The quality of nursing documentation and standardized nursing diagnoses in the children's hospital electronic nursing records

Abstract

Aim

The aim of the paper is to compare the quality of nursing documentation in the Children's Hospital before and after the NANDA-I nursing diagnoses training.

Methods

Research employed the interventional study design, and pre–post study design. Before and after the NANDA-I nursing diagnoses training, 50 nursing records were analyzed in the interventional pre–post study, using D-Catch instrument.

Results

The most often documented problem-centered nursing diagnosis before training was anxiety and after the training, hyperthermia. The most common risk diagnoses before and after the training was risk of infection. Before the training, one health promotion diagnosis was determined in the nursing records, and after the training the number increased to four. The highest value was given to readability of the nursing documentation both before and after the training. The lowest score before the training was given to the quality determiners of the accurate nursing diagnoses and after the training given to the determiners of the results’ quantity. The sum score of documenting the nursing interventions was the most inconsistent before the training and after the training. The most consistent was the readability of the nursing records before and after the training. Statistically significant differences in the improvement of quality were revealed in all areas except for the readability of the nursing documentation and the quantity of nursing assessment.

Conclusions

The results of the study revealed that following the training, the quality of nursing documentation improved, the wording of the nursing diagnoses improved, and the number of accurate nursing diagnoses had increased.

Implications for Nursing Practice

Results of the research provide an overview of the importance of the training in improving the quality of nursing documentation and aid the educators in planning the trainings, focusing more on the challenges in the documentation.

Keywords

children nursing diagnoses nursing record standardized nursing terminology

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References

Avena

M. J.

Pedreira

M. da L. G.

Bassolli de Oliveira Alves

Herdman

T. H.

deGutiérrez

M. G. R.

(2019). Frequency of respiratory nursing diagnoses and accuracy of clinical indicators in preterm infants. International Journal of Nursing Knowledge, 302, 73–80. https://doi.org/10.1111/2047-3095.12205

Borsato

F. G.

Rossaneis

M. Â.

Do Carmo Fernandez Lourenço Haddad

Vannuchi

M. T. O.

Vituri

D. W.

(2011). Avaliação da qualidade das anotações de enfermagem em um Hospital Universitário. ACTA Paulista de Enfermagem, 244, 527–533. https://doi.org/10.1590/s0103-21002011000400013

Bruylands

Paans

Hediger

Müller-Staub

(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, 243, 163–170. https://doi.org/10.1111/j.2047-3095.2013.01248.x

Collins

(2013). Effect of continuing nursing education on nurses’ attitude toward and accuracy of nursing diagnosis. International Journal of Nursing Knowledge, 243, 122–128. https://doi.org/10.1111/j.2047-3095.2013.01237.x

D'Agostino

Barbaranelli

Paans

Belsito

Juarez Vela

Alvaro

Vellone

(2017). Psychometric evaluation of the D-Catch, an instrument to measure the accuracy of nursing documentation. International Journal of Nursing Knowledge, 283, 145–152. https://doi.org/10.1111/2047-3095.12125

deAquino

W. K. M.

Lopes

M. V. de O.

da Silva

V. M.

Fróes

N. B. M.

deMenezes

A. P.

Almeida

A. de A. P.

Sobreira

B. A.

(2019). Accuracy of the defining characteristics of the nursing diagnosis hypothermia in newborns. International Journal of Nursing Knowledge, 301, 21–27. https://doi.org/10.1111/2047-3095.12188

Dzubaty

D. R.

(2016). Providing family-centered care in maternal-newborn settings: A case study. Newborn and Infant Nursing Reviews, 162, 55–57. https://doi.org/10.1053/j.nainr.2016.03.006

Fernanda Da Costa Linch

Amélia

Lima

Nogueira De Souza

Nauderer

T. M.

Paz

A. A.

Da Costa

(2017). An educational intervention impact on the quality of nursing records. Revista Latino-Americana de Enfermagem, 25, 2938. https://doi.org/10.1590/1518-8345.1986.2938

Ferreira

A. M.

Predebon

C. M.

da Cruz

D. de A. L. M.

Rabelo

E. R.

(2011). Clinical validation of nursing diagnoses of acute pain in hospitalized children. International Journal of Nursing Terminologies and Classifications, 224, 162–169. https://doi.org/10.1111/j.1744-618X.2011.01194.x

10.

Gomes

G. L. L.

da Nóbrega

M. M. L.

(2015). Anxiety in children following hospitalization: A proposal for a nursing diagnosis. Revista Latino-Americana de Enfermagem, 235, 963–970. https://doi.org/10.1590/0104-1169.0372.2637

11.

Hasegawa

Ogasawara

Katz

E. C.

(2007). Measuring diagnostic competency and the analysis of factors influencing competency using written case studies. International Journal of Nursing Terminologies and Classifications: The Official Journal of NANDA International, 183, 93–102. https://doi.org/10.1111/j.1744-618X.2007.00057.x

12.

Herdman

T. H.

(2012). NANDA International Õendusdiagnoosid: Definitsioonid ja klassifikatsioon 2012 – 2014 (NANDA International nursing diagnoses: definitions and classification 2012―2014). Elmatar.

13.

Inan

N. K.

Dinç

(2013). Evaluation of nursing documentation on patient hygienic care. International Journal of Nursing Practice, 191, 81–87. https://doi.org/10.1111/ijn.12030

14.

Jefferies

Johnson

Griffiths

(2010). A meta-study of the essentials of quality nursing documentation. International Journal of Nursing Practice, 162, 112–124. https://doi.org/10.1111/j.1440-172X.2009.01815.x

15.

Kaheksa sammu inimese tervise heaks . Eesti õenduse ja ämmaemanduse arengustrateegia aastateks 2011–2020 . (2010). https://www.sm.ee/sites/default/files/content-editors/eesmargid_ja_tegevused/Tervis/Tervishoiususteem/eol_eau_arengustrateegia.pdf

16.

Kamil

Rachmah

Wardani

(2018). What is the problem with nursing documentation? Perspective of Indonesian nurses. International Journal of Africa Nursing Sciences, 9, 111–114. https://doi.org/10.1016/j.ijans.2018.09.002

17.

Kokkuvõte kliinilisest auditist„ Iseseisva statsionaarse õendusabi kvaliteet ja põhjendatus. (2017). https://www.haigekassa.ee/sites/default/files/uuringud_aruanded/auditid/2017_kliinilise_auditi_oendusabi_kokkuvote_kodulehele.pdf

18.

de Leon

P. A. P.

Nóbrega

M. M. L.

da (2012). Nursing diagnosis in hospitalized children using NANDA-I: A case study. Online Brazilian Journal of Nursing, 111, 68–77. https://doi.org/10.5935/1676-4285.20120007

19.

Linch

G. F. da C.

Lima

A. A. A.

deSouza

E. N.

Nauderer

T. M.

Paz

A. A.

da Costa

(2017). Impacto de uma intervenção educativa na qualidade dos registros de enfermagem. Revista Latino-Americana de Enfermagem,25. https://doi.org/10.1590/1518-8345.1986.2938

20.

Lopes

T. A. M. C.

Monteiro

M. D. F. V.

deOliveira

J. D.

deOliveira

D. R.

Pinheiro

A. K. B.

Damasceno

S. S.

(2018). Nursing diagnoses in hospitalized children. Revista Da Rede de Enfermagem Do Nordeste, 186, 756. https://doi.org/10.15253/2175-6783.2017000600008

21.

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, 181, 5–17. https://doi.org/10.1111/j.1744-618X.2007.00043.x

22.

Müller-Staub

Lunney

Odenbreit

Needham

Lavin

M. A.

Van Achterberg

(2009). Development of an instrument to measure the quality of documented nursing diagnoses, interventions and outcomes: The Q-DIO. Journal of Clinical Nursing, 18, 1027–1037. https://doi.org/10.1111/j.1365-2702.2008.02603.x

23.

Müller-Staub

Needham

Odenbreit

Lavin

M. A.

Van Achterberg

(2008). Implementing nursing diagnostics effectively: Cluster randomized trial. Journal of Advanced Nursing, 633, 291–301. https://doi.org/10.1111/j.1365-2648.2008.04700.x

24.

Mykkänen

Saranto

Miettinen

(2012). Nursing audit as a method for developing nursing care and ensuring patient safety. NI 2012 : 11th International Congress on Nursing Informatics, June 23–27, 2012, Montreal, Canada. International Congress in Nursing Informatics (11th : 2012 : Montreal, Quebec), 201218, 301. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24199107%0A http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC3799087

25.

Paans

Sermeus

Nieweg

R. M. B.

van derSchans

C. P.

(2010a). D-Catch instrument: Development and psychometric testing of a measurement instrument for nursing documentation in hospitals. Journal of Advanced Nursing, 666, 1388–1400. https://doi.org/10.1111/j.1365-2648.2010.05302.x

26.

Paans

Sermeus

Nieweg

R. M. B.

Van Der Schans

C. P.

(2010b). Prevalence of accurate nursing documentation in patient records. Journal of Advanced Nursing, 6611, 2481–2489. https://doi.org/10.1111/j.1365-2648.2010.05433.x

27.

Pascoal

L. M.

Lopes

M. V. de O.

da Silva

V. M.

Chaves

D. B. R.

Beltrão

B. A.

Nunes

M. M.

deMoura

K. K. M.

(2016). Clinical differentiation of respiratory nursing diagnoses among children with acute respiratory infection. Journal of Pediatric Nursing, 311, 85–91. https://doi.org/10.1016/j.pedn.2015.08.002

28.

Patiraki

Katsaragakis

Dreliozi

Prezerakos

(2017). Nursing care plans based on NANDA, nursing interventions classification, and nursing outcomes classification: The investigation of the effectiveness of an educational intervention in Greece. International Journal of Nursing Knowledge, 282, 88–93. https://doi.org/10.1111/2047-3095.12120

29.

Pereira

P. J. S.

deSouza

N. F. H.

deAlmeida

R. J.

Menezes

D. C.

Bom

G. C.

Trettene

A. dos S.

(2017). Nursing diagnoses and interventions in children submitted to cochlear implantation. Revista Da Escola de Enfermagem, 51, 1–7. https://doi.org/10.1590/S1980-220x2016045203238

30.

Prideaux

(2011). Issues in nursing documentation and record-keeping practice. British Journal of Nursing, 2022, 1450–1454. https://doi.org/10.12968/bjon.2011.20.22.1450

31.

Saranto

Kinnunen

U. M.

(2009). Evaluating nursing documentation – Research designs and methods: Systematic review. Journal of Advanced Nursing, 653, 464–476. https://doi.org/10.1111/j.1365-2648.2008.04914.x

32.

Setyaningrum

E. E.

Nurjannah

Rustiyaningsih

(2019). Effect of NANDA-I, NIC, and NOC documentation system training on quality of nursing care documentation in the perinatal ward of Yogyakarta regional public hospital. Belitung Nursing Journal, 55, 180–191. https://doi.org/10.33546/bnj.770

33.

Herdman

T. H.

Kamitsuru

(2018). NANDA International nursing diagnoses: Definitions & classification, 2018—2020. (11th ed.). Thieme Publishers.

34.

Teixeira

I. X.

Lopes

M. V. de O.

Martins

L. C. G.

Diniz

C. M.

deMenezes

A. P.

Alves

N. P.

(2016). Validation of clinical indicators of imbalanced nutrition: Less than body requirements in early childhood. Journal of Pediatric Nursing, 312, P179–P186. https://doi.org/10.1016/j.pedn.2015.02.011

35.

Tervishoiuteenuse osutamise dokumenteerimise tingimused ja kord . (2019). Retrieved May 25, 2020, from RTL 2008, 80, 1115 website: https://www.riigiteataja.ee/akt/107072011010?leiaKehtiv

36.

Thoroddsen

Ehrenberg

Sermeus

Saranto

(2012). A survey of nursing documentation, terminologies and standards in European countries. NI 2012 : 11th International Congress on Nursing Informatics, June 23–27, 2012, Montreal, Canada. International Congress in Nursing Informatics (11th : 2012 : Montreal, Quebec), 2012, 406. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/24199130%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC3799179

37.

Tuinman

deGreef

M. H. G.

Krijnen

W. P.

Paans

Roodbol

P. F.

(2017). Accuracy of documentation in the nursing care plan in long-term institutional care. Geriatric Nursing, 386, 578–583. https://doi.org/10.1016/j.gerinurse.2017.04.007

38.

Vabo

Slettebø

Å.

Fossum

(2017). Participants’ perceptions of an intervention implemented in an action research nursing documentation project. Journal of Clinical Nursing, 26(7–8), 983–993. https://doi.org/10.1111/jocn.13389

39.

Wang

Björvell

Hailey

(2014). Development of the quality of Australian nursing documentation in aged care (QANDAC) instrument to assess paper-based and electronic resident records. Australasian Journal on Ageing, 334, E18–E24. https://doi.org/10.1111/ajag.12072

40.

Wang

Hailey

(2011). Quality of nursing documentation and approaches to its evaluation: A mixed-method systematic review. Journal of Advanced Nursing, 679, 1858–1875. https://doi.org/10.1111/j.1365-2648.2011.05634.x