Nursing Process Documentation and Use of Standardized Nursing Terminology (NANDA-I, NOC, NIC) in Undergraduate Nursing Students: An Explanatory Sequential Mixed-Methods Study.
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Abstract
Introduction: The nursing process (NP) is a framework for planning and documenting nursing care. Standardized nursing language (SNL), including NANDA-I, NOC, and NIC, supports consistent documentation and demonstrates nursing contributions to patient outcomes. Understanding students' use of NP and SNL is important for improving nursing education and care quality.
Objectives: This study evaluated the quality of undergraduate nursing students' NP documentation, including the use of NANDA-I, NOC, and NIC, and explored perceived barriers to implementing NP and SNL in clinical practice.
Methods: This explanatory sequential mixed-methods study was conducted in 2024 at a Faculty of Nursing and Midwifery. In the quantitative phase, NP documentation in Pediatric Nursing clinical logbooks, completed after a 17-hour case-based course on NANDA-I, NOC, and NIC, was evaluated using a researcher-developed checklist. Nursing diagnoses were classified according to NANDA-I Taxonomy II domains, and data were analyzed using descriptive statistics in SPSS version 29. In the qualitative phase, purposively selected students participated in semi-structured interviews to explain the quantitative findings. Data were analyzed using conventional content analysis based on Graneheim and Lundman's approach.
Results: A total of 121 clinical logbooks were analyzed. The mean NP documentation score was 3.52 ± 1.05 (out of 5). Students performed best in documenting NIC interventions and lowest in documenting NANDA-I diagnoses and NOC outcomes. Among 633 documented diagnoses, Safety/Protection, Elimination and Exchange, and Nutrition were the most frequent domains, whereas Self-Perception was least represented; no diagnoses were recorded in the Sexuality, Life Principles, or Growth and Development domains. Eighteen students participated in interviews, yielding two themes: education-related and student-related barriers.
Conclusion: Students demonstrated greater proficiency in documenting interventions than in formulating standardized diagnoses and outcomes. The predominance of physiological diagnoses suggests limitations in comprehensive assessment. Strengthening diagnostic and outcome reasoning and promoting holistic NP-based care should be emphasized in nursing education.
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