Developing terminology for documenting perioperative nursing interventions

The documentation practice of perioperative nurses: a literature review

AIMS AND OBJECTIVE

To explore and present the existing knowledge of the documentation practices of perioperative nurses in the operating room.

BACKGROUND

Studies demonstrate that the documentation of nursing care provided is important for the continuity of patient care as well as patient safety. Nurses find that documenting their perioperative services is important to the surgical pathway; however, a number of studies indicate that the documentation practices of perioperative nurses are characterised by subjectivity, randomness and poor quality.

DESIGN

A literature review with a systematic search of scientific material.

METHOD

The content of the studies included was analysed using content analysis as suggested by Krippendorff. The materials were acquired by searching electronic databases. The search was performed for the period 1995-2015 and resulted in 12 studies.

RESULTS

Three general themes were found to be important for perioperative nurses' documentation practices: (1) the documentation tool must be adapted to the clinical practice; (2) nurses document to improve patient safety and protect themselves legally; and (3) traditions and conditions for documentation.

CONCLUSION

Nurses considered documenting their perioperative practices very important. It was of vital importance that the tool used be adapted to the actual clinical practice and to relevant regulations regarding form and content. Nurses' subjective perceptions of and opinions on the effect of documentation influenced their documentation practices, which were widely governed by habits and traditions. Nurses document to safeguard patients against errors but also to protect their own legal status. Nurses also use documentation as proof of their nursing and as 'a window' to gain recognition for their professional practice.

RELEVANCE TO CLINICAL PRACTICE

Our review demonstrates that a focus on the documentation traditions of perioperative nurses combined with training, structure and improved technical tools may facilitate the documentation and thereby improve patient safety.

[Interprofessional education in pain management: development strategies for an interprofessional core curriculum for health professionals in German-speaking countries]

The care of patients, suffering from acute, chronic, or malignant pain, requires systematic and interprofessional collaboration between all team members to ensure a holistic approach to pain management. In doing so, the different professions are often in a competitive, tense, or dependent relationship resulting from a lack of precise definitions and concepts regarding their responsibilities in the wide field of pain management. Considering pain management as a whole, we can define numerous interfaces concerning competencies and tasks which may open up some new perspectives on concepts of interprofessional education (IPE). Internationally, there have been many attempts to establish concepts of interprofessional education, and it is considered a great challenge to improve continuing medical education. However, interdisciplinary subjects like pain management may benefit from it. Apart from enhancing specialized knowledge, interprofessional education aims to consider the different roles, skills, and responsibilities as well as interprofessional strategies of decision-making. In Germany, only a few efforts have been made with regard to interprofessional pain education. In the following paper, different challenges, tasks, and roles within the field of pain management are discussed in the sense of potential areas of collaboration in the context of interprofessional education. Against this background, the Regensburg model for interprofessional pain management education is described as one national program to enhance the effectiveness of pain management.

Developing the standardized wound care documentation model: a Delphi study to improve the quality of patient care documentation

OBJECTIVE

The aim of this study was to validate a set of previously developed criteria for wound care documentation and to use the validated criteria as a framework for developing a wound care documentation model. The Skin Integrity component of the Finnish Care Classification, the Finnish Classification of Nursing Diagnosis, and the Finnish Classification of Nursing Interventions serve as the basis for the wound care documentation model.

SUBJECTS AND SETTING

Finnish wound care specialists, mainly nurses, from different Finnish hospitals, and from the Finnish Wound Care Society having on average 18 years of experience in wound management. Data were collected using electronic survey technology.

METHODS

A Delphi technique was used to develop and validate the documentation system.

RESULTS

The final model consists of 7 main categories and 25 subcategories of the Skin Integrity component of the Finnish Classification of Nursing Diagnosis and 5 main categories and 25 subcategories of the Skin Integrity component of the Finnish Classification of Nursing Intervention. Based on the results of the Delphi survey, consensus was reached on all elements of the wound care documentation model.

CONCLUSION

The Delphi process was used to develop a wound care documentation model for use in an electronic record to promote systematic documentation of both wound assessment and wound care. Future research should address the utility of this documentation model for nurses with expertise in wound care and generalist nurses.

The ISO 18.104: 2003 as Integrative Model of Nursing Terminologies

This paper presents the ISO 18.104:2003 as an integrative model of nursing terminology. It describes the standard, studies and experiences with its use and discusses possibilities to develop knowledge in the field. The standard has been shown to be effective in developing reference terminologies, and as a standard method for interoperability and reuse. Studies have internal limitations such as language and notations unknown to nursing. Correspondence of the model with classifications used in health services and practice is incipient, which hinders its applicability and development due to the lack of examples to be analyzed and discussed.

The validation of AORN recommended practices in Finnish perioperative nursing documentation

In Finland, there are no common guidelines or recommended practices for perioperative documentation. Thus, perioperative nursing documentation varies from one operating department to another. To create minimum criteria for nursing documentation in Finland, we conducted an investigation in a university hospital district in 2006. Purposive sampling was used to invite experts in perioperative nursing documentation (N = 42) to serve as a Delphi panel. The final criteria are 120 items, 71% of which are based on the AORN standards and recommended practices. These criteria may be used to educate students and new perioperative personnel and to enhance the quality of nursing practice. To ensure relevance and usability, the criteria should be tested in various perioperative settings with a variety of surgical patients.

Barriers to effective pain management

In this article my sole aim is to engage the reader to think about the management of pain in a different way. I have deliberately taken a less formal style but provided references if you are interested in following up. The management of pain has often been assumed to be a routine part of care, in fact in the perioperative arena it is the second most common nursing intervention (Juntilla et al 2005). Despite this activity, pain after surgery has been reported to be a consistent problem which has spanned several decades (Marks & Sachar 1973, Wu et al 2002, Ekstein et al 2006). The reasons for this are well documented and include: patient barriers, inadequate knowledge of healthcare professionals, lack of assessment and organisational practices which impede the administration of analgesics and non-pharmacological interventions. Despite this knowledge the changes required in practice are not necessarily forthcoming. The purpose of this paper is to explore the patient, professional and organisational barriers which affect the optimal management of pain in the perioperative period, and provide some practical solutions to help you think about and manage pain more effectively.