Use of Electronic and Paper-based Standardized Nursing Care Plans to Improve Nurses’ Documentation Quality in a Nigerian Teaching Hospital

Abodunrin O. L. Akande T. M. (2009). Knowledge and perception of e-health and telemedicine among health professionals in LAUTECH Teaching Hospital, Osogbo, Nigeria. International Journal of Health Research, 2(1), 51–58.

Adeyemo F. O. Olaogun A. A. (2013). Factors affecting the use of nursing process in health institutions in Ogbomoso Town, Oyo State. International Journal of Medicine and Pharmaceutical Sciences, 3(1), 91–98.

Adubi I. O. Olaogun A. A. Adejumo P. O. (2017). Effect of standardised nursing language continuing education programme on nurses' documentation of care at University College Hospital, Ibadan. Nursing Open, 5(1), 37–44.

American Nurses Association (ANA) . (2016). Nursing Process, Retrieved from http://www.nursingworld.org/EspeciallyforYou/StudentNurses/Thenursingprocess.aspx on 16/11/2017

Ammenwerth E. Kutscha U. Kutscha A. Mahler C. Eichstädter R. Haux R. (2001). Analysis of interrupted time series studies in medication use research. Journal of Clinical Pharmacy and Therapeutics, 27(4), 299–309.

Andel C. Davidow S. L. Hollander M. Moreno D. A. (2012). The economics of healthcare quality and medical errors. Journal of Healthcare Finance, 39(1), 39.

August F. Pembe A. B. Mpembeni R. Axemo P. Darj E. (2016). Effectiveness of the home based life saving skills training by community health workers on knowledge of danger signs, birth preparedness, complication readiness and facility delivery, among women in Rural Tanzania. BMC Pregnancy and Childbirth, 16(1), 129–140.

Avila L. I. da-Silveira R. S. Lunardi V. L. Fernandes G. F. Mancia J. R. da Silveira J. T. (2013). Implications of the visibility of professional nursing practices. Revista Gaúcha de Enfermagem, 34(3), 102–109.

Ballantyne H. (2016). Developing nursing care plans. Nursing Standard, 30(26), 51–57.

Bjorvell C. Wredling R. Thorell-Ekstrand I. (2003). Prerequisites and consequences of nursing documentation in patient records as perceived by a group of registered nurses. Journal of Clinical Nursing, 12(2), 206–214.

Blumenthal D. Tavenner M. (2010). The “meaningful use” regulation for electronic health records. New England Journal of Medicine, 363(6), 501–504.

Bruylands M. Paans W. Hediger H. Müller-Staub M. (2013). Effects on the quality of the nursing care process through an educational program and the use of electronic nursing documentation. International Journal of Nursing Knowledge, 24(3), 163–170.

Bulechek G. Butcher H. Dochterman J. Wagner C. (Eds.). (2013). Nursing interventions classification (NIC) (6th ed.). St. Louis, MO: Elsevier.

Canadian Medical Protective Association . (2011). Why good documentation matters. Retrieved from http://www.cpso.on.ca/uploadedFiles/members/peerassessment/documentation-CMPA.pdf

Chaudhry B. Wang J. Wu S. Maglione M. Mojica W. Roth E. , … Shekelle P. G. (2006). Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care. Annals of Internal Medicine, 144(10), 742–752.

Cheung A Mayhew A Weir M Grimshaw J (2012). Overview of the effectiveness of reminders in improving professional behaviour. Unpublished manuscript obtained by personal communication. Sytematic Reviews, 1(36). Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22898173

Cornish R. (2007). Statistics: Cluster analysis. Mathematics Learning Support Centre, 1–5.

Daniel G. O. Oyetunde M. O. (2013). Nursing informatics: A key to improving nursing practice in Nigeria. International Journal of Nursing and Midwifery, 5(5), 90–98,

Deegan J Simkin K (2010). Expert to novice: Experiences of professional adaptation reported by non-English speaking nurses in Australia. The Australian Journal of Advanced Nursing: A Quarterly Publication of the Royal Australian Nursing Federation, 27, 31–37

Donabedian A. (2003). An introduction to quality assurance in healthcare (1st ed.). New York, NY: Oxford University Press.

Dulon M. Peters C. Schablon A. Nienhaus A. (2014). MRSA carriage among healthcare workers in non-outbreak settings in Europe and the United States: A systematic review. BMC Infectious Diseases, 14(1), 363–367.

Firouzeh M. Jafarjalal E. Emamzadeh Ghasemi H. S. Bahrani N. Sardashti S. (2017). Evaluation of vocal-electronic nursing documentation: A comparison study in Iran. Informatics for Health and Social Care, 42(3), 250–260.

Fossum M. Ehnfors M. Svensson E. Hansen L. M. Ehrenberg A. (2013). Effects of a computerized decision support system on care planning for pressure ulcers and malnutrition in nursing homes: An intervention study. International Journal of Medical Informatics, 82(10), 911–921.

Gardner C. L. Pearce P. F. (2013). Customization of electronic medical record templates to improve end user satisfaction. CIN: Computers, Informatics, and Nursing, 31(3), 115–121.

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

Grove H. D. Wall K. H. Helwig A. Wright S. J. (2015). Using electronic clinical quality measure reporting for public health surveillance. Morbidity and Mortality Weekly Report, 64(16), 439–442.

Habibi-Koolaee M. Safdari R. Bouraghi H. (2015). Nurses readiness and electronic health records. Acta Informatica Medica, 23(2), 105.

Hagos F. Alemseged F. Balcha F. Berhe S. Aregay A. (2014). Application of nursing process and its affecting factors among nurses working in Mekelle Zone Hospitals, Northern Ethiopia. Nursing Research and Practice, 2014, 1–8. Retrieved from https://doi.org/10.1155/2014/675212

Hayrinen K. Saranto K. Nykanen P. (2008). Definition, structure, content, use and impacts of electronic health records: A review of the research literature. International Journal of Medical Informatics, 77(5), 291–304

Herdman T. H. Kamitsuru S. (Eds.). (2014). NANDA International nursing diagnosis: Definitions and classification 2015--2017. Oxford: Wiley Blackwell.

Hillestad R. Bigelow J. Bower A. Girosi F. Meili R. Scoville R. Taylor R. (2005). Can electronic medical record systems transform healthcare? Potential health benefits, savings, and costs. Health Affairs, 24(5), 1103–1117.

Holden S. L. (2014). An educational intervention to increase CLABSI bundle compliance in the ICU (PhD thesis). University of Arkansas. Retrieved from http://scholarworks.uark.edu/cgi/viewcontent.cgi?article=1011andcontext=nursuht on 18/01/2018.

Idowu P. Cornfold D. Bastin L. (2008). Health informatics deployment in Nigeria. Journal of Health Informatics in Developing Countries, 2(1), 15–23.

Institute of Medicine, Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing . (2011). The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press.

Jefferies D. Johnson M. Nicholls D. (2011). Nursing documentation: How meaning is obscured by fragmented language. Nursing Outlook, 59(6), e6–e12. https://doi.org/10.1016/j.outlook.2011.04.002

Jones D. Lunney M. Keenan G. Moorhead S. (2010). Standardised nursing languages: Essential for the nursing workforce. Annual Review of Nursing Research, 28, 253–294.

Kahouei M. Mohammadi H. B. Majdabadi H. A. Solhi M. Parsania Z. Oghani P. S. Firozeh M. (2014). Nurses’ perceptions of usefulness of nursing information system: Module of electronic medical record for patient care in two university hospitals of Iran. Materia Sociomedica, 26(1), 30–34.

Kelley T. F. Brandon D. H. Docherty S. L. (2011). Electronic nursing documentation as a strategy to improve quality of patient care. Journal of Nursing Scholarship, 43(2), 154–162.

Kent P. Morrow K. (2014). Better documentation improves patients care. Nursing Standard, 29(14), 44–51

Kozier B. Erb G. Berman A. Snyder S. Lake R. Harvey S. (2008). Fundamentals of nursing: Concepts, process and practice. Harlow, England: Pearson Education.

Lavin M. Harper E. Barr N. (2015). Health information technology, patient safety, and professional nursing care documentation in acute care settings. Online Journal of Issues in Nursing, 20(2), 6.

Law L. Akroyd K. Burke L. (2010). Improving nurse documentation and record keeping in stoma care. British Journal of Nursing, 19(21), 1328–1332.

Lewin K. (1951). Fied theory in social science. Tavistock Publications, London.

Lindo J. Stennett R. Stephenson-Wilson K. Barrett K. A. Bunnaman D. Anderson-Johnson P. Wint Y. (2016). An audit of nursing documentation at three public hospitals in Jamaica. Journal of Nursing Scholarship, 48(5), 499–507.

Ludwick D. A. Doucette J. (2009). Adopting electronic medical records in primary care: Lessons learned from health information systems implementation experience in seven countries. International Journal of Medical Informatics, 78(1), 22–31. https://doi.org/10.1016/j.ijmedinf.2008.06.005

Lundberg C. Warren J. Brokel J. Bulechek G. Butcher H. Dochterman J. Giarrizzo-Wilson S. (2008). Selecting a standardised terminology for the electronic health record that reveals the impact of nursing on patient care. Online Journal of Nursing Informatics, 12(2). Retrieved from http://www.ojni.org/12_2/lundberg.pdf

Mahler C. Ammenwerth E. Wagner A. Tautz A. Happek T. Hoppe B. Eichstädter R. (2007). Effects of a computer-based nursing documentation system on the quality of nursing documentation. Journal of Medical Systems, 31(4), 274–282.

Moorhead S. Johnson M. Maas M. Swanson E. (Eds.). (2013). Nursing outcomes classification (NOC): Measurement of health outcomes (5th ed.). St. Louis, MO: Elsevier.

Müller-Staub M. Lunney M. Lavin M. A. Needham I. Odenbreit M. Van Achterberg T. (2008). Testing the Q-DIO as an instrument to measure the documented quality of nursing diagnoses, interventions, and outcomes. International Journal of Nursing Knowledge, 19(1), 20–27.

Müller-Staub M. Needham I. Odenbreit M. Ann Lavin M. Van Achterberg T. (2007). Improved quality of nursing documentation: Results of a nursing diagnoses, interventions, and outcomes implementation study. International Journal of Nursing Knowledge, 18(1), 5–17.

Munyisia E. N. Yu P. Hailey D. (2011). The changes in caregivers' perceptions about the quality of information and benefits of nursing documentation associated with the introduction of an electronic documentation system in a nursing home. International journal of medical informatics, 80(2), 116–126.

Musyoka F. N. Adoyo M. Oluoch M. (2015). Influence of performance appraisal on performance of healthcare workers in public hospitals: A case of Mbagathi Hospital, Nairobi County. The Journal of Global Healthcare Systems, 5(3), 1–8. Retrieved from http://jghcs.info/index.php/j/article/view/416 on 18/01/2018.

Nakate M. G. Dahl D. Drake K. B. Petrucka P. (2015). Knowledge and attitudes of select Ugandan nurses towards documentation of patient care. African Journal of Nursing and Midwifery, 2(1), 057–065.

Nakate M. G. Dahl D. Petrucka P. Drake K. B. Dunlap R. (2015). The nursing documentation dilemma in Uganda: Neglected but necessary. A case study at Mulago National Referral Hospital. Open Journal of Nursing, 5, 1063–1071. Retrieved from https://doi.org/10.4236/ojn.2015.512113

O'Brien A. Weaver C. Settergren T. T. Hook M. L. Ivory C. H. (2015). EHRS documentation: The hype and the hope for improving nursing satisfaction and quality outcomes. Nursing Administration Quarterly, 39(4), 333–339. https://doi.org/10.1097/NAQ.0000000000000132

Obioma C. (2017). Improving the quality of nursing documentation in home healthcare setting (PhD thesis). Walden University. Retrieved from http://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=4603andcontext=dissertations Assessed 15/01/2018.

Odutayo P. O Olaogun A. A Oluwatosin A. O Ogunfowokan A. A. (2013). Impact of an educational program on the use of standardised nursing languages for nursing documentation among public health nurse in Nigeria. International Journal of Nursing Knowledge, 24(2), 108–112.

Ofi B. Sowunmi O. (2012). Nursing documentation: Experience of the use of the nursing process model in selected hospitals in Ibadan, Oyo State, Nigeria. International Journal of Nursing Practice, 18(4), 354–362.

Ogunfowokan A. A. Oluwatosin A. O. Olajubu A. O. Alao O. Faremi A. F. (2013). Student nurses’ perceived use of NANDA-I nursing diagnoses in the community setting. International Journal of Nursing Knowledge, 24(1), 37–43.

Olaogun A. A. Ogini M. O. Oyedeji T. A. Nnahiwe B. Olatubi I. (2011). Assessing the use of NANDA nursing diagnosis at OAUTH, Ile-Ife, Nigeria. International Journal of Nursing Terminologies and Classification, 22(4), 157–161.

Østensen E. Hellesø R. (2016). Success criteria for implementing standardised care plans in community. Nursing Informatics, 2016, 1070–1071.

Park H. Lee E. (2015). Incorporating standardised nursing languages into an electronic nursing documentation system in Korea: A pilot study. International Journal of Nursing Knowledge, 26(1), 35–42.

Pearce A. (2009). Creating nursing care plans. Retrieved from http://ezinearticle.com/?Creating-Nursing-CarePlansandid=2290737 on 18/09/2013

Rutherford M. (2008). Standardised nursing language: What does it mean for nursing practice? OJIN: The Online Journal of Issues in Nursing, 13(1). https://doi.org/0.3912/OJIN.Vol13No0IPPT05

Sani S. Sani A. M. (2015). Relationship between knowledge of standardised nursing language and working experience among Nurses in Sokoto, Nigeria. International Journal of Science and Research, 4(2), 1008–1010

Seaman J. B. Evans A. C. Sciulli A. M. Barnato A. E. Sereika S. M. Happ M. B. (2017). Abstracting ICU nursing care quality data from the electronic health record. Western Journal of Nursing Research, 39(9), 1271–1288.

Shekelle P. Morton S. C Keeler E. B. (2006). Costs and benefits of health information technology. Agency for Healthcare Research and Quality (US), Report No.: 06-E006.

Sockolow P. S. Liao C. Chittams J. L. Bowles K. H. (2012). Evaluating the impact of electronic health records on nurse clinical process at two community health sites. Nursing Informatics, 2012, 381–385. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3799128/ on 18/06 2015

Stevenson J. E. Israelsson J. Petersson G. Bath P. A. (2018). Factors influencing the quality of vital sign data in electronic health records: A qualitative study. Journal of Clinical Nursing, 27(5–6), 1276–1286.

Tapp R. A. (1990). Inhibitors and facilitators to documentation of nursing practice. Western Journal of Nursing Research, 12(2), 229–240.

Tastan S. Linch G. C. Keenan G. M. Stifter J. McKinney D. Fahey L. , … Wilkie D. J. (2014). Evidence for the existing American Nurses Association-recognized standardised nursing terminologies: A systematic review. International Journal of Nursing Studies, 51(8), 1160–1170.

Thede L. Schwiran P. (2011). Informatics: The standardised nursing terminologies: A national survey of nurses’ experiences and attitudes—Survey I*. OJIN: The Online Journal of Issues in Nursing, 16(2). https://doi.org/10.3912/OJIN.Vol16No02InfoCol01

Tijani K. H. Lawal A. O. Ojewola R. W. Badmus T. A. (2010). Quality of documentation of urethral catheterization in a Nigerian teaching hospital. Nigerian Quarterly Journal of Hospital Medicine, 20(4), 177–180.

Uys L. R. Naidoo J. R. (2004). A survey of the quality of nursing care in several health districts in South Africa. BMC Nursing, 3(1), 1–7.

Welch W. P. Bazarko D. Ritten K. Burgess Y. Harmon R. Sandy L. G. (2007). Electronic health records in four community physician practices: Impact on quality and cost of care. Journal of American Medical Informatics Association, 14, 320–328. https://doi.org/10.1197/jamia.M2125

World Health Organization . (2006). Electronic health records: manual for developing countries. Manila: WHO Regional Office for the Western Pacific.

Yu P. Hailey D. Li H. (2008). Caregivers’ acceptance of electronic documentation in nursing homes. Journal of Telemedicine and Telecare, 14(5), 261–265. https://doi.org/10.1258/jtt.2008.080310.

Yu P. Qiu Y. Crookes P. (2006). Computer-based nursing documentation in nursing homes: A feasibility study. Studies in Health Technology and Informatics, 122, 570–574.

Zhang Y. Yu P. Shen J. (2012). The benefits of introducing electronic health records in residential aged care facilities: A multiple case study. International Journal of Medical Informatics, 81(10), 690–704.