高级护理程序质量：比较国际护理实践分类法（ICNP）与国际护士会护理诊断分类（NANDA - I）及护理干预分类法（NIC）。
Advanced Nursing Process quality: Comparing the International Classification for Nursing Practice (ICNP) with the NANDA-International (NANDA-I) and Nursing Interventions Classification (NIC).
作者信息
Rabelo-Silva Eneida Rejane, Dantas Cavalcanti Ana Carla, Ramos Goulart Caldas Maria Cristina, Lucena Amália de Fátima, Almeida Miriam de Abreu, Linch Graciele Fernanda da Costa, da Silva Marcos Barragan, Müller-Staub Maria
机构信息
Graduate Program in Nursing at Federal University of Rio Grande do Sul and Hospital de Clínicas de Porto Alegre and Grupo de Estudo e Pesquisa em Enfermagem no Cuidado ao Adulto e Idoso (GEPECADI), Porto Alegre, RS, Brazil.
Universidade Federal Fluminense, Niterói, RJ, Brazil.
出版信息
J Clin Nurs. 2017 Feb;26(3-4):379-387. doi: 10.1111/jocn.13387. Epub 2016 Oct 25.
AIMS AND OBJECTIVES
To assess the quality of the advanced nursing process in nursing documentation in two hospitals.
BACKGROUND
Various standardised terminologies are employed by nurses worldwide, whether for teaching, research or patient care. These systems can improve the quality of nursing records, enable care continuity, consistency in written communication and enhance safety for patients and providers alike.
DESIGN
Cross-sectional study.
METHODS
A total of 138 records from two facilities (69 records from each facility) were analysed, one using the NANDA-International and Nursing Interventions Classification terminology (Centre 1) and one the International Classification for Nursing Practice (Centre 2), by means of the Quality of Diagnoses, Interventions, and Outcomes instrument. Quality of Diagnoses, Interventions, and Outcomes scores range from 0-58 points. Nursing records were dated 2012-2013 for Centre 1 and 2010-2011 for Centre 2.
RESULTS
Centre 1 had a Quality of Diagnoses, Interventions, and Outcomes score of 35·46 (±6·45), whereas Centre 2 had a Quality of Diagnoses, Interventions, and Outcomes score of 31·72 (±4·62) (p < 0·001). Centre 2 had higher scores in the 'Nursing Diagnoses as Process' dimension, whereas in the 'Nursing Diagnoses as Product', 'Nursing Interventions' and 'Nursing Outcomes' dimensions, Centre 1 exhibited superior performance; acceptable reliability values were obtained for both centres, except for the 'Nursing Interventions' domain in Centre 1 and the 'Nursing Diagnoses as Process' and 'Nursing Diagnoses as Product' domains in Centre 2.
CONCLUSION
The quality of nursing documentation was superior at Centre 1, although both facilities demonstrated moderate scores considering the maximum potential score of 58 points. Reliability analyses showed satisfactory results for both standardised terminologies.
RELEVANCE TO CLINICAL PRACTICE
Nursing leaders should use a validated instrument to investigate the quality of nursing records after implementation of standardised terminologies.
目的与目标
评估两家医院护理文件中高级护理流程的质量。
背景
世界各地的护士使用各种标准化术语，无论是用于教学、研究还是患者护理。这些系统可以提高护理记录的质量，实现护理连续性、书面沟通的一致性，并提高患者和医护人员的安全性。
设计
横断面研究。
方法
使用诊断、干预和结果质量工具，对来自两家机构的138份记录（每家机构69份记录）进行分析，一家使用国际护理诊断协会和护理干预分类术语（中心1），另一家使用国际护理实践分类（中心2）。诊断、干预和结果质量得分范围为0 - 58分。中心1的护理记录日期为2012 - 2013年，中心2的护理记录日期为2010 - 2011年。
结果
中心1的诊断、干预和结果质量得分为35.46（±6.45），而中心2的诊断、干预和结果质量得分为31.72（±4.62）（p < 0.001）。中心2在“护理诊断作为过程”维度得分较高，而在“护理诊断作为产物”、“护理干预”和“护理结果”维度，中心1表现更优；两个中心均获得了可接受的可靠性值，但中心1的“护理干预”领域以及中心2的“护理诊断作为过程”和“护理诊断作为产物”领域除外。
结论
中心1的护理文件质量更优，尽管考虑到最高潜在分数为58分，两家机构的得分均处于中等水平。可靠性分析表明两种标准化术语均取得了令人满意的结果。
与临床实践的相关性
护理领导者应使用经过验证的工具，在实施标准化术语后调查护理记录的质量。
Zotero 插件