Improved quality of nursing documentation: results of a nursing diagnoses, interventions, and outcomes implementation study

Int J Nurs Terminol Classif. 2007 Jan-Mar;18(1):5-17. doi: 10.1111/j.1744-618X.2007.00043.x.

Abstract

Purpose: To evaluate the impact of the quality of nursing diagnoses, interventions, and outcomes in an acute care hospital following the implementation of an educational program.

Method: In a pretest-posttest experimental design study, nurses from 12 wards of a Swiss hospital received an educational intervention--an introductory class and consecutive classes, using a case discussion method--to implement nursing diagnoses, interventions, and outcomes. Two sets of 36 randomly selected nursing records were evaluated before and after implementation. The quality of documented nursing diagnoses, interventions, and nursing-sensitive patient outcomes was assessed by 29 Likert-type items with a 0-4 scale instrument, called Quality of Nursing Diagnoses, Interventions, and Outcomes (Q-DIO) and tested using t-tests.

Findings: Significant enhancements in the quality of documented nursing diagnoses, interventions, and outcomes were found following the implementation of a planned educational program.

Conclusions: The implementation of NANDA, NIC, and NOC (NNN) nursing diagnoses, interventions, and outcomes led to higher quality of nursing diagnosis documentation, etiology-specific nursing interventions, and nursing-sensitive patient outcomes.

Implications for nursing practice: Educational measures support nurses to improve documentation of diagnoses, interventions, and outcomes. The Q-DIO is a useful audit tool.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Documentation / standards*
  • Education, Nursing, Continuing / organization & administration*
  • Humans
  • Inservice Training / organization & administration
  • Medical Records Systems, Computerized
  • Nursing Audit
  • Nursing Diagnosis / organization & administration*
  • Nursing Education Research
  • Nursing Evaluation Research
  • Nursing Records / standards*
  • Nursing Staff, Hospital / education*
  • Outcome Assessment, Health Care
  • Patient Care Planning / organization & administration
  • Program Evaluation
  • Switzerland
  • Total Quality Management
  • Vocabulary, Controlled