Deborah Marks Conley

Most frequent nursing diagnoses, nursing interventions, and nursing-sensitive patient outcomes of hospitalized older adults with heart failure: part 1

PURPOSE Rank and compare the 10 most frequently documented nursing diagnoses, interventions, and patient outcomes using NANDA International, Nursing Interventions Classification, and Nursing Outcomes Classification for care of patients with heart failure (HF). METHODS A descriptive comparative multisite study of documented care for 302 older adults with HF. FINDINGS There were four common nursing diagnoses, two interventions, and only three common outcomes across three sites. CONCLUSIONS This and similar analyses of clinical nursing data can be used by nursing administrators and clinicians to monitor the quality and effectiveness of nursing care. IMPLICATIONS Similar analyses may be used for continuing education, quality improvement, and documentation system refinement. Part 2 will discuss data retrieval and implications for building a multiorganizational data warehouse.

Nursing Diagnoses, Interventions, and Patient Outcomes for Hospitalized Older Adults with Pneumonia

A study was conducted by academic and community hospital partners with clinical information systems that included the standardized nursing language classifications of the North American Nursing Diagnosis Association International (NANDA-I), Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC). The aim of the study was to determine the frequency of NANDA-I, NIC, and NOC (NNN) terms documented for older adults with pneumonia who were discharged from three hospitals during a 1-year period. NNN terms were ranked according to frequency for each hospital, and then the rankings were compared with previous studies. Similarity was greater across hospitals in rankings of NANDA-I and NOC terms than in rankings of NIC terms. NANDA-I and NIC terms are influenced by reimbursement and regulatory factors as well as patient condition. The 10 most frequent NNN terms for each hospital accounted only for a small to moderate percentage of the terms selected.

Nursing clinical documentation data retrieval for hospitalized older adults with heart failure: part 2

PURPOSE The study aims to discuss the implications for retrieval of nursing data and building a multiorganizational data warehouse. METHODS The method used was a descriptive comparative multisite study of documented care for 302 older adults with heart failure. Unit and patient level variables were retrieved. FINDINGS Data regarding the most identified variables were retrievable electronically. Important linkages among nursing data elements were not present. CONCLUSIONS Data were retrievable and the building of a data warehouse was possible and lessons were learned. IMPLICATIONS When clinical information systems (CISs) are developed, developers and nurses must discuss how standardized data will be entered to ensure retrieval and usefulness in evaluating nursing care. For nursing effectiveness research, CISs must also provide linkages among nursing diagnoses and specific interventions, and nursing-sensitive patient outcomes.

Evaluation of Outcome Change Scores for Patients With Pneumonia or Heart Failure

This study was conducted to describe the variance in selected Nursing Outcomes Classification (NOC) outcome change scores of hospitalized older patients with pneumonia (n = 216) or heart failure (HF; n = 67) that could be explained by age, length of stay (LOS), number of comorbid conditions, number of nursing diagnoses, and number of nursing interventions. Investigators used a descriptive correlational design to analyze data sets from three U.S. community hospitals. Study participants had at least two ratings on one of nine outcomes selected for their frequency and use across the three hospitals. A significant portion of the variance in the outcomes Knowledge: Illness Care and Fall Prevention Behavior was explained for pneumonia patients. None of the regression models for HF patients showed significance. Individual independent variables were significant in some of the models (i.e., LOS [pneumonia], number of nursing diagnoses [pneumonia and HF]). Implications for research and clinical practice are discussed.