Implementering av sykepleiediagnoser i fritekst

Abstract

Background:The need for good nursing documentation has been highlighted by the Coordination Reform and several studies indicate that nursing documentation does not maintain the purpose of documentation. International studies have shown that implementation of nursing diagnoses has an effect on the quality in nursing documentation. Collaboration between a hospital and a university college was established to study the implementation of nursing diagnoses. This article describes the result from a pilot study of the project. Objective: The pilot study aims to investigate whether the audit instrument in the study is sensitive to change in the nursing documentation after an intervention with teaching and supervision on nursing diagnosis with P(R)ES-structure. Method:The study was a quantitative study with pre-test/post-test design. Data were collected by using Cat-ch-Ing. The intervention consists of teaching and supervision of nursing documentation.Results: There were no significant changes in the quality or quantity in the nursing documentation between pre-test and post-test design. Nursing documentation written as continuing documentation has a higher score than processes-oriented documentation. The audit instrument did not reflect all the changes the researchers experienced in the documentation. Conclusion:Assessment of the audit instrument Cat-ch-Ing indicates a need for more adequate scoring for nursing diagnosis in particular, and nursing documentation in general. There is a need for more knowledge about nursing documentation and what nurses need as working tools in clinical practice.

Impact of an education intervention on nursing diagnoses in free-text format in electronic health records: A pretest–posttest study in a medical department at a university hospital

“…The aim is to establish an individualized diagnostic statement. 12,13,22,23 An example of a nursing diagnosis is described by Ehnfors et al as: Troubled sleep (P) related to itching (E) leads to tiredness and anxiety during the daytime (S). 23(p.105) The PES structure is independent of any existing classification use.…”

“…Internationally, several studies have addressed the shortcomings in nursing documentation. 1,2,19,22,24 The studies involve education interventions emphasizing clinical reasoning to translate the theoretical framework available through the nursing process into the EHRs. Even though the interventions point to improvements in the nursing documentation, there is still a need for more knowledge on easily feasible interventions to be carried out in clinical practice achieving nursing documentation of good quality, in accordance with legislation and nurses' needs for working tools.…”

Implementation of Free Text Format Nursing Diagnoses at a University Hospital’s Medical Department. Exploring Nurses’ and Nursing Students’ Experiences on Use and Usefulness. A Qualitative Study

“…The length of guiding periods is stated as an important factor when implementing the use of nursing diagnoses [ 19 ]. Based on the findings in the study's pilot [ 9 , 46 ], the guidance follow-up period was extended from a period of 9 weeks to a period of 7 months. As illustrated in Table 1 , we targeted this specifically to the key personnel acting as local opinion leaders [ 41 ] within their units.…”

“…A pilot study was completed prior to this paper's study [ 9 , 46 ]. Results pinpointed the importance of extending the time period of the educational intervention together with discovering the advantage of centering part of the intervention to specific key persons in order to promote the implementation process.…”

Kombinerte stillinger gir faglig gevinst

“…Studien målte effekt ved å vurdere pasientjournaler før og etter intervensjonen. Det er gjennomført en pilot på studien (10). I hovedintervensjonen benyttet man et nasjonalt nettverksbygging mellom organisasjonene, men vaere tydelige forankret og organisert som et forskningsprosjekt.…”