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Tischendorf T, Heitmann-Möller A, Ruppert SN, Marchwacka M, Schaffrin S, Schaal T, Hasseler M. Sustainable integration of digitalisation in nursing education-an international scoping review. FRONTIERS IN HEALTH SERVICES 2024; 4:1344021. [PMID: 38665930 PMCID: PMC11043537 DOI: 10.3389/frhs.2024.1344021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 03/11/2024] [Indexed: 04/28/2024]
Abstract
Introduction Trainees and teachers at nursing schools as well as nursing professionals are increasingly facing new challenges as a result of the digital transformation. Opportunities for the entire care system exist in the improvement of care quality and communication between those involved. However, this change also harbours risks, such as the use of immature digital applications in the care sector, data theft and industrial espionage. In order to be able to exploit the potential of digitalisation despite these risks, it is necessary to integrate relevant aspects such as digital skills into nursing training. The aim of this study is to investigate the extent to which the sustainable integration of digitalisation in nursing education is discussed. Methods The methods of the systematic literature and database search were carried out in the form of a scoping review according to the PRISMA scheme. The PubMed and CINAHL databases were used for this purpose. The search period covered the years 2017-2023. Findings After screening the titles and abstracts using inclusion and exclusion criteria, 13 studies were included in the synthesis of findings. The international literature focuses on content areas that highlight trends in digitalisation-related training in nursing. These focal points include concept development, considering the heterogeneity of demand constellations, as well as the reflexive reorientation of existing competences, whereby the technological competence of teachers is not disregarded. Other focal points relate to the initiation of digital skills in training and maintaining the employability of older nursing staff through professional development. Discussion The literature research shows that there is a rudimentary discussion about digitalisation and curricular developments in nursing training in an international context, while the discourse in the German-language literature is less advanced. Among the sustainability desiderata derived from the literature is the involvement of nursing professionals in the development, testing and implementation of digital technologies. Only through active cooperation between nursing professionals and nursing sciences can the topic of digitalisation be integrated into the education and training of professional nursing in a targeted and future-oriented manner, whereby the focus should always be on the ability to deal with digital technologies and the associated change.
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Affiliation(s)
- Tim Tischendorf
- Faculty of Health and Healthcare Sciences, University of Applied Sciences Zwickau, Zwickau, Germany
| | | | - Sven-Nelson Ruppert
- Faculty of Healthcare, Ostfalia University of Applied Sciences, Wolfsburg, Germany
| | - Maria Marchwacka
- Faculty of Healthcare, Ostfalia University of Applied Sciences, Wolfsburg, Germany
| | - Sandra Schaffrin
- Faculty of Healthcare, Ostfalia University of Applied Sciences, Wolfsburg, Germany
| | - Tom Schaal
- Faculty of Health and Healthcare Sciences, University of Applied Sciences Zwickau, Zwickau, Germany
| | - Martina Hasseler
- Faculty of Healthcare, Ostfalia University of Applied Sciences, Wolfsburg, Germany
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Hants L, Bail K, Paterson C. Clinical decision-making and the nursing process in digital health systems: An integrated systematic review. J Clin Nurs 2023; 32:7010-7035. [PMID: 37485751 DOI: 10.1111/jocn.16823] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/19/2023] [Accepted: 07/04/2023] [Indexed: 07/25/2023]
Abstract
AIMS To identify how the nursing process (assessment, planning, intervention and outcome evaluation) has been incorporated into digital health systems (electronic medical records, electronic care plans and clinical decision support systems) to gain an understanding of known benefits and challenges posed to nurses' decision-making processes. BACKGROUND Nursing terminologies, including the International Classification for Nursing Practice (ICNP), and Nursing Minimum Data Set's (NMDS), have been developed to improve standardised language integration of components of nursing care into digital systems. However, there is limited evidence regarding whether the complete nursing process is effectively being incorporated into digital health systems. METHODS An integrative systematic review following PRISMA guidelines. A search strategy was applied to extract articles from included databases: CINAHL, MEDLINE, SCOPUS and Web of Science Core Collection. Articles were limited to English language and published January 2007-March 2022 and assessed using a pre-determined eligibility criteria. Quality assessment and a narrative synthesis were conducted. RESULTS A total of 3321 articles were identified, and 27 studies included. There were (n = 10) qualitative, (n = 4) quantitative non-randomised controlled trials, (n = 3) quantitative descriptive studies and (n = 10) mixed methods. Nurse assessment and planning components were the most comprehensive phases incorporated into digital health systems, and interventions and outcome evaluation were scarcely reported. CONCLUSIONS Inadequate capture of nursing work is a problem unresolved by digital health systems. This omission may be hindering nurse clinical decision-making for patient care and limiting the visibility of the nursing role in health care interventions and the associated impact on patient outcomes. RELEVANCE TO CLINICAL PRACTICE Further research is needed on how digital systems can support nurses to apply the full nursing process and to further evaluate patient outcomes. Digital systems can support health-service level evaluation through capturing missed nursing care and the consequences on patients utilising nurse-sensitive-outcomes; however, this is not yet being realised.
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Affiliation(s)
- Laura Hants
- School of Nursing, Midwifery and Public Health, University of Canberra, Bruce, Australian Capital Territory, Australia
| | - Kasia Bail
- School of Nursing, Midwifery and Public Health, University of Canberra, Bruce, Australian Capital Territory, Australia
- Canberra Health Services and ACT Health, SYNERGY Nursing and Midwifery Research Centre, ACT Health Directorate Level 3, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Catherine Paterson
- School of Nursing, Midwifery and Public Health, University of Canberra, Bruce, Australian Capital Territory, Australia
- Canberra Health Services and ACT Health, SYNERGY Nursing and Midwifery Research Centre, ACT Health Directorate Level 3, Canberra Hospital, Canberra, Australian Capital Territory, Australia
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Harrington L. Nurses' Overreliance on Fallible Technology. AACN Adv Crit Care 2023; 34:84-87. [PMID: 37289622 DOI: 10.4037/aacnacc2023526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Linda Harrington
- Linda Harrington is an Independent Consultant, Health Informatics and Digital Strategy, and Visiting Lecturer at Texas Christian University, 2800 South University Drive, Fort Worth, TX 76109
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Wurster F, Fütterer G, Beckmann M, Dittmer K, Jaschke J, Köberlein-Neu J, Okumu MR, Rusniok C, Pfaff H, Karbach U. The Analyzation of Change in Documentation due to the Introduction of Electronic Patient Records in Hospitals-A Systematic Review. J Med Syst 2022; 46:54. [PMID: 35781136 PMCID: PMC9252957 DOI: 10.1007/s10916-022-01840-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/31/2022] [Indexed: 11/29/2022]
Abstract
The major impact on healthcare through the ongoing digital transformation and new technologies results in opportunities for improving quality of care. Electronic patient records (EPR) are a substantial part in this transformation, even though their influence on documentation remains often unclear. This review aims to answer the question of which effect the introduction of the EPR has on the documentation proper in hospitals. To do this, studies are reviewed that analyze the documentation itself, rather than merely conducting interviews or surveys about it. Several databases were searched in this systematic review (PubMed including PubMed, PubMed Central and Medline; PDQ Evidence; Web of Science Core Collection; CINHAL). To be included, studies needed to analyze written documentation and empirical data, be in either German or English language, published between 2010 and 2020, conducted in a hospital setting, focused on transition from paper-based to electronic patient records, and peer reviewed. Quantitative, qualitative and mixed methods studies were included. Studies were independently screened for inclusion by two researchers in three stages (title, abstract, full text) and, in case of disagreement, discussed with a third person from the research team until consensus was reached. The main outcome assessed was whether the studies indicated a negative or positive effect on documentation (e.g. changing the completeness of documentation) by introducing an EPR. Mixed Methods Appraisal Tool was used to assess the individual risk of bias in the included studies. Overall, 264 studies were found. Of these, 17 met the inclusion criteria and were included in this review. Of all included studies, 11 of 17 proved a positive effect of the introduction of the EPR on documentation such as an improved completeness or guideline adherence of the documentation. Six of 17 showed a mixed effect with positive and negative or no changes. No study showed an exclusively negative effect. Most studies found a positive effect of EPR introduction on documentation. However, it is difficult to draw specific conclusions about how the EPR affects or does not affect documentation since the included studies examined a variety of outcomes. As a result, various scenarios are conceivable with higher or reduced burden for practitioners. Additionally, the impact on treatment remains unclear.
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Affiliation(s)
- Florian Wurster
- Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research, and Rehabilitation Science, University of Cologne, Cologne, Germany.
| | - Garret Fütterer
- Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research, and Rehabilitation Science, University of Cologne, Cologne, Germany
| | - Marina Beckmann
- Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research, and Rehabilitation Science, University of Cologne, Cologne, Germany
| | - Kerstin Dittmer
- Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research, and Rehabilitation Science, University of Cologne, Cologne, Germany
| | - Julia Jaschke
- Center for Health Economics and Health Services Research, University of Wuppertal, Wuppertal, Germany
| | - Juliane Köberlein-Neu
- Center for Health Economics and Health Services Research, University of Wuppertal, Wuppertal, Germany
| | - Mi-Ran Okumu
- Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research, and Rehabilitation Science, University of Cologne, Cologne, Germany
| | - Carsten Rusniok
- Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research, and Rehabilitation Science, University of Cologne, Cologne, Germany
| | - Holger Pfaff
- Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research, and Rehabilitation Science, University of Cologne, Cologne, Germany
| | - Ute Karbach
- Faculty of Human Sciences & Faculty of Medicine and University Hospital Cologne, Institute of Medical Sociology, Health Services Research, and Rehabilitation Science, University of Cologne, Cologne, Germany
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Gruden MK, Müller-Staub M, Pajnkihar M, Štiglic G. Standardization of Quality of Diagnoses, Interventions, and Outcomes (Q-DIO) Measurement Instrument for Use in Slovenia. Zdr Varst 2022; 61:14-23. [PMID: 35111262 PMCID: PMC8776288 DOI: 10.2478/sjph-2022-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 10/13/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To describe the cross-cultural adaptation of the Quality of Diagnoses, Interventions and Outcomes (Q-DIO) Instrument into the Slovene language. METHODS Based on general international guidelines, a six-step process of localization to translate and adjust the instrument from English into the Slovene language was used. Content validity was quantified based on an agreement of eight experts. The instrument was tested using a sample of 140 nursing documentations from two Slovenian tertiary hospitals. RESULTS 26 of 29 items showed an excellent content validity index ranging from 0.857 to 1.000, and a modified kappa index above 0.856. The content validity indexes of the three remaining items adjusted based on experts' comments were subsequently estimated at 1.000. Construct validity was significantly different between the two groups of documentations. The Cronbach coefficient for the whole questionnaire was 0.860. Cronbach's alpha if item deleted reamins above 0.80 for all items. The criteria for the difficulty grades of items and discrimination validity were acceptably met for more than 75% of items. CONCLUSION Based on the results of the study, it may be concluded that Q-DIO is a reliable instrument for measuring the quality of nursing documentation. The deviations in the results of some items are due to poor nursing documentation quality, and indicate that nursing classifications have not yet been fully implemented into practice in the study setting. Additional testing of the instrument is recommended.
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Affiliation(s)
- Maja Klančnik Gruden
- University of Maribor, Faculty of Health Sciences, Žitna ulica 15, 2000Maribor, Slovenia
- University Medical Centre Ljubljana, Zaloška 2, 1000LjubljanaSlovenia
| | - Maria Müller-Staub
- Institute of Nursing, Hanze University of Applied Sciences, Groningen, the Netherlands
- Pflege PBS, Obere Hofbergstrasse, 9500Wil, Switzerland
- Stadtspital Waid, Tièchestrasse 99, 8037Zürich, Switzerland
| | - Majda Pajnkihar
- University of Maribor, Faculty of Health Sciences, Žitna ulica 15, 2000Maribor, Slovenia
| | - Gregor Štiglic
- University of Maribor, Faculty of Health Sciences, Žitna ulica 15, 2000Maribor, Slovenia
- University of Maribor, Faculty of Electrical Engineering and Computer, 2000Maribor, Slovenia
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Munroe B, Curtis K, Fry M, Shaban RZ, Moules P, Elphick TL, Ruperto K, Couttie T, Considine J. Increasing accuracy in documentation through the application of a structured emergency nursing framework: A multisite quasi-experimental study. J Clin Nurs 2021; 31:2874-2885. [PMID: 34791742 DOI: 10.1111/jocn.16115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 09/30/2021] [Accepted: 10/16/2021] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To determine if the use of an emergency nursing framework improves the accuracy of clinical documentation. BACKGROUND Accurate clinical documentation is a nursing professional responsibility essential for high-quality and safe patient care. The use of the emergency nursing framework "HIRAID" (History, Identify Red flags, Assessment, Interventions, Diagnostics, reassessment and communication) improves emergency nursing care by reducing treatment delays and improving escalation of clinical deterioration. The effect of HIRAID on the accuracy of nursing documentation is unknown. DESIGN A quasi-experimental pre-post study was conducted and the report was guided by the strengthening the reporting of observational studies in epidemiology (STROBE) checklist. METHODS HIRAID was implemented in four regional/rural Australian emergency departments (ED) using a range of behaviour change strategies. The blinded electronic healthcare records of 120 patients with a presenting problem of shortness of breath, abdominal pain or fever were reviewed. Quantity measures of completeness and qualitative measures of completeness and linguistic correctness of documentation adapted from the D-Catch tool were used to assess accuracy. Differences between pre-post groups were analysed using Wilcoxon rank-sum and two-sample t-tests for continuous variables. Pearson's Chi-square and Fisher exact tests were used for the categorical data. RESULTS The number of records containing the essential assessment components of emergency care increased significantly from pre- to post-implementation of HIRAID. This overall improvement was demonstrated in both paediatric and adult populations and for all presentation types. Both the quantitative and qualitative measures of documentation on patient history and physical assessment findings improved significantly. CONCLUSION Use of HIRAID improves the accuracy of clinical documentation of the patient history and physical assessment in both adult and paediatric populations. RELEVANCE TO CLINICAL PRACTICE The emergency nursing framework "HIRAID" is recommended for use in clinical practice to increase the documentation accuracy performed by emergency nurses.
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Affiliation(s)
- Belinda Munroe
- Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia.,Illawarra Health and Medical Research Institute, Building 32 University of Wollongong, Wollongong, NSW, Australia
| | - Kate Curtis
- Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia.,Illawarra Health and Medical Research Institute, Building 32 University of Wollongong, Wollongong, NSW, Australia.,Susan Wakil School of Nursing, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia.,George Institute for Global Health, University of NSW, Newtown, NSW, Australia.,Faculty of Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Margaret Fry
- Susan Wakil School of Nursing, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia.,University of Technology Sydney School of Nursing and Midwifery, Sydney, NSW, Australia.,Northern Sydney Local Health District, St Leonards, NSW, Australia.,New South Wales Biocontainment Centre, Western Sydney Local Health District and New South Wales Health, Sydney, NSW, Australia
| | - Ramon Z Shaban
- Susan Wakil School of Nursing, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia.,New South Wales Biocontainment Centre, Western Sydney Local Health District and New South Wales Health, Sydney, NSW, Australia.,Sydney Institute for Infectious Diseases, University of Sydney, Camperdown, NSW, Australia.,Division of Infectious Diseases and Sexual Health, Westmead Hospital and Western Sydney Local Health District, Westmead, NSW, Australia
| | - Peter Moules
- Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
| | - Tiana-Lee Elphick
- Susan Wakil School of Nursing, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW, Australia.,Research Central, Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
| | - Kate Ruperto
- Emergency Services, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
| | - Tracey Couttie
- Division of Kids and Families, Illawarra Shoalhaven Local Health District, Wollongong, NSW, Australia
| | - Julie Considine
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research in the Institute of Health Transformation, Deakin University, Geelong, Vic., Australia.,Centre for Quality and Patient Safety Research - Eastern Health Partnership, Box Hill, Vic., Australia
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Leoni‐Scheiber C, Mayer H, Müller‐Staub M. Measuring the effects of guided clinical reasoning on the Advanced Nursing Process quality, on nurses' knowledge and attitude: Study protocol. Nurs Open 2019; 6:1269-1280. [PMID: 31367454 PMCID: PMC6650691 DOI: 10.1002/nop2.299] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 03/12/2019] [Accepted: 04/29/2019] [Indexed: 11/23/2022] Open
Abstract
AIM This article is a report of a study protocol designed to examine the effects of guided clinical reasoning on the quality of the Advanced Nursing Process-the evidence-based version of the traditional nursing process. It aims to describe the theoretical framework-Kirkpatrick's evaluation model, the key concepts and the instruments for the planned study. DESIGN A complex experimental intervention study using data and method triangulation is proposed. METHODS Registered Nurses (N = 92), nursing records (N = 180) and 24 patients will be included. Nurses' knowledge and attitude will be evaluated by questionnaires/tests, their clinical performance by observations. Patients' perspective will be addressed by qualitative interviews and patient records by using the instrument Quality of Diagnoses, Interventions and Outcomes revised (Q-DIO R). DISCUSSION Kirkpatrick's model (including quantitative and qualitative methods) is providing evaluations from different perspectives on the quality of the Advanced Nursing Process and on intervention effects.
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Affiliation(s)
| | - Hanna Mayer
- Institute of Nursing ScienceUniversity ViennaViennaAustria
| | - Maria Müller‐Staub
- Lectoraat Nursing DiagnosticsHanze University GroningenGroningenthe Netherlands
- City Hospital WaidZurichSwitzerland
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Adereti CS, Olaogun AA. Use of Electronic and Paper-based Standardized Nursing Care Plans to Improve Nurses' Documentation Quality in a Nigerian Teaching Hospital. Int J Nurs Knowl 2018; 30:219-227. [PMID: 30525306 DOI: 10.1111/2047-3095.12232] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE To evaluate the effect of electronic and paper-based standardized nursing care plans (SNCPs) use on quality of nurses' documentation. METHODS Using quasi-experimental design, two wards were grouped into electronic and paper-based wards. Nurses were trained to use electronic- and paper-based SNCPs for care-planning and documentation. Data was collected before, 3, and 6 months postintervention and analyzed with SPSS version 20. FINDINGS There was improvement in documentation quality in the two wards after introducing SNCPs with higher quality scores in the electronic ward postintervention. CONCLUSION Providing SNCPs in electronic and paper formats is critical to improving nursing documentation. IMPLICATION FOR NURSING PRACTICE Adequate training and support for nurses are needed for successful implementation of SNCPs in electronic health records (EHRs) in developing nations.
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da Costa C, Linch GFDC. Implementation of Electronic Records Related to Nursing Diagnoses. Int J Nurs Knowl 2018; 31:50-58. [PMID: 30040237 DOI: 10.1111/2047-3095.12219] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The quality of nursing care is related to the execution of the nursing process, which should be properly documented. In this context, there is an evident need to implement electronic health records with the use of standardized languages. OBJECTIVE To implement electronic records related to nursing diagnoses in a computerized health management system. METHODOLOGY The project followed four stages, based on the plan-do-check-act tool. This tool guided the activities to be carried out in the axes: planning, execution of activities, evaluation, and action. The activities performed included: registration of nursing diagnoses and related factors, as well as the association of these in the Tasy software, test execution, and applicability assessment. RESULTS We included 229 nursing diagnoses and these were associated with 1,664 related factors, a decision tree with 436 defining characteristics was also constructed, which allows the software to suggest nursing diagnoses according to the related signs and symptoms. CONCLUSION The practical consolidation of the steps of the nursing process was verified as well as the possibility of nurses assessing the patients by way of a clinical reasoning and decision making in coherence with the human needs of the patient.
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Affiliation(s)
- Cíntia da Costa
- the Departamento de Enfermagem, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
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Šerková D, Marečková J. CREATION AND VALIDATION OF Q-DIO, AN INSTRUMENT FOR RATING THE QUALITY OF NURSING DOCUMENTATION - LITERATURE REVIEW. CENTRAL EUROPEAN JOURNAL OF NURSING AND MIDWIFERY 2018. [DOI: 10.15452/cejnm.2018.09.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Akhu‐Zaheya L, Al‐Maaitah R, Bany Hani S. Quality of nursing documentation: Paper‐based health records versus electronic‐based health records. J Clin Nurs 2017; 27:e578-e589. [DOI: 10.1111/jocn.14097] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/24/2017] [Indexed: 11/30/2022]
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Linch GFDC, Lima AAA, Souza END, Nauderer TM, Paz AA, da Costa C. An educational intervention impact on the quality of nursing records. Rev Lat Am Enfermagem 2017; 25:e2938. [PMID: 29091124 PMCID: PMC5706603 DOI: 10.1590/1518-8345.1986.2938] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 07/04/2017] [Indexed: 11/22/2022] Open
Abstract
Objective: to evaluate the impact of an educational intervention on the quality of nursing
records. Method: quasi-experimental study with before-and-after design conducted in a hospital. All
the nurses in the cardiac intensive care unit of the hospital received the
intervention, which consisted of weekly meetings during five months. To collect
data, the instrument Quality of Diagnoses, Interventions and Outcomes was applied
to the patients’ charts in two moments: baseline and after intervention. Results: the educational intervention had an impact on the quality of the records, since
most of the items presented a significant increase in their mean values after the
intervention, despite the low values in the two moments. Conclusion: the educational intervention proved to be effective at improving the quality of
nursing records and a lack of quality was identified in the evaluated records,
revealed by the low mean values and by the weakness of some questions presented in
the items, which did not present a significant increase. Therefore, educational
actions focused on real clinical cases may have positive implications for nursing
practice.
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Affiliation(s)
- Graciele Fernanda da Costa Linch
- PhD, Adjunct Professor, Departamento de Enfermagem, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - Ana Amélia Antunes Lima
- PhD, Adjunct Professor, Departamento de Enfermagem, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - Emiliane Nogueira de Souza
- PhD, Adjunct Professor, Departamento de Enfermagem, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - Tais Maria Nauderer
- PhD, Adjunct Professor, Departamento de Enfermagem, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - Adriana Aparecida Paz
- PhD, Adjunct Professor, Departamento de Enfermagem, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil
| | - Cíntia da Costa
- Master's student, Departamento de Enfermagem, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brazil. RN, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
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Implementation of Free Text Format Nursing Diagnoses at a University Hospital's Medical Department. Exploring Nurses' and Nursing Students' Experiences on Use and Usefulness. A Qualitative Study. Nurs Res Pract 2015; 2015:179275. [PMID: 26075091 PMCID: PMC4444573 DOI: 10.1155/2015/179275] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/23/2015] [Indexed: 11/30/2022] Open
Abstract
Background. Nursing documentation has long traditions and represents core element of nursing, but the documentation is often criticized of being incomplete. Nursing diagnoses are an important research topic in nursing in terms of quality of nursing assessment, interventions, and outcome in addition to facilitating communication and continuity. Aim. The aim of this study was to explore the nurses' and nursing students' experiences after implementing free text format nursing diagnoses in a medical department. Method. The study design included educational intervention of free text nursing diagnoses. Data was collected through five focus group interviews with 18 nurses and 6 students as informants. The data was analyzed using qualitative content analysis. Results. The informants describe positive experiences concerning free text format nursing diagnoses' use and usefulness; it promotes reflection and discussion and is described as a useful tool in the diagnostic process, though it was challenging to find the diagnosis' appropriate formulation. Conclusion. Our findings indicate a valid usability of free text format nursing diagnoses as it promotes the diagnostic process. The use seems to enhance critical thinking and may serve as valuable preparation towards an implementation of standardized nursing diagnoses. Use and support of key personnel seem valuable in an implementation process.
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