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Management of constipation in long-term care hospitals and its ward manager and organization factors. BMC Nurs 2020; 19:5. [PMID: 31988637 PMCID: PMC6966903 DOI: 10.1186/s12912-020-0398-z] [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: 09/20/2019] [Accepted: 01/13/2020] [Indexed: 01/28/2023] Open
Abstract
Background Studies examining organizational factors that may influence constipation management in long-term care (LTC) hospitals are lacking. This study aimed to clarify the practice of constipation management in LTC hospitals and to explore its factors, including ward manager’s perception, organizational climate, and constipation assessment. Methods In this cross-sectional questionnaire survey of ward managers and staff nurses working in LTC wards, we determined daily assessment and practices regarding constipation management. We also conducted multivariate analyses to examine factors related to constipation management. Results There was a 20% response rate to the questionnaire. Nearly all LTC wards routinely assessed bowel movement frequency; other assessments were infrequent. Laxatives were used, but the use of dietary fiber and probiotic products was implemented in only 20–30% of wards. The implementation of non-pharmacological management and adequate use of stimulant laxatives were positively associated with the ward manager’s belief and knowledge, organizational climate, the existence of nursing records for constipation assessment, planned nursing care for constipation, and organized conferences and in-hospital study sessions on constipation management. Conclusion Areas to improve constipation management in LTC hospitals include altering the ward manager’s perception, improving hospital’s organizational climate, and introducing standardized assessment/care planning systems.
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Mariani E, Chattat R, Ottoboni G, Koopmans R, Vernooij-Dassen M, Engels Y. The Impact of a Shared Decision-Making Training Program on Dementia Care Planning in Long-Term Care. J Alzheimers Dis 2018; 64:1123-1135. [PMID: 30010130 DOI: 10.3233/jad-180279] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Shared decision-making (SDM) can be a way for staff to adopt international recommendations advocating the involvement of nursing home residents and their family members in care planning and the development of personalized care plans. OBJECTIVE The main aim was to analyze the effects of training nursing home staff in the implementation of SDM on agreement of residents' 'life-and-care plans' with the recommendations (primary outcome) and on family caregivers' quality of life and sense of competence, and staff's job satisfaction (secondary outcomes). METHODS In the intervention condition, staff attended a training program on the use of SDM with residents and family caregivers in the care planning process. In the control condition, care planning as usual took place. For the primary outcome, in-depth qualitative and quantitative analyses of the care plans were performed. Multivariate Permutation Tests were applied to assess the impact on secondary outcomes. RESULTS Forty-nine residents and family caregivers and 34 professionals were involved. Overall, many of the care plans developed during the intervention showed a high level of agreement with the care planning recommendations. Both Italian and Dutch care plans showed improvement in the number of clear problem statements (p < 0.001). In Italy, significant improvements (p < 0.05) were also found regarding specific care objectives, documentation of objectives met, and of residents and families' involvement. No impact was found on secondary outcomes. CONCLUSION The involvement of residents and family caregivers in care planning contributed to an improvement of the residents' care plans, but it did not have an effect on family caregivers and staff outcomes.
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Affiliation(s)
- Elena Mariani
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, Nijmegen, The Netherlands.,Department of Psychology, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Rabih Chattat
- Department of Psychology, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Giovanni Ottoboni
- Department of Psychology, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Raymond Koopmans
- Radboudumc Alzheimer Center, Nijmegen, The Netherlands.,Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands.,Joachimen Anna, Center for Specialized Geriatric Care, Nijmegen, The Netherlands
| | - Myrra Vernooij-Dassen
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, Nijmegen, The Netherlands.,Radboudumc Alzheimer Center, Nijmegen, The Netherlands.,Kalorama Foundation, Beek-Ubbergen, The Netherlands
| | - Yvonne Engels
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
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Noh HK, Lee E. Relationships Among NANDA-I Diagnoses, Nursing Outcomes Classification, and Nursing Interventions Classification by Nursing Students for Patients in Medical-Surgical Units in Korea. Int J Nurs Knowl 2014; 26:43-51. [DOI: 10.1111/2047-3095.12044] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Hyun Kyung Noh
- Department of Nursing; Gyeongsan University; Daegu Korea
| | - Eunjoo Lee
- Department of Nursing; Research Institute of Nursing Science; College of Nursing; Kyungpook National University; Daegu Korea
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Saranto K, Kinnunen U, Kivekäs E, Lappalainen A, Liljamo P, Rajalahti E, Hyppönen H. Impacts of structuring nursing records: a systematic review. Scand J Caring Sci 2013; 28:629-47. [DOI: 10.1111/scs.12094] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 09/27/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Kaija Saranto
- Department of Health and Social Management University of Eastern Finland Kuopio Finland
| | - Ulla‐Mari Kinnunen
- Department of Health and Social Management University of Eastern Finland Kuopio Finland
| | - Eija Kivekäs
- Department of Health and Social Management University of Eastern Finland Kuopio Finland
| | - Anna‐Mari Lappalainen
- Department of Health and Social Management University of Eastern Finland Kuopio Finland
| | - Pia Liljamo
- Department of Health and Social Management University of Eastern Finland Kuopio Finland
| | - Elina Rajalahti
- Department of Health and Social Management University of Eastern Finland Kuopio Finland
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Effects of a computerized decision support system on care planning for pressure ulcers and malnutrition in nursing homes: An intervention study. Int J Med Inform 2013; 82:911-21. [DOI: 10.1016/j.ijmedinf.2013.05.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 05/28/2013] [Accepted: 05/30/2013] [Indexed: 01/19/2023]
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Voyer P, McCusker J, Cole MG, Monette J, Champoux N, Ciampi A, Belzile E, Vu M, Richard S. Nursing Documentation in Long-Term Care Settings. Clin Nurs Res 2013; 23:442-61. [DOI: 10.1177/1054773813475809] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In this study on nursing documentation in long-term care facilities, a set of 9 delirium symptoms was used to evaluate the agreement between symptoms reported by nurses during monthly interviews and those documented in the nursing notes for the same 7-day observation period. Residents aged 65 and above ( N = 280) were assessed monthly over a 6-month period for the presence of delirium and its symptoms using the Confusion Assessment Method. The proportion of symptoms documented in the nursing notes ranged from 1.9% to 53.5%. A trend toward a lower proportion of documented symptoms for higher resident−nurse ratios was observed, although the difference was not statistically significant. Efforts should be made to improve the situation by revisiting the content of academic and clinical training given to nurses in addition to exploring innovative ways to make nursing documentation more efficient and less time-consuming within the current context of nurses’ work overload.
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Affiliation(s)
- Philippe Voyer
- Faculty of Nursing Sciences, Laval University, Quebec City, QC, Canada
- Centre for Excellence in Aging-Research Unit, Quebec City, QC, Canada
| | - Jane McCusker
- St. Mary’s Research Centre, Montreal, QC, Canada
- Departments of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Martin G. Cole
- Department of Psychiatry, St Mary’s Hospital, Montreal, QC, Canada
- Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Johanne Monette
- Division of Geriatric Medicine, Jewish General Hospital, Canada
- Donald Berman Maimonides Geriatric Center, Canada
| | - Nathalie Champoux
- Institut Universitaire de Gériatrie de Montréal, Département de Médecine Familiale, Université de Montréal, QC, Canada
| | - Antonio Ciampi
- St. Mary’s Research Centre, Montreal, QC, Canada
- Departments of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada
| | - Eric Belzile
- St. Mary’s Research Centre, Montreal, QC, Canada
| | - Minh Vu
- Division of Geriatric Medicine, Centre Hospitalier de l’Université de Montréal and Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Sylvie Richard
- Centre for Excellence in Aging-Research Unit, Quebec City, QC, Canada
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Ofi B, Sowunmi O. Nursing documentation: Experience of the use of the nursing process model in selected hospitals in Ibadan, Oyo State, Nigeria. Int J Nurs Pract 2012; 18:354-62. [DOI: 10.1111/j.1440-172x.2012.02044.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Bola Ofi
- Department of Nursing; University of Ibadan; Ibadan; Oyo State; Nigeria
| | - Olanrewaju Sowunmi
- Nurse/Midwife/Public Health Nurse Tutors Programme; University College Hospital; Ibadan; Oyo State; Nigeria
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Güler EK, Eşer I, Khorshid L, Yücel SÇ. Nursing diagnoses in elderly residents of a nursing home: A case in Turkey. Nurs Outlook 2012; 60:21-8. [PMID: 21703650 DOI: 10.1016/j.outlook.2011.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Revised: 02/25/2011] [Accepted: 03/04/2011] [Indexed: 12/14/2022]
Affiliation(s)
- Elem Kocaçal Güler
- Department of Fundamentals of Nursing, Ege University School of Nursing, İzmir, Turkey.
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Fossum M, Alexander GL, Göransson KE, Ehnfors M, Ehrenberg A. Registered nurses’ thinking strategies on malnutrition and pressure ulcers in nursing homes: a scenario-based think-aloud study. J Clin Nurs 2011; 20:2425-35. [DOI: 10.1111/j.1365-2702.2010.03578.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Gjevjon ER, Hellesø R. The quality of home care nurses' documentation in new electronic patient records. J Clin Nurs 2010; 19:100-8. [PMID: 20500248 DOI: 10.1111/j.1365-2702.2009.02953.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIMS The present study explores how community nurses addressed patient care in the EPR and the comprehensiveness of their documentation. BACKGROUND The need for comprehensive nursing documentation in home health care is considerable and quality is regarded as a prerequisite for continuity of care. Documentation according to the nursing process is considered to be of good quality due to its logical structure. Nurses in home health care face different challenges than nurses in institutionalised care because of long-term patient situations and a focus on chronic illness rather than acute disease. DESIGN Retrospective study. METHOD The study was performed on a sample of 91 patient records. Data were analysed in three phases: (1) systematising the unstructured text, (2) structuring the text according to the nursing process and (3) assessing the comprehensiveness using a validated instrument. RESULTS The home care nurses documented patient care chronologically along a time axis rather than using a logical structure according to the nursing process. The documentation reflected today's overall emphasis on patient participation, as more than 70% of the notes on nursing status were connected to subjective nursing status. Paradoxically, the nurses showed a lack of attention to the patients' ability to communicate. Only two of 264 documented nursing diagnoses were connected to communication. The comprehensiveness of the documentation, however, was incomplete. CONCLUSIONS Home health care nurses are attentive to patient participation but fail to address patients' needs with regard to communication. The documentation is incomplete when assessed according to the steps of the nursing process. A question that arises is whether the nursing process may be a limitation for the quality of the nursing documentation. RELEVANCE TO CLINICAL PRACTICE The study contributes to identifying areas of improvement in documentation by nurses in home health care.
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Affiliation(s)
- Edith R Gjevjon
- Faculty of Medicine, Institute of Nursing and Health Sciences, University of Oslo, Blindern, Oslo, Norway.
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Thoroddsen A, Ehnfors M, Nurs Ed D, Ehrenberg A. Nursing Specialty Knowledge as Expressed by Standardized Nursing Languages. ACTA ACUST UNITED AC 2010; 21:69-79. [DOI: 10.1111/j.1744-618x.2010.01148.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Junttila K, Hupli M, Salanterä S. The Use of Nursing Diagnoses in Perioperative Documentation. ACTA ACUST UNITED AC 2010; 21:57-68. [DOI: 10.1111/j.1744-618x.2010.01147.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Jansson I, Pilhammar E, Forsberg A. Obtaining a foundation for nursing care at the time of patient admission: a grounded theory study. Open Nurs J 2009; 3:56-64. [PMID: 19746207 PMCID: PMC2739902 DOI: 10.2174/1874434600903010056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Revised: 07/17/2009] [Accepted: 07/17/2009] [Indexed: 11/22/2022] Open
Abstract
The nursing process can be viewed as a problem-solving model, but we do not know whether use of the whole process including care plans with interventions based on nursing diagnoses improves nurses' ability to carry out assessments. Therefore, the aim of this study was to illuminate and describe the assessment and decision-making process performed by nurses who formulated individual care plans including nursing diagnosis, goals and interventions or who used standardized care plans when a patient was admitted to their ward for care, and those who did not. Data collection and analysis were carried out by means of Grounded theory. Nurses were observed while assessing patients, after which they were interviewed. The main concern of all nurses was to obtain a foundation for nursing care based on four strategies; building pre-understanding, creating a caring environment, collecting information on symptoms and signs and performing an analysis from different perspectives. It appeared that the most important aspect for nurses who did not employ care plans was the medical reason for the patient's admission. The nurses who employed care plans discussed their decisions in terms of nursing problems, needs and risks. The results indicate that nurses who formulated care plans were more aware of their professional role.
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Affiliation(s)
- Inger Jansson
- School of Social and Health Sciences, Halmstad University, Halmstad, Sweden.
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Daskein R, Moyle W, Creedy D. Aged-care nurses' knowledge of nursing documentation: an Australian perspective. J Clin Nurs 2009; 18:2087-95. [PMID: 19374697 DOI: 10.1111/j.1365-2702.2008.02670.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM This study investigated registered nurses' knowledge of documentation used in aged-care nursing home facilities in Queensland, Australia. BACKGROUND The purpose of nursing documentation is to communicate health information, facilitate quality assurance and research, demonstrate nurses' accountability and, within Australia, to support funding of residents' care. Little is known about the relationship between RNs' knowledge of nursing documentation, the documentation process within residential aged care and the outcomes of the documentation. DESIGN Cross-sectional, retrospective design. METHOD The study was conducted with a large sample of RNs (n = 360) located in 162 Queensland aged-care facilities. Participants completed a postage-return questionnaire in which they identified factors that influence their knowledge and understanding of documentation. RESULTS Participants reported that they have considerable knowledge of nursing documentation. They also indicated that they were most knowledgeable about policies on documentation and writing discharge instructions. However, their knowledge of nursing assessments ranked fifth and they were least knowledgeable about reading reports each shift. CONCLUSIONS The modified version of Edelstein's questionnaire provided a valid and reliable instrument for measuring RNs' knowledge of nursing documentation. A factor analysis of the 16 items in the Knowledge scale showed excellent reliability. The data indicated that RNs in aged-care facilities have high levels of knowledge about documentation. Specific recommendations relate to the implementation of comprehensive documentation education programs that reflect the needs of organisations and the level of RNs' skills and knowledge concerning documentation. RELEVANCE TO CLINICAL PRACTICE Accurate nursing documentation is relevant to residents' care outcomes and to government funding allocations. Measuring RNs' knowledge of nursing documentation can identify factors that impede and facilitate their documentation of care.
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Affiliation(s)
- Robyn Daskein
- Research Centre for Clinical and Community Practice Innovation, Griffith University, Nathan, Brisbane, Qld, Australia
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Müller-Staub M, Lunney M, Odenbreit M, Needham I, Lavin MA, van Achterberg T. Development of an instrument to measure the quality of documented nursing diagnoses, interventions and outcomes: the Q-DIO. J Clin Nurs 2009; 18:1027-37. [DOI: 10.1111/j.1365-2702.2008.02603.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
This article presents a conceptual model of the care planning process developed to identify the hypothetical links between structural, process and outcome factors important to the quality of the process. Based on existing literature, it was hypothesized that a thorough assessment of patients' health needs is an important prerequisite when making a rigorous diagnosis and preparing plans for various care interventions. Other important variables that are assumed to influence the quality of the process are the care culture and professional knowledge. The conceptual model was developed as a system dynamics causal loop diagram as a first essential step towards a computed model. System dynamics offers the potential to describe processes in a nonlinear, dynamic way and is suitable for exploring, comprehending, learning and communicating complex ideas about care processes.
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Affiliation(s)
- Marie Elf
- Chalmers University of Technology, Göteborg, Sweden.
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Funkesson KH, Anbäcken EM, Ek AC. Nurses’ reasoning process during care planning taking pressure ulcer prevention as an example. A think-aloud study. Int J Nurs Stud 2007; 44:1109-19. [PMID: 16806220 DOI: 10.1016/j.ijnurstu.2006.04.016] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2005] [Revised: 02/21/2006] [Accepted: 04/27/2006] [Indexed: 11/29/2022]
Abstract
BACKGROUND Nurses' clinical reasoning is of great importance for the delivery of safe and efficient care. Pressure ulcer prevention allows a variety of aspects within nursing to be viewed. OBJECTIVE The aim of this study was to describe both the process and the content of nurses' reasoning during care planning at different nursing homes, using pressure ulcer prevention as an example. DESIGN A qualitative research design was chosen. SETTINGS Seven different nursing homes within one community were included. PARTICIPANTS Eleven registered nurses were interviewed. METHOD The methods used were think-aloud technique, protocol analysis and qualitative content analysis. Client simulation illustrating transition was used. The case used for care planning was in three parts covering the transition from hospital until 3 weeks in the nursing home. RESULT Most nurses in this study conducted direct and indirect reasoning in a wide range of areas in connection with pressure ulcer prevention. The reasoning focused different parts of the nursing process depending on part of the case. Complex assertations as well as strategies aiming to reduce cognitive strain were rare. Nurses involved in direct nursing care held a broader reasoning than consultant nurses. Both explanations and actions based on older ideas and traditions occurred. CONCLUSIONS Reasoning concerning pressure ulcer prevention while care planning was dominated by routine thinking. Knowing the person over a period of time made a more complex reasoning possible. The nurses' experience, knowledge together with how close to the elderly the nurses work seem to be important factors that affect the content of reasoning.
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Bååth C, Hall-Lord ML, Johansson I, Wilde Larsson B. Nursing assessment documentation and care of hip fracture patients’ skin. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/j.joon.2006.10.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Müller-Staub M, Needham I, Odenbreit M, Lavin MA, van Achterberg T. Improved Quality of Nursing Documentation: Results of a Nursing Diagnoses, Interventions, and Outcomes Implementation Study. ACTA ACUST UNITED AC 2007; 18:5-17. [PMID: 17430533 DOI: 10.1111/j.1744-618x.2007.00043.x] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To evaluate the impact of the quality of nursing diagnoses, interventions, and outcomes in an acute care hospital following the implementation of an educational program. METHOD In a pretest-posttest experimental design study, nurses from 12 wards of a Swiss hospital received an educational intervention--an introductory class and consecutive classes, using a case discussion method--to implement nursing diagnoses, interventions, and outcomes. Two sets of 36 randomly selected nursing records were evaluated before and after implementation. The quality of documented nursing diagnoses, interventions, and nursing-sensitive patient outcomes was assessed by 29 Likert-type items with a 0-4 scale instrument, called Quality of Nursing Diagnoses, Interventions, and Outcomes (Q-DIO) and tested using t-tests. FINDINGS Significant enhancements in the quality of documented nursing diagnoses, interventions, and outcomes were found following the implementation of a planned educational program. CONCLUSIONS The implementation of NANDA, NIC, and NOC (NNN) nursing diagnoses, interventions, and outcomes led to higher quality of nursing diagnosis documentation, etiology-specific nursing interventions, and nursing-sensitive patient outcomes. IMPLICATIONS FOR NURSING PRACTICE Educational measures support nurses to improve documentation of diagnoses, interventions, and outcomes. The Q-DIO is a useful audit tool.
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Müller-Staub M, Lavin MA, Needham I, van Achterberg T. Nursing diagnoses, interventions and outcomes ? application and impact on nursing practice: systematic review. J Adv Nurs 2006; 56:514-31. [PMID: 17078827 DOI: 10.1111/j.1365-2648.2006.04012.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM This paper reports a systematic review on the outcomes of nursing diagnostics. Specifically, it examines effects on documentation of assessment quality; frequency, accuracy and completeness of nursing diagnoses; and on coherence between nursing diagnoses, interventions and outcomes. BACKGROUND Escalating healthcare costs demand the measurement of nursing's contribution to care. Use of standardized terminologies facilitates this measurement. Although several studies have evaluated nursing diagnosis documentation and their relationship with interventions and outcomes, a systematic review has not been carried out. METHOD A Medline, CINAHL, and Cochrane Database search (1982-2004) was conducted and enhanced by the addition of primary source and conference proceeding articles. Inclusion criteria were established and applied. Thirty-six articles were selected and subjected to thematic content analysis; each study was then assessed, and a level of evidence and grades of recommendations assigned. FINDINGS Nursing diagnosis use improved the quality of documented patient assessments (n = 14 studies), identification of commonly occurring diagnoses within similar settings (n = 10), and coherence among nursing diagnoses, interventions, and outcomes (n = 8). Four studies employed a continuing education intervention and found statistically significant improvements in the documentation of diagnoses, interventions and outcomes. However, limitations in diagnostic accuracy, reporting of signs/symptoms, and aetiology were also reported (14 studies). One meta-analysis of eight trials including 1497 patients showed no evidence that standardized electronic documentation of nursing diagnosis and related interventions led to better nursing outcomes. CONCLUSION Despite variable results, the trend indicated that nursing diagnostics improved assessment documentation, the quality of interventions reported, and outcomes attained. The study reveals deficits in reporting of signs/symptoms and aetiology. Consequently, staff educational measures to enhance diagnostic accuracy are recommended. The relationships among diagnoses, interventions and outcomes require further evaluation. Studies are needed to determine the relationship between the quality of documentation and practice.
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Axelsson L, Björvell C, Mattiasson AC, Randers I. Swedish Registered Nurses' incentives to use nursing diagnoses in clinical practice. J Clin Nurs 2006; 15:936-45. [PMID: 16879537 DOI: 10.1111/j.1365-2702.2006.01459.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES The purpose of this study was to describe Registered Nurses' incentives to use nursing diagnoses in clinical practice. BACKGROUND The use of nursing diagnoses is scarce in Swedish patient records. However, there are hospital wards were all nurses formulate and use nursing diagnoses in their daily work. This leads to the question of what motivates these nurses who do use nursing diagnoses in clinical practice. DESIGN A qualitative descriptive design. METHODS A purposeful sampling of 12 Registered Nurses was used. Qualitative interviews to collect data and a content analysis were performed. RESULTS Five categories were identified: identification of the patient as an individual and as a whole, a working tool for facilitating nursing care, increasing awareness within nursing, support from the management and influence on the professional role. The principle findings of this study were: (i) that the Registered Nurses perceived that nursing diagnoses clarified the patient's individual needs and thereby enabled them to decide on more specific nursing interventions, (ii) that nursing diagnoses were found to facilitate communication between colleagues concerning patient care and thus promoted continuity of care and saved time and (iii) that nursing diagnoses were perceived to increase the Registered Nurses' reflective thinking leading to a continuous development of professional knowledge. CONCLUSIONS The present findings suggest that the incentives to use nursing diagnoses originate from effects generated from performing a deeper analysis of the patient's nursing needs. Further research is needed to test and validate the usability and consequences of using nursing diagnoses in clinical practice. Motivating factors found in this study may be valuable to Registered Nurses for the use and development of nursing diagnoses in clinical care. Moreover, these factors may be of relevance in other countries that are in a similar situation as Sweden concerning application of nursing diagnoses.
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Müller-Staub M, Lavin MA, Needham I, van Achterberg T. Meeting the criteria of a nursing diagnosis classification: Evaluation of ICNP, ICF, NANDA and ZEFP. Int J Nurs Stud 2006; 44:702-13. [PMID: 16556445 DOI: 10.1016/j.ijnurstu.2006.02.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2005] [Revised: 12/28/2005] [Accepted: 02/02/2006] [Indexed: 11/15/2022]
Abstract
BACKGROUND Few studies described nursing diagnosis classification criteria and how classifications meet these criteria. OBJECTIVES The purpose was to identify criteria for nursing diagnosis classifications and to assess how these criteria are met by different classifications. DESIGN/METHODS First, a literature review was conducted (N=50) to identify criteria for nursing diagnoses classifications and to evaluate how these criteria are met by the International Classification of Nursing Practice (ICNP), the International Classification of Functioning, Disability and Health (ICF), the International Nursing Diagnoses Classification (NANDA), and the Nursing Diagnostic System of the Centre for Nursing Development and Research (ZEFP). Using literature review based general and specific criteria, the principal investigator evaluated each classification, applying a matrix. Second, a convenience sample of 20 nursing experts from different Swiss care institutions answered standardized interview forms, querying current national and international classification state and use. RESULTS The first general criterion is that a diagnosis classification should describe the knowledge base and subject matter for which the nursing profession is responsible. ICNP) and NANDA meet this goal. The second general criterion is that each class fits within a central concept. The ICF and NANDA are the only two classifications built on conceptually driven classes. The third general classification criterion is that each diagnosis possesses a description, diagnostic criteria, and related etiologies. Although ICF and ICNP describe diagnostic terms, only NANDA fulfils this criterion. The analysis indicated that NANDA fulfilled most of the specific classification criteria in the matrix. The nursing experts considered NANDA to be the best-researched and most widely implemented classification in Switzerland and internationally. CONCLUSIONS The international literature and the opinion of Swiss expert nurses indicate that-from the perspective of classifying comprehensive nursing diagnoses-NANDA should be recommended for nursing practice and electronic nursing documentation. Study limitations and future research needs are discussed.
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Junttila K, Salanterä S, Hupli M. Perioperative nurses' attitudes toward the use of nursing diagnoses in documentation. J Adv Nurs 2005; 52:271-80. [PMID: 16194180 DOI: 10.1111/j.1365-2648.2005.03586.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM This paper reports a study of nurses' attitudes towards the use of nursing diagnoses in perioperative documentation and the factors affecting these attitudes. BACKGROUND There are both international and national requests for nurses to move from natural language-based narrative documentation to electronic documentation and clinical use of nursing classifications. However, nurses' attitudes toward nursing classifications have not been widely studied. METHODS A questionnaire was distributed to a purposive sample of perioperative nurses (n = 146) who had participated in clinical testing of nursing diagnoses. The response rate was 60% (n = 87). The data were collected in 2003. RESULTS In general, nurses' attitudes toward nursing diagnoses were positive. Those over 40 years of age who had clinical experience from 10 to 19 years, postbasic nursing education and previous knowledge of nursing diagnoses were most positive in their attitudes. However, the use of nursing diagnoses in perioperative practice was not seen as either necessary or accurate in describing patients' problems. Furthermore, the documentation of perioperative routines was seen as time-consuming and frustrating. CONCLUSIONS Nursing classifications should be included in both preregistration nursing curricula and in-service educational programmes to ensure theoretical knowledge of and practical skills in standardized clinical languages. The perioperative nursing diagnoses should be reviewed to fit better with clinical practice. In addition, current perioperative documentation practices should be reconsidered and updated as appropriate to address clinical requirements better.
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Florin J, Ehrenberg A, Ehnfors M. Quality of Nursing Diagnoses: Evaluation of an Educational Intervention. ACTA ACUST UNITED AC 2005; 16:33-43. [PMID: 16045551 DOI: 10.1111/j.1744-618x.2005.00008.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To investigate the effects on the quality of nursing diagnostic statements in patient records after education in the nursing process and implementation of new forms for recording. METHODS Quasi-experimental design. Randomly selected patient records reviewed before and after intervention from one experimental unit (n = 70) and three control units (n = 70). A scale with 14 characteristics pertaining to nursing diagnoses was developed and used together with the instrument (CAT-CH-ING) for record review. FINDINGS Quality of nursing diagnostic statements improved in the experimental unit, whereas no improvement was found in the control units. Serious flaws in the use of the etiology component were found. CONCLUSION. Nurses must be more concerned with the accuracy and quality of the nursing diagnoses and the etiology component needs to be given special attention. PRACTICE IMPLICATIONS Education of RNs in nursing diagnostic statements and peer review using standardized evaluation instruments can be means to further enhance RNs' documentation practice.
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Affiliation(s)
- Jan Florin
- Department of Health and Social Science, Dalarna University, Falun, Sweden.
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Hakel-Smith N, Lewis NM. A standardized nutrition care process and language are essential components of a conceptual model to guide and document nutrition care and patient outcomes. JOURNAL OF THE AMERICAN DIETETIC ASSOCIATION 2004; 104:1878-84. [PMID: 15565085 DOI: 10.1016/j.jada.2004.10.015] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Documentation of clinical services within health care systems has become increasingly significant because greater amounts of information are now required by accrediting agencies, third-party payers, researchers, and others in their evaluation of patient care and because of the increasing emphasis on patient outcomes. Given the multiple users who depend on health care information in the patient record, it is imperative that clinical nutrition practitioners implement a standardized nutrition care process and language to document comprehensively and communicate meaningful information concerning their role in improving patient outcomes. A body of work has led to the development and adoption of a standardized nutrition care process for the dietetics profession. A standardized nutrition care process consistent with the scientific method and a standardized language are two essential components required to articulate a conceptual model for clinical nutrition practice and documentation and distinguish clinical dietetics' unique body of knowledge. The conceptual model serves as an organizing framework to standardize and guide nutrition practitioners' clinical judgments or critical thinking processes and document information linking nutrition care to patient outcomes.
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Affiliation(s)
- Nancy Hakel-Smith
- Clinical Nutrition Services, BryanLGH Medical Center, Lincoln, NE 68506-1299, USA.
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28
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Gunningberg L, Ehrenberg A. Accuracy and Quality in the Nursing Documentation of Pressure Ulcers. J Wound Ostomy Continence Nurs 2004; 31:328-35. [PMID: 15867708 DOI: 10.1097/00152192-200411000-00004] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the accuracy and describe the quality of nursing documentation of pressure ulcers in a hospital care setting. DESIGN A cross-sectional survey was used comparing retrospective audits of nursing documentation of pressure ulcers to previous physical examinations of patients. SETTING AND SUBJECTS All inpatient records (n = 413) from February 5, 2002, at the surgical/orthopedic (n = 144), medical (n = 182), and geriatric (n = 87) departments of one Swedish University hospital. INSTRUMENTS The European Pressure Ulcer Advisory Panel data collection form and the Comprehensiveness In Nursing Documentation. METHODS All 413 records were reviewed for presence of notes on pressure ulcers; the findings were compared with the previous examination of patients' skin condition. Records with notes on pressure ulcers (n = 59) were audited using the European Pressure Ulcer Advisory Panel and Comprehensiveness In Nursing Documentation instruments. RESULTS The overall prevalence of pressure ulcers obtained by audit of patient records was 14.3% compared to 33.3% when the patients' skin was examined. The lack of accuracy was most evident in the documentation of grade 1 pressure ulcers. The quality of the nursing documentation of pressure ulcer (n = 59) was generally poor. CONCLUSIONS Patient records did not present valid and reliable data about pressure ulcers. There is a need for guidelines to support the care planning process and facilitate the use of research-based knowledge in clinical practice. More attention must be focused on the quality of clinical data to make proper use of electronic patient records in the future.
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Affiliation(s)
- Lena Gunningberg
- Department of Public Health and Caring Sciences, Section of Caring Sciences, Uppsala University, Uppsala, Sweden.
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Abstract
The aim of this study was to describe and analyse nursing documentation based on an electronic patient record (EPR) system in primary health care (PHC) with emphasis on the nurses' opinions and what, according to the nursing process and the use of the keywords, the nurses documented. The study was performed in one county council in the south of Sweden and included 42 Primary Health Care Centres (PHCC). It consisted of a survey, an audit of nursing records with the Cat-ch-Ing instrument and calculation of frequencies of keywords used during a 1-year period. For the survey, district nurses received a postal questionnaire. The results from the survey indicated an overall positive tendency concerning the district nurses' opinions on documentation. Lack of in-service training in nursing documentation was noted and requested from the district nurses. All three parts of the study showed that the keywords nursing interventions and status were frequently used while nursing diagnosis and goal were infrequent. From the audit, it was noted that medical status and interventions appeared more often than nursing status. The study demonstrated limitations in the nursing documentation that inhibited the possibility of using it to evaluate the care given. In order to develop the nursing documentation, there is a need for support and education to strengthen the district nurses' professional identity. Involvement from the heads of the PHCC and the manufactures of the EPR system is necessary, in cooperation with the district nurses, to render the nursing documentation suitable for future use in the evaluation and development of care.
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Affiliation(s)
- Eva Törnvall
- Department of Care and Welfare, Division of Nursing Science, Faculty of Health Sciences, University of Linköping, Linköping, Sweden.
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Voutilainen P, Isola A, Muurinen S. Nursing documentation in nursing homes - state-of-the-art and implications for quality improvement. Scand J Caring Sci 2004; 18:72-81. [PMID: 15005666 DOI: 10.1111/j.1471-6712.2004.00265.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This study was designed to gain information on the quality of nursing care based on the comments in nursing records. The specific aims of the study were to find out if the patients' (i) individual needs are assessed, the goals for nursing care are set, and the nursing interventions are determined; (ii) if the patients' needs are met and (iii) if goal achievement is regularly evaluated by including comments in nursing documents. In addition, the study aimed to describe the up-to-dateness of nursing care plans as well as the frequency of making daily notes. The data were collected on 36 wards of four residential homes. A 30% sample of the nursing documents on each ward was collected (n=332) using the Senior Monitor instrument. The documents studied were mainly nursing care plans and daily note sheets. Seventy-three per cent of the nursing home residents had an up-to-date nursing care plan at the time of data collection. The main results demonstrated that a written statement on the patient's mental ability was lacking in every fourth document although 75% of the patients suffer from at least moderate dementia in Finnish long-term care institutions. Development activities should also be targeted to the documentation of clear and concrete means by which patients' independent functioning is supported. In addition, evaluation was the area that warranted attention and development activities since only every fourth record included information on changes in the patients' functional capability. Although a lot of in-service training has been focused on improving the documentation practices, there is still a need for development. The means by which knowledge is transferred to guide the practice should be carefully considered. Also forms should be developed to meet the special requirements for recording nursing care in long-term care settings.
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Affiliation(s)
- Päivi Voutilainen
- Stakes (National Research and Development Centre for Welfare and Health)/Policy and Services for Ageing People, Helsinki, Finland.
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Pérez Rivas FJ, Carrera Manchado C, Ángeles López Blasco M, Auñón Muelas Á, García López M, Beamud Lagos M. Nuevos indicadores en la provisión de servicios: diagnósticos enfermeros en atención primaria. ENFERMERIA CLINICA 2004. [DOI: 10.1016/s1130-8621(04)73859-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Ehrenberg A, Birgersson C. Nursing documentation of leg ulcers: adherence to clinical guidelines in a Swedish primary health care district. Scand J Caring Sci 2003; 17:278-84. [PMID: 12919463 DOI: 10.1046/j.1471-6712.2003.00231.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The aim of this study was to investigate the adherence of nursing documentation to clinical guidelines in leg ulcer patients. Using two audit instruments, 100 patient records from primary health care were reviewed. The nursing content in the records was assessed according to instructions for documentation in local clinical guidelines for leg ulcers and the comprehensiveness of the nursing process in recording was reviewed. The results indicated deficiencies in the documentation of aspects of relevance in the care of leg ulcer patients. In addition, the findings indicated flaws in the adoption of the nursing process in recording. Only one problem in one patient record was recorded that consistently used the nursing process. The conclusion is that, despite specific and locally developed guidelines for care of leg ulcer patients, nursing records did not provide a precise audit of the care process. Because patient record information without a clear structure following the nursing process tends to impede communication and evaluation of care, such defective information is likely to have a significant impact on the continuity and quality in patient care.
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Affiliation(s)
- Anna Ehrenberg
- Department of Health and Society, Dalarna University, Falun, Sweden.
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Ehnfors M, Florin J, Ehrenberg A. Applicability of the International Classification of Nursing Practice (ICNP) in the areas of nutrition and skin care. INTERNATIONAL JOURNAL OF NURSING TERMINOLOGIES AND CLASSIFICATIONS : THE OFFICIAL JOURNAL OF NANDA INTERNATIONAL 2003; 14:5-18. [PMID: 12747302 DOI: 10.1111/j.1744-618x.2003.tb00052.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate completeness, granularity, multiple axial content, and clinical utility of the beta version of the ICNP in the context of standardized nursing care planning in a clinical setting. METHODS An 35-bed acute care ward for infectious diseases at a Swedish university hospital was selected for clinical testing. A convenience sample of 56 patient records with data on nutrition and skin care was analyzed and mapped to the ICNP. FINDINGS Using the ICNP terminology, 59%-62% of the record content describing nursing phenomena and 30%-44% of the nursing interventions in the areas of nutrition and skin care could be expressed satisfactorily. For about a quarter of the content describing nursing phenomena and interventions, no corresponding ICNP term was found. CONCLUSIONS The ICNP needs to be further developed to allow representation of the entire range of nursing care. Terms need to be developed to express patient participation and preferences, normal conditions, qualitative dimensions and characteristics, nonhuman focus, and duration. PRACTICE IMPLICATIONS The practical usefulness of the ICNP needs further testing before conclusions about its clinical benefits can be determined.
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Björvell C, Wredling R, Thorell-Ekstrand I. Long-term increase in quality of nursing documentation: effects of a comprehensive intervention. Scand J Caring Sci 2002; 16:34-42. [PMID: 11985747 DOI: 10.1046/j.1471-6712.2002.00049.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This study aimed to evaluate the longitudinal effects of a nursing-documentation intervention on the quantity and quality of the nursing documentation in a sample of patient records at a university hospital in Stockholm, Sweden. In this quasi-experimental longitudinal study, two hospital wards participated in a 2-year intervention and a third ward was used for comparison. The intervention consisted of organizational changes and education regarding nursing documentation in accordance with the VIPS model, a model designed to structure nursing documentation. To evaluate the effect, patient records were audited at three different time points: before the intervention, directly after the intervention and 3 years after the intervention. A total of 269 patient records were used. The findings showed a significant score increase in quantity as well as in quality of the nursing documentation, in the intervention wards directly after the intervention, as compared with those from the comparison ward. The results suggests that a comprehensive intervention based on the VIPS model and including organizational support for registered nurses (RN) may improve nursing documentation in an acute care hospital setting.
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Affiliation(s)
- Catrin Björvell
- Division of Nursing Research, Department of Nursing, Borgmästarvillan, Karolinska Institutet Hospital, S-171 76 Stockholm, Sweden.
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Gunningberg L, Lindholm C, Carlsson M, Sjödén PO. Risk, prevention and treatment of pressure ulcers--nursing staff knowledge and documentation. Scand J Caring Sci 2002; 15:257-63. [PMID: 11564234 DOI: 10.1046/j.1471-6712.2001.00034.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The aims were to investigate (i) registered nurses' and nursing assistants' knowledge of risk, prevention and treatment of pressure ulcer before implementing a system for risk assessment and pressure ulcer classification for patients with hip fracture (ii) interventions documented in the patient's records by registered nurses, and (iii) to what extent reported and documented interventions accord with the Swedish quality guidelines. Nursing staff (n=85) completed a questionnaire, and patient's records (n=55) were audited retrospectively. The majority of the nursing staff reported that they performed risk assessment when caring for a patient with hip fracture. These risk assessments were, however, not comprehensive. The most frequently reported preventive interventions were repositioning, use of lotion, mattresses/overlays and cushions for the heels. These interventions were to some extent documented in the patient's records. Nutritional support, reduction of shear and friction, hygiene and skin moisture, and patient's education were reported to a small extent and not documented at all. The Swedish quality guidelines regarding prevention and treatment of pressure ulcers were not fully implemented in clinical practice. It was concluded that nursing staff's knowledge and documentation of risk, prevention and treatment of pressure ulcers for patients with hip fractures could be improved.
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Affiliation(s)
- L Gunningberg
- Department of Public Health and Caring Sciences, Section of Caring Sciences, Uppsala University, Uppsala, Sweden.
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Thoroddsen A, Thorsteinsson HS. Nursing diagnosis taxonomy across the Atlantic Ocean: congruence between nurses' charting and the NANDA taxonomy. J Adv Nurs 2002; 37:372-81. [PMID: 11872107 DOI: 10.1046/j.1365-2648.2002.02101.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE AND AIMS The purpose of this study was to analyse expressions or terms used by nurses in Iceland to describe patient problems. The classification of NANDA was used as reference. The research questions were: (a) Does NANDA terminology represent patient problems documented by Icelandic nurses? (b) If so, what kind of nursing diagnoses does it represent? (c) What kind of patient problems are not represented by NANDA terminology? (d) What are the most frequent nursing diagnoses used? METHODS A retrospective chart review was conducted in a 400 bed acute care hospital in Iceland. The sample was defined as nursing diagnosis statements in charts of patients hospitalized in two 6-month periods in two separate years. The data were analysed according to a predefined grading system based on the PES format or Problem -- (A)aetiology -- Signs and symptoms. RESULTS A total of 1217 charts were used for the study, which yielded 2171 nursing diagnoses statements for analysis. Charts with at least one nursing diagnosis documented were 60.1% and the number of diagnoses per patient ranged from 0 to 10, with 65% of charts with three diagnoses or less. The number of diagnoses correlated with patients' length of stay, but not with increased age of the patients. The average number of statements per patient was 3.28. Almost 60% of the diagnoses were according to NANDA terminology, another 20% were stated as procedures, medical diagnoses or risks for complications. The 20 most frequently used nursing diagnoses accounted for 80% of all diagnoses documented. Discrepancy between nurses' documentation on emotional problems and availability of diagnosis in the NANDA taxonomy was evident. CONCLUSION It can be concluded that the NANDA taxonomy seems to be culturally relevant for nurses in different cultures.
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Affiliation(s)
- Asta Thoroddsen
- Faculty of Nursing, University of Iceland, Reykjavik, Iceland.
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Björvell C, Thorell-Ekstrand I, Wredling R. Development of an audit instrument for nursing care plans in the patient record. Qual Health Care 2000; 9:6-13. [PMID: 10848373 PMCID: PMC1743497 DOI: 10.1136/qhc.9.1.6] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To develop, validate, and test the reliability of an audit instrument that measures the extent to which patient records describe important aspects of nursing care. MATERIAL Twenty records from each of three hospital wards were collected and audited. The auditors were registered nurses with a knowledge of nursing documentation in accordance with the VIPS model--a model designed to structure nursing documentation. (VIPS is an acronym formed from the Swedish words for wellbeing, integrity, prevention, and security.) METHODS An audit instrument was developed by determining specific criteria to be met. The audit questions were aimed at revealing the content of the patient for nursing assessment, nursing diagnosis, planned interventions, and outcome. Each of the 60 records was reviewed by the three auditors independently and the reliability of the instrument was tested by calculating the inter-rater reliability coefficient. Content validity was tested by using an expert panel and calculating the content validity ratio. The criterion related validity was estimated by the correlation between the score of the Cat-ch-Ing instrument and the score of an earlier developed and used audit instrument. The results were then tested by using Pearson's correlation coefficient. RESULTS The new audit instrument, named Cat-ch-Ing, consists of 17 questions designed to judge the nursing documentation. Both quantity and quality variables are judged on a rating scale from zero to three, with a maximum score of 80. The inter-rater reliability coefficients were 0.98, 0.98, and 0.92, respectively for each group of 20 records, the content validity ratio ranged between 0.20 and 1.0 and the criterion related validity showed a significant correlation of r = 0.68 (p < 0.0001, 95% CI 0.57 to 0.76) between the two audit instruments. CONCLUSION The Cat-ch-Ing instrument has proved to be a valid and reliable audit instrument for nursing records when the VIPS model is used as the basis of the documentation.
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Affiliation(s)
- C Björvell
- Karolinska Hospital, Department of Nursing, Karolinska Institutet, Stockholm, Sweden.
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