Perioperative nurses' attitudes toward the use of nursing diagnoses in documentation

AIM: This paper reports a study of nurses' attitudes towards the use of nursing diagnoses in perioperative documentation and the factors affecting these attitudes. BACKGROUND: There are both international and national requests for nurses to move from natural language-based narrative documentation to electronic documentation and clinical use of nursing classifications. However, nurses' attitudes toward nursing classifications have not been widely studied. METHODS: A questionnaire was distributed to a purposive sample of perioperative nurses (n = 146) who had participated in clinical testing of nursing diagnoses. The response rate was 60% (n = 87). The data were collected in 2003. RESULTS: In general, nurses' attitudes toward nursing diagnoses were positive. Those over 40 years of age who had clinical experience from 10 to 19 years, postbasic nursing education and previous knowledge of nursing diagnoses were most positive in their attitudes. However, the use of nursing diagnoses in perioperative practice was not seen as either necessary or accurate in describing patients' problems. Furthermore, the documentation of perioperative routines was seen as time-consuming and frustrating. CONCLUSIONS: Nursing classifications should be included in both preregistration nursing curricula and in-service educational programmes to ensure theoretical knowledge of and practical skills in standardized clinical languages. The perioperative nursing diagnoses should be reviewed to fit better with clinical practice. In addition, current perioperative documentation practices should be reconsidered and updated as appropriate to address clinical requirements better.