Laura Elena Gligor, Horațiu Rusu, Carmen Daniela Domnariu, Maria Müller-Staub
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引用次数: 0
Abstract
Purpose: To investigate the factors influencing the completion quality of nursing documentation (NDoc) in Romania using multilevel modeling.
Design: Retrospective descriptive study.
Methods: A mixed-effect logistic regression analysis was conducted to identify factors affecting the completion of NDoc by using the Q-DIO instrument. A total of 395 NDocs were selected by probabilistic sampling.
Findings: The study identified significant correlations among the Q-DIO sub-concepts. Specifically, "Nursing Diagnoses as Process" was significantly correlated with both "Nursing Diagnoses as Product" and "Nursing-Sensitive Patient Outcomes." Additionally, "Nursing Diagnoses as Product" is correlated with "Nursing Interventions." Among the external factors, the number of nurses involved in documentation was significantly linked to the completeness of both "Nursing Diagnoses as Product" and "Nursing Interventions." Documentation quality also varied by hospital specialty, whereas the length of stay did not show any significant correlation with the Q-DIO sub-concepts.
Conclusions: The relationships between Q-DIO sub-concepts underscore the importance of addressing every phase of the nursing process for meaningful nursing-sensitive patient outcomes. External factors significantly affect documentation completion, requiring the consideration of organizational aspects when implementing NDoc.
Implications for nursing practice: This study highlights the need for nurses to systematically collect and document data across all phases of the nursing process. Training and support should be provided to improve the accuracy and completeness of nursing diagnoses and their linkage to interventions and outcomes. Additionally, organizational factors, such as staffing levels and the type of hospital specialty, should be carefully considered when implementing documentation innovations, as they significantly impact the quality and completeness of NDoc.
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.
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