Nursing Specialty Knowledge as Expressed by Standardized Nursing Languages

The Clinical Value of Comprehensive Nursing Intervention in Preventing Severe Lymphopenia and Improving the Survival Rate Among Patients with Sepsis

Background

Intensive care unit (ICU) patients with sepsis who experience severe lymphopenia are at a higher risk of mortality, and they serve as a more accurate indicator of bacteremia compared to traditional infection markers.

Aim

Our study aimed to examine the influence of severe lymphopenia on ICU mortality and outcomes in sepsis patients, while also evaluating the clinical significance of comprehensive nursing intervention in preventing severe lymphopenia.

Methods

Patients with sepsis in the ICU at our hospital between January 2015 and January 2021 were split into a control group and a test group.The control group received regular nursing care, while the test group was provided with comprehensive nursing care in addition to the control group. The results encompassed mortality rates of 28 days, mortality rates of 1 year, and lengths of stay in the ICU.

Results

Our attention was directed towards day 4 absolute lymphocyte counts, taking into account the receiver operating characteristic (ROC) outcome. Patients with severe lymphopenia were older, more patients with 2 above comorbidities, higher co-infection rates and SOFA score. In addition, patients with severe lymphopenia required longer days stay in ICU (P<0.001), and presented with higher 28-day mortality (P=0.038) and 1-year mortality (P=0.004). Patients in control group have a higher incidence of severe lymphopenia (P=0.006), 28-day mortality (P=0.015) and 1-year mortality (P=0.019) compared with the test group.

Conclusion

Comprehensive nursing intervention can prevent the occurrence of severe lymphopenia, improve patients satisfaction and reduce mortality.

Perceptions of Turkish Nursing Students on Nursing Diagnose

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

An ESP Approach to Teaching Nursing Note Writing to University Nursing Students

For nursing students in the vocational education system in Taiwan, English-language writing skills, whether for general or specific purposes, have long been ignored, which may jeopardize their success in medical-oriented courses and their future careers. This study designed a nursing note-writing course (NNWC) for university nursing students and explored the teaching outcomes of its implementation. The three main objectives were to (a) examine the effectiveness of the NNWC in enhancing learners’ competencies; (b) survey learners’ satisfaction with the NNWC, and (c) investigate learners’ perceptions of the NNWC. In this action research, 49 students practiced five writing tasks while guided with five teaching tools, namely an online writing platform, multiple revisions, peer-review activities, and direct and indirect teacher feedback, for a semester. External examiners included a language teacher and a nursing professional, and the data-collection instruments used included a writing competence scale and a course satisfaction questionnaire. The results showed that the learners’ writing competence significantly improved after the NNWC. They also demonstrated a fair level of satisfaction toward the NNWC. A total of 90% of the learners preferred online writing compared to traditional handwriting. The learners also indicated a preference for feedback from the teacher rather than from peers, and they perceived vocabulary capability to be crucial. ESP/ENP teachers are advised to consider the implementation of the NNWC when designing syllabi.

Mapping the evidence-based practice research field in nursing from 1995 to 2021: A bibliometric analysis

BACKGROUND

Evidence-based nursing and its practices are increasing rapidly in the health and nursing literature. A holistic image of evidence-based nursing research is needed to address evidence-based studies and available information on nursing.

AIM

The aim of this study was to evaluate evidence-based nursing-related research with bibliometric analysis in order to provide a structured macroscopic overview of its features and advances.

METHODS

A bibliometric analysis of 4,159 publications from 1995 to 2021 was performed to map the literature of evidence-based nursing studies and assess the structure of the scientific community. The studies' publication output and growth trend, authors and collaborations, publishing journals, terms, current trends, subject categories, global distribution and collaboration, and the authors' average number of citations were all assessed.

RESULTS

It was found that the number of evidence-based nursing publications increased until 2016, reaching the publication peak (n = 369), after which they began to decline. Most studies on the topic (n = 543) have been published in the journal Worldviews on Evidence-Based Nursing. Evidence-based knowledge, dissemination, implementation, implementation barriers, and implementation and training curricula in particular fields have all evolved over time as the key concepts of research. The United States (6,218), Australia (1,247), and England (790) are the three nations with the highest number of publications. On the other hand, it is seen that the subject has yet to be discussed in a few developing or underdeveloped countries.

CONCLUSIONS

In the last 12 years, evidence-based nursing has been a comprehensive area of research. In comparison with the research areas in its field, it can be speculated that it has a more practical focus. It was determined that the authors' keywords primarily began with research implementation, practice development, and knowledge utilization over time, and then evolved to specific areas, educational areas, process applications, and important current topics such as Covid19.

Use of standardized terminologies in clinical practice: A scoping review

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.

Conceptual development and validation of the nursing diagnosis "Disturbed thought process"

PURPOSE

To validate the content of the nursing diagnosis proposal Disturbed thought process.

METHODS

With an exploratory and descriptive design, the content validation for each component of the diagnosis proposal was pursued, based on a previous broad conceptual work, through consulting experts, applying Fehring's Diagnosis Content Validation Model. The modified Delphi technique was used by sending out three rounds of questionnaires electronically to seek consensus among the experts.

FINDINGS

The nursing diagnosis version validated in this study includes the diagnosis label Disturbed thought process, the corresponding definition, 15 defining characteristics, and 13 related factors. The resulting diagnosis total Diagnosis Content Validation score was 0.99, implying its content validation.

CONCLUSIONS

The validated diagnosis proposal describes a human response for which nursing professionals can autonomously assess and prescribe interventions leading to improvement of this health problem and/or alleviate its consequences, preserving the patient's autonomy and helping them to address their situation. It will be included in the next edition of the nursing diagnosis classification NANDA-I 2021-2023.

IMPLICATIONS FOR NURSING PRACTICE

The results of this study will help nursing professionals reduce the potential impact among patients who suffer from an alteration in cognitive functioning in its executive function dimension, as the validated diagnosis proposal will make it possible to identify and report this problem precisely.

Veterans Health Administration nurses' training and beliefs related to care of patients with traumatic brain injury

BACKGROUND

Veteran patients with traumatic brain injury (TBI) and their family members regularly receive care from nurses. Understanding nurses' training and beliefs can provide direction for intervention work aimed at ensuring the best possible care is delivered to this population.

AIMS

We examined Veterans Health Administration (VHA) nurses' training and beliefs related to care of patients with moderate-to-severe TBI.

DESIGN AND METHODS

We conducted an exploratory, cross-sectional survey with 211 VHA nurses and analyzed data using descriptive statistics.

RESULTS

The average years of nursing experience was 18 years, and 90% reported ever caring for a patient with TBI. Most nurses (70%) reported only seeing patients with TBI ≤1-2 times per year in their current role; 20% reported seeing these patients 1-2 times per month. Even with infrequent care, almost 50% reported previously receiving TBI-related training. Beliefs items with the highest accuracy indicated nurses agreed that they need specialized training to care for patients with TBI and that TBI recovery may continue for several years (96.39% accuracy respectively). The beliefs item with the lowest accuracy indicated focus on whether nurses agreed that TBI severity was important in developing care plans (27.84% accuracy). Nurses reported the need for clarity of the nursing role in caring for patients with TBI (77.32% agreement).

CONCLUSION

VHA nurses do have accurate beliefs about caring for Veteran patients with moderate-to-severe TBI; however, there is the need for further role clarification regarding nursing care of patients with TBI.

IMPACT

These findings have implications for development of education and training interventions for nurses who care for Veteran patients with TBI.

Nursing interventions in mental health and psychiatry: Content analysis of records from the nursing information systems in use in Portugal

WHAT IS KNOWN ABOUT THE SUBJECT?: Planning and implementation of care are based on the selection and application of nursing interventions, which correspond to a key element in the nursing process. No information was found in the literature about which major nursing interventions are documented by nurses working in psychiatric wards. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Despite the criteria applied to the intervention records' analysis may have led to the exclusion of certain important aspects of mental health nursing, this study provides information on some of the most relevant interventions in the field of psychiatric and mental health nursing documented in Portugal, placing them into the different steps of the nursing process. This study revealed the lack of standardized language used by nurses in intervention definitions, which results in the use of varied terminology to describe the same intervention. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This study constitutes an important contribution towards the standardization of language used by mental health nurses in intervention definitions, which may lead to the production of health indicators that will show policymakers the importance of nursing care towards population health. This study also contributes to the improvement of nursing informatics systems in use in psychiatric departments, particularly through the differentiation between different types of intervention, placing them into the proper steps of the nursing process. The problems identified in this study regarding nursing documentation may suggest that more training for professional nurses in the field of intervention formulation is needed. ABSTRACT: Introduction The nursing intervention corresponds to a key element in the nursing process. No information was found in the literature about which major interventions are documented by nurses working in psychiatric wards. Aims (a) To identify the interventions documented by nurses in Portugal that respond to nursing needs within the scope of psychiatric nursing; (b) to identify the main problems in identifying these interventions. Method A descriptive study combining: (a) quantitative content analysis of intervention records identified by mental health nurses in Portugal and (b) a focus group meeting with 14 nurses exploring the results of the first study phase. Results The 2,881 initial intervention records were systematized into 198 intervention categories. Some problems in the interventions' documentation by nurses were identified. Discussion Despite certain important aspects of mental health nursing may have been excluded, this study provides information on some of the most relevant interventions in the field of mental health nursing documented in Portugal. Implications for practice This study may offer an important contribution to the improvement of nursing informatics systems and the production of health indicators that reveal the contribution of nursing care towards population health.

Identifying Nursing Diagnosis Patterns in Three Intensive Care Units Using Network Analysis

PURPOSE

This study aimed to analyze the patterns of nursing diagnoses used in three different types of intensive care units (ICUs) using network analysis.

METHODS

A secondary analysis was conducted using clinical datasets of 582 patients. Frequency, degree/betweenness centrality, and subgroup analysis were performed.

FINDINGS AND CONCLUSIONS

The findings illuminated core nursing diagnoses with high centrality as well as high frequency. The centrality analysis identified the differences between and unique characteristics of each ICU. The subgroup analysis revealed the nursing problem groups related to the specific nursing care delivered to ICU patients.

IMPLICATIONS FOR NURSING PRACTICE

Theses results provide a knowledge base to aid ICU nurses' prompt decision making regarding nursing diagnoses.

Pediatric nurses' perceived knowledge and beliefs of evidence-based practice in the care of children and adolescents with moderate-to-severe traumatic brain injury

PURPOSE

Pediatric nurses play a significant role in all phases of traumatic brain injury (TBI) recovery, particularly during the hospital stay. Although evidence-based nursing practice is known to improve patient outcomes, limited research exists on nurses' evidence-based perceived knowledge and beliefs specific to TBI care. As nurses' perceived knowledge and beliefs are known to guide their practice behaviors, this assessment is important to overall TBI outcomes. The purpose of this study was to evaluate pediatric nurses' evidence-based perceived knowledge and beliefs in providing care for children and adolescents with moderate-to-severe TBI.

DESIGN AND METHODS

Data for this study were obtained from a larger parent study on nurses' perceptions of caring for patients of all ages with moderate-to-severe TBI. The parent study was an exploratory, cross-sectional electronic survey of registered nurses across all hospital departments within a large Midwestern health system. Only data specific to pediatric nurses (n = 330) were analyzed for this study. Descriptive statistics and latent class analysis (LCA) were performed.

RESULTS

Pediatric nurses, on average, were 38.79 years, female (90.37%), had over a decade of nursing experience (13.55 years), and practiced as a staff nurse (80.07%) on an inpatient unit (45.51%). Findings indicated pediatric nurses reported overall low levels of evidence-based perceived knowledge and had inaccurate beliefs about caring for patients with TBI. LCA indicated two distinct homogenous subgroups specific to evidence-based perceived knowledge: low (41%) and high (59%). Nurses in the low evidence-based perceived knowledge group were younger, had less nursing experience, worked primarily on an inpatient unit, and cared for patients with TBI at a higher frequency compared to high evidence-based perceived knowledge nurses. Additionally, there were significant differences in beliefs about sex-based patient differences after TBI and the role of nurses in caring for patients with TBI based on level of evidence-based perceived knowledge.

PRACTICE IMPLICATIONS

Assessing nurses' perceived knowledge and beliefs of evidence-based practice is a foundational step toward implementing evidence-based care for patients with moderate-to-severe TBI. Implications of these findings indicate the need to provide additional education to increase pediatric nurses' perceived knowledge and ensure accurate beliefs about evidence-based TBI care.

Caring for Patients with traumatic brain injury: a survey of nurses' perceptions

AIMS AND OBJECTIVES

The purpose of this study was to determine nurses' perceptions about caring for patients with traumatic brain injury.

BACKGROUND

Annually, it is estimated that over 10 million people sustain a traumatic brain injury around the world. Patients with traumatic brain injury and their families are often concerned with expectations about recovery and seek information from nurses. Nurses' perceptions of care might influence information provided to patients and families, particularly if inaccurate knowledge and perceptions are held. Thus, nurses must be knowledgeable about care of these patients.

METHODS

A cross-sectional survey, the Perceptions of Brain Injury Survey (PBIS), was completed electronically by 513 nurses between October and December 2014. Data were analysed with structural equation modelling, factor analysis, and pairwise comparisons.

RESULTS

Using latent class analysis, authors were able to divide nurses into three homogeneous sub-groups based on perceived knowledge: low, moderate and high. Findings showed that nurses who care for patients with traumatic brain injury the most have the highest perceived confidence but the lowest perceived knowledge. Nurses also had significant variations in training.

CONCLUSIONS

As there is limited literature on nurses' perceptions of caring for patients with traumatic brain injury, these findings have implications for training and educating nurses, including direction for development of nursing educational interventions.

RELEVANCE TO CLINICAL PRACTICE

As the incidence of traumatic brain injury is growing, it is imperative that nurses be knowledgeable about care of patients with these injuries. The traumatic brain injury PBIS can be used to determine inaccurate perceptions about caring for patients with traumatic brain injury before educating and training nurses.

Uso de ácidos grasos en la prevención de úlceras por presión y de extremidad inferior

<p class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph; line-height: normal;"><strong style="mso-bidi-font-weight: normal;"></strong><span style="font-size: 12.0pt;"><strong>Objetivo:</strong> Analizar la literatura científica acerca del uso y la efectividad de los ácidos grasos hiperoxigenados y las actuaciones de los profesionales de enfermería en la prevención y tratamiento de úlceras por presión y heridas crónicas.</span></p><p class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph; line-height: normal;"><span style="font-size: 12.0pt;"><strong>Metodología:</strong> Se llevó a cabo una revisión bibliográfica de la literatura en las principales bases de datos de las ciencias de la salud y las ciencias sociales (MEDLINE-PUBMED, CINHAL, WEB of SCIENCE, LILACS, SOCIOLOGOCAL ABSTRACTS, CUIDEN, EMBASE, PSYCOINFO e ISI WEB of KNOWLEDGE). Se hizo una revisión analítica de los artículos seleccionados utilizando un protocolo para extraer los datos.</span></p><p class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph; line-height: normal;"><span style="font-size: 12.0pt;"><strong>Resultados:</strong> Del total de artículos encontrados, 14 reportaron los resultados de ensayos clínicos o estudios cualitativos. Los autores señalaron los beneficios de la utilización de los ácidos grasos hiperoxigenados en la prevención y tratamiento de las úlceras por presión y heridas crónicas.</span></p><p class="MsoNormal" style="text-align: justify; text-justify: inter-ideograph; line-height: normal;"><span style="font-size: 12.0pt;"><strong>Conclusiones:</strong> En los estudios analizados se identificaron principalmente asuntos sobre la prevención, el tratamiento y el cuidado de enfermería en personas con úlceras crónicas y agudas. Como estrategia<br />de intervención, se reportó la efectividad de los ácidos grasos hiperoxigenados, lo que permite sugerir el uso protocolizado en el ámbito institucional, bajo la consideración de un plan de cuidados estructurado con la metodología científica del Proceso de Atención de Enfermería.</span></p>

Basic nursing care: retrospective evaluation of communication and psychosocial interventions documented by nurses in the acute care setting

PURPOSE

This study aimed to evaluate the frequency of psychosocial aspects of basic nursing care, as e-charted by nurses, when using an interface terminology.

METHODS

An observational, multicentre study was conducted in acute wards. The main outcome measure was the frequency of use of the psychosocial interventions in the electronic nursing care plans, analysed over a 12 month retrospective review.

FINDINGS

Overall, 150,494 electronic care plans were studied. Most of the intervention concepts from the interface terminology were used by registered nurses to illustrate the psychosocial aspects of fundamentals of care in the electronic care plans.

CONCLUSIONS AND IMPLICATIONS

The results presented help to demonstrate that the interventions of this interface terminology may be useful to inform psychosocial aspects of basic and advanced nursing care.

CLINICAL RELEVANCE

The identification of psychosocial elements of basic nursing care in the nursing documentation may lead to obtain a deeper understanding of those caring interventions nurses consider essential to represent nurse-patient interactions. The frequency of psychosocial interventions may contribute to delineate basic and advanced nursing care.

Developing nurse educators' computer skills towards proficiency in nursing informatics

The purpose of this paper is to assess nurse educators' competence development in nursing informatics (NI) and to compare their competence to the NI competence of other healthcare professionals. Electronic health records (EHR) have been in use for many years. However, the adoption of the nursing care plan finally made it possible for nurses in Finland to develop a model for structured documentation with nursing terminology. A total of n = 124 (n = 85 pre-test and n = 39 post-test) participants from Universities of Applied Sciences (UAS), hospitals, hospitals' information management and health centres were surveyed with a e-questionnaire designed to assess the development of their NI competences during the nursing documentation development project. The questionnaire included 145 structured questions and 6 open questions. Data analysis focused on classification and comparison of NI competences through data description and statistical parameters using figures and tables. The basic NI competences of the nurse educators were good at the end of project and the nurse educators had better information literacy and information management competences than other participants. The information retrieval skills varied greatly, but they improved evenly towards the end. The nurse educators mastered better evidence-based nursing and use of nursing process models in their work.

What patients' problems do nurses e-chart? Longitudinal study to evaluate the usability of an interface terminology

BACKGROUND

The nurses' ability to document patient's status, problems and progress is an important issue in patients' safety. Nursing terminologies are intended to support nursing practice but as any other clinical tool, they should be evaluated to assure quality and warrant effective written communication among clinicians.

OBJECTIVES

This study was aimed to evaluate the usability of the diagnosis axis of an interface terminology by assessing its completeness and the frequency of use of its concepts.

DESIGN

Observational, longitudinal, multicentre study.

SETTING

A total of 8 hospitals representing 162 acute medical-surgical, obstetric and mental health nursing wards, step-down units and home in-patient units were included.

PARTICIPANTS

Overall, 246,400 electronic care plans were studied; 53.5% from male patients; 14.6% paediatrics and 33.7% from patients elder than 70 years old. Most were admitted due to cardiocirculatory, respiratory, digestive or musculoskeletal conditions (50.5%), other acute medical or surgical disorders (29.8%) and obstetrics (19.3%).

METHODS

The main outcome measures were: the use of nursing diagnoses from the interface terminology evaluated and their accumulated frequency, analysed over a 3-year retrospective review of the electronic nursing care plans. The analysis of data included descriptive statistics with a confidence level of 95% for confidence intervals.

RESULTS

Most of the diagnostic concepts from the interface terminology were used (92.3%) by nurses to illustrate patients' problems in the electronic care plans. Their frequency of use widely varied, from some very frequent diagnoses like Risk for haemorrhage (51.4%; CI 95%: 51.25-51.65) or Acute pain (49.6%; CI: 49.49-49.88) to others used only in exceptional cases like Faecal impaction or Extravasation. The first nursing diagnosis related to family or caregiver emerges in the 32nd place of the ranking.

CONCLUSIONS

Results for outcome measures oriented that the diagnosis axis of this interface terminology meets the usability criterion of completeness when assessing for the use of its concepts in the acute care setting.

Consulta de enfermagem ambulatorial e diagnósticos de enfermagem relacionados a características demográficas e clínicas

Trata-se de um estudo que verificou a relação entre as características demográficas e clínicas com os diagnósticos de enfermagem definidos durante a consulta com enfermeira em ambulatório de um hospital geral. É um estudo transversal, que avaliou 237 consultas de enfermagem de pacientes atendidos no Programa de Saúde da Mulher (46 em enfermagem obstétrica e 24 em enfermagem em mastologia) e 167 no Programa de Educação em Diabetes Melito. Foram identificados 49 diagnósticos de enfermagem. Os mais frequentes no programa de saúde da mulher foram: Conhecimento deficiente, Conforto prejudicado, Integridade tissular prejudicada e Ansiedade. No programa de educação em diabetes: Controle ineficaz do regime terapêutico e Nutrição desequilibrada: mais do que as necessidades corporais. Foi encontrada associação significativa entre os diagnósticos mais frequentes com determinadas características demográficas e clínicas. Os resultados confirmaram que a identificação dos diagnósticos de enfermagem durante a consulta pode propiciar acurácia nos focos de cuidado ambulatorial.

Caracterização dos diagnósticos de enfermagem de pacientes internados em uma unidade de cardiologia

Trata-se de um estudo retrospectivo, descritivo-exploratório, com objetivo de formular os diagnósticos de enfermagem (DE) mais frequentes no subgrupo de pacientes portadores de doenças isquêmicas do coração, internados em unidade de cardiologia e verificar sua associação com características sociodemográficas e clínicas. Os dados foram coletados a partir de instrumento baseado nas características definidoras e fatores de risco (Taxonomia II, North American Nursing Diagnosis Association International) e submetidos à análise descritiva simples e inferencial para verificar a associação entre os DE e as características sociodemográficas e clínicas. Foram formulados 77 DE, dos quais 18 encontravam-se acima do percentil 75. Destes, 15 foram associados a alguma característica sociodemográfica ou clínica como sexo, idade, estado civil, atividade profissional e condições clínicas associadas.

Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review

AIMS

This paper reports a review that identified and synthesized nursing documentation audit studies, with a focus on exploring audit approaches, identifying audit instruments and describing the quality status of nursing documentation.

INTRODUCTION

Quality nursing documentation promotes effective communication between caregivers, which facilitates continuity and individuality of care. The quality of nursing documentation has been measured by using various audit instruments, which reflected variations in the perception of documentation quality among researchers across countries and settings.

DATA SOURCES

Searches were made of seven electronic databases. The keywords 'nursing documentation', 'audit', 'evaluation', 'quality', both singly and in combination, were used to identify articles published in English between 2000 and 2010.

REVIEW METHODS

A mixed-method systematic review of quantitative and qualitative studies concerning nursing documentation audit and reports of audit instrument development was undertaken. Relevant data were extracted and a narrative synthesis was conducted.

RESULTS

Seventy-seven publications were included. Audit approaches focused on three natural dimensions of nursing documentation: structure or format, process and content. Numerous audit instruments were identified and their psychometric properties were described. Flaws of nursing documentation were identified and the effects of study interventions on its quality.

CONCLUSION

Research should pay more attention to the accuracy of nursing documentation, factors leading to variation in practice and flaws in documentation quality and the effects of these on nursing practice and patient outcomes, and the evaluation of quality measurement.

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

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