Effects on the quality of the nursing care process through an educational program and the use of electronic nursing documentation.

PURPOSE

To evaluate the effect of the educational program "Guided Clinical Reasoning" (GCR) and the introduction of an intelligent electronic nursing documentation system (e-doc) on the quality of the nursing process.

METHODS

Evaluation was conducted at three measurement points and rated with the instrument "Quality of Nursing Diagnoses, Interventions and Outcomes" (Q-DIO).

FINDINGS

GCR showed the best Q-DIO-scores. No long-term effect was found after GCR cessation. The e-doc delivered the lowest scores, while showing adequate support in using nursing diagnoses.

CONCLUSIONS

E-docs can support conducting the nursing process, but for meaningful e-doc use, clinical reasoning is essential.

IMPLICATIONS

High-quality nursing documentation requires recognition of factors obstructing or supporting nurses in the use of e-docs while conducting the nursing process.