Research topic

Nursing Diagnosis and Documentation

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Research papers

2015 · International Journal of Nursing Knowledge · 94 citations

Nursing Students' Perceptions of Their Own Caring Behaviors: A Multicountry Study

Purpose The aim of this study was to identify perceptions of caring behaviors in student nurses from four countries. Methods This study employed a descriptive, comparative survey design. Four hundred sixty-seven students were recruited from four countries (Nigeria, India, Greece, and the Philippines) to participate in the study during the months of September 2013 to January 2014. Data were collected using the Caring Behavior Inventory. Findings The highest ranked subscale was “assurance of human presence” (4.827 ± 0.927), while “positive connectedness” (4.610 ± 0.949) was the lowest ranked subscale. There were no statistically significant correlations between the Caring Behavior Inventory scale and gender ( F = 0.215, p = .643), educational level ( F = 0.396, p = .529), and family structure of students ( F = 0.680, p = .410), except for age ( F = 9.380, p = .002, η 2 = 0.141) and the country of origin ( F = 5.772, p = .001, η 2 = 0.036). Conclusion Students from four countries possess positive caring behaviors, specifically on physically based caring interventions, while there is a need to emphasize expressive caring behaviors during nursing education and training. Implication for Nursing Practice Caring interventions should be carried out in order to help students build or enhance their caring behaviors that can be adapted to clinical situations.

2022 · BMC Nursing · 38 citations

Development and evaluation of an electronic nursing documentation system

BACKGROUND: Nursing documentation is a critical aspect of the nursing care workflow. There is a varying degree in how detailed nursing reports are described in scientific literature and care practice, and no uniform structured documentation is provided. This study aimed to describe the process of designing and evaluating the content of an electronic clinical nursing documentation system (ECNDS) to provide consistent and unified reporting in this context. METHODS: A four-step sequential methodological approach was utilized. The Minimum Data Set (MDS) development process consisted of two phases, as follows: First, a literature review was performed to attain an exhaustive overview of the relevant elements of nursing and map the available evidence underpinning the development of the MDS. Then, the data included from the literature review were analyzed using a two-round Delphi study with content validation by an expert panel. Afterward, the ECNDS was developed according to the finalized MDS, and eventually, its performance was evaluated by involving the end-users. RESULTS: The proposed MDS was divided into administrative and clinical sections; including nursing assessment and the nursing diagnosis process. Then, a web-based system with modular and layered architecture was developed based on the derived MDS. Finally, to evaluate the developed system, a survey of 150 registered nurses (RNs) was conducted to identify the positive and negative impacts of the system. CONCLUSIONS: The developed system is suitable for the documentation of patient care in nursing care plans within a legal, ethical, and professional framework. However, nurses need further training in documenting patient care according to the nursing process, and in using the standard reporting templates to increase patient safety and improve documentation.

2017 · Journal of Nursing and Midwifery Sciences · 38 citations

Evaluation of the nursing process utilization in a teaching hospital, Ogun State, Nigeria

Context: Nursing process is the systematic method of thinking used by nurses to develop an individualized plan of care for patients. Effective use of the nursing process depends on a nurse's familiarity with the standardized nursing language. Aim: This study evaluates the utilization of nursing process on the day of admission and within 24 h of patient admission in a teaching hospital.Setting and Design: Descriptive and Retrospective design was utilized.Materials and Methods: Systematic sampling technique was adopted to evaluate 959 patients' records from 2014 to 2016 in 2 medical and 2 surgical wards over 3 months period using a self designed checklist.Statistical Analysis Used: Data collected was analyzed using SPSS version 21 and presented as frequencies and percentages. T test was used to test the significant difference between variables with P value set at ≤ 0.05.Results: Only 24.9% of the medical records contained the nursing process form. On the day of admission, <25% of the charts included a complete record of nursing assessment, nursing diagnoses, nursing intervention, and the evaluation. The highest phase of nursing process recorded is nursing diagnosis followed by patient assessment. At 24h postadmission, no significant increase was noted in the phases of nursing process recorded. There was a significant difference between the frequencies of documentation of nursing diagnosis and the nurses' area of practice (P = 0.001).Conclusions: Nursing process utilization remained poorly incorporated into the activities of nurses in this institution. Therefore, continuing professional education on nursing process and supervision should be mandated.

2017 · Nursing Open · 36 citations

Effect of standardized nursing language continuing education programme on nurses' documentation of care at University College Hospital, Ibadan

Aim: The study assessed the documentation of nursing care before, during and after the Standardized Nursing Language Continuing Education Programme (SNLCEP). It evaluates the differences in documentation of nursing care in different nursing specialty areas and assessed the influence of work experience on the quality of documentation of nursing care with a view to provide information on documentation of nursing care. The instrument used was an adapted scoring guide for nursing diagnosis, nursing intervention and nursing outcome (Q-DIO). Design: Retrospective record reviews design was used. Methods: A total of 270 nursing process booklets formed the sample size. From each ward, 90 booklets were selected in this order: 30 booklets before the SNLCEP, 30 booklets during SNLCEP and 30 booklets after SNLCEP. Results: Overall, the study concluded that the SNLCEP had a significant effect on the quality of documentation of nursing care using Standardized Nursing Languages.

2012 · International Journal of Nursing Practice · 32 citations

Nursing documentation: Experience of the use of the nursing process model in selected hospitals in<scp>I</scp>badan,<scp>O</scp>yo<scp>S</scp>tate,<scp>N</scp>igeria

The descriptive study was conducted to determine the extent of utilization of the nursing process for documentation of nursing care in three selected hospitals, Ibadan, Nigeria. One hundred fifty nurses and 115 discharged clients' records were selected from the hospitals. Questionnaires and checklists were used to collect data. Utilization of nursing process for care was 100%, 73.6% and 34.8% in the three hospitals. Nurses encountered difficulties in history taking, formulation of nursing diagnoses, objectives, nursing orders and evaluation. Most nurses disagreed or were undecided with the use of authorized abbreviations and symbols (34.3%, 40.3% and 69.5%), recording errors that occurred during care (37.1%, 56.1% and 52.2%) and inclusion of change in clients' condition (54.3%, 56.1% and 73.8%). Most nurses appreciated the significance of documentation. Lack of time, knowledge and need for extensive writing are the major barriers against documentation. Seventy-seven point four per cent of the 115 clients' records from one hospital showed evidence of documentation, no evidence from the other two. Study findings have implications for continuing professional education, practice and supervision.

2013 · International Journal of Nursing Knowledge · 19 citations

Impact of an Educational Program on the Use of Standardized Nursing Languages for Nursing Documentation Among Public Health Nurses in Nigeria

PURPOSE: To measure the effect of an educational package on documentation of care among public health nurses (PHNs). METHOD: A quasi-experimental design was adopted. Forty PHNs working in primary healthcare settings were selected. Education was given through a 5-day workshop. Documentation of care was assessed using a modified "Muller-Staub Q-DIO instrument." Data were analyzed using t test third and twelfth months postintervention. FINDINGS: There was a significant improvement on documentation of care at p = .0001. CONCLUSION: Educating PHNs and providing them with standardized nursing care plans enhance documentation of care. IMPLICATION TO PRACTICE: A combination of education on the use of standardized nursing languages and standardized nursing care plans can enhance documentation of care. There is a need for more research on the use of standardized nursing languages in developing nations.