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.

The Influence of Checklist Model Documentation on the Completeness of Nursing Care Documentation at Arosuka Hospitals 2017

Background: The nursing care documentation technique that applied at Arosuka Hospital was narrative recording technique. Based on documentation evaluation of nursing care, nursing documentation at Arosuka Hospital was still not equal to documentation of nursing care. Methods: This research intends to analyze the effect of checklist documenting model to the documentation of nursing care in Arosuka Hospital. This research had been conducted since January to June 2017 and the data were collected from May to June 2017. The method of this research was quasi-experiment, pre-test and post-test group research. There were forty-five nurses taken as the samples with total sampling techniques applied. The instruments that used in this research were the forms of checklist documenting model and nursing care evaluation sheet. Result: The result of the research has shown that there is difference of the completeness of nursing care documentation before and after using the checklist model documenting format. The average number of nursing care documentation is higher with the checklist model compared to narrative model mean (40,533). This checklist documenting model is recommended to be applied in Arosuka Distric Hospital to improve the completeness of nursing care documentation in Arosuka Distric Hospital. Keywords:Checklist model, documentation, nursing care.

Standardization of quality of diagnoses, interventions, and outcomes (Q-DIO) measurement instrument for use in Slovenia

Purpose To describe the cross-cultural adaptation of the Quality of Diagnoses, Interventions and Outcomes (Q-DIO) Instrument into the Slovene language. Methods Based on general international guidelines, a six-step process of localization to translate and adjust the instrument from English into the Slovene language was used. Content validity was quantified based on an agreement of eight experts. The instrument was tested using a sample of 140 nursing documentations from two Slovenian tertiary hospitals. Results 26 of 29 items showed an excellent content validity index ranging from 0.857 to 1.000, and a modified kappa index above 0.856. The content validity indexes of the three remaining items adjusted based on experts’ comments were subsequently estimated at 1.000. Construct validity was significantly different between the two groups of documentations. The Cronbach coefficient for the whole questionnaire was 0.860. Cronbach’s alpha if item deleted reamins above 0.80 for all items. The criteria for the difficulty grades of items and discrimination validity were acceptably met for more than 75% of items. Conclusion Based on the results of the study, it may be concluded that Q-DIO is a reliable instrument for measuring the quality of nursing documentation. The deviations in the results of some items are due to poor nursing documentation quality, and indicate that nursing classifications have not yet been fully implemented into practice in the study setting. Additional testing of the instrument is recommended.

Updating the Standardized Terminology for Nurses’ Daily Documentation

In Finland, the nationally unified and standardized nursing documentation model comprises the nursing process model and the Finnish Care Classification (FinCC). The aim of the study was to assess how well the further developed FinCC complies with actual nursing practices and how pragmatic and understandable it is. An e-questionnaire based on the revised version of the FinCC was sent to healthcare organizations (n=34) and Universities of Applied Sciences (n=14). Data was gathered and organized in Excel. Narrative comments were read and analyzed. The mean of questions of 17 components of both the FICND and the FICNI was over four (scale 1–5). The biggest revision of the FinCC is that different scales and evidence-based research have been utilized in the development of the terminology. Based on the findings, revisions have been made, and the new version, FinCC 4.0, will be published at the end of 2019.

Ethical dilemmas in nursing documentation

Background: Nursing documentation is an essential aspect of ethical nursing care. Lack of awareness of ethical dilemmas in nursing documentation may increase the risk of patient harm. Considering this, ethical dilemmas within nursing documentation need to be explored. Aim: To explore ethical dilemmas in nurses’ conversations about nursing documentation. Research design, participants and context: The study used a qualitative design. Participants were registered nurses from a Patient Hotel at a Danish University Hospital. Data were collected in three focus groups with a total of 12 participants. Data analysis consisted of qualitative content analysis inspired by Graneheim and Lundman. Ethical consideration: This study was conducted in accordance with the ethical principles of research and regulations in terms of confidentiality, anonymity and provision of informed consent. Findings: Ethical dilemmas were strongly present in nurses’ conversations about nursing documentation. These dilemmas were demonstrated in two themes: (1) a dilemma between respecting patients’ autonomy and not causing harm, which was visible in nurses’ navigation between written documentation and oral tradition, and (2) a dilemma concerning justice and fair distribution of goods, which was visible in nurses’ balancing between documenting deviations and proof of nursing practice. Discussion: Ethical dilemmas in nursing documentation regarding respecting patients’ autonomy and not causing harm accentuated discussions on professional responsibility and patient participation in clinical decisions. Dilemmas in justice and fair distribution of goods emphasised discussions on trust in relationships versus trust in electronic health records. Conclusion: Actual tendencies in the healthcare system may increase ethical dilemmas in nursing documentation. Sharing otherwise invisible and individual experiences of ethical dilemmas in nursing documentation among nurses, nurse leaders and decision-makers will enable addressing these in reflections and discussions as well as in considering adjustments of conditions for nursing documentation.

Physiological Observations and Nursing Interventions in the Pre-Arrest Patient: A Descriptive Study

<p>Aim: To identify how nurses respond to abnormal physiological observations in the 12 hours prior to a patient having a cardiac arrest. Methods: A descriptive observational design was used to retrospectively review the observation charts and nursing notes of 28 patients who had an in-hospital cardiac arrest, during a 20 month period. This study was performed in a large, tertiary teaching hospital in New Zealand. Key Findings Only one patient met the hospitals minimum standard of four hourly observations and a full set of vital signs were performed on only three patients. The nursing responses were limited to increasing the frequency of observations or informing the doctor. There were few other interventions to treat the abnormality. Eight (32%) patients who had either no response or a partial response to their abnormal physiology did not survive. The nursing documentation demonstrated that abnormal neurological observations were tolerated for significant periods of time and were not acted upon in 62% of these patients. The nursing documentation revealed that the delivery of oxygen was often insufficient to meet the patient's requirements and the medical staff were aware of less than half the patients with abnormal physiology. Discussion removed statement re pt survival: This research identified major deficiencies with recording patient vital signs. If these are not recorded regularly, patient deterioration will be missed and treatment cannot be initiated. Nurses need to respond to abnormal physiology beyond repeating vital signs and informing the medical staff. They are accountable for initiating interventions to prevent further deterioration. Conclusion: The early recognition of patient deterioration and treatment are essential to prevent cardiac arrest. Education strategies are required to improve compliance with recording patient vital signs, communication between nursing and medical staff and how to respond to patient deterioration. The barriers to these must be addressed and solutions sought if patient mortality is to be improved.</p>

Physiological Observations and Nursing Interventions in the Pre-Arrest Patient: A Descriptive Study

<p>Aim: To identify how nurses respond to abnormal physiological observations in the 12 hours prior to a patient having a cardiac arrest. Methods: A descriptive observational design was used to retrospectively review the observation charts and nursing notes of 28 patients who had an in-hospital cardiac arrest, during a 20 month period. This study was performed in a large, tertiary teaching hospital in New Zealand. Key Findings Only one patient met the hospitals minimum standard of four hourly observations and a full set of vital signs were performed on only three patients. The nursing responses were limited to increasing the frequency of observations or informing the doctor. There were few other interventions to treat the abnormality. Eight (32%) patients who had either no response or a partial response to their abnormal physiology did not survive. The nursing documentation demonstrated that abnormal neurological observations were tolerated for significant periods of time and were not acted upon in 62% of these patients. The nursing documentation revealed that the delivery of oxygen was often insufficient to meet the patient's requirements and the medical staff were aware of less than half the patients with abnormal physiology. Discussion removed statement re pt survival: This research identified major deficiencies with recording patient vital signs. If these are not recorded regularly, patient deterioration will be missed and treatment cannot be initiated. Nurses need to respond to abnormal physiology beyond repeating vital signs and informing the medical staff. They are accountable for initiating interventions to prevent further deterioration. Conclusion: The early recognition of patient deterioration and treatment are essential to prevent cardiac arrest. Education strategies are required to improve compliance with recording patient vital signs, communication between nursing and medical staff and how to respond to patient deterioration. The barriers to these must be addressed and solutions sought if patient mortality is to be improved.</p>

FACTORS INFLUENCING DOCUMENTATION IN NURSING CARE BY NURSES AT THE TAMALE TEACHING HOSPITAL, GHANA

In Ghana, nursing documentation practice by nurses is sub-optimal. This analytical cross-sectional study assessed socio-demographic determinants of nursing documentation practice among 278 nurses at the Tamale Teaching Hospital (TTH). Data was gathered using a questionnaire and both descriptive and inferential analyses were done to determine factors influencing nursing documentation practice. A large majority of the respondents (84.6%) had adequate knowledge on nursing documentation. Most of them (84.2%) had positive attitudes towards it and a large majority of them (77.1%) asserted to practice it always but only 74.0% adequately practiced nursing documentation. Knowledge of nursing documentation was statistically associated with age (AOR 0.12, 95% C1: 0.029-1.507; p=0.004) and work experience (AOR 15.29, 95% C1: 3.083-75.872; p=0.001), males were significantly more likely to have positive attitudes towards it (AOR, 2.81 CI, 1.434-5.501, p=0.003) whilst respondents aged 21-30 years (AOR, 5.85 (2.64-12.97), p

774. Outbreak of Central-Line-Associated Bloodstream Infections (CLABSI) amid the COVID-19 Pandemic Associated with Changes in Central Line Dressing Care Accompanying Changes in Nursing Education, Nursing Documentation, and Dressing Supply Kits

Background National Healthcare Safety Network (NHSN) data have revealed an increase in CLABSI associated with the COVID-19 pandemic, but data on factors mediating the increase are limited. Our hospital had been free of CLABSI for 18 months, but we encountered an outbreak of 7 CLABSI over a 5-month period beginning in November 2020. This led to an investigation that revealed that some underlying issues were related to COVID-19. Methods Infection prevention staff at Omaha’s Veterans Affairs Medical Center interviewed hospital staff and performed a retrospective chart review of patients with CLABSI (based on the NHSN definition) amid the COVID-19 pandemic. Results The first case of CLABSI in the outbreak was detected in November 2020. Prior to that, there was no case of CLABSI since April 2019, as shown in the graph. Each case of CLABSI was associated with a different microorganism. Further investigation revealed deviations from our usual practices in central line dressing care. Our response to COVID-19 had included alterations in periodic competency training (including dressing care) for nursing staff as well as the rapid introduction of streamlined inpatient nursing documentation. Previously, dressing kits included chlorhexidine-impregnated dressings; in November, a kit without these dressings was introduced. A weekly audit of dressing care was begun in March 2021. No CLABSI was identified in April 2021. Types of Microorganisms identified Different types of microorganisms isolated during the CLABSI outbreak each month. The trend of CLABSI in VA Nebraska-Western Iowa Health Care System Conclusion We encountered a CLABSI outbreak associated with deviations from usual central line dressing care. Using the concept of the Swiss cheese model of error prevention, we recognized alterations in three barriers: competency training; thorough documentation; and complete supply kits. The first two of these factors were directly related to our COVID-19 response. Our findings illustrate the relevance of the Swiss cheese model for maintaining a safe healthcare environment. Disclosures Marvin J. Bittner, MD, Merck (Advisor or Review Panel member)Sanofi Pasteur (Speaker's Bureau)