Nool Irma, Tupits Mare, Parm Lily, Hõrrak Eha, Ojasoo Merle
Senior Lecturer at the Chair of Nursing, Tallinn Health Care College, Tallinn, Estonia.
Junior Lecturer at the Chair of Nursing, Tallinn Health Care College, Tallinn, Estonia.
Int J Nurs Knowl. 2023 Jan;34(1):4-12. doi: 10.1111/2047-3095.12363. Epub 2022 Mar 28.
The aim of the paper is to compare the quality of nursing documentation in the Children's Hospital before and after the NANDA-I nursing diagnoses training.
Research employed the interventional study design, and pre-post study design. Before and after the NANDA-I nursing diagnoses training, 50 nursing records were analyzed in the interventional pre-post study, using D-Catch instrument.
The most often documented problem-centered nursing diagnosis before training was anxiety and after the training, hyperthermia. The most common risk diagnoses before and after the training was risk of infection. Before the training, one health promotion diagnosis was determined in the nursing records, and after the training the number increased to four. The highest value was given to readability of the nursing documentation both before and after the training. The lowest score before the training was given to the quality determiners of the accurate nursing diagnoses and after the training given to the determiners of the results' quantity. The sum score of documenting the nursing interventions was the most inconsistent before the training and after the training. The most consistent was the readability of the nursing records before and after the training. Statistically significant differences in the improvement of quality were revealed in all areas except for the readability of the nursing documentation and the quantity of nursing assessment.
The results of the study revealed that following the training, the quality of nursing documentation improved, the wording of the nursing diagnoses improved, and the number of accurate nursing diagnoses had increased.
Results of the research provide an overview of the importance of the training in improving the quality of nursing documentation and aid the educators in planning the trainings, focusing more on the challenges in the documentation.
本文旨在比较南丁格尔护理诊断协会（NANDA - I）护理诊断培训前后儿童医院护理文件记录的质量。
本研究采用干预性研究设计和前后对照研究设计。在NANDA - I护理诊断培训前后，使用D - Catch工具对50份护理记录进行了干预性前后对照研究分析。
培训前记录最频繁的以问题为中心的护理诊断是焦虑，培训后是体温过高。培训前后最常见的风险诊断是感染风险。培训前，护理记录中确定了一项健康促进诊断，培训后这一数字增加到四项。培训前后对护理文件记录的可读性评价最高。培训前对准确护理诊断的质量决定因素评分最低，培训后对结果数量的决定因素评分最低。培训前后护理干预记录的总分最不一致。培训前后护理记录的可读性最一致。除护理文件记录的可读性和护理评估的数量外，所有领域在质量改善方面均显示出统计学上的显著差异。
研究结果表明，培训后护理文件记录的质量有所提高，护理诊断的措辞有所改进，准确护理诊断的数量有所增加。
研究结果概述了培训对提高护理文件记录质量的重要性，并有助于教育工作者规划培训，更多地关注文件记录中的挑战。
