[The congruence of nursing diagnoses, interventions, and outcomes between care observations, patient perceptions, and nursing records: a qualitative multiple case study].

UNLABELLED

The congruence of nursing diagnoses, interventions, and outcomes between care observations, patient perceptions, and nursing records: a qualitative multiple case study Background: Nurses with good decision-making competencies state more relevant and accurate nursing diagnoses, perform more effective nursing interventions, and achieve better nursing-sensitive patient outcomes. It was reported that the content of nursing records sometimes doesn't match with statements of patients and nurses.

RESEARCH QUESTION

In what extent do the recorded nursing diagnoses, interventions, and outcomes match with observed care situations and patients' statements?

METHODS

A multiple case study with structured observations, guided interviews, and document analyses was performed. The congruence of nursing diagnoses, interventions, and outcomes between the three data sources was investigated by within- and cross-case-analysis in a sample of 24 patients.

RESULTS

In total, 114 nursing diagnoses were identified of which 66 were recorded, 37 were found by observations, and 11 by patient interviews. A high congruence between the three perspectives was determined in 59 % of the recorded nursing diagnoses, in 41 % of nursing interventions, and in 33 % of nursing-sensitive patient outcomes. Almost all documented nursing diagnoses (89 %) were supported by most codes from all three sources.

CONCLUSIONS

To increase the congruence of the three perspectives, nurses' clinical decision-making competencies should be fostered, so that nurses choose more effective nursing interventions that lead to better nursing-sensitive patient outcomes. Patient participation should be fostered.