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.     

Registered nurse incentives to return to practice in the United States

This US study uniquely listened to registered nurses with current licenses who do not work as nurses or are unemployed. An electronic survey was advertised in 13 Boards of Nursing newsletters. Investigated was why nurses left nursing, what would entice them to return to nursing, and what skill review is essential to competent and confident return to nursing practice. Herzberg's theory was used to study factors affecting registered nurses' decision to practise nursing. Data were analysed using SPSS and manifest content analysis. Nurses ( n  = 127) identified various work conditions as the primary reasons for leaving nursing. Work condition improvement, recognition of one's work, opportunities for professional growth and family needs consideration were identified as key enticing factors for returning to nursing. Many respondents identified needing review of medicines, intravenous skills, new technologies and a refresher course. Acting on their voiced concerns will enhance nurse recruitment and retention.     

Nurses' experiences of caring encounters with older people living in Swedish nursing homes

Aim. The aim of the study was to describe and interpret the meaning of nurses' experiences of caring encounters with residents in nursing homes. Background. Life for residents in nursing homes can be characterized as a process of decreased physical and psychological resources. Therefore, encounters with nurses are important activities for providing meaning and security for the residents. Research in this field has previously focused on communication, attitudes and job satisfaction, but gives limited knowledge about what the human encounters in this context mean for the nurses. Method. A hermeneutic method was used in this study. Interviews were conducted with 14 nurses from two nursing homes about their experiences of caring encounters. The transcribed interview texts were interpreted as a whole. Results. In the interpretation of the text concerning the meaning of nurses' experiences of encounters with resident's four themes and 11 subthemes emerged. The comprehensive interpretation mainly showed possible ways available being present, being significant and being aware of opportunities for the nurse to find meaning in the encounter with the resident, but impossible ways as being inadequately were also revealed. Conclusion. This study shows the importance of caring encounters between nurses and residents in nursing homes. The good encounters provide various possible ways for nurses to find meaning and a sense of communion with residents. However, bad encounters, described as being inadequate, were found to inhibit nurses from finding meaning in their encounters with residents. Relevance to clinical practice. Meeting the needs of older people in nursing homes requires special knowledge about the importance of the caring encounter. Therefore, nurses in this care context need supervision and continuous education in order to gain relevant knowledge about the meaning of caring encounters for themselves and residents.     

Coming and staying: a qualitative exploration of Registered Nurses' experiences working in nursing homes

Aim. This paper reports on a qualitative study that explored the reasons why Registered Nurses (RNs) chose to work in nursing homes in Southern Ontario, Canada and what factors attracted them to remain.
Background.  There is a paucity of information about factors associated with the recruitment and retention of RNs within long-term care (LTC) in Canada. As the population of older people is growing in Canada and elsewhere, it is essential that we better understand what attracts RNs to work and remain in this setting.
Design and method. A case study approach was used in this study of nine RNs working in three nursing homes. Data were collected through in-depth interviews.
Findings. Six sub-themes were identified: 'Job of Choice', 'Job of Convenience', 'Caring for the Residents', 'A Supportive Environment', 'Heavy Workload' and 'Supervisory Role of the RN'.
Conclusion. Nurses chose to work in the nursing home because it was a 'Job of Convenience'. However, characteristics of the organizational environment played a major role in their remaining. Also, the caring relationship with residents played a role in the nurses remaining in this setting.
Relevance to clinical practice. Strategies are provided that nurse managers may consider when planning recruitment and retention activities for LTC settings.     

The relationship between research and the nursing process in clinical practice

The nursing process was originally adopted by the North American nursing profession from the general systems theory (GST) and quickly became a symbol of contemporary nursing as well as a professionalist nurse ideology. In contrast its initial introduction in the United Kingdom (UK) was not a complete success. This could be attributed to the mode of its implementation, which utilized a power-coercive change strategy, that is, comprising of imposition from above without sufficient time for education regarding its scientific and philosophical foundations. Consequently the nursing process was initially regarded as a professional and educational mandate rather than an organizational component of nursing care delivery. It has been maintained that the theoretical basis from which the nursing process was derived, together with the theoretical developments in diagnostic and intervention studies, has established the nursing process as a key element of the nurse's role in research, education and practice. This paper will briefly review the early theoretical developments and fate of the nursing process as a tool for clinical practice and research. It will then examine recent attempts to revitalize and modernize the theory for practice through research into nursing diagnosis.     

社区护士护理文件书写相关知识管理现状调查

目的:了解社区护理人员在家庭护理过程中护理文件书写现状。方法:采用自设问卷,对16家社区卫生服务机构94名社区护理人员进行问卷调查。结果:94例社区护士中44例(46.8%)不熟悉病历书写规范;70例(74.5%)认为病人有权复印护理记录单、医疗病历、病程记录等资料;74例(78.1%)不了解因抢救急危病人未能及时书写护理记录,应在6小时内核实后据实补记;89例(94.7%)认为试用期人员经医疗机构审核可以独立书写护理记录;15例(16.0%)不能够在完成家庭护理后即刻完成护理记录;49例(52.1%)护士在家庭护理的病人无签字能力时,经病人口头授权会让保姆代签。结论:社区护理人员医疗文书书写相关知识掌握不足,应针对家庭护理过程中如何完善护理记录的知识进行培训。     

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.     

Structure and content in Norwegian nursing care documentation.

In 1994, the Norwegian Board of Health (NBH) published recommendations for nursing care documentation. The two-fold purpose of the present study was to see if 5 wards in 2 Norwegian hospitals fulfilled the proposed NBH recommendations and guidelines regarding documentation, and to evaluate them in terms of the proposed structure and key words of the VIPS model. Results showed that all nursing records (n = 55) had an admission assessment. A nursing care plan was present in 62% of the records. Nursing goals were lacking in the remaining 38%, diagnosis and planned interventions were absent in 18%, and 45% of the diagnoses lacked information concerning patient progress or outcome. The nursing care plans were updated in only 40% of the records and discharge notes were present in 35%, confirming that NBH recommendations were not met in this sample. The key words of the VIPS model covered all information present in the records, and high interrater reliability was obtained for the majority of key words categorized by two independent researchers. It is suggested that the VIPS model components and key words can contribute to a reliable and uniform model for nursing care documentation and enhance comprehensive and systematic documentation, which is presently lacking in Norwegian records.     

Implementation and evaluation of a nursing process support system for long‐term care: a Taiwanese study

Aims. To (1) develop and implement a Nursing Process Support System in Chinese (NPSSC) enabling computerised documentation for nursing home residents, (2) evaluate the efficiency of NPSSC, (3) assess obstacles to the use of the NPSSC and (4) assess nurse users’ satisfaction with the NPSSC. Background. Long‐term care facilities in Taiwan have been slow to computerise resident’s medical records. The development and implementation of a computerised documentation system provides a way to enhance nursing documentation in long‐term care settings and can prevent hazards that result from documentation errors. Design. Quasi‐experimental. Methods. This study used one group pre/post‐test. Five nursing homes in Taiwan were included in the study. Twenty‐seven nurses used the NPSSC to computerise 396 residents’ medical records. Using the NPSSC allowed nurses to enter health assessment data into the computer system, which automatically triggered appropriate nursing diagnoses. The NPSSC included geriatric nursing interventions and the use of alternative Chinese therapies. Results. Obstacles that hindered nurses' use of the NPSSC were identified and possible solutions to overcome these hindering factors were discussed. The use of the NPSSC significantly improved nursing documentation in that resident’s records were organised and consistent and nurses were able to complete a comprehensive care plan within 48 hours. Nurses reported a higher satisfaction in nursing documentation after the implementation of the NPSSC than previously. Conclusions. This study suggested a pathway to develop and implement a computer‐based, user‐friendly nursing documentation system for nursing homes. This study may be used as a template for implementing computerised documentation worldwide. Relevance to clinical practice. Nursing home providers may consider implementing the NPSSC to replace the traditional hand‐written documentation system. An effective use of in‐service programs within the workplace helped ease the transition from hand‐written documentation to the computer‐based NPSSC.     

Clinical leadership in contemporary clinical practice: implications for nursing in Australia

BACKGROUND: Leadership in the clinical practice environment is important to ensure both optimal patient outcomes and successive generations of motivated and enthusiastic clinicians. AIM: The present paper seeks to define and describe clinical leadership and identify the facilitators and barriers to clinical leadership. We also describe strategies to develop clinical leaders in Australia. Key drivers to the development of nursing leaders are strategies that recognize and value clinical expertise. These include models of care that highlight the importance of the nursing role; evidence-based practice and measurement of clinical outcomes; strategies to empower clinicians and mechanisms to ensure participation in clinical decision-making. KEY ISSUES: Significant barriers to clinical leadership are organizational structures that preclude nurses from clinical decision making; the national shortage of nurses; fiscal constraints; absence of well evaluated models of care and trends towards less skilled clinicians. CONCLUSIONS: Systematic, strategic initiatives are required to nurture and develop clinical leaders. These strategies need to be collegial collaborations between the academic and health care sectors in order to provide a united voice for advancing the nursing profession.     

Prerequisites and consequences of nursing documentation in patient records as perceived by a group of Registered Nurses

The issue of nursing documentation and care planning has been discussed in numerous articles, revealing barriers and few facilitators in nursing practice. Few of these articles are scientifically researched and they are often based on small samples. This study aimed to illuminate the factors that Registered Nurses (RNs) in acute care perceived as prerequisites and consequences relevant to their documentation of nursing care when using the VIPS model (VIPS is an acronym formed from the Swedish words for Well-being, Integrity, Prevention and Security). In total 377 RNs divided into two groups (Groups A and B) completed a questionnaire concerning opinions about nursing documentation. Both groups had received a 3-day course on nursing documentation based on the VIPS model. Group A had also participated in a 2-year comprehensive intervention programme. The findings showed that most participants, regardless of group, perceived nursing documentation to be beneficial to them in their daily practice and to increase patient safety, and that use of the VIPS model facilitated documentation of nursing care. The inhibitors, facilitators and consequences of nursing documentation identified here should help both RNs in practice and their leaders to be more attentive to the prerequisites needed to achieve satisfactory nursing documentation in patient records.     

Transformation of admission interview to documentation for nursing practice

The admission interview is usually the first structured meeting between patient and nurse. The interview serves as the basis for personalised nursing and care planning and is the starting point for the clinic's documentation of the patient and his course of treatment. In this way, admission interviews constitute a basis for reporting by each nurse on the patient to nursing colleagues. This study examined how, by means of the admission interview, nurses constructed written documentation of the patient and his course of treatment for use by fellow nurses. A qualitative case study inspired by Ricoeur was conducted and consisted of five taped admission interviews, along with the written patient documentation subsequently worked out by the nurse. The findings were presented in four constructed themes: Admission interviews are the nurse's room rather than the patient's; Information on a surgical object; The insignificant but necessary contact; and Abnormalities must be medicated. It is shown how the nurse's documentation was based on the admission interview, the medical record details on the patient (facts that are essential to know in relation to disease and treatment), as well as the nurse's preconception of how to live a good life, with or without disease. Often, the patient tended to become an object in the nurse's report. It is concluded that in practice, the applied documentation system, VIPS, comes to act as the framework for what is important to the nurse to document rather than a tool that enables her to document what is important to the individual patient and his special circumstances and encounter with the health system.     

Registered Nurses' perceptions of geriatric rehabilitation nursing in three Scandinavian countries

This study describes Registered Nurses' perceptions of geriatric rehabilitation nursing as well as their experiences of working in the rehabilitation of older patients in Denmark, Finland and Norway. The aim was to gain deeper insights into how Registered Nurses think about geriatric rehabilitation nursing and how their perceptions differ in these countries. The data were collected among 600 Registered Nurses using a structured questionnaire with five background items and 88 geriatric rehabilitation nursing items. The response rate was 65%. Data analysis was with SPSS statistical software. Geriatric rehabilitation nursing was experienced as something that required knowledge and experience, patience and creativity, as well as professional skills. The nurses talked with their patients about their rehabilitation goals, but not all nurses were aware of those goals. Progress in the rehabilitation process was evaluated on a daily basis and results were noted in the patients' records. The nurses motivated patients by giving them positive feedback, by preventing pain, by pausing to share with the patients their joy about progress, and by giving the patients the opportunity to cope with daily activities. The Registered Nurses in Denmark were more team oriented and they set out the goals in the patient's records more often than their colleagues did in Finland and Norway.     

护理临床实习环境的研究进展

综述了临床实习环境的概念、评估工具、国内外研究进展以及展望,旨在为今后研究临床实习环境对护生的影响提供信息和方向.