Maria Müller-Staub

Development of an instrument to measure the quality of documented nursing diagnoses, interventions and outcomes: the Q-DIO.

AIMS AND OBJECTIVES 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. BACKGROUND 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. DESIGN A qualitative design was used for instrument development. METHODS 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. RESULTS 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. CONCLUSIONS 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. RELEVANCE TO CLINICAL PRACTICE 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.

Testing the Q‐DIO as an Instrument to Measure the Documented Quality of Nursing Diagnoses, Interventions, and Outcomes

PURPOSE To describe pilot testing of Quality of Diagnoses, Interventions and Outcomes (Q-DIO), an instrument to measure quality of nursing documentation. DESIGN 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. METHODS Internal consistency and intrarater and interrater reliabilities were tested. Through item analyses, the grades of difficulty and the discrimination validity of items were evaluated. FINDINGS Internal consistency of nursing diagnoses as process produced Cronbachs 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.

Pflegediagnosen, -interventionen und -ergebnisse: Anwendung und Auswirkungen auf die Pflegepraxis: Eine systematische Literaturübersicht.

Dieser Artikel beschreibt eine systematische Literaturubersicht zu den Auswirkungen der Pflegediagnostik. Es werden Auswirkungen auf die Qualitat des Pflegeassessments sowie auf die Haufigkeit, Genauigkeit und Vollstandigkeit von Pflegediagnosen und auf die Koharenz zwischen Pflegediagnosen, -interventionen und -ergebnissen aufgezeigt, wie sie in Patientenakten2 dokumentiert werden. Steigende Kosten machen es erforderlich, den Beitrag der Pflege zur Gesundheitsversorgung zu bestimmen. Dies wird durch den Einsatz standardisierter Terminologien erleichtert. Zwar liegen Studien vor, in denen eine standardisierte Dokumentation von Pflegediagnosen und ihre Beziehung zu Pflegeinterventionen und Pflegergebnissen evaluiert wurden, eine systematische Ubersicht fehlte jedoch bislang. Es wurde eine Suche in MEDLINE, CINAHL und der Cochrane Database (1982–2004) durchgefuhrt und durch Grundlagenartikel und Tagungsberichte erweitert. Einschlusskriterien wurden bestimmt und umgesetzt. Anschliesend sind sechsunddreisig A...

Nursing phenomena in inpatient psychiatry

Little is known about the question if the nursing diagnosis classification of North American Nursing Association-International (NANDA-I) describes the adult inpatient psychiatric nursing care. The present study aimed to identify nursing phenomena mentioned in journal articles about the psychiatric inpatient nursing care and to compare these phenomena with the labels and the definitions of the nursing diagnoses to elucidate how well this classification covers these phenomena. A search of journal articles took place in the databases MedLine, PsychInfo, Cochrane and CINAHL. A qualitative content analysis approach was used to identify nursing phenomena in the articles. Various phenomena were found in the articles. The study demonstrated that NANDA-I describes essential phenomena for the adult inpatient psychiatry on the level of labels and definitions. However, some apparently important nursing phenomena are not covered by the labels or definitions of NANDA-I. Other phenomena are assigned as defining characteristics or as related factors to construct nursing diagnoses. The further development of the classification NANDA-I will strengthen the application in the daily work of psychiatric nurses and enhance the quality of nursing care in the inpatient setting.

Nursing diagnoses determined by first year students: a vignette study.

Purpose The study aimed to determine the ability of first year students in identifying nursing diagnoses. Methods In a descriptive evaluation study, an expert-validated vignette containing 18 nursing diagnoses was used. Results The students determined 15 nursing diagnoses. The highest percentages of diagnoses identified were disturbed sleep pattern and nutrition imbalance. Students also considered medical diagnoses as nursing diagnoses: hypertension and tachycardia. Conclusions Despite the fact that students were only at the end of their first semester and had limited clinical experience, they successfully identified the majority of nursing diagnoses. Implications for Nursing Practice Patient case study vignettes are recommended for education. To foster students’ knowledge and experience, it is also suggested that evaluating nursing diagnoses in clinical practicals becomes a requirement. Amac Bu calismada birinci sinif ogrencilerinin hemsirelik tanilarini belirleyebilme durumlarinin saptanmasi amacladi. Yontem Uzmanlar tarafindan belirlenmis 18 hemsirelik tanisini iceren bir vaka kullanilarak yapilan tanimlayici bir calismadir. Bulgular Ogrenciler 15 hemsirelik tanisi belirlemistir. En cok belirlenen hemsirelik tanilari uyku oruntusunde rahatsizlik ve beslenmede dengesizlik tanisidir. Ogrenciler ayrica hipertansiyon ve tasikardi gibi tibbi tanilari da hemsirelik tanisi olarak dusunmuslerdir. Sonuclar Ogrenciler sadece birinci donemin sonunda ve sinirli klinik deneyimlere sahip olmasina ragmen, hemsirelik tanilarinin buyuk bir cogunlugunu tanimlamada basarili olmuslardir. Hemsirelik Uygulamalari Icin Oneriler Egitim icin hasta vaka calismalarinin kullanilmasi onerilmektedir. Ogrencilerin bilgi ve deneyimlerini gelistirmek icin ayrica klinik uygulamalarda hemsirelik tanilarinin degerlendirilmesi gerektigi onerilmektedir.

Cross-Cultural Adaptation of the Quality of Diagnoses, Interventions and Outcomes (Q-DIO) Instrument into Brazilian Portuguese

PURPOSE   To describe the cross-cultural adaptation of the Quality of Diagnoses, Interventions and Outcomes instrument into Brazilian Portuguese. METHOD   This process entailed translation, synthesis, back-translation, expert committee review, and pretesting. FINDINGS   Six items were altered in the Brazilian version, and the scoring system was changed from a five-point to a three-point Likert-type scale. Pretesting was conducted on a sample of 40 randomly selected nursing records. Overall reliability as measured by Cronbachs alpha was 0.96. CONCLUSIONS   Adaptation resulted in a preliminary version of the instrument. IMPLICATIONS FOR NURSING PRACTICE   Assessment of the psychometric properties of the instrument in a larger sample of nursing records is required, and such a study is underway.PURPOSE:  To describe the cross-cultural adaptation of the Quality of Diagnoses, Interventions and Outcomes instrument into Brazilian Portuguese. METHOD:  This process entailed translation, synthesis, back-translation, expert committee review, and pretesting. FINDINGS:  Six items were altered in the Brazilian version, and the scoring system was changed from a five-point to a three-point Likert-type scale. Pretesting was conducted on a sample of 40 randomly selected nursing records. Overall reliability as measured by Cronbachs alpha was 0.96. CONCLUSIONS:  Adaptation resulted in a preliminary version of the instrument. IMPLICATIONS FOR NURSING PRACTICE:  Assessment of the psychometric properties of the instrument in a larger sample of nursing records is required, and such a study is underway.

Quality of nursing records and standardized language: literature review

Abstract. Context. The time spent to produce nursing records, to become aware of the policy of the institution, to use standardized nursing language, as well as the tools available (printed or electronic tools) may directly interfere on quality of nursing records. Objective. To identify and analyze the literature data on factors that affect the quality of nursing records and the use of standardized language. Methods. Literature review was conducted in the databases CINAHL, PubMed and SciELO. For selecting the texts for review, abstracts and available full texts, in Portuguese or English, about the subject were read. Result. This review allowed to evidence that the quality of nursing care is directly related to the quality of professionals’ records. Additionally, appropriate use of standardized language combined with electronic tools is helpful for nurses and their teams on the care provided. Conclusion. In the near future, standardized electronic documentation will allow remote and recurring access to data among different health professionals and organizations. Relevance to clinical practice. This fact can improve patient care, as well as it can assist the development of clinical protocols and researches. Improvement of nursing records is still a challenge for nurses.

Klinische Entscheidungsfindung: Förderung des kritischen Denkens im pflegediagnostischen Prozess durch Fallbesprechungen

Pflegediagnostische Fallbesprechungen, die sich auf reale Patientensituationen beziehen, sind eine Form klinischer Entscheidungsfindung, welche kritisches Denken von Pflegenden fordern. Der Artikel...

Erhebung der Patientenzufriedenheit im Notfallzentrum eines Schweizer Universitätsspitals: Vorkommen von Angst, Unsicherheit, Belastung, Schmerz, Atemnot, Übelkeit, Durst und Hunger sowie Zusammenhänge zur Patientenzufriedenheit (Teil 2)

Der Artikel beschreibt den zweiten Teil einer Studie zur Patientenzufriedenheit ambulanter Patientinnen eines Schweizer Notfallzentrums. Mittels Fragebogen wurden 114 Patientinnen zur Patientenzufr...

Klinische Entscheidungsfindung und kritisches Denken im pflegediagnostischen Prozess

Der berufliche Alltag erfordert von Pflegenden komplexe Denkprozesse. Bisher wurde der klinischen Entscheidungsfindung und kritischem Denken wenig Beachtung geschenkt. Bei Pflegenden wurde ein gros...