Effect of an educational program on the quality of Nursing Process recording

Quasi-experimental study comparing the quality of records in medical charts according to the version adapted for use in Brazil of the instrument Quality of Nursing Diagnoses, Interventions and Outcomes. The instrument was applied before and after four educational meetings with nurses of the clinic units of a hospital, conducted between 2015 and 2016. The intervention was based on the use of an instrument with standardized language systems for diagnoses, interventions and outcomes, discussed based on real clinical situations. The data were organized and analyzed using the software Statistical Package for Social Science (SPSS), version 20.0, considering as significant p<0.05.

Results

The mean total score regarding the quality of nursing records presented significant improvement (p = 0.003), and the dimensions “Nursing Diagnoses as Process”, “Nursing Diagnoses as Product” and “Nursing Outcomes” presented improvement, but their scores remained low.

Conclusion

The intervention was effective in improving the quality of nursing records, proving the need for educational programs for the implementation of standardized language systems in hospital practice, which should guide the diagnostic reasoning and the decision-making process of nurses.

Nursing Process; Nursing Records; Education, nursing

Dimensions of the Q-DIO (Brazilian version)	Pre-Intervention	Post-intervention	p-value
“Nursing Diagnoses as Process”*	1.0 (0-1.5)	6.0 (0-7.0)	0.012†
“Nursing Diagnoses as Product”*	2.0 (1.0-4.0)	7.0 (3.5-11.5)	0.006†
Nursing Interventions *	3.0 (3.0-3.0)	3.0 (3.0-3.0)	0.157†
Nursing Outcomes *	0 (0-1.5)	4.0 (0.5-6.0)	0.027†
Total score ‡	8.3±4.6	18.3±10.0	0.003§

Items	Pre-intervention ^*	Post-intervention ^*	p-value†
“Nursing Diagnoses as Process”
1. Actual situation leading to the hospitalization	0 (0-1)	1 (0-2)	0.62
2. Anxiety and worries related to hospitalization, expectations and desires about hospitalization	0 (0-0)	1 (0-2)	0.015
3. Social situation and living environment/ circumstances	0 (0-0)	0 (0-1)	0.038
4. Coping in the actual situation/with the illness	0 (0-0)	0 (0-1)	0.23
5. Beliefs and attitudes about life (related to the hospitalization)	0 (0-0)	0 (0-0)	0.317
6. Information of the patient and relatives/ significant others about the situation	0 (0-0)	0 (0-1)	0.84
7. Intimacy, being female/male	0 (0-0)	0 (0-0)	0.317
8. Hobbies, activities for leisure	0 (0-0)	0 (0-0)	1
9. Significant others (contact persons)	0 (0-0)	0 (0-0)	0.564
10. Activities of daily living	0 (0-0)	0 (0-0)	0.157
11. Relevant nursing priorities according to the assessment	0 (0-1)	0 (0-0)	0.059

“Nursing Diagnoses as Product”

12. Nursing problem/nursing diagnosis label is documented	1 (0.5-1)	1 (0.5-2)	0.157
13. Nursing diagnosis label is formulated and numbered according to NANDA-International	1 (0-1)	1 (0.5-1)	0.157
14. The aetiology is documented	0 (0-1)	1 (0.5-1.5)	0.014
15. The aetiology is correct and corresponding to the Nursing Diagnosis	0 (0-0.5)	1 (0.5-2)	0.005
16. Signs and symptoms are formulated	0 (0-1)	1 (0.5-1.5)	0.004
17. Signs and symptoms are correctly related to the Nursing Diagnosis	0 (0-0.5)	1 (0.5-1)	0.005
18. The nursing goal relates/corresponds to the Nursing Diagnosis	0 (0-0.5)	0 (0-1)	0.157
19. The nursing goal is achievable through nursing interventions	0 (0-1)	1 (0-1.5)	0.102
Nursing Interventions
20. Concrete, clearly named Nursing Interventions according to NIC are planned	1 (1-1)	1 (1-1)	1
21. The Nursing Interventions effect the aetiology of the Nursing Diagnosis	1 (1-1)	1 (1-1)	1
22. Nursing Interventions carried out are documented	1 (1-1)	1 (1-1)	0.157
Nursing Outcomes
23. Acute, changing diagnoses are assessed daily or from shift to shift	0 (0-0)	1 (0-1.0)	0.157
24. The Nursing Diagnosis is reformulated	0 (0-0)	0 (0-0)	0.655
25. The Nursing Outcome is documented	0 (0-0)	1 (0-1.0)	0.059
26. The Nursing Outcome is observably/ measurably documented according to NOC	0 (0-0)	0 (0-0)	0.05
27. The Nursing Outcome shows improvement	0 (0-0)	1 (0-1.0)	0.008
28. There is a relationship between Nursing Outcomes and Nursing Interventions	0 (0-0)	1 (0-1.0)	0.02
29. Nursing Outcomes and Nursing Diagnoses are internally related	0 (0-0)	1 (0-1.0)	0.059

Escola Paulista de Enfermagem, Universidade Federal de São Paulo R. Napoleão de Barros, 754, 04024-002 São Paulo - SP/Brasil, Tel./Fax: (55 11) 5576 4430 - São Paulo - SP - Brazil
E-mail: actapaulista@unifesp.br

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[1] Corresponding author Ana Carla Dantas Cavalcanti E-mail: anacarladc.uff@gmail.com