the extent to which their units' care plans included RAI information did not match the observed care plan contents. The care plan analysis revealed that managers significantly overestimated the extent to which care plans included RAI-related content. CONCLUSION Managers at LTCF organisations need more training to be able to sufficiently support their staff in using RAI information to draft high-quality care plans. IMPLICATION FOR PRACTICE Care plans must include a higher level of information related to RAI assessments. To develop competencies in drafting high-quality care plans, training related to RAI information utilisation on all aspects of the care plan should be emphasised and training should be provided to first-line managers and more broadly across the nursing staff.
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Affiliation(s)
- Suvi Kuha
- Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland
| | - Katriina Niemelä
- Raahe area Joint Authority for Health and Wellbeing, Raahe, Finland
| | | | - Anja Noro
- Aging, Disability and Functioning unit, Finnish Institute for Health and Welfare, Finland
| | - Sinikka Lotvonen
- Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland
| | - Outi Kanste
- Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland
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22
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Ting J, Garnett A, Donelle L. Nursing education and training on electronic health record systems: An integrative review. Nurse Educ Pract 2021; 55:103168. [PMID: 34411879 DOI: 10.1016/j.nepr.2021.103168] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 07/19/2021] [Accepted: 08/01/2021] [Indexed: 11/27/2022]
Abstract
AIM This integrative review aimed to synthesize evidence pertaining to interventions that have been used to facilitate nurse education and training on electronic health records. BACKGROUND Inadequate education and training can threaten the adoption of electronic health records and negatively impact the quality of nursing documentation. A review of the literature may help facilitate the development of evidence-based interventions for nursing education and training on electronic health records. DESIGN An integrative review framework was used to address the research question: What is the available evidence to inform best practices for nursing education and training on electronic health records? METHODS A systematic search was conducted in five databases: the Cumulative Index to Nursing and Allied Health Literature, Scopus, PubMed, CBCA Education, and ProQuest Education Database. Included articles were peer-reviewed studies, published in English, in which nurses participated in an electronic health record education or training intervention. RESULTS Fifteen articles, from a search conducted between 2010 and 2020, were reviewed. Findings identified a shift from classroom learning towards blended approaches for nursing education and training on electronic health records, incorporating methods such as e-learning, peer coaching, and simulation. Ongoing staff engagement is needed to develop interventions that allow nurses to integrate electronic health records into their daily workflows. Higher quality studies and more meaningful assessment of learning outcomes are needed to identify the most effective interventions to incorporate in blended learning strategies. CONCLUSIONS Consensus in the reviewed literature indicated that electronic health record education and training for nurses should be multipronged and targeted to nurses' clinical workflows. Key findings of this review identified a shift from classroom-based learning towards blended approaches for electronic health record education and training. Blended approaches often incorporated non-traditional methods that could support interactive and workflow-based content. These included e-learning, nurse superusers or peer coaches, and simulation training. The findings of this review also highlighted the need for early and ongoing involvement of frontline nurses during electronic health record education and implementation. However, more rigorous studies that assess both patient and organizational outcomes are needed to identify the most effective "cocktail" of blended learning strategies.
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Affiliation(s)
- Justine Ting
- FNB 2036, Arthur Labatt School of Nursing, Western University, London, Ontario N6A 5C1, Canada.
| | - Anna Garnett
- FNB 2036, Arthur Labatt School of Nursing, Western University, London, Ontario N6A 5C1, Canada.
| | - Lorie Donelle
- FNB 2036, Arthur Labatt School of Nursing, Western University, London, Ontario N6A 5C1, Canada.
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Saunders R, Seaman K, Glass C, Gullick K, Andrew J, Davray A. Improving the safety and quality of end-of-life in an Australian private hospital setting: An audit of documented end-of-life care. Australas J Ageing 2021; 40:449-456. [PMID: 34342382 DOI: 10.1111/ajag.12986] [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: 11/17/2020] [Revised: 06/20/2021] [Accepted: 07/05/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This study reviewed the audit outcomes of the documented end-of-life care in a private hospital against the Australian Commission on Safety and Quality in Health Care's five recommended processes of care (Essential Elements (EE) 1-5). METHODS A retrospective database review of deaths over a three-year period was undertaken. This was followed by a sequential medical record audit (n = 100) to evaluate the end-of-life care documented in the three days preceding death. RESULTS There were 997 deaths from 2015 to 2017. The audit found communication to family the patient was dying (91%) and to the patient (36%) (EE1); evidence of specialist referral (68%) (EE2); assessment of the ability to eat/drink in the last 72 hours (86%) (EE3); advance care directives (13%) and hospital resuscitation plans (92%) (EE4); and response to patient or family concerns (100%) (EE5). CONCLUSIONS Components of the processes of care of the Essential Elements need to be addressed to improve patient-centred communication and shared decision-making.
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Affiliation(s)
- Rosemary Saunders
- Centre for Research in Aged Care, School of Nursing and Midwifery, Edith Cowan University, Joondalup, WA, Australia
| | - Karla Seaman
- Centre for Research in Aged Care, School of Nursing and Midwifery, Edith Cowan University, Joondalup, WA, Australia
| | - Courtney Glass
- Centre for Research in Aged Care, School of Nursing and Midwifery, Edith Cowan University, Joondalup, WA, Australia
| | | | - Julie Andrew
- Hollywood Private Hospital, Nedlands, WA, Australia
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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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Austin RR, Lu SC, Geiger-Simpson E, Ringdahl D, Pruinelli L, Lindquist R, Koithan M, Monsen KA, Kreitzer MJ, Delaney CW. Evaluating Systemized Nomenclature of Medicine Clinical Terms Coverage of Complementary and Integrative Health Therapy Approaches Used Within Integrative Nursing, Health, and Medicine. Comput Inform Nurs 2021; 39:1000-1006. [PMID: 34074871 DOI: 10.1097/cin.0000000000000764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The use of complementary and integrative health therapy strategies for a wide variety of health conditions is increasing and is rapidly becoming mainstream. However, little is known about how or if complementary and integrative health therapies are represented in the EHR. Standardized terminologies provide an organizing structure for health information that enable EHR representation and support shareable and comparable data; which may contribute to increased understanding of which therapies are being used for whom and for what purposes. Use of standardized terminologies is recommended for interoperable clinical data to support sharable, comparable data to enable the use of complementary and integrative health therapies and to enable research on outcomes. In this study, complementary and integrative health therapy terms were extracted from multiple sources and organized using the National Center for Complementary and Integrative Health and former National Center for Complementary and Alternative Medicine classification structures. A total of 1209 complementary and integrative health therapy terms were extracted. After removing duplicates, the final term list was generated via expert consensus. The final list included 578 terms, and these terms were mapped to Systemized Nomenclature of Medicine Clinical Terms. Of the 578, approximately half (48.1%) were found within Systemized Nomenclature of Medicine Clinical Terms. Levels of specificity of terms differed between National Center for Complementary and Integrative Health and National Center for Complementary and Alternative Medicine classification structures and Systemized Nomenclature of Medicine Clinical Terms. Future studies should focus on the terms not mapped to Systemized Nomenclature of Medicine Clinical Terms (51.9%), to formally submit terms for inclusion in Systemized Nomenclature of Medicine Clinical Terms, toward leveraging the data generated by use of these terms to determine associations among treatments and outcomes.
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Affiliation(s)
- Robin R Austin
- Author Affiliations: School of Nursing (Dr Austin, Mr Lu, and Drs Geiger-Simpson, Ringdahl, Pruinelli, Lindquist, Monsen, and Delaney) and Earl E. Bakken Center for Spiritualty and Healing (Drs Austin, Ringdahl, Lindquist, and Monsen), University of Minnesota, Minneapolis; and College of Nursing, University of Arizona, Tucson (Dr Koithan)
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Oliveira NBD, Peres HHC. Quality of the documentation of the Nursing process in clinical decision support systems. Rev Lat Am Enfermagem 2021; 29:e3426. [PMID: 34037121 PMCID: PMC8139382 DOI: 10.1590/1518-8345.4510.3426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/27/2020] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE to compare the quality of the Nursing process documentation in two versions of a clinical decision support system. METHOD a quantitative and quasi-experimental study of the before-and-after type. The instrument used to measure the quality of the records was the Brazilian version of the Quality of Diagnoses, Interventions and Outcomes, which has four domains and a maximum score of 58 points. A total of 81 records were evaluated in version I (pre-intervention), as well as 58 records in version II (post-intervention), and the scores obtained in the two applications were compared. The interventions consisted of planning, pilot implementation of version II of the system, training and monitoring of users. The data were analyzed in the R software, using descriptive and inferential statistics. RESULTS the mean obtained at the pre-intervention moment was 38.24 and, after the intervention, 46.35 points. There was evidence of statistical difference between the means of the pre- and post-intervention groups, since the p-value was below 0.001 in the four domains evaluated. CONCLUSION the quality of the documentation of the Nursing process in version II of the system was superior to version I. The efficacy of the system and the effectiveness of the interventions were verified. This study can contribute to the quality of documentation, care management, visibility of nursing actions and patient safety.
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Affiliation(s)
- Neurilene Batista de Oliveira
- Universidade de São Paulo, Hospital Universitário, São Paulo, SP, Brazil.,Universidade de São Paulo, Escola de Enfermagem, São Paulo, SP, Brazil
| | - Heloísa Helena Ciqueto Peres
- Universidade de São Paulo, Hospital Universitário, São Paulo, SP, Brazil.,Universidade de São Paulo, Escola de Enfermagem, São Paulo, SP, Brazil
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Rommerskirch-Manietta M, Roes M, Palm R, Albers B, Müller-Widmer R, Stacke TI, Bergmann JM, Manietta C, Purwins D. [Preferences for everyday living written in the nursing record - An explorative document analysis in various nursing settings]. Pflege 2021; 34:191-202. [PMID: 33971724 DOI: 10.1024/1012-5302/a000811] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Preferences for everyday living written in the nursing record - An explorative document analysis in various nursing settings Abstract. Background: In Germany, there was previously no instrument for the systematic recording of preferences for the everyday living of older and people in need of care. Subsequently, in a pilot study, an instrument was translated in a culturally sensitive way (PELI-D), piloted and tested psychometrically. In terms of documentation quality, it is important that the preferences recorded by nursing staff are written down in the nursing record using PELI-D, plausibly based on the nursing process. AIM To find out which preferences, assessed by the nursing staff in the pilot study with the PELI-D, were written down in the nursing record. METHODS An exploratory document analysis was carried out. Included were 13 nursing records and five discussion participants from five institutions in three nursing settings. The data were evaluated descriptively and by a structuring content analysis. RESULTS A total of 2% of the preferences, which were assessed with the PELI-D, were found in the nursing records and may be due to the use of PELI-D. Preferences mainly from the categories "interventions" and "biography" were found in the nursing record. CONCLUSIONS 98% of the preferences assessed with the PELI-D were not written down. This can probably be attributed to the fact that the PELI-D was an "innovation" for the nursing staff. Therefore, the execution of an implementation study seems to be reasonable to improve the plausibility of the captured PELI-D data in the nursing documentation. In the context of this, it is also recommended to analyze how the PELI-D influences nursing processes and contents of the nursing record.
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Affiliation(s)
- Mike Rommerskirch-Manietta
- Deutsches Zentrum für Neurodegenerative Erkrankungen e.V., Department für Pflegewissenschaft, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten
| | - Martina Roes
- Deutsches Zentrum für Neurodegenerative Erkrankungen e.V., Department für Pflegewissenschaft, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten
| | - Rebecca Palm
- Deutsches Zentrum für Neurodegenerative Erkrankungen e.V., Department für Pflegewissenschaft, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten
| | - Bernd Albers
- Deutsches Zentrum für Neurodegenerative Erkrankungen e.V., Department für Pflegewissenschaft, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten
| | - René Müller-Widmer
- Deutsches Zentrum für Neurodegenerative Erkrankungen e.V., Department für Pflegewissenschaft, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten
| | - Tobias Ingo Stacke
- Deutsches Zentrum für Neurodegenerative Erkrankungen e.V., Department für Pflegewissenschaft, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten
| | - Johannes Michael Bergmann
- Deutsches Zentrum für Neurodegenerative Erkrankungen e.V., Department für Pflegewissenschaft, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten
| | - Christina Manietta
- Deutsches Zentrum für Neurodegenerative Erkrankungen e.V., Department für Pflegewissenschaft, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten
| | - Daniel Purwins
- Deutsches Zentrum für Neurodegenerative Erkrankungen e.V., Department für Pflegewissenschaft, Fakultät für Gesundheit, Universität Witten/Herdecke, Witten
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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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Aleandri M, Scalorbi S, Pirazzini MC. Electronic nursing care plans through the use of NANDA, NOC, and NIC taxonomies in community setting: A descriptive study in northern Italy. Int J Nurs Knowl 2021; 33:72-80. [PMID: 33960713 PMCID: PMC9290471 DOI: 10.1111/2047-3095.12326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/02/2021] [Accepted: 04/10/2021] [Indexed: 11/29/2022]
Abstract
Purpose To carry on a descriptive analysis of nursing standardized language through the use of a software within outpatient facilities in northern Italy, organized according to the Chronic Care Model (CCM) and called Community Health Centers (CHC). Methods A descriptive design was adopted for the study. NANDA‐I, NOC, and NIC taxonomies have been used to analyze care plans pulled from the software. Both qualitative and quantitative data were analyzed. Findings The average of nursing diagnosis correctly identified with respect to the nursing assessment is 83.7% (SD 29.9%). Class 4 diagnoses from Domains 4 have been identified as the most prevalent (22.4%), followed by risk for unstable blood glucose level 00179 (16.4%) and risk for overweight 00234 (13%). The main nursing outcomes were vital signs 0802 (22.5%), blood glucose level 2300 (16%), and weight loss behavior 1627 (11%). The most prevalent nursing interventions are wound care 3660 (27%), medication administration: intramuscular 2313 (19%), and health education 5510 (14%). The analysis shows ability in identifying nursing diagnoses, but a larger variability with outcomes and interventions. The study highlights the nursing role within CHC and identifies the main areas of expertise in chronic disease management: prevention and health education. Conclusions Nurses’ role is fundamental for chronic disease management within CHC; NANDA‐I taxonomy helps to analyze care plans. Implications for nursing practice ‐ A taxonomy such as NANDA‐I represents a valid opportunity to make more visible how much nursing skills affect the achievement of a higher level of health in chronic patients. ‐ This study is useful in the further training of outpatient nurses who works in CHC. ‐ The study represents the starting point for future research to deepen the development of a standardized nursing language in outpatient facilities.
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De Groot K, Sneep EB, Paans W, Francke AL. Patient participation in electronic nursing documentation: an interview study among community nurses. BMC Nurs 2021; 20:72. [PMID: 33933079 PMCID: PMC8088564 DOI: 10.1186/s12912-021-00590-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 04/22/2021] [Indexed: 11/10/2022] Open
Abstract
Background Patient participation in nursing documentation has several benefits like including patients’ personal wishes in tailor-made care plans and facilitating shared decision-making. However, the rise of electronic health records may not automatically lead to greater patient participation in nursing documentation. This study aims to gain insight into community nurses’ experiences regarding patient participation in electronic nursing documentation, and to explore the challenges nurses face and the strategies they use for dealing with challenges regarding patient participation in electronic nursing documentation. Methods A qualitative descriptive design was used, based on the principles of reflexive thematic analysis. Nineteen community nurses working in home care and using electronic health records were recruited using purposive sampling. Interviews guided by an interview guide were conducted face-to-face or by phone in 2019. The interviews were inductively analysed in an iterative process of data collection–data analysis–more data collection until data saturation was achieved. The steps of thematic analysis were followed, namely familiarization with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and reporting. Results Community nurses believed patient participation in nursing documentation has to be tailored to each patient. Actual participation depended on the phase of the nursing process that was being documented and was facilitated by patients’ trust in the accuracy of the documentation. Nurses came across challenges in three domains: those related to electronic health records (i.e. technical problems), to work (e.g. time pressure) and to the patients (e.g. the medical condition). Because of these challenges, nurses frequently did the documentation outside the patient’s home. Nurses still tried to achieve patient participation by verbally discussing patients’ views on the nursing care provided and then documenting those views at a later moment. Conclusions Although community nurses consider patient participation in electronic nursing documentation important, they perceive various challenges relating to electronic health records, work and the patients to realize patient participation. In dealing with these challenges, nurses often fall back on verbal communication about the documentation. These insights can help nurses and policy makers improve electronic health records and develop efficient strategies for improving patient participation in electronic nursing documentation.
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Affiliation(s)
- Kim De Groot
- Netherlands Institute for Health Services Research (Nivel), PO Box 1568, 3513 CR, Utrecht, The Netherlands.
| | - Elisah B Sneep
- Nursing Science, Programme in Clinical Health Sciences, University Medical Centre Utrecht, Utrecht University, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Wolter Paans
- Research Group Nursing Diagnostics, School of Nursing, Hanze University of Applied Sciences, Petrus Driessenstraat 3, 9714 CA, Groningen, The Netherlands.,Department of Critical Care, University Medical Centre Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Anneke L Francke
- Netherlands Institute for Health Services Research (Nivel), PO Box 1568, 3513 CR, Utrecht, The Netherlands.,Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
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van Driel AG, Becqué Y, Rietjens JAC, van der Heide A, Witkamp FE. Supportive nursing care for family caregivers - A retrospective nursing file study. Appl Nurs Res 2021; 59:151434. [PMID: 33947507 DOI: 10.1016/j.apnr.2021.151434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 04/01/2021] [Accepted: 04/10/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Family caregivers enable patients to be cared for and die at home whereas nurses aim to support the family caregivers of these patients. Information on how this support is provided and how this is documented in nursing files is largely lacking. AIM To gain insight in nurses' reports on the supportive care for family caregivers. METHODS We studied 59 nursing files of adult patients who had received hospice home care in the Netherlands from 4 home care organisations between August 2017 and October 2018. Information on supportive nursing care for family caregivers was retrieved from the nursing files based on a prestructured form. Data was quantitatively and qualitatively analysed. RESULTS 54 out of 59 nursing files contained information about family caregivers; 40 files contained nursing diagnoses on family caregivers and in 26 files nursing interventions on supportive care for family caregivers were reported. CONCLUSION Only half of the nursing files contained information about supportive nursing care for family caregivers. Complete nursing documentation of provided care to family caregivers is needed.
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Affiliation(s)
- Anne Geert van Driel
- Research Centre Innovations in Care, Rotterdam University of Applied Sciences, P.O. Box 25035, 3001, HA, Rotterdam, the Netherlands.
| | - Yvonne Becqué
- Research Centre Innovations in Care, Rotterdam University of Applied Sciences, P.O. Box 25035, 3001, HA, Rotterdam, the Netherlands.
| | - Judith A C Rietjens
- Department of Public Health, Erasmus MC, Erasmus University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands.
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, Erasmus University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands.
| | - Frederika E Witkamp
- Research Centre Innovations in Care, Rotterdam University of Applied Sciences, P.O. Box 25035, 3001, HA, Rotterdam, the Netherlands; Department of Public Health, Erasmus MC, Erasmus University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, the Netherlands.
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Brooks N. How to undertake effective record-keeping and documentation. Nurs Stand 2021; 36:31-33. [PMID: 33719232 DOI: 10.7748/ns.2021.e11700] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 11/09/2022]
Abstract
RATIONALE AND KEY POINTS Effective record-keeping and documentation is an essential element of all healthcare professionals' roles, including nurses, and can support the provision of safe, high-quality patient care. This article explains the importance of record-keeping and documentation in nursing and healthcare, and outlines the principles for maintaining clear and accurate patient records. REFLECTIVE ACTIVITY: 'How to' articles can help to update your practice and ensure it remains evidence-based. Apply this article to your practice. Reflect on and write a short account of.
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Affiliation(s)
- Nicola Brooks
- Faculty of Health and Life Sciences, De Montfort University, Leicester, England
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Fennelly O, Grogan L, Reed A, Hardiker NR. Use of standardized terminologies in clinical practice: A scoping review. Int J Med Inform 2021; 149:104431. [PMID: 33713915 DOI: 10.1016/j.ijmedinf.2021.104431] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/20/2021] [Accepted: 02/19/2021] [Indexed: 12/13/2022]
Abstract
AIM To explore the use and impact of standardized terminologies (STs) within nursing and midwifery practice. INTRODUCTION The standardization of clinical documentation creates a potential to optimize patient care and safety. Nurses and midwives, who represent the largest proportion of the healthcare workforce worldwide, have been using nursing-specific and multidisciplinary STs within electronic health records (EHRs) for decades. However, little is known regarding ST use and impact within clinical practice. METHODS A scoping review of the literature was conducted (2019) across PubMed, CINAHL, Embase and CENTRAL in collaboration with the Five Country Nursing and Midwifery Digital Leadership Group (DLG). Identified studies (n = 3547) were reviewed against a number of agreed criterion, and data were extracted from included studies. Studies were categorized and findings were reviewed by the DLG. RESULTS One hundred and eighty three studies met the inclusion criteria. These were conducted across 25 different countries and in various healthcare settings, utilising mainly nursing-specific (most commonly NANDA-I, NIC, NOC and the Omaha System) and less frequently local, multidisciplinary or medical STs (e.g., ICD). Within the studies, STs were evaluated in terms of Measurement properties, Usability, Documentation quality, Patient care, Knowledge generation, and Education (pre and post registration). As well as the ST content, the impact of the ST on practice depended on the healthcare setting, patient cohort, nursing experience, provision of education and support in using the ST, and usability of EHRs. CONCLUSION Employment of STs in clinical practice has the capability to improve communication, quality of care and interoperability, as well as facilitate value-based healthcare and knowledge generation. However, employment of several different STs and study heterogeneity renders it difficult to aggregate and generalize findings.
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Affiliation(s)
- Orna Fennelly
- Insight Centre for Data Analytics, University College Dublin, Ireland; School of Public Health, Physiotherapy and Sports Science, University College Dublin, Ireland.
| | - Loretto Grogan
- Office of the Nursing and Midwifery Services Director, Health Service Executive (HSE), Ireland.
| | - Angela Reed
- Northern Ireland Practice & Education Council for Nursing and Midwifery, Northern Ireland.
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Do HTT, Edwards H, Finlayson K. Postoperative wound assessment documentation and acute care nurses' perception of factors impacting wound documentation: A mixed methods study. Int J Clin Pract 2021; 75:e13668. [PMID: 32772448 DOI: 10.1111/ijcp.13668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 08/06/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Wound care documentation is an essential component of best practice wound management in order to enhance inter-disciplinary communication and patient care. However, evidence suggests that wound care documentation is often carried out poorly and sporadically. OBJECTIVES Determine postoperative wound assessment documentation by acute care nurses and explore their perception of factors constraining adequate nursing documentation. METHODS A two-phase sequential exploratory mixed methods design was used. Phase one: A retrospective clinical chart audit of nurses' documentation was undertaken. A random selection of 200 medical records were reviewed over 3 months at a provincial hospital in Vietnam. Phase two: semi-structured interviews were conducted with 13 surgical nurses to explore their perceptions of factors influencing appropriate documentation. Inductive qualitative content analysis was applied for qualitative data. This manuscript adheres to COREQ guidelines for reporting the qualitative phase. FINDINGS Phase one: 200 records were audited. Less than 10% of preoperative factors (such as co-morbidities, smoking and nutrition status) related to the risk of delayed wound healing were documented. During the first 5 days postoperation, there was no documentation about incision location, wound dimension, wound bed (in wounds healing by secondary intention) or odour. In less than 10% colour and type of exudate were recorded. Phase two: Emerging key categories were: unimportance of nursing documentation, difficulty to change existing practice, and personal factors. CONCLUSION This study indicated that surgical wound assessment documentation was insufficient and inconsistent among nurses. Nurses viewed the wound assessment documentation as unimportant. Therefore, extensive exploration of strategies is required to enhance the quality of wound assessment documentation.
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Affiliation(s)
- Hien Thi Thu Do
- Nursing Faculty, Haiduong Medical Technical University, Haiduong, Vietnam
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Helen Edwards
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Kathleen Finlayson
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
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Wiebe N, Otero Varela L, Niven DJ, Ronksley PE, Iragorri N, Quan H. Evaluation of interventions to improve inpatient hospital documentation within electronic health records: a systematic review. J Am Med Inform Assoc 2021; 26:1389-1400. [PMID: 31365092 DOI: 10.1093/jamia/ocz081] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 04/14/2019] [Accepted: 05/04/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Despite the widespread and increasing use of electronic health records (EHRs), the quality of EHRs is problematic. Efforts have been made to address reasons for poor EHR documentation quality. Previous systematic reviews have assessed intervention effectiveness within the outpatient setting or paper documentation. The purpose of this systematic review was to assess the effectiveness of interventions seeking to improve EHR documentation within an inpatient setting. MATERIALS AND METHODS A search strategy was developed based on elaborated inclusion/exclusion criteria. Four databases, gray literature, and reference lists were searched. A REDCap data capture form was used for data extraction, and study quality was assessed using a customized tool. Data were analyzed and synthesized in a narrative, semiquantitative manner. RESULTS Twenty-four studies were included in this systematic review. Owing to high heterogeneity, quantitative comparison was not possible. However, statistically significant results in interventions and affected outcomes were analyzed and discussed. Education and implementation of a new EHR reporting system were the most successful interventions, as evidenced by significantly improved EHR documentation. DISCUSSION Heterogeneity of interventions, outcomes, document type, EHR user, and other variables led to difficulty in measuring EHR documentation quality and effectiveness of interventions. However, the use of education as a primary intervention aligned closely with existing literature in similar fields. CONCLUSIONS Interventions implemented to enhance EHR documentation are highly variable and require standardization. Emphasis should be placed on this novel area of research to improve communication between healthcare providers and facilitate data sharing between centers and countries. PROSPERO Registration Number: CRD42017083494.
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Affiliation(s)
- Natalie Wiebe
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Lucia Otero Varela
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Daniel J Niven
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Paul E Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Nicolas Iragorri
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Hude Quan
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Rios Jimenez AM, Artigas Lage M, Sancho Gómez M, Blanco Aguilar C, Acedo Anta M, Calvet Tort G, Hermosilla Perez E, Adamuz-Tomás J, Juvé-Udina ME. [Standardized nursing languages and care plans. Perception of use and utility in primary healthcare]. Aten Primaria 2020; 52:750-758. [PMID: 32417166 PMCID: PMC8054280 DOI: 10.1016/j.aprim.2019.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 07/24/2019] [Accepted: 10/21/2019] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To identify opinions of Primary Healthcare nurses on the use and usefulness of standardised nursing care plans and traditional nursing language systems in the practice settings. DESIGN Multicentre, observational, cross-sectional study. SETTING Primary Healthcare centres in Catalonia. PARTICIPANTS Sample size was estimated at 1,668 registered nurses. Consecutive sampling was applied. INTERVENTIONS On-line survey containing questions on ease, usefulness, and use of nursing care plans and standardised nursing language systems. MEASUREMENTS Descriptive statistics, including percentages, central tendency, and dispersion measures. Statistical significance was set at P≤.05. RESULTS The final analysis included 1,813 questionnaires. Participants stated that care plans have a medium added value, however their use is frequently incorrect. They stated to have a fair level of knowledge on traditional standardised nursing languages, and most were of the opinion that these languages are difficult to use in practice (81%) and not useful to represent nursing care provision and its outcomes (78%). Regardless of their education level and years of experience, the participants assessed as insufficient the clarity (P=.058), ease of use (P=.240), and usefulness (P=.039) of these language systems in practice. CONCLUSIONS Nurses say that urgent changes are required in the use of care plans. This includes changing the language systems, and improving data and information that positively impacts on the provision of nursing care, as well as to enhance the health outcomes of the individuals receiving Primary Healthcare services.
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Affiliation(s)
| | | | - Marta Sancho Gómez
- Dirección de Atención Primaria Metropolitana Sud, Institut Català de la Salut, L’Hospitalet de Llobregat, Barcelona, España
| | - Carmen Blanco Aguilar
- Dirección de Atención Primaria Metropolitana Nord, Institut Català de la Salut, Sabadell, Barcelona, España
| | - Mateo Acedo Anta
- Dirección de Atención Primaria Metropolitana Sud, Institut Català de la Salut, L’Hospitalet de Llobregat, Barcelona, España
| | - Gemma Calvet Tort
- Dirección de Cuidados, Institut Català de la Salut, Barcelona, España
| | - Eduardo Hermosilla Perez
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, España
| | - Jordi Adamuz-Tomás
- Instituto de Investigación Biomédica de Bellvitge (IDIBELL) , L’Hospitalet de Llobregat, Barcelona, España,Escuela Universitaria de Enfermería, Facultad de Medicina y Ciencias de la Salud, Universidad de Barcelona, Barcelona, España
| | - Maria-Eulàlia Juvé-Udina
- Dirección de Cuidados, Institut Català de la Salut, Barcelona, España,Instituto de Investigación Biomédica de Bellvitge (IDIBELL) , L’Hospitalet de Llobregat, Barcelona, España,Escuela Universitaria de Enfermería, Facultad de Medicina y Ciencias de la Salud, Universidad de Barcelona, Barcelona, España
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Olsson M, Friman A. Quality of life of patients with hard-to-heal leg ulcers: a review of nursing documentation. Br J Community Nurs 2020; 25:S13-S19. [PMID: 33300847 DOI: 10.12968/bjcn.2020.25.sup12.s12] [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: 11/11/2022]
Abstract
People with hard-to-heal leg ulcers experience reduced quality of life (QoL), including physical, mental and social aspects; this, in turn, negatively affects the wound healing process. QoL is often overlooked by health professionals treating those with hard-to-heal wounds, for whom the focus is instead on the wound itself and the healing process. This study aimed to investigate how the QoL of patients with hard-to-heal wounds is documented and followed up by nurses. The healthcare records of patients with hard-to-heal wounds were reviewed using an audit instrument. Data were collected retrospectively from 12 patient healthcare records. The nursing documentation included few notes related to patients' QoL. The nurses focused on issues such as nutrition, mobilisation and smoking, while the patients expressed concerns about anxiety/depressed mood, pain and sleeping difficulties. Only nine of the documented problems were approved according to the instrument. Most importantly, documentation of planned interventions and outcomes was missing. Documentation by nurses around the QoL of patients with hard-to-heal wounds is lacking, because of which QoL might be neglected and wound healing might not progress well.
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Affiliation(s)
- Malin Olsson
- Malin Olsson, Head Nurse, Rinkeby Healthcare Center, Sweden
| | - Anne Friman
- Anne Friman, Lecturer in Nursing, Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institute
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Khan MA, Nilima N, Prathibha J, Tiwary B, Singh M. Documentation compliance of in-patient files: A cross sectional study from an east India state. CLINICAL EPIDEMIOLOGY AND GLOBAL HEALTH 2020. [DOI: 10.1016/j.cegh.2020.03.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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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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Østensen E, Hardiker NR, Bragstad LK, Hellesø R. Introducing standardised care plans as a new recording tool in municipal health care. J Clin Nurs 2020; 29:3286-3297. [PMID: 32472572 DOI: 10.1111/jocn.15355] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/07/2020] [Accepted: 05/09/2020] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To explore how nurses use standardised care plans as a new recording tool in municipal health care, and to identify their thoughts and opinions. BACKGROUND In spite of being an important information source for nurses, care plans have repeatedly been found unsatisfactory. Structuring and coding information through standardised care plans is expected to raise the quality of recorded information, improve overviews, support evidence-based practice and facilitate data aggregation. Previous research on this topic has mostly focused on the hospital setting. There is a lack of knowledge on how standardised care plans are used as a recording tool in the municipal healthcare setting. DESIGN An exploratory design with a qualitative approach using three qualitative methods of data collection. The study complied with the Consolidated Criteria for Reporting Qualitative Research. METHODS Empirical data were collected in three Norwegian municipalities through participant observation and individual interviews with 17 registered nurses. In addition, we collected nursing records from 20 electronic patient records. RESULTS Use of standardised care plans was influenced by the nurses' consideration of their benefits. Partial implementation created an opportunity for nonuse. There was no consensus regarding how much information to include, and the standardised care plans could become both short and generic, and long and comprehensive. The themes "balancing between the old and the new care planning system," "considering the usefulness of standardised care plans as a source of information" and "balancing between overview and detail" reflect these findings. CONCLUSIONS Nurses' use of standardised care plans was influenced by the plans' partial implementation, their views on usefulness and their personal views on the detail required in a care plan. RELEVANCE TO CLINICAL PRACTICE The structuring of nursing records is a fast-growing trend in health care. This study gives valuable information for those attempting to implement such structures in municipal health care.
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Affiliation(s)
- Elisabeth Østensen
- Department of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Nicholas R Hardiker
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Line Kildal Bragstad
- Institute of Health and Society and Research Center for Habilitation and Rehabilitation Services and Models (CHARM), University of Oslo, Oslo, Norway
| | - Ragnhild Hellesø
- Department of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
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Gathara D, Zosi M, Serem G, Nzinga J, Murphy GAV, Jackson D, Brownie S, English M. Developing metrics for nursing quality of care for low- and middle-income countries: a scoping review linked to stakeholder engagement. HUMAN RESOURCES FOR HEALTH 2020; 18:34. [PMID: 32410633 PMCID: PMC7222310 DOI: 10.1186/s12960-020-00470-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 03/25/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND The use of appropriate and relevant nurse-sensitive indicators provides an opportunity to demonstrate the unique contributions of nurses to patient outcomes. The aim of this work was to develop relevant metrics to assess the quality of nursing care in low- and middle-income countries (LMICs) where they are scarce. MAIN BODY We conducted a scoping review using EMBASE, CINAHL and MEDLINE databases of studies published in English focused on quality nursing care and with identified measurement methods. Indicators identified were reviewed by a diverse panel of nursing stakeholders in Kenya to develop a contextually appropriate set of nurse-sensitive indicators for Kenyan hospitals specific to the five major inpatient disciplines. We extracted data on study characteristics, nursing indicators reported, location and the tools used. A total of 23 articles quantifying the quality of nursing care services met the inclusion criteria. All studies identified were from high-income countries. Pooled together, 159 indicators were reported in the reviewed studies with 25 identified as the most commonly reported. Through the stakeholder consultative process, 52 nurse-sensitive indicators were recommended for Kenyan hospitals. CONCLUSIONS Although nurse-sensitive indicators are increasingly used in high-income countries to improve quality of care, there is a wide heterogeneity in the way indicators are defined and interpreted. Whilst some indicators were regarded as useful by a Kenyan expert panel, contextual differences prompted them to recommend additional new indicators to improve the evaluations of nursing care provision in Kenyan hospitals and potentially similar LMIC settings. Taken forward through implementation, refinement and adaptation, the proposed indicators could be more standardised and may provide a common base to establish national or regional professional learning networks with the common goal of achieving high-quality care through quality improvement and learning.
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Affiliation(s)
- David Gathara
- KEMRI Wellcome Trust Research Programme, P.O Box 43640 00100, Nairobi, Kenya.
- School of Nursing and Midwifery, Aga Khan University, P.O Box 39340 00623, Nairobi, Kenya.
| | - Mathias Zosi
- Kenya Medical Training College, Kilifi Campus, Nairobi, Kenya
| | - George Serem
- KEMRI Wellcome Trust Research Programme, P.O Box 43640 00100, Nairobi, Kenya
| | - Jacinta Nzinga
- KEMRI Wellcome Trust Research Programme, P.O Box 43640 00100, Nairobi, Kenya
| | | | - Debra Jackson
- School of Nursing & Midwifery, University of Technology, Sydney, Australia
| | - Sharon Brownie
- PRAXIS Forum, Green Templeton College, University of Oxford, Oxford, OX2 6HG, UK
- School of Medicine, Griffith University, Queensland, Australia
| | - Mike English
- KEMRI Wellcome Trust Research Programme, P.O Box 43640 00100, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7FZ, UK
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Standardized Hospital Discharge Communication for Patients With Pressure Injury: A Quasi-experimental Trial. J Wound Ostomy Continence Nurs 2020; 47:236-241. [PMID: 32384527 DOI: 10.1097/won.0000000000000644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To determine if improved communication between certified wound care nurses and home health nurses, through use of standardized electronic wound care order sets and discharge instructions, decreased delay in treatment and 30-day readmission rates and improved wound healing for patients discharged to home with pressure injuries. DESIGN Quasi-experimental, nonequivalent group trial. SUBJECTS AND SETTING Cognitively intact adult patients hospitalized in the Midwestern United States with a stage 2 or higher pressure injury discharged to home care services. METHODS We revised the electronic medical record to include an adapted, standardized version of the Project Re-Engineered Discharge wound care order set that included specific wound care instructions for use following discharge to home care. Medical records of 12 patients were reviewed prior to the change and 9 records were reviewed postchange for information about initiation of care, wound healing, and 30-day readmission. The Pressure Ulcer Scale of Healing tool was used to evaluate wound healing. RESULTS Time to initiation of treatment was 2.4 days for the control group and 1.6 days for the intervention group. Missing documentation made it difficult to evaluate the control group, as 73% of all wound measurements were missing from the electronic medical record. Use of the standardized wound care order set resulted in 100% of wound care orders and 92% of discharge instructions being present in the intervention group's electronic medical record at the time of hospital discharge. There was no statistically significant difference between control and intervention group's Pressure Ulcer Scale of Healing scores for any postdischarge measurement or in 30-day readmission rates. CONCLUSIONS The new standardized wound care order sets at the time of discharge did increase adherence to time to implementation and documentation of executing wound care orders by home care nurses. Further research of standardized order sets is needed to determine the impact on improving patient outcomes.
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Quality of Care: Ecological Study for the Evaluation of Completeness and Accuracy in Nursing Assessment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17093259. [PMID: 32392838 PMCID: PMC7246491 DOI: 10.3390/ijerph17093259] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/25/2020] [Accepted: 05/02/2020] [Indexed: 01/04/2023]
Abstract
Nursing documentation is an important proxy of the quality of care, and quality indicators in nursing assessment can be used to assess and improve the quality of care in health care institutions. The study aims to evaluate the completeness and the accuracy of nursing assessment, analyzing the compilation of pain assessment and nutritional status (body mass index (BMI)) in computerized nursing records, and how it is influenced by four variables: nurse to patient ratio, diagnosis related group weight (DRG), seniority of charge nurse, and type of ward (medical, surgical or other). The observational ecological pilot study was conducted between September and October 2018 in an Italian Tertiary-Level Teaching Hospital. The nursing documentation analyzed for the ‘Assessment’ phase included 12,513 records, 50.4% concerning pain assessment, and 45% BMI. The nurse–patient ratio showed a significant direct association with the assessment of nutritional status (p = 0.032). The average weight DRG has a negative influence on pain and BMI assessment; the surgical units positively correlate with the compilation of nursing assessment (BMI and pain). The nursing process is an essential component for the continuous improvement in the quality of care. Nurses need to be accountable to improve their knowledge and skills in nursing 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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Tuinman A, de Greef MHG, Finnema EJ, Nieweg RMB, Krijnen WP, Roodbol PF. The consistency between planned and actually given nursing care in long-terminstitutional care. Geriatr Nurs 2020; 41:564-570. [PMID: 32238268 DOI: 10.1016/j.gerinurse.2020.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 02/27/2020] [Accepted: 03/02/2020] [Indexed: 10/24/2022]
Abstract
Continuous information exchange between healthcare professionals is facilitated by individualized care plans. Compliance with the planned care as documented in care plans is important to provide person-centered care which contributes to the continuity of care and quality of care outcomes. Using the Nursing Interventions Classification, this study examined the consistency between documented and actually provided interventions by type of nursing staff with 150 residents in long-term institutional care. The consistency was especially high for basic (93%) and complex (79%) physiological care. To a lesser extent for interventions in the behavioral domain (66%). Except for the safety domain, the probability that documented interventions were provided was high for all domains (≥ 91%, p > 0.05). NAs generally provided the interventions as documented. Findings suggest that HCAs worked beyond there scope of practice. The results may have implications for the deployment of nursing staff and are of importance to managers.
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Affiliation(s)
- Astrid Tuinman
- Department of Health and Well-being, Windesheim University of Applied Sciences, Zwolle, The Netherlands.
| | - Mathieu H G de Greef
- Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Evelyn J Finnema
- Research Group Living, Wellbeing and Care for Older People, NHL University of Applied Sciences, Leeuwarden, The Netherlands
| | - Roos M B Nieweg
- School of Nursing, Hanze University of Applied Sciences Groningen, Groningen, The Netherlands
| | - Wim P Krijnen
- Health Care and Nursing, Hanze University of Applied Sciences Groningen, Groningen, The Netherlands
| | - Petrie F Roodbol
- Department of Health Science, Section of Nursing Research, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Pérez‐Rivas FJ, Martín‐García Á, Sánz‐Bayona MT, Fernández‐Díaz MC, Barberá‐Martín A, Cárdenas‐Valladolid J, López‐Palacios S, Rico‐Blázquez M. Establishing Technical Values for Nursing Diagnoses in Primary Healthcare. Int J Nurs Knowl 2020; 31:124-133. [DOI: 10.1111/2047-3095.12253] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 07/01/2019] [Accepted: 07/08/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Francisco Javier Pérez‐Rivas
- Gerencia Asistencial de Atención Primaria, Servicio Madrileño de Salud, Madrid, Spain, and Associate Professor at the Departamento de Enfermería, Facultad de Enfermería, Fisioterapia y PodologíaUniversidad Complutense de Madrid Madrid Spain
| | - Ángel Martín‐García
- San Blas Primary Healthcare Center (Southern Area) of the Gerencia Asistencial de Atención PrimariaServicio Madrileño de Salud Madrid Spain
| | - María Teresa Sánz‐Bayona
- Primary Healthcare Centers (Western Area) at the Gerencia Asistencial de Atención PrimariaServicio Madrileño de Salud Madrid Spain
| | | | | | - Juan Cárdenas‐Valladolid
- Gerencia Asistencial de Atención PrimariaServicio Madrileño de Salud, Madrid, Spain, and Associate Professor at the Facultad de EnfermeríaUniversidad Alfonso X el Sabio Madrid Spain
| | - Sonia López‐Palacios
- Primary Healthcare Centers (Central Area) at the Gerencia Asistencial de Atención PrimariaServicio Madrileño de Salud Madrid Spain
| | - Milagros Rico‐Blázquez
- Gerencia Asistencial de Atención PrimariaServicio Madrileño de Salud, Madrid, Spain and Associate Professor at the Departamento de Enfermería, Facultad de Enfermería, Fisioterapia y PodologíaUniversidad Complutense de Madrid Madrid Spain
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Ramukumba MM, El Amouri S. Nurses' perspectives of the nursing documentation audit process. Health SA 2020; 24:1121. [PMID: 31934421 PMCID: PMC6917393 DOI: 10.4102/hsag.v24i0.1121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 08/13/2019] [Indexed: 11/17/2022] Open
Abstract
Background Nursing has an obligation to the public to develop measures for the quality of care to enhance patient safety and efficiency of the system. The first hospital to introduce the clinical audit of nursing documentation was in Abu Dhabi. The rationale was the recognition of the link between clinical audits and the quality of patient care and safety. This article recognises the importance of documentation audits in nursing practice and the role of nurses related to conducting audits in a selected hospital in Abu Dhabi. Many studies have shown the potential benefits of documentation audits to evaluate or assess the quality of recorded nursing assessments and care. Aim The aim of this study was to explore nurses’ perspectives of the documentation audit process. Method The study adopted an exploratory, descriptive qualitative approach using the evaluation method. Data were collected using three focus group interviews consisting of 4 informatics and 13 documentation link nurses involved in the implementation of the clinical audit on nursing documentation in the selected hospital. Thematic analysis was used to analyse the data. Results Three major themes evolved from the research findings: implementation of documentation audit, evaluation of audit and measures to improve documentation audit. Strengths and weaknesses of the documentation audit were articulated by the nurses. Generally, nurses were satisfied with the audit process and made recommendations on improvements. Conclusion Processes adopted by the team were reasonable and useful, and the preparation and planning for the clinical audit were regarded as areas of strength. Areas of weaknesses in the implementation processes identified included dissemination of findings and executing improvements. This could be improved with necessary support from the hospital management, especially with regard to release time to implement required changes. The complexity of auditing electronic versus paper-based nursing documentation is acknowledged.
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De Groot K, De Veer AJE, Paans W, Francke AL. Use of electronic health records and standardized terminologies: A nationwide survey of nursing staff experiences. Int J Nurs Stud 2020; 104:103523. [PMID: 32086028 DOI: 10.1016/j.ijnurstu.2020.103523] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 12/31/2019] [Accepted: 12/31/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Nursing documentation could improve the quality of nursing care by being an important source of information about patients' needs and nursing interventions. Standardized terminologies (e.g. NANDA International and the Omaha System) are expected to enhance the accuracy of nursing documentation. However, it remains unclear whether nursing staff actually feel supported in providing nursing care by the use of electronic health records that include standardized terminologies. OBJECTIVES a. To explore which standardized terminologies are being used by nursing staff in electronic health records. b. To explore to what extent they feel supported by the use of electronic health records. c. To examine whether the extent to which nursing staff feel supported is associated with the standardized terminologies that they use in electronic health records. DESIGN Cross-sectional survey design. SETTING AND PARTICIPANTS A representative sample of 667 Dutch registered nurses and certified nursing assistants working with electronic health records. The respondents were working in hospitals, mental health care, home care or nursing homes. METHODS A web-based questionnaire was used. Descriptive statistics were performed to explore which standardized terminologies were used by nursing staff, and to explore the extent to which nursing staff felt supported by the use of electronic health records. Multiple linear regression analyses examined the association between the extent of the perceived support provided by electronic health records and the use of specific standardized terminologies. RESULTS Only half of the respondents used standardized terminologies in their electronic health records. In general, nursing staff felt most supported by the use of electronic health records in their nursing activities during the provision of care. Nursing staff were often not positive about whether the nursing information in the electronic health records was complete, relevant and accurate, and whether the electronic health records were user-friendly. No association was found between the extent to which nursing staff felt supported by the electronic health records and the use of specific standardized terminologies. CONCLUSIONS More user-friendly designs for electronic health records should be developed. The poor user-friendliness of electronic health records and the variety of ways in which software developers have integrated standardized terminologies might explain why these terminologies had less of an impact on the extent to which nursing staff felt supported by the use of electronic health records.
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Affiliation(s)
- Kim De Groot
- Netherlands Institute for Health Services Research (Nivel), PO Box 1568, 3513 CR Utrecht, The Netherlands; Thebe Wijkverpleging [Home care organisation], Lage Witsiebaan 2a, 5042 DA Tilburg, The Netherlands.
| | - Anke J E De Veer
- Netherlands Institute for Health Services Research (Nivel), PO Box 1568, 3513 CR Utrecht, The Netherlands
| | - Wolter Paans
- Research Group Nursing Diagnostics, School of Nursing, Hanze University of Applied Sciences, Petrus Driessenstraat 3, 9714 CA Groningen, The Netherlands
| | - Anneke L Francke
- Netherlands Institute for Health Services Research (Nivel), PO Box 1568, 3513 CR Utrecht, The Netherlands; Department of Public and Occupational Health, Amsterdam Public Health Research Institute (APH), Amsterdam UMC, Vrije Universiteit Amsterdam, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
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Engen EJH, Devik SA, Olsen RM. Nurses' Experiences of Documenting the Mental Health of Older Patients in Long-Term Care. Glob Qual Nurs Res 2020; 7:2333393620960076. [PMID: 33134432 PMCID: PMC7576930 DOI: 10.1177/2333393620960076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 08/11/2020] [Accepted: 08/18/2020] [Indexed: 11/17/2022] Open
Abstract
Nursing documentation is repeatedly reported to be insufficient and unsatisfactory. Although nurses should apply a holistic approach, they tend to document physical needs more often than other caring dimensions. This study aimed to describe nurses' experiences documenting mental health in older patients receiving long-term care. Individual interviews were conducted with nine nurses and were analyzed by content analysis. One main theme, two categories and seven sub-categories emerged. The findings showed that the nurses perceived mental health as an ambiguous phenomenon that could be difficult to observe, interpret, and agree upon. Thus, the nurses were uncertain about what concepts and words corresponded to their observations. They also struggled with finding the right words to create accurate and complete documentation without breaking confidentiality or diminishing the dignity of the patient. The findings are relevant for nurses in different types of healthcare services and in the educational context to ensure comprehensive nursing documentation.
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50
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Cohorting Trauma Patients in a Medical/Surgical Unit at a Level I Pediatric Trauma Center to Enhance Interdisciplinary Collaboration and Documentation. J Trauma Nurs 2019; 26:17-25. [PMID: 30624378 DOI: 10.1097/jtn.0000000000000418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Medical errors are a significant issue in health care that may be avoided through enhanced communication and documentation. This study examines interdisciplinary communication and compliance with trauma standards of care demonstrated through following the implementation of cohorting trauma patients to one medical/surgical unit and instituting daily interdisciplinary trauma patient rounds. Potential benefits include enhanced communication, improved nursing satisfaction, and increased compliance with trauma standards of care demonstrated through documentation, which the literature suggests improves quality of care. Pre- and postcohorting surveys related to safety attitudes, comfort with caring for trauma patients, and the efficacy of cohorting were administered to the nursing staff. As a marker for increased compliance with trauma standards of care, medical records were reviewed for completion of substance abuse screening upon admission and Functional Independence Measure screening at discharge. The results were compared after the cohorting initiative with 2 years prior. The rate of compliance with substance abuse screening increased from an average of 62.5% in 2015 and 2016 to 84% in 2017. Functional Independence Measure compliance increased from an average of 72.5% in 2015 and 2016 to 94% in 2017 following the cohorting intervention. Nursing perceptions of teamwork, safety climate, and staff support significantly improved (p < .05) from pre- to postcohorting surveys. Improvements were noted in comfort with performing tasks associated with caring for trauma patients but were not statistically significant. Cohorting trauma patients to one medical/surgical unit resulted in positive perceptions of professional relationships, improved communication, and compliance with trauma standards of care for documentation.
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