Müller-Staub Maria
Pflege PBS, Selzach, Switzerland.
Int J Nurs Terminol Classif. 2009 Jan-Mar;20(1):9-15. doi: 10.1111/j.1744-618X.2008.01108.x.
This paper aims to provide insight into nursing classifications and to report the effects of nursing diagnostics implementation. This paper summarizes the results of six studies.
Two systematic reviews, instrument development and testing, a pre-post intervention study, and a cluster-randomized trial were performed.
The NANDA International classification met most of the literature-based classification criteria, and results showed the Quality of Nursing Diagnoses, Interventions and Outcomes (Q-DIO) to be a reliable instrument to measure the documented quality of nursing diagnoses, interventions, and outcomes. Implementation of standardized nursing language significantly improved the quality of documented nursing diagnoses, related interventions, and patient outcomes. As a follow-up measure, Guided Clinical Reasoning (GCR) was effective in supporting nurses' clinical reasoning skills.
Carefully implementing classifications led to enhanced, accurately stated nursing diagnoses, more effective nursing interventions, and better patient outcomes.
Rethinking implementation methods for standardized language and using GCR is recommended. Based on the results of this study, the inclusion of NANDA International diagnoses with related interventions and outcomes in electronic health records is suggested.
本文旨在深入探讨护理分类，并报告护理诊断实施的效果。本文总结了六项研究的结果。
进行了两项系统评价、工具开发与测试、一项干预前后研究以及一项整群随机试验。
国际护理诊断协会（NANDA）分类符合大多数基于文献的分类标准，结果表明护理诊断、干预及结果质量（Q-DIO）是衡量护理诊断、干预及结果记录质量的可靠工具。标准化护理语言的实施显著提高了护理诊断、相关干预及患者结局的记录质量。作为一项后续措施，引导式临床推理（GCR）在支持护士临床推理技能方面是有效的。
谨慎实施分类可提高护理诊断的准确性、增强护理干预效果并改善患者结局。
建议重新思考标准化语言的实施方法并使用GCR。基于本研究结果，建议将国际护理诊断协会的诊断及相关干预和结果纳入电子健康记录。
