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Rabelo‐Silva, Eneida Rejane; Dantas Cavalcanti, Ana Carla; Ramos Goulart Caldas, Maria Cristina; Lucena, Amália de Fátima; Almeida, Miriam de Abreu; Linch, Graciele Fernanda da Costa; Silva, Marcos Barragan; Müller‐Staub, Maria
Journal of clinical nursing, February 2017, 2017-Feb, 2017-02-00, 20170201, Letnik: 26, Številka: 3-4Journal Article
Aims and objectives To assess the quality of the advanced nursing process in nursing documentation in two hospitals. Background Various standardised terminologies are employed by nurses worldwide, whether for teaching, research or patient care. These systems can improve the quality of nursing records, enable care continuity, consistency in written communication and enhance safety for patients and providers alike. Design Cross‐sectional study. Methods A total of 138 records from two facilities (69 records from each facility) were analysed, one using the NANDA‐International and Nursing Interventions Classification terminology (Centre 1) and one the International Classification for Nursing Practice (Centre 2), by means of the Quality of Diagnoses, Interventions, and Outcomes instrument. Quality of Diagnoses, Interventions, and Outcomes scores range from 0–58 points. Nursing records were dated 2012–2013 for Centre 1 and 2010–2011 for Centre 2. Results Centre 1 had a Quality of Diagnoses, Interventions, and Outcomes score of 35·46 (±6·45), whereas Centre 2 had a Quality of Diagnoses, Interventions, and Outcomes score of 31·72 (±4·62) (p < 0·001). Centre 2 had higher scores in the ‘Nursing Diagnoses as Process’ dimension, whereas in the ‘Nursing Diagnoses as Product’, ‘Nursing Interventions’ and ‘Nursing Outcomes’ dimensions, Centre 1 exhibited superior performance; acceptable reliability values were obtained for both centres, except for the ‘Nursing Interventions’ domain in Centre 1 and the ‘Nursing Diagnoses as Process’ and ‘Nursing Diagnoses as Product’ domains in Centre 2. Conclusion The quality of nursing documentation was superior at Centre 1, although both facilities demonstrated moderate scores considering the maximum potential score of 58 points. Reliability analyses showed satisfactory results for both standardised terminologies. Relevance to clinical practice Nursing leaders should use a validated instrument to investigate the quality of nursing records after implementation of standardised terminologies.
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JCR | SNIP | JCR | SNIP | JCR | SNIP | JCR | SNIP |
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Povezave do osebnih bibliografij avtorjev | Povezave do podatkov o raziskovalcih v sistemu SICRIS |
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Vir: Osebne bibliografije
in: SICRIS
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