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Michl G, Paterson C, Bail K. 'It's all about ticks': A secondary qualitative analysis of nurse perspectives about documentation audit. J Adv Nurs 2023; 79:3440-3455. [PMID: 37106563 DOI: 10.1111/jan.15685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 03/02/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023]
Abstract
AIM To understand how nurses talk about documentation audit in relation to their professional role. BACKGROUND Nursing documentation in health services is often audited as an indicator of nursing care and patient outcomes. There are few studies exploring the nurses' perspectives on this common process. DESIGN Secondary qualitative thematic analysis. METHODS Qualitative focus groups (n = 94 nurses) were conducted in nine diverse clinical areas of an Australian metropolitan health service for a service evaluation focussed on comprehensive care planning in 2020. Secondary qualitative analysis of the large data set using reflexive thematic analysis focussed specifically on the nurse experience of audit, as there was the significant emphasis by participants and was outside the scope of the primary study. RESULTS Nurses': (1) value quality improvement but need to feel involved in the cycle of change, (2) highlight that 'failed audit' does not equal failed care, (3) describe the tension between audited documentation being just bureaucratic and building constructive nursing workflows, (4) value building rapport (with nurses, patients) but this often contrasted with requirements (organizational, legal and audit) and additionally, (5) describe that the focus on completion of documentation for audit creates unintended and undesirable consequences. CONCLUSION Documentation audit, while well-intended and historically useful, has unintended negative consequences on patients, nurses and workflows. IMPACT Accreditation systems rely on care being auditable, but when individual legal, organizational and professional standards are implemented via documentation forms and systems, the nursing burden is impacted at the point of care for patients, and risks both incomplete cares for patients and incomplete documentation. NO PATIENT OR PUBLIC CONTRIBUTION Patients participated in the primary study on comprehensive care assessment by nurses but did not make any comments about documentation audit.
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Affiliation(s)
- Gabriella Michl
- School of Nursing, Midwifery and Public Health, University of Canberra, Bruce, Australian Capital Territory, Australia
| | - Catherine Paterson
- School of Nursing, Midwifery and Public Health, University of Canberra, Bruce, Australian Capital Territory, Australia
- Canberra Health Services & ACT Health, SYNERGY Nursing & Midwifery Research Centre, Canberra, Australian Capital Territory, Australia
- Robert Gordon University, Aberdeen, UK
| | - Kasia Bail
- School of Nursing, Midwifery and Public Health, University of Canberra, Bruce, Australian Capital Territory, Australia
- Canberra Health Services & ACT Health, SYNERGY Nursing & Midwifery Research Centre, Canberra, Australian Capital Territory, Australia
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2
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Ebnehoseini Z, Khorasani H, Moharari F, Ebrahimi AR, Boroujerdi M, Jamei F, Mehri MR, Tabesh H. A quantitative study on completeness rate of documentation in psychiatric medical records. Indian J Psychiatry 2022; 64:185-191. [PMID: 35494327 PMCID: PMC9045351 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_495_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 12/12/2021] [Accepted: 02/10/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Mental disorders are one of the leading causes of illness and disability worldwide. According to the World Health Organization (WHO), one in four people in the world will be affected by mental or neurological disorders during their lifetime. Regular evaluation of mental health outcomes plays an important role in making decisions about timely treatment of the patient. Studies show that a medical record does not provide enough information about the diagnosis, current symptoms, psychiatric medications, and side effects of current medications and treatments for ongoing health care. In this study, the completeness of paper-based psychiatric records was investigated. AIM The current study aimed to explore the completeness rate of paper-based psychiatric medical records (PMRs) and to investigate the factors effective on documentation status. SETTING The study was conducted in Ebnesina and Dr. Hejazi Psychiatric Hospital and Education Center. The case hospital is a psychiatric teaching hospital, which has 900 beds. MATERIALS AND METHODS The completeness rate of PMRs was determined using descriptive statistics. Fleiss' Kappa agreement and effective factors on PMRs' documentation status were assessed. RESULTS In total, 83.65% (n = 312) of the PMRs had at least one documentation defect. A significantly higher level of documentation completeness rate between different psychiatric wards was observed. CONCLUSION Based on our results, it is suggested to conduct regular evaluation and provide feedback to the health-care providers, and conduct training courses.
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Affiliation(s)
- Zahra Ebnehoseini
- Department of Medical Informatics, Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hediye Khorasani
- Department of Medical Informatics, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fatemeh Moharari
- Department of Psychiatry, Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Reza Ebrahimi
- Department of Psychiatry, Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Masoumeh Boroujerdi
- Department of Health Information Technology, Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fatemeh Jamei
- Department of Nursing, Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Reza Mehri
- Traditional Medicine Specialist, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hamed Tabesh
- Department of Medical Informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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3
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Martin K, Ricciardelli R. A Qualitative Review of What Forensic Mental Health Nurses Include in Their Documentation. Can J Nurs Res 2021; 54:134-143. [PMID: 34024163 DOI: 10.1177/08445621211018061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Documentation of mental health care is a critical component of nursing practice. Despite being identified as playing a critical role, researchers continue to question the quality of nursing documentation and missing and/or inaccurate information. PURPOSE Our aim is to explore the content of nursing documentation among mental health nurses providing care to forensic inpatients. METHODS Using a constructed semi-grounded emergent theme approach for data analysis, we reviewed the types of activities, subjects, and interactions described within nursing notes and identified themes of the content. RESULTS Our results demonstrate that nursing documentation could be categorized into one of seven themes: interactions, food, activities, sleep, mental health, physical health and hygiene. These areas were not consistent with the recommendations from nursing bodies in Canada, specifically the areas of assessment, planning, implementation, and evaluation. Furthermore, missing in the nursing notes is context. CONCLUSIONS The discussion highlights the importance of nursing documentation within the context of best practice, bias, and the impact on patient care. We also discuss missing information (context, clinical relevance, and case conceptualization), and suggest that nurses are not injecting this expertise in patient notes. Clinical implications for documentation practices are presented in relation to education and reflective practice.
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Affiliation(s)
- Krystle Martin
- Research & Academics Department, Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada.,Faculties of Health Science and Social Science and Humanities, Ontario Tech University, Oshawa, ON, Canada
| | - Rosemary Ricciardelli
- Research & Academics Department, Ontario Shores Centre for Mental Health Sciences, Whitby, ON, Canada.,Department of Sociology, Memorial University of Newfoundland, St. John's, NL, Canada
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4
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Tobiano G, Jerofke‐Owen T, Marshall AP. Promoting patient engagement: a scoping review of actions that align with the interactive care model. Scand J Caring Sci 2020; 35:722-741. [DOI: 10.1111/scs.12914] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/22/2020] [Accepted: 09/07/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Georgia Tobiano
- Nursing and Midwifery Education and Research Unit Gold Coast Health Southport Qld Australia
- Menzies Health Institute Queensland Griffith University Southport Qld Australia
| | | | - Andrea P. Marshall
- Nursing and Midwifery Education and Research Unit Gold Coast Health Southport Qld Australia
- Menzies Health Institute Queensland Griffith University Southport Qld Australia
- School of Nursing and Midwifery, Griffith University Southport Qld Australia
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5
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Buller AM, Pichon M, McAlpine A, Cislaghi B, Heise L, Meiksin R. Systematic review of social norms, attitudes, and factual beliefs linked to the sexual exploitation of children and adolescents. CHILD ABUSE & NEGLECT 2020; 104:104471. [PMID: 32371213 DOI: 10.1016/j.chiabu.2020.104471] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 02/28/2020] [Accepted: 03/18/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Despite growing interest in the role of social norms in perpetuating the harmful practice of sexual exploitation of children and adolescents (SECA), little is known about the state of the literature on this issue. OBJECTIVE This systematic review aims to summarize what associated norms, attitudes and factual beliefs have been identified by the SECA literature worldwide. METHODS Multiple database searches were conducted using controlled vocabulary and keywords referring to SECA. RESULTS Our searches identified 3690 unique references. After applying our exclusion criteria, 49 studies, including over 14,000 participants from 37 countries and most world regions, were included. Across studies we identified six injunctive norms perpetuating SECA: owning goods as a social status marker ; being sexually active; exchanging sex for favors; contributing financially to the household; stigma and discrimination against young people who experienced SECA; and lack of social sanctions for SECA perpetrators. These norms were supported by enhanced tolerance of SECA when it involved older or more physically developed adolescents and when it occurred in poverty-affected contexts. Beliefs around markers that denote adolescents' readiness for sex; men's entitlement to sex; and the perceived benefits of intergenerational relationships, also contributed to the maintenance and reproduction of SECA. Findings from all regions suggested that marginalized young people are particularly vulnerable to SECA. CONCLUSIONS Interventions to reduce SECA must consider individual, social, and structural factors and how they interrelate. Context-specific social norms interventions are needed to address harmful norms, promote protective norms, and improve services for those who have experienced SECA.
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Affiliation(s)
- Ana Maria Buller
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Pl, Kings Cross, London, WC1H 9SH, United Kingdom.
| | - Marjorie Pichon
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Pl, Kings Cross, London, WC1H 9SH, United Kingdom.
| | - Alys McAlpine
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Pl, Kings Cross, London, WC1H 9SH, United Kingdom.
| | - Beniamino Cislaghi
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Pl, Kings Cross, London, WC1H 9SH, United Kingdom.
| | - Lori Heise
- Johns Hopkins Bloomberg School of Public Health, 615N. Wolfe Street, Room E4644, Baltimore, MA, 21205, USA.
| | - Rebecca Meiksin
- London School of Hygiene and Tropical Medicine, 15-17 Tavistock Pl, Kings Cross, London, WC1H 9SH, United Kingdom.
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6
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Engen EJH, Devik SA, Olsen RM. Nurses' Experiences of Documenting the Mental Health of Older Patients in Long-Term Care. Glob Qual Nurs Res 2020; 7:2333393620960076. [PMID: 33134432 PMCID: PMC7576930 DOI: 10.1177/2333393620960076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 08/11/2020] [Accepted: 08/18/2020] [Indexed: 11/17/2022] Open
Abstract
Nursing documentation is repeatedly reported to be insufficient and unsatisfactory. Although nurses should apply a holistic approach, they tend to document physical needs more often than other caring dimensions. This study aimed to describe nurses' experiences documenting mental health in older patients receiving long-term care. Individual interviews were conducted with nine nurses and were analyzed by content analysis. One main theme, two categories and seven sub-categories emerged. The findings showed that the nurses perceived mental health as an ambiguous phenomenon that could be difficult to observe, interpret, and agree upon. Thus, the nurses were uncertain about what concepts and words corresponded to their observations. They also struggled with finding the right words to create accurate and complete documentation without breaking confidentiality or diminishing the dignity of the patient. The findings are relevant for nurses in different types of healthcare services and in the educational context to ensure comprehensive nursing documentation.
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7
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Purcell G, McCartney J, Boschmans SA. Documentation of antipsychotic-related adverse drug reactions: An educational intervention. S Afr J Psychiatr 2019; 25:1378. [PMID: 31824746 PMCID: PMC6890559 DOI: 10.4102/sajpsychiatry.v25i0.1378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 10/03/2019] [Indexed: 11/01/2022] Open
Abstract
Background Antipsychotic agents are associated with harmful adverse reactions which impact negatively on patient adherence and clinical management. Accurate and complete documentation of signs and symptoms in the clinical notes is an important means of communication between healthcare providers, and an essential component in the management of antipsychotic-induced adverse drug reactions. Aim To determine the impact of an educational intervention on the incidence and extent of antipsychotic-induced adverse drug reaction documentation in patient medical records. Setting The research was conducted in an acute care, public sector psychiatric facility in the Eastern Cape province of South Africa. Methods A quasi-experimental, before and after method was used, which focused on an educational intervention. The study design consisted of three phases: pre-intervention, intervention and post-intervention. A clinical audit was conducted, reviewing 102 patient medical records in the pre-intervention phase and a further 102 patient medical records in the post-intervention phase, in order to determine the impact of the intervention on the frequency and extent of documentation of suspected antipsychotic-induced adverse drug reactions. Results Following the educational intervention, documentation of adverse drug reactions to antipsychotic drugs increased from 66 instances in the pre-intervention phase to 82 instances in the post-intervention phase. A statistically significant increase (Pearson's Chi-square p < 0.05) was observed in the number of patient medical records that identified suspected adverse drug reactions. Conclusion The educational intervention was found to increase the incidence of documentation of adverse drug reactions, and increased awareness of the potential adverse drug reactions associated with antipsychotic drugs following the intervention.
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Affiliation(s)
- Gregory Purcell
- Department of Pharmacy, Faculty of Health Sciences, Nelson Mandela University, Port Elizabeth, South Africa
| | - Jane McCartney
- School of Pharmacy, Faculty of Natural Sciences, University of the Western Cape, Cape Town, South Africa
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8
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Maguire T, Daffern M, Bowe SJ, McKenna B. Evaluating the impact of an electronic application of the Dynamic Appraisal of Situational Aggression with an embedded Aggression Prevention Protocol on aggression and restrictive interventions on a forensic mental health unit. Int J Ment Health Nurs 2019; 28:1186-1197. [PMID: 31290238 DOI: 10.1111/inm.12630] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2019] [Indexed: 01/04/2023]
Abstract
Risk assessment is a pre-requisite for violence prevention in mental health settings. Extant research concerning risk assessment and nursing intervention is limited and has focused on the predictive validity of various risk assessment approaches and instruments, with few attempts to elucidate and test interventions that might prevent aggression, and reduce reliance on coercive interventions. The integration of risk assessment and violence prevention strategies has been neglected. The aim of this feasibility study was to test a novel Aggression Prevention Protocol designed to prioritize the instigation of less restrictive interventions on an acute forensic mental health unit for female patients. A prospective quasi-experimental study was designed to test an Aggression Prevention Protocol, linked to an electronic application of the Dynamic Appraisal of Situational Aggression (DASA). Following introduction of the DASA and Aggression Prevention Protocol, there were reductions in verbal aggression, administration of Pro Re Nata medication, the rate of seclusion, and physical and mechanical restraint. There was also an increase in documented nursing interventions. Overall, these results support further testing of the electronic application of the DASA and the Aggression Prevention Protocol.
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Affiliation(s)
- Tessa Maguire
- Centre for Forensic Behavioural Science, Swinburne University of Technology, Melbourne, Victoria, Australia.,Victorian Institute of Forensic Mental Health, Forensicare, Melbourne, Victoria, Australia
| | - Michael Daffern
- Centre for Forensic Behavioural Science, Swinburne University of Technology, Melbourne, Victoria, Australia.,Victorian Institute of Forensic Mental Health, Forensicare, Melbourne, Victoria, Australia
| | - Steven J Bowe
- Faculty of Health, Biostatistics Unit, Deakin University, Melbourne, Victoria, Australia
| | - Brian McKenna
- Centre for Forensic Behavioural Science, Swinburne University of Technology, Melbourne, Victoria, Australia.,Auckland University of Technology, Auckland, New Zealand
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9
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Alıcı CB, Koç Z. Quality of life and satisfaction affect individualized nursing care perceptions in intensive care. PSYCHOL HEALTH MED 2019; 25:148-159. [PMID: 31407602 DOI: 10.1080/13548506.2019.1654110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This study was conducted as a cross-sectional and correlational study in order to determine the affects of quality of life and life satisfaction on individualized nursing care perceptions in intensive care patients. This study was conducted with the participation of 317 patients who were treated as inpatients in the adult intensive care units of two state hospitals between 15.02.2017-15.08.2017. The data were collected using the patient information form, SF-36 Quality of Life scale, Satisfaction with Life scale, ICS-A Patient Version and ICS-B Patient Version. The patients' mean total score of the ICS-A Patient Version was 3.5±0.7 while that of the ICS-B Patient Version 3.3±0.6, and that of the Satisfaction with Life scale was found to be 21.7±5.9. The scores of the ICS-A and ICS-B Patient Version as well as SF-36 Quality-of-Life Scale and Satisfaction with Life scalewere identified to differ depending on some sociodemographic and clinical characteristics of the patients. The individualized nursing care perceptions of the patients in the intensive care unit were found to be above moderate, and a relationship between quality of life, life satisfaction, and individualized care perceptions was found.
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Affiliation(s)
| | - Zeliha Koç
- Health Science Faculty, Department of Nursing, Ondokuz Mayıs University, Samsun, Turkey
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10
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Østensen E, Bragstad LK, Hardiker NR, Hellesø R. Nurses' information practice in municipal health care-A web-like landscape. J Clin Nurs 2019; 28:2706-2716. [PMID: 30938870 DOI: 10.1111/jocn.14873] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/23/2019] [Accepted: 03/23/2019] [Indexed: 11/24/2022]
Abstract
AIM To uncover the characteristics of nurses' information practice in municipal health care and to address how, when and why various pieces of information are produced, shared and managed. BACKGROUND Nursing documentation in the electronic patient record has repeatedly been found unsatisfactory. Little is known about how the information practice of nurses in municipal health care actually is borne out. In order to understand why nursing documentation continues to fail at living up to the expected requirements, a better understanding of nurses' information practice is needed. DESIGN A qualitative observational field study. The study complied with the Consolidated Criteria for Reporting Qualitative Research. METHODS Empirical data were collected in three Norwegian municipalities through participant observations and individual interviews with 17 registered nurses on regular day shifts. The data were analysed through thematic content analysis. RESULTS Nurses' information practice in municipal health care can be described as complex. The complexity is reflected in four themes that emerged from the data: (1) web of information sources, (2) knowing the patient and information redundancy, (3) asynchronous information practice and (4) compensatory workarounds. CONCLUSIONS The complex and asynchronous nature of nurses' information practice affected both how and when information was produced, recorded and shared. When available systems lacked functions the nurses wanted, they created compensatory workarounds. Although electronic patient record was an important part of their information practice, nurses in long-term care often knew their patients well, which meant that a lot of information about the patients was in their heads, and that searching for information in the electronic patient record sometimes seemed redundant. RELEVANCE TO CLINICAL PRACTICE This study provides contextual knowledge that might be valuable (a) in the further development of information systems tailored to meet nurses' information needs and (b) when studying patient safety in relation to nurses' information practice.
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Affiliation(s)
- Elisabeth Østensen
- Department of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Line Kildal Bragstad
- Department of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Nicholas R Hardiker
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Ragnhild Hellesø
- Department of Nursing Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
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11
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Jakobsson S, Eliasson B, Andersson E, Johannsson G, Ringström G, Simrén M, Jakobsson Ung E. Person-centred inpatient care - A quasi-experimental study in an internal medicine context. J Adv Nurs 2019; 75:1678-1689. [PMID: 30793351 DOI: 10.1111/jan.13953] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 11/05/2018] [Accepted: 11/13/2018] [Indexed: 11/28/2022]
Abstract
AIM The aim of this study was to evaluate effects of person-centred inpatient care on care processes in terms of satisfaction with care and person-centred content in medical records, and to evaluate effects on self-reported health and self-efficacy. BACKGROUND Internal medicine inpatient care is complex, covering patients varying in age, medical conditions, health status, and other aspects. There has been limited research on the impact of person-centred care (PCC) on satisfaction with care and health outcomes in internal medicine care environments regardless of diagnosis and care pathway. DESIGN A quasi-experimental study with pre- and postmeasurements. METHODS Adult patients admitted to an internal medicine inpatient unit were consecutively included over 16 weeks in 2014 and 24 weeks in 2015-2016. Data were collected before a person-centred inpatient care intervention (N = 204) and 12 months after the intervention was implemented (N = 177). Data on satisfaction with care and self-reported health were collected at discharge and medical records were reviewed. The intervention included systematically applied person-centred assessment, health plans, and persistent PCC. RESULTS After the intervention, patients rated higher satisfaction with care regarding essential components of PCC and more patients had received effective pain relief. There were no differences in information on self-care or medications, self-rated health, or self-efficacy. CONCLUSION Care focused on the foundations of person-centredness seems to enhance both patients' perceptions of satisfaction and symptom management. Situational aspects such as care pathways should be considered when implementing person-centred inpatient care. TRIAL REGISTRATION CLINICALTRIALS. GOV, REGISTRATION NUMBER NCT03725813.
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Affiliation(s)
- Sofie Jakobsson
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden
| | - Björn Eliasson
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eva Andersson
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gudmundur Johannsson
- Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Gisela Ringström
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden.,Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Simrén
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden.,Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Internal Medicine & Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eva Jakobsson Ung
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden.,Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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12
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Jones J, Strube P, Mitchell M, Henderson A. Conflicts and con-fusions confounding compassion in acute care: Creating dialogical moral space. Nurs Ethics 2017; 26:116-123. [PMID: 29281923 DOI: 10.1177/0969733017693470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND: Compassion, understood as empathy for another who is experiencing physical, mental, emotional and/or spiritual suffering, is an essential element of our shared understandings of nursing and the constitution of the professional nurse. THEORETICAL FOUNDATION: Charles Taylor account of ethics which concerns 'what or who is it good to be' rather than the predominant analytical moral philosophy approach which concentrates on 'what ought one to do' is the core concern of this discussion. An ontological appreciation of our shared human condition is the premise upon which the discussion is based. DISCUSSION: This article proposes that concept by opening a dialogical space, nurses can engage in reflection and sense making wherein they explore individually and collectively the conflicts and confusions encountered in their day-to-day work. Through their dialogues, nurses - individually and collectively - orient and reorient themselves and each other towards what they see as meaningful and purposeful in their lives and in doing so they are well positioned to reaffirm their commitment to compassion as a value which both anchors and orients their day-to-day work. IMPLICATIONS: The provision of opportunities in the workplace, in the form of dialogue, to articulate often unspoken assumptions and frameworks in which nursing work is carried out can not only initiate the building of pathways of support but also assist nurses reaffirm their compassion - arguably the essence of their nursing practice.
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Affiliation(s)
- Jenny Jones
- Metro South Clinical Ethics Service, Australia
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13
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Making midwifery work visible: The multiple purposes of documentation. Women Birth 2017; 31:232-239. [PMID: 28958764 DOI: 10.1016/j.wombi.2017.09.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 08/17/2017] [Accepted: 09/12/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Midwives have a professional, ethical and legal obligation to effectively and thoroughly document the care provided to women and the decisions made within the partnership relationship. To appreciate the best approach to documenting midwifery care, it is important to first understand the purpose of midwifery documentation. AIM The aim of this article is to explore the literature in relation to the purposes of midwifery documentation. METHOD A literature search was performed using the CINAHL and Pubmed databases. Hand searching of reference and citation lists was employed to deepen the literature pool. FINDINGS AND DISCUSSION No research articles with a midwifery focus were found addressing the purpose of documentation. Broader searching of literature from other healthcare fields was drawn on to identify the contribution of record keeping to: partnership and continuity of care; communication between health professionals; improved standards of care; audits and clinical reviews; research and education; the visibility of midwifery work; the reflective practices of midwives; professional accountability; the legal record of care; the narrative record of experience for women. CONCLUSION The purpose of midwifery documentation is complex and multi-factorial, involving much more than the recording of clinical and legal details of a woman's care. Midwifery documentation may potentially enhance the maternity care experience for women, support the role of the midwife, positively impact collaboration between health professionals, and contribute to organisational processes and research. Further research is needed to clarify how to address the documentation priorities of women and midwives, within the context of the maternity record.
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14
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Vabo G, Slettebø Å, Fossum M. Participants' perceptions of an intervention implemented in an Action Research Nursing Documentation Project. J Clin Nurs 2017; 26:983-993. [PMID: 27192412 DOI: 10.1111/jocn.13389] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2016] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES The aim of this study is to describe healthcare professionals' experiences and perceptions of an intervention implemented in an action research project conducted to improve nursing documentation practices in four municipalities in Norway. BACKGROUND Documentation of individualized patient care is a continuing concern in healthcare services and could impacts the quality and safety of healthcare. Use of electronic systems has made some aspects of documentation more comprehensive, but creation of an individualized care plan remains a pressing issue. DESIGN A qualitative descriptive design was used. METHODS An action research project was conducted between 2010-2012 to improve the content and quality of nursing documentation in community healthcare services in four municipalities. One year after the project was completed four focus group interviews were conducted with healthcare professionals, one for each involved municipality. Two unit managers were interviewed individually. Qualitative content analysis was used. RESULTS Three themes emerged: healthcare professionals perceived competing interest; they experienced that they had to manage complexity and changes; and they highlighted a clear and visible leader as important for success. CONCLUSIONS Quality improvement activities are essential. Healthcare professionals experience a complicated situation when electronic health record systems do not support workflow. Further research is recommended to focus on the functionality and user interface of electronic health record systems, and on the role of leadership when implementing changes in clinical practice. RELEVANCE TO CLINICAL PRACTICE Stronger cooperation among policymakers, electronic health record system vendors, and healthcare professionals is essential for improving electronic health record systems and documentation practices. Involvement of end-users in these improvements can make a difference in the way the systems are perceived in the clinical workflow.
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Affiliation(s)
- Grete Vabo
- Department of Health and Nursing Science, Faculty of Health and Sport Sciences, University of Agder, Kristiansand, Norway
| | - Åshild Slettebø
- Department of Health and Nursing Science, Faculty of Health and Sport Sciences, University of Agder, Grimstad, Norway
| | - Mariann Fossum
- Department of Health and Nursing Science, Faculty of Health and Sport Sciences, University of Agder, Kristiansand, Norway.,Faculty of Health, School of Nursing and Midwifery, Deakin University, Melbourne, Vic., Australia
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15
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Keenan GM, Lopez KD, Sousa VEC, Stifter J, Macieira TGR, Boyd AD, Yao Y, Herdman TH, Moorhead S, McDaniel A, Wilkie DJ. A Shovel-Ready Solution to Fill the Nursing Data Gap in the Interdisciplinary Clinical Picture. Int J Nurs Knowl 2017; 29:49-58. [PMID: 28093877 DOI: 10.1111/2047-3095.12168] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 12/05/2016] [Indexed: 12/01/2022]
Abstract
PURPOSE To critically evaluate 2014 American Academy of Nursing (AAN) call-to-action plan for generating interoperable nursing data. DATA SOURCES Healthcare literature. DATA SYNTHESIS AAN's plan will not generate the nursing data needed to participate in big data science initiatives in the short term because Logical Observation Identifiers Names and Codes and Systematized Nomenclature of Medicine - Clinical Terms are not yet ripe for generating interoperable data. Well-tested viable alternatives exist. CONCLUSIONS Authors present recommendations for revisions to AAN's plan and an evidence-based alternative to generating interoperable nursing data in the near term. These revisions can ultimately lead to the proposed terminology goals of the AAN's plan in the long term.
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Affiliation(s)
- Gail M Keenan
- College of Nursing, University of Florida, Gainesville, Florida
| | - Karen Dunn Lopez
- College of Nursing, University of Illinois at Chicago, Chicago, Illinois
| | - Vanessa E C Sousa
- College of Nursing, University of Illinois at Chicago, Chicago, Illinois
| | - Janet Stifter
- American Organization of Nurse Executives, American Hospital Association, Chicago, Illinois
| | - Tamara G R Macieira
- College of Nursing, University of Florida, Gainesville, Gainesville, Florida
| | - Andrew D Boyd
- College of Applied Health Sciences, University of Illinois at Chicago, Chicago, Illinois
| | - Yingwei Yao
- College of Nursing, University of Florida, Gainesville, Gainesville, Florida
| | - T Heather Herdman
- NANDA International and University of Wisconsin-Green Bay, Green Bay, Wisconsin
| | - Sue Moorhead
- Nursing Classification Center, College of Nursing, University of Iowa, Iowa City, Iowa
| | - Anna McDaniel
- College of Nursing, University of Florida, Gainesville, Gainesville, Florida
| | - Diana J Wilkie
- College of Nursing, University of Florida, Gainesville, Gainesville, Florida
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16
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Charalambous L, Goldberg S. ‘Gaps, mishaps and overlaps’. Nursing documentation: How does it affect care? J Res Nurs 2016. [DOI: 10.1177/1744987116678900] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Complete, accurate and relevant nursing documentation is essential for the multidisciplinary comprehensive geriatric assessment (CGA) process which can improve older patients’ outcomes following a hospital admission. Our aim is to understand older person nurses’ experiences of and attitudes to documentation, via semi-structured, in-depth interviews of eight qualified nurses at an acute hospital trust. Interviews were analysed using the framework approach to identify key themes. Three overarching themes were identified: gaps, mishaps and overlaps. Gaps refer to information which was missing, inaccurate or inconsistent; mishaps refer to the consequences of these inaccuracies and inconsistencies; and overlaps refer to the problem of duplications in recording of information. Older person nurses report many inconsistencies, omissions and duplications in their documentation. This has implications for how nursing contributes to the CGA and the quality of care of older patients. New ways must be found to minimise and streamline existing documentation to ensure that records are complete, timely and person-centred. Nurses should be mindful that emerging digital technology systems do not create further problems. Ward nurses need to take greater control of development of documentation.
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Affiliation(s)
- Liz Charalambous
- Staff Nurse, Nottingham University Hospitals NHS Trust, University of Nottingham, UK
| | - Sarah Goldberg
- Associate Professor in Older Persons Care, School of Health Sciences, University of Nottingham, UK
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17
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Patiraki E, Katsaragakis S, Dreliozi A, Prezerakos P. Nursing Care Plans Based on NANDA, Nursing Interventions Classification, and Nursing Outcomes Classification: The Investigation of the Effectiveness of an Educational Intervention in Greece. Int J Nurs Knowl 2015; 28:88-93. [PMID: 26472136 PMCID: PMC6120146 DOI: 10.1111/2047-3095.12120] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Purpose The aim of this study was to investigate the effectiveness of an educational intervention on home nursing care plans based on NANDA, Nursing Interventions Classification, and Nursing Outcomes Classification for registered nurses working at primary healthcare settings in Greece. Methods This is a quasi‐experimental study without a control group. The sample consisted of 19 registered nurses. The study tool was a questionnaire administered pre‐ and post‐educational intervention. Findings The intervention improved their skills on nursing diagnoses' nomination, proper formulation, and individualization of defining characteristics, but it did not improve them in desired outcomes formulation. Conclusions A significant effect of an educational intervention on nursing care plans was demonstrated. Implications for Nursing Practice Nurses' knowledge and attitudes are important for understanding and integrating documentation within the nursing process.
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Affiliation(s)
- Elisabeth Patiraki
- Department of Nursing, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Angeliki Dreliozi
- 2nd Regional Health Authority of Piraeus and Aegean Islands, Piraeus, Greece
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18
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Laukvik LB, Mølstad K, Fossum M. The construction of a subset of ICNP® for patients with dementia: a Delphi consensus and a group interview study. BMC Nurs 2015; 14:49. [PMID: 26446570 PMCID: PMC4596372 DOI: 10.1186/s12912-015-0100-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 10/01/2015] [Indexed: 11/21/2022] Open
Abstract
Background The International Classification for Nursing Practice (ICNP®) 2013 includes over 4000 concepts for global nursing diagnoses, outcomes and interventions and is a large and complex set of standardised nursing concepts and expressions. Nurses may use subsets from the ICNP as concepts and expressions for research, education and clinical practice. The objective of this study was to identify and validate concepts for an ICNP subset to guide observations and documentation of nursing care for patients with dementia. Method The process model for developing ICNP subsets was followed, according to the guidelines adopted by the International Council of Nursing (ICN). To identify relevant and useful concepts for the subset, a modified form of the Delphi method was used. Six nurses working in healthcare services in three municipalities in Norway with postgraduate education in geriatric psychiatry and dementia care participated in two Delphi sessions. The participants reviewed and scored the concepts included in the suggested subset and had an opportunity to rewrite them and offer alternatives. To validate the subset after the Delphi study, a group interview was conducted with six other nurses with postgraduate education in geriatric psychiatry and dementia care. The group interview was recorded and transcribed, and summative content analysis was used. Results Suitable concepts for an ICNP subset to guide observations and documentation of nursing care for patients with dementia were identified. In total, 301 concepts were identified, including 77 nursing diagnoses, 78 outcomes and 146 nursing interventions. An increased focus on concepts to describe basic psychosocial needs such as identity, comfort, connection, inclusion and engagement was recommended by nurses in the validation process. Conclusions Relevant and pre-formulated nursing diagnoses, goals and interventions were identified, which can be used to develop care plans and facilitate accuracy in the documentation of individuals with dementia. The participants believed that it may be difficult to find formulations for all steps of the nursing process. In particular, nursing diagnoses and psychosocial needs are often inadequately documented. The participants highlighted the need for the subset to contain essential information about psychosocial needs and communication.
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Affiliation(s)
- Lene Baagøe Laukvik
- Department of Health and Nursing Science, Faculty of Health and Sport Sciences, University of Agder, PO Box 509, NO-4898 Grimstad, Norway
| | | | - Mariann Fossum
- Department of Health and Nursing Science, Faculty of Health and Sport Sciences, University of Agder, PO Box 509, NO-4898 Grimstad, Norway ; Deakin University and Deakin Alfred Health Nursing Research Centre, Alfred Health, Melbourne, Victoria Australia
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19
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Petkovšek-Gregorin R, Skela-Savič B. Nurses' perceptions and attitudes towards documentation in nursing. OBZORNIK ZDRAVSTVENE NEGE 2015. [DOI: 10.14528/snr.2015.49.2.50] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction: Nursing documentation is essential for ensuring a safe, high-quality and continuous nursing care and research work. By means of documentation nurses communicate with each other, other members of the healthcare team and other care providers. The aim of the present research was to investigate nurses' opinions about the importance of nursing documentation. Methods: For the purposes of the study, a quantitative non-experimental research design was employed. A quota sampling included the nursing employees in ten Slovenian hospitals. The survey was composed of closed-ended questions. The data were collected from June 1, 2012 to March 31, 2013. The response rate was 44.95 %. A total of 592 respondents participated in the research, 47.3 % with secondary education and 52.7 % with completed undergraduate study programme. Chrombach's coefficient alpha was 0.898. Descriptive statistics, Kolmogorov-Smirnov test, Spearman's correlation coefficient, and Mann-Whitney U test were used. Results: Nurses with at least college degree attributed more importance to documentation compared to those with secondary education (p = 0.001). Statistically significant correlation was not established (p = 0.98). However, a negative correlation was identified between the time used for documentation and positive attitude towards documentation (p = 0.04). Discussion and conclusion: Nurses perceive documentation as an important part of their work. They believe that documentation enhances transparency, quality and continuity of care, and patient safety. It would be necessary to identify the differences in practices and perceptions of handovers between nurses and other healthcare providers.
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20
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Pezaro S, Lilley L. Digital voice recorders - A conceptual intervention to facilitate contemporaneous record keeping in midwifery practice. Women Birth 2015; 28:e171-6. [PMID: 25997729 DOI: 10.1016/j.wombi.2015.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 04/29/2015] [Accepted: 04/30/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND The first responder, faced with any obstetric incident, frequently finds themselves within a dichotomy of multi-tasking activities. One challenge for the midwife, is to keep accurate and contemporaneous medical records, whilst simultaneously providing immediate clinical care. AIM This paper aims to propose an innovative conceptualisation and a practical solution for maternity services, which strive to uphold best practice in creating contemporaneous and accurate medical records. The feasibility of introducing the use of voice recorders within maternity services will be explored, and offered as a mechanism to facilitate record keeping and simultaneous clinical care. METHODS A synthesised narrative review of the literature is conducted. This review academically tests the conceptual hypothesis that the implementation of voice recorders within maternity services may augment the midwife's ability to generate contemporaneous medical records. A background literature review will also explore the key drivers for this particular innovation, and the challenges facing healthcare leaders in service improvement. FINDINGS This paper builds upon previous suggestions that digital voice recorders may be an effective solution to enhance overall obstetric outcomes, and focuses upon conceptual processes for implementation. CONCLUSIONS This paper offers the principal conclusion that the integration of voice recorders into midwifery practice for the purpose of supporting contemporaneous record keeping may be feasible within the current healthcare climate.
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Affiliation(s)
- Sally Pezaro
- Coventry University, Centre for Technology Enabled Health Research, UK.
| | - Linda Lilley
- School of Health, University of Northampton, Park Campus, Boughton Green Road, Northampton NN2 7AL, UK
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21
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Darawad MW, Hammad S, Al-Hussami M, Haourani E, Aboshaiqah AE, Hamdan-Mansour AM. Investigating critical care nurses' perception regarding enteral nutrition. NURSE EDUCATION TODAY 2015; 35:414-419. [PMID: 25497040 DOI: 10.1016/j.nedt.2014.11.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Revised: 11/07/2014] [Accepted: 11/25/2014] [Indexed: 06/04/2023]
Abstract
BACKGROUND Evidences showed that nurses lack the needed knowledge to administer nutritional care. Besides, nutritional information was found to be incomplete in patients' record, and nurses' responsibilities regarding EN were not well understood. In Jordan, literature regarding nurses' perceptions of EN is scarce. AIM To investigate critical care nurses' perceptions regarding enteral nutrition (EN) of critically-ill adult patients. METHODS A descriptive, cross-sectional, comparative design was used to collect data from 151 Jordanian critical care nurses utilizing the Nurses' Perception of Enteral Nutrition Questionnaire. RESULTS Nurses in private hospitals scored the highest in regard to responsibility and support from documentation. Education, internet, and nursing school were the primary sources of EN knowledge. Besides, female nurses differ significantly from male nurses in regard to the perception of responsibility of EN. CONCLUSION Awareness of responsibility, supportive documentation system, and implementation of the current evidences of EN in the actual daily practices can be used to improve EN practices.
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Affiliation(s)
| | - Sawsan Hammad
- Faculty of Nursing, The University of Jordan, Amman 11942, Jordan.
| | | | - Eman Haourani
- Faculty of Nursing, The University of Jordan, Amman 11942, Jordan.
| | | | - Ayman M Hamdan-Mansour
- Faculty of Nursing, The University of Jordan, Amman 11942, Jordan; Department of Nursing, Al Farabi College, Riyadh 11514, Saudi Arabia.
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22
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Instefjord MH, Aasekjær K, Espehaug B, Graverholt B. Assessment of quality in psychiatric nursing documentation - a clinical audit. BMC Nurs 2014; 13:32. [PMID: 25349532 PMCID: PMC4207848 DOI: 10.1186/1472-6955-13-32] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 10/03/2014] [Indexed: 11/24/2022] Open
Abstract
Background Quality in nursing documentation facilitates continuity of care and patient safety. Lack of communication between healthcare providers is associated with errors and adverse events. Shortcomings are identified in nursing documentation in several clinical specialties, but very little is known about the quality of how nurses document in the field of psychiatry. Therefore, the aim of this study was to assess the quality of the written nursing documentation in a psychiatric hospital. Method A cross-sectional, retrospective patient record review was conducted using the N-Catch audit instrument. In 2011 the nursing documentation from 21 persons admitted to a psychiatric department from September to December 2010 was assessed. The N-Catch instrument was used to audit the record structure, admission notes, nursing care plans, progress and outcome reports, discharge notes and information about the patients’ personal details. The items of N-Catch were scored for quantity and/or quality (0–3 points). Results The item ‘quantity of progress and evaluation notes’ had the lowest score: in 86% of the records progress and outcome were evaluated only sporadically. The items ‘the patients’ personal details’ and ‘quantity of record structure’ had the highest scores: respectively 100% and 71% of the records achieved the highest score of these items. Conclusions Deficiencies in nursing documentation identified in other clinical specialties also apply to the clinical field of psychiatry. The quality of electronic written nursing documentation in psychiatric nursing needs improvements to ensure continuity and patient safety. This study shows the importance of the existence of a validated tool, readily available to assess local levels of nursing documentation quality.
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Affiliation(s)
| | - Katrine Aasekjær
- Centre for Evidence-Based Practice, Bergen University College, Bergen, Norway
| | - Birgitte Espehaug
- Centre for Evidence-Based Practice, Bergen University College, Bergen, Norway
| | - Birgitte Graverholt
- Centre for Evidence-Based Practice, Bergen University College, Bergen, Norway
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23
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Breakdown in informational continuity of care during hospitalization of older home-living patients: a case study. Int J Integr Care 2014; 14:e012. [PMID: 24868195 PMCID: PMC4027933 DOI: 10.5334/ijic.1525] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 02/04/2014] [Accepted: 02/07/2014] [Indexed: 12/21/2022] Open
Abstract
Introduction The successful transfer of an older patient between health care organizations requires open communication between them that details relevant and necessary information about the patient's health status and individual needs. The objective of this study was to identify and describe the process and content of the patient information exchange between nurses in home care and hospital during hospitalization of older home-living patients. Methods A multiple case study design was used. Using observations, qualitative interviews and document reviews, the total patient information exchange during each patient's episode of hospitalization (n = 9), from day of admission to return home, was captured. Results Information exchange mainly occurred at discharge, including a discharge note sent from hospital to home care, and telephone reports from hospital nurse to home care nurse, and meetings between hospital nurse and patient coordinator from the municipal purchaser unit. No information was provided from the home care nurses to the hospital nurses at admission. Incompleteness in the content of both written and verbal information was found. Information regarding physical care was more frequently reported than other caring dimensions. Descriptions of the patients’ subjective experiences were almost absent and occurred only in the verbal communication. Conclusions The gap in the information flow, as well as incompleteness in the content of written and verbal information exchanged, constitutes a challenge to the continuity of care for hospitalized home-living patients. In order to ensure appropriate nursing follow-up care, we emphasize the need for nurses to improve the information flow, as well as to use a more comprehensive approach to older patients, and that this must be reflected in the verbal and written information exchange.
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24
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A Usability Evaluation of an Electronic Health Record System for Nursing Documentation Used in the Municipality Healthcare Services in Norway. ACTA ACUST UNITED AC 2014. [DOI: 10.1007/978-3-319-07293-7_67] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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25
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Johnson M, Sanchez P, Suominen H, Basilakis J, Dawson L, Kelly B, Hanlen L. Comparing nursing handover and documentation: forming one set of patient information. Int Nurs Rev 2013; 61:73-81. [DOI: 10.1111/inr.12072] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- M. Johnson
- School of Nursing & Midwifery; University of Western Sydney; Sydney NSW Australia
- Centre for Applied Nursing Research (a joint facility of the South Western Sydney Local Health District and the University of Western Sydney); Sydney NSW Australia
| | - P. Sanchez
- Centre for Applied Nursing Research; Sydney NSW Australia
| | - H. Suominen
- NICTA; Canberra ACT Australia
- The Australian National University; Canberra ACT Australia
- University of Canberra; Canberra ACT Australia
| | - J. Basilakis
- University of Western Sydney; Sydney NSW Australia
| | - L. Dawson
- University of Wollongong; Wollongong NSW Australia
| | - B. Kelly
- The University of Melbourne; Melbourne Vic. Australia
| | - L. Hanlen
- NICTA; Canberra ACT Australia
- The Australian National University; Canberra ACT Australia
- University of Canberra; Canberra ACT Australia
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26
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Inan NK, Dinç L. Evaluation of nursing documentation on patient hygienic care. Int J Nurs Pract 2013; 19:81-7. [PMID: 23432893 DOI: 10.1111/ijn.12030] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This study was conducted to evaluate nursing documentation on patient hygienic care and to analyze the consistency between actual care given by nurses and that of documented in nursing record. Data were collected from 85 nurses employed at critical care units, on whom 255 sets of observations were performed through a structured participant observation form, which could be used to record the observation episodes and to audit nursing records. Results indicated that the most frequent performed hygienic care was oral care, perianal care, hand washing and bed bathing. The consistency between actual patient hygienic care and its documentation was 77.6%. The quality of nursing records was poor and inadequate to reflect individualized nursing care. Results suggest that more emphasis is needed in nursing practice and nursing education on the quality of record keeping in nursing to increase its evidential value.
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Copanitsanou P, Valkeapää K. Effects of education of paediatric patients undergoing elective surgical procedures on their anxiety - a systematic review. J Clin Nurs 2013; 23:940-54. [DOI: 10.1111/jocn.12187] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2012] [Indexed: 11/28/2022]
Affiliation(s)
| | - Kirsi Valkeapää
- Department of Nursing Science; University of Turku; Turku Finland
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28
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Keenan GM, Yakel E, Yao Y, Xu D, Szalacha L, Tschannen D, Ford Y, Chen YC, Johnson A, Lopez KD, Wilkie DJ. Maintaining a consistent big picture: meaningful use of a Web-based POC EHR system. Int J Nurs Knowl 2012; 23:119-33. [PMID: 23043651 PMCID: PMC3674817 DOI: 10.1111/j.2047-3095.2012.01215.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To test the hypothesis that Hands-on Automated Nursing Data System (HANDS) "big picture summary" can be implemented uniformly across diverse settings, and result in positive registered nurse (RN) and plan of care (POC) data outcomes across time. DESIGN In a longitudinal, multisite, full test study, a representative convenience sample of eight medical-surgical units from four hospitals (one university, two large community, and one small community) in one Midwestern state implemented the HANDS intervention for 24 (four units) or 12 (four units) months. MEASUREMENTS (a) RN outcomes-percentage completing training, satisfaction with standardized terminologies, perception of HANDS usefulness, POC submission compliance rate. (b) POC data outcomes-validity (rate of optional changes/episode); reliability of terms and ratings; and volume of standardized data generated. RESULTS One hundred percent of the RNs who worked on the eight study units successfully completed the required standardized training; all units selected participated for the entire 12- or 24-month designated period; compliance rates for POC entry at every patient hand-off were 78-92%; reliability coefficients for use of the standardized terms and ratings were moderately strong; the pattern of optional POC changes per episode declined but remained reasonable across time; and the nurses generated a database of 40,747 episodes of care. LIMITATIONS Only RNs and medical-surgical units participated. CONCLUSION It is possible to effectively standardize the capture and visualization of useful "big picture" healthcare information across diverse settings. Findings offer a viable alternative to the current practice of introducing new health information layers that ultimately increase the complexity and inconsistency of information for frontline users.
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Affiliation(s)
- Gail M Keenan
- College of Nursing, University of Illinois at Chicago, Chicago, IL, USA.
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29
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Almasalha F, Xu D, Keenan GM, Khokhar A, Yao Y, Chen YC, Johnson A, Ansari R, Wilkie DJ. Data mining nursing care plans of end-of-life patients: a study to improve healthcare decision making. Int J Nurs Knowl 2012; 24:15-24. [PMID: 23413930 DOI: 10.1111/j.2047-3095.2012.01217.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE To reveal hidden patterns and knowledge present in nursing care information documented with standardized nursing terminologies on end-of-life (EOL) hospitalized patients. METHOD 596 episodes of care that included pain as a problem on a patient's care plan were examined using statistical and data mining tools. The data were extracted from the Hands-On Automated Nursing Data System database of nursing care plan episodes (n = 40,747) coded with NANDA-I, Nursing Outcomes Classification, and Nursing Intervention Classification (NNN) terminologies. System episode data (episode = care plans updated at every hand-off on a patient while staying on a hospital unit) had been previously gathered in eight units located in four different healthcare facilities (total episodes = 40,747; EOL episodes = 1,425) over 2 years and anonymized prior to this analyses. RESULTS Results show multiple discoveries, including EOL patients with hospital stays (<72 hr) are less likely (p < .005) to meet the pain relief goals compared with EOL patients with longer hospital stays. CONCLUSIONS The study demonstrates some major benefits of systematically integrating NNN into electronic health records.
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Berg A, Idvall E, Katajisto J, Suhonen R. A comparison between orthopaedic nurses’ and patients’ perception of individualised care. Int J Orthop Trauma Nurs 2012. [DOI: 10.1016/j.ijotn.2012.04.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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31
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Jefferies D, Johnson M, Nicholls D, Langdon R, Lad S. Evaluating an intensive ward-based writing coach programme to improve nursing documentation: lessons learned. Int Nurs Rev 2012; 59:394-401. [DOI: 10.1111/j.1466-7657.2012.00994.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- D Jefferies
- School of Nursing and Midwifery, Centre for Applied Nursing Research (Joint Facility of SSWAHS & the University of Western Sydney), College of Health & Science, University of Western Sydney, Sydney, NSW, Australia.
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Olsen RM, Hellzén O, Skotnes LH, Enmarker I. Content of nursing discharge notes: Associations with patient and transfer characteristics. ACTA ACUST UNITED AC 2012. [DOI: 10.4236/ojn.2012.23042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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von Krogh G, Nåden D. The use of hermeneutic interpretation statements in EPR documentation to capture qualities of caring. J Clin Nurs 2011; 20:3523-31. [DOI: 10.1111/j.1365-2702.2010.03683.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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JOHNSON MAREE, JEFFERIES DIANA, LANGDON RACHEL. The Nursing and Midwifery Content Audit Tool (NMCAT): a short nursing documentation audit tool. J Nurs Manag 2010; 18:832-45. [DOI: 10.1111/j.1365-2834.2010.01156.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Patient centeredness in terminologies: Coverage of health assets concepts in the International Classification of Nursing Practice. J Biomed Inform 2010; 43:805-11. [DOI: 10.1016/j.jbi.2010.04.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Revised: 04/29/2010] [Accepted: 04/30/2010] [Indexed: 11/19/2022]
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Jefferies D, Johnson M, Griffiths R. A meta-study of the essentials of quality nursing documentation. Int J Nurs Pract 2010; 16:112-24. [PMID: 20487056 DOI: 10.1111/j.1440-172x.2009.01815.x] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The aim of this study was to synthesize all relevant information about nursing documentation and present the essential aspects of quality nursing documentation. Literature searches, limited to the English language, were conducted on both CINAHL (1982 to week 3, April 2008) and MEDLINE (1996 to April 2008) using the following search terms: attitude, audit, care, culture, documentation, guideline health, in service, legal, liability, medical, nurses, nursing, organizational, patient, personnel, planning practice, quality, records, research and training. One hundred and seventy-one papers were reviewed for their relevance to the clinical question. Twenty-eight articles were read by two researchers. Data informing the clinical question were extracted and categorized into key concepts by an analysis of similarities. The seven major themes (essentials) of quality nursing documentation were identified. This paper has reviewed contemporary literature, research evidence and local policies to identify the seven essential components of quality nursing documentation. Some of the barriers or more controversial aspects of the final policy are described.
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Affiliation(s)
- Diana Jefferies
- Centre for Applied Nursing Research, Liverpool BC, New South Wales 1871, Australia.
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Suhonen R, Leino-Kilpi H. Older orthopaedic patients’ perceptions of individualised care: a comparative survey. Int J Older People Nurs 2010; 7:105-16. [DOI: 10.1111/j.1748-3743.2010.00243.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
PURPOSE The purpose of this study was to investigate the frequency and type of post-seclusion debriefing provided by nurses at a psychiatric unit in Melbourne, Australia. DESIGN AND METHODS The study employed an exploratory research design. An analysis of the seclusion register was undertaken to identify the total number of seclusions over a 1-year period. A file audit tool was developed to identify seclusion debriefing interventions documented in consumer case files. FINDINGS Post-seclusion debriefing is not routinely performed following an episode of seclusion. PRACTICE IMPLICATIONS A post-seclusion debriefing framework needs to be developed to support best practice in managing seclusion.
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Affiliation(s)
- Heather Needham
- Eastern Health, Maroondah Hospital, East Ringwood, Victoria, Australia.
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Rotegård AK, Moore SM, Fagermoen MS, Ruland CM. Health assets: A concept analysis. Int J Nurs Stud 2010; 47:513-25. [DOI: 10.1016/j.ijnurstu.2009.09.005] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Revised: 08/21/2009] [Accepted: 09/06/2009] [Indexed: 10/20/2022]
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Bondas T, Hall EO. A decade of metasynthesis research in health sciences: A meta-method study. Int J Qual Stud Health Well-being 2009. [DOI: 10.1080/17482620701251684] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Rykkje L. Implementing Electronic Patient Record and VIPS in Medical Hospital Wards: Evaluating Change in Quantity and Quality of Nursing Documentation by Using the Audit Instrument Cat-Ch-Ing. ACTA ACUST UNITED AC 2009. [DOI: 10.1177/010740830902900203] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Individualised care from the orthopaedic and trauma patients’ perspective: An international comparative survey. Int J Nurs Stud 2008; 45:1586-97. [DOI: 10.1016/j.ijnurstu.2007.12.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2007] [Revised: 12/09/2007] [Accepted: 12/27/2007] [Indexed: 11/17/2022]
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Clausson EK, Köhler L, Berg A. Ethical challenges for school nurses in documenting schoolchildren's health. Nurs Ethics 2008; 15:40-51. [PMID: 18096580 DOI: 10.1177/0969733007083933] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This study explored Swedish school nurses' experiences of school health record documentation. Fifty per cent of a representative sample of Swedish school nurses (n = 129) reported difficulties with documenting mental and social health problems in family relationships, schoolchildren's behaviour, and school situations. Ethical considerations concerning fears of misinterpretation and practical barriers to documentation were expressed as reasons for their worries. Mental and social ill health is an increasing and often dominating problem among schoolchildren, thus proper documentation is a basic issue, both for individuals and for the population as a whole. School nurses obviously need professional guidance regarding documentation and ethical challenges. Systematic effort should be directed towards recognition and support of these nurses' unique opportunities to consider, follow and promote all aspects of schoolchildren's health.
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Affiliation(s)
- Eva K Clausson
- Kristianstad University, Kristianstad, and Nordic School of Public Health, Göteborg, Sweden.
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von Krogh G, Nåden D. A Nursing-Specific Model of EPR Documentation: Organizational and Professional Requirements. J Nurs Scholarsh 2008; 40:68-75. [DOI: 10.1111/j.1547-5069.2007.00208.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Suominen H, Lehtikunnas T, Back B, Karsten H, Salakoski T, Salanterä S. Applying language technology to nursing documents: pros and cons with a focus on ethics. Int J Med Inform 2007; 76 Suppl 2:S293-301. [PMID: 17604685 DOI: 10.1016/j.ijmedinf.2007.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The present study discusses ethics in building and using applications based on natural language processing in electronic nursing documentation. Specifically, we first focus on the question of how patient confidentiality can be ensured in developing language technology for the nursing documentation domain. Then, we identify and theoretically analyze the ethical outcomes which arise when using natural language processing to support clinical judgement and decision-making. In total, we put forward and justify 10 claims related to ethics in applying language technology to nursing documents. METHODS A review of recent scientific articles related to ethics in electronic patient records or in the utilization of large databases was conducted. Then, the results were compared with ethical guidelines for nurses and the Finnish legislation covering health care and processing of personal data. Finally, the practical experiences of the authors in applying the methods of natural language processing to nursing documents were appended. RESULTS Patient records supplemented with natural language processing capabilities may help nurses give better, more efficient and more individualized care for their patients. In addition, language technology may facilitate patients' possibility to receive truthful information about their health and improve the nature of narratives. Because of these benefits, research about the use of language technology in narratives should be encouraged. In contrast, privacy-sensitive health care documentation brings specific ethical concerns and difficulties to the natural language processing of nursing documents. Therefore, when developing natural language processing tools, patient confidentiality must be ensured. While using the tools, health care personnel should always be responsible for the clinical judgement and decision-making. One should also consider that the use of language technology in nursing narratives may threaten patients' rights by using documentation collected for other purposes. CONCLUSIONS Applying language technology to nursing documents may, on the one hand, contribute to the quality of care, but, on the other hand, threaten patient confidentiality. As an overall conclusion, natural language processing of nursing documents holds the promise of great benefits if the potential risks are taken into consideration.
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Affiliation(s)
- Hanna Suominen
- Turku Centre for Computer Science (TUCS), Joukahaisenkatu 3-5 B, 20520 Turku, Finland.
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