The quality of nursing diagnoses, interventions, and outcomes in Romanian nursing documentation measured with the Q-DIO: A cross-sectional study

IF 1.4 4区医学 Q3 NURSING

International Journal of Nursing Knowledge Pub Date : 2023-09-10 DOI:10.1111/2047-3095.12446

Laura Elena Gligor MSc, RN, Horațiu Rusu PhD, Carmen Daniela Domnariu PhD, DR, Maria Müller-Staub PhD, MNS, EdN, RN, FNI, FEANS

{"title":"The quality of nursing diagnoses, interventions, and outcomes in Romanian nursing documentation measured with the Q-DIO: A cross-sectional study","authors":"Laura Elena Gligor MSc, RN, Horațiu Rusu PhD, Carmen Daniela Domnariu PhD, DR, Maria Müller-Staub PhD, MNS, EdN, RN, FNI, FEANS","doi":"10.1111/2047-3095.12446","DOIUrl":null,"url":null,"abstract":"<div>\n \n \n <section>\n \n <h3> Purpose</h3>\n \n <p>To assess the quality of the nursing process in Romania by evaluating nursing documentations with the quality of diagnoses, interventions and outcomes (Q-DIO) measurement instrument.</p>\n </section>\n \n <section>\n \n <h3> Methods</h3>\n \n <p>A quantitative cross-sectional research design was employed using probabilistic sampling to select nursing documentations from a Romanian university hospital. The data were analyzed using the Q-DIO measurement instrument.</p>\n </section>\n \n <section>\n \n <h3> Findings</h3>\n \n <p>Low quality levels of nursing process documentation were found. The Q-DIO subscale “Nursing diagnoses as process” (assessment) revealed a mean = 1.36 (SD 0.52) of maximum 2. Nurses collected lots of data but did not use these to state nursing diagnoses. “Nursing diagnoses as product” showed inaccurate diagnoses; mean = 1.24 (SD 0.48) of maximum 4. Nursing interventions were planned and documented, but their impact on the etiology of nursing diagnoses was low; mean = 0.76 (SD 0.18). The quality of nursing outcomes mean was 0.57 (SD 0.29).</p>\n \n <p>Nurses failed making connections between nursing assessment, diagnoses, interventions, and outcomes, and standardized nursing languages (SNLs) were not used. Statistically significant differences were found among all Q-DIO sub-concepts except for “Nursing diagnoses as process.”</p>\n </section>\n \n <section>\n \n <h3> Conclusions</h3>\n \n <p>The documentation was structured but did not support the nursing process and its documentation, and SNLs were not implemented. There was an underutilization of data to state nursing diagnoses, and nursing interventions were mostly ineffective, leading to low nursing outcomes.</p>\n </section>\n \n <section>\n \n <h3> Implications for nursing practice</h3>\n \n <p>This study provides new insights on the nursing process and its documentation in Romania and a baseline for future research. Policymakers, administrators, and educators should consider educating nurses to use standardized nursing languages and apply the <i>Advanced Nursing Process</i>.</p>\n </section>\n </div>","PeriodicalId":49051,"journal":{"name":"International Journal of Nursing Knowledge","volume":"35 3","pages":"298-307"},"PeriodicalIF":1.4000,"publicationDate":"2023-09-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"International Journal of Nursing Knowledge","FirstCategoryId":"3","ListUrlMain":"https://onlinelibrary.wiley.com/doi/10.1111/2047-3095.12446","RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q3","JCRName":"NURSING","Score":null,"Total":0}

引用次数: 0

Abstract

Purpose

To assess the quality of the nursing process in Romania by evaluating nursing documentations with the quality of diagnoses, interventions and outcomes (Q-DIO) measurement instrument.

Methods

A quantitative cross-sectional research design was employed using probabilistic sampling to select nursing documentations from a Romanian university hospital. The data were analyzed using the Q-DIO measurement instrument.

Findings

Low quality levels of nursing process documentation were found. The Q-DIO subscale “Nursing diagnoses as process” (assessment) revealed a mean = 1.36 (SD 0.52) of maximum 2. Nurses collected lots of data but did not use these to state nursing diagnoses. “Nursing diagnoses as product” showed inaccurate diagnoses; mean = 1.24 (SD 0.48) of maximum 4. Nursing interventions were planned and documented, but their impact on the etiology of nursing diagnoses was low; mean = 0.76 (SD 0.18). The quality of nursing outcomes mean was 0.57 (SD 0.29).

Nurses failed making connections between nursing assessment, diagnoses, interventions, and outcomes, and standardized nursing languages (SNLs) were not used. Statistically significant differences were found among all Q-DIO sub-concepts except for “Nursing diagnoses as process.”

Conclusions

The documentation was structured but did not support the nursing process and its documentation, and SNLs were not implemented. There was an underutilization of data to state nursing diagnoses, and nursing interventions were mostly ineffective, leading to low nursing outcomes.

Implications for nursing practice

This study provides new insights on the nursing process and its documentation in Romania and a baseline for future research. Policymakers, administrators, and educators should consider educating nurses to use standardized nursing languages and apply the Advanced Nursing Process.

查看原文本刊更多论文

用Q-DIO测量罗马尼亚护理文献中护理诊断、干预和结果的质量：一项横断面研究。

目的：通过使用诊断、干预和结果质量（Q-DIO）测量仪评估护理文件，评估罗马尼亚护理过程的质量。方法：采用定量横断面研究设计，采用概率抽样法从罗马尼亚一所大学医院选择护理文献。使用Q-DIO测量仪对数据进行分析。结果：发现护理过程文件的质量水平较低。Q-DIO分量表“护理诊断为过程”（评估）显示平均值=1.36（SD 0.52），最大值为2。护士们收集了大量数据，但没有用这些数据来说明护理诊断。“护理诊断即产品”显示诊断不准确；平均值=最大值4的1.24（SD 0.48）。护理干预措施是有计划和记录的，但它们对护理诊断病因的影响很低；平均值=0.76（SD 0.18）。护理结果质量平均值为0.57（SD 0.29）。护士未能将护理评估、诊断、干预和结果联系起来，也未使用标准化护理语言（SNL）。除“护理诊断为过程”外，所有Q-DIO子概念之间存在统计学上的显著差异。结论：文件是结构化的，但不支持护理过程及其文件，SNL也没有实施。对护理诊断的数据利用不足，护理干预大多无效，导致护理效果低下。对护理实践的启示：这项研究为罗马尼亚的护理过程及其文献提供了新的见解，并为未来的研究提供了基线。政策制定者、管理者和教育工作者应考虑教育护士使用标准化护理语言并应用高级护理流程。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

求助全文

约1分钟内获得全文求助全文

来源期刊

International Journal of Nursing Knowledge NURSING-

CiteScore

2.90

自引率

14.30%

发文量

审稿时长

>12 weeks

期刊介绍： The International Journal of Nursing Knowledge, the official journal of NANDA International, is a peer-reviewed publication for key professionals committed to discovering, understanding and disseminating nursing knowledge. The Journal aims to clarify the knowledge base of nursing and improve patient safety by developing and disseminating nursing diagnoses and standardized nursing languages, and promoting their clinical use. It seeks to encourage education in clinical reasoning, diagnosis, and assessment and ensure global consistency in conceptual languages. The International Journal of Nursing Knowledge is an essential information resource for healthcare professionals concerned with developing nursing knowledge and /or clinical applications of standardized nursing languages in nursing research, education, practice, and policy. The Journal accepts papers which contribute significantly to international nursing knowledge, including concept analyses, original and applied research, review articles and international and historical perspectives, and welcomes articles discussing clinical challenges and guidelines, education initiatives, and policy initiatives.