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An Internationally Consented Standard for Nursing Process-Clinical Decision Support Systems in Electronic Health Records
Abstract
Nurses are accountable to apply the nursing process, which is key for patient care: It is a problem-solving process providing the structure for care plans and documentation. The state-of-the art nursing process is based on classifications that contain standardized concepts, and therefore, it is named Advanced Nursing Process. It contains valid assessments, nursing diagnoses, interventions, and nursing-sensitive patient outcomes. Electronic decision support systems can assist nurses to apply the Advanced Nursing Process. However, nursing decision support systems are missing, and no "gold standard" is available. The study aim is to develop a valid Nursing Process-Clinical Decision Support System Standard to guide future developments of clinical decision support systems. In a multistep approach, a Nursing Process-Clinical Decision Support System Standard with 28 criteria was developed. After pilot testing (N = 29 nurses), the criteria were reduced to 25. The Nursing Process-Clinical Decision Support System Standard was then presented to eight internationally known experts, who performed qualitative interviews according to Mayring. Fourteen categories demonstrate expert consensus on the Nursing Process-Clinical Decision Support System Standard and its content validity. All experts agreed the Advanced Nursing Process should be the centerpiece for the Nursing Process-Clinical Decision Support System and should suggest research-based, predefined nursing diagnoses and correct linkages between diagnoses, evidence-based interventions, and patient outcomes. Copyright
... The nursing process, being the application of the scientific method to caregiving, provides a work system that allows clinical documentation to be structured, thus facilitating communication between professionals, and improving the safety and continuity of care (De Groot et al., 2020;De Oliveira & Peres, 2021;Müller-Staub et al., 2016). In addition, standardised nursing terminologies enable health outcomes to be compared, making it possible to develop quality standards of care and to carry out research that is purely nurse-centred (Zhang et al., 2021). ...
... Standardised nursing terminologies are a prerequisite for the development of electronic health records and clinical decision support systems (Müller-Staub, De Graaf-Waar and Paans, 2016). To promote quality of care, nurses should rely on clinical decision support systems that are structured according to the nursing process and use standardised nursing terminologies (Müller-Staub, De Graaf-Waar and Paans, 2016;Chand and Sarin, 2019;Mebrahtu et al., 2021). ...
... Standardised nursing terminologies are a prerequisite for the development of electronic health records and clinical decision support systems (Müller-Staub, De Graaf-Waar and Paans, 2016). To promote quality of care, nurses should rely on clinical decision support systems that are structured according to the nursing process and use standardised nursing terminologies (Müller-Staub, De Graaf-Waar and Paans, 2016;Chand and Sarin, 2019;Mebrahtu et al., 2021). In addition, current research suggests that the use of clinical decision support systems guides nurses throughout the nursing process, improving their clinical reasoning skills (D'Agostino et al., 2019;De Groot et al., 2020). ...
The aim of this study was to validate the diagnostic content and the NANDA-I and NOC linkages for six psychosocial nursing diagnoses. This multicentre, descriptive, cross-sectional validation study followed Fehring's model. Expert nurses in nursing methodology and standardised nursing languages in Spain participated, with expertise criteria based on academic level and clinical, teaching, and research experience in the fields of nursing methodology and standardised nursing languages. This study adhered to the STROBE guidelines for cross-sectional studies. Eighty-seven professionals participated in the diagnostic content validation phase, and 57 in the NANDA-I and NOC linkages validation phase. The content validity indices of the six diagnoses ranged from 0.74 to 0.84, all considered valid. All 84 proposed defining characteristics were valid, with 42 scoring ≥0.8. Thirty-two linkages between diagnoses and NOC outcomes were proposed, all valid, with mean scores between 0.73 and 0.98. Each diagnosis was linked to 5-6 NOC outcomes, comprising 26 main outcomes and 6 supplementary outcomes. Overall coverage rates for each diagnosis ranged from 68.42% to 100%. All linkages between defining characteristics and NOC outcome indicators were validated. The six selected psychosocial diagnoses, their defining characteristics, and the proposed linkages between diagnoses and outcomes have been validated. The validation of linkages between NOC indicators and nearly all major defining characteristics of these six psychosocial diagnoses will make it possible to enhance diagnostic accuracy and enable continuous assessment of the effects of nursing interventions on the clinical progression of these diagnoses.
... 4 Ideally, CDSSs used by nurses should incorporate SNLs to allow nurses to describe and communicate the central elements of nursing practice and, consequently, to extract, analyze, and exchange data on nursing practice. [5][6][7] The use of SNLs, such as International Classification Nursing Practice (ICNP), Community Health System (OMAHA), Clinical Care Classification (CCC), Nanda International (NANDA-I), Nursing Intervention Classification (NIC), and Nursing Outcome Classification (NOC), has been shown to improve communication among healthcare providers, enhance documentation of nursing care, and promote evidence-based practice. They also have been associated with improved patient outcomes such as reduced length of hospital stay, decreased mortality rates, and improved patient satisfaction. ...
... 14 In the study, PROCEnf-USP V R achieved more than 70% positive responses in most of the quality characteristics evaluated, such as functional adequacy, performance efficiency, compatibility, usability, reliability, security, maintainability, and portability. 13 PROCEnf-USP V R also complies with the recommendations of the Nursing Process-Clinical Decision Support System (NP-CDSS) standard, 5,15 which is a guide to developing nursing CDSSs. According to the NP-CDSS, the Advanced Nursing Process should be the centerpiece of the system, as it recommends that the NP-CDSS should suggest research-based, predefined nursing diagnoses and correct linkages between diagnoses, evidence-based interventions, and patient outcomes. ...
... According to the NP-CDSS, the Advanced Nursing Process should be the centerpiece of the system, as it recommends that the NP-CDSS should suggest research-based, predefined nursing diagnoses and correct linkages between diagnoses, evidence-based interventions, and patient outcomes. 5,15 PROCEnf-USP V R is structured according to the Advanced Nursing Process steps (assessment, diagnosis, planned outcomes, interventions, and outcome evaluation), and the harmonization of the NANDA International Classification (NANDA-I), Nursing Intervention Classification (NIC), and Nursing Outcomes Classification (NOC), also known as NNN taxonomy. 16 It has 2 environments: professional and academic. ...
Objective:
To analyze the nursing diagnostic concordance among users of a clinical decision support system (CDSS), The Electronic Documentation System of the Nursing Process of the University of São Paulo (PROCEnf-USP®), structured according to the Nanda International, Nursing Intervention Classification and Nursing Outcome Classification (NNN) Taxonomy.
Materials and methods:
This pilot, exploratory-descriptive study was conducted from September 2017 to January 2018. Participants were nurses, nurse residents, and nursing undergraduates. Two previously validated written clinical case studies provided participants with comprehensive initial assessment clinical data to be registered in PROCEnf-USP®. After having registered the clinical data in PROCEnf-USP®, participants could either select diagnostic hypotheses offered by the system or add diagnoses not suggested by the system. A list of nursing diagnoses documented by the participants was extracted from the system. The concordance was analyzed by Light's Kappa (K).
Results:
The research study included 37 participants, which were 14 nurses, 10 nurse residents, and 13 nursing undergraduates. Of the 43 documented nursing diagnoses, there was poor concordance (K = 0.224) for the diagnosis "Ineffective airway clearance" (00031), moderate (K = 0.591) for "Chronic pain" (00133), and elevated (K = 0.655) for "Risk for unstable blood glucose level" (00179). The other nursing diagnoses had poor or no concordance.
Discussion:
Clinical reasoning skills are essential for the meaningful use of the CDSS.
Conclusions:
There was concordance for only 3 nursing diagnoses related to biological needs. The low level of concordance might be related to the clinical judgment skills of the participants, the written cases, and the sample size.
... Standardized data supports evidence-based decision-making and facilitates the assessment of nursing care and outcomes as well as valuebased healthcare and knowledge generation [1,4,5,13,14]. With the help of unified nursing concepts, it has been possible to analyze the documented state of care given; what nursing diagnoses and interventions have been used [4,15] and how, for example, patients' pain management has been identified, implemented, and evaluated [16]. ...
... Nursing documentation has evolved through the introduction of electronic health records (EHR). The nursing process framework was the key component when developing the structure to describe nursing diagnoses, interventions, and outcomes already in paper records [14,18,19]. In many countries, the use of the original World Health Organization's (WHO) model [20] varies based on the number of phases [13]. ...
... This study applies only aggregated ward level data, free text was not the focus of this study. Overall, the use of standardized terminology [2][3][4][5][6][7][8][9][10][12][13][14][15][16], patient-specific narrative descriptions [3,14] provide highly valued supplementary information [15,16]. ...
Background
Standardized nursing terminology is a prerequisite for describing nursing care processes and generating knowledge for decision-making and management. The structure of the Finnish Care Classification (FinCC) facilitates documentation of nationally agreed core nursing data: nursing diagnoses, interventions, and outcomes.
Purpose
To analyze the use of FinCC to assess patient care needs (nursing diagnoses), care implementations (interventions) and evaluation of the outcomes of nursing care in electronic health records.
Methods and materials
The descriptive study applied purposeful sampling of nursing data from nursing data repositories in three surgical wards in tertiary and secondary care hospitals. The aggregated, anonymous ward level data from a six-month period was analyzed to show distributions within frequencies and means of component, main and subcategory level use of FinCC in the three hospitals.
Results
Each of the three levels of the FinCC (component, main and subcategory) were used for recording nursing care. In all hospitals, the three most used diagnosis components covered about one third of the use of all the 17 components. The five most used intervention components cover about one third of the components. The most often used components for diagnoses and interventions were Coordination of care and follow-up care, Pain Management, Activities of daily living and independence and Medication. The prevalence of different components and the main and subcategory level usage for both diagnoses and interventions varied between the hospitals.
Conclusion
Standardized point-of-care nursing data makes patients’ daily nursing care transparent. Structured, standardized, and point-of-care nursing data can be utilized to generate new knowledge of nursing care processes and nursing care practice at ward level.
... However, other studies indicated that the setup for the electronic health records does not always match nurses' routines and can therefore be a potential source of perceived time pressure among nurses [29,30]. Yet when the electronic health records follow the phases of the nursing process, this might be supportive for nurses' clinical documentation [31]. ...
... Next, two questions focussed specifically on clinical documentation, namely whether the electronic health record of individual patients was user-friendly and whether the nursing process was central in this record. These questions were derived from the 'Nursing Process-Clinical Decision Support Systems Standard', an internationally accepted and valid standard for guiding the further development of electronic health records [31]. ...
... For optimal integration of clinical documentation in patient care, it is important that the electronic health records reflect the phases of the nursing process [6,31]. ...
Background
The time that nurses spent on documentation can be substantial and burdensome. To date it was unknown if documentation activities are related to the workload that nurses perceive. A distinction between clinical documentation and organizational documentation seems relevant. This study aims to gain insight into community nurses’ views on a potential relationship between their clinical and organizational documentation activities and their perceived nursing workload.
Methods
A convergent mixed-methods design was used. A quantitative survey was completed by 195 Dutch community nurses and a further 28 community nurses participated in qualitative focus groups. For the survey an online questionnaire was used. Descriptive statistics, Wilcoxon signed-ranked tests, Spearman’s rank correlations and Wilcoxon rank-sum tests were used to analyse the survey data. Next, four qualitative focus groups were conducted in an iterative process of data collection - data analysis - more data collection, until data saturation was reached. In the qualitative analysis, the six steps of thematic analysis were followed.
Results
The majority of the community nurses perceived a high workload due to documentation activities. Although survey data showed that nurses estimated that they spent twice as much time on clinical documentation as on organizational documentation, the workload they perceived from these two types of documentation was comparable. Focus-group participants found organizational documentation particularly redundant. Furthermore, the survey indicated that a perceived high workload was not related to actual time spent on clinical documentation, while actual time spent on organizational documentation was related to the perceived workload. In addition, the survey showed no associations between community nurses’ perceived workload and the user-friendliness of electronic health records. Yet focus-group participants did point towards the impact of limited user-friendliness on their perceived workload. Lastly, there was no association between the perceived workload and whether the nursing process was central in the electronic health records.
Conclusions
Community nurses often perceive a high workload due to clinical and organizational documentation activities. Decreasing the time nurses have to spend specifically on organizational documentation and improving the user-friendliness and intercommunicability of electronic health records appear to be important ways of reducing the workload that community nurses perceive.
... Items: 29. Table 2 shows that only two studies (10,27) reported the instrument's creation process, identifying that Müller (27) did not report if the problems identified in the first evaluation by experts were addressed or if the instrument was again tested with these improvements. ...
... Items: 29. Table 2 shows that only two studies (10,27) reported the instrument's creation process, identifying that Müller (27) did not report if the problems identified in the first evaluation by experts were addressed or if the instrument was again tested with these improvements. ...
... With respect to content validity, four studies (10,27,28,31) show evaluation of this aspect; only the D-CATH original (29) reported numerical value with K > 0.62; phase validity was conducted by an average of eight experts (NPCDSS: 8, Q-DIO Portuguese: 9, D-CATCH Italy: 4, D-CATCH original: 12). It was found that in most of the studies the number of experts was < 30; participation by at least two or more researchers was not clearly identified, nor was clarity found on the method and approach to analyze the evaluation data. ...
Objectives:
To analyze the literature available on the psychometric properties of the instruments to measure knowledge, attitudes, and practices of the nursing care process.
Methods:
This was a narrative-type review conducted by following the recommendations of the PRISMA declaration. The search strategy was executed in two stages; through the search in databases by two reviewers and - thereafter - three reviewers identified independently the studies and evaluated the methodological quality of the measurement instruments by using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) property checklist boxes.
Results:
Of 71 studies identified for the full-text review, only seven complied with the inclusion criteria that represent four instruments (Q-DIO, D-CATCH, NP-CDSS, PNP). It was found that the instruments continue in their validation and appropriation processes to reality in health services.
Conclusions:
In spite of the evident evolution of the instruments to evaluate the implementation of the nursing care process, the need is still valid for an instrument that measures aspects of knowledge, attitudes, and practices in every stage of the process.
... A documentação do PE requer do enfermeiro conhecimento sobre conceitos padronizados, enraizados em bases científicas das Classificações de Enfermagem, também conhecidos como Sistemas de Linguagem Padronizadas (SLP) (6) . Esses sistemas oferecem a estrutura para organizar conceitos importantes sobre diagnósticos, intervenções e resultados. ...
... Os SLP são um pré-requisito para a construção de Registros Eletrônicos em Saúde (RES), visando a recuperação de informações para pesquisas, análises estatísticas, benchmarking, big data, interoperabilidade dos dados entre os diversos sistemas de saúde e sobretudo para garantir a continuidade e qualidade dos cuidados (6) . ...
... O suporte à decisão é um recurso que possibilita o acesso a diretrizes clínicas e protocolos baseados em evidências científicas. Além disso, podem apoiar os enfermeiros na documentação do PE e na formulação de diagnósticos precisos e intervenções eficazes, que podem contribuir para resultados altamente significativos e clinicamente relevantes para o paciente (6,12) . A usabilidade é definida como "até que ponto um sistema, produto ou serviço pode ser utilizado por usuários específicos para atingir objetivos com eficácia, eficiência e satisfação em um contexto específico de uso". ...
Objective:
to compare the quality of the Nursing process documentation in two versions of a clinical decision support system.
Method:
a quantitative and quasi-experimental study of the before-and-after type. The instrument used to measure the quality of the records was the Brazilian version of the Quality of Diagnoses, Interventions and Outcomes, which has four domains and a maximum score of 58 points. A total of 81 records were evaluated in version I (pre-intervention), as well as 58 records in version II (post-intervention), and the scores obtained in the two applications were compared. The interventions consisted of planning, pilot implementation of version II of the system, training and monitoring of users. The data were analyzed in the R software, using descriptive and inferential statistics.
Results:
the mean obtained at the pre-intervention moment was 38.24 and, after the intervention, 46.35 points. There was evidence of statistical difference between the means of the pre- and post-intervention groups, since the p-value was below 0.001 in the four domains evaluated.
Conclusion:
the quality of the documentation of the Nursing process in version II of the system was superior to version I. The efficacy of the system and the effectiveness of the interventions were verified. This study can contribute to the quality of documentation, care management, visibility of nursing actions and patient safety.
... Os bancos de dados se agregam e são sistematizados, vão caracterizar o nível de saúde da população e favorecer a construção de outros modelos de políticas de atendimentos aos usuários (6) .. ...
... Importante destacar que a construção deste algoritmo, necessariamente foi sedimentada em três grandes eixos para decisão clínica, os "Sistemas e Estruturas" onde se considera as áreas topográficas do corpo para avaliação, os "Sinais Vitais" incluindo Enfermagem 1,2,3,4,5,6,8,9,10,11,14,15,16,17,18,19,20,21,22,23,26,27,28,30,31,32,33,35,36,38,39,40,41,42,43,44,45,46,47,48,49,50,52,53,54,55,56, , 103, 104, 105, 112, 114, 117, 119, 120, 125, 127, 128, 130, 131, 132, 133, 134, 135, 136, 137, 138, 139, 140, 142, 143, 145, 146, 147, 148, 162, 176, 177, 179, 180, 181, 182, 183, 184, 185, 186 Enfermagem baseada em evidências 50 ...
... Erros de medicação 39,42,43,44,45,48,49 F Fatores de risco 3,31,54,59,83,89,146 Ferimentos e lesões 177, 179 H Higiene das mãos 29, 30, 33, 37, 57, 140 Hospitalização 1,2,3,5,6,7,8,9,10,12,13,14,15,16,145,172 17,30,32,33,36,37,39,40,41,42,44,45,46,47,48,49,50,54,58 Sistemas de apoio a decisões clínicas 68 ...
Objetivo: Este estudo objetivou desenvolver um algoritmo computacional de decisão clínica para classificação de pacientes adultos em urgência e emergência, como um subsídio para sistemas de informação em saúde. Método: Trata-se de um estudo metodológico tecnológico de caráter transversal. A trajetória metodológica deste estudo seguiu duas fases: sendo a primeira a revisão integrativa e a segunda etapa contemplaram a construção do algoritmo. Resultados: Na primeira etapa, o estudo identificou 844 artigos, destes, 7(0,83%) artigos selecionados para revisão integrativa. Na segunda etapa, estudo produziu um abrangente catálogo de algoritmos que convergem para um escopo de interpretações de condições clínicas em pacientes adultos, como requisito para tomada de decisão clínica para os atendimentos. Conclusões: O estudo atingiu seu objetivo, os resultados podem ser utilizados em interface a qualquer sistema de prontuário eletrônico, facilmente interpretado por programadores. Assim, o produto obtido até aqui, oferece projeção embrionária, com possibilidades a uma arquitetura de ramificação.
... The Law & Ethics axis will measure the social appropriateness of AI-generated procedures and indicators developed by the health axis to make sure that they do not discriminate against any demographic group or worsen pre-existing medication inequities (Blais et al., 2014). The Quebec Integrated Chronic Disease Surveillance System (QICDSS) collects information on medication claims (generic name, dose, route, and treatment duration), physician claims (dates, ICD-9 diagnostic codes), hospitalizations (dates, ICD-9 or ICD-10 diagnostic codes, provided services), deaths (date and up to 10 causes), and sociodemographic data (age, sex, region of residence) (Müller-Staub et al., 2016). ...
... To ensure that the established indicators do not discriminate against any demographic group or exacerbate already-existing medication inequities, the Law & Ethics axis will evaluate the social acceptability of AI-generated algorithms and indicators developed by the health axis (Blais et al., 2014). The Quebec Integrated Chronic Disease Surveillance System (QICDSS) includes medication claims (generic name, dose, route, and duration of treatment), physician claims (dates, diagnostic codes of International Statistical Classification of Diseases and Related Health Problems [ICD-9]), hospitalizations (dates, diagnostic codes based on ICD-9 or ICD-10, provided services), deaths (date and up to 10 causes), and sociodemographic data (age, sex, region of residence) (Müller-Staub et al., 2016). Electronic Clinical Decision Support Systems (CDSS) have been created to address some concerns in polypharmacy. ...
... Clinical decision support systems (CDSSs) that support the Nursing Process (NP) are systems that enhance nursing decision-making throughout a comprehensive approach of the Nursing Process: assessment, diagnosis, planning, implementation and evaluation [1]. Whereas NP-CDSSs are considered as holding promises for improving nursing quality of care, recommendations from the 2016 internationally consented standard for NP-CDSSs [1] highlighted the importance of automated linkages between the five NP phases and the integration with other components of the EMR, in particular with Risk Assessment Scores. ...
... Clinical decision support systems (CDSSs) that support the Nursing Process (NP) are systems that enhance nursing decision-making throughout a comprehensive approach of the Nursing Process: assessment, diagnosis, planning, implementation and evaluation [1]. Whereas NP-CDSSs are considered as holding promises for improving nursing quality of care, recommendations from the 2016 internationally consented standard for NP-CDSSs [1] highlighted the importance of automated linkages between the five NP phases and the integration with other components of the EMR, in particular with Risk Assessment Scores. The most famous risk assessment scores in nursing are those used to identify Hospital Acquired Pressure Injuries (HAPIs) defined as damages localized on the skin and underlying soft tissues, usually over a bony prominence or related to a medical device [2]. ...
Clinical decision support systems for Nursing Process (NP-CDSSs) help resolve a critical challenge in nursing decision-making through automating the Nursing Process. NP-CDSSs are more effective when they are linked to Electronic Medical Record (EMR) Data allowing for the computation of Risk Assessment Scores. Braden scale (BS) is a well-known scale used to identify the risk of Hospital-Acquired Pressure Injuries (HAPIs). While BS is widely used, its specificity for identifying high-risk patients is limited. This study develops and evaluates a Machine Learning (ML) model to predict the HAPI risk, leveraging EMR readily available data. Various ML algorithms demonstrated superior performance compared to BS (pooled model AUC/F1-score of 0.85/0.8 vs. AUC of 0.63 for BS).
Integrating ML into NP-CDSSs holds promise for enhancing nursing assessments
and automating risk analyses even in hospitals with limited IT resources, aiming for better patient safety.
... In addition, these systems have been shown to help nurses identify "high-accuracy" nursing diagnoses that reflect a patient's clinical condition. 1,17,18 A variety of electronic documentation systems (such as PROCEnf-USP, WiseNurse, Plataforma PEnsinar, and Nurse Diagnostician software) have been created to assess nursing students' diagnostic accuracy and have been found to strengthen nurses' clinical reasoning. 11,12,[19][20][21] Peres and colleagues 21 examined the diagnostic accuracy of nursing students from a paper-based diagnostic approach compared with a CDSS diagnostic approach. ...
... According to an internationally standard consensus, this system should contain 25 criteria grouped in eight main categories that include the following: (1) nursing process; (2) standardized nursing terminologies; (3) evidence-based nursing diagnoses and (4) evidence-based interventions; (5) standardized, knowledge-based outcome-indicators; (6) connections between measurement instrument results and nursing diagnoses, interventions and outcomes; (7) holistic nursing; and (8) coded, standardized concepts for data gathering and research. 17 ...
Computer-based technologies have been widely used in nursing education, although the best educational modality to improve documentation and nursing diagnostic accuracy using electronic health records is still under investigation. It is important to address this gap and seek an effective way to address increased accuracy around nursing diagnoses identification. Nursing diagnoses are judgments that represent a synthesis of data collected by the nurse and used to guide interventions and to achieve desirable patients' outcomes. This current investigation is aimed at comparing the nursing diagnostic accuracy, satisfaction, and usability of a computerized system versus a traditional paper-based approach. A total of 66 nursing students solved three validated clinical scenarios using the NANDA-International terminologies traditional paper-based approach and then the computer-based Clinical Decision Support System. Study findings indicated a significantly higher nursing diagnostic accuracy (P < .001) in solving cancer and stroke clinical scenarios, whereas there was no significant difference in acute myocardial infarction scenario. The use of the electronic system increased the number of correct diagnostic indicators (P < .05); however, the level of students' satisfaction was similar. The usability scores highlighted the need to make the electronic documentation systems more user-friendly.
... support for nursing decision-making, enable patient care plans to be reasonably developed, and allow for the accurate assessment of nursing processes, thereby leading to effective nursing interventions being implemented and patient-care goals being reached [25,26,28,29]. ...
... NP-CDSSs with SNLs can support users by providing evidence-based nursing diagnoses, outcomes, and interventions [25][26][27][28][29]77]. In the present study, the knowledge-based database of the utilized KBCDSSs applied a CDV model or Bayesian decision model to compute patient information with an inference engine, translate evidence-based practices, and emulate the thought process of real-life professionals to provide best practice guidelines for decision-making. ...
Background
The most suitable and reliable inference engines for Clinical Decision Support Systems in nursing clinical practice have rarely been explored.
Purpose
This study examined the effect of Clinical Diagnostic Validity-based and Bayesian Decision-based Knowledge-Based Clinical Decision Support Systems on the diagnostic accuracy of nursing students during psychiatric or mental health nursing practicums.
Methods
A single-blinded, non-equivalent control group pretest–posttest design was adopted. The participants were 607 nursing students. In the quasi-experimental design, two intervention groups used either a Knowledge-Based Clinical Decision Support System with the Clinical Diagnostic Validity or a Knowledge-Based Clinical Decision Support System with the Bayesian Decision inference engine to complete their practicum tasks. Additionally, a control group used the psychiatric care planning system without guidance indicators to support their decision-making. SPSS, version 20.0 (IBM, Armonk, NY, USA) was used for data analysis. chi-square (χ2) test and one-way analysis of variance (ANOVA) used for categorical and continuous variables, respectively. Analysis of covariance was done to examine the PPV and sensitivity in the three groups.
Results
Results for the positive predictive value and sensitivity variables indicated that decision-making competency was highest in the Clinical Diagnostic Validity group, followed by the Bayesian and control groups. The Clinical Diagnostic Validity and Bayesian Decision groups significantly outperformed the control group in terms of scores on a 3Q model questionnaire and the modified Technology Acceptance Model 3. In terms of perceived usefulness and behavioral intention, the Clinical Diagnostic Validity group had significantly higher 3Q model and modified Technology Acceptance Model 3 scores than the Bayesian Decision group, which had significantly higher scores than the control group.
Conclusion
Knowledge-Based Clinical Decision Support Systems can be adopted to provide patient-oriented information and assist nursing student in the rapid management of patient information and formulation of patient-centered care plans.
... Potilaskertomusten rakenteisuus tuottaa hyötyjä potilaiden hoitoprosessien kirjaamiselle [8,9]. Lisäksi vakiintunut kirjaamiskäytäntö on oleellinen osa potilasturvallisuutta ja hoidon tehokkuutta [7,[10][11][12]. FinJeHeW 2023; 15 ( ...
... FinCC:n mukainen kirjaaminen on määritelty myös sairaanhoitajien kansallisissa osaamiskuvauksissa [46]. Hoitajat ovat yleisesti olleet tyytyväisiä koulutuksen määrään, mutta koulutuksen ajoitus on saanut kritiikkiä [47] ja koulutusmenetelmät halutaan käytännönläheisiksi [10]. Myös kansainvälisesti on todettu, että tietojärjestelmien käyttöönoton yhteydessä olisi syytä miettiä uudenlaisia koulutusratkaisuja [48]. ...
Rakenteisen hoitotyön luokituksen käyttö potilashoidon kirjaamisessa tekee potilaan hoidon läpinäkyväksi. Se mahdollistaa hoidon prosessien ja hoitamisen sisällön kuvaamisen sekä tiedon tuottamisen päätöksentekoa ja johtamista varten. Suomalaisen hoitotyön luokituskokonaisuuden (FinCC) rakenne jäsentää kansallisesti sovittujen hoitotyön keskeisten rakenteisten tietojen kirjaamista. Tutkimuksen tarkoituksena oli analysoida FinCC:n käyttöä potilaan hoidon tarpeiden, hoitotoimien ja hoidon tulosten kirjaamisessa sähköisissä potilaskertomuksissa. Tässä kuvailevassa tutkimuksessa sovellettiin tarkoituksenmukaista otantaa kolmen sairaalan medisiinisten osastojen tietovarastoista. Tutkimusaineisto muodostui anonyymeistä osastotason tiedoista, jotka kerättiin kuuden kuukauden ajalta. Aineisto analysoitiin FinCC:n komponentti-, pää- ja alaluokkatasojen käytön jakaumien mukaan. Tulosten mukaan prosessin vaiheita hoidon tarve, hoitotoimet ja hoidon tulokset käytetään kaikissa sairaaloissa. Kaikkia FinCC:n kolmea tasoa käytettiin hoidon kirjaamiseen. Pääsääntöisesti hoidon tarpeiden ja hoitotoimien kirjaaminen tehtiin pää- ja alaluokkatasoille, lukuun ottamatta yhtä sairaalaa, jossa osa hoidon tarpeista kirjattiin käyttämällä komponenttitasoa. Lisäksi kahdessa sairaalassa hoidon tarvetta kirjattiin suoraan prosessin vaiheeseen hoidon tarve, käyttämättä komponentti-, pää- tai alaluokkatasoa. Kaikissa sairaaloissa käytettiin FinCC:n kaikkia komponentteja kuvattaessa hoidon tarpeita ja hoitotoimia, lukuun ottamatta yhtä sairaalaa, joissa komponenttia Elämänkaari ei käytetty hoitotoimien kirjaamisessa. Rakenteista ja tarkkaa potilaan hoidosta tuotettua tietoa voidaan hyödyntää toissijaisessa käytössä analysoitaessa hoitotyön prosesseja ja hoitotyön käytäntöjä. Tätä tietoa voidaan käyttää muun muassa myös henkilöstön osaamisen johtamisessa.
... W ith the widespread use of nursing information systems (NISs) in hospital settings, electronic documentation has become the mainstream form of information storage, exchange, and analysis. 1 Embedded with a combination of standardized nursing language (SNL) and software algorithms based on an abundance of scientific evidence, the nursing clinical decision support system (Nu-CDSS) mimics expert thinking, representing the advanced stage of NIS. 2 The nursing CDSS provides nurses with suggested nursing diagnoses, interventions, and care evaluations based on the clients' clinical information, 3 which foster clinical reasoning and evidence-based practice. 4 The adoption of nursing process-based CDSS has been reported to reduce nurses' documentation burden, 5 improve documentation completeness, 6 and nursing-sensitive outcomes. ...
... 6 Standardized care plans (SCPs) are an integrated component of the Nu-CDSS, representing nurses' decision-making based on clinical thinking and professional judgment together with decision support by the CDSS. 3 It has been pointed out that "care plans provide a course of direction for personalized care tailored to an individual's unique needs," 7 which suggests the formulation of care plans according to nursing diagnoses as central to the nursing process and the foundation of quality care. ...
Standardized care plans are being increasingly introduced to health facilities; however, their level of adoption remains unsatisfactory. Little is known about nurses' use of standardized care plans in China. This study aims to investigate acute care nurses' practices and experiences of care planning within a clinical decision support system embedded with standardized nursing languages. We explored the importance and performance of nursing interventions by retrospective analysis of 400 standardized care plans (performance) and a survey among nurses (importance). Semistructured interviews were conducted to supplement quantitative findings and delve deeper into nurses' experience with standardized care plans. A total of six core nursing diagnoses were determined, each corresponding to seven to 15 nursing interventions. The correlations between nurses' perceived importance and actual performance of nursing interventions in the care plan were weak. Qualitative interviews identified three themes: negative attitudes toward the care plan, uncertainty regarding care planning, and new routines with the care plan. Our findings indicate that nurses' care planning may not reflect their professional judgments. Effective leadership from nurse administrators is warranted to engage nurses with standardized care plan implementation. The content of the standardized nursing language embedded-knowledge base should be continuously adapted to clinical needs to facilitate nurses' care planning practices.
... The American Nurses Association (ANA) has worked since 1989 developing a process for recognizing nursing languages, vocabularies, and terminologies. The ANA has recognized two minimum data sets, two reference terminologies, and eight interface terminologies for facilitating standardized nursing documentation and interoperability of nursing data between different IT systems [9] ( The need for developing a unified SNT in order to enhance comparability of nursing data is well recognized [8,12]. Cross-mapping and coordination across classifications render it possible to evaluate the equivalence of the content and concepts used and to promote shared use of the various nursing classifications and data generated while avoiding redundancy in the information saved [13,14]. ...
... Documentation in accordance with the nursing process has demonstrated the accuracy of documentation and the connection to legal requirements. In addition, patient orientation and the logical whole of documentation are key aspects of documentation evaluation [12]. Nursing documentation assessment models have primarily been developed for local or regional purposes, and a lack of international cooperation to assess the nursing record has been identified [25,26]. ...
This chapter describes milestones in the development of electronic health record systems, aiming to highlight the possibilities of interdisciplinary records to advance nursing care. Nursing data is a central element in the electronic documentation of patient care, and the use structures and terminologies facilitate safe and secure information processing and knowledge sharing. Along with patients’ diminishing length of stay, continuity of care needs tools to guarantee care coordination and information sharing between care givers. Only high-quality data can be reused for secondary purposes such as administration, statistics, and research to benefit planning, estimate costs, as well as predict and guide care processes. Nursing care is more often delivered in digital environments where professionals and patients act together.KeywordsDocumentation modelInterprofessional health recordsUnified documentationDigital care environment
... Portanto, a falha do registro pode suscitar uma percepção equivocada da inexistência de aplicação do PE. No que tange à aplicação na APS, apontam ainda despreparo desde a formação acadêmica, e isso corrobora achados de outros estudos (5,(24)(25)(27)(28) . ...
... Os relatos parecem desvelar o desejo tanto de aprender mais sobre o PE quanto de aplicá-lo como instrumento de qualificação da prática profissional, o que é relevante. A literatura aponta que o ensino proporciona aumento do uso dessa tecnologia e melhora dos registros (2)(3)(25)(26)(27)(28) . Assim, atividades de educação em serviço podem ter impacto positivo nesse contexto. ...
Objectives:
to understand the perception of Primary Health Care nurses about the application of the Nursing Process.
Methods:
this is a qualitative, descriptive study. Data was collected through semi-structured interviews with Primary Health Care nurses from a city in the interior of the state of São Paulo, analyzed by Content Analysis under the theoretical framework of Work Process.
Results:
three categories were obtained: Extrinsic factors to the Nursing Process; Intrinsic factors to the Nursing Process; and Knowledge.
Final considerations:
the nurses considered the Nursing Process relevant for the profession, but historical, political, and social issues related to nursing, and health, as well as conflicts regarding its concept and academic training, hinder its application.
... Portanto, a falha do registro pode suscitar uma percepção equivocada da inexistência de aplicação do PE. No que tange à aplicação na APS, apontam ainda despreparo desde a formação acadêmica, e isso corrobora achados de outros estudos (5,(24)(25)(27)(28) . ...
... Os relatos parecem desvelar o desejo tanto de aprender mais sobre o PE quanto de aplicá-lo como instrumento de qualificação da prática profissional, o que é relevante. A literatura aponta que o ensino proporciona aumento do uso dessa tecnologia e melhora dos registros (2)(3)(25)(26)(27)(28) . Assim, atividades de educação em serviço podem ter impacto positivo nesse contexto. ...
Objectives
to understand the perception of Primary Health Care nurses about the application of the Nursing Process.
Methods
this is a qualitative, descriptive study. Data was collected through semi-structured interviews with Primary Health Care nurses from a city in the interior of the state of São Paulo, analyzed by Content Analysis under the theoretical framework of Work Process.
Results
three categories were obtained: Extrinsic factors to the Nursing Process; Intrinsic factors to the Nursing Process; and Knowledge.
Final Considerations
the nurses considered the Nursing Process relevant for the profession, but historical, political, and social issues related to nursing, and health, as well as conflicts regarding its concept and academic training, hinder its application.
Descriptors:
Nursing Process; Primary Health Care; Community Health Nursing; Public Health Nursing; Qualitative Research
... Clinical Decision Support Systems (CDSSs) are resources developed to support clinical decision-making and may influence nurses' ability to diagnose (Muller-Staub, Graaf-Waar, & Paans, 2016;D'Agostino et al., 2018;Kang et al., 2020). CDSSs are designed to enable the organization and processing of a large amount of data and information in real time (Dagliatim et al., 2018). ...
... The CDSS in nursing should be designed and developed on the basis of the nursing staff's continuous engagement, in accordance with the knowledge which reflects the nursing practice, from beginners to specialists, and for the purpose of meeting the nursing staff's needs. These criteria influence the acceptance and use of the system(Gephart, Carrington & Finley, 2015;Müller-Staub, Graaf-Waar & Paans, 2016).Two variables seem to influence the accuracy of NDs: experience in PROCEnf-USP ® applied to clinical practice and diagnoses added by users. None or a low level of experience in PROCEnf-USP ® applied to clinical practice reduced the percentage of accuracy by 5.41. ...
Purpose
To analyze the accuracy of nursing diagnoses determined by users of a clinical decision support system (CDSS) and to identify the predictive factors of high/moderate diagnostic accuracy.
Methods
This is an exploratory‐descriptive study carried out from September 2017 to January 2018. Participants were nurses, resident nurses, and senior year undergraduates. Two written case studies provided the participants with the clinical data to fill out the assessment forms in the CDSS. The accuracy of the selected diagnostic labels was determined by a panel of experts using the Diagnostic Accuracy Scale, Version 2. Descriptive statistics were used to describe the level of accuracy according to each group of participants. Analysis of variance was used to compare the mean percentages of accuracy categories across groups. A linear regression model was used to identify the predictors of diagnostic accuracy. The significance level was 5%. The study was approved by the Ethics Committee.
Results
Fifteen undergraduates, 10 residents, and 22 nurses were enrolled in the study. Although resident nurses and students had selected predominantly highly accurate diagnoses (51.8 ± 19.1 and 48.9 ± 27.4, respectively), and nurses had selected mostly diagnoses of moderate accuracy (54.7 ± 14.7), there were no differences in the accuracy level of selected diagnoses across groups. According to the linear regression model, each diagnosis added by the participants decreased the diagnostic accuracy by 2.09% ( p = .030), and no experience or a low level of experience using the system decreased such diagnostic accuracy by 5.41% ( p = .022).
Conclusions
The CDSS contributes to decision making about diagnoses of less experienced people. Adding diagnoses not indicated by the CDSS and experience with the system are predictors of diagnostic accuracy.
Clinical Relevance
In‐service education regarding the use of CDSSs seems to be crucial to improve users’ clinical judgment and decision making.
... De manera general, las normas CARE son utilizadas por los editores y directores de revistas científicas en ciencias de la salud para definir las normas de publicación a los autores. Si bien, en el ámbito de la enfermería, aún no han sido desarrollados sistemas de apoyo unificados específicos para la toma de decisiones 36 . Esta disertación ha sido planteada con el objetivo de analizar las publicaciones de casos clínicos con perspectiva enfermera en revistas científicas, así como los estándares de calidad y sistemas de evaluación empleados. ...
El informe de un caso clínico es una narración detallada que describe el problema de uno o varios pacientes. La lista de comprobación Case Report (CARE) es el documento de consenso para reportar los informes de casos clínicos y a través de adaptaciones a las diferentes disciplinas, es utilizada para definir las normas a los autores en revistas científicas; no obstante, la especificidad del proceso enfermero (PE) dificulta ajustar los informes de casos enfermeros a CARE. El objetivo de este artículo es analizar las publicaciones de casos clínicos con perspectiva enfermera en revistas científicas, así como analizar los estándares de calidad y sistemas de
evaluación empleados. Pocas revistas consultadas aceptaron publicar informes de casos enfermeros o declararon normas a los autores para ajustarse a CARE. Los resultados preliminares
indicaron adherencia media o pobre a CARE, siendo los elementos más reportados: palabras clave, información del paciente e introducción. La adherencia fue menor para los elementos: calendario, intervención terapéutica, seguimiento y resultados y perspectiva del paciente. Las
características del PE implican una baja adherencia a CARE, por lo que es necesario unificar criterios para guiar a los investigadores, autores, revisores y editores de revistas científicas y
mejorar el rigor y la calidad de los informes. En la actualidad, no existen directrices específicas para la presentación de informes de casos clínicos con perspectiva enfermera. Estas carencias normativas podrían solventarse desarrollando una extensión CARE adaptada a las características
metodológicas del PE.
... Within clinical reasoning of allied healthcare professionals and nurses, the ICF [43] and NANDA-I [60] are often used as theoretical knowledge based classifications. These classifications contain social, functional, environmental and personal determinants as elements and can be combined with reasoning frameworks like the hypothesis-oriented algorithm for clinicians II [75,76], or the nursing process model [77]. While these classifications are useful to describe, clinical concepts are not widely implemented in EHR systems for documentation [62]. ...
Abstract
In this paper, we present a framework for developing a Learning Health System (LHS) to provide means to a computerized clinical decision support system for allied healthcare and/or nursing professionals. LHSs are well suited to transform healthcare systems in a mission-oriented approach, and is being adopted by an increasing number of countries. Our theoretical framework provides a blueprint for organizing such a transformation with help of evidence based state of the art methodologies and techniques to eventually optimize personalized health and healthcare. Learning via health information technologies using LHS enables users to learn both individually and collectively, and independent of their location. These developments demand healthcare innovations beyond a disease focused orientation since clinical decision making in allied healthcare and nursing is mainly based on aspects of individuals’ functioning, wellbeing and (dis)abilities. Developing LHSs depends heavily on intertwined social and technological innovation, and research and development. Crucial factors may be the transformation of the Internet of Things into the Internet of FAIR data & services. However, Electronic Health Record (EHR) data is in up to 80% unstructured including free text narratives and stored in various inaccessible data warehouses. Enabling the use of data as a driver for learning is challenged by interoperability and reusability.
To address technical needs, key enabling technologies are suitable to convert relevant health data into machine actionable data and to develop algorithms for computerized decision support. To enable data conversions, existing classification and terminology systems serve as definition providers for natural language processing through (un)supervised learning.
To facilitate clinical reasoning and personalized healthcare using LHSs, the development of personomics and functionomics are useful in allied healthcare and nursing. Developing these omics will be determined via text and data mining. This will focus on the relationships between social, psychological, cultural, behavioral and economic determinants, and human functioning.
Furthermore, multiparty collaboration is crucial to develop LHSs, and man-machine interaction studies are required to develop a functional design and prototype. During development, validation and maintenance of the LHS continuous attention for challenges like data-drift, ethical, technical and practical implementation difficulties is required.
... perhaps the patient of the future will increasingly have an opinion that is similar to the conclusion you as a professional also draw. Certainly, if your own system will soon contain rich, reliable, logically ordered information and explanations, in that case, you may even want to stimulate your patient's digital search [15,16,28,29]. ...
This chapter describes the growing influence of point-of-care diagnostics (POCD) on the daily lives of citizens, their immediate families, and healthcare providers. With a view to the future, the most important contemporary developments in this field are discussed, such as noninvasive sensor technology in the diagnostic process, practical examples of point-of-care diagnostics (POCD), including the quantify-self movement and infrared technology. Cost-effectiveness, adoption of POCD, and the contribution of POCD innovations to self-management and health literacy are also discussed. Developments in which deep learning and artificial intelligence are used to make the diagnostic results more reliable are also conferred, such as the development of point-of-care Internet diagnostics. The discussion of professional advice dilemma’s in POCD, the patient’s appreciation of POCD, and ethical and philosophical considerations conclude this chapter.
... Developed in accordance with the internationally consented standard for nursing clinical decision support systems in EHRs [21], Care Direct integrated the SNL, evidence-based nursing knowledge base and big data analysis resources, with all data contents completely disassembled into the minimun data set and encoded with the SNL, meeting the national requirements of healthcare data standardization in China. An illustration of the modules in Care Direct and algorithms for documenting patient care is provided in the Additional file 2: Fig. S1. ...
Background
Nursing information systems embedded with standardized nursing language and clinical decision support have been increasingly introduced in health care settings. User experience is key to the adoption of health information technologies. Despite extensive research into the user experience with nursing information systems, few studies have focused on the interaction between user, technology and organizational attributes during its implementation. Guided by the human, organization and technology-fit framework, this study aimed to investigate nurses’ perceptions and experiences with transition to a new nursing information system (Care Direct) 2 years after its first introduction.
Methods
This is a mixed-method study using an embedded design. An online survey was launched to collect nurses’ self-reported use of the new system, perceived system effectiveness and experience of participation in system optimization. Twenty-two semi structured interviews were conducted with twenty nurses with clinical or administrative roles. The quantitative and qualitative data were merged using the Pillar Integration Process.
Results
The average score of system use behavior was 3.76 ± 0.79. Regarding perceived system effectiveness, the score of each dimension ranged 3.07–3.34 out of 5. Despite large variations in approaches to participating in system optimization, nurses had generally positive experiences with management and technical support. Eight main categories emerged from the integrated findings, which were further condensed into three themes: perceptions on system content, structure, and functionality; perceptions on interdisciplinary and cross-level cooperation; and embracing and accepting the change.
Conclusions
Effective collaboration between clinicians, administrators and technical staff is required during system promotion to enhance system usability and user experience. Clear communication of organizational missions to staff and support from top management is needed to smooth the system implementation process and achieve broader system adoption.
... Müller-Staub et al. proposed that nurses are responsible for applying the nursing process, which is essential for patient care: It is a problem-solving process that provides structure for nursing plans and documentation. The author sorted out the nursing process but only conducted an interview study on the nursing process, without combining specific data [3]. ...
With the development of society and economy, patients with coronary heart disease increasingly hope to receive more humanized services after surgery, and the reengineering of the nursing process is precisely based on humanized management. In order to create a nursing intervention that helps in boosting total nursing gains and lowering disasters, the primary element of the nursing business process reengineering is to reintegrate or condense the creative work flow that was fragmented by specialization into a whole job. The “patient” is positioned in the center of nursing process reengineering, with service quality as the main guiding principle. It follows the management principles of continuous regulation and innovation, and cultivates and promotes the development of the nursing field from the perspective of “sublation.” In the method part, this article introduces and supplements related information on nursing process reengineering, coronary heart disease, and postoperative cognitive behavioral intervention. Algorithmically, this paper proposes 3D RPN structure, loss function, capsule network, and improved activation function algorithm for coronary heart disease region extraction. In the part of experiment and results, this article collects general data of patients and compares memory ability, grades of self-management behaviors of patients treated with coronary heart disease, scores of quality control standards before and after nursing process reengineering, scores of patients’ mental state, and comparison of postoperative physical indicators. According to the test results, the test group’s diastolic and systolic blood pressure declined by more than 20, their total cholesterol dropped from 6.23 to 5.28, and their triglyceride levels dropped from 1.82 to 1.39 after the stent was implanted. Triglycerides reduced from 1.82 to 1.39, and total cholesterol dropped from 6.15 to 5.98. It indicates postoperative memory in patients with coronary heart disease. Abilities, including recognition, number, touch memory, and associative memory, decline significantly, but it can be improved after receiving the nursing process reengineering. It can be seen that nursing process reengineering can play a positive role in the postoperative cognitive behavior of patients with coronary heart disease.
... The diagnoses included in its structure represent human responses arising from life processes, health conditions, or situations of susceptibility (Lopes et al., 2013). As a form of standardized language, the structure of nursing diagnoses should enable communication between nurses (De Groot et al., 2019), the development of care plans based on scientific evidence (Johnson et al., 2018), and the crossover of electronic data between different national and international databases (Müller-Staub et al., 2016). ...
Background:
Nursing diagnoses should reasonably represent global nursing practice phenomena, organizing indicators in their clinical structure that represent different scenarios and populations. However, few studies have summarized the evidence of these indicators, mainly for behavioral diagnoses.
Aim:
This systematic review aimed to identify the best clinical indicators (CI) to determine the presence or absence of the nursing diagnosis "Ineffective Health Management" (IHM).
Method:
A systematic review with meta-analysis was utilized. Six electronic databases were consulted to retrieve studies that identified the nursing diagnosis IHM, with at least one CI. The period of data collection was between September and October 2020. The research group independently conducted the selection, quality assessment, data extraction, and analysis of all included studies. Fixed-effect measures and meta-analyses summarized sensitivity, specificity measures, and diagnostic odds ratios using the statistical software R. The preferred reporting items for systematic reviews and meta-analyses and standards for reporting studies of diagnostic accuracy guidelines were used to guide this review, and quality assessment of diagnostic accuracy studies was used for the critical appraisal of the methodological quality of the included studies.
Results:
The systematic review included 11 studies on people with chronic conditions, the elderly, and pregnant women. The analyzed four CI showed diagnostic odds ratios statistically higher than the unit value, highlighting the "Failure to include the treatment regimen in daily living" (DOR = 45.53; CI = 10.1, 205.6).
Linking evidence to action:
Overall, findings showed that all CI of the IHM nursing diagnosis had good sensitivity, specificity, and diagnostic odds ratio measures to identify their presence correctly. These findings can contribute to better accuracy in nurses' decision-making process, providing indicators to infer the IHM nursing diagnosis early in different population spectra based on the best measures of diagnostic accuracy.
... Evidence-based diagnoses by the use of SLS result in several benefits to health organizations and patients (Sanson et al., 2017), even the identification and consolidation of clinical and epidemiological indicators Sanson et al., 2019). Additionally, the use of SLS in various contexts can provide support for the elaboration of clinical guidelines by matching the information from similar patterns of response to specific conditions of the life cycle or health (Müller-Staub et al., 2016). ...
Purpose:
A standardized language system can support the elaboration of clinical guidelines by matching information from similar patterns of response to people. To identify the factors that are related to a higher likelihood of an ineffective health management nursing diagnosis.
Methods:
We conduct a systematic review and meta-analysis. An electronic search was conducted in MEDLINE databases via PubMed, Web of Science, SciELO, CINAHL, SCOPUS, and Embase between October and November 2020. Descriptive data were extracted from each article. The odds ratios for each etiological factor related to ineffective health management were directly extracted from the articles or calculated from the data described in the articles. The analysis of the measurements of exposure and the magnitude of the effect was performed using the statistical software R, and a forest plot was constructed for each etiological factor.
Findings:
Ten studies were included, and 15 related factors were recovered from the primary studies. The factors that significantly increased the likelihood of an ineffective health management nursing diagnosis were insufficient knowledge of the therapeutic regimen, perceived barriers, powerlessness, economic disadvantage, and difficulty managing complex treatment regimens. No effect was verified with the following factors: decision conflict, family pattern of healthcare, and inadequate number of cues to action.
Conclusion:
Factors related to a higher likelihood of ineffective health management may be the focus of early and targeted nursing interventions, contributing to an improved quality of care.
Clinical relevance:
Understanding exposure to these factors can improve diagnostic reasoning at different population levels.
... Furthermore, if electronic patient portals follow the nursing process, it might also help electronic health records themselves to become better structured according to the same process. Research shows that this is often not the case for the current generation of electronic health records [4,39]. ...
Background
Patient participation in nursing documentation has several benefits like including patients’ personal wishes in tailor-made care plans and facilitating shared decision-making. However, the rise of electronic health records may not automatically lead to greater patient participation in nursing documentation. This study aims to gain insight into community nurses’ experiences regarding patient participation in electronic nursing documentation, and to explore the challenges nurses face and the strategies they use for dealing with challenges regarding patient participation in electronic nursing documentation.
Methods
A qualitative descriptive design was used, based on the principles of reflexive thematic analysis. Nineteen community nurses working in home care and using electronic health records were recruited using purposive sampling. Interviews guided by an interview guide were conducted face-to-face or by phone in 2019. The interviews were inductively analysed in an iterative process of data collection–data analysis–more data collection until data saturation was achieved. The steps of thematic analysis were followed, namely familiarization with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and reporting.
Results
Community nurses believed patient participation in nursing documentation has to be tailored to each patient. Actual participation depended on the phase of the nursing process that was being documented and was facilitated by patients’ trust in the accuracy of the documentation. Nurses came across challenges in three domains: those related to electronic health records (i.e. technical problems), to work (e.g. time pressure) and to the patients (e.g. the medical condition). Because of these challenges, nurses frequently did the documentation outside the patient’s home. Nurses still tried to achieve patient participation by verbally discussing patients’ views on the nursing care provided and then documenting those views at a later moment.
Conclusions
Although community nurses consider patient participation in electronic nursing documentation important, they perceive various challenges relating to electronic health records, work and the patients to realize patient participation. In dealing with these challenges, nurses often fall back on verbal communication about the documentation. These insights can help nurses and policy makers improve electronic health records and develop efficient strategies for improving patient participation in electronic nursing documentation.
... Expert opinion, appears to agree that the core of the Nursing Process-Clinical Decision Support System should be based on the Advanced Nursing Process as it is research-based. Considering the Nursing diagnoses and true linkages between diagnoses, evidence based interventions, and patient outcomes [46]. In other studies, the use of creative learning models in other areas and the use of different and interconnected phases of the nursing process was mentioned [47]. ...
Background
The nursing process is the core and the standard of practice in nursing profession. Nowadays, the use of information technology in the field of nursing processes, education and practice has been emphasized. Since nurse’s attitudes towards clinical information systems are considered as an indicator of the success rate of information systems, and nurse’s attitudes about the nursing process can affect their execution of the process. So the purpose of this study was to evaluate nursing students’ attitudes towards the nursing process software.
Methods
In this quasi-experimental study, 160 undergraduate nursing students (terms 4–8) in Tabriz University of Medical Sciences were selected by convenience sampling. To evaluate the effectiveness of nursing process software in this study, Mazlom and Rajabpoor (IJME 14(4):312–322, 2014) a questionnaire consisting of 21 components based on a five-point Likert scale was completed by students after using the software. Data were then analyzed by SPSS 19 software.
Results
The mean score of students’ attitude toward nursing process software was high (80.70 ± 5.58). The nursing students’ highest scoring attitudes were respectively related to “Effectiveness of software in prioritizing patient care and problems”, “Completeness of patient’s electronic information compared to handwritten mode” and “Software’s effectiveness in saving your time”. The lowest scoring attitudes towards the software was respectively related to the “feeling of fairness in labor division”, “the effectiveness of the software in determining your workload” and “the feeling of satisfaction in labor division”. There was a statistically significant relationship between gender and age, and student’s attitude toward nursing process software.
Conclusions
According to the results and analysis of nursing student’s attitudes toward nursing process software, the use of such software would be welcomed by students. It seems that changing policies in the educational and clinical substructure of nursing in order to develop, adapt and use the nursing process software is an important responsibility for nursing authorities to consider. Providing educational and clinical technology equipment, periodic evaluation of software by stakeholders and promoting the use of this software, can be fundamental steps in operationalizing the findings of this research.
... 39 Muller-Staub and colleagues described the usefulness of the nursing process as a systematic approach to the organization of nursing knowledge and clinical decision-making through assessing, diagnosing and identifying appropriate interventions, as well as following up and evaluating the effects of these interventions. 40 Creating opportunities for healthcare professionals to communicate with patients about bowel issues may be one way to increase awareness about patients' subjective perceptions of constipation. This will open up for a dialogue between patients and healthcare professionals and might change clinical practice. ...
Purpose
Constipation is a common and troublesome condition among older patients and can result in a variety of negative health consequences. It is often undiagnosed or undertreated. Healthcare professionals have a responsibility to understand and address patients’ overall healthcare needs; so exploring their experiences is, therefore, highly relevant. The purpose of the study was to explore healthcare professionals’ experiences of assessing, treating and preventing constipation among older patients.
Methods
A qualitative design with an exploratory approach was used. The participants (registered nurses and physicians) were purposively sampled from three wards in a geriatric department in a medium-sized hospital in Sweden. Data were collected through focus group discussions and individual interviews, and analyzed using content analysis.
Results
Three categories were generated: Reasons for suboptimal management of constipation, Strategies for management, and Approaching the patients’ needs. In the care of older patients at risk of or with constipation, decisions were made based on personal knowledge, personal experience and clinical reasoning. A person-centered approach was highlighted but was not always possible to incorporate.
Conclusion
Different strategies for preventing and treating constipation were believed to be important, as was person-centered care, but were found to be challenging in the complexity of the care situation. It is important that healthcare professionals reflect on their own knowledge and clinical practice. There is a need for more support, information and specific guidance for healthcare professionals caring for older patients during hospitalization. Overall, this study underscores the importance of adequate access to resources and education in constipation management and that clinical guidelines, such as the Swedish Handbook for Healthcare, could be used as a guide for delivering high-quality care in hospitals.
... Clinical decision making is an important element of professional nursing care; nurses' ability to form effective clinical decisions is the most significant issue affecting the care standard. Nurses build 2 kinds of choices associated with the practice: patient care decisions that affect direct patient care and occupational decisions that affect the work context or teams [11][12][13][14][15][16]. ...
Background
The complex health system and challenging patient care environment require experienced nurses, especially those with high cognitive skills such as problem-solving, decision- making and critical thinking. Therefore, this study investigated the impact of social problem-solving training on nursing students’ critical thinking and decision-making.
Methods
This study was quasi-experimental research and pre-test and post-test design and performed on 40 undergraduate/four-year students of nursing in Borujen Nursing School/Iran that was randomly divided into 2 groups; experimental ( n = 20) and control (n = 20). Then, a social problem-solving course was held for the experimental group. A demographic questionnaire, social problem-solving inventory-revised, California critical thinking test, and decision-making questionnaire was used to collect the information. The reliability and validity of all of them were confirmed. Data analysis was performed using SPSS software and independent sampled T-test, paired T-test, square chi, and Pearson correlation coefficient.
Results
The finding indicated that the social problem-solving course positively affected the student’ social problem-solving and decision-making and critical thinking skills after the instructional course in the experimental group ( P < 0.05), but this result was not observed in the control group ( P > 0.05).
Conclusions
The results showed that structured social problem-solving training could improve cognitive problem-solving, critical thinking, and decision-making skills. Considering this result, nursing education should be presented using new strategies and creative and different ways from traditional education methods. Cognitive skills training should be integrated in the nursing curriculum. Therefore, training cognitive skills such as problem- solving to nursing students is recommended.
... It is assumed that the Nursing Process is a method to systematize care and thus, in addition to allowing personalization of care, it unites nurses, patients, family and community. The Nursing Process is classified into five sequential and interrelated steps: data collection, diagnosis, planning, implementation and evaluation (13) . Studies have identified that the nursing process is capable of providing autonomy for the professional nurse, given that it enables the planning and organization of the actions of this team, enabling improvement and efficiency in the care provided, reduction of complications, length of stay in the hospital and the cost of care (14) . ...
Objective:
to verify the existence of elements that justify the use of pharmacogenetics by the Brazilian nurse.
Method:
this is a quantitative, cross-sectional, observational, descriptive study, whose final sample was 67 individuals. The participants were healthy at the time of the study and reported a history of previous use and the occurrence of adverse effects by drugs commonly used and metabolized by CYP2C9. We collected 4 mL of venous blood for subsequent DNA extraction by salting out method and genotyping of the CYP2C9*2 and CYP2C9*3 polymorphisms, using Polymerase Chain Reaction in real time using Taqman assays.
Results:
the use of drugs metabolized by CYP2C9 was frequent (more than 75% of the individuals have already used between 2 or 4 of these drugs). Regarding adverse events, there were 19 perceived symptomatic occurrences associated with drugs metabolized by CYP2C9. The allele frequency of the polymorphism * 2 and * 3 in the population studied was 11.1% and 7.5%, respectively, and there was a coincidence between the presence of alleles of low enzyme activity and the occurrence of adverse effects.
Conclusion:
there are elements that justify the adoption of pharmacogenetics in the nursing care to reduce the occurrence of adverse reactions to drugs metabolized by CYP2C9.
Resumen Objetivo: describir factores de influencia de la teleenfermería en la toma de decisión naturalista sobre el autocuidado de personas con insuficiencia cardíaca durante la pandemia de COVID-19. Método: estudio descriptivo de enfoque cualitativo, con 16 participantes entrevistados tras la hospitalización por la descompensación de la insuficiencia cardíaca. Los datos se recopilaron mediante tecnología de audio y vídeo y se sometieron a análisis de contenido, guiado por la Teoría de Situación Específica del Autocuidado de la Insuficiencia Cardíaca. Resultados: dos categorías temáticas surgieron del análisis: Autocuidado como proceso de toma de decisión y Factores que influyen en la toma de decisión, las cuales describen a la teleenfermería como recurso de apoyo a la persona con insuficiencia cardíaca, durante modificaciones de atención en el período pandémico. Conclusión: fue posible comprender la relación entre la teleenfermería y el establecimiento de vínculo, de manera a estimular la toma de decisión naturalista por la persona con insuficiencia cardíaca en su cotidianidad de forma coherente, impulsando mejores resultados en salud.
Objective
to describe factors of influence of telenursing on naturalistic decision making about self-care of people with heart failure during COVID-19.
Method
this is a descriptive study with a qualitative approach, with 16 participants interviewed after hospitalization for decompensated heart failure. The data was collected using audio and video technology and submitted to content analysis, guided by the Situation-Specific Theory of Heart Failure Self-Care.
Result
two thematic categories emerged from the analysis: Self-care as a decision-making process and Factors influencing decision-making, which describe tele-nursing as a support resource for people with heart failure, during changes in care in the pandemic period.
Conclusion
it was possible to understand the relationship between telenursing and the establishment of a bond, in order to stimulate naturalistic decision-making by people with heart failure in their daily lives in a coherent way, leading to better health outcomes.
Objetivo: descrever fatores de influência da telenfermagem na
tomada de decisão naturalista sobre o autocuidado de pessoas com
insuficiência cardíaca durante a COVID-19. Método: estudo descritivo
de abordagem qualitativa, com 16 participantes entrevistados após
hospitalização pela descompensação da insuficiência cardíaca.
Os dados foram coletados por tecnologia de áudio e vídeo e
submetidos à análise de conteúdo, norteada pela Teoria de Situação
Específica do Autocuidado da Insuficiência Cardíaca. Resultados:
duas categorias temáticas emergiram da análise: Autocuidado como
processo de tomada de decisão e Fatores que influenciam a tomada
de decisão, as quais descrevem a telenfermagem como recurso de
apoio à pessoa com insuficiência cardíaca, durante modificações
de atendimento no período pandêmico. Conclusão: foi possível
compreender a relação entre a telenfermagem e o estabelecimento
de vínculo, de maneira a estimular a tomada de decisão naturalista
pela pessoa com insuficiência cardíaca em seu cotidiano de forma
coerente, impulsionando melhores resultados em saúde.
Case report is a narrative description of the problem of one or several patients. TheCARE checklist (CAse REport) is the consensus document for reporting clinical case reports andthrough adaptations to the different CARE disciplines is used to define standards for authors inscientific journals; however, the specificity of the nursing process makes it difficult to adjustnursing case reports to CARE. The aim was to analyze the publications of clinical cases with anursing perspective in scientific journals, as well as the quality standards and evaluation systems used. Few journals reviewed agreed to publish nursing case reports or stated standardsfor authors to adjust to CARE. Preliminary results indicated average or poor adherence to CARE,with the most reported elements being: Keywords, patient information and introduction. Adherence was lower for the elements: Timeline, therapeutic intervention, follow-up and outcomes,and patient perspective. The characteristics of the nursing process implies a low adherence toCARE, so it is necessary to unify criteria to guide researchers, authors, reviewers and editors ofscientific journals, as well as to improve the rigor and quality of the reports. Currently, thereare no specific guidelines for reporting clinical case reports with a nursing perspective available. These normative gaps could be solved by developing a CARE extension adapted to themethodological characteristics of the nursing process.
Objective: To map the software programs developed to operationalize the nursing process in patient care in health services. Methods: This is a scoping review developed within the recommendations of the Joanna Briggs Institute and PRISMA Extension for Scoping Reviews. A search was carried out in seven databases, a library, eight databases and an academic search engine with no time limit. Results: 19,645 studies were found, of them were included 35. 51% addressed Nursing Theory and 20% of the studies covered the entire nursing process. In addition, 82% used the Nursing Process in a fragmented way. The highlighted target audience for which the software programs were developed: adults (26; 74.2%), and the hospital service (33; 94%). Conclusion: It was understood through this study that Brazilian nursing seeks systems that can provide subsidies regarding the application of knowledge in nursing care and process.
Providing 80% of healthcare worldwide, nurses focus on physiologic and psychosocial aspects of health, which incorporate social determinants of health (SDOH). Recognizing their important role in SDOH, nurse informatics scholars included standardized measurable terms that identify and treat issues with SDOH in their classification systems, which have been readily available for over 5 decades. In this Perspective, we assert these currently underutilized nursing classifications would add value to health outcomes and healthcare, and to the goal of decreasing disparities. To illustrate this, we mapped 3 rigorously developed and linked classifications: NANDA International (NANDA-I), Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC) called NNN (NANDA-I, NIC, NOC), to 5 Healthy People 2030 SDOH domains/objectives, revealing the comprehensiveness, usefulness, and value of these classifications. We found that all domains/objectives were addressed and NNN terms often mapped to multiple domains/objectives. Since SDOH, corresponding interventions and measurable outcomes are easily found in standardized nursing classifications (SNCs), more incorporation of SNCs into electronic health records should be occurring, and projects addressing SDOHs should integrate SNCs like NNN into their ongoing work.
OLIVEIRA, Reinaldo Ribeiro de. Construction of a computational algorithm of clinical
decision for classification of adult patients in emergency and emergency unit: subsidy
for health information systems.2019. 263p. Dissertation (Master's Degree in Nursing) -
Centro Universitário São Camilo, São Paulo, 2019.
At the present time, nurses are divided between bureaucratic and administrative processes,
with a shortage of human resources. This study made possible the reflection of innovation,
which occupies more and more space in the hospital environment, in the screening of adult
patients. The research in question developed a process interface in the health application
environment, interconnected with computerized systems. This study aims to develop a
computational algorithm of clinical decision for classification of adult patients in emergency
and emergency as a subsidy for health information systems. It is a cross-sectional
technological methodological study. To reach the objective of the study, the methodology
was based on a life cycle, consolidated in the concepts of prototyping. The methodological
trajectory of this study followed two phases: the first being the integrative review and the
second stage contemplating the construction of the algorithm. The integrative review had as
its guiding question, "To verify the use of algorithms of clinical decision support systems for
the classification of adult patients in emergency and emergency services?" data (MEDLINE),
(LILACS), (BDENF), through the Virtual Health Library Portal (VHL). Using the keywords and
keywords "Nursing"; "Screening"; "Medical Infomatics"; "Clinical Decision Support System"
and "Health Informatics" with the Boolean qualifier "AND". As inclusion criterion, articles with
publication cut from 2006 were established. As an exclusion criteria, articles that were
repeated in the databases and those that did not meet the scope of the study were removed.
The development and elaboration of the art and illustrations of the proposed algorithms of
the study were built from the Windows® operating system environment creation platform via
Microsoft Visio® Professional version, a resource for building organization charts, flowcharts,
diagrams and data modeling . In the first phase, the study identified 844 articles, 176
(20.85%) in LILACS, 638 (75.60%) in MEDLINE and 30 (3.56%) in BDEnf, of these 196
(23.23%) were available. Of the 844 articles found, 812 (96.20%) were excluded after
reading the title, 32 (3.80%) were selected for reading, 22 (2.60%) were excluded after
reading the abstract, 10 (1, 19%) were selected for reading in full, and 7 (0.83%) were
selected for integrative review. In the second stage, at the end, the study produced a
comprehensive catalog of algorithms that converge to a network interface scope that
supports interpretations of clinical conditions in adult patients presented for a first aid
environment as a requirement for clinical decision making in conditions for setting service
priorities. The study reached its goal, considering that it was possible to formalize the result
of a feasible product and the practice of classifying clinical priorities in the emergency and
clinical emergencies environment of adult patients. It is worth noting that the result of this
product can be used in interface with any electronic medical record system, easily interpreted
by programmers. The results obtained so far, offers the algorithm a matrix form, with
embryonic projection, it has an architecture that can easily branch to other arms to subsidize
other specialties such as pediatrics, obstetrics, psychiatry and others.
Keyword (s): Algorithms, Nursing, Medical Informatics, Decision Support Systems, Clinical
Decision Support Systems, Screening
Background
Nursing information systems embedded with standardized nursing language and clinical decision support have been increasingly introduced in health care settings. User experience is key to the adoption of health information technologies. Despite extensive research into the user experience with nursing information systems, few studies have focused on the interaction between user, technology and organizational attributes during its implementation. Guided by the HOT-fit framework, this study aimed to investigate nurses’ perceptions and experiences with transition to a new nursing information system (Care Direct) two years after its first introduction.
Methods
This is a mixed-method study using an embedded design. An online survey was launched to collect nurses’ self-reported use of the new system, perceived system effectiveness and experience of participation in system optimization. Twenty-two semi structured interviews were conducted with twenty nurses with clinical or administrative roles. The quantitative and qualitative data were merged using the Pillar Integration Process.
Results
Nurses had medium-level perceptions of system effectiveness and participation in system development. They demonstrated good system use behavior and generally positive experiences with management and technical support. Eight main categories emerged from the integrated findings, which were further condensed into three themes: perceptions on system content, structure and functionality; perceptions on interdisciplinary and cross-level cooperation; and accepting the new thing.
Conclusions
Effective collaboration between clinicians, administrators and technical staff is required during system promotion to enhance system usability and user experience. Clear communication of organizational missions to staff and support from top management is needed to smooth the system implementation process and achieve broader system adoption.
Diese Publikation fasst relevante, wissenschaftliche sowie Praxis bezogene Erkenntnisse zum Pflegeprozess, zu Pflegeklassifikationen und -dokumentation zusammen. Der Advanced Nursing Process wird vorgestellt und dessen Umsetzung präsentiert. Die Publikation basiert auf langjährigen Erfahrungen der Autorin sowie auf über 200 Quellen und soll Studierende, Lehrpersonen und Forschende darin unterstützen, den Pflegeprozess Evidenz-basiert umzusetzen.
Background
Information communication technology (ICT) is instrumental in pharmacists' current practice and emerging roles. One such role is prescribing, which requires the use of clinical guidelines and documentation of decision-making, commonly via ICT. Development and refinement of ICT should be guided by evaluation frameworks that describe or measure features of ICT and its implementation. In the context of pharmacist prescribing, these evaluation frameworks should be specific to health stakeholders and the pharmacy setting.
Objectives
To identify ICT evaluation frameworks from health-related literature and review frameworks relevant to the development, implementation, and evaluation of pharmacist prescribing.
Methods
A database search of CINAHL, Cochrane Library, EMBASE, Medline (Ovid), ProQuest, Scopus, Web of Science and grey literature was conducted, using combinations of keywords relating to ‘ICT’, ‘utilization’, ‘usability’, and ‘evaluation framework’. Abstracts and titles were screened according to inclusion criteria. Identified evaluation frameworks were critiqued for relevance to pharmacy practice.
Results
Twenty-two articles were identified, describing the development or application of 20 evaluation frameworks. None of the frameworks was developed specifically for pharmacy practice. The Technology Acceptance Model (TAM), describing use behavior, behavior intention, perceived usefulness, and perceived ease of use, was the most widely utilized framework. The Information System Success (ISS) and Human-Organization and Technology Fit (HOT-fit) are notable evaluation frameworks that address user and organizational influences in health ICT utility, and factors of both can address the limitation of TAM.
Conclusions
The findings call for development of an agile evaluation framework for the system under review; however, this can prove difficult due to the heterogenicity and complexity of the healthcare system, particularly contemporary pharmacy practice.
While the TAM appears useful to evaluate user attitudes and intentions towards ICT, its relevance to ICT in contemporary community pharmacy practice requires exploration.
O Guia “Processo de Enfermagem: guia para a prática” é fruto das discussões do Grupo de Trabalho sobre Processo de Enfermagem. A edição original foi revisada, com acréscimo de sete capítulos nesta segunda edição, que apresentam os modelos teóricos de enfermagem e sua aplicabilidade prática, relação do processo de enfermagem
com a segurança do paciente, aspectos ético-jurídicos do processo de enfermagem e do prontuário eletrônico, instrumentos de medida como alicerce para a aplicação do processo de enfermagem, prontuário eletrônico do paciente, registros de enfermagem: avaliação/evolução de enfermagem e anotação de enfermagem, telenfermagem e pareceres técnicos relacionados ao Processo de Enfermagem
Nursing information systems are increasingly acting as catalyst agents to restructure the profession, forcing nurses to explore the nature of the profession, the essence of the practice, the body of scientific knowledge, leading them to acquire increasingly specialized skills to provide a better level of healthcare patients and citizen. The data collection and information analyses are based on quality of data collection. Standardized terminologies are supposed to provide rationality on the nursing process. This chapter summarizes some experiences in Brazil on the use on terminology integrated in the nursing system: over more than three decades, nurses in the Nursing Department at the University Hospital of the University of São Paulo have based the care delivery and educational practice on the nursing process. PROCEnf-USP® was built to integrate the core information systems of the hospital and includes the regular phases of the nursing process: data collection, nursing diagnosis and planning, and nursing evaluation utilizing well-established nursing terminologies to obtain high quality of data. The imperative is to have more and better analytics tools to promote continuous quality improvement, better clinical decision support systems, and more intelligence on the electronic health records.KeywordsICT adoptionBrazilNursing processData qualityNursing terminologiesSystem evaluation
Nursing care plans, the result of the nursing process, are important because they guide quality patient care, define the nurse's role in patient treatment, and support patient specific nursing interventions. Nurse leaders at a community hospital identified that 70% of hospitalized patients shared the same three nursing problems and three-day resolution target dates. This quality improvement project involved the implementation of a nursing care plan system within the organization's existing electronic health record platform that supported the development of individualized plans. The implementation included a) integration of care plan activities into the nursing workflow, b) adoption of a standardized nursing language to provide structure nursing care plan data capture and reporting, c) configuration of the electronic health record to recommend patient data-driven care plan problems based on nursing assessment documentation; and d) trended care plan data to identify problem patterns within the patient population. A postimplementation audit indicated a 130% improvement in achieving individualized care plans within 24 hours of admission.
Quality discharge teaching prepares patients and families to transition safely from hospital to home. Technology can enhance and support quality discharge teaching by promoting patient family engagement during the transition. The purpose of this mixed methods study was to explore clinical nurses' experience with using Engaging Parents in Education for Discharge, an iPad application to guide quality discharge teaching. Twelve nurses at a large Midwestern Children's Hospital participated in small focus groups after use of the Engaging Parents in Education for Discharge application and completed a questionnaire on their perception of the acceptability and feasibility of the app. Findings revealed three themes: (1) development and deployment issues focused on the importance of training and support by the study team during implementation; (2) workflow integration centered on the importance of incorporating use of the app into current workflows and to preserve effective communication strategies with parents to optimize use in the healthcare setting; and (3) nurses perceived value in the use of the Engaging Parents in Education for Discharge app for beneficial scripting, questions on discharge topics often forgotten, and guidance for complex patients. Results of this study offer insight into key components for consideration when implementing and integrating technology to aid nursing practice.
The study aim was to assess the perception of healthcare workers in primary healthcare centers toward the integration of EHRs into practice. A descriptive cross-sectional design was used. Out of 10 primary healthcare centers, 120 healthcare workers were selected by simple random sampling, whereas 109 questionnaires were fit for analysis. Data were collected using a questionnaire, and both descriptive and inferential statistics were used for data analyses. The findings revealed that the healthcare workers disagreed on EHR integration. They believed that user resistance, missing funds, and unavailability of knowledgeable support personnel are challenges that are hindering EHR integration. Also, limited training on how to use EHRs and lack of computer literacy were identified as challenges. Based on the literature and findings of this study, EHRs can improve the quality of the given patient care, reduce errors, increase productivity, and enable standardization of care. Therefore, education on EHR implementation and funding are needed to successfully integrate EHRs into primary healthcare centers in Nigeria.
This chapter describes clinical decision support (CDS) systems, challenges and success criteria. Furthermore, the development of knowledge- and decision support tool for nurses is exemplified with a case study: VAR Healthcare, a general knowledge- and decision support system for nurses to be used across healthcare settings. This system responds to many of the previous uncovered lacks of CDS for nursing care. The Five Rights theoretical framework by Osheroff is used to evaluate the development of VAR Healthcare. The success of CDS development can be optimised when the interventions in the CDS transfer the right information, to the right person, in the right format, through the right channel at the right time in the workflow. Also, to ensure continuous, clinical care of good quality for patient safety and best-possible health outcomes, clinical data models (CDM) and reference terminologies/models are needed to ensure interoperability.KeywordsClinical decision supportKnowledge supportInformation standardsElectronic patient record systemsNursing documentationHealth documentationEvidence-based proceduresEvidence-based guidelines.
Background
The present paper explores the introduction of computer-based nursing documentation in a hospital as an example of organizational learning viewed through the lens of organizational education. It provides insights into existing routines and patterns of nursing practice within the organization and seeks, in understanding them, to support organizational learning in hospital settings. The focus of this article is on the analysis of patterns of practice specific to the organization in order to derive the specific need for support of organizational learning for the hospital as an organization.
Methods
A mixed-methods approach was used to record data, combining qualitative and quantitative techniques. Its theoretical focus draws on organizational education in examining organizational learning – a context in which the use of mixed-methods approaches, triangulation and multiperspectivity appeared to be best suited for the task.
Results
The results demonstrate that the practical implementation of computer-based nursing documentation calls, alongside technical adaptations, for the consideration of organizational learning, defined as learning undertaken by a social unit comprising a range of groups with distinct interests. The key challenge to organizational learning consists in disrupting long established routines and standardizing new patterns of practice. Success in this endeavor requires time and space for employees’ dialog-based, cooperative exploration of the patterns previously in place.
Conclusion/Originality
The literature on organizational learning provides numerous examples of members of organizations rupturing previous patterns and routines, yet few examples aimed at creating an understanding of existing practices, particularly in relation to hospital settings. This paper fills this lacuna by describing extant practices in such a setting and seeks to support organizational learning processes in this context.
Standardised nursing language provides a means to document the nursing process. But standards for implementing enduring change and standards for meaningful nursing process SNL implementation and evaluation into electronic healthcare records are missing. A criterion-based measurement needs to be developed to evaluate accuracy in nursing documentation in the electronic health record. A summary of the article has been published in the print magazine HIMSS Insights on 15 November 2012: File: “HIMSS_Insights_paans_print” (see page 58 and 60). Full text: www.himssinsights.eu<http://www.himssinsights.eu
The evolution of standardized nursing languages (SNLs) has been occurring for more than four decades. The importance of this work continues to be acknowledged as an effective strategy to delineate professional nursing practice. In today's health care environment, the demand to deliver cost-effective, safe, quality patient care is an essential mandate embedded in all health reform policies. Communicating the contributions of professional nursing practice to other nurses, health providers, and other members of the health care team requires the articulation of nursing's focus of concern and responses to these concerns to improve patient outcomes. The visibility of the electronic health record (EHR) in practice settings has accelerated the need for nursing to communicate its practice within the structure of the electronic format. The integration of SNLs into the patient record offers nurses an opportunity to describe the focus of their practice through the identification of nursing diagnosis, interventions and outcomes (IOM, 2010). Continued development, testing, and refinement of SNLs offers nursing an accurate and reliable way to use data elements across populations and settings to communicate nursing practice, enable nursing administrators and leaders in health care to delineate needed resources, cost out nursing care with greater precision, and design new models of care that reflect nurse-patient ratios and patient acuity that are data driven (Pesut & Herman, 1998). The continued use of nursing languages and acceleration of nursing research using this data can provide the needed evidence to help link nursing knowledge to evidence-driven, cost-effective, quality outcomes that more accurately reflect nursing's impact on patient care as well as the health care system of which they are a part. The evaluation of research to support the development, use, and continued refinement of nursing language is critical to research and the transformation of patient care by nurses on a global level.
Computerised clinical decision support systems (CDSS) are increasingly being used by nurses to support their clinical practice. One of the factors which may affect how nurses use technology such as CDSS may be their clinical experience. This paper uses data from a wider study examining how nurses use CDSS to examine the role of experience in nurses' use of CDSS. Data was drawn from two sources; a secondary analysis of interviews from a study examining nurses' use of CDSS in telephone triage and the analysis of observations and interviews of nurses using CDSS in two case sites. Two themes arose from the analysis of the data; the integration of knowledge from CDSS and how experience affects CDSS use. The implications of these results are discussed in relation to our knowledge of the characteristics of the development of expertise in nursing.
This paper is a report of a review conducted to assess the research methods applied in the evaluation of nursing documentation.
The material was drawn from three databases: CINAHL, PubMed and Cochrane using the keywords nursing documentation, nursing care plan, nursing record system, evaluation and assessment. The search was confined to relevant electronically-retrievable studies published in the English language from 2000 to 2007. This yielded 41 studies, including two reviews.
Content analysis produced a classification into three themes: nursing documentation, patient-centred documentation and standardized documentation. Each study was assessed according to its research design, methodology, sample size and focus of data collection. In addition, the studies categorized under the heading of standardized documentation were assessed in terms of their outcomes.
Most of the studies (n = 19) focused on patient-centred documentation. Most (n = 20) were retrospective studies and used data collected from patient records (n = 35). An audit instrument was used to assess nursing documentation in almost all the studies. Studies classified under the heading of standardized documentation showed more positive than negative effects with respect to quality, the nursing process and terminology use, knowledge level and acceptance of computer use in documentation.
The use of structured nursing terminology in electronic patient record systems will extend the scope of documentation research from assessing the quality of documentation to measuring patient outcomes. More data should also be collected from patients and family members when evaluating nursing documentation.
This book provides a comprehensive and timely introduction to clinical decision support systems, coming at a time when electronic health records are being routinely used in clinical practice, and clinical decision support systems are seeing more use.
Building on the success of the previous editions, Clinical Decision Support Systems: Theory and Practice, Third Edition, once again brings together worldwide experts to illustrate the underlying science and day-to-day use of decision support systems in clinical and educational settings.
This fully revised and updated edition is essential reading for informatics specialists, teachers and students in health or medical informatics training programs, and clinicians, with or without expertise in the applications of computers in medicine, who are interested in learning about current developments in computer-based clinical decision support systems.
Little is known regarding nurses' usage of clinical decision support systems. A review of the literature was conducted to understand the extant knowledge surrounding the topic of nurses' usage of clinical decision support systems. The common themes that emerged from the review of literature on clinical decision support systems usage by nurses include (1) nurse factors affecting usage, (2) patient factors affecting usage, (3) technology and design factors affecting usage, and (4) organizational factors affecting usage. Two major implications are that these systems may not be designed to support nursing practice and may not be having the intended effect on patient care and quality.
PurposeTo assess the reliability and validity of Quality of Diagnoses, Interventions, and Outcomes (Q-DIO) in Brazil and in the United States.Methods
The sample comprised 180 records: centers 1 (electronic records and standardized language) and 2 (paper-based records without standardized language in Brazil, and center 3 (electronic records without standardized language) in the United States. Reliability and discriminant construct validity was analyzed.FindingsCronbach's alpha for all 29 Q-DIO items were greater than or equal to 0.70 for all centers; construct validity was significantly different between the three study centers.Conclusions
These results indicate that Q-DIO is valid and reliable for assessing the quality of nursing records.Implications for Nursing PracticeThe Q-DIO may be useful to assess the quality and accuracy of nursing records.
Decision support is an extension of electronic health record or electronic patient record systems. As well as enabling health professionals to look up information about individual patients stored in the system and to consult evidence-based guidance, they give advice on the treatment and management most appropriate for that patient. They are designed to help with the process of clinical decision making. Computerised decision-support systems match patient characteristics to a computerised knowledge base to produce patient-specific assessments or recommendations. Decision support can be paper-based, but computerised systems have the advantage of being able to quickly process patient-specific information and match it to computerised decision rules or algorithms. This article discusses the benefits and limitations of using decision-support technology, which is becoming increasingly important as the use of health information technology systems becomes more common across healthcare.
To evaluate the effect of the educational program "Guided Clinical Reasoning" (GCR) and the introduction of an intelligent electronic nursing documentation system (e-doc) on the quality of the nursing process.
Evaluation was conducted at three measurement points and rated with the instrument "Quality of Nursing Diagnoses, Interventions and Outcomes" (Q-DIO).
GCR showed the best Q-DIO-scores. No long-term effect was found after GCR cessation. The e-doc delivered the lowest scores, while showing adequate support in using nursing diagnoses.
E-docs can support conducting the nursing process, but for meaningful e-doc use, clinical reasoning is essential.
High-quality nursing documentation requires recognition of factors obstructing or supporting nurses in the use of e-docs while conducting the nursing process.
This paper reports a study about the effect of knowledge sources, such as handbooks, an assessment format and a predefined record structure for diagnostic documentation, as well as the influence of knowledge, disposition toward critical thinking and reasoning skills, on the accuracy of nursing diagnoses.Knowledge sources can support nurses in deriving diagnoses. A nurse's disposition toward critical thinking and reasoning skills is also thought to influence the accuracy of his or her nursing diagnoses.
A randomised factorial design was used in 2008-2009 to determine the effect of knowledge sources. We used the following instruments to assess the influence of ready knowledge, disposition, and reasoning skills on the accuracy of diagnoses: (1) a knowledge inventory, (2) the California Critical Thinking Disposition Inventory, and (3) the Health Science Reasoning Test. Nurses (n = 249) were randomly assigned to one of four factorial groups, and were instructed to derive diagnoses based on an assessment interview with a simulated patient/actor.
The use of a predefined record structure resulted in a significantly higher accuracy of nursing diagnoses. A regression analysis reveals that almost half of the variance in the accuracy of diagnoses is explained by the use of a predefined record structure, a nurse's age and the reasoning skills of `deduction' and `analysis'.
Improving nurses' dispositions toward critical thinking and reasoning skills, and the use of a predefined record structure, improves accuracy of nursing diagnoses.
Objective:
To examine information flow, a vital component of a patient's care and outcomes, in a sample of multiple hospital nursing units to uncover potential sources of error and opportunities for systematic improvement.
Design:
This was a qualitative study of a sample of eight medical-surgical nursing units from four diverse hospitals in one US state. We conducted direct work observations of nursing staff's communication patterns for entire shifts (8 or 12 h) for a total of 200 h and gathered related documentation artifacts for analyses. Data were coded using qualitative content analysis procedures and then synthesized and organized thematically to characterize current practices.
Results:
Three major themes emerged from the analyses, which represent serious vulnerabilities in the flow of patient care information during nurse hand-offs and to the entire interdisciplinary team across time and settings. The three themes are: (1) variation in nurse documentation and communication; (2) the absence of a centralized care overview in the patient's electronic health record, ie, easily accessible by the entire care team; and (3) rarity of interdisciplinary communication.
Conclusion:
The care information flow vulnerabilities are a catalyst for multiple types of serious and undetectable clinical errors. We have two major recommendations to address the gaps: (1) to standardize the format, content, and words used to document core information, such as the plan of care, and make this easily accessible to all team members; (2) to conduct extensive usability testing to ensure that tools in the electronic health record help the disconnected interdisciplinary team members to maintain a shared understanding of the patient's plan.
We report findings on the current state of pain care in hospitals for end-of-life (EOL) patients using longitudinal data from 8 diverse medical-surgical units located in 4 different Midwestern hospitals over 24 months. We identified 1425 EOL care episodes, 596 (41.3%) of which had a pain diagnosis. The percentage of EOL patients with pain varied significantly across units (P < .001) and was even lower (27.7%) for those with "acute confusion." Additionally, 30% of EOL patients had severe or significant pain at death or discharge to hospice and only 42.7% actually met the expected pain-related outcome ratings. Pain often improved within 48 hours of admission (P < .005), the improvement, however, stagnated following this initial time period (P = .92). A sizable gap between pain science and clinical practice continues.
To identify what determinants influence the prevalence and accuracy of nursing diagnosis documentation in clinical practice.
Nursing diagnoses guide and direct nursing care. They are the foundation for goal setting and provide the basis for interventions. The literature mentions several factors that influences nurses' documentation of diagnoses, such as a nurse's level of education, patient's condition and the ward environment.
Systematic review.
MEDLINE and CINAHL databases were searched using the following headings and keywords: nursing diagnosis, nursing documentation, hospitals, influence, utilisation, quality, implementation and accuracy. The search was limited to articles published between 1995-October 2009. Studies were only selected if they were written in English and were primary studies addressing factors that influence nursing diagnosis documentation.
In total, 24 studies were included. Four domains of factors that influence the prevalence and accuracy of diagnoses documentation were found: (1) the nurse as a diagnostician, (2) diagnostic education and resources, (3) complexity of a patient's situation and (4) hospital policy and environment.
General factors, which influence decision-making, and nursing documentation and specific factors, which influence the prevalence and accuracy of nursing diagnoses documentation, need to be distinguished. To support nurses in documenting their diagnoses accurately, we recommend taking a comprehensive perspective on factors that influence diagnoses documentation. A conceptual model of determinants that influence nursing diagnoses documentation, as presented in this study, may be helpful as a reference for nurse managers and nurse educators.
This review gives hospital management an overview of determinants for possible quality improvements in nursing diagnoses documentation that needs to be undertaken in clinical practice.
This paper reports a review that identified and synthesized nursing documentation audit studies, with a focus on exploring audit approaches, identifying audit instruments and describing the quality status of nursing documentation.
Quality nursing documentation promotes effective communication between caregivers, which facilitates continuity and individuality of care. The quality of nursing documentation has been measured by using various audit instruments, which reflected variations in the perception of documentation quality among researchers across countries and settings.
Searches were made of seven electronic databases. The keywords 'nursing documentation', 'audit', 'evaluation', 'quality', both singly and in combination, were used to identify articles published in English between 2000 and 2010.
A mixed-method systematic review of quantitative and qualitative studies concerning nursing documentation audit and reports of audit instrument development was undertaken. Relevant data were extracted and a narrative synthesis was conducted.
Seventy-seven publications were included. Audit approaches focused on three natural dimensions of nursing documentation: structure or format, process and content. Numerous audit instruments were identified and their psychometric properties were described. Flaws of nursing documentation were identified and the effects of study interventions on its quality.
Research should pay more attention to the accuracy of nursing documentation, factors leading to variation in practice and flaws in documentation quality and the effects of these on nursing practice and patient outcomes, and the evaluation of quality measurement.
To assess the changes in the quality of information processing in nursing after the introduction of a computer-based nursing information system.
94 nurses filled out the HIS-monitor survey, comprising 41 questions and focusing on the quality of the information processing, shortly before and again one year after the introduction of a computer-based nursing information system. A McNemar-Bowker-test was used to assess the changes in quality over time. The HIS-monitor instrument was formally validated by calculating Cronbach Alpha.
Despite some technical problems, the quality of the information processing in nursing significantly improved after the introduction of a computer-based nursing information system in many areas. The results show improved support during patient anamnesis and care planning, higher availability and completeness of nursing documentation, better overview on the patient, better readability of nursing documentation, reduction of duplicate documentation, better workflow support with task lists and checklists, and better fulfillment of the legal regulations. The results with regard to time efforts for nursing documentation and the related impact on patient care were mixed, however. Most of the expectations of the nurses that were stated before IT introduction seem to have been realized.
The HIS-monitor was found to be a useful instrument, in turn showing that the quality of the information processing in nursing strongly increased after the introduction of a nursing information system.
The purpose of this study is to describe and discuss physicians' and nurses' documentation of the patient's needs assessment in electronic health records (EHR) in the neurological care setting. Both physicians and nurses collect, record and interpret data during patient care episodes. Assessment of patient's need for care and treatment is an important part of the care process. Planning, implementation and outcome assessment of the care process are based on needs assessment data. The data of this study consist of 48 neurological medical narratives and nursing care plans. The data were analyzed using descriptive statistics and content analysis. Physician's medical narratives include referrals to physiotherapy and consultations in other care specialties in which they have recorded the reason for the care, anamnesis and status praesens data. Nurses have documented patient's needs assessment in nursing care plans using Finnish Classification of Nursing Diagnoses (FiCND) and additional narrative text. Physicians' and nurses' patient needs assessment documentation complement each other. Nursing documentation includes more detailed information about patients' needs for care due the use of FiCND in documentation. The use of standardised documentation improves quality documentation and retrieval of data from EHR.
This paper is a report of the development and testing of the psychometric properties of an instrument to measure the accuracy of nursing documentation in general hospitals.
Little information is available about the accuracy of nursing documentation. None of the existing instruments that quantify accuracy of nursing diagnoses, interventions, and progress and outcome evaluations are suitable to measure documentation in general hospital environments, nor were they intended for this purpose.
The D-Catch instrument, based on the Cat-ch-Ing instrument and the Scale for Degrees of Accuracy in Nursing Diagnoses, was developed in 2007-2008. Content validity of the D-Catch instrument was assessed by two Delphi panels, in which pairs of independent reviewers assessed 245 patient records in seven hospitals in the Netherlands. Construct validity was assessed by explorative factor analysis with principal components and varimax rotation. Internal consistency was measured by Cronbach's alpha. The inter-rater reliability of the D-Catch instrument was tested by calculating Cohen's weighted kappa (K(w)) for each pair of reviewers. Results. Quantity and quality variables were used to assess the accuracy of nursing documentation. Three constructs were identified in the factor analysis. 'Accuracy of the nursing diagnosis' was the only variable with substantial loading on component two (0.907) and a modest loading on component one (0.230). Internal consistency (Cronbach's alpha) was 0.722. The inter-rater reliability (K(w)) varied between 0.742 and 0.896.
The D-Catch instrument is a valid and reliable measurement instrument to assess nursing documentation in general hospital settings.
Originaltext vom Verlag; nicht vom SfBS bearbeitet. Prüfungsrelevanz und ein durchdachtes didaktisches Konzept zeichnen auch die fünfte Auflage des mittlerweile zum Standardwerk gewordenen Lehrbuchs der Statistik aus. Die Neuauflage wurde durch eine Formelsammlung erweitert und ermöglicht somit ein schnelles Auffinden der zentralen Formeln der Statistik. Das ebenfalls neue Glossar enthält die wichtigsten Begriffs-Definitionen in Kürze. Um die Lösungen der Übungsaufgaben garantiert verständlich und nachvollziebar darzustellen, wurden sie unter Mitarbeit von Studenten nochmals vollständig überarbeitet. Interpretationshilfen, Anleitungen für die Auswertung mit dem PC und Hinweise zur Bestimmung optimaler Stichprobenumfänge für die wichtigsten Verfahren und ein gut strukturiertes Layout gewährleisten nach wie vor ein effektives Arbeiten und Lernen.
This paper aims to report the development stages of an audit instrument to assess standardised nursing language. Because research-based instruments were not available, the instrument Quality of documentation of nursing Diagnoses, Interventions and Outcomes (Q-DIO) was developed.
Standardised nursing language such as nursing diagnoses, interventions and outcomes are being implemented worldwide and will be crucial for the electronic health record. The literature showed a lack of audit instruments to assess the quality of standardised nursing language in nursing documentation.
A qualitative design was used for instrument development.
Criteria were first derived from a theoretical framework and literature reviews. Second, the criteria were operationalized into items and eight experts assessed face and content validity of the Q-DIO.
Criteria were developed and operationalized into 29 items. For each item, a three or five point scale was applied. The experts supported content validity and showed 88.25% agreement for the scores assigned to the 29 items of the Q-DIO.
The Q-DIO provides a literature-based audit instrument for nursing documentation. The strength of Q-DIO is its ability to measure the quality of nursing diagnoses and related interventions and nursing-sensitive patient outcomes. Further testing of Q-DIO is recommended.
Based on the results of this study, the Q-DIO provides an audit instrument to be used in clinical practice. Its criteria can set the stage for the electronic nursing documentation in electronic health records.
Many computer software developers and vendors claim that their systems can directly improve clinical decisions. As for other health care interventions, such claims should be based on careful trials that assess their effects on clinical performance and, preferably, patient outcomes.
To systematically review controlled clinical trials assessing the effects of computer-based clinical decision support systems (CDSSs) on physician performance and patient outcomes.
We updated earlier reviews covering 1974 to 1992 by searching the MEDLINE, EMBASE, INSPEC, SCISEARCH, and the Cochrane Library bibliographic databases from 1992 to March 1998. Reference lists and conference proceedings were reviewed and evaluators of CDSSs were contacted.
Studies were included if they involved the use of a CDSS in a clinical setting by a health care practitioner and assessed the effects of the system prospectively with a concurrent control.
The validity of each relevant study (scored from 0-10) was evaluated in duplicate. Data on setting, subjects, computer systems, and outcomes were abstracted and a power analysis was done on studies with negative findings.
A total of 68 controlled trials met our criteria, 40 of which were published since 1992. Quality scores ranged from 2 to 10, with more recent trials rating higher (mean, 7.7) than earlier studies (mean, 6.4) (P<.001). Effects on physician performance were assessed in 65 studies and 43 found a benefit (66%). These included 9 of 15 studies on drug dosing systems, 1 of 5 studies on diagnostic aids, 14 of 19 preventive care systems, and 19 of 26 studies evaluating CDSSs for other medical care. Six of 14 studies assessing patient outcomes found a benefit. Of the remaining 8 studies, only 3 had a power of greater than 80% to detect a clinically important effect.
Published studies of CDSSs are increasing rapidly, and their quality is improving. The CDSSs can enhance clinical performance for drug dosing, preventive care, and other aspects of medical care, but not convincingly for diagnosis. The effects of CDSSs on patient outcomes have been insufficiently studied.
This paper reports a systematic review on the outcomes of nursing diagnostics. Specifically, it examines effects on documentation of assessment quality; frequency, accuracy and completeness of nursing diagnoses; and on coherence between nursing diagnoses, interventions and outcomes.
Escalating healthcare costs demand the measurement of nursing's contribution to care. Use of standardized terminologies facilitates this measurement. Although several studies have evaluated nursing diagnosis documentation and their relationship with interventions and outcomes, a systematic review has not been carried out.
A Medline, CINAHL, and Cochrane Database search (1982-2004) was conducted and enhanced by the addition of primary source and conference proceeding articles. Inclusion criteria were established and applied. Thirty-six articles were selected and subjected to thematic content analysis; each study was then assessed, and a level of evidence and grades of recommendations assigned.
Nursing diagnosis use improved the quality of documented patient assessments (n = 14 studies), identification of commonly occurring diagnoses within similar settings (n = 10), and coherence among nursing diagnoses, interventions, and outcomes (n = 8). Four studies employed a continuing education intervention and found statistically significant improvements in the documentation of diagnoses, interventions and outcomes. However, limitations in diagnostic accuracy, reporting of signs/symptoms, and aetiology were also reported (14 studies). One meta-analysis of eight trials including 1497 patients showed no evidence that standardized electronic documentation of nursing diagnosis and related interventions led to better nursing outcomes.
Despite variable results, the trend indicated that nursing diagnostics improved assessment documentation, the quality of interventions reported, and outcomes attained. The study reveals deficits in reporting of signs/symptoms and aetiology. Consequently, staff educational measures to enhance diagnostic accuracy are recommended. The relationships among diagnoses, interventions and outcomes require further evaluation. Studies are needed to determine the relationship between the quality of documentation and practice.
To describe pilot testing of Quality of Diagnoses, Interventions and Outcomes (Q-DIO), an instrument to measure quality of nursing documentation.
Instrument testing was performed using a random, stratified sample of 60 nursing documentations representing hospital nursing with and without implementation of standardized nursing language (30 for both strata) in a Swiss General Acute Hospital.
Internal consistency and intrarater and interrater reliabilities were tested. Through item analyses, the grades of difficulty and the discrimination validity of items were evaluated.
Internal consistency of nursing diagnoses as process produced Cronbach's alpha .83; nursing diagnoses as product .98; nursing interventions .90; and nursing-sensitive patient outcomes .99. With Kappas of .95, the intrarater and interrater reliabilities were good. Criteria for the grades of difficulty of items and discrimination validity were well met. The results of this study suggest that Q-DIO is a reliable instrument to measure the documentation quality of nursing diagnoses, interventions, and outcomes. Further testing of Q-DIO in other settings is recommended.
The aim of this paper is to report a systematic literature review on the outcomes of nursing diagnostics. Specifically, it examines effects on documentation of assessment quality; frequency, accuracy and completeness of nursing diagnoses; and on coherence between nursing diagnoses, interventions and outcomes. Escalating health care costs demand the measurement of nursing's contribution to care. Use of standardized terminologies facilitates this measurement. Although several studies evaluated nursing diagnosis documentation and their relationship with interventions and outcomes, a systematic review was lacking. A MEDLINE, CINAHL, and Cochrane Database search (1982-2004) was conducted and enhanced by the addition of primary source and conference proceedings articles. Inclusion criteria were established and applied. Thirty-six articles were selected and subjected to thematic content analysis, then each study was assessed, and a level of evidence and grades of recommendations assigned. Nursing diagnosis use improved the quality of documented patient assessments (n = 14 studies), the identification of commonly occurring diagnoses within similar settings (n = 10), and coherence among nursing diagnoses, interventions, and outcomes (n = 8). Four studies employed a continuing education intervention and found significant improvements in the documentation of diagnoses, interventions and outcomes. However limitations in diagnostic accuracy, reporting of signs/symptoms, and etiology were also reported (14 studies). Despite variable results, the trend indicated that nursing diagnostics improved assessment documentation, the quality of interventions reported, and outcomes attained. The study reveals deficits in reporting of signs/symptoms and etiology. Consequently, staff educational measures to enhance diagnostic accuracy are recommended. The relationships among diagnoses, interventions and outcomes require further evaluation. Studies are needed to determine the relationship between the quality of documentation and practice.
- M Müller-Staub
- J Abt
- A Brenner
- B Hofer
Müller-Staub M, Abt J, Brenner A, Hofer B. Expert Report on Nurses'
Responsibility. Bern, Switzerland: Swiss Nursing Science Association (ANS);
2015.
Advanced Computation Laboratory of the Imperial Cancer Research Fund
- Openclinical
OpenClinical. Decision support systems. Advanced Computation Laboratory
of the Imperial Cancer Research Fund. July 8, 2013. http://www.
openclinical.org/dss.html. Accessed January 7, 2015.
Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
- B J Ackley
- G B Ladwig
Ackley BJ, Ladwig GB. Nursing Diagnosis Handbook: An Evidence-Based
Guide to Planning Care. 10 ed. St Louis, MO: Mosby/Elsevier; 2014.
Electronically supported nursing documentation. Paper presented at: Nanda International 2008 Conference: Capturing the Expert Knowledge of Nursing
- M Odenbreit
Odenbreit M. Electronically supported nursing documentation. Paper
presented at: Nanda International 2008 Conference: Capturing the Expert
Knowledge of Nursing; November 13-15, 2008; Miami, FL.
Standard for Nursing Process Clinical Decision Support Systems (NP-CDSS) in EHRs. ACENDIO. Bern, Switzerland: Association for Common European Nursing Diagnoses, Intervention and Outcomes
- Müller Staub
- M De Graaf-Waar
- H Paans
Müller Staub M, de Graaf-Waar H, Paans W. Standard for Nursing Process
Clinical Decision Support Systems (NP-CDSS) in EHRs. ACENDIO. Bern,
Switzerland: Association for Common European Nursing Diagnoses,
Intervention and Outcomes; 2015.
Validation of the Quality of Diagnoses, Interventions, and Outcomes (Q-DIO) instrument for use in Brazil and the United States
- Gf Linch
- Er Rabelo-Silva
- Gm Keenan
- Ma Moraes
- J Stifter
- M Muller-Staub
Linch GF, Rabelo-Silva ER, Keenan GM, Moraes MA, Stifter J, Muller-Staub M.
Validation of the Quality of Diagnoses, Interventions, and Outcomes (Q-DIO)
instrument for use in Brazil and the United States. Int J Nurs Knowl. 2015;
26(1): 19–25.
Developing an international nursing documentation audit instrument: Expert consensus study. ACENDIO Conference proceedings
- W Paans
- M Müller-Staub
- M Odenbreit
Paans W, Müller-Staub M, Odenbreit M. Developing an international nursing
documentation audit instrument: Expert consensus study. ACENDIO
Conference proceedings. Dublin, Ireland: ACENDIO; 2013.
Nursing Research: Generating and Assessing Evidence for Nursing Practice
- D F Polit
- Tatano Beck
Polit DF, Tatano Beck C. Nursing Research: Generating and Assessing
Evidence for Nursing Practice. 9th ed. Philadelphia, PA: Wolters Kluwer/
Lippincott, Williams & Wilkins; 2012.
- S Moorhead
- M Johnson
- M Maas
- E Swanson
Moorhead S, Johnson M, Maas M, Swanson E. Nursing Outcomes
Classification (NO(3). 5th ed. St Louis, MO: Elsevier; 2013.
Expert Report on Nurses' Responsibility
- M Müller-Staub
- J Abt
- A Brenner
- B Hofer
Müller-Staub M, Abt J, Brenner A, Hofer B. Expert Report on Nurses'
Responsibility. Bern, Switzerland: Swiss Nursing Science Association (ANS);
Keeping Patients Safe
- Institute Of Medicine
Institute of Medicine. Keeping Patients Safe. Washington, DC: National
Academy Press; 2004.