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Nyberg A, Jirwe M, Fagerdahl A, Otten V, Haney M, Olofsson B. Perioperative patient safety indicators-A Delphi study. J Clin Nurs 2024. [PMID: 38757741 DOI: 10.1111/jocn.17212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 03/28/2024] [Accepted: 04/27/2024] [Indexed: 05/18/2024]
Abstract
AIM To identify, define and achieve consensus on perioperative patient safety indicators within a Swedish context. DESIGN A modified Delphi method. METHODS A purposeful sample of 22 experts, all experienced operating room nurse specialists, was recruited for this study. A questionnaire was constructed incorporating statements derived from a preceding study. The experts were asked to rate the importance of each statement concerning patient safety during the perioperative phase. The data collection occurred through an online survey platform between November 2022 and April 2023. The CREDES checklist guided the reporting of this study. RESULTS The three-round Delphi study resulted in consensus on 73 statements out of 103, encompassing 74% process indicators and 26% structure indicators. Key areas of consensus included the use of the Surgical Safety Checklist and optimizing the operating room environment. CONCLUSION Consensus was reached on perioperative safety indicators, underscoring the intricate challenges involved in ensuring patient safety in the operating room. It emphasizes the important integration of both structure and process indicators for comprehensive safety assessment during surgical procedures. Recognizing the difficulty in measuring factors like teamwork and communication, essential for patient safety, the study offers practical guidance. It underlines a balanced approach and specific consensus areas applicable in clinical practice to enhance perioperative patient safety. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE This study provides concrete practice guidance and establishes a structured framework for evaluating perioperative care processes. It emphasizes the critical role of professionals having the necessary skills and being present during surgical procedures. Additionally, the study underscores the paramount importance of effective communication and teamwork within the operating room team, substantively contributing to overall patient safety enhancement. IMPACT The study focused on addressing the challenge of ensuring patient safety in operating rooms, acknowledging the persistent complications related to surgery despite global efforts to eliminate avoidable harm in healthcare. Consensus was reached on 73 crucial indicators for perioperative patient safety, emphasizing a balanced approach integrating both process and structure indicators for a comprehensive assessment of safety during surgical procedures. The study has a broad impact on professionals and healthcare systems, providing concrete guidance for practice and offering a structured process for evaluating perioperative care. REPORTING METHOD The study is reported informed by 'Guidance on Conducting and REporting DElphi Studies (CREDES) in palliative care: Recommendations derived from a methodological systematic review'. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution.
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Affiliation(s)
- Anette Nyberg
- Department of Nursing, Umeå University, Umeå, Sweden
- Department of Diagnostics and Intervention, Anaesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
| | - Maria Jirwe
- Department of Health Sciences, Swedish Red Cross University, Huddinge, Sweden
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Solna, Sweden
| | - Ami Fagerdahl
- Department of Clinical Research and Education, Södersjukhuset, Karolinska Institutet, Solna, Sweden
| | - Volker Otten
- Department of Diagnostics and Intervention, Orthopaedics, Umeå University, Umeå, Sweden
| | - Michael Haney
- Department of Diagnostics and Intervention, Anaesthesiology and Intensive Care Medicine, Umeå University, Umeå, Sweden
| | - Birgitta Olofsson
- Department of Nursing, Umeå University, Umeå, Sweden
- Department of Diagnostics and Intervention, Orthopaedics, Umeå University, Umeå, Sweden
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Pengelly C, Spring C, Taylor RM. An evaluation of staff experiences of the Royal Literary Fund writer-in-residence service to support improvements in written communication in healthcare. QUALITATIVE RESEARCH IN MEDICINE & HEALTHCARE 2023; 7:11601. [PMID: 38213668 PMCID: PMC10782892 DOI: 10.4081/qrmh.2023.11601] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 11/28/2023] [Indexed: 01/13/2024] Open
Abstract
Written communication is essential to staff and patient experience in healthcare. The Royal Literary Fund has hosted a writing fellow in an NHS Trust since 2018 providing professional writing training. The aim of this evaluation was to explore the experiences of staff using the service. Semi-structured interviews were conducted with 21 staff members from a range of professions who had accessed the service. Data were analysed using thematic analysis. Findings: The writing service was highly valued. Three themes emerged: feelings about writing at work, reported benefits of attending sessions, and perceived barriers to accessing them. Staff felt underskilled in professional writing and described the wish to write more succinctly and reflectively. Self-reported confidence increased after sessions. Stigma around writing skills prevented some staff from recommending the service. Wider adoption of professional writing skills training through the NHS could have benefits in terms of increasing self-perceived skills and confidence.
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Affiliation(s)
| | | | - Rachel M. Taylor
- Centre for Nurse, Midwife and Allied Health Profession Led Research (CNMAR), University College London Hospitals NHS Foundation Trust, London, United Kingdom
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Sydykova B, Smailova D, Khismetova Z, Brimzhanova M, Baigozhina Z, Hosseini H, Latypova N, Izmailovich M. Enhancing nursing documentation in Kazakhstan: assessing utilization and standardization for improving patient care. Front Public Health 2023; 11:1267809. [PMID: 38074771 PMCID: PMC10702541 DOI: 10.3389/fpubh.2023.1267809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/02/2023] [Indexed: 12/18/2023] Open
Abstract
Background and aim This article stresses the importance of comprehensive nursing documentation in scientific medicine and discusses the adoption of standardized terminologies in Europe. The study also presents findings from a cross-sectional study conducted in Kazakhstan, assessing the utilization of standard operating procedures and nursing documentation in various clinical scenarios. The aim was evaluate the level of use of the form of nursing documentation and Standard Operating Procedure within the framework of reforming the Republic of Kazakhstan. Materials and methods During the period from December 2021 to February 2022, a cross-sectional study was conducted in Kazakhstan, involving a randomly selected sample of nurses with technical and vocational education as well as those with applied/academic baccalaureate degrees in nursing. Results In this cross-sectional study of 2,263 female nurses, 75.3% were nurse practitioners, and 44% held the highest qualification category. Awareness levels varied, with around 64.7% aware of the pilot program for care services, 65.8% aware of the deputy head position, and 73.8% familiar with the "extended practice nurse" role. Only 55.2% knew about the International Clinical Nursing Classification, and 54.5% observed changes in their nursing approach due to education. The limb edema measurement checklist was not used by the majority (88.4%) of respondents, and 68% did not utilize the antibiotic susceptibility testing checklist. Various other checklists and algorithms had limited utilization, with percentages ranging from 9.1 to 69.3%, indicating varying levels of adoption among participants. For assisting children with cerebral palsy, the "Assessment of hand use capacity according to the MACS classification system" was utilized by 9.1%, while 90.9% did not employ it. In the context of communication, 30.7% of the respondents utilized the "Algorithm of actions of a medical registrar when communicating with a patient," while 69.3% did not use it. These findings highlight variable adoption rates among participants for these medical procedures and protocols. Conclusion In Kazakhstan, nursing documentation forms and Standard Operating Procedures face challenges and limited utilization, but their implementation has shown positive impacts on patient care and healthcare outcomes. Overcoming resistance to change, increasing awareness, and addressing resource constraints are essential for further improvement.
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Affiliation(s)
| | | | | | - Marzhan Brimzhanova
- Department of Health Economics and Insurance Medicine, Kazakhstan Medical University “KSPH”, Almaty, Kazakhstan
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Qualey R. Documenting Perioperative Care in the Electronic Health Record. AORN J 2023; 118:261-266. [PMID: 37750799 DOI: 10.1002/aorn.14010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 09/27/2023]
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Kymre IG, PhD LU, Pedersen MK, Ingstad K, Pedersen PU. Development and validation of the perioperative care and user participation (POUP) questionnaire. Scand J Caring Sci 2023; 37:141-152. [PMID: 36050922 DOI: 10.1111/scs.13119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 07/13/2022] [Accepted: 08/14/2022] [Indexed: 11/27/2022]
Abstract
AIM To validate a Perioperative User Participation questionnaire (POUP) that measures elective adult surgical patient experiences and evaluation of the significance of selected perioperative care items. MATERIALS AND METHODS A generic perioperative user involvement questionnaire (POUP) was developed in the form of four psychometric scales based on the Fundamentals of Care (FoC) framework. The POUP is designed to capture patients' perceived and subjective importance of selected items of perioperative care. It was developed in Danish and comprehensive Danish-Norwegian translations were conducted. Face and content validation were conducted involving patients and expert nurses. The relevance of items was assessed by 68 patients, and the internal consistency of the scales was calculated. RESULTS Danish and Norwegian patients assessed the POUP's face validity, and perioperative expert nurses reported no problems in clarity or ambiguity. However, a few reformulations of the questionnaire texts were suggested. None of the questions were reported as irrelevant or difficult to answer nor was any topic reported missing. Patients assessed all items as relevant, and the internal consistency for the three scales was between 0.8 and 0.9, and no differences between countries were found. CONCLUSION The POUP questionnaire has four scales; the items are valid, but the scales need further statistical validation and refinement. At present, the POUP might provide insight into how elective adult surgical patients value the significance of perioperative care.
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Affiliation(s)
| | | | - Mona Kyndi Pedersen
- Centre for Clinical research, North Denmark Regional Hospital, Hjørring, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Kari Ingstad
- Faculty of Nursing and Health Sciences, Nord University, Levanger, Norway
| | - Preben Ulrich Pedersen
- Centre of Clinical Guidelines, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Cesare M, D’agostino F, Maurici M, Zega M, Zeffiro V, Cocchieri A. Standardized Nursing Diagnoses in a Surgical Hospital Setting: A Retrospective Study Based on Electronic Health Data. SAGE Open Nurs 2023; 9:23779608231158157. [PMID: 36824318 PMCID: PMC9941607 DOI: 10.1177/23779608231158157] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/06/2022] [Accepted: 01/30/2023] [Indexed: 02/22/2023] Open
Abstract
Introduction In electronic health records (EHRs), standardized nursing terminologies (SNTs), such as nursing diagnoses (NDs), are needed to demonstrate the impact of nursing care on patient outcomes. Unfortunately, the use of NDs is not common in clinical practice, especially in surgical settings, and is rarely included in EHRs. Objectives The aim of the study was to describe the prevalence and trend of NDs in a hospital surgical setting by also analyzing the relationship between NDs and hospital outcomes. Methods A retrospective study was conducted. All adult inpatients consecutively admitted to one of the 15 surgical inpatient units of an Italian university hospital across 1 year were included. Data, including the Professional Assessment Instrument and the Hospital Discharge Register, were collected retrospectively from the hospital's EHRs. Results The sample included 5,027 surgical inpatients. There was a mean of 6.3 ± 4.3 NDs per patient. The average distribution of NDs showed a stable trend throughout the year. The most representative NANDA-I ND domain was safety/protection. The total number of NDs on admission was significantly higher for patient whose length of stay was longer. A statistically significant correlation was observed between the number of NDs on admission and the number of intra-hospital patient transfers. Additionally, the mean number of NDs on admission was higher for patients who were later transferred to an intensive care unit compared to those who were not transferred. Conclusion NDs represent the key to understanding the contribution of nurses in the surgical setting. NDs collected upon admission can represent a prognostic factor related to the hospital's key outcomes.
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Affiliation(s)
- Manuele Cesare
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Fabio D’agostino
- Unicamillus, Saint Camillus International University of Health Sciences, Rome, Italy
| | - Massimo Maurici
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Maurizio Zega
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Valentina Zeffiro
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Antonello Cocchieri
- Section of Hygiene, Woman and Child Health and Public Health, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,Antonello Cocchieri, Section of Hygiene, Woman and Child Health and Public Health, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Francesco Vito 1, 00168 Rome, Italy.
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Kassie SY, Demsash AW, Chereka AA, Damtie Y. Medical documentation practice and its association with knowledge, attitude, training, and availability of documentation guidelines in Ethiopia, 2022. A systematic review and meta-analysis. INFORMATICS IN MEDICINE UNLOCKED 2023. [DOI: 10.1016/j.imu.2023.101237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023] Open
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Abstract
BACKGROUND Nursing documentation is an essential aspect of ethical nursing care. Lack of awareness of ethical dilemmas in nursing documentation may increase the risk of patient harm. Considering this, ethical dilemmas within nursing documentation need to be explored. AIM To explore ethical dilemmas in nurses' conversations about nursing documentation. RESEARCH DESIGN, PARTICIPANTS AND CONTEXT The study used a qualitative design. Participants were registered nurses from a Patient Hotel at a Danish University Hospital. Data were collected in three focus groups with a total of 12 participants. Data analysis consisted of qualitative content analysis inspired by Graneheim and Lundman. ETHICAL CONSIDERATION This study was conducted in accordance with the ethical principles of research and regulations in terms of confidentiality, anonymity and provision of informed consent. FINDINGS Ethical dilemmas were strongly present in nurses' conversations about nursing documentation. These dilemmas were demonstrated in two themes: (1) a dilemma between respecting patients' autonomy and not causing harm, which was visible in nurses' navigation between written documentation and oral tradition, and (2) a dilemma concerning justice and fair distribution of goods, which was visible in nurses' balancing between documenting deviations and proof of nursing practice. DISCUSSION Ethical dilemmas in nursing documentation regarding respecting patients' autonomy and not causing harm accentuated discussions on professional responsibility and patient participation in clinical decisions. Dilemmas in justice and fair distribution of goods emphasised discussions on trust in relationships versus trust in electronic health records. CONCLUSION Actual tendencies in the healthcare system may increase ethical dilemmas in nursing documentation. Sharing otherwise invisible and individual experiences of ethical dilemmas in nursing documentation among nurses, nurse leaders and decision-makers will enable addressing these in reflections and discussions as well as in considering adjustments of conditions for nursing documentation.
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Affiliation(s)
- Lone Jørgensen
- Aalborg University Hospital and Aalborg University, Denmark
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Nyberg A, Olofsson B, Otten V, Haney M, Fagerdahl AM. Patient safety during joint replacement surgery: experiences of operating room nurses. BMJ Open Qual 2021; 10:bmjoq-2021-001604. [PMID: 34750189 PMCID: PMC8576473 DOI: 10.1136/bmjoq-2021-001604] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 10/25/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Avoidable complications for surgical patients still occur despite efforts to improve patient safety processes in operating rooms. Analysis of experiences of operating room nurses can contribute to better understanding of perioperative processes and flow, and why avoidable complications still occur. AIM To explore aspects of patient safety practice during joint replacement surgery through assessment of operating room nurse experiences. METHOD A qualitative design using semistructured interviews with 21 operating room nurses currently involved in joint replacement surgery in Sweden. Inductive qualitative content analysis was used. RESULTS The operating room nurses described experiences with patient safety hazards on an organisational, team and individual level. Uncertainties concerning a reliable plan for the procedure and functional reporting, as well as documentation practices, were identified as important. Teamwork and collaboration were described as crucial at the team level, including being respected as valuable, having shared goals and common expectations. On the individual level, professional knowledge, skills and experience were needed to make corrective steps. CONCLUSION The conditions to support patient safety, or limit complication risk, during joint replacement surgery continue to be at times inconsistent, and require steady performance attention. Operating room nurses make adjustments to help solve problems as they arise, where there are obvious risks for patient complications. The organisational patient safety management process still seems to allow deviation from established practice standards at times, and relies on individual-based corrective measures at the 'bedside' at times for good results.
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Affiliation(s)
- Anette Nyberg
- Department of Nursing, Faculty of Medicine, Umeå University, Umeå, Sweden .,Department of Surgical and Perioperative Sciences, Faculty of Medicine, Umeå University, Umeå, Sweden
| | - Birgitta Olofsson
- Department of Nursing, Faculty of Medicine, Umeå University, Umeå, Sweden.,Department of Surgical and Perioperative Sciences, Orthopedics, Faculty of Medicine, Umeå University, Umeå, Sweden
| | - Volker Otten
- Department of Surgical and Perioperative Sciences, Orthopedics, Faculty of Medicine, Umeå University, Umeå, Sweden
| | - Michael Haney
- Department of Surgical and Perioperative Sciences, Anesthesiology, Faculty of Medicine, Umeå University, Umeå, Sweden
| | - Ann-Mari Fagerdahl
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
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Adeapena W, Afari-Asiedu S, Najjemba R, van Griensven J, Delamou A, Ohene Buabeng K, Poku Asante K. Antibiotic Use in a Municipal Veterinary Clinic in Ghana. Trop Med Infect Dis 2021; 6:tropicalmed6030138. [PMID: 34287386 PMCID: PMC8293393 DOI: 10.3390/tropicalmed6030138] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/12/2021] [Accepted: 07/16/2021] [Indexed: 11/29/2022] Open
Abstract
Antimicrobial resistance (AMR) is a threat to public health, impacting both human and animal health as well as the economy. This study sought to describe antibiotic prescription practices and use in the Kintampo North Municipal Veterinary Clinic in Ghana using routinely collected data. Of the 513 animals presented for care between 2013 and 2019, the most common animals were dogs (71.9%), goats (13.1%), and sheep (11.1%). Antibiotics were prescribed for 273/513 (53.2%) of the animals. Tetracycline was the most commonly prescribed class of antibiotics, (99.6%). Of the 273 animals that received antibiotics, the route of administration was not documented in 68.9%, and antibiotic doses were missing in the treatment records in 37.7%. Details of the antibiotic regimen and the medical conditions diagnosed were often not recorded (52.8%). This study recommends appropriate documentation to enable continuous audit of antibiotic prescription practice and to improve quality of use. There is also the need for a national survey on antibiotic prescribtion and use in animal health to support policy implementation and decision making in One-Health in Ghana.
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Affiliation(s)
- Wisdom Adeapena
- Kintampo Health Research Centre, Ghana Health Service, Kintampo North Municipality, Kintampo P.O. Box 200, Ghana; (S.A.-A.); (K.P.A.)
- Correspondence: ; Tel.: +233-24-071388
| | - Samuel Afari-Asiedu
- Kintampo Health Research Centre, Ghana Health Service, Kintampo North Municipality, Kintampo P.O. Box 200, Ghana; (S.A.-A.); (K.P.A.)
| | | | | | - Alexandre Delamou
- Africa Centre of Excellence for Prevention and Control of Transmissible Diseases (CEA-PCMT), Gamal Abdel Nasser University of Conakry, Maferinyah 4099, Guinea;
| | - Kwame Ohene Buabeng
- Department of Pharmacy Practice, Faculty of Pharmacy and Pharmaceutical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi P.O. Box 93, Ghana;
| | - Kwaku Poku Asante
- Kintampo Health Research Centre, Ghana Health Service, Kintampo North Municipality, Kintampo P.O. Box 200, Ghana; (S.A.-A.); (K.P.A.)
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Ranjbar K, Sabetsarvestani R, Oghlaee H, Sarvestani PS, Dehghan A, Shirazi ZH. Using Electronic Software for Nursing Documentation in Nursing Students. Florence Nightingale Hemsire Derg 2021; 29:128-136. [PMID: 34263231 PMCID: PMC8245020 DOI: 10.5152/fnjn.2021.20077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 01/16/2021] [Indexed: 11/22/2022] Open
Abstract
AIM This study aimed to assess the effect of using electronic software for nursing documentation on students. METHOD A quasi-experimental study was performed. The study population comprised 80 nursing students who were randomly divided into 2 groups. The software used for nursing documentation was designed according to the nursing process model. Students in the experimental group received theoretical and practical training. The control group attended a 1-day course on the nursing process model. A questionnaire was used to assess student satisfaction in nursing documentation. The data were analyzed using the Statistical Package for Social Sciences software 16 (Chicago, USA). The standard and comprehensiveness of documentation were analyzed using the summative content analysis with the MaxQDA 10 software (USA). TREND statement was followed for reporting. RESULTS The analysis showed that the mean scores of satisfaction in both groups increased significantly (p < .05). Furthermore, the result of the summative content analysis showed that the comprehensiveness and the standard of nursing documentation increased significantly in the experimental group (p < .05). CONCLUSION The findings confirmed the usefulness of electronic software in improving the standard and comprehensiveness of nursing documentation and the students' satisfaction.
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Affiliation(s)
| | - Raheleh Sabetsarvestani
- Department of Child Health and Diseases Nursing, Necmettin Erbakan University, Faculty of Nursing, Konya, Turkey
| | | | | | - Azizallah Dehghan
- Noncommunicable Disease Research Center, Fasa University of Medical Sciences, Fasa, Iran
| | - Zahra Hadian Shirazi
- Community-Based Psychiatric Care Research Center, Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran
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Do HTT, Edwards H, Finlayson K. Postoperative wound assessment documentation and acute care nurses' perception of factors impacting wound documentation: A mixed methods study. Int J Clin Pract 2021; 75:e13668. [PMID: 32772448 DOI: 10.1111/ijcp.13668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 08/06/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Wound care documentation is an essential component of best practice wound management in order to enhance inter-disciplinary communication and patient care. However, evidence suggests that wound care documentation is often carried out poorly and sporadically. OBJECTIVES Determine postoperative wound assessment documentation by acute care nurses and explore their perception of factors constraining adequate nursing documentation. METHODS A two-phase sequential exploratory mixed methods design was used. Phase one: A retrospective clinical chart audit of nurses' documentation was undertaken. A random selection of 200 medical records were reviewed over 3 months at a provincial hospital in Vietnam. Phase two: semi-structured interviews were conducted with 13 surgical nurses to explore their perceptions of factors influencing appropriate documentation. Inductive qualitative content analysis was applied for qualitative data. This manuscript adheres to COREQ guidelines for reporting the qualitative phase. FINDINGS Phase one: 200 records were audited. Less than 10% of preoperative factors (such as co-morbidities, smoking and nutrition status) related to the risk of delayed wound healing were documented. During the first 5 days postoperation, there was no documentation about incision location, wound dimension, wound bed (in wounds healing by secondary intention) or odour. In less than 10% colour and type of exudate were recorded. Phase two: Emerging key categories were: unimportance of nursing documentation, difficulty to change existing practice, and personal factors. CONCLUSION This study indicated that surgical wound assessment documentation was insufficient and inconsistent among nurses. Nurses viewed the wound assessment documentation as unimportant. Therefore, extensive exploration of strategies is required to enhance the quality of wound assessment documentation.
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Affiliation(s)
- Hien Thi Thu Do
- Nursing Faculty, Haiduong Medical Technical University, Haiduong, Vietnam
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Helen Edwards
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - Kathleen Finlayson
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
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Brima N, Sevdalis N, Daoh K, Deen B, Kamara TB, Wurie H, Davies J, Leather AJM. Improving nursing documentation for surgical patients in a referral hospital in Freetown, Sierra Leone: protocol for assessing feasibility of a pilot multifaceted quality improvement hybrid type project. Pilot Feasibility Stud 2021; 7:33. [PMID: 33504369 PMCID: PMC7839195 DOI: 10.1186/s40814-021-00768-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 01/07/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND There is an urgent need to improve quality of care to reduce avoidable mortality and morbidity from surgical diseases in low- and middle-income countries. Currently, there is a lack of knowledge about how evidence-based health system strengthening interventions can be implemented effectively to improve quality of care in these settings. To address this gap, we have developed a multifaceted quality improvement intervention to improve nursing documentation in a low-income country hospital setting. The aim of this pilot project is to test the intervention within the surgical department of a national referral hospital in Freetown, Sierra Leone. METHODS This project was co-developed and co-designed by in-country stakeholders and UK-based researchers, after a multiple-methodology assessment of needs (qualitative, quantitative), guided by a participatory 'Theory of Change' process. It has a mixed-method, quasi-experimental evaluation design underpinned by implementation and improvement science theoretical approaches. It consists of three distinct phases-(1) pre-implementation(project set up and review of hospital relevant policies and forms), (2) intervention implementation (awareness drive, training package, audit and feedback), and (3) evaluation of (a) the feasibility of delivering the intervention and capturing implementation and process outcomes, (b) the impact of implementation strategies on the adoption, integration, and uptake of the intervention using implementation outcomes, (c) the intervention's effectiveness For improving nursing in this pilot setting. DISCUSSION We seek to test whether it is possible to deliver and assess a set of theory-driven interventions to improve the quality of nursing documentation using quality improvement and implementation science methods and frameworks in a single facility in Sierra Leone. The results of this study will inform the design of a large-scale effectiveness-implementation study for improving nursing documentation practices for patients throughout hospitals in Sierra Leone. TRIAL REGISTRATION Protocol version number 6, date: 24.12.2020, recruitment is planned to begin: January 2021, recruitment will be completed: December 2021.
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Affiliation(s)
- Nataliya Brima
- King's Centre for Global Health & Health Partnerships, School of Population Health & Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
| | - Nick Sevdalis
- Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - K Daoh
- Connaught Teaching Hospital Complex, Freetown, Sierra Leone
| | - B Deen
- Connaught Teaching Hospital Complex, Freetown, Sierra Leone
| | - T B Kamara
- Department of Surgery, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Haja Wurie
- Faculty of Nursing, College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown, Sierra Leone
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, UK; Centre for Global Surgery, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
| | - Andrew J M Leather
- King's Centre for Global Health & Health Partnerships, School of Population Health & Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Sandelin A, Gustafsson BÅ, Kalman S. Congruency Between Planned and Performed Procedures and Adherence to Recommended Perioperative Practices: A Chart Audit of High-Risk Surgical Patients. AORN J 2020; 112:663-673. [PMID: 33252792 DOI: 10.1002/aorn.13251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 03/31/2020] [Accepted: 04/27/2020] [Indexed: 11/11/2022]
Abstract
Documentation in an electronic health record system helps ensure that perioperative personnel provide appropriate treatment and care to surgical patients. A retrospective chart review performed with an audit instrument sought to describe the extent to which the documented preoperative plan for a surgery corresponded to the procedure performed. The secondary aim was to describe to what extent perioperative nurses' and physicians' documented care was in accordance with national and international guidelines. Extracted data consisted of physicians' and nurses' documentation of 24 high-risk surgical patients who died within 30 days after a procedure at two hospitals within a single health system. Surgeons documented a planned surgical method for 23 of the 24 patients and the surgical team performed 20 surgeries as planned. Perioperative nurses' and anesthesia professionals' documentation showed a lack of adherence to recommended practices: compliance with guidelines concerning antibiotic prophylaxis and preoperative hygiene preparation were low.
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Søndergaard SF, Frederiksen K, Sørensen EE, Lorentzen V. A Realistic Evaluation of Danish Perioperative Nurses’ Documentation Practices. AORN J 2019; 110:500-509. [DOI: 10.1002/aorn.12840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Håkonsen SJ, Pedersen PU, Bygholm A, Thisted CN, Bjerrum M. Lack of focus on nutrition and documentation in nursing homes, home care- and home nursing: the self-perceived views of the primary care workforce. BMC Health Serv Res 2019; 19:642. [PMID: 31492130 PMCID: PMC6729022 DOI: 10.1186/s12913-019-4450-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 08/22/2019] [Indexed: 11/10/2022] Open
Abstract
Background Malnutrition is a comprehensive challenge for the nursing home, home care- and home nursing sector. Nutritional care and the subsequent documentation are a common and multifaceted healthcare practice that requires that the healthcare professionals possess complex combinations of competencies in order to deliver high-quality care and treatment. The purpose of this study was to investigate how a varied group of healthcare professionals’ perceive their own competencies within nutrition and documentation and how organizational structures influence their daily work and the quality of care provided. Methods Two focus groups consisting of 14 healthcare professionals were conducted. The transcribed focus group interviews was analyzed using the qualitative content analysis approach. Results Six categories were identified: 1) Lack of uniform and systematic communication affect nutritional care practices 2) Experience-based knowledge among the primary workforce influences daily clinical decisions, 3) Different attitudes towards nutritional care lead to differences in the quality of care 4) Differences in organizational culture affect quality of care, 5) Lack of clear nutritional care responsibilities affect how daily care is performed and 6) Lack of clinical leadership and priorities makes nutritional care invisible. Conclusions The six categories revealed two explanatory themes: 1) Absent inter- and intra-professional collaboration and communication obstructs optimal clinical decision-making and 2) quality deterioration due to poorly-established nutritional care structure. Overall, the two themes explain that from the healthcare professionals’ point of view, a visible organization that allocates resources as well as prioritizing and articulating the need for daily nutritional care and documentation is a prerequisite for high-quality care and treatment. Furthermore, optimal clinical decision making among the healthcare professionals are compromised by imprecise and unclear language and terminology in the patients’ healthcare records and also a lack of clinical guidelines and standards for collaboration between different healthcare professionals working in nursing homes, home care or home nursing. The findings of this study are beneficial to support organizations within these settings with strategies focusing on increasing nutritional care and documentation competencies among the healthcare professionals. Furthermore, the results advocate for the daily involvement and support of leaders and managers in articulating and structuring the importance of nutritional care and treatment and the subsequent documentation. Electronic supplementary material The online version of this article (10.1186/s12913-019-4450-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- S J Håkonsen
- Centre of Clinical Guidelines - Danish National Clearing house, Department of Health Science and Technology, University of Aalborg, Aalborg, Denmark. .,Danish Centre of Systematic Reviews: A Joanna Briggs Institute Centre of Excellence, Aalborg, Denmark.
| | - P U Pedersen
- Centre of Clinical Guidelines - Danish National Clearing house, Department of Health Science and Technology, University of Aalborg, Aalborg, Denmark.,Danish Centre of Systematic Reviews: A Joanna Briggs Institute Centre of Excellence, Aalborg, Denmark
| | - A Bygholm
- Department of Communication and Psychology, University of Aalborg, Aalborg, Denmark
| | - C N Thisted
- Department of Public Health, Section of Nursing Science, Aarhus University, Aarhus, Denmark
| | - M Bjerrum
- Centre of Clinical Guidelines - Danish National Clearing house, Department of Health Science and Technology, University of Aalborg, Aalborg, Denmark.,Danish Centre of Systematic Reviews: A Joanna Briggs Institute Centre of Excellence, Aalborg, Denmark.,Department of Public Health, Section of Nursing Science, Aarhus University, Aarhus, Denmark
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Søndergaard SF, Lorentzen V, Sørensen EE, Frederiksen K. Danish Perioperative Nurses' Documentation: A Complex, Multifaceted Practice Connected With Unit Culture and Nursing Leadership. AORN J 2017; 106:31-41. [PMID: 28662782 DOI: 10.1016/j.aorn.2017.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 12/11/2016] [Accepted: 05/04/2017] [Indexed: 11/25/2022]
Abstract
Researchers have described the documentation practices of perioperative nurses as flawed and characterized by subjectivity and poor quality, which is often related to both the documentation tool and the nurses' level of commitment. Studies suggest that documentation of nursing care in the OR places special demands on electronic health records (EHRs). The purpose of this study was to explore how the use of an EHR tailored to perioperative practice affects Danish perioperative nurses' documentation practices. This study was a follow-up to a baseline study from 2014. For three months in the winter of 2015 to 2016, six participants tested an EHR containing a Danish edition of a selected section of the Perioperative Nursing Data Set. This study relied on realistic evaluation and participant observations to generate data. We found that nursing leadership was essential for improving perioperative nurses' documentation practices and that a tailored EHR may improve documentation practices.
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Jylhä V, Mikkonen S, Saranto K, Bates DW. The Impact of Information Culture on Patient Safety Outcomes. Development of a Structural Equation Model. Methods Inf Med 2017; 56:e30-e38. [PMID: 28272647 PMCID: PMC5388883 DOI: 10.3414/me16-01-0075] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 01/25/2017] [Indexed: 12/20/2022]
Abstract
Background An organization’s information culture and information management practices create conditions for processing patient information in hospitals. Information management incidents are failures that could lead to adverse events for the patient if they are not detected. Objectives To test a theoretical model that links information culture in acute care hospitals to information management incidents and patient safety outcomes. Methods Reason’s model for the stages of development of organizational accidents was applied. Study data were collected from a cross-sectional survey of 909 RNs who work in medical or surgical units at 32 acute care hospitals in Finland. Structural equation modeling was used to assess how well the hypothesized model fit the study data. Results Fit indices indicated a good fit for the model. In total, 18 of the 32 paths tested were statistically significant. Documentation errors had the strongest total effect on patient safety outcomes. Organizational guidance positively affected information availability and utilization of electronic patient records, whereas the latter had the strongest total effect on the reduction of information delays. Conclusions Patient safety outcomes are associated with information management incidents and information culture. Further, the dimensions of the information culture create work conditions that generate errors in hospitals.
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Affiliation(s)
- Virpi Jylhä
- Virpi Jylhä, PhD, Department of Health and Social Management, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland, E-mail:
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