An educational intervention impact on the quality of nursing records

ABSTRACT Objective: to evaluate the impact of an educational intervention on the quality of nursing records. Method: quasi-experimental study with before-and-after design conducted in a hospital. All the nurses in the cardiac intensive care unit of the hospital received the intervention, which consisted of weekly meetings during five months. To collect data, the instrument Quality of Diagnoses, Interventions and Outcomes was applied to the patients’ charts in two moments: baseline and after intervention. Results: the educational intervention had an impact on the quality of the records, since most of the items presented a significant increase in their mean values after the intervention, despite the low values in the two moments. Conclusion: the educational intervention proved to be effective at improving the quality of nursing records and a lack of quality was identified in the evaluated records, revealed by the low mean values and by the weakness of some questions presented in the items, which did not present a significant increase. Therefore, educational actions focused on real clinical cases may have positive implications for nursing practice.

and further improve the scientific bases associated to practice. Thus, the present study was designed to assess the impact before and after an educational intervention on the quality of nursing records.

Method
Quasi-experimental study with before-and-after design, conducted in a philanthropic hospital complex in the South Region of Brazil, with beds available for the  The nursing records included were not computerized, they did not use standardized language and they were chosen for convenience, that is, all the nursing records registered by the nurses, in agreement with the collection instrument and available during the collection period were included. The nursing records contained information about hospitalized patients who stayed for at least 48 hours in the unit and had their medical record, history, evolutions and nursing prescriptions recorded during a minimum period of four days. The evaluation started in the first record (admission or first evolution). This period is determined according to the recommendations of the Quality of Diagnosis, Interventions and Outcomes (Q-DIO) (7)(8) .
There was no collection of patient information, such as age or diagnosis, and there were no interviews, since those were not the focus of the study or part of the instrument items. No exclusion criteria were adopted in this study.
The nursing records selected for convenience were assessed by applying the Q-DIO instrument in two moments: baseline (data collection 1), applied before the intervention and at the second data collection, five months after the intervention.
The purpose of the Q-DIO Brazilian version is to evaluate the quality of the documentation of nursing diagnoses, interventions and results. It can be used for electronic or paper records and for nursing records with or without standardized language. This instrument was developed and validated in 2007 and published in 2009 by researchers from Switzerland, the Netherlands and the United States of America (7) .
The Q-DIO version for use in Brazil has been published recently (8) . The instrument is a Likert scale composed of 29 items divided in four concepts: nursing diagnoses as process (11 items), nursing diagnoses as product (eight items), nursing interventions (three items) and nursing outcomes (seven items). The scores range from 0 to 2 for all items, 0 being undocumented, 1 partially documented and 2 fully documented (7)(8) .

Intervention
The intervention consisted of weekly meetings lasting one and a half hours, during five months, with a total of 30 hours in 20 meetings.

Data analysis
The data were organized and analyzed using the program Statistical Package for the Social Sciences (SPSS). Continuous variables were described based on mean and standard deviation. The categorical variables were described with absolute and relative frequencies.
The pre and post-intervention periods were compared by the Student's t-test. The choice for this test considered the evaluation of the data from the normality test. The results were considered statistically significant if p <0.05, with a 95% confidence interval.

Ethical Considerations
The

Results
Records of 30 patients were evaluated before and after the intervention. The results presented in Tables 1   to 4 Table 1 shows the values of items included in the concept Nursing Diagnoses as Process. It should be noted that, for item 7, there was no result in the calculation because the value remained zero in the two moments. In the remaining items, except 8 and 9, there was a statistically significant increase. Table 2 presents the values of the items included in the concept Nursing Diagnoses as Product. It should be noted that for items 12, 16, 18 and 19 there was no statistically significant increase. Table 3 shows the values of the items included in the concept Nursing Interventions. It should be noted that only item 20 presented no statistically significant increase.
All the items from the concept Nursing Outcomes displayed in Table 4 presented a statistically significant increase, except for item 23.   Linch GFC, Lima AAA, Souza EN, Nauderer TM, Paz AA, Da Costa C.

Discussion
The results demonstrated the effectiveness of the intervention, the lack of quality of the records assessed, Studies have demonstrated that education-focused interventions addressing the nursing process can improve the quality of nursing records (5)(6) . A quasi-experimental study conducted in a developing country evaluated 40 nurses using a five-day workshop (with concepts for documentation and use of standardized language). In this study, our researchers identified that the combination of education on the use of nursing diagnoses, standardized nursing languages and standardized nursing care plans can improve the documentation of care (6) . Another study, carried out in Switzerland, assessed the effect of Guided Clinical Reasoning as a method to improve the quality of records with the implementation of electronic documentation (5) . In both studies, the Q-DIO instrument was used for evaluation before and after it (5)(6) .
In the present study, Table 1  The information regarding hobbies and leisure activities is assessed in item 8, which presents a small variation before and after the intervention.
Considering that the patients, whose nursing records were analyzed were hospitalized in a cardiac intensive care unit, information on sexual life, hobbies and leisure are potentially relevant, as patients will need postdischarge instructions for their rehabilitation. From this perspective, the collection of nursing record data will contribute to the processes of decision making and nursing care plans (2) .
Item 9 presents a question considered as fundamental in care: contact information of relatives or significant others. However, the nurses in the present study have not been recording this piece of information.
In general, nurses have used the nursing record partially, prioritizing the collection of data regarding some human needs to the detriment of others, with emphasis on biological aspects, and even failing to complete patient and professional identification data. This contributes to the fragmentation of the care provided and hinders the delivery of a more individualized care (9) .
The analysis of the concept Diagnosis as Product found no significant increase in the items 12, 16, 18 and 19.
Items 12 and 16 can be discussed under the same perspective, since both address issues fundamental for Rev. Latino-Am. Enfermagem 2017;25:e2938.
nursing care and documentation: the description of the problem and the signs/symptoms. However, these items would only receive maximum scores if their records were in accordance with NANDA-I (8) .
A systematic review with the main objective of evaluating the studies and evidences produced according to the five taxonomies validated by the American Nursing Association (ANA) demonstrated that the NANDA-I taxonomy predominates in studies developed worldwide, as well as in studies with higher evidence level (4) . Another study compared the quality of nursing records that used NANDA-I and International Classification for Nursing Practice (ICNP) using the Q-DIO instrument. The study identified that the hospital that used NANDA-I in the records presented a better quality nursing documentation than the other hospital, which used ICNP (10) .
Items 18 and 19 are fundamental, since they address the issue of nursing goals. In the present study, these items did not show significant improvement and also presented values very close to zero, meaning there were no records of nursing goals. Thus, in addition to the fact that nurses did not register those topics, they also failed to describe specific nursing goals for the problems or even achievable objectives through the registered intervention. The nurse will always have a goal already set by the work process when facing a nursing problem. However, the nurses rarely document the goal of the interventions (daily activities). A recent study was developed to assess the records of patients admitted in the medical clinic of a Brazilian teaching hospital. It revealed that, despite the fact the records were in compliance with the norms of the Regional Nursing Council, there were significant flaws related to medical history, physical examination, absence of date or time, blank spaces, spelling errors and non-standard abbreviations (11) . Therefore, it is worth emphasizing that investments in permanent and continuing education are necessary not only to adjust the work process through the systematization of nursing care, but also to find the factors or conditions that represent difficulties or solutions for the production of adequate nursing records.
A Norwegian study pointed out some weaknesses of electronic health records, even among those implemented more than 15 years ago, highlighting: lack of accuracy and quality, complicated documentation process, competing interests and lack of functionalities (12) .
On the other hand, another study that documented the nursing process in six German hospitals found as the main barriers: lack of motivation, insufficient technology for data collection at the bedside, low financial benefit at a high cost, failures or insufficient technology and lack of knowledge of (on) the programs (13) .
In the present study, item 20, which addresses naming and evaluation of the interventions and its accordance with the Nursing Interventions Classification Regarding the concept Nursing Outcomes, only item 23 did not present significant improvement. However, it should be noted that the item already had a high value, and came close to being classified as fully documented.
This item represents an ideal condition of care, and the evaluation/change of diagnoses daily or shift to shift is a fundamental part of the continuity of care.
A study that assessed nursing records and their implications on quality of care pointed out that the correct filling up of medical records from admission to discharge allows the nurse auditor, for example, to analyze the processes based on the hospital accreditation standards and document the indicators in which failures are found.
Thus, it was possible to verify how the nursing records reflected the quality of the nursing care delivered to the patient and the continuity of the care provided by the nursing team (14) .
A study carried out in two hospitals with 843 nursing records evidenced that the records are deficient, do not portray the patient's reality or the nursing care provided and do not contribute to the development of the nursing process. These data demonstrate that, in professional practice, nursing care is not always properly documented (15) . Also, when assessing continuity of care, the study found differences between the two hospitals surveyed (15) : in one, there was no logical sequence of information between one registry or another system Linch GFC, Lima AAA, Souza EN, Nauderer TM, Paz AA, Da Costa C.
which would allow the evaluation of the patient's evolution by any health professional; in the other, 100% of the analyzed records presented continuity in the patient information, allowing the evaluation of the evolution of the clinical conditions (15) .
Thus, different studies have demonstrated weaknesses in the nursing documentation process (9,11,(14)(15) . However, other studies point to educational interventions allied to the use of taxonomies and electronic records as a way to improve the quality of nursing records (5)(6) .

Final considerations
The educational intervention proved to be effective at improving the quality of nursing records. Therefore,