Ulla-Mari Kinnunen

Evaluating nursing documentation - research designs and methods: systematic review.

AIM This paper is a report of a review conducted to assess the research methods applied in the evaluation of nursing documentation. DATA SOURCES 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. METHODS 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. RESULTS 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. CONCLUSION 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.

Impacts of structuring nursing records: a systematic review

AIM The study aims to describe the impacts of different data structuring methods used in nursing records or care plans. This systematic review examines what kinds of structuring methods have been evaluated and the effects of data structures on healthcare input, processes and outcomes in previous studies. MATERIALS AND METHODS Retrieval from 15 databases yielded 143 papers. Based on Population (Participants), Intervention, Comparators, Outcomes elements and exclusion and inclusion criteria, the search produced 61 studies. A data extraction tool and analysis for empirical articles were used to classify the data referring to the study aim. Thirty-eight studies were included in the final analysis. FINDINGS The study design most often used was a single measurement without any control. The studies were conducted mostly in secondary or tertiary care in institutional care contexts. The standards used in documentation were nursing classifications or the nursing process model in clinical use. The use of standardised nursing language (SNL) increased descriptions of nursing interventions and outcomes supporting daily care, and improving patient safety and information reuse. DISCUSSION The nursing process model and classifications are used internationally as nursing data structures in nursing records and care plans. The use of SNL revealed various positive impacts. Unexpected outcomes were most often related to lack of resources. LIMITATIONS Indexing of SNL studies has not been consistent. That might cause bias in database retrieval, and important articles may be lacking. The study design of the studies analysed varied widely. Further, the time frame of papers was quite long, causing confusion in descriptions of nursing data structures. CONCLUSION The value of SNL is proven by its support of daily workflow, delivery of nursing care and data reuse. This facilitates continuity of care, thus contributing to patient safety. Nurses need more education and managerial support in order to be able to benefit from SNL.

Developing the standardized wound care documentation model: a Delphi study to improve the quality of patient care documentation.

OBJECTIVE: The aim of this study was to validate a set of previously developed criteria for wound care documentation and to use the validated criteria as a framework for developing a wound care documentation model. The Skin Integrity component of the Finnish Care Classification, the Finnish Classification of Nursing Diagnosis, and the Finnish Classification of Nursing Interventions serve as the basis for the wound care documentation model. SUBJECTS AND SETTING: Finnish wound care specialists, mainly nurses, from different Finnish hospitals, and from the Finnish Wound Care Society having on average 18 years of experience in wound management. Data were collected using electronic survey technology. METHODS: A Delphi technique was used to develop and validate the documentation system. RESULTS: The final model consists of 7 main categories and 25 subcategories of the Skin Integrity component of the Finnish Classification of Nursing Diagnosis and 5 main categories and 25 subcategories of the Skin Integrity component of the Finnish Classification of Nursing Intervention. Based on the results of the Delphi survey, consensus was reached on all elements of the wound care documentation model. CONCLUSION: The Delphi process was used to develop a wound care documentation model for use in an electronic record to promote systematic documentation of both wound assessment and wound care. Future research should address the utility of this documentation model for nurses with expertise in wound care and generalist nurses.

Curricula challenges and informatics competencies for nurse educators

Nursing informatics competencies are fundamental to nursing practice in all areas of nursing work, including direct patient care, administration and education. The recent activity relating to the development of nursing informatics competencies for beginning level nurses has exposed a paucity of understanding of the requirements for nursing informatics competencies for nurse educators. So, whilst the challenge of educating faculty to teach informatics has been limited, research into such competencies is required to meet this challenge. This paper describes the challenges and issues associated with nursing informatics competency development for faculty, outlines the capabilities of faculty, and presents a vision for the future of informatics education for faculty. The final requirement of the introduction of new competencies is to determine appropriate evaluation measures that reflect the requirements of all stakeholders.

Tiedonhallinnan prosessimallin hyödyntäminen sosiaali- ja terveydenhuollon tiedonhallintaa koskevissa tutkimuksissa

Scientific research is based on a selected theory or a theoretical model which also will serve a basis for reviewing the results. Information management cycle has been used as a theoretical model in social and health care studies, but gathered information on the usability of the model in social and health care research has been lacking. The aim of this study is to reduce this lack of information. A descriptive literature review was used and in total 16 social and health care studies were selected for the study. Information management cycle was used to review the results and to develop new information management models. The studies were mainly qualitative and informants mainly social and health care professionals. Information from data warehouses was used only in three studies. Studies results were reviewed according to information management cycle. The use of information was mainly reviewed in the studies were results were reviewed according to every phase of the information management cycle or in which also information needs and/or information acquisition were reviewed. This study showed that information management cycle is well applicable in social and health care studies. This study also showed that social- and health care information management research needs more quantitative and register research. This article reviewed studies, dissertations and master’s theses which had been carried out in social and health care context and in which information management cycle was used.