Contribuições dos registros eletrônicos para a segurança do paciente em terapia intensiva: uma revisão integrativa

Electronic Records With Tablets at the Point of Care in an Internal Medicine Unit: Before-After Time Motion Study

BACKGROUND

There are many benefits of nursing professionals being able to consult electronic health records (EHRs) at the point of care. It promotes quality and patient security, communication, continuity of care, and time dedicated to records.

OBJECTIVE

The aim of this study was to evaluate whether making EHRs available at the point of care with tablets reduces nurses' time spent on records compared with the current system. The analysis included sociodemographic and qualitative variables, time spent per patient, and work shift. This time difference can be used for direct patient care.

METHODS

A before-after time motion study was carried out in the internal medicine unit. There was a total of 130 observations of 2 hours to 3 hours in duration of complete patient records that were carried out at the beginning of the nurses' work shifts. We calculated the time dedicated to measuring vital signs, patient evaluation, and EHR recording. The main variable was time spent per patient.

RESULTS

The average time spent per patient (total time/patients admitted) was lower with the tablet group (mean 4.22, SD 0.14 minutes) than with the control group (mean 4.66, SD 0.12 minutes); there were statistically significant differences (W=3.20, P=.001) and a low effect (d=.44) between groups. The tablet group saved an average of 0.44 (SD 0.13) minutes per patient. Similar results were obtained for the afternoon shift, which saved an average of 0.60 (SD 0.15) minutes per patient (t₃₄=3.82, P=.01) and high effect (d=.77). However, although there was a mean difference of 0.26 (SD 0.22) minutes per patient for the night shift, this was not statistically significant (t₂₉=1.16, P=.25). The "nonparticipating" average age was higher (49.57, SD 2.92 years) compared with the "afternoon shift participants" and "night shift participants" (P=.007). "Nonparticipants" of the night shift had a worse perception of the project.

CONCLUSIONS

This investigation determined that, with EHRs at the point of care, the time spent for registration by the nursing staff decreases, because of reduced movements and avoiding data transcription. It eliminates unnecessary work that does not add value, and therefore, care is improved. So, we think EHRs at the point of care should be the future or natural method for nursing to undertake. However, variables that could have a negative effect include age, night shift, and nurses' perceptions. Therefore, it is proposed that training in the different work platforms and the participation of nurses are fundamental axes that any institution should consider before their implementation.

Nursing diagnoses focused on universal self-care requisites

AIMS

(1) To identify and analyse diagnoses documented by nurses in Portugal within the scope of universal self-care requisites; (2) to determine the main problems with nursing diagnoses syntaxes for semantic interoperability purposes; and (3) to suggest unified nursing diagnoses syntaxes within the scope of universal self-care requisites.

BACKGROUND/INTRODUCTION

Ageing societies and the increase in chronic diseases have led to significant concern regarding individuals' dependence to ensure self-care. ICNP is widely used by Portuguese nurses in electronic health records for documentation of nursing diagnoses and interventions.

METHODS

A qualitative study using inductive content analysis and focus group: 1. nursing e-documentation content analysis and 2. focus group to explore implicit criteria or insights from content analysis results.

RESULTS

From a corpus of analysis with 1793 nursing diagnoses, 432 nursing diagnoses centred on universal self-care requisites emerged from the content analysis. One hundred ten nursing diagnoses resulted from the application of new encoding criteria that emerged after a focus group meeting.

CONCLUSION

Results reveal that nursing diagnoses related to universal self-care requisites can emphasize the impairment or potentialities of the individuals performing self-care. It also shows a lack of consensus on nominating the nursing diagnoses of people with a deficit in universal self-care requisites, resulting in different diagnoses to express the same needs.

IMPLICATIONS FOR NURSING PRACTICE

Representation of most relevant nursing diagnoses within the scope of universal self-care requisites.

IMPLICATIONS FOR HEALTH POLICY

Incorporating standardized language into electronic health records is not enough for improving quality and continuity of care and semantic interoperability achievement. Electronic health records need to work with a nursing ontology in the backend to meet these requirements.

Attitude of nursing students following the implementation of comprehensive computer-based nursing process in medical surgical internship: a quasi-experimental study

Background

The nursing process is the core and the standard of practice in nursing profession. Nowadays, the use of information technology in the field of nursing processes, education and practice has been emphasized. Since nurse’s attitudes towards clinical information systems are considered as an indicator of the success rate of information systems, and nurse’s attitudes about the nursing process can affect their execution of the process. So the purpose of this study was to evaluate nursing students’ attitudes towards the nursing process software.

Methods

In this quasi-experimental study, 160 undergraduate nursing students (terms 4–8) in Tabriz University of Medical Sciences were selected by convenience sampling. To evaluate the effectiveness of nursing process software in this study, Mazlom and Rajabpoor (IJME 14(4):312–322, 2014) a questionnaire consisting of 21 components based on a five-point Likert scale was completed by students after using the software. Data were then analyzed by SPSS 19 software.

Results

The mean score of students’ attitude toward nursing process software was high (80.70 ± 5.58). The nursing students’ highest scoring attitudes were respectively related to “Effectiveness of software in prioritizing patient care and problems”, “Completeness of patient’s electronic information compared to handwritten mode” and “Software’s effectiveness in saving your time”. The lowest scoring attitudes towards the software was respectively related to the “feeling of fairness in labor division”, “the effectiveness of the software in determining your workload” and “the feeling of satisfaction in labor division”. There was a statistically significant relationship between gender and age, and student’s attitude toward nursing process software.

Conclusions

According to the results and analysis of nursing student’s attitudes toward nursing process software, the use of such software would be welcomed by students. It seems that changing policies in the educational and clinical substructure of nursing in order to develop, adapt and use the nursing process software is an important responsibility for nursing authorities to consider. Providing educational and clinical technology equipment, periodic evaluation of software by stakeholders and promoting the use of this software, can be fundamental steps in operationalizing the findings of this research.

Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review

AIM

To review the evidence on the effects/impact of electronic nursing documentation interventions on promoting or improving quality care and/or patient safety in acute hospital settings.

BACKGROUND

Electronic documentation has been recommended to improve quality care and patient safety. With the gradual move from paper-based to electronic nursing documentation internationally, there is a need to identify interventions that can effectively improve quality care and patient safety.

EVALUATION

We conducted a systematic review on the effectiveness of electronic nursing documentation interventions on promoting or improving quality care and/or patient safety in acute hospital settings.

KEY ISSUES

Six articles reporting on six individual studies met all eligibility criteria. They were uncontrolled pre/post intervention studies reporting positive impacts on at least one or more outcomes. Most outcomes related to documentation practice and documentation of content.

CONCLUSION

Some evidence from our review indicates that implementing electronic nursing documentation in acute hospital settings is time saving, reduces rates of documentation errors, falls and infections.

IMPLICATIONS FOR NURSING MANAGEMENT

A planned approach from management over time to allow nurses adapt to new electronic systems of documentation would seem a good investment in terms of efficiency of work time, possibly resulting in more time for clinical care.

Computerized clinical decision support system utilization in nursing: a scoping review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this scoping review is to comprehensively identify and examine the available literature on computerized clinical decision support systems utilized in nursing. The following focus questions will be used as an initial starting point in order to map and discuss important characteristics of the work done in this field.

A descriptive study of effect-size reporting in research reviews

AIM

To describe effect-size reporting in research reviews completed in support of evidence-based practice in nursing.

BACKGROUND

Many research reviews report nurses' critical appraisal of level, quality and overall strength of evidence available to address clinical questions. Several studies of research-review quality suggest effect-size information would be useful to include in these reviews, but none focused on reviewers' attention to effect sizes.

DESIGN

Descriptive.

METHODS

One hundred and four reviews indexed in CINAHL as systematic reviews and published from July 2012-February 2014 were examined. Papers were required to be peer-reviewed, written in English, contain an abstract and have at least one nurse author. Reviews were excluded if they did not use critical appraisal methods to address evidence of correlation, prediction or effectiveness. Data from remaining papers (N = 73) were extracted by three or more independent coders using a structured coding form and detailed codebook. Data were stored, viewed and analysed using Microsoft Office Excel^® spreadsheet functions.

RESULTS

Sixteen percent (n = 12) of the sample contained effect-size information. Of the 12, six included all the effect-size information recommended by APA guidelines. Independent of completeness of reporting, seven contained discussion of effect sizes in the paper, but none included effect-size information in abstracts.

CONCLUSION

Research reviews available to practicing nurses often fail to include information needed to accurately assess how much improvement may result from implementation of evidence-based policies, programs, protocols or practices. Manuscript reviewers are urged to hold authors to APA standards for reporting/discussing effect-size information in both primary research reports and research reviews.

Quality of nursing documentation before and after the Hospital Accreditation in a university hospital

Objective

to analyze the quality of nursing documentation by comparing the periods before and after the preparation for the hospital accreditation, using the Quality of Nursing Diagnoses, Interventions and Outcomes - Brazilian version (Q-DIO- Brazilian version).

Method

observational study of interventions conducted in a university hospital. Nursing documentation of 112 medical records for the period before and 112 for the period after the hospital accreditation were compared using the Q-DIO instrument - Brazilian version. Data were statistically analyzed.

Results

there was a significant improvement in the quality of nursing documentation. When the total score of the instrument was evaluated, a significant improvement was observed in 24 out of the 29 items (82.8%).

Conclusion

there was commitment to the shift of culture by means of the interventions carried out, which resulted in the conquest of the quality seal ensured by the Joint Commission International.

Patient safety culture in a teaching hospital: differences in perception existing in the different scenarios of this institution

This quantitative descriptive-exploratory study aimed to evaluate the perception of nursing professionals regarding the patient safety culture and to identify differences in perception in the hospital's units. A total of 301 nursing professionals participated. The collection instrument was the Agency for Healthcare Research and Quality questionnaire, titled 'Hospital Survey on Patient Safety Culture'. Data analysis was undertaken through descriptive and analytical statistics. As a result, it was observed that there were significant differences between the units, emphasis being placed on the pediatric units, which had better perceptions of safety (mean: 3.43 and median: 3.44). These findings make it possible to outline models for quality improvement which are more specific for each department, and the analysis of the contexts makes it possible to build good practices in health which are directed towards each work process performed in the institution.

Análise da estrutura categorial da Norma ISO 18104 na documentação em Enfermagem

OBJETIVO: Verificar se a estrutura categorial da Norma ISO 18104 é adequada para apoiar a documentação eletrônica de diagnósticos e ações de enfermagem e auxiliar na formação de expressões diagnósticas e ações de enfermagem. MÉTODOS: Desenho transversal com dois casos de uso nos registros eletrônicos de dois hospitais universitários que utilizam diferentes terminologias de Enfermagem. RESULTADO: O caso de uso A forneceu 40 expressões diagnósticas e 97 intervenções. Todos os registros para diagnósticos de enfermagem continham foco, julgamento ou achado clínico. As intervenções foram registradas usando verbo de ação e alvo. Os demais qualificadores foram pouco empregados. O caso de uso B forneceu dois diagnósticos e 371 expressões para ações de enfermagem. Os diagnósticos possuíam foco e julgamento. Todas as intervenções, exceto uma, foram documentadas usando verbos de ação e alvo. CONCLUSÃO: A Norma ISO18104 mostrou-se adequada para apoiar a documentação de expressões diagnósticas e de ação de enfermagem.