PURPOSE. This paper aims to provide insight into nursing classifications and to report the effects of nursing diagnostics implementation. This paper summarizes the results of six studies.
METHODS. Two systematic reviews, instrument development and testing, a pre–post intervention study, and a cluster-randomized trial were performed.
FINDINGS. The NANDA International classification met most of the literature-based classification criteria, and results showed the Quality of Nursing Diagnoses, Interventions and Outcomes (Q-DIO) to be a reliable instrument to measure the documented quality of nursing diagnoses, interventions, and outcomes. Implementation of standardized nursing language significantly improved the quality of documented nursing diagnoses, related interventions, and patient outcomes. As a follow-up measure, Guided Clinical Reasoning (GCR) was effective in supporting nurses’ clinical reasoning skills.
CONCLUSIONS. Carefully implementing classifications led to enhanced, accurately stated nursing diagnoses, more effective nursing interventions, and better patient outcomes.
IMPLICATIONS. Rethinking implementation methods for standardized language and using GCR is recommended. Based on the results of this study, the inclusion of NANDA International diagnoses with related interventions and outcomes in electronic health records is suggested.
Get full access to this article
View all access options for this article.
References
1.
BartholomeyczikS. (2004). Qualitätsdimensionen in der Pflegedokumentation—eine standardisierte Analyse von Dokumenten in Altenpflegeheimen. Pflege: Die wissenschaftliche Zeitschrift für Pflegeberufe, 17, 187–195.
2.
Bernisches Gesundheitsgesetz. (1984). Dokumentationspflicht. Bern, Switzerland: Grosser Rat, Kt. Bern.
3.
CurrellR.UrquhartC. (2003). Nursing record systems: Effects on nursing practice and health care outcomes. Cochrane Review, 3(CD002099).
4.
DalyJ. M.BuckwalterK.MaasM. (2002). Written and computerized care plans. Journal of Gerontological Nursing, 28(9), 14–23.
5.
Departement des Innern. (2003). Richtlinien des Departements des Innern: Pflege und Betreuungsdokumentation. Departement des Innern, Kt. Solothurn.
6.
DoengesM. E.MoorhouseM. F.MurrA. C. (2008). Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales(10th ed.). Philadelphia: F.A. Davis.
7.
FlorinJ.EhrenbergA.EhnforsM. (2005). Quality of nursing diagnoses: Evaluation of an educational intervention. International Journal of Nursing Terminologies and Classifications, 16(2), 33–43.
8.
Institute of Medicine. (2004). Keeping Patients Safe. Washington, DC: National Academy Press.
9.
KVG. (1995). Schweizerisches Krankenversicherungsgesetz. Bern, Switzerland: Bundesamt für Gesundheit.
10.
LunneyM. (2006). Helping nurses use NANDA, NOC, and NIC. Journal of Nursing Administration, 36(3), 118–125.
11.
LunneyM.DelaneyC.DuffyM.MoorheadS.WeltonJ. (2005). Advocating for standardized nursing languages in electronic health records. Journal of Nursing Administration, 35(1), 1–3.
12.
Müller-StaubM. (2007). Evaluation of the implementation of nursing diagnostics. Doctoral Thesis, Radboud University, Nijmegen, The Netherlands.
13.
Müller-StaubM.LavinM. A.NeedhamI.Van AchterbergT. (2006). Nursing diagnoses, interventions and outcomes—Application and impact on nursing practice: A systematic literature review. Journal of Advanced Nursing, 56(5), 514–531.
14.
Müller-StaubM.LavinM. A.NeedhamI.Van AchterbergT. (2007). Meeting the criteria of a nursing diagnosis classification: Evaluation of ICNP®, ICF, NANDA and ZEFP. International Journal of Nursing Studies, 44(5), 702–713.
15.
Müller-StaubM.NeedhamI.OdenbreitM.LavinM. A.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.
16.
Müller-StaubM.NeedhamI.OdenbreitM.LavinM. A.Van AchterbergT. (2008). Implementing nursing diagnostics effectively: A cluster randomized trial. Journal of Advanced Nursing, 63(3), 291–301.
17.
Müller-StaubM.LunneyM.LavinM. A.NeedhamI.OdenbreitM.Van AchterbergT. (2008). 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.
18.
Müller-StaubM.LunneyM.OdenbreitM.NeedhamI.LavinM. A.Van AchterbergT. (in press). Development of an instrument to measure the quality of documentation of nursing diagnoses, interventions and outcomes: The Q-DIO. Journal of Clinical Nursing.
19.
PourasgharF.MalekafzaliH.KochS.ForsU. (2008). Factors influencing the quality of medical documentation when a paper-based medical records system is replaced with an electronic medical records system: An Iranian case study. International Journal of Technology Assessment in Health Care, 24(4), 445–451.
20.
ThoroddsenA.EhnforsM. (2007). Putting policy into practice: Pre- and posttests of implementing standardized languages for nursing documentation. Journal of Clincal Nursing, 16(10), 1820–1836.
