Development and Validation of a Computerized Assessment Form to Support Nursing Diagnosis

Abstract

Purpose

Describe the development and validation of the Nursing Assessment Form (NAF), within a clinical nursing information system, to support nurses in the identification of nursing diagnoses.

Methods

Content validity and consensus on NAF contents were established using a panel of experts in nursing diagnosis and Delphi rounds.

Findings

Expert consensus was achieved to validate an instrument to support nurses in the process of nursing diagnoses identification.

Conclusions

The use of the NAF can help nurses in diagnostic reasoning, facilitating the identification of the more suitable nursing diagnoses, and provide a basis for the best nursing interventions and outcomes.

Implications for Nursing Practice

The use of computerized decision support can improve the implementation of standardized terminology and the accuracy of nursing diagnosis.

Scopo

Descrivere lo sviluppo e il processo di validazione della Scheda di Accertamento Infermieristico (SAI), contenuta all'interno di un sistema informativo infermieristico, ideata al fine di supportare gli infermieri nel processo di identificazione delle diagnosi infermieristiche.

Metodi

La validità di contenuto e il consenso sui contenuti della SAI sono state stabilite tramite un panel di esperti sulla diagnosi infermieristica e Delphi rounds.

Risultati

Un consenso di esperti è stato ottenuto al fine di validare uno strumento utile per supportare gli infermieri nel processo di identificazione delle diagnosi infermieristiche.

Conclusioni

L'uso della SAI può aiutare gli infermieri nel ragionamento diagnostico, facilitando l'identificazione delle diagnosi infermieristiche più adatte e fornire una base per i migliori interventi e risultati infermieristici.

Implicazioni per la Pratica Infermieristica

L'uso di sistemi di supporto decisionale computerizzati può favorire l'implementazione della terminologia standard e l'accuratezza della diagnosi infermieristica.

Keywords

Computer-assisted decision support diagnosis nursing assessment nursing diagnosis

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References

Agency for Public Health, Lazio Region . Directive No. 6, December 28, 2010. Extension of the hospital discharge form (Ampliamento della Scheda di Dimissione Ospedaliera per la rilevazione di informazioni sulla Continuità Assistenziale). (July 4, 2012). Retrieved from http://www.asplazio.it/asp_online/att_ospedaliera/files/files_sio/rad_sica/DIR_6_28_12_2010_Ampliamento_scheda_RAD_SICA.zip

American Nurses Association . (2010). Nursing-standards of practice . (January 17, 2012). Retrieved from http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/NursingStandards/3-S-Booklet.pdf

Bergh

A. L.

Bergh

C. H.

Friberg

(2007). How do nurses record pedagogical activities? Nurses' documentation in patient records in a cardiac rehabilitation unit for patients who have undergone coronary artery bypass surgery. Journal of Clinical Nursing, 16(10), 1898–1907.

Bernhart-Just

Lassen

Schwendimann

(2010). Representing the nursing process with nursing terminologies in electronic medical record systems: A Swiss approach. Computers, Informatics, Nursing: CIN, 28(6), 345–352.

Carpenito-Moyet

L. J.

(2008). Nursing diagnosis: Application to clinical practice (12th ed.). Philadelphia: Lippincott Williams & Wilkins.

Choi

Bae

Y. R.

Lee

S. M.

(2011). Clinical decision support systems for patient safety: A focus group needs assessment with Korean ICU nurses. Computers, Informatics, Nursing: CIN, 29(11), 671–678.

D'Agostino

Vellone

Tontini

Zega

Alvaro

(2012). Sviluppo di un sistema informativo utilizzando un linguaggio infermieristico standard per la realizzazione di un Nursing Minimum Data Set [Development of a computerized system using standard nursing language for creation of a Nursing Minimum Data Set]. Professioni Infermieristiche, 65(2), 103–109.

De Marinis

M. G.

Piredda

Pascarella

M. C.

Vincenzi

Spiga

Tartaglini

, … Matarese

(2010). “If it is not recorded, it has not been done!”? Consistency between nursing records and observed nursing care in an Italian hospital. Journal of Clinical Nursing, 19(11–12), 1544–1552.

Gordon

(1994). Nursing diagnosis: Process and application (3rd ed.). St. Louis, MO: Mosby.

10.

Gordon

(2008). Manuale delle diagnosi infermieristiche [Manual of nursing diagnosis] (2nd ed.). Naples, Italy: EdiSES.

11.

Hasson

Keeney

McKenna

(2000). Research guidelines for the Delphi survey technique. Journal of Advanced Nursing, 32(4), 1008–1015.

12.

Häyrinen

Lammintakanen

Saranto

(2010). Evaluation of electronic nursing documentation—Nursing process model and standardized terminologies as keys to visible and transparent nursing. International Journal of Medical Informatics, 79, 554–564.

13.

Herdman

T. H.

(Ed.) (2012). NANDA International nursing diagnoses: Definitions and classification, 2012–2014. Oxford: Wiley-Blackwell.

14.

Higuchi

K. A.

Dulberg

Duff

(1999). Factors associated with nursing diagnosis utilization in Canada. Nursing Diagnosis, 10(4), 137–147.

15.

Johnson

Bulechek

McCloskey Dochterman

Maas

Moorhead

(2001). Nursing diagnosis, outcomes and interventions: NANDA, NOC and NIC linkages. St. Louis, MO: Mosby.

16.

Kurashima

Kobayashi

Toyabe

Akazawa

(2008). Accuracy and efficiency of computer-aided nursing diagnosis. International Journal of Nursing Terminologies and Classifications, 19(3), 95–101.

17.

Law Decree No. 251 . August 10, 2000. Regulation of the health care professions (Disciplina delle professioni sanitarie infermieristiche, tecniche, della riabilitazione, della prevenzione nonché della professione ostetrica). (July 4, 2012). Retrieved from http://www.camera.it/parlam/leggi/00251l.htm

18.

Lemay

C. A.

Cashman

S. B.

Savageau

J. A.

Reidy

P. A.

(2004). Effect of a low-cost intervention on recording body mass index in patients' records. Journal of Nursing Scholarship, 36(4), 312–315.

19.

Lunney

(2010). Il pensiero critico nell'assistenza infermieristica: Casi clinici con Nanda-I, NOC e NIC [Critical thinking to achieve positive health outcomes: nursing case studies and analyses]. Milan, Italy: Casa Editrice Ambrosiana.

20.

Lynn

M. R.

(1986). Determination and quantification of content validity. Nursing Research, 35(6), 382–385.

21.

Ministerial Decree No. 739 . September 14, 1994. Nurse professional profile (Regolamento concernente l'individuazione della figura e del relativo profilo professionale dell'infermiere). (July 4, 2012). Retrieved from http://www.ipasvi.it/archivio_news/leggi/179/DM140994n739.pdf

22.

Müller-Staub

Lavin

M. A.

Needham

vanAchterberg

(2006). Nursing diagnoses, interventions and outcomes—application and impact on nursing practice: Systematic review. Journal of Advanced Nursing, 56(5), 514–531.

23.

Müller-Staub

Needham

Odenbreit

Lavin

M. A.

vanAchterberg

(2007). Improved quality of nursing documentation: Results of a nursing diagnoses, interventions, and outcomes implementation study. International Journal of Nursing Terminologies and Classifications, 18(1), 5–17.

24.

Müller-Staub

Needham

Odenbreit

Lavin

M. A.

vanAchterberg

(2008). Implementing nursing diagnostics effectively: Cluster randomized trial. Journal of Advanced Nursing, 63(3), 291–301.

25.

Naylor

M. D.

Hirschman

K. B.

Bowles

K. H.

Bixby

M. B.

Konick-McMahan

Stephens

(2007). Care coordination for cognitively impaired older adults and their caregivers. Home Health Care Services Quarterly, 26(4), 57–78.

26.

Paans

Nieweg

R. M.

van derSchans

C. P.

Sermeus

(2011). What factors influence the prevalence and accuracy of nursing diagnoses documentation in clinical practice? A systematic literature review. Journal of Clinical Nursing, 20(17–18), 2386–2403.

27.

Paans

Sermeus

Nieweg

R. M.

van derSchans

C. P.

(2010). Prevalence of accurate nursing documentation in patient records. Journal of Advanced Nursing, 66(11), 2481–2489.

28.

Paganin

Moraes

M. A.

Pokorski

Rabelo

E. R.

(2008). Factors that inhibit the use of nursing language. International Journal of Nursing Terminologies and Classifications, 19(4), 150–157.

29.

Peres

H. H.

deAlmeida Lopes Monteiro da Cruz

Lima

A. F.

Gaidzinski

R. R.

Ortiz

D. C.

Mendes e Trindade

, … Batista de Oliveira

(2010). Conceptualization of an electronic system for documentation of nursing diagnosis, outcomes, and intervention. Studies in Health Technology and Informatics, 160, 279–283.

30.

Tanner

C. A.

(2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204–211.

31.

Thoroddsen

Ehnfors

(2007). Putting policy into practice: Pre-and posttests of implementing standardized languages for nursing documentation. Journal of Clinical Nursing, 16(10), 1826–1838.

32.

Welton

J. M.

Halloran

E. J.

(2005). Nursing diagnoses, diagnosis-related group, and hospital outcomes. Journal of Nursing Administration, 35(12), 541–549.

33.

Yeh

S. H.

Jeng

Lin

L. W.

T. H.

Hsiao

C. Y.

Lee

L. N.

Chen

S. L.

(2009). Implementation and evaluation of a nursing process support system for long-term care: A Taiwanese study. Journal of Clinical Nursing, 18(22), 3089–3097.