Factors associated with nursing diagnosis utilization in Canada

Nursing process from theory to practice: Evidence from the implementation of "Coming back to existence caring model" in burn wards

Aim

To develop the caring model and utilize and evaluate the effect of the model in the nursing student's learning process in burn wards.

Design

A longitudinal multiphase study.

Methods

In the first phase, "Coming back to existence caring model" was developed, in the second phase, to evaluate the program, 35 students in the first semester and 31 students in the second semester of the 2017–2018 academic year were selected randomly, and their logbooks were analysed.

Results

Components of the nursing process, based on the model, were wound management, care and documentation, early mobilization, discharge planning and patient education. The lowest nursing process utilization in both semesters was in the sexuality domain. The most nursing diagnosis was a risk for infection. In the discharge plan, education about how the patient communicates with others in the second semester was less than other educational content (61/3%). However, empowering students was remarkable.

Reliability, Validity and Empirical Dimensionality of the Minnesota Nurses' Perceptions of Nursing Diagnoses Scale Among Italian Nursing Students

BACKGROUND AND PURPOSE

Perceptions toward nursing diagnosis (ND) may represent core drivers of its adoption within clinical practice. Few studies have investigated perceptions toward ND within nursing academic contexts. The study was conducted to validate the Italian version of the Minnesota Nurses' Perceptions of Nursing Diagnoses (MNPND) scale on a sample of Italian nursing students and explore the psychometric structure of perceptions in a sample drawn from this population.

METHODS

A cross-sectional survey with an online self-administered questionnaire was used. The study used exploratory factor analysis (EFA) and confirmatory factor analysis (CFA).

RESULTS

A three-factorstructure was obtained from parallel analysis and EFA. This was confirmed using CFA; fit statistics: MLRχ² ₍₁₃₂₎ = 230.150, p <. 001; CFI = 0.94; TLI = 0.93; RMSEA = 0.05 [90% CI = 0.041-0.064]; SRMR = 0.056).

CONCLUSIONS

The MNPND scale is a useful instrument to measure nursing students' perceptions of ND.

Factors that influence the clinical utilization of the nursing process at a hospital in Accra, Ghana

Background

The nursing process is a tool that is recommended for use by all professional nurses working in Ghana, in order to provide nursing care. However, there is currently a limited use of this tool by nurses in Ghana. The purpose of this research study was to explore the various factors that influence the utilization of this nursing process.

Method

An exploratory descriptive qualitative-research design was employed. Ten participants were involved by using the purposive sampling method. A semi-structured interview guide was used to collect the data from the research participants; and the data were analysed by using content analysis. One main theme, with five subthemes, emerged from the analysis.

Results

It was found that there are factors, such as nurses not having a better understanding of the nursing process, whilst in school; the absence of the care plan in the ward, as well as the lack of adequate staff, with limited time being available for coping with contributed to the non-usage of the nursing process.

Conclusions

We conclude that the clinical utilization of the Nursing process at the clinical setting is influenced by lack of understanding of Nurses on the Nursing process and care plan as well as lack of adequate nurses and time. We recommend that the care-plan form be made officially a part of the admission documents. Furthermore, the nursing administration should put measures in place to provide nurses with the needed resources to implement the nursing process. Additionally, they should ensure that the care-plan forms and other resources needed by the nurses are regularly and adequately provided. Nurses should further see the nursing process as a means of providing comprehensive care to their patients and addressing their specific problems. They should therefore make time despite their busy schedules to use it in order to improve quality of care and the image of nursing in Ghana.

Electronic supplementary material

The online version of this article (doi:10.1186/s12912-017-0228-0) contains supplementary material, which is available to authorized users.

Content and completeness of care plans after implementation of standardized nursing terminologies and computerized records

The nursing process and standardized nursing terminologies are essential elements to structure nursing documentation in daily nursing information management. The aim of this study was to describe sustainability and whether and how standardized nursing terminologies, in handwritten versus preprinted versus computerized nursing care plans, changed the content and completeness of documented nursing care. Three audits of patient records were performed: a pretest (n = 291) before a yearlong implementation of standardized nursing terminologies in nursing care plans followed by two posttests: (1) 3 weeks after implementation of nursing terminologies (n = 299) and (2) 22 months after implementation of nursing terminologies and 8 months after implementation of a computerized system (n = 281) in a university hospital. Content and completeness of documented nursing care improved after implementation of standardized nursing terminologies. Documentation of nursing care plans, signs and symptoms, related factors, and nursing interventions increased, whereas mean number of nursing diagnoses per patient did not change between audits. Computerized nursing care plans had the biggest impact, with more variety of nursing diagnoses and increased documentation of signs and symptoms, related factors, and nursing interventions. The use of standardized nursing terminologies improved nursing content in the nursing care plans. Moreover, computerized nursing care plans, in comparison with handwritten and preprinted care plans, increased documentation completeness.

What factors influence the prevalence and accuracy of nursing diagnoses documentation in clinical practice? A systematic literature review

AIM

To identify what determinants influence the prevalence and accuracy of nursing diagnosis documentation in clinical practice.

BACKGROUND

Nursing diagnoses guide and direct nursing care. They are the foundation for goal setting and provide the basis for interventions. The literature mentions several factors that influences nurses' documentation of diagnoses, such as a nurse's level of education, patient's condition and the ward environment.

DESIGN

Systematic review.

METHOD

MEDLINE and CINAHL databases were searched using the following headings and keywords: nursing diagnosis, nursing documentation, hospitals, influence, utilisation, quality, implementation and accuracy. The search was limited to articles published between 1995-October 2009. Studies were only selected if they were written in English and were primary studies addressing factors that influence nursing diagnosis documentation.

RESULTS

In total, 24 studies were included. Four domains of factors that influence the prevalence and accuracy of diagnoses documentation were found: (1) the nurse as a diagnostician, (2) diagnostic education and resources, (3) complexity of a patient's situation and (4) hospital policy and environment.

CONCLUSION

General factors, which influence decision-making, and nursing documentation and specific factors, which influence the prevalence and accuracy of nursing diagnoses documentation, need to be distinguished. To support nurses in documenting their diagnoses accurately, we recommend taking a comprehensive perspective on factors that influence diagnoses documentation. A conceptual model of determinants that influence nursing diagnoses documentation, as presented in this study, may be helpful as a reference for nurse managers and nurse educators.

RELEVANCE TO CLINICAL PRACTICE

This review gives hospital management an overview of determinants for possible quality improvements in nursing diagnoses documentation that needs to be undertaken in clinical practice.

Can mental health nurses diagnose in Australia?

The naming of health related conditions has been the traditional province of the medical profession. Occasional concessions have been made in specific narrow domains, such as psychology or speech-related pathology, but diagnosis typically has been seen as medical practitioner business. "Ownership" of language is worthy of critical discussion. The answer to why the tradition has persisted, and nurses have invested lots of energy within the established rules of who can say what, may well be found through the lens of psycholinguistics. Nurses can name states of health and ill health using the currently accepted nomenclature. The authors argue that there is an unconditional "yes," to the question of can nurses diagnose, as long as they are not holding themselves out to be a medical practitioner by doing so. Additionally it is argued that advanced practice nurses must diagnose in order to fulfill their role as advanced practice clinicians.

Nursing process: from literature to practice. What are we actually doing?

OBJECTIVES

To describe the steps of the nursing process as prescribed in the literature and to investigate the process as actually applied in the daily routine of a general hospital.

METHODS

Cross-sectional retrospective study (May/June 2005), performed in a hospital in Porto Alegre, RS. Medical records of adult patients admitted to a surgical, clinical or intensive care unit were reviewed to identify the nursing process steps accomplished during the first 48 h after admission. The form for data collection was structured according to other reports.

RESULTS

302 medical records were evaluated. Nursing records and physical examination were included in over 90% of them. Nursing diagnosis was not found in any of the records. Among the steps performed, prescription was the least frequent. Evolution of the case was described in over 95% of the records.

CONCLUSIONS

All nursing steps recommended in the literature, except for diagnosis, are performed in the research institution.

Relations between nursing data collection, diagnoses and prescriptions for adult patients at an intensive care unit

This descriptive, retrospective study aimed to analyze the relation between nursing data collection, diagnoses and prescriptions for 26 adult patients who were hospitalized at the intense care unit of a large teaching hospital for at least 24 hours. Through the analysis of medical records, 135 diagnoses and 421 nursing prescriptions were established, and 24 different diagnosis categories and 20 different items for prescriptions were identified. The most frequent diagnosis risk was that for infection, present in the medical records of 22 (84.60%) patients, with 175 prescriptions (42%) related to this diagnosis. The data the nurses collected were sufficient to establish the nursing diagnoses, and the majority of prescriptions (87.9%) were related to the diagnoses.

Improved Quality of Nursing Documentation: Results of a Nursing Diagnoses, Interventions, and Outcomes Implementation Study

PURPOSE

To evaluate the impact of the quality of nursing diagnoses, interventions, and outcomes in an acute care hospital following the implementation of an educational program.

METHOD

In a pretest-posttest experimental design study, nurses from 12 wards of a Swiss hospital received an educational intervention--an introductory class and consecutive classes, using a case discussion method--to implement nursing diagnoses, interventions, and outcomes. Two sets of 36 randomly selected nursing records were evaluated before and after implementation. The quality of documented nursing diagnoses, interventions, and nursing-sensitive patient outcomes was assessed by 29 Likert-type items with a 0-4 scale instrument, called Quality of Nursing Diagnoses, Interventions, and Outcomes (Q-DIO) and tested using t-tests.

FINDINGS

Significant enhancements in the quality of documented nursing diagnoses, interventions, and outcomes were found following the implementation of a planned educational program.

CONCLUSIONS

The implementation of NANDA, NIC, and NOC (NNN) nursing diagnoses, interventions, and outcomes led to higher quality of nursing diagnosis documentation, etiology-specific nursing interventions, and nursing-sensitive patient outcomes.

IMPLICATIONS FOR NURSING PRACTICE

Educational measures support nurses to improve documentation of diagnoses, interventions, and outcomes. The Q-DIO is a useful audit tool.

Nursing diagnoses, interventions and outcomes ? application and impact on nursing practice: systematic review

AIM

This paper reports a systematic review on the outcomes of nursing diagnostics. Specifically, it examines effects on documentation of assessment quality; frequency, accuracy and completeness of nursing diagnoses; and on coherence between nursing diagnoses, interventions and outcomes.

BACKGROUND

Escalating healthcare costs demand the measurement of nursing's contribution to care. Use of standardized terminologies facilitates this measurement. Although several studies have evaluated nursing diagnosis documentation and their relationship with interventions and outcomes, a systematic review has not been carried out.

METHOD

A Medline, CINAHL, and Cochrane Database search (1982-2004) was conducted and enhanced by the addition of primary source and conference proceeding articles. Inclusion criteria were established and applied. Thirty-six articles were selected and subjected to thematic content analysis; each study was then assessed, and a level of evidence and grades of recommendations assigned.

FINDINGS

Nursing diagnosis use improved the quality of documented patient assessments (n = 14 studies), identification of commonly occurring diagnoses within similar settings (n = 10), and coherence among nursing diagnoses, interventions, and outcomes (n = 8). Four studies employed a continuing education intervention and found statistically significant improvements in the documentation of diagnoses, interventions and outcomes. However, limitations in diagnostic accuracy, reporting of signs/symptoms, and aetiology were also reported (14 studies). One meta-analysis of eight trials including 1497 patients showed no evidence that standardized electronic documentation of nursing diagnosis and related interventions led to better nursing outcomes.

CONCLUSION

Despite variable results, the trend indicated that nursing diagnostics improved assessment documentation, the quality of interventions reported, and outcomes attained. The study reveals deficits in reporting of signs/symptoms and aetiology. Consequently, staff educational measures to enhance diagnostic accuracy are recommended. The relationships among diagnoses, interventions and outcomes require further evaluation. Studies are needed to determine the relationship between the quality of documentation and practice.

Nurses' perceptions of their documentation experiences in a computerized nursing care planning system

AIM

To explore how the content design of a computerized nursing care plan affects nurses' perceptions of their documentation experience, specifically in making care plans.

BACKGROUND

Nurses' attitudes towards and experiences of computer use in daily practice have been studied. However, no studies have examined how using a computerized nursing care planning system affects nurses' perceptions of the documentation process.

METHODS

A descriptive, exploratory qualitative approach was used to conduct one-on-one, in-depth interviews with 20 nurses. The major interview question was, 'What do you think the content of the computerized care plan provided in making care plans?' Data analysis was based on Miles and Huberman's data reduction, data display, and a conclusion verification process.

FINDINGS

Nurses generally viewed the content of the computerized nursing care planning system as a reference to aid memory, a learning tool for patient care, and a vehicle for applying judgement to modify care plan content.

CONCLUSIONS

Although computer technology is designed to streamline nurses' work, using a computerized care plan system can also enhance their knowledge, experience and judgement of descriptions of patient problems and care strategies. Thus, the effects of using technology on documentation behaviours or patterns may deserve further exploration.

RELEVANCE TO CLINICAL PRACTICE

While computerized documentation systems have been used widely in patient care, little attention has been given to how the design of care plan content affects the documentation process. Electronic documentation systems can introduce nurses to new skills and knowledge that may improve care quality.

Swedish Registered Nurses' incentives to use nursing diagnoses in clinical practice

AIMS AND OBJECTIVES

The purpose of this study was to describe Registered Nurses' incentives to use nursing diagnoses in clinical practice.

BACKGROUND

The use of nursing diagnoses is scarce in Swedish patient records. However, there are hospital wards were all nurses formulate and use nursing diagnoses in their daily work. This leads to the question of what motivates these nurses who do use nursing diagnoses in clinical practice.

DESIGN

A qualitative descriptive design.

METHODS

A purposeful sampling of 12 Registered Nurses was used. Qualitative interviews to collect data and a content analysis were performed.

RESULTS

Five categories were identified: identification of the patient as an individual and as a whole, a working tool for facilitating nursing care, increasing awareness within nursing, support from the management and influence on the professional role. The principle findings of this study were: (i) that the Registered Nurses perceived that nursing diagnoses clarified the patient's individual needs and thereby enabled them to decide on more specific nursing interventions, (ii) that nursing diagnoses were found to facilitate communication between colleagues concerning patient care and thus promoted continuity of care and saved time and (iii) that nursing diagnoses were perceived to increase the Registered Nurses' reflective thinking leading to a continuous development of professional knowledge.

CONCLUSIONS

The present findings suggest that the incentives to use nursing diagnoses originate from effects generated from performing a deeper analysis of the patient's nursing needs. Further research is needed to test and validate the usability and consequences of using nursing diagnoses in clinical practice. Motivating factors found in this study may be valuable to Registered Nurses for the use and development of nursing diagnoses in clinical care. Moreover, these factors may be of relevance in other countries that are in a similar situation as Sweden concerning application of nursing diagnoses.

Perioperative nurses' attitudes toward the use of nursing diagnoses in documentation

AIM

This paper reports a study of nurses' attitudes towards the use of nursing diagnoses in perioperative documentation and the factors affecting these attitudes.

BACKGROUND

There are both international and national requests for nurses to move from natural language-based narrative documentation to electronic documentation and clinical use of nursing classifications. However, nurses' attitudes toward nursing classifications have not been widely studied.

METHODS

A questionnaire was distributed to a purposive sample of perioperative nurses (n = 146) who had participated in clinical testing of nursing diagnoses. The response rate was 60% (n = 87). The data were collected in 2003.

RESULTS

In general, nurses' attitudes toward nursing diagnoses were positive. Those over 40 years of age who had clinical experience from 10 to 19 years, postbasic nursing education and previous knowledge of nursing diagnoses were most positive in their attitudes. However, the use of nursing diagnoses in perioperative practice was not seen as either necessary or accurate in describing patients' problems. Furthermore, the documentation of perioperative routines was seen as time-consuming and frustrating.

CONCLUSIONS

Nursing classifications should be included in both preregistration nursing curricula and in-service educational programmes to ensure theoretical knowledge of and practical skills in standardized clinical languages. The perioperative nursing diagnoses should be reviewed to fit better with clinical practice. In addition, current perioperative documentation practices should be reconsidered and updated as appropriate to address clinical requirements better.

Nursing diagnoses: factors affecting their use in charting standardized care plans

AIMS AND OBJECTIVES

The purpose of this study was to explore factors that may affect nurses' use of nursing diagnoses in charting standardized nursing care plans in their daily practice.

BACKGROUND

Care plans have been viewed as providing a structured approach to the assessment, planning and delivery of patient care. Nonetheless, the challenge for many institutions is to help professional nursing staff refine their understanding of nursing diagnoses and charting skills, to identify patient problems and propose appropriate care plans.

METHOD

Twelve clinical nurses working at a medical center in Taiwan underwent one-on-one in-depth interviews from May to July 2000. Data analysis was based on Miles and Huberman's data reduction, data display, and a conclusion verification process to investigate the charting process.

FINDINGS

Nurses tended to match patient conditions to the designated nursing diagnoses, be unfamiliar with statements of related factors, use objective data to describe patient conditions, ignore descriptions of nursing goals, dutifully check interventions without always executing them, and choose the same evaluation to meet hospital requirements.

CONCLUSIONS

These findings suggest that using educational programmes for enhancing nurses' ability to use nursing diagnoses and exploring the process of diagnostic reasoning would improve the quality of patient documentation.

RELEVANCE TO CLINICAL PRACTICE

The trend in health care is to focus on chart audit to reveal indicators of quality of care. Therefore, the experience of nurses in this study could be applied to in-service training programmes by institutions that are replacing traditional, manually written care plans with a standardized care planning system, thus helping other nurses through this transition process.

Health care implications and space allocation of research published in nursing journals

PURPOSE

To examine how research is disseminated through nursing journals and to examine characteristics of published research.

DESIGN

A cross-sectional descriptive survey was conducted with manuscripts from 78 nursing journals that publish research.

METHOD

The final issue for 1999 was examined. Pairs of independent raters content-analyzed all research manuscripts.

DISCUSSION

Research studies comprised 241 (42.9%) of the manuscripts and 51.4% of the journal space. Many empirical studies omitted validity and reliability. Few manuscripts reported the date for completion of data collection, and fewer than one third contained the length of time from acceptance to publication.

CONCLUSIONS

Enhanced instrumentation reporting, shorter time from data collection to publication, and an increase in journal space devoted to research might enable nurses to make more cutting-edge clinical decisions.