AIMS AND OBJECTIVES: To assess the quality of the advanced nursing process in nursing documentation in two hospitals. BACKGROUND: Various standardised terminologies are employed by nurses worldwide, whether for teaching, research or patient care. These systems can improve the quality of nursing records, enable care continuity, consistency in written communication and enhance safety for patients and providers alike. DESIGN: Cross-sectional study. METHODS: A total of 138 records from two facilities (69 records from each facility) were analysed, one using the NANDA-International and Nursing Interventions Classification terminology (Centre 1) and one the International Classification for Nursing Practice (Centre 2), by means of the Quality of Diagnoses, Interventions, and Outcomes instrument. Quality of Diagnoses, Interventions, and Outcomes scores range from 0-58 points. Nursing records were dated 2012-2013 for Centre 1 and 2010-2011 for Centre 2. RESULTS: Centre 1 had a Quality of Diagnoses, Interventions, and Outcomes score of 35·46 (±6·45), whereas Centre 2 had a Quality of Diagnoses, Interventions, and Outcomes score of 31·72 (±4·62) (p < 0·001). Centre 2 had higher scores in the 'Nursing Diagnoses as Process' dimension, whereas in the 'Nursing Diagnoses as Product', 'Nursing Interventions' and 'Nursing Outcomes' dimensions, Centre 1 exhibited superior performance; acceptable reliability values were obtained for both centres, except for the 'Nursing Interventions' domain in Centre 1 and the 'Nursing Diagnoses as Process' and 'Nursing Diagnoses as Product' domains in Centre 2. CONCLUSION: The quality of nursing documentation was superior at Centre 1, although both facilities demonstrated moderate scores considering the maximum potential score of 58 points. Reliability analyses showed satisfactory results for both standardised terminologies. RELEVANCE TO CLINICAL PRACTICE: Nursing leaders should use a validated instrument to investigate the quality of nursing records after implementation of standardised terminologies.
AIMS AND OBJECTIVES: To assess the quality of the advanced nursing process in nursing documentation in two hospitals. BACKGROUND: Various standardised terminologies are employed by nurses worldwide, whether for teaching, research or patient care. These systems can improve the quality of nursing records, enable care continuity, consistency in written communication and enhance safety for patients and providers alike. DESIGN: Cross-sectional study. METHODS: A total of 138 records from two facilities (69 records from each facility) were analysed, one using the NANDA-International and Nursing Interventions Classification terminology (Centre 1) and one the International Classification for Nursing Practice (Centre 2), by means of the Quality of Diagnoses, Interventions, and Outcomes instrument. Quality of Diagnoses, Interventions, and Outcomes scores range from 0-58 points. Nursing records were dated 2012-2013 for Centre 1 and 2010-2011 for Centre 2. RESULTS: Centre 1 had a Quality of Diagnoses, Interventions, and Outcomes score of 35·46 (±6·45), whereas Centre 2 had a Quality of Diagnoses, Interventions, and Outcomes score of 31·72 (±4·62) (p < 0·001). Centre 2 had higher scores in the 'Nursing Diagnoses as Process' dimension, whereas in the 'Nursing Diagnoses as Product', 'Nursing Interventions' and 'Nursing Outcomes' dimensions, Centre 1 exhibited superior performance; acceptable reliability values were obtained for both centres, except for the 'Nursing Interventions' domain in Centre 1 and the 'Nursing Diagnoses as Process' and 'Nursing Diagnoses as Product' domains in Centre 2. CONCLUSION: The quality of nursing documentation was superior at Centre 1, although both facilities demonstrated moderate scores considering the maximum potential score of 58 points. Reliability analyses showed satisfactory results for both standardised terminologies. RELEVANCE TO CLINICAL PRACTICE: Nursing leaders should use a validated instrument to investigate the quality of nursing records after implementation of standardised terminologies.
Keywords:
International Classification for Nursing Practice; NANDA-International; Nursing Interventions Classification; Quality of Diagnoses, Interventions, and Outcomes instrument; classification; nursing process; nursing records
Authors: Tamara G R Macieira; Tania C M Chianca; Madison B Smith; Yingwei Yao; Jiang Bian; Diana J Wilkie; Karen Dunn Lopez; Gail M Keenan Journal: J Am Med Inform Assoc Date: 2019-11-01 Impact factor: 4.497
Authors: Tamara G R Macieira; Madison B Smith; Nicolle Davis; Yingwei Yao; Diana J Wilkie; Karen Dunn Lopez; Gail Keenan Journal: AMIA Annu Symp Proc Date: 2018-04-16
Authors: Graciele Fernanda da Costa Linch; Ana Amélia Antunes Lima; Emiliane Nogueira de Souza; Tais Maria Nauderer; Adriana Aparecida Paz; Cíntia da Costa Journal: Rev Lat Am Enfermagem Date: 2017-10-30
Authors: Harlon França de Menezes; Alessandra Conceição Leite Funchal Camacho; Maria Miriam Lima da Nóbrega; Patrícia Dos Santos Claro Fuly; Sâmara Fontes Fernandes; Richardson Augusto Rosendo da Silva Journal: Rev Lat Am Enfermagem Date: 2020-05-11
Authors: Juan Gómez-Salgado; Lia Jacobsohn; Fátima Frade; Macarena Romero-Martin; Carlos Ruiz-Frutos Journal: Int J Environ Res Public Health Date: 2018-10-13 Impact factor: 3.390