Creating Subsets of International Classification for Nursing Practice Precoordinated Concepts: Diagnoses/Outcomes and Interventions Categorized Into Areas of Nursing Practice.

The International Classification for Nursing Practice is a comprehensive terminology representing the domain of nursing practice. A categorization of the diagnoses/outcomes and interventions may further increase the usefulness of the terminology in clinical practice. The aim of this study was to categorize the precoordinated concepts of the International Classification for Nursing Practice into subsets for nursing diagnoses/outcomes and interventions using the structure of an established documentation model. The aim was also to investigate the distribution of the precoordinated concepts of the International Classification for Nursing Practice across the different areas of nursing practice. The method was a descriptive content analysis using a deductive approach. The VIPS model was used as a theoretical framework for categorization. The results showed that all the precoordinated concepts of the International Classification for Nursing Practice could be categorized according to the keywords in the VIPS model. It also revealed the parts of nursing practice covered by the concepts of the International Classification for Nursing Practice as well as the parts that needed to be added to the International Classification for Nursing Practice. This has not been identified in earlier subsets as they covered only one specific area of nursing.

A comparison between the ICNP and the ICF for expressing nursing content in the electronic health record.

BACKGROUND: The use of standardised terminologies for electronic health records (EHRs) is important and a sufficient coverage of all aspects of health care is increasingly being developed worldwide. The International Classification of Functioning, Disabilities and Health (ICF) is suggested as a unifying terminology suitable in a multi-professional EHR, but the level of representation of nursing content is unclear. OBJECTIVES: The aim was to describe lexical and semantic accordance in relation to comprehensiveness and granularity of concepts between the International Classification of Nursing Practise (ICNP) and the ICF. METHODS: 806 pre-coordinated concepts for diagnoses and outcomes in the ICNP terminology were manually mapped to 1516 concepts on level 4-6 in the ICF. RESULTS: Several dimensions of nursing diagnoses and outcomes in the ICNP were missing in the ICF. 60% of the concepts for diagnosis and outcome in the ICNP could not be stated using the ICF while another 31% could only be matched either as a subordinate or as a superordinate concept. CONCLUSIONS: The lexical and semantic accordance in relation to comprehensiveness and granularity between concepts in the ICNP and ICF was rather low. A large proportion of concepts for diagnoses and outcomes in the ICNP could not be satisfactorily stated using the ICF. Standardised terminologies rooted in a nursing tradition (e.g., the ICNP) is needed for communication and documentation in health care to represent the patient's health situation as well as professional diagnostic decisions and evaluations in nursing.

How to Optimize Integrated Patient Progress Notes: A Multidisciplinary Focus Group Study in Indonesia.

INTRODUCTION: Hospitals in Indonesia are obligated to implement Integrated Patient Progress Notes (IPPNs), also known as the "Catatan Perkembangan Pasien Terintegrasi". A progress note contains the entire interaction between patients and health professionals, including physicians, nurses, pharmacists, dietitians, and physiotherapists. However, since the first launch in 2012, obstacles and problems in completing this integrated documentation remains nationwide. AIM: The objective of this investigation was to identify health professional's perspectives on obstacles and problems using IPPNs and facilitators that may optimize their use. METHODS: Five focus group discussions (FGDs) involving 37 participants took place. All FGDs were recorded, translated, and transcribed verbatim. A thematic analysis was used to interpret the data. RESULTS: The thematic analysis of the material revealed three main categories for each of the two topics; Topic 1. Perceived problems hindering integrated documentation: lack of supervision, competence, workload; topic 2: perceived strategies to optimize integrated documentation: organizational support, joint practices, integrating technology with IPPN. CONCLUSION: The results indicate that health professionals see the importance of using IPPNs but only if implemented with educational and organizational support and that the use of an electronic patient record may be more effective than a paper record. To continue the implementation of IPPNs, it is suggested that it is preceded by educational and organizational support.

Development of the Quality of Australian Nursing Documentation in Aged Care (QANDAC) instrument to assess paper-based and electronic resident records.

AIM: To develop an Australian nursing documentation in aged care (Quality of Australian Nursing Documentation in Aged Care (QANDAC)) instrument to measure the quality of paper-based and electronic resident records. METHODS: The instrument was based on the nursing process model and on three attributes of documentation quality identified in a systematic review. The development process involved five phases following approaches to designing criterion-referenced measures. The face and content validities and the inter-rater reliability of the instrument were estimated using a focus group approach and consensus model. RESULTS: The instrument contains 34 questions in three sections: completion of nursing history and assessment, description of care process and meeting the requirements of data entry. Estimates of the validity and inter-rater reliability of the instrument gave satisfactory results. CONCLUSION: The QANDAC instrument may be a useful audit tool for quality improvement and research in aged care documentation.

A comparison between the VIPS model and the ICF for expressing nursing content in the health care record.

BACKGROUND: Multi-professional standardized terminologies are needed that cover common as well as profession-specific care content in order to obtain a full coverage and description of the contributions from different health professionals' perspectives in health care. Implementation of terminologies in clinical practice that do not cover professionals' needs for communication might jeopardize the quality of care. PURPOSE: The aim of the study was to compare the structure and content of the Swedish VIPS model for nursing documentation and the international classification of function, disability and health (ICF). METHOD: Mapping was performed between key words and prototypical examples for patient status in the VIPS model and terms in the ICF and its framework of domains, chapters and specific terms. The study had two phases. In the first phase 13 key words for patient status in the VIPS model and the 289 terms (prototypical examples) describing related content were mapped to comparable terms in the ICF. In phase two, 1424 terms on levels 2-4 in the ICF were mapped to the key words for patient status in the VIPS model. RESULTS: Differences in classification structures and content were found, with a more elaborated level of detail displayed in the ICF than in the VIPS model. A majority of terms could be mapped, but several essential nursing care concepts and perspectives identified in the VIPS model were missing in the ICF. Two-thirds of the content in the ICF could be mapped to the VIPS' key words for patient status; however, the remaining terms in the ICF, describing body structure and environmental factors, are not part of the VIPS model. CONCLUSION: Despite that a majority of the nursing content in the VIPS model could be expressed by terms in the ICF, the ICF needs to be developed and expanded to be functional for nursing practice. The results have international relevance for global efforts to implement unifying multi-professional terminologies. In addition, our results underline the need for sufficient coverage and level of detail to support different professional perspectives in health care terminologies.

Does the use of a classification for nursing diagnoses affect nursing students' choice of nursing interventions?

The Swedish health care system stands before an implementation of standardized language. The first classification of nursing diagnoses translated into Swedish, The NANDA, was released in January 2011. The aim of the present study was to examine whether the usage of the NANDA classification affected nursing students' choice of nursing interventions. Thirty-three nursing students in a clinical setting were divided into two groups. The intervention group had access to the NANDA classification text book, while the comparison group did not. In total 78 nursing assessments were performed and 218 nursing interventions initiated. The principle findings show that there were no statistical significant differences between the groups regarding the amount, quality or category of nursing interventions when using the NANDA classification compared to free text format nursing diagnoses.

Outpatient versus inpatient laparoscopic cholecystectomy: a prospective randomized study of symptom occurrence, symptom distress and general state of health during the first post-operative week.

BACKGROUND: Few randomized clinical trials focus on patients' symptoms of the first post-operative week following outpatient (OPS) versus inpatient (IPS) laparoscopic cholecystectomy (LC). The objective was to compare these treatment modalities with regard to patients' perceptions of pain and other post-operative symptoms, amount of distress, level of anxiety and general state of health during the first post-operative week. METHODS: One hundred patients were randomized. Seventy-three LC patients were valid for efficacy (OPS n=34, IPS n=39). Data were collected by means of questionnaires. RESULTS: The main result was that only minor [corrected] differences were seen between the groups regarding the occurrence of post-operative symptoms or symptom distress. Approximately 90% of the patients in both groups perceived pain, reduced mobility and tiredness on day 1. Nausea and loss of appetite were reported by half of the patients. Post-operative day 1, both groups reported much or very much distress related to pain and reduced mobility (approximately 40%) and nausea (approximately 20%). Although both groups reported less symptoms on day 7, one-third still experienced pain, but only one patient reported this to be distressing. CONCLUSION: Laparoscopic cholecystectomy patients in both groups recover equally well, indicating that a greater proportion of LC patients should be offered the outpatient modality.

Swedish Registered Nurses' incentives to use nursing diagnoses in clinical practice.

AIMS AND OBJECTIVES: The purpose of this study was to describe Registered Nurses' incentives to use nursing diagnoses in clinical practice. BACKGROUND: The use of nursing diagnoses is scarce in Swedish patient records. However, there are hospital wards were all nurses formulate and use nursing diagnoses in their daily work. This leads to the question of what motivates these nurses who do use nursing diagnoses in clinical practice. DESIGN: A qualitative descriptive design. METHODS: A purposeful sampling of 12 Registered Nurses was used. Qualitative interviews to collect data and a content analysis were performed. RESULTS: Five categories were identified: identification of the patient as an individual and as a whole, a working tool for facilitating nursing care, increasing awareness within nursing, support from the management and influence on the professional role. The principle findings of this study were: (i) that the Registered Nurses perceived that nursing diagnoses clarified the patient's individual needs and thereby enabled them to decide on more specific nursing interventions, (ii) that nursing diagnoses were found to facilitate communication between colleagues concerning patient care and thus promoted continuity of care and saved time and (iii) that nursing diagnoses were perceived to increase the Registered Nurses' reflective thinking leading to a continuous development of professional knowledge. CONCLUSIONS: The present findings suggest that the incentives to use nursing diagnoses originate from effects generated from performing a deeper analysis of the patient's nursing needs. Further research is needed to test and validate the usability and consequences of using nursing diagnoses in clinical practice. Motivating factors found in this study may be valuable to Registered Nurses for the use and development of nursing diagnoses in clinical care. Moreover, these factors may be of relevance in other countries that are in a similar situation as Sweden concerning application of nursing diagnoses.

Testing of an audit instrument for the nursing discharge note in the patient record.

OBJECTIVES: This study validates and tests the reliability of an audit instrument constructed to evaluate the content of nursing discharge notes. DESIGN: Instrument validation and reliability testing. MAIN OUTCOME MEASURES: Factor analysis identifying structure through data summarization of the instrument, association between scores in test-retest, and interrater reliability between auditors. VALIDITY: Three factors emerged in the factor analysis: 'General information', 'Planning', and 'Assessment', accounting for 76% of the variance regarding the quantitative aspect and 79% of the variance regarding the qualitative aspect, confirming the distinctiveness. Reliability: The Spearman rank-order correlation coefficient calculated per item in the test-retest ranged from 0.72 to 1.0 (p=0.01). The correlation coefficient for the total score was 0.98 (p=0.01). There were no differences in item scores between the test and retest in 93% of the comparisons (n=486). Between the two auditors, the Spearman rank-order correlation coefficient in each item ranged from 0.83 to 1.00 (p=0.01) and weighted kappa values from 0.70 to 1.00 with the exception of one item in both calculations. The correlation coefficient for the auditors' total score was 0.99 (p=0.01). The Student's paired t-test comparing the two auditors' mean values in five different parts of the instrument showed no significant differences in score. CONCLUSION: The Cat-ch-Ing EPI instrument shows a high reliability and validity as an audit instrument to evaluate the content of nursing discharge notes.

Experiences of using the VIPS-model for nursing documentation: a focus group study [corrected].

BACKGROUND: The present investigation is part of a study where the Registered Nurses on three hospital wards received a 2 year intervention programme on nursing documentation in accordance with a keyword structure based on the nursing process. AIM: To describe the Registered Nurses' perceptions of and attitudes towards the effects of the intervention, and to generate hypotheses for further research. METHOD: Focus group discussions were used to collect data, with a qualitative content analysis method for the processing of the data. FINDINGS: The most interesting finding in these group discussions was the statements made by participants that the structured way of documenting nursing care made them think more, and think in a different way about their work with their patients. Two types of role changing were reported; from a medical technical focus to a more nursing expertise orientation and from a "hands on clinician" to more of an administrator and secretary. CONCLUSION: A number of issues debated among the participants in this study could be seen as organizational matters and lead to the important issue of multidisciplinary and organizational work when implementing innovations within nursing.

Prerequisites and consequences of nursing documentation in patient records as perceived by a group of Registered Nurses.

The issue of nursing documentation and care planning has been discussed in numerous articles, revealing barriers and few facilitators in nursing practice. Few of these articles are scientifically researched and they are often based on small samples. This study aimed to illuminate the factors that Registered Nurses (RNs) in acute care perceived as prerequisites and consequences relevant to their documentation of nursing care when using the VIPS model (VIPS is an acronym formed from the Swedish words for Well-being, Integrity, Prevention and Security). In total 377 RNs divided into two groups (Groups A and B) completed a questionnaire concerning opinions about nursing documentation. Both groups had received a 3-day course on nursing documentation based on the VIPS model. Group A had also participated in a 2-year comprehensive intervention programme. The findings showed that most participants, regardless of group, perceived nursing documentation to be beneficial to them in their daily practice and to increase patient safety, and that use of the VIPS model facilitated documentation of nursing care. The inhibitors, facilitators and consequences of nursing documentation identified here should help both RNs in practice and their leaders to be more attentive to the prerequisites needed to achieve satisfactory nursing documentation in patient records.

Long-term increase in quality of nursing documentation: effects of a comprehensive intervention.

This study aimed to evaluate the longitudinal effects of a nursing-documentation intervention on the quantity and quality of the nursing documentation in a sample of patient records at a university hospital in Stockholm, Sweden. In this quasi-experimental longitudinal study, two hospital wards participated in a 2-year intervention and a third ward was used for comparison. The intervention consisted of organizational changes and education regarding nursing documentation in accordance with the VIPS model, a model designed to structure nursing documentation. To evaluate the effect, patient records were audited at three different time points: before the intervention, directly after the intervention and 3 years after the intervention. A total of 269 patient records were used. The findings showed a significant score increase in quantity as well as in quality of the nursing documentation, in the intervention wards directly after the intervention, as compared with those from the comparison ward. The results suggests that a comprehensive intervention based on the VIPS model and including organizational support for registered nurses (RN) may improve nursing documentation in an acute care hospital setting.