scholarly journals Implementation of Effective Nurse Communication in Hospital Through Electronic Nursing Documentation (END)

2021 ◽  
Keyword(s):  
Nursing Documentation ◽  
Nurse Communication

scholarly journals Patient participation in electronic nursing documentation: an interview study among community nurses

BMC Nursing ◽  
2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Kim De Groot ◽  
Elisah B. Sneep ◽  
Wolter Paans ◽  
Anneke L. Francke
Keyword(s):  
Data Collection ◽  
Electronic Health Records ◽  
Thematic Analysis ◽  
Patient Participation ◽  
Medical Condition ◽  
Nursing Documentation ◽  
Health Records ◽  
Technical Problems ◽  
Care Plans ◽  
Electronic Health

Abstract 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.

scholarly journals Improving nursing documentation for surgical patients in a referral hospital in Freetown, Sierra Leone: protocol for assessing feasibility of a pilot multifaceted quality improvement hybrid type project

2021 ◽  
Vol 7 (1) ◽  
Author(s):  
Nataliya Brima ◽  
Nick Sevdalis ◽  
K. Daoh ◽  
B. Deen ◽  
T. B. Kamara ◽  
...  
Keyword(s):  
Quality Improvement ◽  
Quality Of Care ◽  
Sierra Leone ◽  
Referral Hospital ◽  
Audit And Feedback ◽  
Health System Strengthening ◽  
Theory Of Change ◽  
Improve Quality ◽  
Nursing Documentation

Abstract Background There is an urgent need to improve quality of care to reduce avoidable mortality and morbidity from surgical diseases in low- and middle-income countries. Currently, there is a lack of knowledge about how evidence-based health system strengthening interventions can be implemented effectively to improve quality of care in these settings. To address this gap, we have developed a multifaceted quality improvement intervention to improve nursing documentation in a low-income country hospital setting. The aim of this pilot project is to test the intervention within the surgical department of a national referral hospital in Freetown, Sierra Leone. Methods This project was co-developed and co-designed by in-country stakeholders and UK-based researchers, after a multiple-methodology assessment of needs (qualitative, quantitative), guided by a participatory ‘Theory of Change’ process. It has a mixed-method, quasi-experimental evaluation design underpinned by implementation and improvement science theoretical approaches. It consists of three distinct phases—(1) pre-implementation(project set up and review of hospital relevant policies and forms), (2) intervention implementation (awareness drive, training package, audit and feedback), and (3) evaluation of (a) the feasibility of delivering the intervention and capturing implementation and process outcomes, (b) the impact of implementation strategies on the adoption, integration, and uptake of the intervention using implementation outcomes, (c) the intervention’s effectiveness For improving nursing in this pilot setting. Discussion We seek to test whether it is possible to deliver and assess a set of theory-driven interventions to improve the quality of nursing documentation using quality improvement and implementation science methods and frameworks in a single facility in Sierra Leone. The results of this study will inform the design of a large-scale effectiveness-implementation study for improving nursing documentation practices for patients throughout hospitals in Sierra Leone. Trial registration Protocol version number 6, date: 24.12.2020, recruitment is planned to begin: January 2021, recruitment will be completed: December 2021.

Developing a Standardized Tool to Improve Nurse Communication During Shift Report

2012 ◽  
Vol 27 (3) ◽  
pp. 240-246 ◽  
Author(s):  
Angela M. Jukkala ◽  
David James ◽  
Pamela Autrey ◽  
Andres Azuero ◽  
Rebecca Miltner
Keyword(s):  
Shift Report ◽  
Nurse Communication

Psychometric Evaluation of the D-Catch, an Instrument to Measure the Accuracy of Nursing Documentation

2015 ◽  
Vol 28 (3) ◽  
pp. 145-152 ◽  
Author(s):  
Fabio D'Agostino ◽  
Claudio Barbaranelli ◽  
Wolter Paans ◽  
Romina Belsito ◽  
Raul Juarez Vela ◽  
...  
Keyword(s):  
Psychometric Evaluation ◽  
Nursing Documentation

scholarly journals Retention Strategy to Minimize Nurse Turnover: A Systematic Review

2019 ◽  
Vol 1 (2) ◽  
pp. 99-109
Author(s):  
Rr.Tutik Sri Hariyati ◽  
Nurdiana Nurdiana
Keyword(s):  
Systematic Review ◽  
Communication Skills ◽  
Work Experience ◽  
Journal Article ◽  
Organization Culture ◽  
Communication Analysis ◽  
Design Data ◽  
Nurse Turnover ◽  
Nurse Communication

Background: Communication skills are essential for nurses in providing health services. Efficacious communication will impact in the quality of care and patient safety. This manuscript is to identify factors predisposing implementation of effective nurse communication. Method: This study that data was retrieved uses systematic review design. Data was retrieved from database ProQuest, SCOPUS, EBSCO, Science-Direct, JSTOR, and Wiley-Online in the period of 2011 – 2017. The study was done for journal, article and literature review by applying the keywords nurse communication, health’s communication, effective communication of nurse. Results: A total of 12518 studies was found from six databases. From, the number of these direct search, systematic review identifies conformity based on the title, so that it obtained 31 studies with a title that suitable for a selected discussion. The total of selected papers were 16 studies and identified Efficacious communication. Analysis result from the paper research was there were 16 papers that complement the criteria determined. Six factors are identified to have effect in an implementation of effective nurse communication: (1) intelligence and self-efficacy, (2) Communication Skills, (3) Work Experience, (4) Perceptions, (5) Socio-cultural, and (6) Organization culture.

scholarly journals Improvement Legal Aspects and Completeness of Documentation using Electronic Nursing Record: A Report Study

2019 ◽  
Vol 1 (2) ◽  
pp. 32-39
Author(s):  
Rr.Tutik Sri Hariyati ◽  
Krisna Yetti Malawat ◽  
Retno Purwandari ◽  
Effy Afifah
Keyword(s):  
Legal Aspect ◽  
Legal Aspects ◽  
Control Group ◽  
Nursing Documentation ◽  
Study Approach ◽  
Before And After ◽  
Post Test ◽  
Nursing Activity ◽  
Quality Of Nursing

Background: Completeness of documentation as a legal aspect and proof a nursing activity. Nothing documentation means nothing activity.Objective: The Purpose of research to identify the legal aspect and completeness of nursing documentation after applying electronic nursing documentation. Methods: Report study approach and using pre and post-test with the control group. Thirty Four documentation collected using consecutive sampling on one-week observation before and after using electronic nursing information. The research compared the legal aspect and completeness of data conducted before and after the implementation of the new system.Results: The study showed improvement of the legal aspects increased by 50% (4,40 to 8,00) and completeness documentation by 10.39%  (43,00 to 49,00) after used of a system.   Conclusion: Nursing Electronic Documentation improved legal aspect, completeness nursing and enhance the quality of nursing care. Recommendation: Electronic nursing documentation can be done to support and increase the quality of nursing.  

scholarly journals HUBUNGAN INTENSI DENGAN PERILAKU PERAWAT DALAM PENDOKUMENTASIAN ASUHAN KEPERAWATAN DI INSTALASI GAWAT DARURAT

2018 ◽  
Vol 4 (1) ◽  
Author(s):  
Ardhiles Wahyu Kurniawan
Keyword(s):  
Health Care ◽  
Work Environment ◽  
Nursing Care ◽  
Care Process ◽  
Nursing Documentation ◽  
Exclusion Criteria ◽  
Cross Sectional ◽  
Good Intention ◽  
Care Health

Abstract : The complex IGD work environment will affect the quality of care, health care, including inaccurate or incomplete documentation. Incomplete nursing documentation indicates that the nursing care process is not working properly and continuously. Intentionin documenting can predict the appearance of person behavior including the behavior of nurses, especially in documenting nursing care. The purpose of this study was to analyze correlation intention with nurse behavior in documenting nursing care in Emergency Installation. The research design used correlational analysis with cross sectional approach. The sample in this research is part of nurse of executing at IGD Rumkit TK II dr Soepraoen, IGD RS Panti Waluya Sawahan and IGD RS Islam Malang. The sample of 45 nurses IGD and 341 documents were selected according to inclusion and exclusion criteria. The result of statistical analysis of gamma that there is a significant correlation between intention and nursing documentation behavior evidenced by value of p = 0,000, positive correlation direction and strong correlation value is proved by r = 0,739. Hospital and nurse IGD is expected to develop a good intention then formed good nursing documenting behavior as well.Keywords : Nurse IGD, Intention, Nursing Documentation. Abstrak: Lingkungan kerja IGD yang kompleks akan mempengaruhi kualitas perawatan, pelayanan kesehatan, termasuk dokumentasi yang dilakukan tidak tepat atau tidak lengkap. Dokumentasi keperawatan yang tidak lengkap menunjukkan proses asuhan keperawatan tidak berjalan dengan baik dan berkesinambungan. Intensi dalam pendokumentasian dapat memprediksi munculnya perilaku seseorang termasuk perilaku perawat khususnya dalam pendokumentasian asuhan keperawatan. Tujuan penelitian ini untuk menganalis hubungan intensi dengan perilaku perawat dalam pendokumentasian asuhan keperawatan di Instalasi Gawat Darurat. Desain penelitian menggunakan analysis correlationaldengan pendekatan cross sectional. Sampel dalam penelitian ini adalah sebagian perawat pelaksana di IGD Rumkit TK II dr Soepraoen, IGD RS Panti Waluya Sawahan Malang dan IGD RS Islam Malang. Sampel berjumlah 45 perawat IGD dan 341 dokumen dipilih sesuai dengan kriteria inklusi dan ekslusi. Hasil analisis statistik uji gammamenunjukkan terdapat hubungan signifikan antara intensi dengan perilaku pendokumentasian keperawatan dibuktikan dengan nilai p = 0,000, arah korelasi positif, dan nilai korelasi kuat dibuktikan dengan nilai r = 0,739. Rumah Sakit dan perawat IGD diharapkan mengembangkan intensi yang baik sehingga diharapkan terbentuk perilaku pendokumentasian keperawatan yang baik pula. Kata Kunci : Perawat IGD, Intensi, Dokumentasi Keperawatan.

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