Content and completeness of care plans after implementation of standardized nursing terminologies and computerized records

The nursing process and standardized nursing terminologies are essential elements to structure nursing documentation in daily nursing information management. The aim of this study was to describe sustainability and whether and how standardized nursing terminologies, in handwritten versus preprinted versus computerized nursing care plans, changed the content and completeness of documented nursing care. Three audits of patient records were performed: a pretest (n = 291) before a yearlong implementation of standardized nursing terminologies in nursing care plans followed by two posttests: (1) 3 weeks after implementation of nursing terminologies (n = 299) and (2) 22 months after implementation of nursing terminologies and 8 months after implementation of a computerized system (n = 281) in a university hospital. Content and completeness of documented nursing care improved after implementation of standardized nursing terminologies. Documentation of nursing care plans, signs and symptoms, related factors, and nursing interventions increased, whereas mean number of nursing diagnoses per patient did not change between audits. Computerized nursing care plans had the biggest impact, with more variety of nursing diagnoses and increased documentation of signs and symptoms, related factors, and nursing interventions. The use of standardized nursing terminologies improved nursing content in the nursing care plans. Moreover, computerized nursing care plans, in comparison with handwritten and preprinted care plans, increased documentation completeness.     

Standardized care plans in Swedish health care: their quality and the extent to which they are used

Objectives:  To investigate the quality of standardized care plans and the extent to which they are used within Swedish in-hospital somatic care. Further, to examine the quality of the knowledge summaries on which existing standardized care plans were supposed to be based.
Design:  Submitted documents were reviewed with study-specific protocols.
Setting:  A national survey, based on a structured selection of Swedish hospitals.
Participants:  A total of 25 Swedish hospitals participated, and were asked to submit all documents in use that were labelled standardized care plan.
Results:  Only 4% (34 out of 782) of the reviewed documents fulfilled the criteria for being a standardized care plan. None of the 34 knowledge summaries (an accompanying document with a compilation of scientific facts and reliable experience) was evidence-based.
Conclusions:  There is a lack of knowledge regarding what a standardized care plan is, and how such a document should emanate from evidence-based knowledge. Our results raise the question of how recent developments in research are used to create standardized care plans for the best possible care. In the process of developing standardized care plans it is important to acknowledge that staff who develop these plans need scientific training and experience. Standardized care plans are in the early stages of development, and at this stage it seems appropriate to initiate a discussion regarding possible cooperation at national level when developing standardized care plans for certain large groups of patients suffering from specific diseases, or undergoing the same treatment.     

Standardized nursing care plans for acute care SCI: improved documentation

Adequate documentation of spinal cord injury (SCI) nursing care is necessary for evaluation of patient progress and compliance with standards of care. The objective criteria used to evaluate nursing care include the nursing data base, the care plan, and the nurses' notes. The nursing care plan reflects the needs of the SCI client and is the basis from which documentation about these needs arises. Standards for acute care SCI nursing were recently developed for the 10 designated SCI centers in Florida. To improve the documentation of these standards, neuroscience nurses at Shands Hospital developed standardized care plans that can be individualized for each SCI client. The implementation of these care plans improved documentation of the standards for acute care SCI nursing. Additional benefits included an increased awareness of the nursing diagnoses among staff nurses and improved equality of care for the SCI client.     

Professional nursing societies and evidence-based practice: strategies to cross the quality chasm

The Institute of Medicine (IOM) published Crossing the Quality Chasm: A New Health Care System for the 21st Century nearly 10 years ago. Nursing societies are in a unique position to promote evidence-based practice (EBP). The purpose of this article is to describe EBP strategies that nursing societies can use to improve the quality of health care, thus decreasing the gap between research knowledge and practice. Nursing societies can take the lead in two key EBP activities: (1) development of evidence-based syntheses, systematic reviews, and guidelines for EBP; and (2) development, implementation, and testing strategies for these EBP resources to become available and used in clinical decision-making. The Oncology Nursing Society will be discussed as an exemplar of developing EBP programs and increasing knowledge of EBP and practice change resources for its members. The discussion stresses the importance of nursing society members and leaders in guiding their societies to contribute to the closing of the US health care quality chasm.     

Standardizing Documentation for Postoperative Nausea and Vomiting in the Electronic Health Record

Postoperative nausea and vomiting (PONV) remains a common postoperative complication that causes patient discomfort and increases health care costs. Clinicians use the American Society of PeriAnesthesia Nurses (ASPAN) guideline to help prevent and treat PONV. However, the lack of standardized terminology in the electronic health record (EHR) and the lack of clinical decision support tools make it difficult for clinicians to document guideline implementation and to determine the effects of nursing care on PONV. To address this, we created a concept map of the Perioperative Nursing Data Set (PNDS) that illustrates the relationship between elements of this standardized nursing terminology and the ASPAN guideline, using the Systematized Nomenclature of Medicine—Clinical Terms multidisciplinary terminology to fill any gaps. This mapping results in a standardized dataset specific to PONV for use in an EHR, which links nursing care to nursing diagnoses, interventions, and outcomes. The mapping and documentation in the EHR also allows standardized data collection for research, evaluation, and benchmarking, which makes perioperative nursing care of patients who are at risk for or experiencing PONV measureable and visible. Distributing this information to perioperative and perianesthesia nursing personnel, in addition to implementing risk assessment tools for PONV and clinical support alerts in electronic documentation systems, will help support implementation of the PONV clinical practice guideline in the EHR.     

Improving care of patients with insulin pumps during hospitalization: translating the evidence

The purpose of this quality improvement project was to determine whether implementation of an evidence-based standardized protocol would enhance documentation and management of blood glucose levels for patients using continuous subcutaneous insulin infusion during hospitalization. Using a comparative design, documentation and blood glucose control measures were assessed before and after implementation of the protocol. Although some improvements have been recognized, we continue to refine the process and anticipate stronger outcomes in the future.     

The Australian experience of nurses' preparedness for evidence-based practice

Aim  This study aimed to determine current knowledge and attitudes towards evidence-based practice (EBP) among pre- and post-registration nurses in New South Wales (NSW), Australia.
Background  Educational and clinical strategies for EBP in nursing assume a readiness to interpret and integrate evidence into clinical care despite continued reports of low levels of understanding and skill in this area.
Method  Perceptions of EBP were examined through a self-complete, anonymous postal survey distributed to 677 (post-registration) clinical nurses and to 1134 final year (pre-registration) nursing students during 2002 and 2003.
Results  A completed survey was returned by 126 post-registration and 257 final year nursing students (combined 21% response rate). Both pre- and post-registration nurses had a welcoming attitude towards EBP. Pre-registration nurses expressed more confidence in their EBP skills but self-rated knowledge and skill were low to moderate in both groups.
Conclusion  Nurses in Australia are clearly supportive of EBP but it is incorrect to assume that even recent graduates have a level of knowledge and skill that is sufficient to permit direct engagement in evidence implementation.
Implications for nursing management  Among a range of clinical supports, nurse managers and leaders can contribute to evidence-based health care by understanding the EBP knowledge and skills of their workforce and demanding a more practical approach in nursing education towards evidence-based guidelines and summaries appropriate to the clinical context.     

The effects of information technology on perioperative nursing

Numerous advances in technology during the past decade require that nurses not only be knowledgeable in nursing science but that they also become educated in information technology (IT). Perioperative IT has the potential to improve the quality of health care, reduce costs, decrease medication administration errors, reduce time spent on paperwork, increase management efficacy, and allow affordable access to health care. Nursing knowledge is needed for designing, implementing, and updating software, including an electronic health record (EHR). With the support of EHR data, nurses will be able to develop best practices for patient care and support research for evidence-based practice. When a standardized terminology, such as the Perioperative Nursing Data Set, is incorporated into an EHR, consistent documentation can be shared among systems. With advances in technology, perioperative nursing roles are expanding in relation to IT requirements and nurses are pursuing additional education. In addition to traditional methods, e-learning is an effective way to provide ongoing technological education.     

The impact of an evidence-based practice education program on the role of oral care in the prevention of ventilator-associated pneumonia.

BACKGROUND: Despite strong evidence in the literature on the role of oral care in the prevention of ventilator-associated pneumonia (VAP), nurses continue to view oral care as a comfort measure with low priority and utilise foam swabs rather than toothbrushes. Although an evidence-based oral care protocol existed and best-practice oral care tools were available, the VAP rates had not significantly decreased even though nurses reported providing oral care. OBJECTIVES: The aim of the study was to determine if an evidence-based practice (EBP) educational programme would improve the quality of oral care delivered to mechanically ventilated patients; thereby, reducing the VAP rate. RESULTS: Improvement in oral health was demonstrated by a decrease in median scores on the Oral Assessment Guide (pre (11.0), post (9.0)). A t-test analysis revealed a statistically significant difference (p=0.0002). The frequency of oral care documentation also improved as demonstrated by a positive shift to the more frequent timeframes. The VAP rates have decreased by 50% following the EBP education intervention. CONCLUSIONS: The implementation of an EBP educational programme focused on patient outcome rather than a task to be performed improved the quality of oral care delivered by the nursing staff.     

Evaluation of the adherence to nursing care protocols in a district

An experience of construction and implementation of nursing care protocols and procedures for district nurses is described. A course was offered to all the district nurses, where the indications for the nursing care of some common patients' problems (pressure sores management, mobilization of the stroke patient, the management of patients in pain; the nursing care to stoma patients etc.) were presented. After having compared their work habits with the indications derived from the literature, the nurses were asked to produce protocols and procedures for the problems addressed during the course. The protocols were revised by experts and formally adopted by the responsible of the District, printed in a booklet and mailed with an official letter, to all the district nurses. After two years from the mailing, the knowledge of the nurses (44) on the areas covered by the guidelines was assessed with a multiple choice questionnaire. The level of knowledge varied from 100% of correct answers for the meatal care before catheterization, to the 23% of correct answers on how to remove the needle from a port-a-cath system. The level of knowledge was dishomogenous not only across nurses but also across subjects. In fact low level of correct answers were obtained also for frequently encountered problems, such as patients with pressure sores. The possible causes of the failure of the implementation of the guidelines are discussed.     

脑卒中患者口腔健康管理的最佳证据总结

目的 总结脑卒中患者口腔健康的最佳证据,为临床实践提供依据。方法 计算机检索BMJ Best Practice、美国国立指南库、加拿大安大略注册护士协会、国际指南协作网、苏格兰院际指南网、Cochrane Library、JBI循证卫生保健中心数据库、英国国家卫生与临床优化研究所、PubMed、中国知网、CBM、万方数据库的所有关于脑卒中患者口腔健康管理的证据,包括最佳实践信息册、临床决策、指南、系统评价、证据总结、专家共识,检索从建库至2021年6月8日。按照纳入排除标准进行筛选,由2名研究者进行独立评价,依据专家意见提取并综合证据。结果 共纳入10篇文献,其中8篇指南,2篇系统评价,从组织团队、培训教育、计划与评估、实施、特殊患者、健康宣教6个方面总结出20条脑卒中患者口腔健康管理的最佳证据。结论 临床实践中医务人员需加强口腔健康管理知识的教育培训,通过跨专业团队为患者制定口腔护理计划,动态评估患者口腔健康状况,把握口腔护理实施的时机和频率,为患者选择合适的口腔护理用具,加强特殊患者的口腔健康管理,为脑卒中患者及其照护者提供口腔健康信息支持。需结合具体临床判断及需求,有指向性地选择证据,以促进最佳证据在脑卒中患者口腔健康管理中的应用。     

Return on investment imperative: the cost of care calculator for an evidence-based practice program

The key elements of the evaluation process of an evidence-based practice (EBP) program and the infrastructure needed as identified by a large health care organization. The EBP evaluation program has 2 major elements for measuring success. The first component for evaluation is the impact on the clinical outcomes of care and the second is the fiscal implications of implementing the EBP. This article focuses on the fiscal evaluation component and describes a process to calculate the cost of care compared to before and after implementation of the EBP. The literature to support the care calculations is examined and a cost algorithm is described.     

Handling of peripheral intravenous cannulae: effects of evidence-based clinical guidelines

Aim. This study aimed at evaluating the outcome of implemented evidence‐based clinical guidelines by means of surveying the frequency of thrombophlebitis, nurses’ care, handling and documentation of peripheral intravenous cannulae. Background. Peripheral intravenous cannulae are frequently used for vascular access and, thereby, the patients will be exposed to local and systemic infectious complications. Evidence‐based knowledge of how to prevent these complications and how to care for patients with peripheral intravenous cannula is therefore of great importance. Deficient care, handling and documentation of peripheral intravenous cannulae have previously been reported. Design. A cross‐sectional survey was conducted by a group of nurses at three wards at a university hospital before and after the implementation of the evidence‐based guidelines. Method. A structured observation protocol was used to review the frequency of thrombophlebitis, the nurses’ care, handling and the documentation of peripheral intravenous cannulae in the patient's record. Results. A total of 107 and 99 cannulae respectively were observed before and after the implementation of the guidelines. The frequency of peripheral intravenous cannulae without signs of thrombophlebitis increased by 21% (P < 0·01) and the use of cannula size 0·8 mm increased by 22% (P < 0·001). Nurses’ documentation of peripheral intravenous cannula improved significantly (P < 0·001). Conclusion. We conclude that implementation of the guidelines resulted in significant improvements by means of decreased frequency of signs of thrombophlebitis, increased application of smaller cannula size (0·8 mm), as well as of the nurses’ documentation in the patient's record. Relevance to clinical practice. Further efforts to ameliorate care and handling of peripheral intravenous cannulae are needed. This can be done by means of increasing nurses’ knowledge and recurrent quality reviews. Well‐informed patients can also be more involved in the care than is common today.     

Why isn't evidence based practice improving health care for minorities in the United States?

Achieving health equity by improving the health care of all racial/ethnic groups is one of the key goals of Healthy People 2020. The implementation of evidence based practice (EBP) has been a major recommendation to achieve health equity in hopes of eliminating the subjectivity of clinical decision making. However, health disparities among racial/ethnic minorities are persistent in spite of the adoption of standardized care based on evidence.The EBP with racial and ethnic minorities is often seen as a possible cause of health and health care disparities. Three potential issues of using EBP to reduce health disparities have been identified: (1) a lack of data for EBP with ethnic/racial minority populations; (2) limited research on the generalizability of the evidence based on a European-American middle-class; and (3) sociocultural considerations in the context of EBP. Using EBP to reduce disparities in health care and health outcomes requires that nurse professionals should know how to use relevant evidence in a particular situation as well as to generate knowledge and theory which is relevant to racial/ethnic minorities. In addition, EBP implementation should be contextualized within the sociocultural environments in which patients are treated rather than solely focusing on the health problems.     

Chemical Dependency and Standardized Nursing Language

BACKGROUND. Chemical dependency (CD) documentation and nursing documentation within a hospital have differed in many ways. The organization's direction toward a multidisciplinary patient record using NANDA, NIC, and NOC standardized nursing languages (SNL) was a challenge for the CD counselors. The use of SNLs caused some discord with the counseling staff as to how a care plan could be individualized with the use of standardized language. MAIN CONTENT POINTS. The CD counselors needed to resolve some issues before the change in documentation could proceed. The words “standardized language” provoked thoughts of “cookbook” care, so the counselors needed to reconcile the use of SNLs and the ability to develop individualized treatment plans. The counselors were initially uncertain about using nursing languages to describe their practice and the minimal counseling terms within the languages. These issues were overcome by studying the languages and seeing that they did address the practice of the CD counselors even though nursing developed the SNLs. Implementation included education about NANDA, NIC, and NOC. The staff needed time to accept the need for standardized languages to enhance interdisciplinary documentation and to remove the attitude barrier of “we've always done it this way.” The next step was to create and revise care plans and documentation screens. CONCLUSIONS. The practice of providing care to patients in CD treatment is enhanced by using NANDA, NIC, and NOC because of the ability to develop a true interdisciplinary patient record, retain individualization of patient plans of care, use the outcomes to substantiate discharge status and recommendations, and assess effectiveness through use of outcome data. Pilot outcomes data indicate that CD counselors and nursing exhibit statistically significant results related to coping, decision making, knowledge: substance use control, leisure participation, psychosocial adjustment, life change, substance addiction consequences, self‐esteem, and spiritual well‐being. Future research efforts should include monitoring patient outcomes over the continuum of care. Most patients participate in an aftercare program following inpatient or outpatient treatment. It would be beneficial to follow outcomes throughout the entire course of a patient's treatment.     

The impact of workplace factors on evidence-based speech-language pathology practice for children with autism spectrum disorders

Abstract

Although researchers have examined barriers to implementing evidence-based practice (EBP) at the level of the individual, little is known about the effects workplaces have on speech-language pathologists’ implementation of EBP. The aim of this study was to examine the impact of workplace factors on the use of EBP amongst speech-language pathologists who work with children with Autism Spectrum Disorder (ASD). This study sought to (a) explore views about EBP amongst speech-language pathologists who work with children with ASD, (b) identify workplace factors which, in the participants’ opinions, acted as barriers or enablers to their provision of evidence-based speech-language pathology services, and (c) examine whether or not speech-language pathologists’ responses to workplace factors differed based on the type of workplace or their years of experience. A total of 105 speech-language pathologists from across Australia completed an anonymous online questionnaire. The results indicate that, although the majority of speech-language pathologists agreed that EBP is necessary, they experienced barriers to their implementation of EBP including workplace culture and support, lack of time, cost of EBP, and the availability and accessibility of EBP resources. The barriers reported by speech-language pathologists were similar, regardless of their workplace (private practice vs organization) and years of experience.     

Providing direct care nurses research and evidence-based practice information: an essential component of nursing leadership

staffileno b.a. & carlson e. (2010) Journal of Nursing Management  18, 84–89
Providing direct care nurses research and evidence-based practice information: an essential component of nursing leadership
Aims  This commentary describes the reasons, strategies and benefits of providing direct care nurses with research and evidence-based practice (EBP) education.
Background  A component of nursing leadership is to provide nurses opportunities for professional growth and development, yet this can be challenging during a time when resources are constrained and need to be used wisely.
Evaluation  Our research and EBP education programmes have been evaluated qualitatively, as well as by the number of research/EBP projects implemented.
Key issues  Providing direct care nurses with support and additional education empowers them to seek, critically appraise and integrate research findings into their daily patient care.
Conclusions  Direct care nurses, who participated in our programme, demonstrated a strong desire to learn about research and EBP so they could practice using evidence-based care with confidence, thus transitioning from a 'tradition-based' care approach to an evidence-based way of providing care as the standard for nursing practice.
Implications for Nursing Management  Providing a dedicated time for additional education sends a clear message that research and EBP are important elements embedded in patient care. The organisation, then, is seen as an environment that emphasizes the value of research and EBP at the unit and organisational level.     

Aged‐care nurses’ knowledge of nursing documentation: an Australian perspective

Aim. This study investigated registered nurses’ knowledge of documentation used in aged‐care nursing home facilities in Queensland, Australia. Background. The purpose of nursing documentation is to communicate health information, facilitate quality assurance and research, demonstrate nurses’ accountability and, within Australia, to support funding of residents’ care. Little is known about the relationship between RNs’ knowledge of nursing documentation, the documentation process within residential aged care and the outcomes of the documentation. Design. Cross‐sectional, retrospective design. Method. The study was conducted with a large sample of RNs (n = 360) located in 162 Queensland aged‐care facilities. Participants completed a postage‐return questionnaire in which they identified factors that influence their knowledge and understanding of documentation. Results. Participants reported that they have considerable knowledge of nursing documentation. They also indicated that they were most knowledgeable about policies on documentation and writing discharge instructions. However, their knowledge of nursing assessments ranked fifth and they were least knowledgeable about reading reports each shift. Conclusions. The modified version of Edelstein's questionnaire provided a valid and reliable instrument for measuring RNs’ knowledge of nursing documentation. A factor analysis of the 16 items in the Knowledge scale showed excellent reliability. The data indicated that RNs in aged‐care facilities have high levels of knowledge about documentation. Specific recommendations relate to the implementation of comprehensive documentation education programs that reflect the needs of organisations and the level of RNs’ skills and knowledge concerning documentation. Relevance to clinical practice. Accurate nursing documentation is relevant to residents’ care outcomes and to government funding allocations. Measuring RNs’ knowledge of nursing documentation can identify factors that impede and facilitate their documentation of care.