General Introduction

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Chapter 1

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dr. van der Schans prof.General Introduction Katholieke Universiteit Leuven Group Biomedical Sciences Faculty of Medicine School of Public Health Center for Health Services and Nursing Research Accuracy of nursing diagnoses: knowledge. knowledge sources and reasoning skills Wolter Paans Jury: Promotor: Copromotor: Chair: Jury Members: prof. Cees P. dr. dr. Anna Ehrenberg prof. Philip Moons prof. Benoit Nemery de Bellevaux prof. dr. dr. dr. dr. Walter Sermeus prof. Theo van Achterberg prof. Gerrit Storms prof. dr. Peter Donceel Thesis submitted to obtain the degree of Doctor in Biomedical Sciences 3 .

recording.Chapter 1 This thesis was funded by the Hanze University of Applied Sciences. Utrecht. the Netherlands. The use of the reproduction of the image as front cover picture of this thesis is licensed by The Bridgeman Art Library. Copyright © 2011 by Wolter Paans. Groningen and Brink&. electronic or mechanical. Front cover picture: Alexis de Broca (French. Walter Sermeus. The manuscript is printed by Drukkerij G. All rights reserved. No part of this book may be reproduced or transmitted in any form by any means. without permission from the authors. 1868 – 1948). Cees van der Schans. A l’ hôpital. la pártie d’ échecs (1917). van Ark. including photocopying. Colour litho in private collection. Haren. Roos Nieweg. or by any other information storage and retrieval system. London (KW359947). the Netherlands ISBN-NUMBER: 978-90-77724-11-8 NUR: 897 4 .

Maar zeker ook als collega met wie ik frequent inhoudelijke discussies voerde die ondermeer tot nieuwe inzichten en nauwkeurigere omschrijvingen leidde. Ook dank ik de volgende leden van de examencommissie voor de constructieve commentaren ter verbetering van dit werk. Nico Oud. dr. Zij heeft als medeonderzoeker zowel inhoudelijk als organisatorisch substantieel bijgedragen aan het onderzoek. prof. zowel op kantoor van Brink& in Rotterdam en Utrecht als op de Hanzehogeschool te Groningen. Walter Sermeus en mijn copromotor prof. zijn bijdrage is zeer ondersteunend geweest om de verslaglegging te verbeteren. Dr.General Introduction Dankwoord Mijn dank gaat uit naar mijn promotor prof. Marja Zwaan. Theo van Achterberg. 5 . Wim Krijnen dank ik voor zijn adviezen op statistisch en op tekstueel vlak. prof. ondermeer voor haar kritische en deskundige kijk op door mij aangeleverde teksten en haar buitengewoon waardevolle bijdrage als coauteur. verpleegkundig experts en adviseurs. prof. Benoit Nemery de Bellevaux. dr. Philip Moons en prof. vanuit bureau Brink& financieel en organisatorisch is bijgedragen aan het onderzoek. dr. dr. dr. Van hen beiden heb ik zeer veel geleerd. prof. die een bijdrage hebben geleverd aan het onderzoek dank ik hierbij met nadruk. uitermate deskundig en verliep daarbij altijd aangenaam. We werkten samen met teamleden van Brink& en met onderzoeksassistenten in de klinieken die we bezochten. Gerrit Storms voor hun meedenken en opbouwende kritiek gedurende het tot stand komen van dit werk. Jan Gulmans dank ik voor zijn reflectie op verschillende manuscripten en de waardevolle literatuur. Hilde te Riet en de andere inhoudsdeskundigen. Peter Donceel en prof. Daarbij hebben zij het mogelijk gemaakt dat. Cees van der Schans. Marleen Vermeulen ben ik veel dank verschuldigd. Hun begeleiding was onontbeerlijk. gedurende de gehele looptijd. Eveneens gaat mijn dank uit naar Joost van Daalen en Hans Niendieker. Dr. dr. De samenwerking met Marleen was altijd plezierig. Ik dank de leden van de begeleidingscommissie. Het werken aan de Katholieke Universiteit Leuven en de contacten daar hebben mij erg geholpen met het uitvoeren van het onderzoek. dr. veelal van eigen hand. Tanja Stam. Anna Ehrenberg. Roos Nieweg ben ik zeer erkentelijk. dr. Zij zijn de initiatoren van het onderzoek en hebben mij het vertrouwen in de uitvoering ervan gegeven. Het team van Brink& waaronder Erwin Raemakers.

Elvira de Vries. Steven Smits en Bert Jansen hebben een bijdrage geleverd waardoor de werving van deelnemers aan het onderzoek vergemakkelijkt werd en hen dank ik daar zeer voor. die mij geheel belangeloos toegang verschaften tot hun kliniek. Op locatie hielpen ze mij op vele manieren om het onderzoek uit te kunnen voeren.Chapter 1 I would like to thank dr. voor. Zij zijn bereid geweest uitgebreide casuïstiek en script in te studeren en te oefenen om vervolgens met mij door het land te reizen om de rol van simulatiepatiënt in de verschillende klinieken te vervullen ten einde de experimenten goed te kunnen uitvoeren. waaronder zorgmanagers en afdelingshoofden. De verpleegkundigen die aan het onderzoek hebben deelgenomen wil ik hierbij veel dank betuigen. Mijn collega’s. Ik heb bemoediging en collegialiteit van hen ervaren. Freija Noest en Jeanet Klinkert. paneldiscussies. Janny Bijma en Greet Buiter wil ik mijn dank betuigen omdat zij mij de afgelopen periode als mijn leidinggevenden van de Academie voor Verpleegkunde van de Hanzehogeschool het vertrouwen schonken. 6 . Judith van der Boom en Jacqueline de Leeuw dank ik voor de administratieve -en regelzaken die zij voor mij uitvoerden. Woorden van dank gaan uit naar de acteurs. Maria Müller-Staub and Matthias Odenbreit for sharing with me their knowledge. Ze waren bereid zich vaak. insight and valuable scientific experiences in the field of nursing diagnoses and for their kind hospitality during work visits at their home in Switzerland and throughout conferences. proefpresentaties en proefverdedigingen. hebben zich naar mij de afgelopen jaren geïnteresseerd en betrokken betoond. Mijn dank gaat uit naar alle directies en leidinggevenden. Liesbeth Wolda en Sophie de Kam ben ik beiden zeer erkentelijk voor het nauwgezette zoekwerk dat zij voor mij hebben verricht en het advies dat zij mij verleenden als vakkundige bibliothecaressen. Daarbij hebben verschillende collega’s waardevolle bijdragen geleverd aan casusbeoordelingen. zowel binnen het lectoraat Transparante Zorgverlening als binnen de Academie voor Verpleegkunde van de Hanzehogeschool. Ineke Kuil. Hiervoor ben ik hen veel dank verschuldigd. of na hun dienst voor het onderzoek nog enkele uren geestelijk in te spannen. Zij zijn een cruciale schakel geweest om tot uitvoering van het onderzoek te kunnen komen. mij middelen ter beschikking stelden en voorwaarden creëerden zoals het beperken en gunstig laten roosteren van mijn onderwijsverplichtingen opdat ik efficiënt met de beschikbare tijd kon omgaan. Zij hebben hun taak professioneel ingevuld en het was een groot plezier om met hen samen te werken. Verpleegkundigen in verschillende klinieken hebben zich veel moeite getroost om invulling te geven aan de vragen die hen gesteld werden gedurende het onderzoek.

Zij hebben extra veel energie en vrije tijd gestoken in de eerste fase van het onderzoek. Mede door hun inzet. zowel aan het dossieronderzoek als aan de experimenten. zijn rol is onuitsprekelijk. Chris. Veerle. Mijn vader. 7 . Dit genoegen met jou te delen is een dagelijks geluk dat je me ten volle hebt gegund door mij op alle fronten te steunen en je naast je baan altijd volledig voor ons gezin in te zetten. dank ik met nadruk. Door jullie verliep het werk nog plezieriger. Eva en Wout. Met name wil ik Anita Berendsen en Selinde de Kok danken. heeft met het overbrengen van zijn interesse en waardering voor de wetenschap dit proefschrift mede mogelijk gemaakt. Ik wil mijn moeder en mijn vader buitengewoon bedanken voor hun grote interesse. jullie zijn mij enorm tot steun geweest in wie jullie zijn en in wat jullie doen. door jou toedoen heb ik aan dit werk enorm veel vreugde beleefd. betrokkenheid en steun. Zij hebben zich in hun afstudeerfase volledig ingezet en zich daarbij flexibel en leergierig betoond. talent en betrokkenheid is de uitvoering vanaf het begin goed verlopen. die onverwacht op 28 maart 2010 overleed.General Introduction De studenten Verpleegkunde van de Hanzehogeschool die een bijdrage geleverd hebben aan de organisatie en uitvoering van het onderzoek.

Prevention. and Outcomes instrument Quality Of nursing Diagnosis instrument Strengthening the Reporting of observational Studies in Epidemiology United Kingdom United States of America Välbefinnande. and Health North American Nursing Diagnosis Association International Nursing Diagnosis Nursing Intervention Classification Nursing Outcome Classification Problem label. Integrity. Prevention. Säkerhet (Wellbeing.randomised Designs Quality of Diagnoses.Chapter 1 LIST OF ABBREVIATIONS AIC: ANOVA: CCTDI: CI: CONSORT: COPD: HSRT: ICC: ICF: NANDA-I: ND: NIC: NOC: PES-Structure: RCT: SD: SE: SNOMED CT: Kw: TREND: Q-DIO: QOD: STROBE: UK: USA: VIPS: ZCEQNP: Akaike’s Information Criterion Analysis Of Variance California Critical Thinking Disposition Inventory Confidence Intervals Consolidated Standards of Reporting Trials Chronic Obstructive Pulmonary Disease Health Science Reasoning Test Intra-class Correlation Coefficient International Classification of Functioning. Aetiology (related factors) and Signs and Symptoms \ (defining characteristics) Randomized Controlled Trial Standard Deviation Standard Error Systemized Nomenclature of Medicine Clinical Terms Cohen’s weighted kappa Transparent Reporting of Evaluations with Non. Disability. Interventions. Security) Ziegler Criteria for Evaluating the Quality of the Nursing Process Instrument 8 . Integritet.

and reasoning skills Chapter 6: The effect of a predefined record structure and knowledge sources on the accuracy of nursing diagnoses: a randomised study Chapter 7: General discussion and recommendations Summary Samenvatting Curriculum vitae 11 23 47 73 89 113 135 157 161 167 9 . knowledge sources. a measurement instrument for nursing documentation in hospitals Chapter 4: Prevalence of accurate nursing documentation in the patient record in Dutch hospitals Chapter 5: Determinants of the accuracy of nursing diagnoses: influence of ready knowledge.General Introduction TABLE OF CONTENTS Chapter 1: General introduction Chapter 2: What factors influence the prevalence and accuracy of nursing diagnoses documentation in clinical practice? A systematic literature review Chapter 3: Development and psychometric testing of the D-Catch instrument. disposition toward critical thinking.

Chapter 1 10 .

General Introduction CHAPTER 1 GENERAL INTRODUCTION 11 .

and What It Is Not” (1859) was published. Wittgenstein 1952). diagnose. and gignōskein or gnō. systematic. NANDA-I 2009). This became a paramount responsibility of nurses. primarily retrospectively. the American Nurses’ Association (ANA) developed a five-step nursing process: a framework of how nurses work that includes as a separate step nursing diagnoses. a sound. During the 1970s and 1980s the nursing process—a relational. The Greek term diagnōsis (διάγνωση) means ‘to distinguish’. p. verifiable inference in the form of knowledge as to what accounts for that internal process” (Bandman & Bandman 1995. Nurses are now required not only to document performed interventions but also to explain why an intervention was selected (Wilkinson 2007). What It Is. who defined both aspects of diagnosis as ‘an inner process’ that stands in need towards ‘outward criteria’. meaning ‘to come to know’ (Bandman & Bandman 1995. and related to nursing actions based on doctors’ orders (Björvell 2002). 2009). 113). leaders in nursing have increasingly recognised the need for nurses to describe and evaluate their contribution to care for reasons as improving efficiency. Duijn et al. so that information can be forwarded to colleagues and other health care professionals (Björvell 2002. the nursing profession changed progressively towards independent nursing practice based on explicit evidence-based nursing knowledge. 2004. meaning ‘apart’. as it was seen as a theory that underlies that development of a systematic approach based on patients’ health problems. Starting in the early 1970s in the United States of America (USA).(γνώση). which nurses address (Müller-Staub 2007. Björvell 2002). nursing diagnoses ought to be the key component of nursing documentation.Chapter 1 Nursing diagnoses: a conceptual history in brief Since Florence Nightingales “Notes on Nursing. and is derived from ‘dia’ (δια). problem-solving method—was introduced internationally (NANDA-I 2004). 2009. Traditionally this was done verbally. The World Health Organization (1982) promoted the use of the nursing process as the foundation for nursing documentation. and evaluate (American Nurses Association 2009). Bandman and Bandman (1995) refer to the philosopher Ludwig Wittgenstein (1952). A nursing diagnosis is defined as “A clinical judgment about individual. In 1974. plan. It is essential for selecting and planning interventions and for providing highquality nursing care (Gordon 1994. 90. In the past decades. and quality of care (Lunney 2001). the nursing diagnosis increasingly has become an integral part of professional nursing practice and is seen from the perspective of being a ‘clinical judgment’ (Gordon 1994). Wilkinson 2007). Although the analysis and identification of human responses is a complex process involving the interpretation of human behaviour related to health (Lunney 2001. patient safety. implement. p. family or community responses or experiences to actual or potential health problems 12 . The national and international consensus is that nurses assess.

in the patient’s judgement. In that case. Wilkinson 2007). having a foundation in cognitive psychology. internationally. 1986. the quintessence of the nursing diagnosis is still under discussion. risk states. The second is the intuitive-humanist paradigm. and evaluate the nursing care plan (Gordon 1994). From the cognitive psychology perspective. two main nursing theory paradigms on decision making and nursing diagnostics exists. Nursing diagnoses focus on human responses to health problems or life processes. and community. Aetiological factors should include conditions that are usually resolved by nursing intervention (Iyer et al. if appropriate (NANDA-I 2009). Benner & Tanner 1987). Accurate (complete and precise) nursing diagnoses describe a patient’s problem and include related factors (aetiology of the problem) and defining characteristics in terms of signs and symptoms. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability” (NANDA-International 2009). it might be possible that the diagnosis is documented in the PES-format accurately. A nursing diagnosis is based on patients’ individual physical.General Introduction or life processes. but may be in content irrelevant. According to Thompson (1999). A statement can be clear. The objective of nursing diagnoses is to name problems. Aetiological factors can be predicted to change with nursing interventions intended to resolve the problem. ‘to be sure that.239). social. family. Nevertheless. It is nurses’ professional responsibility to verify their diagnoses with the patient. which is less systematic and predictable in processing information and is based on empirical expertise (Dreyfus and Dreyfus 1986. accurate and precise but not relevant to the issue. This paradigm is related to the hypothetico-deductive rational process. Lee 2006). readiness for health promotions. The observed signs and symptoms contain the critical defining characteristics for the problem and aetiological factors” (Gordon 1994). Both paradigms may be vital in order to document clinical phenomena of nursing importance such as nursing diagnoses (Easen & Wilkockson 1996). E = aetiology (related factors). which are derived in collaboration with an individual. and S = signs/symptoms) (Gordon 1994). Therefore accuracy in the PES-format can be subdivided from relevancy in content (Carpenito 2008. the cue cluster represents a problem’ (Wilkinson 2007. enabling health care workers to develop. and strengths as bases for developing a plan of interventions based on predetermined outcome(s). p. This way of documenting diagnostic findings is called the PES structure (P = problem label. The first is the systematic-positivist stance. Not validating data can be a cause of irrelevant issues in the documentation. “Both the problem and aetiology refer to distinct clusters of signs and symptoms. Gordon 1994). Accordingly. and psychological response to an illness or health problem that have an impact on activities of daily living (Ehrenberg & Ehnfors 2006). the purpose of the 13 . cognitive errors are not solely the result of ignorance or incompetent diagnosticians but may be predictable and preventable (Redelmeier 2005). also known as the information-processing theory (Banning 2005. implement.

Ehrenberg et al. 2006. Nordström & Gardulf 1996. 2005. Most of these studies reported that patient records contain relatively few accurately formulated nursing diagnoses. need to be documented accurately. 2006). and written in unambiguous. in clinical hospital practice. 9). as well as the aetiology and the signs/symptoms. since the mid 1990s. Zeegers 2009). Several studies examining the accuracy of nursing documentation were carried out in a limited number of hospitals in the USA. the context in which the studies in this dissertation were accomplished. Nursing documentation in general hospitals Internationally. nursing documentation is acknowledged as a part of nurses’ communication that is in the form of charting and reporting (Eggland & Heinemann 1994). Lee et al. In nursing education programs in the Netherlands. related factors. These studies used different measurement instruments. Sweden. Wilkinson 2007). and signs and symptoms so that nurses can correctly plan nursing care. Iceland. 2006. Müller-Staub et al. The purpose of documentation is to document the nursing care of individuals in such a way as to promote optimal continuity of care (Iyer & Camp 2005). 2006. Inaccurate nursing documentation can cause nurses’ misinterpretations and might put patients in unsafe situations (Koczmara 2005. The details of their interventions were poorly documented as well (Müller-Staub et al. clear language (Kautz et al. and pertinent signs and symptoms. Additionally. In the Netherlands. and Switzerland. the nursing process—and more specifically diagnosis documentation according to the PES structure—has been implemented in all basic nursing education curricula and in numerous postgraduate programmes. Documentation of nursing diagnoses in terms of the PES structure became part of the nursing standard curriculum in the Netherlands (CBO 1999. related factors. 9. Underreporting might result in a lack of recognition of patients’ needs or adverse events (World Health Organization 2008). identification. p. well structured. 14 . Studies on the nature of nursing reports contribute to the development of resources for documentation accuracy improvements internationally. Since 1999 this way of documenting nursing diagnoses is a professional standard in the Netherlands as well (CBO 1999). analysis and description of present (actual) or at-risk (potential) diagnostic findings must be precisely for understanding the reasons for the recommended intervention. and the diagnostician describes the specific type of problem in that area (CBO 1999. 2006. these studies can support the development of an internationally accepted gold standard for nursing documentation accuracy (Florin et al. and documentation of nursing diagnoses is to categorize the problem area. 1996. The problem label describes the general area of the problem. p.Chapter 1 analysis. Moloney & Maggs 1999). The problem label.

General Introduction

Müller-Staub 2007). Knowledge regarding the accuracy of nursing documentation in patient records is needed for improving the structure and quality of the content of handwritten and electronic patient records (Kurihara et al. 2001, Kurashima 2008). On the basis of their systematic review, Saranto & Kinnunen (2009) concluded that nursing documentation has received little research attention. As stated by the World Alliance for Patient Safety (2008), the lack of standardised nomenclature for reporting hampers good written documentation. Müller-Staub et al. (2009) noted a lack of psychometrically tested instruments for use in general hospitals to measure the quality of and the relationships between diagnoses, interventions, and outcomes. To assess the accuracy of nursing documentation in general hospitals, a reliable and valid instrument is needed to quantify accuracy variables. As none of the instruments described in the literature were originally developed to measure documentation in general hospital environments or were tested in this context, we concluded that no such instrument was available. Existing studies that examined influences on documentation accuracy used mostly questionnaires, interviews, observations, and descriptive evaluations about methods of data collection. A few of these studies described the relationship between the accuracy of reported admission information, nursing diagnoses, interventions, and progress and outcome evaluations in hospital settings (Bostick et al. 2003, Müller-Staub et al. 2006, Saranto & Kinnunen 2009). Most of the studies examined the accuracy of nursing reports, focussed on the influences of education programmes, focussed on record improvements, or focussed on the implementation of a nursing model in a specific hospital setting. Indeed, knowledge of the current status of the accuracy in nursing documentation is lacking in most countries. It is unknown whether current nursing documentation in clinical practice in the Netherlands is generally structured according to the phases of the nursing process and whether diagnoses in patient records are presented according to the PES structure. For nurses in daily hospital practice, the documentation of nursing diagnoses is vital if we are to evaluate the contribution of care for which nurses are accountable. Therefore, knowledge on the subject associated with determinants influencing nursing diagnosis documentation may provide a foundation to support nurses in documenting their diagnostic findings accurately (Thoroddsen & Thorsteinsson 2001, Lee 2005, Saranto & Kinnunen 2009). Determinants of the accuracy of nursing diagnoses Little information is available on what factors affect the description of accurate nursing diagnoses. There seems to be an association between influences of nurses’ documentation process, the diagnostic decision-making process, and the prevalence of accurate nursing diagnoses in patient records of general hospitals. Several studies have shown that nurses’ decision-making process is determined

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Chapter 1

by work procedures, allocation of work, disrupted working conditions, and time pressure (Hedberg & Satterlund-Larsson 2004, Coiera & Tombs 1998, Björg & Kirkevold 2000); doctors’ treatment orders, ward protocols, and policies; conflicting personal values; and ‘knowing the patient’ (Bucknall & Thomas 1997, Bucknall 2000, Currey & Worrall-Carter 2001, Radwin 1995, 1998). Nurses’ documentation is determined by disruption of documentation activities, limited nurses’ competence in documenting, confidence in documentation skills, inadequate supervision (Cheevakasemsook et al. 2006); and electronic nursing process documentation systems (Ammenwerth et al. 2001). These studies evaluated the impact of the decision-making process and the documentation process on nursing documentation in general. To date, no overview exists of what factors influence documented nursing diagnoses. It is unknown what factors affect the prevalence and accuracy of nursing diagnosis documentation. Specific reasoning skills and knowledge sources for planning nursing care, such as electronic patient records, seem to affect the formulation of nursing diagnoses. The accuracy of diagnoses seems to be related to a nurse’s capacity for critical thinking and for applying his/her reasoning skills (Profetto-McGrath et al. 2003). Thus, a factor that may influence the accuracy of nursing diagnoses is one’s disposition towards critical thinking and reasoning skills. Dispositions towards critical thinking include attitudes such as open-mindedness, truthseeking, analyticity, systematicity, inquisitiveness, and maturity (Facione 2000). Reasoning skills include inductive and deductive skills such as skills in analyzing, inference, and evaluation. These skills are essential for the diagnostic process (Facione 2000). From a cognitive perspective, knowledge needed to derive diagnoses can be subdivided into ‘declarative knowledge’ and ‘procedural knowledge’ (Gulmans 1994). Declarative knowledge is ‘know that’ and is related to the ability of a diagnostician to associate facts, concepts, and procedures. Nevertheless, ‘knowing that’ is insufficient: a nurse needs to ‘know how’ as well. “Know how” is the kind of knowledge recognised as procedural knowledge. Procedural knowledge refers to having the skills and knowing the rules on how to apply declarative knowledge. One needs procedural knowledge to use declarative knowledge in different and new situations, in particular (Gulmans 1994, Scheer, van der 1994). Knowledge about a patient’s case history and knowledge about how to analyze relevant patient data appears to be a central factor in being able to derive accurate diagnoses (Cholowski & Chan 1992; Hasegawa et al. 2007, Lunney 2008). A distinction between ‘ready knowledge’ and ‘knowledge obtained through the use of knowledge sources’ can be made as well. Ready knowledge is previously acquired knowledge that an individual can recall to mind. It is achieved through education programmes and situational experience in changing nursing contexts (Gulmans 1994, Ozsoy & Ardahan 2007). Knowledge obtained through knowledge sources is acquired through the use of handbooks, protocols, pre-

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General Introduction

structured data sets, assessment formats, pre-structured report forms, and clinical pathways. This type of knowledge is looked up and recognised as relevant and useful at that moment. The literature indicates that knowledge sources may help nurses derive diagnoses that are more accurate than those derived without the use of such resources (Goossen 2000, Spenceley et al. 2008). For deriving nursing diagnoses in an educational context, knowledge sources prove to be valuable guides for nurses. However, no studies have been published that describe the effects of knowledge sources on the accuracy of nursing diagnoses in hospital practice. Aims and outline of the dissertation This dissertation had two main objectives. The first objective was to describe factors that influence the accuracy of documented nursing diagnosis. The second objective was to describe the prevalence of accurate nursing documentation in the patient record. The research questions that were addressed are as follows: 1. What factors influence the prevalence and accuracy of the nursing diagnosis documentation in hospital practice? Do knowledge sources and a predefined record structure affect the accuracy of nursing diagnoses? Does ready knowledge influence the accuracy of nursing diagnoses? Do dispositions towards critical thinking influence the accuracy of nursing diagnoses? Does reasoning skills influence the accuracy of nursing diagnoses?

2. What is the prevalence of accurate nursing documentation in patient records in hospitals in the Netherlands? The aim of the study presented in chapter two was to review what factors influence the prevalence and accuracy of nursing diagnosis documentation in hospital practice. A systematic literature search of the electronic databases MEDLINE and CINAHL for articles published between January 1995 and October 2009 was performed. The prevalence of accurate nursing documentation in patient records is presented in chapters three and four. The purpose of the study presented in chapter three was (1) to develop a measurement instrument (the D-Catch) to assess nursing documentation, which includes record structure, admission data, nursing diagnoses, interventions, progress data, and outcome evaluations in various hospitals and wards, and (2) to test the validity and reliability of this instrument. The aim of the study presented in chapter four was to describe the accuracy of nursing documentation in patient records in hospitals. The D-Catch instrument was used to measure the accuracy of nursing documentation in hospitals in the Netherlands.
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aetiology. dispositions towards critical thinking. The aim of the next study. was to determine the effect of knowledge sources and a predefined record structure (problem label.Chapter 1 The second objective of this dissertation—to describe factors influencing the accuracy of nursing diagnosis documentation—is further addressed in chapters five and six. and reasoning skills. Chapter seven contains the general discussion of the results and methodological considerations of this dissertation as well as suggestions for further research. 18 . This pilot study. and the accuracy of nursing diagnoses. and reasoning skills influence the accuracy of student nurses’ diagnoses. in chapter six. ready knowledge. which used a four-group randomised factorial design and involved registered hospital nurses. to determine the association between ready knowledge. signs/symptoms [PES] format) on the accuracy of nursing diagnoses. and disposition towards critical thinking. which used a two-group randomised design. The purpose of the pilot study presented in chapter five was to determine how knowledge sources. examined our methodological approach to studying how nursing students document diagnoses.

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van der Schans. This chapter is accepted for publication in the Journal of Clinical Nursing and reproduced with the kind permission of Wiley and Sons. 23 . Walter Sermeus. Roos M.B. Nieweg.What factors influence the prevalence and accuracy of nursing diagnoses? CHAPTER 2 What factors influence the prevalence and accuracy of nursing diagnoses documentation in clinical practice? A systematic literature review Wolter Paans. Cees P. 2010.

allocation of work. and pertinent signs and symptoms (Björvell et al. 1998). The nurses’ decision-making process is determined by work procedures. Several authors have reported that patient records contain relatively few formulated nursing diagnoses. the aim of this review was to study the factors that determine the frequency and accuracy of nursing diagnoses documentation. and evaluate nursing care for individuals and to accomplish optimal continuity of care and patient safety (Needleman & Buerhaus 2003). Nurses’ daily documentation in the patient’s record is negatively influenced by several factors. Currey & Worrall-Carter 2001. lacking motivation to enter information into the patient record and receiving inadequate supervision (Cheevakasemsook et al. A positive influence on the documentation in the patient record is the use of electronic nursing process documentation systems (Ammenwerth et al. Radwin 1995. 2006). 1996. Thus. the accuracy of nursing diagnoses documentation has been found to be moderate to poor (Ehrenberg et al. and policies. Bucknall 2000. 2001). Furthermore. However. doctors’ treatment orders. and ‘knowing the patient’ (Bucknall & Thomas 1997.Chapter 2 Introduction Accurate documentation of nursing diagnoses is vital to nurses in daily hospital practice. related factors. disrupted working conditions. such as being disrupted during documentation activities. conflicting personal values. Florin et al. 2006). nurses’ limited competence regarding documenting. Björg & Kirkevold 2000). Several studies have shown that the prevalence and accuracy of nursing diagnoses have an indirect impact on the decision-making processes and documentation of nurses (Brunt 2005. intervene. Müller-Staub et al. Coiera & Tombs 1998. and time pressures (Hedberg & Satterlund-Larsson 2004. 2005. Moloney & Maggs 1999. ward protocols. 24 . how these various factors affect the prevalence and accuracy of nursing diagnoses documentation is less known. The aim of diagnoses documentation is to help nurses to correctly plan. 2007). Müller-Staub et al. These studies evaluated the general impact of these factors on the decisionmaking process and the documentation process. 2002. Banning 2007).

Lee et al. family. 2008). and decision making. Moreover. A central element of the nursing process is how nurses derive a nursing diagnosis based on clinical assessments. and signs/symptoms (S). 2006. 1999). From the mid 1990s nurse researchers have increasingly studied factors that influence nursing diagnoses. 1999. Although nursing educators acknowledge the importance of developing skills in diagnostic reasoning. and observations (Wilkinson 2007). the North American Nursing Diagnosis Association (NANDA) defined nursing diagnosis as “a clinical judgement about individual. Cruz et al. which in turn results in a desired outcome. evaluating. interviews. 2002. These analyses can be complex since there is a large variety in responses to illness and diseases (Müller-Staub et al. Müller-Staub et al. In 1990. a concise term or phrase that represents a pattern of related cues. Nurses have to analyse a patient’s responses to health problems using interviews and observations. the development and implementation of electronic documentation resources and pre-formulated templates have been demonstrated to positively influence the frequency of diagnoses documentation (Smith Higuchi et al. 2009). an aetiology or related factors (E). or community responses to actual or potential health problems/ life processes” (NANDA 2004). 2006). the majority of graduate and undergraduate programmes in nursing education do not focus on factors that affect reporting diagnostic inferences in the ward in daily practice (Smith Higuchi et al. Saranto & Kinnunen 2009). Evidence shows that educational programmes geared to improving diagnostic-reasoning skills significantly increase the prevalence and accuracy of documented nursing diagnoses (Björvell et al. reflective judgement. such as education programmes and electronic documentation devices to improve diagnoses documentation (Kurashima et al. 2009.What factors influence the prevalence and accuracy of nursing diagnoses? Background In the 1970s the nursing process was introduced into nursing educational programmes and hospital nursing practice worldwide as a systematic method of planning. This diagnostic structure is known as the “PES structure” (Gordon 1994). The nursing process facilitates problem solving. Diagnoses contain a problem label (P). Gunningberg et al. Nurses are trained to document their knowledge and judgements explicitly according to the nursing process (Warren & Hoskins 1990. and documenting nursing care (Gordon 1994). 2006). 25 .

excluded studies conducted in non-hospital environments or those involving nursing students and studies on diagnostic inferences in emergency room triage situations. Studies on the decision-making process or reasoning process were included only if a clear connection to nursing diagnoses documentation was described. and (4) related toto registered nurses hospital practice. Four sets (I. (3) addressed influencing the prevalence and and accuracy of the documentationof nursing factors influencing the prevalence accuracy of the documentation of nursing diagnoses. III. The for CINAHL search. (CINAHL) (Figure 1). Figure 1 Database search Figure 1 Database search • I: MEDLINE ("nursing diagnosis"[MeSH Terms] OR "nursing diagnosis"[All Fields]) AND "nursing documentation"[All Fields] AND ("hospitals"[MeSH Terms] OR "hospitals"[All Fields] OR "hospital"[All Fields]) II: CINAHL: MH nursing diagnosis AND nursing documentation AND hospital III: MEDLINE: ("nursing diagnosis"[MeSH Terms] OR "nursing diagnosis"[All Fields]) AND (Influence OR influenceable OR influenced OR influences OR "utilization"[Subheading] OR quality OR implementation[All Fields] OR accuracy[All Fields]) IV: CINAHL: MH nursing diagnosis AND (influenc* or utili?ation or quality or accuracy or implementation) • • • Our search returned 1032 titles.Chapter 2: What factors influence the prevalence and accuracy of nursing diagnoses? The Study Chapter 2 Aim Study The The aim of this study was to review what factors influence the prevalence and Aim accuracy of nursing diagnosis documentation in hospital practice. We usedfor relevant articles published between and thesaurus terms for the 2009. for III. We applied the following inclusion criteria to the Our search returned 1032 titles. and IV) of search terms thesaurus termssets the CINAHL search. We used MeSH terms II. (3) addressed factors to the articles: (1) published in English. two groups: Sets and III of search terms were II & IV were subdivided into Four sets (I. II. The sets were subdivided into two groups: Sets I & III (MEDLINE) and sets II & IV (CINAHL) (Figure 1). (2) primary research. We applied the following inclusion criteria articles: (1) published in English. the MEDLINE search and were used. The aim of this study was to review what factors influence the prevalence and accuracy of nursing diagnosis documentation in hospital practice. Methods We conducted a systematic literature search of the electronic databases MEDLINE Methods and conducted for relevant literature search ofbetween January 1995 and October We CINAHL a systematic articles published the electronic databases MEDLINE and CINAHL MeSH terms for the MEDLINE search January 1995 and October 2009. I & IV) (MEDLINE) and setsused. We We excluded diagnoses. Studies describing the validation or evaluation of measurement instruments or guidelines dealing with the accuracy of nursing diagnoses in patient records were 25 26 . and (4) related registered nurses in in hospital practice. (2) primary research.

after duplicates removed: n= 567 Set II & Set IV. III. We excluded studies that discussed possible influencing factors without researchbased evidence (Figure 2). In total. II. 63 articles were retained for full-text analysis. To assess the quality of the selected studies. 2009: n= 454 * Non-English language: n= 173 * Nursing students / professions other than nurses: n= 21 * Non-hospital settings / triage settings: n= 51 * Influences on reasoning / decision making / attitudes: n= 122 * Validation and/or evaluation of instruments and guidelines: n= 9 * Level of evidence 5: n= 55 Perceived to be relevant to the study based on title and abstract and included for full-text assessment: n= 63 Analysis of full text: n= 63 Papers excluded based on title and abstract: n= 969 Papers excluded based on full-text analysis: n= 39 Total papers included: n= 24 27 . and IV after duplicates removed: n= 1032 Excluded: * Published < 1995 to > October 01. the prevalence and accuracy of nursing diagnoses? Figure 2 Search strategy and number of records identified Figure 2 Search strategy and number of records identified MEDLINE (Set I): n= 18 MEDLINE (Set III): n= 556 CINAHL (set II):n= 9 CINAHL (set IV): n= 613 Set I & Set III. we followed the meta-synthesis Chapter 2: What factors influence (2001).What factors influence the prevalence and accuracy of nursing diagnoses? included if influences on the documented nursing diagnoses were described. after duplicates removed : n= 615 Set I. approach of Paterson et al.

reports of randomised. quasi-experimental designs. representing more than expert opinion. these Level 2 studies used pre-test/ post-test designs. the Transparent Reporting of Evaluations with Non-randomised Designs (TREND) statement was used (Des Jarlais et al. (2006). cross-sectional designs. exploratory study methods. 2009). sample size. systematic analyses of qualitative studies Level 5. Cohort studies. In our appraisal. as published by the Centre for Evidence Based Medicine (Phillips et al. record reviews Level 3. The Level 1. Expert opinions Critical appraisal revealed that the design of most of the research papers included in our review did not employ highest level of evidence. design. two reviewers assessed the methodology used in each study. The consensus discussions enabled us to construct a categorisation of domains. Randomised trials Level 2. which in turn enabled us to present 28 . in which papers were re-read purposively in order to identify influencing factors. For instance. For this purpose. To categorise the factors influencing the prevalence and accuracy of nurses’ diagnoses documentation. and general and key findings concerning factors that influence the prevalence and/or accuracy of nursing diagnoses in patient records. The Level 4 studies used qualitative interview methods and qualitative descriptive designs. 16 Level 2 studies. Next.Chapter 2 While examining the included articles. 2. we used the updated version of the Oxford Levels of Evidence. Based on Müller-Staub et al. and record reviews. two reviewers qualitatively structured the factors independently into ‘themes’. In addition. 2004). database research. In order to compose a more distinct categorisation of influencing factors. pre-test/post-test designs. 24 articles were included for further analysis. data analysis. 2007). cross-sectional designs. For cohort or case control studies Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) was applied (Vandenbroucke et al. Case-controlled studies Level 4. 2001). For the assessment of reports of non-randomised studies. slight adaptations were made for research in nursing or studies with qualitative research methods. We excluded Level 5 studies. the reviewers compared and discussed their themes until they reached consensus. The following categories were used: Level 1. one Level 3 study and four Level 4 studies. and 3 studies used adequate sample sizes and an acceptable reference standard/clinical decision rule. Based on the quality analysis. qualitative interviews. we categorised each article according to the level of evidence contained within the article. controlled trials were assessed according to the recommendations of the Consolidated Standards of Reporting Trials (CONSORT) statement (Moher et al. Observational studies. (2001) and Cooper (1998). quasi-experimental designs. we performed an in-depth analysis of the papers’ contents using the approach of Paterson et al. two independent reviewers systematically abstracted the focus of the studies. The Level 3 study was a case-controlled study. The Level 2 studies used a variety of designs and were described in papers examining nursing diagnoses documentation. The Level 1 studies were clinically relevant randomised studies. There were three Level 1 studies.

(3) complexity of a patient’s situation. (3) case-related and diagnostic knowledge. as described in the literature. Four domains were identified: (1) the nurse as a diagnostician. Darmer et al. Reliability and validity We identified various instruments previously used to measure factors that influence the prevalence and accuracy of nursing diagnoses documentation: the Cat-ch-Ing instrument (Björvell et al. and the Quality of Nursing Diagnoses Interventions and Outcomes (Q-DIO) (Müller-Staub et al. In studies that used questionnaires in surveys. The development of such disposition can be explored by providing a formal education program in hospital practice. 2009). Inter-rater reliablity outcomes were described for all of the aforementioned instruments. (2) diagnostic experience and expertise. The attitude or disposition of nurses towards nursing diagnoses and the criticalthinking approach of nurses may influence the way they document diagnostic findings. Cruz et al. we identified four sub-themes related to the individual nurse as a diagnostician as a factor that influences the prevalence and accuracy of nursing diagnoses documentation: (1) attitude and disposition towards diagnosis. These four themes were subdivided into 18 sub-themes that influence diagnoses documentation (Figure 3). Based on the findings of Armitage (1999) and Hasegawa et al. Results We included 24 articles that examined factors that influence the prevalence and accuracy of nursing diagnoses documentation.61 or higher and therefore. according to Fleiss et al. even though the PES structure was used in various scoring ranges and scales. 2005). and (4) hospital policy and environment.What factors influence the prevalence and accuracy of nursing diagnoses? a conceptual framework of determinants that influence the prevalence and accuracy of nursing diagnoses. nurses may have to learn how to examine their criticalthinking disposition in areas such as open-mindedness. the Quality of Nursing Diagnoses (QOD) (Florin et al. These studies reported on aspects of content validity and reliability. Smith Higuchi et al. (2) diagnostic education and resources. 2006). (1999) suggest that to be able to document diagnoses accurately and to perform at satisfactory levels of diagnostic competency. All the aforementioned instruments included the PES structure as the theoretical basis for quantifying accuracy of diagnoses. acceptable. (2007) it seems that nurses do not examine how they should reflect on their critical-thinking approach and their diagnostic findings in clinical practice. the Scale for Degrees of Accuracy compiled by Lunney (2001) (Kurashima et al. (2003). the PES format of Gordon (1976) (Thoroddsen & Thorsteinsson 2002. 2002. 2006). and (4) diagnostic reasoning skills. because nurses do not document nursing diagnoses on their own initiative 29 . validity and reliability were often unclear or not mentioned at all. The nurse as a diagnostician In the literature. Thoroddsen & Ehnfors 2006). Reported over all inter-rater reliability scores were . 2008.

2007). Several factors affect nurses’ knowledge and experience: the presence of case-related knowledge and reasoning skills acquired in formal education programmes (Smith Higuchi et al. the motivation to learn diagnostic tasks (Whitley & Gulanick 1996). Armitage (1999) and Axelsson et al. Using a qualitative research approach. 1999). 1999).Chapter 2 (Smith Higuchi et al. and the frequency of studying diagnostics (Hasegawa et al. 2009). Figure 3 Determinants that influence the prevalence and accuracy of nursing diagnosis documentation Figure 3 Determinants that influence the prevalence and accuracy of nursing diagnosis documentation Hospital policy and diagnostic environment Chapter 2: What factors influence the prevalence and accuracy of nursing diagnoses? Number of administrative tasks Number of patients per nurse Physician’s disposition towards nursing diagnoses Workload level and time to spend on diagnostic task Education & Resources Patients’ complexity Used information structure Medical model Cultural / racial differences in expressing patients’ needs and in naming diagnoses Guided clinical reasoning Educational background in nursing process application Pre-structured record forms Implementation of classification structure. 2007. Hasegawa et al. In hospital practice. NANDA Diagnostic experience and expertise Computer-generated care plans & patient records Diagnoses Documentation Patients’ expressing severe diagnoses Severe medical diagnoses in specialty areas Attitude and disposition towards diagnosis Case-related and diagnostic knowledge Diagnostic reasoning skills Diagnosticians 30 31 .e. Cruz et al. the degree of nurses’ experience in diagnosing significantly and positively influences the accuracy of nursing diagnoses documentation (Reichman & Yarandi 2002.. i. (2005) also reported that diagnostic experience positively influences the prevalence of accurate diagnoses.

e. Lee 2005. 2008) are examples of educational programmes for registered nurses intended to improve the accuracy of diagnoses documentation significantly. and (5) computer-generated care plans and patient records. 2005. 2006. as the current literature indicates. such as NANDA. (1995) found significant cultural differences in the discharge diagnoses of adolescents hospitalised for psychiatric disorders. Classification structures. This approach has a significant positive effect on the accuracy of nursing diagnoses documentation (Björvell et al. (1996) showed in a study of newborns that nurses attributed the highest pain score to a child when the medical diagnosis was severe and the child vocally expressed his/her pain. it is important for nurses to be aware of their subjectivity in diagnostic judgements and to develop mental abilities that reflect this subjectivity. These factors. we extracted five educational or resources-related sub-themes that influence the accuracy of nursing diagnosis documentation: (1) guided clinical reasoning. Müller-Staub et al. (4) implementation of classification systems. 2005 Cruz et al. Kilgus et al. especially in complex patient situations or in specialty areas. (1996) stated that. 2002. (3) pre-structured record forms. Consistent theoretical teaching and practical training in ongoing educational programmes may offer procedural and conceptual knowledge as a basis for accurate diagnostic documentation (Müller-Staub et al. 2009). On the basis of a record review. Resources that reduce the lack of clarity in diagnostic statements—for instance. 2006. (2) nurses’ educational background in nursing process application. 2006) in combination with applicable electronic resources facilitate more accurate diagnoses documentation (Smith Higuchi et al. Educational programmes intended for both novice and experienced nurses can give both the opportunity to reflect on how to document diagnoses in the present hospital environment of their own ward (Kawashima & Petrini 2004. 1999). Hamers et al. Complexity of a patient’s situation Factors that indicate the complexity of a patient’s situation in clinical practice may influence the accuracy of the nursing diagnosis documentation. (1995) and Hamers et al. 1999). The authors of this 31 . 2009) and guided clinical reasoning (Müller-Staub et al.. Nursing process education (Björvell et al. (2) patients’ severe medical diagnosis in specialty areas.What factors influence the prevalence and accuracy of nursing diagnoses? Diagnostic education and resources From the included articles. Cruz et al. Kilgus et al. Florin et al. Educational programmes related to patient populations are needed to educate nurses on how to derive and report diagnoses in the actual hospital information structure in which they work (Darmer et al. 2002. 2006). and (3) patients’ way of expressing severe diagnoses. (2008) found that the time needed to derive a diagnosis was significantly shorter when nurses used a computer aid. NANDA-I classification (Thoroddsen & Ehnfors 2006). Darmer et al.g. 2006). can be categorised into three themes: (1) cultural differences in expressing patients’ needs. Kurashima et al. and new forms for recording in the PES format (Florin et al. Turner 2005). specific computer-generated standardised nursing care plans—may support nurses in their administrative work (Smith Higuchi et al.

Different designs and sample sizes were used in various studies. 2006). however. Brannon & Carson 2003. (5) physicians’ disposition towards nursing diagnoses. and (6) the information structure used in the ward. the way nurses process the diagnostic opinions of physicians is a factor that influences how nurses document their own diagnostic findings. our review of the literature failed to identify arguments distinguishing major and minor factors of influence. pre-structured care plans or schemes appears to be helpful (Björvell et al. Hospital policy and environment We identified six sub-themes concerning the influence of the hospital environment on nursing diagnoses: (1) the number of patients per nurse. severe medical diagnosis in specialty areas and complexity of the patient situation. Martin (1995) and Paganin et al. It seems that each domain comprises important influencing factors. and difficulties in analysing diagnoses in specialty areas are factors influencing nursing diagnosis documentation as well (Whitley & Gulanick 1996. length of stay seems to be an influencing factor with respect to the number of documented diagnoses. as Thoroddsen & Thorsteinsson (2002) suggested. Discussion Factors that influence diagnoses documentation We identified four themes that characterise factors that influence the prevalence and accuracy of nursing diagnoses documentation. (3) the use of a medical model.Chapter 2 study pointed out that some of these differences may reflect ethnocentric clinician bias in the diagnostic assessment of youths with different cultural backgrounds. can obstruct. interpretation difficulties of cues. (2) nurses’ workload level and time to spend on diagnostic tasks. lack of administrative support. However. although. and workload level as the main barriers nurses face when documenting nursing diagnoses. since pre-structuring information by using. According to Griffiths (1998). based on the results of their study. In complex patient situations nurses’ confidence in the diagnostic task in cases of severe diagnoses. There may be an association between length of stay. (2008) identified the number of administrative tasks. Nurses appear to adopt medical language instead of nursing language. The medical-situational context appears to be one of the important factors that influences the prevalence and accuracy of nursing diagnoses documentation. lack of time. or at least hinder the implementation of nursing education courses or resource innovations in documentation. Müller-Staub et al. as mentioned by (Whitley & Gulanick 1996). for instance. no 32 . Physicians’ objections or rejections toward the implementation of nursing diagnoses. as was reported by Thoroddsen & Thorsteinsson (2002). Armitage 1999). 2002. Nevertheless. One possible measure providing administrative support is the implementation of a pre-structured information approach. this association was not clear. (4) the number of administrative tasks nurses have to carry out.

2006). Examples of general factors that influence nursing decision-making procedures and documentation include work procedures. ‘inadequate staff development’ was not found. and 600 journals (Darmer et al. As a result. For example. a comprehensible description of activities that disrupt nurses as they document diagnoses was missing. since the terms used in the literature denote subjective notions. knowing the patient.What factors influence the prevalence and accuracy of nursing diagnoses? major contradictions in outcomes were found. disrupted work conditions. without taking other factors that influence 33 . For instance. 427 charts (Smith Higuchi 1999). We found results from qualitative research to be comparable to those obtained from quantitative methods. we distinguished two classes of factors that influence nursing documentation: (1) general factors. clear diagnostic expectations regarding documenting accurate nursing diagnoses. and staff development. 225 records (Müller-Staub et al. In our analyses. We hypothesise that there might be a number of underlying issues that influence nurses’ decision making and diagnoses documentation. These courses and resources may only be successful if there are restrictions in workload. The provision of these programmes depends on a hospital’s policy on offering educational courses and resources. 352 records (Kilgus et al. which influence the reasoning and documentation process in general. motivation. 2006). For instance. We found representative record reviews that reported factors influencing diagnoses documentation: 1103 charts (Thoroddsen & Thorsteinsson 2002). Also missing was information about the background of conflicting personal values. which specifically influence the prevalence and accuracy of nursing diagnoses documentation. and interdisciplinary support to give nurses the opportunity to learn and to carry out their diagnostic tasks. The differentiation of general versus specific factors that influence diagnoses documentation may have common characteristics that need to be investigated more intensely. 1995). both Armitage (1999) and Reichman and Yarandi (2002) arrived at the same conclusion—nurses’ experience is an important factor that influences the accuracy of nursing diagnoses documentation—even though the former study was based on in-depth interviews of ten nurses and the latter was based on analysis of 184 written patient simulations. which is based on the influencing factors mentioned in the included papers (Table 1). conflicting personal values. as stated in a conceptual framework (Figure 3). Consequently. and (2) specific factors. we assume that a single innovation. ‘intuition’. the knowledge of individual nurses partly depends on education programmes provided in hospital practice. such as an education programme dealing with diagnostics or a computerised care plan. a clear and uniform definition or consistent description of the meaning of ‘knowing the patient’. We only included studies that had examined nursing diagnosis documentation as a research topic. These issues need to be investigated in more depth in future research. we hypothesise that the influencing factors positioned within the four domains may be interrelated. allocation of work. With regard to specific factors that influence diagnoses documentation. however. ‘motivation’.

Limitations The present review is limited in several respects. there may be no interdisciplinary agreement on what an accurate nursing diagnosis is and what it is not. healthcare professionals may not fully accept a nurse’s responsibility to make diagnoses. Research on nurse’s interpretation and judgement of frequently documented or severe diagnoses. knowledge and a positive attitude towards the use of diagnoses by nurses. We only included papers published in English. Björvell et al. Nurses’ impression of the hospital policy in the case of diagnostic tasks may sometimes reflect their motivation for learning how to document and for documenting nursing diagnoses (Whitley & Gulanick 1996). physicians. 2007). nurses usually do not perceive a sharp distinction between ‘diseases’ and ‘levels of wellness’ (Bandman & Bandman 1995. and the hospital administration may stimulate nurses to derive accurate diagnoses (Whitley& Gulanick 1996. In hospital practice. Being unfamiliar with the nursing diagnosis domain and the diagnostic language used by nurses may lead to uncertainties and misunderstandings both for nurses and physicians. (2009) that focus on recognising the signs and symptoms of severe diagnoses may help nurses to avoid diagnostic misperceptions. (2007). Hamers et al. 2002). (1996) and Shapiro (1993) studies. Therefore. Educational programmes. However. This observation suggests that nurses’ ‘misperceptions’ could affect their diagnoses and ultimately the amount of medication dispensed. in general. In the ‘nurse as a diagnostician’ context. nurses’ ‘misperceptions’ caused newborns to receive inadequate pain medication. in the Hamers et al. Reducing the nurse-to-patient ratio and limiting additional administrative tasks in order to give nurses enough time to accomplish their diagnostic tasks creates limits in the hospital environment and will give nurses the notion that hospital management support them in their diagnostic responsibilities. since education in diagnostic documentation skills can enhance the quality of documented nursing diagnoses. Higher quality of diagnoses documentation correlates with qualitative improvements in the documentation of nursing-sensitive patient outcomes. Indeed. may not be as effective as it could be in the long term. as suggested by Müller-Staub et al. (1996) and Shapiro (1993) found that nurses’ perceptions or misperceptions of a newborn’s pain affected how much analgesics they gave the newborn.Chapter 2 diagnoses documentation into account. Therefore. Still. we focused more on papers written by authors who carried 34 . such as pain. is rare and further research is required. The distinction between medical diagnoses and nursing diagnoses appears to be unclear for both physicians and nurses (Whitley & Gulanick 1996). In contrast. as mentioned in the implementation study of Müller-Staub et al. studies discussing the possible effects of education programmes intended for accurate diagnostic documentation in terms of patient safety and quality of care are lacking and may be needed as well (Lunney 2007). Hasegawa et al. (2006) and Cruz et al.

this possible association is still unclear and needs to be researched. nurse staffing in hospitals. Also lacking is research about the influences of interdisciplinary exchange of knowledge concerning the essentials of medical and nursing diagnosis. we conclude that nursing diagnosis documentation is not limited to classification in an autonomous nursing domain but is limited to inference to an individual process influenced by a number of internal and external factors (Bandman & Bandman 1995. physicians. we may have overlooked some papers due to the search strategy or database filters used. it was not feasible to perform statistical procedures on the aggregated data. Moreover. Therefore. Despite the advanced literature search. Conclusion Despite the lack of knowledge about factors that influence diagnoses documentation. No statistical procedures to aggregate data were used. 35 . and other healthcare workers can understand it and can rely on the content of the documentation. However.What factors influence the prevalence and accuracy of nursing diagnoses? out their research in the North American and North-western European context. since the instruments and methods described in the reviewed articles differed. and accuracy in diagnostic documentation. The outcomes of an individual diagnostic process ought to be documented by nurses in such a way that patients. Wilkinson 2007). We assessed papers qualitatively. there might be an association between a nurse’s level of education. colleagues.

Chapter 2 Table 1 Factors that influence the prevalence and accuracy of nursing diagnoses documentation Reference Focus Research Design/ Level of Evidence (LE) Cross-sectional design using qualitative interviews and a survey LE: 4 Data Collection/Sample Size Key Findings Factors That Influence Diagnoses Armitage (1999) Title: Nursing assessment and diagnosis of respiratory distress in infants by children’s nurses Axelsson et al. exchange of information during conferences. supervision. (2002) Title: Long-term increase in quality of nursing documentation: effects of a comprehensive intervention Long-term effects of a nurse-documentation intervention Quasi-experimental longitudeinal design LE: 2 A two-year intervention composed of theoretical training. followed by a record review of 269 records in three acute-care wards in one hospital using the Cat-chIng instrument A comprehensive intervention of nursing documentation significantly improved the quality of nursing diagnoses documentation in the short term and the long term Theoretical training in documentation of diagnoses Individual supervision and support Information exchange Development of structured forms and standardised care plans 36 . (2005) Title: Swedish Registered Nurses’ incentives to use nursing diagnoses in practice The nursing assessment of respiratory distress in infants Qualified children’s nurses (n= 10) completed questionnaires and partook in qualitative interviews Nurses’ assessment was influenced by the medical model The concept ‘nursing diagnosis’ was poorly understood Medical model Nurses’ diagnostic experience Incentives for using nursing diagnoses in clinical practice Qualitative descriptive design LE: 4 Qualitative interviews of registered nurses (n= 12) Incentives for using nursing diagnoses originated from effects generated from performing a deeper analysis of the patient’s nursing needs Motivation to provide individual and holistic nursing care Experiencing that diagnoses facilitate decisions in terms of actions Recorded nursing diagnoses perceived as time saving Experiencing that diagnoses facilitate evaluation of nursing care Support from the management in using diagnoses Björvell et al. and organisational support regarding nursing documentation based on the Swedish VIPS Model.

n= 50) of four departments were randomly selected and audited annually for three years using the Cat-ch-Ing instrument (n= 600) Nursing documentation improved significantly during the course of the study A pragmatic approach: reversed ‘problems’ and consequences and reduced diagnostic statements to problem. aetiology.What factors influence the prevalence and accuracy of nursing diagnoses? Reference Focus Research Design/ Level of Evidence (LE) Quasi-experimental / case-controlled design LE: 3 Data Collection/Sample Size Key Findings Factors That Influence Diagnoses Brannon & Carson (2003) The influence of nursing expertise and information structure on certainty Title: of diagnostic decision Nursing expertise making and information structure influence medical decision making Nurses (experts). and nonnurse (naive) participants (n= 216) read patient scenarios either high in information structure or low in information structure and rated their certainty about what the potential diagnosis might be Afterwards. five-meeting educational program Randomly selected patient records were reviewed before and after the intervention Data analyses using a measurement scale with 14 characteristics pertaining to nursing diagnoses named: quality of nursing diagnosis used in two experimental units (n= 70) and one control unit (n= 70) Quality of nursing diagnostic statements improved significantly in the experimental units. whereas no improvement was found in the control unit Education in the nursing process and implementation of new forms for recording might improve RNs’ skills in expressing nursing diagnoses Implementation of new forms for recording Education in the nursing process 37 . (2005) Nurses’ adherence to the VIPS model. each participant was asked to generate a diagnosis and rate their level of confidence in their own diagnosis from 0%-100% By using pre-existing Nurses’ diagnostic expertise cognitive schemata for processing patient Use of structured information. (2006) Title: Nursing documentation audit –the effect of a VIPS implementation Florin et al. student nurses (novices). (2009) Continuing education courses related to critical Title: thinking and clinical Improving critical reasoning thinking and clinical reasoning with a continuing education course Darmer et al. participants information were more certain about their decision making when using structured information than they were about using unstructured information Cruz et al. a systematic method of nursing documentation to improve the accuracy of the nursing report Pre-test / post-test design LE: 2 Nurses completed a pre-test and a post-test consisting of two written case studies designed to measure the accuracy of nurses’ diagnoses (n= 39) Significant differences were found in accuracy on the pre-test and the post-test due to the education courses related to critical thinking and clinical reasoning Continuing education courses (16 hours) related to critical thinking and clinical reasoning Longi-tudinal retrospective nursing journal review LE: 2 Nursing documentation (journals. description of signs and symptoms in the nursing status Effects of education on the nursing process and implementation of new Title: forms for recording on Quality of nursing the quality of nursing diagnoses: diagnostic statements in evaluation of patient records an educational intervention Pre-test / post-test design LE: 2 The intervention consisted of a 3-hour.

Chapter 2 Reference Focus Research Design/ Level of Evidence (LE) Data Collection/Sample Size Key Findings Factors That Influence Diagnoses Griffiths (1998) Title: An investigation into the description of patients problems by nurses using two different needsbased nursing models Description of patients’ Qualitativedescriptive problems by nurses using study design and two different needs. each of which consisted of to children who were less a vignette and a videotape expressive with different factors Nurses also attributed the most pain to a child when The child’s expressions the diagnosis was severe were operationalised via videotapes of the same child Nurses’ diagnostic competencies by using written case studies and the factors influencing these competencies Cross-sectional study design based on written case studies LE: 2 Two written case studies were used to measure the diagnostic competencies of the subjects A convenience sample of 376 nurses practicing in medical-surgical nursing positions was obtained from nine different hospitals Japanese nurses in the sample. age. whereas Ward B utilized the model of Dorothea Orem (1980) Data collected were subjected to content analysis using Gordon’s Functional Health Patterns to order the data Nurses most commonly used medical diagnoses or the medical reasons for admission Patients’ problems identified predominately addressed biopsychical needs Medical diagnoses Medical reasons for admission Gunningberg et al. Ward A utilized the nursing model of Roper Logan and Tierney (1980).based literature review nursing models LE: 4 Two wards were investigated in one hospital. (2007) Title: Measuring diagnostic competency and the analysis of factors influencing competency using written case studies The influence of taskrelated factors on nurses’ pain assessments and decisions regarding interventions Cross-sectional retrospective review of health records LE: 2 Analysis of recorded data on pressure ulcers Paper-based records (n= 59) identified by notes on pressure ulcers and electronic health records (n= 71) with pressure ulcer recordings were retrospectively reviewed Electronic patient records Pre-formulated templates in showed significantly more electronic health records diagnostic notes on pressure ulcer grade Randomised experimental design LE: 1 Paediatric nurses (n= 202) Paediatric nurses attributed Vocally expressing pain more pain to and were from 11 hospitals were randomised into four groups more inclined to administer Severe medical diagnosis non-narcotic analgesics to children who vocally Each group was exposed expressed their pain than to four sequential cases.of an electronic health veness in nursing record and the use of predocumentation of formulated templates for pressure ulcers pressure ulcer recording after implementing an electronic health record in hospital care Hamers et al. (2009) The quality and comprehensiveness of nursing documentation Title: of pressure ulcers before Improved quality and after implementation and comprehensi. (1996) Title: The influence of children’s vocal expressions. medical diagnosis and information obtained from parents on nurses’ pain assessments and decisions regarding interventions Hasegawa et al. did not perform satisfactory levels of diagnostic competency Length of clinical experience Decision-making responsibility Frequency of studying nursing diagnosis 38 . in general.

What factors influence the prevalence and accuracy of nursing diagnoses? Reference Focus Research Design/ Level of Evidence (LE)
Record review LE: 2 Title: Influence of race on diagnosis in adolescent psychiatric inpatients

Data Collection/Sample Size

Key Findings

Factors That Influence Diagnoses

Kilgus et al. (1995)

Influence of race on diagnoses

Data were abstracted from patients’ records and nursing incident reports

DSM-III-R discharge diagnoses were assigned to five non-mutually exclusive Organic/psychotic groups diagnoses were much more frequent in African Hospital medical records Americans, whereas whites (n= 352); whites (n= 251), were almost twice more African Americans (n= likely to receive mood/ 101) in one hospital anxiety diagnoses Substance abuse was more often diagnosed in whites

Significant racial differences were found in the discharge diagnoses of adolescents hospitalized for psychiatric disorders

Racial differences in patients Cultural backgrounds in patients

Kurashima et al. (2008) Title: Accuracy and efficiency of computer-aided nursing diagnosis

Whether a computerRandomised crossover aided nursing (CAN) trial diagnosis system improves diagnostic accuracy and LE: 1 efficiency

Registered nurses (n= 42) were divided into groups: one using the CAN diagnosis system and the other using a handbook of nursing diagnosis Degree of accuracy was judged by using Lunney’s seven-point interval scale, while efficiency was evaluated according to the time required for diagnosis

No significant difference was found between the two groups in terms of diagnostic accuracy Time required for diagnosis was significantly shorter for subjects who used the CAN diagnosis system than for those who did not

Using a computer aid significantly shortens the time needed to derive diagnosis

Factors that may affect nurses’ use of nursing diagnoses in charting Title: standardised nursing Nursing diagnoses: factors care plans in their daily practice affecting their use in charting standardized care plans Lee (2005)

One-on-one, in-depth interviews LE: 4

Clinical nurses (n= 12) at a Nurses do not regularly medical centre underwent use objective data to record one-on-one, in-depth patients’ condition interviews Data analysis was based on Miles and Huberman’s (1994) data reduction, data display, and conclusionverification process to investigate the charting process

Use of standardised care plans

Martin (1995) Title: Nurse practitioners use of nursing diagnosis

The independent nursing role of nurse practitioners (NPs) and the advantages and barriers of using nursing diagnosis in NP practice

Cross-sectional study design based on a survey LE: 2

Self-administered questionnaires (n= 181) included biographical data and forced choice questions about knowledge of nursing diagnosis

No statistical significance was seen between NPs’ knowledge and use of nursing diagnoses and their educational background, specialty, years of practice as a NP, and practice setting 85 % of NPs’ surveyed reported they did not use nursing diagnoses in their clinical practice

Lack of time Lack of clarity of diagnostic statements Lack of administrative support for writing nursing diagnosis

39

Chapter 2 Reference Focus Research Design/ Level of Evidence (LE) Data Collection/Sample Size Key Findings Factors That Influence Diagnoses

Müller-Staub et al. (2007) Title: Improved quality of nursing documentation: results of a Nursing Diagnoses Interventions and Outcomes Implementation study

Evaluation of the effects Pre-test/ post-test design of the Nursing Diagnostics Educational Program LE: 2 (NDEP)

Nurses of hospital wards (n= 12) of one hospital received an educational intervention called NDEP Before and after the intervention, a total of 72 randomly selected nursing records were evaluated The instrument Quality of Nursing Diagnoses, Interventions, and Outcomes was used to measure the quality of the nursing diagnoses

The guided clinical reasoning program significantly improved the formulation of nursing diagnostic labels and identification of signs/ symptoms and correct aetiologies Post-test data showed almost no nursing diagnoses without signs/symptoms in comparison with the pre-test

NDEP Guided clinical reasoning

Müller-Staub et al. (2008) Title: Implementing nursing diagnostics effectively: cluster randomized trial

The effect of guided clinical reasoning on nursing diagnoses, interventions, and outcomes

Cluster-randomised controlled experimental study in a pre-test / posttest design LE: 1

Nurses from three wards received guided clinical reasoning training Nurses of three other wards participated in classic case discussions and functioned as a control group

The mean scores of nursing Guided clinical reasoning diagnoses increased significantly in the intervention group Guided clinical reasoning led to significantly higher quality of nursing diagnosis documentation to aetiologyspecific interventions and to enhance nursing-sensitive patient outcomes

The quality of 225 randomly selected nursing records, containing 444 documented nursing diagnoses corresponding to interventions and outcomes, In the control group, the was evaluated by the quality of the diagnoses was Q-DIO instrument not significantly changed The impact of institutional, professional, and personal factors on nurses and on their efforts to derive nursing diagnoses Cross-sectional study design based on a survey LE: 2 Responses of 21 nurses for each group of factors (institutional, personal, and professional) were evaluated and scored on a scale of 0 (none of the impact parameters identified) to 100 (all impact parameters) Data were collected using a closed, structured questionnaire during the work shift of 21 nurses The professional factor scores were significantly lower among nurses with previous theoretical training in nursing diagnosis compared to those with no previous theoretical training The recognition of these factors and improved institutional support may facilitate the implementation of nursing diagnoses Workload level Number of patients per nurse Number of administrative tasks Previous nursing diagnosis experience Previous theoretical training

Paganin et al. (2008) Title: Factors that inhibit the use of nursing language

40

What factors influence the prevalence and accuracy of nursing diagnoses? Reference Focus Research Design/ Level of Evidence (LE) Data Collection/Sample Size Key Findings Factors That Influence Diagnoses

Reichman & Yarandi. (2002) Title: Critical care cardiovascular nurse expert and novice diagnostic cue utilization Smith Higuchi et al. (1999) Title: Factors associated with nursing diagnosis utilization in Canada

Diagnostic cue utilization Experimental design between expert and novice critical care cardiovascular LE: 2 nurses (CCCV)

Five written patient simulations (WPSs) served as instruments in the study Verbal recalls of the respondents were audio taped for analysis; expert (n= 23) and novice (n= 23) nurses were tested

Of the 184 WPSs that were Level of experience diagnosed, 88 were accurate Nurses’ background as Of the 88 accurate an expert diagnoses, 63 (72%) were made by CCCV nurse experts, while 25 (28%) were made by nurse novices

Factors associated with nursing diagnosis utilisation

Cross-sectional study design based on a survey and a retrospective chart review LE: 2

Attitude survey included In two hospitals in 47 Likert-scale items and 2 which nursing diagnosis open-ended questions implementation programs was not implemented, All nurses (n= 65) from none of the 22 nurses four hospitals that cared for documented nursing patients with respiratory diagnoses conditions were invited to participate in the study In the two hospitals in which nursing diagnosis In addition, a retrospective was formally implemented chart audit of discharged through hospital educational patients (n= 427) was programmes, 37 of 43 conducted nurses (86%) documented nursing diagnoses Eighty-three nurses from 20 different hospital units in which the nursing process was regularly implemented answered structured research questionnaires

Attitude towards diagnosis utilisation Knowledge Nursing administration expectations Presence of formal hospital educational programmes in nursing diagnostics Computer-generated nursing care plans

Takahashi et al. (2008) Title: Difficulties and facilities pointed out by nurses of a university hospital when applying the nursing process Thoroddsen & Ehnfors (2006)

Difficult and easy aspects Cross-sectional study of performing the different design based on a survey stages of the nursing process, according to the LE: 2 reports of nurses

Nurses had most difficulties Lack of theoretical with the phases nursing knowledge diagnoses and evaluations Lack of practical exercise Most of the difficult and easy aspects reported were related to the nurses’ theoretical and practical knowledge needed to perform the phases of the process The number of diagnoses per patient increased, incomplete diagnoses decreased along with the use of medical diagnoses, and the documentation of signs and symptoms increased Implementation of the NANDA classification for nursing diagnoses

Differences in documented Pre-test, post-test, crossnursing diagnoses, signs sectional study design and symptoms, and Title: aetiological factors before LE: 2 Putting policy and after an educational into practice: pre- effort and post-tests of implementing standardized languages for nursing documentation

For the pre-test, 355 nursing records in a hospital were reviewed After the implementation of the Functional Health Patterns for assessment documentation and the NANDA classification for nursing diagnoses, a post-test was conducted in which 349 records were reviewed

41

Chapter 2 Reference Focus Research Design/ Level of Evidence (LE) Data Collection/Sample Size Key Findings Factors That Influence Diagnoses

Thoroddsen & Thorsteinsson (2002) Title: Nursing diagnosis taxonomy across the Atlantic Ocean: congruence between nurses’ charting and the NANDA taxonomy Whitley & Gulanick (1996)

Expressions or terms used Retrospective chart by nurses to describe review patient problems LE: 2

The patient records in 1103 Nurses failed to document charts from a 400-bed the problems of patients in acute-care hospital were about 40% of the records analysed The NANDA taxonomy Nursing diagnoses seems to be culturally statements (n= 2171) in relevant for nurses in charts were analysed based different cultures on the PES format

Patient length of stay is associated with the number of diagnoses

The current status regarding utilisation of nursing diagnosis and the Title: interest in educational Barriers to the use consultation sessions that of nursing diag- were provided by the nosis language in nursing diagnosis council clinical settings

Cross-sectional study design based on a survey LE: 2

A survey instrument was mailed to all hospitals (n= 239) in the state of Illinois, USA The survey instruments were completed and returned by 139 agencies

Nursing diagnoses were Limited ongoing education performed in 109 of the 139 responding hospitals Lack of motivation to learn Of the 109 respondents who performed nursing diagnoses, 88% included nursing diagnosis in an orientation program, and almost all utilised NANDA terminology (95%) Difficulties in using diagnoses in specialty areas Physician objections or resistance

42

What factors influence the prevalence and accuracy of nursing diagnoses?

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2010. 47 . a measurement instrument for nursing documentation in hospitals Wolter Paans. Nieweg. This chapter is published and reproduced with the kind permission of Wiley and Sons: Development and psychometric testing of the D-Catch instrument. Journal of Advanced Nursing 66 (6). 146. vol. Amsterdam.B.Development and psychometric testing of the D-Catch instrument CHAPTER 3 Development and psychometric testing of the D-Catch instrument. Walter Sermeus. van der Schans. 1388-1400 and partly in: Health Technology and Informatics. 2009. 297-300. a measurement instrument for nursing documentation in hospitals. IOS Press. Cees P. Roos M.

and clinical reasoning (Johnson et al. either handwritten or typed. and self-care (Johnson et al. such as information from the assessment interview (Curtis 2001. 2007). Wilkinson 2007. Poorly legible handwriting 48 . McFarland & McFarlane 1997). 2008. aetiology or ‘related factors’ (E). Nursing outcomes refer to changes in a patient’s status. Gordon 2003. Subsequently. behaviour. Inaccurate nursing documentation can be a cause of nurses’ misinterpretations. 2007). The content and structure of the nursing process is internationally acknowledged as constituting the theoretical background of the elements needed for accurate nursing documentation (Delaney et al. it is the basis of planning interventions and focuses nurses towards measurable outcomes (Doenges & Moorhouse 2003). (5) For nurses’ accountability. it is obvious that the nursing documentation not only has to be accurate and complete but also legible. These outcomes are documented in nurses’ progress evaluations and outcome reports. nurses ought to describe the patient’s current health status and to reflect on the ongoing nursing process (Gordon 1994). also known as the PES structure. 2005). Accurate nursing documentation ought to contain (1) patients’ personal information and a description of the admission data. Johnson et al. or perception and can be measured along a continuum. (3) Accurate interventions (planned and implemented interventions). including symptoms. To provide safe care. functional abilities. coping strategies. An outcome can relate to the level of the family. Therefore the World Alliance for Patient Safety recommends further research toward medical and nursing documentation to be able to identify and report potential areas for improvement. which are based on education. aetiology. Diagnoses are reported in terms of a problem. and signs and symptoms (S). (4) Outcomes have to be documented as well. (2) Accurate nursing diagnoses. Nursing interventions describe the actions of nurses on behalf of the patient to improve outcomes. Nursing interventions are regarded as nursing treatments. and may cause unsafe patient situations (Koczmara 2005. 2006). documentation in the patient record is part of each nurse’s daily routine.Chapter 3 Introduction In clinical practice. the diagnosis implies the possibility of an intervention (Gordon 1994). Lunney 2007). This gives nurses the opportunity to evaluate what kind of care is given and to describe the results (Lunney 2001. 1992. The PES structure explains the content of the nursing diagnosis: It contains a problem label (P). community state. and signs and symptoms. nurses derive nursing diagnoses in order to plan interventions and to evaluate outcomes (CarpenitoMoyet 1991. among other informational tasks. The nursing diagnosis can be seen as a core element of the nursing process. and knowledge sources -such as handbooks or protocols. knowledge state. 2007. Arnold & Mitchell 2008). On the basis of observations and the admission assessment. The basis of a diagnostic concept in nursing was accepted by the North American Nursing Diagnosis Association (NANDA) in 1988. safe and efficient nursing care (Wilkinson 2007). knowledge. best practices can be established to provide decision-makers with options when shaping national strategies to improve patient safety (World Alliance for Patient Safety 2008). Gordon 1994. It is considerate to be essential for adequate.

2005. and descriptive evaluations about methods of data collection. After thoroughly examining the abstracts. it had to include the assessment of the nursing diagnosis. a total of 10 articles were included in the present study. Background In 2006. which produced 105 hits on MEDLINE and 16 hits on CINAHL. 2001). We also later included the publication of Müller-Staub (2007) in our analysis of relevant articles. (2009) stated that there are no psychometrically tested instruments for use in general hospitals to measure the quality of and the relationships among diagnoses. Published studies used mostly questionnaires. After assessing the titles and/or abstracts of these articles for relevance. In order for papers to be included for further analysis. and (2) to assess the response to the diagnosis and aetiology separately. The articles were identified by searching the electronic databases CINAHL and MEDLINE for articles published from 1980 to 2007. Knowledge about the accuracy of nursing documentation in patient records may be helpful in improving the structure and quality of the content of handwritten and electronic patient records (Goossen et al. observations. To assess the accuracy of the nursing documentation in general hospitals. there is a need for a reliable and valid instrument to quantify accuracy variables. interventions. it might be misinterpreted (Koczmara et al. On the basis of their systematic review of nursing documentation. we carried out a systematic literature search with the goal of identifying research describing measurement instruments for quantifying the accuracy of nursing documentation. and at a minimum. The initial search using the keywords and search strategy “nurs* AND documentation AND patient record” produced 1320 hits on MEDLINE and 240 on CINAHL. Müller-Staub et al. interviews. Its purpose is twofold: (1) to assess the overall diagnosis. Whyte 2005). the paper had to be published in English. Kurihara et al. (1) The Ziegler Criteria for Evaluating the Quality of the Nursing Process (ZCEQNP) instrument (Ziegler 1984) is composed of 12 specific criteria. it had to describe a measurement instrument for assessing and quantifying the accuracy of nursing documentation. Instruments for qualitative. Saranto and Kinnunen (2009) concluded that this area of nursing has received little research attention. we refined the search strategy to “nurs* AND patient record AND instrument”. The abstracts yielded by this search were then studied. we identified six relevant articles from the first search and two additional articles from the second search. 1997. Review of the reference citations of the relevant articles yielded two additional articles. and outcomes. descriptive evaluation of documents were excluded. 2006.Development and psychometric testing of the D-Catch instrument could obviously be harmful to the patient because. The instrument was originally designed to measure the quality of nursing diagnoses derived by 49 . Thus. From these we retrieved the following six instruments.

is 0. such as patient history. The scale ranges from -1 to + 5. and evaluation. is > 0.98 (See Addendum I & II in Björvell. The Cat-ch-Ing (Björvell 2002) is an instrument that measures both quantity and quality criteria of documentation based on the nursing process and on Swedish regulations for documentation practice. Measurement of quantity criteria is evaluated using a 4-point ordinal scale ranging from 0 (not at all) to 3 (always) on the various domains. interventions. We found no description of the psychometric properties of the ZCEQNP. The Quality of Nursing Diagnosis (QOD) instrument (Florin et al. The inter-rater reliability of the QOD. is between 0. and signature of notes. NoGA was used to study nurses’ documentation in 380 records (Nördstrom & Gardulf 1996) and to study the effect of an educational intervention on nurses’ documentation in 515 records (Nilsson & Willman 2000). Cat-ch-Ing was originally developed to evaluate a comprehensive intervention program based on a Swedish model (the VIPS model. Assessment takes place by using the terminology “exists” or “does not exist” (Nilsson & Willman 2000). and its internal consistency. The latter study also compared the ability of NoGA and Cat-ch-Ing to assess the quality of the nurses’ documentation. and on Lunney’s 7-point Scale for Degrees of Accuracy in Nursing Diagnoses (Lunney 2001). prevention and security). nursing diagnoses. The inter-rater reliability of the Cat-ch-Ing. The QOD was based on the ZCEQNP (Ziegler 1984). The instrument is composed of 17 variables that reflect various issues relating to the nursing process. which was calculated by using Cohen’s kappa.96 (Lunney 2001).75. which was calculated by using Cohens’s kappa. It was initially developed for evaluating an educational intervention in a pre-post-test design.863 (Florin et al. with higher positive scores indicating higher accuracy.Chapter 3 (2) (3) (4) (5) nursing students (Ziegler 1984. is 0. The scale is designed to measure nurses’ diagnostic competency and to analyze the factors that influence competency by using written case studies. integrity. which was calculated by using Pearson product-moment correlation. but is now used to analyze component signs and symptoms. which was designed for use in documenting a problembased nursing care plan and discharge note (Björvell 2002). implementation. which was determined by using Cronbach’s alpha. analysis. This instrument contains five domains: assessment.92 and 0. planning. The NoGA instrument (Nördstrom & Gardulf 1996) is a quantitative instrument that evaluates the structure of nursing documentation. 2002). an acronym formed from the Swedish words for wellbeing. Dobrzyn 1995). 2005) lists 14 criteria that are used to measure the accuracy of the written diagnoses of nurses. 50 .97 and 0. containing modified wording from the ZCEQNP. 2005). patient status. The Scale for Degrees of Accuracy in Nursing Diagnoses (Lunney 2001) is a 7-point ordinal scale that measures the accuracy of diagnoses relative to identified signs and symptoms. The inter-rater reliability of this scale.

Group 1 items are rated on a 3-point scale. and Outcomes (Q-DIO) instrument (Müller-Staub 2007) consists of 29 items categorised into four groups: (1) nursing diagnoses as a process. The Q-DIO was originally developed to evaluate the implementation of nursing diagnostics in a hospital in Switzerland (Müller-Staub 2007). and (4) nursing-sensitive patient outcomes. (2) nursing diagnoses as a product. its psychometric properties were not tested (Müller-Staub et al. We concluded that no such instrument was available (Figure 1). Interventions. (3) nursing interventions. Although the Q-DIO was implemented in a pilot study.Development and psychometric testing of the D-Catch instrument (6) The Quality of Diagnoses. 51 . As none of the aforementioned instruments were originally developed to measure documentation in several general hospital environments nor were they tested in that context. whereas group 2-4 items are rated on a 5-point scale. 2009).

Accuracy of the admission documentation and patients’ personal details. 52 . Legibility. and progress and outcome evaluations. 4. separately in quantity and quality criteria. 2. Accuracy of the nursing diagnoses. including the problem label. Accuracy of the nursing diagnoses. aetiology. and progress and outcome evaluations related to the nursing diagnoses. 7. 8.Chapter 3 Figure 1 Measurement instruments and their variables Instruments ZCEQNP (Ziegler 1984) NoGA (Nördstrom & Gardulf 1996) Scale for Degrees in Accuracy of Nursing Diagnoses (Lunney 2001) Cat-ch-Ing (Björvell 2002) QOD (Florin et al. and signs and symptoms (PES structure). Documentation related to international nursing standards (NANDA-I and/or NIC and/or NOC). 3. or hospital-specific variables. Accuracy of the interventions. 6. without national-. regional-. 2005) Q-DIO (Müller-Staub 2007) * * * * * * 1 2 3 4 * * * * * 5 6 7 8 * * * * * * * * * * Measurement of the: 1 Accuracy of the record structure (according to the nursing process). Accuracy of the admission. nursing diagnoses. interventions. 5.

To prepare the panellists for the panel discussion. all members of this panel had a master’s degree in nursing. the panels assessed the available instruments for content. and for assessment of nursing diagnoses. we selected the Scale for Degrees of Accuracy in Nursing Diagnoses (Lunney 2001) and the Q-OD (Florin et al. The panellists were selected based on their nursing background and their personal expertise recognized by their (inter)national publications. the aim of the Delphi panels. and with expertise in nursing process evaluation. as author of book chapters or were acknowledged as contributor of implementation programs for computer software on behalf of nursing documentation or as lecturer with their specialty in nursing process application. structure. Since reliable outcomes can be obtained through Delphi panels consisting of a relatively small group of homogenous experts (Akins et al. contributions to (inter)national conferences. and outcome evaluations) in various hospitals and wards. and (2) to test the validity and reliability of this instrument. and instructions for taking notes as they analyse the 53 . four questions on which to base their analyses.Development and psychometric testing of the D-Catch instrument The Study Aim The purpose of this study was (1) to develop a measurement instrument for the assessment of nursing documentation (which includes record structure. Methods Instrument development We pre-selected three measurement instruments and presented them to two Delphi panels (n= 6 experts per panel). interventions. These six panelists per panel had a similar general understanding of nursing documentation and equally understood how to use effective and reliable discussion and consensus techniques. The ZCEQNP (Ziegler 1984. Dobrzyn 1995) and the NoGA instrument (Nördstrom & Gardulf 1996. One of the Delphi panels consisted of six lecturers. specificity. 2005). Their expertise was in developing or implementing nursing documentation systems. admission data. For assessment of the nursing documentation we selected the Cat-ch-Ing instrument (Björvell 2002). a list of the three instruments they were to analyse. nursing diagnoses. because these instruments did not allow the measuring of diagnoses in terms of the PES structure. and usability in general hospitals. we mailed to each panellist a letter containing an introduction to our study. Members of this panel either had a post-graduate specialization degree or a master’s degree in nursing science. we invited a limited number of experts who were willing to share their specialist knowledge and experience to participate as Delphi panelist in one of the two Delphi panels in our study. The other panel consisted of expert nurses that worked in hospital practices. 2005). Nilsson & Willman 2000) were excluded from the pre-selection and not presented to the panels. all Dutch. progress data.

Therefore. The members then discussed each question during the next session. criteria of Lunney’s instrument were integrated into a modified version of the Cat-ch-Ing instrument (Björvell 2002) with regard to both quantity and quality criteria. Four reviewers. which we appended afterwards to the final version of the instrument. the draft version of the D-Catch lacked guide A & B for Diagnoses. “Are VIPS keywords used?”) (Björvell 2002. aetiology (or related factors). ultimately leading to the formation of a new instrument—the D-Catch. the panel members concluded that the ideal nursing documentation instrument should have a quantifiable accuracy measurement scale subdivided into quantity and quality criteria. The Delphi panels decided that consensus was obtained. On the basis of consensus discussions of both Delphi panels. The members also concluded that incorporating Lunney’s 7-point scale into our instrument would allow us to measure each nursing diagnoses separately in terms of a problem label. Based on the Delphi panels’ comments.Chapter 3 instruments. each member had the opportunity to present their opinion based on the aforementioned questions. p. The four questions were as follows: (1) What is your opinion about the content of the instruments (including relevancy and completeness)? (2) What is your opinion about the structure of the instruments? (3) What is your opinion about the instruments’ specificity for measuring nursing documentation? (4) What is your opinion about the usability of the instruments in hospitals? During the first plenary Delphi session.. and the Catch-Ing instrument for measuring intervention and outcome evaluations and legibility. and signs and symptoms. because they agreed on the items of the new D-Catch instrument (Figure 2). Pilot study Using a draft version of the D-Catch instrument. these items needed to be modified to fit the broader hospital context. Thus. the panels surmised that the Cat-ch-Ing instrument was not directly applicable for measuring the accuracy of nursing documentation in hospitals. All patients gave written informed consent to have the documentation in their patient records assessed in our pilot study. During the pilot study. Nevertheless. all nurses selected for the measurement in the pilot study since they had their specialty in nursing documentation in hospital practice. as does the Cat-ch-Ing instrument. and two 54 . the two Delphi panels selected Lunney’s Scale for Degrees of Accuracy in Nursing Diagnoses as the basis for measuring nursing diagnoses. since it contains items specifically designed for use in a problem-based nursing care plan in the Swedish VIPS model (e. two pairs of reviewers assessed 60 patient records from four different nursing wards in two hospitals. that is the PES structure.12).g. The linguistic validation of the D-Catch was performed by forward and backward translation by two independent translators.

The course was subdivided into the following sections: (a) an individual study of the theoretical background of nursing documentation and the use of the NANDA-I classification. The reviewers and two Delphi panelists reached consensus on how to improve the D-Catch instrument by developing a guide on scoring nursing diagnoses— Guide A & B for Diagnoses (Figure 3)—and by completing a 20-hour training course on how to score items on the D-Catch. Figure 3 contains Guide A & B for Diagnoses. none = 1 point.62). (b) an individual review of the skills needed to use the D-Catch instrument. Quantity criteria address the question: “Are the PES components of the diagnosis present?” Quantity criteria can be scored as follows: complete = 4 points. Reliability results from the pilot study indicated that the D-Catch instrument was suitable for measuring the accuracy of the record structure. however. This process provided valuable information enabling us to refine the measurement process and the instrument. The D-Catch instrument The final version of the D-Catch instrument quantifies the accuracy of the (1) record structure (according to the nursing process). (3) nursing diagnosis (PES structure.Development and psychometric testing of the D-Catch instrument Delphi panellists evaluated the properties of the D-Catch instrument after the assessment of approximately every 20 records. the entire review process was considered in detail during a measurement training session supervised by an expert nurse. and the specific measurement form used for nursing diagnosis (this form can be used as a tool to achieve consensus on the accuracy score of each diagnosis found in a record). which outlines scoring of the quantity and quality criteria of the D-Catch. and (c) skills needed to discuss consensus. thus. (6) legibility (readable handwriting or typewritten). 55 . potential intervention based on the diagnosis). a list was compiled of the reviewers’ experiences and achievements and of common flaws in their measurement approach while using the D-Catch instrument. partially complete = 3 points. differed in their interpretation of the quantity and quality criteria scores for the nursing diagnoses and concluded that this type of subjectivity was unacceptable. The reviewers agreed that they scored these items in a comparable way. (2) admission data (information from the admission interview). Subsequently. Guide A & B for Diagnoses. incomplete = 2 points. admission data. Therefore. (5) progress and outcome evaluations (related to the nursing diagnoses). obtaining consensus scores based on brief consensus discussions was possible. (4) nursing interventions (related to the nursing diagnoses). in preparation for implementing trial measurements in a hospital practice setting. The reviewers. interventions. and legibility (weighted kappa > 0. At the beginning of the training. Items 2-5 are measured as a sum score of quantity and quality criteria. most of the reviewers were not experts in nursing documentation and had to learn more about the theoretical background underlying documentation and the associated skills. and progress and outcome evaluations.

we invited two other hospital managers to take part. according to Fleiss et al. Two reviewers assessed each of the records independently. The 245 records were assessed by 8 pairs of reviewers (12 reviewers participated and some changed partners during the assessment. hence the 8 pairs).Chapter 3 Quality criteria address the question: “What is the quality of the description with respect to relevancy. 245 patient records from 25 wards were assessed with the D-catch instrument. Items 1 and 6 are measured on a 4-point Likert scale according to the aforementioned quality criteria. single) analyses—which were used if an overall agreement on a variable was obtained—and the results of weighted kappa (Kw) analyses with linear weighting. we asked a nurse from the participating wards to select 10 records based on two criteria: (1) patient length of stay was at least 3 days. poor = 1 point. although Kw values were lower than the intraclass correlation coefficients. The reviewers were registered nurses (n= 4) or fourth-year bachelor’s degree nursing students (n= 8). 56 . we presented the conventional inter-rater reliability of Kw. We invited manager directors of the hospitals to take part in our study. Sample Of the 94 medical centres in the Netherlands in 2007 (86 general hospitals and 8 university hospitals). and linguistic correctness?” Quality criteria can be scored as follows: very good = 4 points. Construct validity was assessed using explorative factor analysis with principal components. All components of the records of each consenting patient were included. The outcomes were highly related. moderate = 2 points. specific reasons for declining were not given. and (2) patients’ ability to give written informed consent. All completed the 20-hour training course on how to score items on the D-Catch. Since we used an ordinal scale. Each hospital manager in our sample was asked to contribute at least 10 patient records from at least one hospital ward. and varimax rotation was used to identify underlying constructs. (2003). good = 3 points. we randomly selected 7 of these hospitals. We compared the results of the intraclass correlation coefficients (one way. Two manager directors did not consent to participate. For our calculations we used VassarStats on-line statistics software (Lowry 2008). Statistical analyses SPSS version 14 was used for factor analyses and for assessing internal consistency. On the basis of the regional inclusion criterion. Internal consistency was assessed using Cronbach’s alpha. unambiguity. In total. This sample was a part of a larger study addressing the prevalence of the accuracy of the nursing documentation in the Netherlands. which were located in different parts of the country. to test the accuracy of the D-Catch in hospital settings. Data collection On the day of the measurement.

722.516 0. The inter-rater reliability of the D-Catch was calculated using eight pairs (n= 245 records). Construct three was named ‘legibility accuracy’ (Table 1).8% and 17.7 and the variance accounted for was 45. accuracy of the report on admission. the interventions. resulting in a Kw between 0. Eigen values were 4.084 -0.480 0. We named this construct ‘chronologically descriptive accuracy’.4%.874 0. 57 . Construct 2 contained only one item: accuracy of the nursing diagnoses.Development and psychometric testing of the D-Catch instrument Results Construct validity Three underlying constructs were identified in the D-Catch instrument.448 0.032 0. n = 245 records).878 0.494 Communalities *Extraction method: explorative factor analysis with principal components and varimax rotation. as determined by Cronbach’s alpha. respectively (cumulative variance accounted for was 63. We named this construct ‘diagnostic accuracy’.707 0.742 and 0.2 %.870 0. and nursing progress and outcome evaluations.896 (Table 2).224 0.777 0.129 0.765 0.539 Component 2 0.075 -0.230 0. Table 1 Results of the factor loading of six items in the D-Catch instrument* No.5 and 1. of records: 245 Items Accuracy of record structure Accuracy of admission Accuracy of nursing diagnosis Accuracy of intervention Accuracy of progress / outcome evaluation Legibility 1 0. was 0. Reliability Internal consistency of the D-Catch instrument. Construct 1 contained the following items: accuracy of the structure of the patient record.907 -0.

for example nursing homes or primary healthcare settings.855) 0.836 (0.849-0.856 (0. Kw (CI)* 0.742 (0.771-0. Study limitations This study had limitations in several aspects.942) 0. For the assessment of nursing documentation in other healthcare settings.896 (0. The D-Catch instrument was tested in hospitals only.806 (0.Chapter 3 Table 2 Cohen’s weighted kappa (Kw) inter-rater reliability of the D-Catch instrument Accuracy scale (1-4) Record structure Admission report quantity Admission report quality Diagnosis report quantity Diagnosis report quality Intervention report quantity Intervention report quality Progress & outcome report quantity Progress & outcome report quality Legibility *CI: confidence intervals (95%-confidence intervals).747-0.792-0.711-0. For international use of the instrument.664-0. as the state of nursing documentation in other countries may be different from that in the Netherlands (Saranto & Kinnunen 2009).919) 0.725-0. additional validity and reliability testing is needed. 58 .859) 0. The results of the D-Catch measurement are based on a study in the national context of a single country.845 (0.803 (0.822) 0.743-0.776 (0.900) 0.788-0.699-0.767 (0.835) 0.840) 0.902) 0. more studies are needed to test the validation and reliability further.790 (0.868) Discussion This paper presents the results of a study that developed and psychometrically tested a new instrument (D-Catch) for measuring the accuracy of nursing documentation in general hospital settings.

As we interpreted the factor loading of the variable ‘legibility’. we concluded that homogeneous scores might underlie the lack of discrimination between the components. we noted that the item ‘diagnosis’ was the only variable with substantial loading on component two (0. this may be because the factor model we used does not work well in the case of this variable. and then to determine the accuracy of interventions. a ‘chronological. interventions. we found that interactions between the panellists during consensus discussions yielded the most valuable arguments that were ultimately used to choose the final criteria of the new D-Catch instrument. Taking the communalities and the interpretation of the factors into account (Table 1). since its communality is low (0. Additional exploration of this variable is required in order to determine the reason for this finding. descriptive component’ and a ‘diagnostic component’ may underlie the D-Catch instrument. The ability to separately assess each diagnosis in the nursing documentation. The specific diagnosis measurement form and Guide A and B for Diagnoses were tools that aided in achieving consensus on the accuracy score of each diagnosis. These previous studies were valuable in discussing the foundation of the D-Catch instrument in rather small panels. The Kw values and the results indicate that the reviewers disagreed mostly during the rating of two items: ‘accuracy of intervention report’ and ‘accuracy of progress and outcome report’. From the results of the reliability analysis. According to Sermeus (1993). We conclude that the internal consistency of the D-Catch instrument.Development and psychometric testing of the D-Catch instrument Validity and reliability of the D-Catch instrument The results show that the instrument had acceptable validity and reliability when used in general hospital settings. 59 .722 (n=245 records). We used two Delphi panels to analyse the criteria of existing instruments. was 0. Therefore. although these items also received high scores. To obtain detailed information on the inter-rater reliability of the D-Catch. as determined by Cronbach’s alpha. However. Reflecting on this qualitative approach. we calculated the Kw of each item.230). even though all the reviewers were trained the same way. On the basis of patterns of item loadings (Table 1). was an efficient and systematic assessment approach that produced satisfactory reliability results. descriptive way of documenting admission information. and progress and outcome evaluations. we conclude that the variable ‘accuracy of the admission documentation’ has little in common with the others. The reason for this finding may be that we measured a chronological. we conclude that the reliability outcomes between pairs of reviewers differed. nursing documentation can be subdivided into chronological registration and problem-oriented registration. Further validation of this item is required. Elements of similar instruments have been evaluated in earlier studies in the United States (Lunney 2001) and Sweden (Björvell et al.907) and modest loading on component one (0. Björvell 2002).224). 2000. and progress and outcome evaluations on the basis of both quantitative and qualitative criteria. which is an acceptable index for estimating the homogeneity of the measure composed of the D-Catch subparts (Polit & Beck 2007).

60 .Chapter 3 This suggests that measurement outcomes may be influenced by a reviewer’s personal interpretation of the documentation. Differences in documentation complexity may be another factor that contributed to the variability in measurement outcomes. Consequently the D-Catch instrument may be valuable to determine the quality of nurses’ documentation in more dept to distinguish areas for improvement. But an international gold standard for accurate nursing documentation is not yet acknowledged. We recommend that future assessments should evaluate the inter-rater outcomes as a part of the assessment process evaluation. 2003. in nursing homes. As Saranto & Kinnunen (2009) have stated. This may also contribute to the development of a standardized nursing language and facilitate further development of electronic nursing documentation devices. for instance. International research collaborations should evaluate the existing nursing documentation measurement instruments for further validation in an international context. For the assessment of documentation in other health care settings. Conclusion As stated by the World Alliance for Patient Safety (2008). This appears to be achievable since the psychometric properties of the D-Catch are estimated to be satisfactory in general hospital settings. the lack of standardized nomenclature for devices and reporting hampers good written documentation. additional reliability and validity testing is needed. Thus. the latter type was often associated with long-stay situations. Documentation ranged from brief and structured summaries to 10-page or more unstructured patient accounts overflowing with redundancies. nursing documentation is an important area of research. or primary health care settings. we have to take into account this subjectivity. Polit & Beck 2007). We conclude that there was no item with outstanding inter-rater reliability scores and that the scores were satisfactory (Fleiss et al.

D-Catch magnitude: (4): Complete (3): Partially (2): Incomplete (1): None (Quantity) (4): Very good (3): Good (2): Moderate (1): Poor (Quality) D-Catch is available in a paper version and in an electronic version.:◘ Electronic rec. therefore. It is important. that the measurement is performed independently by two different persons. Complete the measurement form individually and compare scores afterwards to obtain consensus scores. usable as a stand alone application.:◘ Paper rec. 61 .:◘ No. SPSS◘ Click on buttons [◘] to fill in (electronic version) There is always a certain amount of subjectivity when measuring patient records.Development and psychometric testing of the D-Catch instrument Figure 2 The D-Catch Instrument D-Catch Measurement Method for Nursing Documentation in the Patient Record Date:◘ Hospital:◘ Ward:◘ Record no.

Chapter 3 D-Catch 1) Is an accurate nursing record structure present? 4 points: An individual record is present with a structure that allows describing: 1) Personal details of the patient 2) Assessment form and admission data 3) Nursing problem inventory (nursing diagnoses) 4) Nursing interventions inventory 5) Daily progress report with outcome evaluations inventory 3 points: An individual record that contains 4 of the 5 items listed above 2 points: An individual record that contains at least a note of personal details and a progress evaluation report form 1point: It is not possible to note details in an individual nursing record or the items are included in a collective record with other patients’ details. 4 Score Consensus score ◘ ◘ 3 ◘ ◘ 2 ◘ ◘ 1 ◘ ◘ 62 .

and contain all relevant information needed to admit the patient. linguistically incorrect. or the notes are unclear. 3 points: The admission report contains the medical diagnosis and reason for admission but not a nursing diagnosis. address. but they are not always clear or linguistically correct. The notes are clear. marital status). the reason for admission. both name and address and information about the reason for admission / state of health are missing. linguistically correct. Quality 4 points: The admission report contains the medical diagnosis and reason for admission with relevant aspects of recorded diagnoses. date of birth. 4 Score (first quantity) Consensus Score ◘ ◘ 3 ◘ ◘ 2 ◘ ◘ 1 ◘ ◘ 4 ◘ ◘ 3 ◘ ◘ 2 ◘ ◘ 1 ◘ ◘ 63 . 1 point: There is no admission report or reason for admission. There are some correct notes. 2 points: The admission report contains some medical issues but not a medical or a nursing diagnosis. 1 point: Personal details and the reason for admission / state of health are not documented. 2 points: Personal details are incomplete. and the patient’s state of health of the patient are fully documented.Development and psychometric testing of the D-Catch instrument D-Catch 2) Is an accurate nursing report about the admission present? Quantity 4 points: Personal details (name. the patient’s name and address or information about the reason for admission / state of health are missing. Most of the notes are clear and contain relevant information needed to assess the patient. 3 points: Personal details are partially available.

Please score on additional form diagnosis accuracy 64 . the diagnosis implies the possibility of an intervention. The diagnosis is not contradicted by other notes. These notes are not contradicted by other notes in the same record. an aetiology / a cause or a sign / symptom is listed with reference to a possible intervention or with reference to a vaguely described intervention. and a sign / symptom are clearly and unambiguously listed in the text. an aetiology / a cause (related factor). or is linguistically incorrect. but these questions appear to be relevant. 2 points: A diagnosis label is suggested by a note from the report but is unclear or linguistically incorrect. or is contradicted by other notes in the same report. but no (planned) intervention is listed. No reference is made to an intervention. Alternatively. 1 point: A diagnosis label is mentioned but not supported by any note. 3 points: A problem label. an aetiology / a cause. 1 point: A note relating to a problem label is listed with no further explanation. 3 points: The diagnosis raises diagnostic questions. Quality 4 points: The diagnosis is supported by one or more relevant notes from the report concerned. The diagnosis raises no other diagnostic questions and is linguistically correct.Chapter 3 D-Catch 3) Is an accurate nursing diagnosis structured in PES present? (Please note: see also supplemental Guide A & B for Diagnoses) Quantity 4 points: A problem label. and a sign / symptom are listed. 2 points: A problem label and either an aetiology /a cause or a sign / symptom is listed with reference to either a planned intervention or a not clearly described intervention.

4 Score (first quantity) Consensus Score ◘ ◘ 3 ◘ ◘ 2 ◘ ◘ 1 ◘ ◘ 4 ◘ ◘ 3 ◘ ◘ 2 ◘ ◘ 1 ◘ ◘ 65 . the notes are unclear. Some notes may contain unnecessary wording or relevant information is missing. linguistically incorrect.Development and psychometric testing of the D-Catch instrument D-Catch 4) Are accurate interventions present? Quantity 4 points: Each intervention in terms of nursing actions is linked to or can be directly related to a diagnosis. 1 point: Generally. linguistically correct. 1 point: No interventions in terms of nursing actions are mentioned. 3 points: At least 50% of the notes meet the above description. and contain all relevant information needed to act. Quality 4 points: Interventions are clear. 2 points: Interventions have been noted. These interventions are described in terms of the aim for which they are used and are logical results of the diagnosis. the language in some notes is incorrect (e.. but less than 50% are related to the diagnosis. and relevant information is missing. These interventions are described in terms of the aim for which they are used and are logical results of the diagnosis.g. The aim for which the interventions are used is unclear. use of non-standard abbreviations that can be misinterpreted). incomplete sentences. concise. there are some correct notes. The intervention date is mentioned. 3 points: At least 50% of the interventions in terms of nursing actions are linked to or can be directly related to a diagnosis. 2 points: Less than 50% of the notes are written as described above.

in less than 50% of the evaluations. The progress evaluations are fully available and updated daily. 3 points: At least 50% of the progress evaluations in terms of nursing outcomes is linked to diagnoses. 2 points: Less than 50% of the notes are written as described above. Interventions are described in terms of the patient’s health status and are logical results of the diagnosis and the intervention. and contain all relevant information needed to understand the patient’s health status. the patient’s health status is mentioned in terms of outcomes. Some notes may contain unnecessary wording or relevant information is missing. incomplete sentences. the language in some notes is incorrect (e. linguistically incorrect. use of non-standard abbreviations that can be misinterpreted). Updates for several days of the week are missing. concise.. Interventions are described in terms of the patient’s health status and are logical results of the diagnosis and the intervention. there are some correct notes.g. The evaluation date is stated. No outcomes are mentioned. 1 point: The progress evaluations are not available. 4 Score (first quantity) Consensus Score ◘ ◘ 3 ◘ ◘ 2 ◘ ◘ 1 ◘ ◘ 4 ◘ ◘ 3 ◘ ◘ 2 ◘ ◘ 1 ◘ ◘ 66 . Quality 4 points: The progress evaluations are clear. The progress evaluations are not updated daily (but are updated at least 6 days a week).Chapter 3 D-Catch 5) Are accurate progress & outcome evaluations present? Quantity 4 points: The progress evaluations report nursing outcomes related to nursing diagnoses. linguistically correct. the notes are unclear. There is no logical relationship between diagnoses and interventions. and relevant information is missing. 1 point: Generally. 3 points: At least 50% of the notes meet the above description. 2 points: The progress evaluations are incomplete.

and the reader must guess what the text states or means 4 Score Consensus score ◘ ◘ 3 ◘ ◘ 2 ◘ ◘ 1 ◘ ◘ END OF MEASUREMENT 67 . barely legible. overall. 1 point: Most of the text is illegible. 3 points: The handwriting forces the reader to reread the text. 2 points: The text is written sloppily and is. but some parts of the text are legible.Development and psychometric testing of the D-Catch instrument D-Catch 6) Is the record legible? 4 points: The text is written clearly or typed legibly.

and linguistic correctness?”) 4 points: (relevant) + (completely unambiguous) + (linguistically correct) 3 points: (relevant) + (not unambiguous) + (linguistically correct) 2 points: (unclear but relevant) + (ambiguous) + (linguistically incorrect) 1 point: (not relevant) + (ambiguous) + (linguistically incorrect) Very good Good Moderate Poor 68 . E= Aetiology.Chapter 3 Figure 3 D-Catch Guide A & B for Diagnoses GUIDE FOR DIAGNOSES A Quantity (Main question: “Are the PES components of the diagnosis present?”) (P= Problem. unambiguity. I= reference to a potential intervention) 4 points: 3 points: (P+E+S)→(I) (P)+(E)+(S)→(?) or (P)+(E)+(?)→(I) or (P)+(?)+(S)→(I) 2 points: (P)+(?)+(?)→(I) or (P)+(E)+(?)→(?) or (P)+(?)+(S)→(?) 1 point: (P)+(?)+(?)→(?) None Incomplete Complete Partially complete Quality (Main question: “What is the quality of the description with respect to relevancy. S= Signs and Symptoms.

as in point no. commas. “because of” “related to (r/t)”. the diagnostic label is followed by the basis for the diagnosis. For example: “cannot insert drip”. • All nursing entries that refer to technical activities. “tissue damage (wound)” or “tissue damage. “tissue damage. “patient smokes”. etc. “therefore”. Patient was fumbling with the sheets. This means that the text should be clear and cohesive and should contain link words such as “because”. Therefore. wounds on feet (poor blood circulation peripheral vessels. “subsequently”. Patient was restless. varying blood sugar levels)”. Diagnostic terms associated with parentheses. 4. text is treated as clear and coherent text. “patient walked in the corridor”. In records in which the diagnoses and resulting interventions are stated in different places but it is evident that these diagnoses are part of the identified interventions. A diagnosis should form a textual whole. 1. 2. NO SCORE: • All nursing entries that clearly report an observation without a diagnostic label. For example: “250 ml urine in container”. (Link words may be substituted with arrows. 69 . hyphens). “owing to”. The diagnostic label should precede link words. In this example.g. or commas—for example. and scored accordingly. which is stated within parentheses. However.. signs / symptoms can be enclosed within parentheses or brackets—for example.Development and psychometric testing of the D-Catch instrument D-Catch GUIDE FOR DIAGNOSES B 1. 3. “Patient was in acute pain. wound”—are scored as diagnostic labels not as signs / symptoms.” It is clear from this example that the diagnostic label is acute pain and that the subsequent sentences refer to signs / symptoms. 5. E. “dressing has leaked”. Vague sentences without link words are not considered as a coherent whole but as separate sentences. “drain is blocked”. brackets. each of these types of sentences is scored separately. Assess the use of brackets on a case-by-case basis. Consecutive sentences and/or phrases without link words but clearly forming comprehensive whole text may be read as one diagnosis.

M. M. 608-610. 16 (4). Bellinger.J. 70 .. R. instrument development and evaluation of a comprehensive intervention programme. (1995). Wolters Kluwer. Nursing Documentation in Clinical Practice.. 12th edition.M. Garner-Huber. Ellerbe.. 2-8.F. (2008). M. Moorhouse.F. Fleiss. J. Thorell-Ekstrand. Wredling. (2003). C.. Nursing Standard. Arnold. M. Philadelphia. doi: 10.. An Interactive Text for Diagnostic Reasoning.. McGraw Publishers. 3-8. Philadelphia.. M. 32-54. Levin... Components of Written Diagnostic Statements. International Journal of Nursing Terminologies and Classifications. Nurses’ perceptions of care received by older people with mental health issues in an acute hospital environment. in: Naming Nursing. Björvell. B. Davis Company. Journal of Medical Systems. Lippincott. J. 15 (6): 307-315.. Mehmert. Application of Nursing Process and Nursing Diagnosis. Karolinska Institutet. Amsterdam. K. (2003)..C. Doenges. L. Criteria for Nursing Information Systems as a Component of the Electronic Patient Record: An International Delphi Study. Goossen. Medical Research Methodology 37 (5). 20 (10).J. 33-38.M. Ehrenberg. p. Gordon. Nursing diagnoses: process and application. p.. Lippincott Company. Ehnfors. Third Edition. Delaney. Mitchell. New York. p.L. edition 4. Stockholm. J. M.J. 29-36. International Journal of Nursing Terminologies and Classifications. 6-13. International Journal Of Older People Nursing. New Jersey. P. Cole. Tolson.R. The NANDA definition of nursing diagnosis. (2003).B. Epping. 28-34. Björvell.. (2000). Nurses’ experiences of working with trauma patients. M.R. J. Computers in Nursing. Quality in Health Care.A.L. Bern. D. (1994). Development of an audit instrument for nursing care plans in the patient record. (1991). PhD-thesis. Prophet.Chapter 3 References Akins. Johnson.) Hans Huber. (1992). H. Stability of response characteristics of a Delphi panel: application of bootstrap data expansion.M. Quality of Nursing Diagnoses: Evaluation of an Educational Intervention. S.A. Paik. Carpenito-Moyet. 6. A. Curtis. p.F. Clark. Capturing Patient Problems: Nursing Diagnosis and Functional Health Patterns. (Ed. T. C. B.E. (Ed. (2001). F. (2008). T. Standardized nursing language for healthcare information systems. Nursing Diagnosis: Application to Clinical Practice. Th. p. (2002). J. New York. 9.).R. (2005)... Carpenito-Moyet. C. 16 (9). 87-94. L. Dassen. Wiley-Interscience. C.. 145-159. Dobrzyn. 33-34. Statistical Methods for Rates and Proportions. 16 (2). C.1186/1471-2288-5-37.B. P. R. Gordon. (2005). Proceedings of the Ninth Conference. Florin. In: Classifications of Nursing Diagnoses. I. (1997). S..

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.V. Sermeus. Tjeenk Willink. Journal of Advanced Nursing. (Eds.M.Chapter 3 Saranto. Paediatric Nursing. (Ed). St Louis. (2005) Computerised versus handwritten records.the state of the art as reflected in graduate students’ work.K.M. M. (2009). Samsom. 127-128. G.J. p. fourth edition. p.). Mosby Company. Alphen aan den Rijn. (1993). 72 . (1984). In: Classification of nursing diagnoses.M. 65 (3). in: Verpleegkundige registratie. M. 464-476. Nursing diagnosis . W. J.M. Whyte. Evers. World Alliance for Patient Safety (2008). McFarlane & McLane A.M. C. Nursing Process and Critical Thinking. Guidelines for Safe Surgery (First Edition). World Health Organization.C. S. Kim. Evaluating nursing documentation – research designs and methods: systematic review. Pearson Prentice Hall. U. H. Ziegler. K. Kinnunen.H. Geneva.. Methoden van verpleegkundige registratie. Wilkinson. (2007). W. WHO Press. 15-18.O.D. G. 17 (7). 61-62. New Jersey.

Walter Sermeus.2010. Journal of Advanced Nursing.x 73 .B. This chapter is published and reproduced with the kind permission of Wiley and Sons: Prevalence of accurate nursing documentation in the patient record in Dutch hospitals. van der Schans. Nieweg. doi:10.1111/ j. Cees P. 66 (11). Roos M.Prevalence of accurate nursing documentation in the patient record CHAPTER 4 Prevalence of accurate nursing documentation in the patient record in Dutch hospitals Wolter Paans. 2010.05433.1365-2648. 2481-2490.

Moreover. and progress and outcome evaluations in hospital settings (Bostick et al. additional clinical signs. McFarland & McFarlane 1997. Saranto & Kinnunen 2009). Accurate nursing documentation allows nurses to evaluate nursing outcomes as a logical result of nursing diagnoses and interventions (Delaney et al. relevant. Additionally. Moloney & Maggs 1999. Müller-Staub et al. Knowledge based on studies completed in several different countries on the nature of nursing reports might contribute to the development of international resources for documentation accuracy improvements. Sweden. 2005. or on the implementation of a nursing model in a specific hospital setting. 2006. and unambiguous. accurate documentation addresses admission data. 1996. and Switzerland in a limited number of hospitals. as well as linguistically correct. 1992). Müller-Staub et al. The documentation needs to be coherent. Müller-Staub 2007). Indeed. Müller-Staub et al. and related factors (Martin 1995. focused on the influences of education programmes. Although there is no internationally accepted gold standard for measuring the accuracy of nursing documentation. Needleman & Buerhaus’ review (2003) led them to conclude that the greatest conceptual issue impeding better nursing-related patient safety is failure to recognize that nursing processes are not well documented. several studies have reported that the patient records they examined contained relatively few precisely formulated diagnoses. Doenges & Moorhouse 2008). thereby adversely affecting efficiency and patient safety (Committee on the Work Environment for Nurses and Patient Safety 2004). and a few of these studies described the relationship between the accuracy of reported admission information. Moreover. poor layout of communication technologies reduces the amount of time nurses have to provide direct care. nursing diagnoses. interventions. interventions and progress and outcome evaluations. Nordström & Gardulf 1996. 2006. Björvell 2002). Saranto & Kinnunen 2009). 2006). the phases of the nursing process are internationally acknowledged as having the theoretical elements needed for accurate nursing documentation (Gordon 1994. most studies examined the accuracy of nursing reports. these studies might encourage the development of an internationally accepted gold standard for nursing documentation accuracy as well (Florin et al. 2003. Nevertheless. and failures in these processes that lead to adverse outcomes often fail to be observed or documented in patient charts. The above-mentioned studies were carried out in the United States of America. pertinent signs and symptoms. It is internationally acknowledged that a nurse’s ability to report a patient’s problems or complaints. nursing diagnoses. and that the details of interventions and outcomes were poorly documented (Ehrenberg et al. and patients’ responses is important for the patients’ safety and well being (Carpenito-Moyet 2008. 74 . on report improvements.Chapter 4 Introduction The ability to document both patients’ responses to an illness and information regarding the care given is a core competence of nurses (Wilkinson 2007).

2006). The D-Catch instrument quantifies the accuracy of the following items: (1) Record structure (according to the phases of the nursing process) (2) Admission data (information of the admission interview) (3) Nursing diagnosis (problem label. McCargar et al. Nurses initiated international exchanges with the goal of developing standardized nursing diagnoses (e. Johnson et al. Disability. 2006. NANDA-I 2004. 10. if the accuracy of nurses’ reports is to improve (Kurihara et al. p. Pathologic signs were recorded. Nursing Intervention Classification. and accurate nursing reports in the patient record (Gordon 1994. They also supported multidisciplinary classification systems such as the International Classification of Functioning.g. 371). Henderson and Nite remarked that a common flaw in narrative problemoriented notes was that the notes tended to be confined to physical manifestations and abnormalities. In 1978. Furthermore. the use of standardized nursing language is increasing in electronic versions of patient records (Saranto & Kinnunen 2009). understanding techniques and methods that support nurses in writing their reports is important. 24) mention that using the diagnosisoriented nursing process in clinical practice is not effective. and outcomes (e. The Study Aim The aim of the present study was to describe the accuracy of nursing documentation in hospital nursing records. Methods and instruments We used the D-Catch instrument to measure the accuracy of nursing documentation. NANDA). Pesut and Herman (1999. standardized. Cheevakasemsook et al. 2001. 2001. signs and 75 . and normal behaviour were neglected (Henderson & Nite 1978. it is unclear whether the problem-oriented nursing process leads to accurate nursing reports (Heartfield 1996. However.g. As a result in clinical practice. 2004). 2007). Kautz et al. Nursing Outcome Classification. 2006). NIC). whereas moods. NOC) (Johnson et al.Prevalence of accurate nursing documentation in the patient record Background The introduction of the nursing process to hospitals in the United States and Europe. interventions (e. prompted nurses to think seriously about the importance of systematic. McFarland & McFarlane 1997. because receiving training on how to apply the nursing process does not guarantee accurate documenting performance (Pesut & Herman 1999. p. 2007). and Health (ICF) and the Systemized Nomenclature of Medicine Clinical Terms (SNOMED CT). aetiology or related factors. favourable signs. Törnvall et al. p. combined with information on the value of nursing diagnoses from the North American Nursing Diagnosis Association (NANDA) in the early 1980s. Assessment of nurses’ reports in the patient record can also be helpful for determining the content and structure of future electronic report systems. attitudes. Cheevakasemsook et al.g.

36. they were replaced by other hospital directors from that region with a response rate of 4 out of 6. and legibility) and a diagnostic accuracy construct (nursing diagnosis). comprising the sample size of the study. and linguistic correctness?” Quantity criteria can be scored as follows: complete = 4 points. stratification by province was applied. good = 3 points. p. Quality criteria can be scored as follows: very good = 4 points. and (2) patients’ ability to give written informed consent. Each record was assessed by both reviewers independently. The records were assessed by individual external reviewers who worked in pairs. (86 general hospitals and 8 university hospitals). Afterwards they discussed their scores until a consensus and final accuracy score were reached. 76 . 276) and the Cat-ch-Ing instrument (Björvell 2002). The manager directors were asked to select at least one ward per hospital. partially complete = 3 points. The inter-rater reliability of the D-Catch instrument was tested on a convenience sample of the first seven hospitals (25 wards and 250 records). the same as the aforementioned quality criteria.896. On the day of the measurement. therefore. a nurse of the ward was asked to select 10 records out of all records available in the ward on the basis of two criteria: (1) patients’ length of stay was at least 3 days. Quantity criteria address the question: “Are the components of the documentation present?” Quality criteria address the question: “What is the quality of the description with respect to relevancy.Chapter 4 symptoms. p. with respect to criteria and information structure. As four hospital manager directors declined. In 10 hospitals—35 wards—341 records were assessed.742 – 0. incomplete = 2 points. Internal consistency reliability for 245 patient records was calculated by Cronbach’s Alpha: 0. a diagnosis establishes the prospect of an intervention) (4) Nursing interventions (related to the nursing diagnoses) (5) Progress and outcome evaluations (related to the nursing diagnoses) (6) Legibility (readable handwriting or typed) Items 2-5 are measured as a sum score of questions addressing quantity and quality criteria.722. the manager directors asked heads of the nursing staff to volunteer in reviewing records. In case of rather large wards it was possible to take an additional sample of ten records to review from the same ward. moderate = 2 points. The selection of the wards was carried out by the manager director of the hospital in question. Population and sample Of the 94 medical centres in the Netherlands. admission data. we randomly selected 10 of these hospitals. Item 1 and 6 are measured on a 4-point Likert scale. none = 1 point. poor = 1 point. also known as the diagnostic PES structure. interventions. Cohen’s weighted kappa (Kw) varies from: 0. unambiguity. It appeared to be unfeasible to take a random sample of wards per hospital. The D-Catch instrument consists of a chronological descriptive accuracy construct (record structure. progress and outcome evaluations. The D-Catch instrument is a modification of the Scale for Degrees in Accuracy of Nursing Diagnoses (Lunney 2001.

Statistical analyses For the statistical analyses. Registered nurses (n= 4) and fourth-year bachelor’s degree nursing students (n= 8) who received the 20 hours training reviewed the records. the SPSS Benelux software package version 14 was used. it was required to accomplish a 20-hour training addressing the theoretical background of nursing documentation and measurement skills. Explorative factor analysis with principal components and varimax rotation was performed to confirm underlying constructs. including 35 wards (Table 1) and seven different specialties (Table 2). Results We assessed patient records (n= 341) from 10 hospitals. We aggregated and transformed construct scores according to a 100-point scale. means and standard deviations were calculated. Training also included a skill program on how to reach consensus by using discussion techniques after each record is assessed separately. Frequencies in percentages scores. Ward nurses were not familiar with the content of the D-Catch instrument and were not informed about when and where the assessments were to take place. Table 1 Sample accuracy of the nursing reports Hospital category General Subtotal Total University General & university n of Hospitals 9 1 10 n of Wards 32 3 35 n of Records 296 45 341 n of Diagnoses 1746 175 1921 77 .Prevalence of accurate nursing documentation in the patient record To be qualified as a reviewer.

and 38% were not structured at all according to these phases. which was the maximum number of diagnoses observed. 34% were more or less structured according to the nursing process phases. cardiology. Highest accuracy scores were found on the admission report and the progress and outcome evaluations: resp. and pulmonology. the evaluations contained unnecessary wording or lacked relevant 78 . haematology. b Paediatric ward with units for specialized care for children under 16 years of age. and eight records contained 20 diagnoses. In these records. 80% and 64% of the records revealed a score over 5 (range: 2-8). most of the notes were clear and contained relevant information. 28% contained all of the nursing process phases. In more than 50% of the notes.3) diagnoses per record. The mean (SD) number of diagnoses was 6 (4. At least 50% of the progress evaluations were linked to diagnoses and interventions and appeared to logically result from the diagnosis.Chapter 4 Table 2 Nursing wards in sample Wards Internal medicineª Intensive care Neurology Obstetrics Orthopaedics Paediatric medium careb Surgeryc Totals n of Hospitals 9/10 2/10 6/10 1/10 4/10 1/10 10/10 10/10 n of Wards 11 2 6 1 4 1 10 35 n of Records 110 17 70 18 48 10 68 341 n of Diagnoses 710 77 458 40 176 117 343 1921 ªInternal medicine wards include specific care units for medical oncology. and plastic surgery. marital status) were present in over 95% of the nursing records. The personal details of patients (name. address. Five records described no diagnoses. Of the 341 records examined. More than 50% of the admission information was complete and contained medical diagnoses and reasons for admission. Lowest scores were found on the accuracy of the documentation of the interventions: 5 percent of the records revealed a score higher than 5 (2-8) (Table 3). urology. however. date of birth. c Surgical wards include specific care units for surgical oncology.

good. the purpose of the intervention was unclear. variable 2-5 as a sum score of a four-point quality and quantity criteria scale (2-8). 3. these records were scored as “incomplete” and “ambiguous. b Scale scores: 1. if they consisted of incomplete sentences and non-standard abbreviations that could be misinterpreted. The chronological descriptive construct had a mean (SD) score of 54 (15).” This translated to an accuracy sum score of 4 (range: 2-8 points) for records that listed diagnostic labels but no related factors or diagnostic labels and no signs and/or symptoms. the interventions. very good. The legibility accuracy construct contains only one item as well. the reports contained unnecessary wording or lacked relevant information. for example. Thus. Less than 50% of the interventions were related to diagnoses.Prevalence of accurate nursing documentation in the patient record information.230). Although some correct notes did exist. The diagnostic accuracy construct contains only one item: the accuracy of the nursing diagnoses. Factor analyses confirmed our previous findings that the D-Catch captures three constructs (Paans et al. on the basis of quantity and quality criteria for diagnoses.907) and a low loading on component one (0. whereas the diagnostic construct had a mean score of 40 (27) and the legibility construct had a mean score of 41 (27). in over 50% of the intervention notes. and in more than 50% of the intervention notes. Based on patterns of item loadings. Table 3 D-Catch Scores of Accuracy of Documentation in the Nursing Record Items of the D-Catch instrument Accuracy of the Record Structure Accuracy of the Admission Documentation Accuracy of the Diagnosis Documentation Accuracy of the Intervention Documentation Accuracy of the Progress and Outcome Evaluation Legibility \ a Scalea 1-4 2-8 2-8 2-8 2-8 1-4 1 1 <3 2 <3 28 <3 51 <3 1 1 3 Scale Scores in Percentagesb N 2 37 >3<5 18 >3<5 48 >3<5 44 >3<5 35 2 30 3 34 >5 < 6 32 >5 < 6 14 >5 < 6 4 >5 < 6 24 3 66 4 28 >6<8 48 >6<8 10 >6<8 1 >6<8 40 4 1 341 341 336 341 341 341 Note: D-Catch measurement variable one and six on a four-point scale. 2. poor. 4. As a result of recoding the scale scores to a 100-point scale. Notes were incorrect. the accuracy of the nursing report on the admission. the item ‘diagnoses’ was the only variable with substantial loading on component two (0. moderate. The chronological descriptive accuracy construct contains the following items: accuracy of the structure of the nursing record. and the nursing progress and outcome evaluations. 2010). 79 . we found that nursing documentation was more chronologically descriptive than diagnoses based.

such as interdisciplinary or environmental characteristics of the ward. Also. Manager Directors did not explain their reasons for declining. We replaced the hospitals that declined by approaching hospital managers in the same region as those that declined.e. We used a random sample in the case of 6 out of 10 hospitals. We found that records containing several accurate diagnoses also contained inaccurate ones. in small wards with few patients. The measurement process This study presents our findings on the accuracy of nursing documentation in various hospitals and wards in the Netherlands. progress and outcome evaluations were linked to diagnoses. nurses that had a specific interest in nursing documentation). Accuracy of nursing documentation Although the records were mainly structured according to the phases of the nursing process. This way of sampling may have caused potential selection bias at the ward level. the records we included in our study may have been reviewed by nurses that oversaw nursing documentation (i. Therefore. However. we believe that our sampling method did not affect representativeness due to selection bias. the reports tended to be written and organized in chronological order.. We reviewed nurses’ documentation in seven specialties (35 wards) that differed in the conditions of the patients. we had planned to assess 10 records from each of the participating wards. patient-to-staff ratio. the number of available records was sometimes insufficient. Therefore. Manager Directors of 4 of the 10 hospitals included in the first sample declined to participate in our accuracy measurement study and had to be replaced. 80 . This approach was feasible in hospital practice despite differences in the documentation. Generally. whereas new information was located towards the end of the report. and the nursing staff’s educational background and years of experience. In the intensive care and surgical wards. These and other factors. might influence or confound accuracy scores. The ward-level sampling method we used in the present study required that managers to ask heads of ward staff to volunteer in reviewing the records. The influence of these factors was not assessed in our study. we found no significant differences between the nursing documentation accuracy scores of the four replacement hospitals and those of the six randomly selected hospitals.Chapter 4 Discussion Limitations of the study This study had limitations in several aspects. Twelve pairs of reviewers assessed the nursing documentation. not all patients were able to give informed consent. That is. the first registrations were located at the beginning of the report. Initially. and we did not pursue this issue. This may have confounded random sampling. this was not possible. however.

The sequential nature of the documentation may explain why these reports contained redundant information. The latter scenario may only be feasible when nurses become accountable for verifying their documentation in terms of a diagnostic hypothesis or a current diagnosis and when nurses report these verifications accurately (Pesut & Herman 1999). reports involving extended-stay situations were repetitious and contained redundancies of evaluative information. We found that. putting together possible outcomes and making clinical decisions in terms of interventions (Pesut & Herman 1999). Deriving diagnoses can be complex because deriving diagnoses involves a search for or a verifiable discovery of the related factors of a health problem that may not always be easily accessible (Bandman & Bandman 1995. This may be further explained by the presupposition that. 81 . p. nurses may not check or properly verify whether their chosen interventions are linked to a patient’s problems. Indeed. nurses generally do not describe these verifications in their reports. If this is indeed the case. 71-96. Moreover. most of the records we assessed included only diagnostic labels but not related factors or signs and symptoms. nurses can report evaluations of the effect of interventions in progress and outcome reports without mentioning any diagnoses. 1999. nurses may first choose nursing actions that will most likely achieve an outcome. p. as an aid to retaining information. 2006) and Pesut and Herman (1999. 2006). the evaluations represented more general appraisals of the patients’ current state of health rather than reflections based on diagnoses. p. In this case. The higher score of the chronological descriptive construct (54 ± 15) compared to that of the diagnostic construct (40 ± 27) confirms our observation that nurses tend to use a more descriptive approach in documenting than a diagnoses-based approach. On the other hand. it is evident that there may be no logical relationship between interventions and diagnoses (Martin 1995. However. Benner and colleagues (1996. Thus. nurses do not systematically report their findings according to these phases. 91). revising the nursing process into a more flexible process that would make the core element focus on nursing interventions and progress and outcome evaluations may be helpful for experienced nurses (Pesut & Herman 1998. Nordström & Gardulf 1996). This may also suggest that nurses usually do not verify their diagnoses with their patients as well (Wilkinson 2007).10. nurses may rephrase information that they had previously documented. Additionally. 24) noted that expert nurses especially are more outcome focused and less problem focussed. For example. p.Prevalence of accurate nursing documentation in the patient record However. Kautz et al. despite using pre-structured record forms based on nursing process phases. One reason for this finding may be that diagnostic inference requires more than just naming and classifying. In the present study. Choosing nursing diagnoses as the core element of nursing documentation may be helpful for avoiding redundancy and may stimulate nurses to structure their reports (Wilkinson 2007). in particular. we mainly observed reflections on interventions. on the basis of a patient’s history. expert nurses reason on how and what type of care to deliver to the patient. rather than documentation related to specific diagnoses.

the diagnoses contain a problem label (P). Wilkinson 2007). related factor. 2008. Knowledge about how to derive and to report diagnoses and interventions may be insufficient as well (Lunney 2001. Expert nurses know what steps can be safely skipped. The influence of the PES structure on the accuracy of nursing diagnoses may be more apparent when a nurse is specifically asked to use this structure consciously and actively when deriving diagnoses. 2007).Chapter 4 There are diverse reasons why nurses’ reports are in general unsystematic and incoherent (Alfaro-Lefevre 2004. 2006). if it is to be understood by patients and by nurses of various levels of experience. and signs and/or symptoms (S). p. Smith et al. Novice nurses may need to learn how to use the PES structure as a tool to aid them in cultivating diagnostic reasoning. or aetiology (E). Kautz et al. apart from using the structure to convey their findings in a way that the resulting nursing documentation is accurate. which in turn will enable them to document accurately. Their reasoning approach may not always be transparent and understandable to other nurses or novice nurses that read the expert nurses’ reports. confidence in 82 . Nurses can learn how to use diagnostic structures such as the PES structure to report accurately. p. When nurses formulate diagnoses based on the PES structure. 2-8). 1994. Nursing documentation must be understandable and must be presented in a logical order. combined. 30. Expert and novice nurses may benefit differently from a pre-structured record content. Müller-Staub 2007). With respect to expert nurses. carefully reflecting on each step (Alfaro-LeFevre 2004. Yet another reason may relate to the idea that the way nurses report their clinical judgment may reflect the characteristics of nurses’ clinical judgment. 89-100. Interventions should be described in terms of nursing actions and should be linked to a diagnosis (Carpenito-Moyet 1991. The findings of our study led us to hypothesize that the use of a nursing process-based documentation system is insufficient to achieve accurate nursing documentation. 63). 2003. Despite such a documentation system. Björvell 2002. or delayed. Lunney 2001. such as disruption of documentation activities. for instance. Novice nurses need to follow steps more rigidly. Johnson et al. Facione 2000. Several factors might influence nurses’ documentation. the ability to recognize patterns in clinical situations that are linked to patterns in the nursing process (Kautz et al. Expert nurses do not have to use diagnostic structures to analyse a patient’s problems. 2006. CarpenitoMoyet 2008. nurses fail to systematically document their findings according to the nursing process. precept structures may impede or hinder their reasoning process. One way to address the problem of inaccurate nursing documentation is to use the PES structure as a guideline for nursing documentation. a cause. p. since expert nurses use the nursing process in a flexible and dynamic way (Benner 2006). limited competence in documenting. 2003. p. 2008. A second reason relates to the hypothesis that reasoning skills and nurses’ disposition towards diagnostic reasoning influence the accuracy of nursing diagnoses and the way nurses structure their reports (Facione et al.

Hasegawa et al. in general. in hospital practice nurses might not be capable of detecting sharp distinctions across different ‘diseases’ and ‘levels of wellness’ or might be completely unfamiliar with nursing diagnoses (Bandman & Bandman 1995. The effect of this type of document innovation will be an interesting new area of research. implement. 2007). Still. may lead to uncertainties and misunderstandings by both nurses and physicians. Nevertheless. Clinical implications The present study may motivate and encourage nurse managers and nurses to develop. and use documentation guidelines and flexible and efficient electronic documentation systems in their daily hospital practice. there appears to be no interdisciplinary agreement on what accurate nursing documentation is and what it is not. Moreover. and hospital administrators may stimulate nurses to take responsibility for diagnoses documentation (Björvell 2002). the results of this study may be relevant in other countries that are in a similar situation as the Netherlands concerning the application of digital documentation systems instead of handwritten records.Prevalence of accurate nursing documentation in the patient record documentation skills. Goossen 2000. and inadequate supervision or inadequate staff development (Cheevakasemsook et al. McCargar et al. and (2) be supplemented with knowledge sources and guidelines that can aid nurses of various levels in combining all nursing process variables (Mason & Attree 1997. Mayes 2001). 83 . 2006). knowledge and a positive attitude towards nursing diagnoses by nurses. and the United States of America. For instance. the ideal system—a logically structured electronic documentation system—should have the following characteristics: (1) flexibility in using the phases of the nursing process. 2001. This type of study will enable us to acquire additional knowledge and to explore the nature of nursing documentation in more depth. we recommend that electronic record designers prepare systems that support nurses in improving the accuracy of their reports. The outcomes of the present study are comparable to those of previous studies accomplished in Sweden. we recommend conducting an international cooperative study that will assess the accuracy of nursing documentation using a measurement instrument similar to the one used in the present study. physicians. Unfamiliarity with the nursing diagnosis domain and the diagnostic language used by nurses. Recommendations On the basis of the results of this study. If we are to reach the goal of attaining accurate nursing documentation in the future. In contrast. Switzerland.

supplemented with resources such as the PES format. additional research is needed to enhance accuracy in wards of different specialties and nursing staff. might not be the only solution for obtaining accuracy. The implementation and use of electronically produced documentation. However. it might help nurses to organize their notes more accurately. Our findings suggest that nursing documentation accuracy needs to be improved in order to promote patient safety (Heartfield 1996. or a combination of these variables influenced our findings. 84 . In addition. Additional studies are required to analyze in more depth whether nurses’ diagnostic skills. the use of diagnostic structures. supplementary factors affecting the accuracy of nursing documentation. we conclude that. Determinants influencing the documentation process might be multifactorial. indicating that the concept of “accuracy of nursing documentation” appears to be heterogeneous. thus. nursing diagnoses did not comprise the core element of nursing documentation. we often encountered records that contained various levels of accuracy.Chapter 4 Conclusion On the basis of our findings. Needleman & Buerhaus 2003). in general.

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18. Bohn Stafleu. J. (2008). Evaluation of the implementation of nursing diagnostics.M. 27-33. Houten. 1388-1400.J. Nordström. S. M. Psychometric properties of the D-Catch instrument. Sermeus. Wilhelmsson. The Art & Science of Critical & Creative Thinking. Factors influencing clinical decision making. D. Journal of Advanced Nursing. Amsterdam p. New Jersey. J.B. 46 (1). Schans.. 66 (6). G. (2007). 464-476.M. 89-95. Nieweg. M. Van Loghum. Higgs. third edition. Verpleegkundige Diagnoses. (2009). J. van der. OPT: transformation of nursing process for contemporary practice. 29-36. Müller-Staub. 18 (1). (1998). & Kinnunen. Print: Wageningen. Smith. Delmar Publishers. Scandinavian Journal of Caring Sciences. Evaluating nursing documentation – research designs and methods: systematic review. Pesut. 275-277. Elsevier / Blackwell Publishing. Butterworth-Heinemann/Elsevier. W. Pearson. 87 . & Buerhaus. (2007). Scandinavian Journal of Caring Sciences. Saranto.. Definities en Classificaties 2003/2004. U. (1999). Nurse staffing and patient safety: current knowledge and implications for action. Törnvall. 65 (3). an instrument for evaluation of the nursing documentation in the patient record. New York. Nursing documentation in patient records.J. Nursing Outlook. K. J. D. Pesut. Paans. J. Wilkinson. M. Ellis.. 5-17. P. & Herman. (2003). Clinical Reasoning.. International Journal of Quality in Health Care.Prevalence of accurate nursing documentation in the patient record International Journal of Nursing Terminologies and Classifications.K. Wahren. E. & Gardulf. (1996). interventions and outcomes in nursing documentation. W.. 10 (1). fourth edition. (2010). Needleman. in: Clinical Reasoning in the Health Professions. Journal of Advanced Nursing. L.P. C. North American Nursing Diagnosis Association International (NANDA-I) (2004). (2004). & Herman. E.. Electronic nursing documentation in primary health care. PhD-thesis. Nursing Process and Critical Thinking. A. A study on the use of nursing diagnoses. 310-317. 15.

Chapter 4 88 .

This chapter is published and reproduced with the kind permission of Elsevier Limited: Determinants of the accuracy of nursing diagnoses: influence of ready knowledge. Cees P. 2010. and reasoning skills. Walter Sermeus. van der Schans. and reasoning skills. Wolter Paans. 26 (4). Roos M. Nieweg. disposition toward critical thinking. knowledge sources. knowledge sources.Determinants of the accuracy of nursing diagnoses CHAPTER 5 Determinants of the accuracy of nursing diagnoses: influence of ready knowledge. Journal of Professional Nursing.B. disposition toward critical thinking. 232-241 89 .

and attitudes toward using knowledge as well as 90 . or community responses to actual or potential health problems/life processes’ (North American Nursing Diagnosis Association International. Accurate diagnoses describe a patient’s problem. et al. knowledge sources are useful for helping health care workers to formulate standardized terminology based on the North American Nursing Diagnosis Association International (NANDA–I). Several factors are known to influence students’ and graduates’ diagnostic processes. 2004). and reporting of actual and potential problems in terms of an understandable diagnosis could have an adverse effect on the quality of patient care (Kautz. Wilkinson 2007). and clinical paths (Goossen. 2005). 2003. related factors (aetiology) and defining characteristics (signs and symptoms). For nursing diagnoses. as included in the Handbook of Nursing Diagnoses (Carpenito 2002). Gordon 1994. as suggested by Cholowski and Chan (1992) and Martin (1995). Gulmans. An accurate nursing diagnosis is essential to provide highquality nursing care (Lunney 2001. analysis. however. 2007). diagnoses should also be written in unambiguous. Because of their relevance. NANDA-I. Gordon 1994). Stating a problem in terms of its label without related factors and defining characteristics is a source of interpretation errors (Lunney 2001. One’s disposition toward critical thinking and reasoning skills should influence the accuracy of nursing diagnosis as well. is to achieve a greater number of accurate diagnoses (Carpenito 1991. habits of mind. Lunney. 2005. 2003). 2000.Chapter 5 Introduction Nurses use nursing diagnoses as the basis for providing adequate nursing care (Lunney 2001. Thompson et al. 1994. Knowledge sources consist of information that can be looked up in reference works such as handbooks. protocols. clear language (Florin et al. Dispositions toward critical thinking include attributes. datasets. Hasegawa et al. Knowledge is an important factor. no known studies have been published that describe the effects of knowledge sources on the accuracy of nursing diagnoses. Inaccurate identification. Lunney 2001. 2001).’ Ready knowledge is knowledge that was acquired earlier and can be recalled by an individual. Gordon 1994). Ozsoy and Ardahan (2007) and Gulmans (1994) differentiate ‘ready knowledge’ from ‘knowledge with the use of knowledge sources. family. assessment formats. Background A nursing diagnosis is described as ‘A clinical judgment about individual. To date. Authors of handbooks suggest that greater standardization may lead to a less marked difference in interpretation of patient data (Carpenito 2002. 2006. (2007) and Ozsoy and Ardahan (2007) suggested that students might diagnose ailments more systematically if they had access to knowledge sources. 2007). The aim of using assessment formats based on functional health patterns and standard nursing diagnoses (labels).

disposition toward critical thinking. while the other group was not. such as open-mindedness. Lee (2006). 91 . and evaluation fields. Lee et al. Steward & Dempsey 2005). Stewart & Dempsey 2005). that no clear relationship has been demonstrated between specific reasoning skills and the quality of clinical nursing decisions. such as skills in the analytical. inference.Determinants of the accuracy of nursing diagnoses reasoning skills. What is the effect of knowledge sources? 2. controlled trial design (RCT) was used to determine how knowledge sources affect the accuracy of nursing diagnoses. These skills are essential for the diagnostic process (Facione & Facione 2006. and reasoning skills influence accuracy of nursing diagnoses. 2003). Research Questions We addressed the following research questions related to the accuracy of nursing diagnoses: 1. This was a pilot study that examined our methodological approach to studying how nursing students make diagnoses. One group of students was allowed to use knowledge sources. Reasoning skills include inductive and deductive skills. What is the influence of disposition toward critical thinking? 4. Little information is available on how specific reasoning skills affect the formulation of accurate nursing diagnoses. What is the influence of reasoning skills? Subjects and Methods Design A randomized. The Study The aim The aim of the present study was twofold: (1) to determine how the use of knowledge sources affects accuracy of nursing diagnoses. Fesler 2005. However. If our approach proves to be feasible. and (2) to determine how knowledge. inquisitiveness. Using knowledge sources to plan interventions based on a diagnosis seem to be related to nurses’ capacity for critical thinking and for applying their reasoning skills (Profetto-McGrath et al. What is the influence of knowledge? 3. 2006. truth-seeking. based on their literature review. then we will carry out a more comprehensive follow-up study of registered nurses throughout the Netherlands. analyticity. and maturity (Facione & Facione 2006). Two groups of nursing students were asked to formulate diagnoses based on an assessment interview with a standardized simulation patient (a professional actor). and Turner (2005) concluded. Gulmans 1994. systematicity. Several studies that focused on dispositions toward critical thinking and reasoning by nurses provided no information about whether nurses used their reasoning skills to attain the diagnoses reported (Edwards 2003. Tanner (2005).

including pen. Group A students had access to knowledge sources. 96 students were included in our study: 46 in group A. Therefore. 2. allocated in group A. The Handbook of Nursing Diagnoses (Carpenito. with knowledge sources and 50 in group B. The students were allowed to take notes during the interview. Finally. reason for hospital admission. 100 students volunteered to take part in our study. Of the 96 students. 2002). The Handbook of Nursing Diagnoses. In preparation for the assessment interviews. the Netherlands. The interviews lasted at most 30 minutes. Groningen. profession. gender. and 50 students were allocated to the control group (group B). group A (n= 46) students were allowed to review the following knowledge sources as they prepared for the assessment interview. family situation. without sources. age and address. and hobbies. The researchers were unaware of the group allocation. (2) questionnaire that maps disposition toward critical thinking.and fourth-year students enrolled in the Bachelor of Nursing program at Hanze University. and paper). all students were given the following written information about the patient: name. disposition toward critical thinking. we identified several script inconsistencies. After the interviews. and (3) reasoning test (Figure 1). were excluded. 2002) 3. 92 . The students were asked to formulate accurate diagnoses based on the assessment interview. 50 students were allocated to the experimental group (group A). All participants had at least 40 weeks of practical nursing experience. Students (n= 100) were sent to different admission rooms and were instructed to prepare for 10 minutes for an assessment interview with either a diabetes mellitus type 1 patient (n= 56) or a chronic obstructive pulmonary disease patient (COPD) (n= 44).Chapter 5 To determine how knowledge. and formulated diagnoses: 1. Population and Random Sample Of the 300 third. Group allocation took place by randomization: Each participant was given two sealed envelopes from which they had to choose one. data from four respondents. and reasoning skills influence the accuracy of nursing diagnoses. the students were given an additional 10 minutes to formulate diagnoses. NANDA-I classification (NANDA-I. whereas group B students did not. medical history. hereafter referred to as “assessment format”. notebook. 52 that assessed a diabetes patient (24 students in the experimental group and 28 students in the control group) and 44 students that assessed a COPD patient (22 students in the experimental group and 22 students in the control group). On the basis of video recordings of the assessment interviews and on the notes of observers. The form inside the envelopes described whether the student was allocated to group A or group B. we subsequently asked the participants to complete the following assessments: (1) knowledge inventory. and description of the current situation. An overview table with functional health patterns and standard nursing diagnoses (labels) per pattern as included in the Handbook of Nursing Diagnoses (Carpenito. interviewed the patients. In addition. 2004) (all items were within reach on the table.

an observer noted whenever the simulation patient failed to adhere to the script. All students gave informed consent.5 hours of their time. To ensure that the students would not prepare for the study ahead of time or discuss the details of the study among themselves. we asked each student to keep the contents and methods of the investigation confidential and to sign a confidentiality agreement form to this effect. The entire procedure. At the beginning of the study. did not have access to any reference material or to the assessment format. starting from preparations for the assessment interview to noting on paper the diagnoses. 93 . During the interviews. They were given a pen. and that the entire study would take about 2. however. notebook. and paper.Determinants of the accuracy of nursing diagnoses Group B (n= 50) students. was recorded on film and tape. the students were told that part of the study would be experimental. that they would be asked to complete questionnaires.

94 118 .Critical thinking disposition & Reasoning skills (CCTDI & HSRT) N= 96 To determine the effect of knowledge sources on the accuracy of nursing diagnoses and to determine the influence of ready knowledge. and reasoning skills on the accuracy of nursing diagnoses. disposition toward critical thinking.Chapter 5: Determinants of the accuracy of nursing diagnoses Chapter 5 Figure 1 Research framework Determinants of the accuracy of nursing diagnoses N= 100 Group A With knowledge sources N= 46 Group B Without knowledge sources N= 50 Measurement: .Knowledge inventory .

After the last practice rounds. an instrument that quantifies the degree of accuracy in written diagnoses. there were four lecturers in each group.Determinants of the accuracy of nursing diagnoses Instrumentation Case Development Two cases scenarios were developed. Cohen’s weighted Kappa inter-rater reliability of the quantitative criteria was between . adequately responding patient who answered questions put to him and who provided only an occasional brief elaboration. the four patients—all of them professional actors with over five years of experience as simulation patients in nursing allied health and medical education programs—were attuned to one another. was tested in five hospitals by screening 100 records. the simulation patients were questioned during practice rounds by lecturers and students and assessed for script consistency. 2000. also with respect to behavior. both scales were independently tested in a pilot study that screened 60 nursing records in two hospitals at four different nursing wards in the Netherlands. The script was also assessed for clarity (clear language and sentence structure) and nursing relevance. The D-Catch instrument is an integration of the Cat-ch-Ing instrument (Björvel et al. were developed by two different groups of lecturers from Hanze University. and their knowledge in these fields had been assessed by examinations. The cases were subsequently assessed for specificity by two external Delphi panels on the basis of a semi-structured questionnaire. These practice rounds were recorded on film and tape and analyzed by two lecturers and two bachelor’s students for script consistency and behavior during the interviews. The other panel consisted of experienced nurses working in clinical practice that had either a post-graduate specialization or a master’s degree in nursing science (n= 6). The simulation patients were instructed to act like an introverted. It was important that there were exactly six diagnoses per script. 2001). All participants had attended courses on diabetes and COPD. One of the Delphi panels consisted of lecturers that had a master’s degree in nursing science (n= 6) and fourth-year bachelor’s degree nursing students (n= 2). D-Catch.843 and that of the qualitative criteria was between . other diagnoses were demonstrably assessed as incorrect diagnoses. The students were assumed to possess basic knowledge of the problem areas to be diagnosed. Björvel 2002) and the Scale for Degrees of Accuracy in Nursing Diagnosis (Lunney 2001). A physician screened the case scenarios for medical correctness. we decided to integrate the two instruments. The development process was based on the Guidelines for Development of Written Case Studies (Lunney. Initially.436 95 . the script was considered fully consistent and it was adopted for the study. Following these rounds. Due to low inter-rater reliability in the Dutch study. even after the screeners had practiced for quite a while.4and . everything was included in the script. Accuracy of Nursing Diagnoses The accuracy of nursing diagnoses was measured by D-Catch. Both cases. along with an accompanying script for the simulation patient. Subsequently. The combined instrument.

96 . Because qualitative and quantitative criteria appear to be associated. and linguistic correctness? The D-Catch instrument is shown in Figure 2. what is the quality of the description with respect to relevancy. the total score for the accuracy of the reported diagnoses was calculated as the sum of the quantitative and qualitative scores (Cronbach’s alpha 0. unambiguity.886. we hypothesized that this disposition and skills are associated with the degree of accuracy in reported diagnoses in the sense that positive scores on critical thinking disposition and reasoning skills are associated with more accurate diagnoses. are the components of the diagnosis present? and (2) Quality. for each student.Chapter 5 and . which addresses the question. Adequate disposition toward critical thinking and reasoning skills are thought to be key in the process of diagnostic reasoning. Therefore. which addresses the question.94). Therefore. The D-Catch instrument is composed of two sections: (1) Quantity. the number of relevant diagnoses was calculated.

I= reference to a potential intervention) 4 points: 3 points: (P+E+S) → (I) (P)+(E)+(S) → (?) or (P)+(E)+(?) → (I) or (P)+(?)+(S) → (I) 2 points: (P)+(?)+(?) → (I) or (P)+(E)+(?) → (?) or (P)+(?)+(S) → (?) 1 point: (P)+(?)+(?) → (?) Hardly Incomplete Complete Partly Quality (Main question: what is the quality of the description with respect to relevancy.Determinants of the accuracy of nursing diagnoses Figure 2 D-Catch Diagnoses Criteria Quantity (Main question: are the components of the diagnosis present?) (P = Problem. unambiguity and linguistic correctness?) 4 points: (relevant)+(completely unambiguous)+(linguistically correct) 3 points: (relevant)+(not unambiguous)+(linguistically correct) 2 points: (unclear but relevant)+(ambiguous)+(linguistically incorrect) 1 point: (not relevant)+(ambiguous)+(linguistically incorrect) Very good Good Moderate Poor 97 . S= Signs and Symptoms. E= Aetiology.

This inventory was selected because it has been validated in a nursing context (Facione et al. 4. wanting to know how things work and fit together. Open-mindedness: being open-minded and tolerant of divergent views with sensitivity to the possibility of one’s own bias. Self-Confidence: being confident. and being willing to learn. 7. The CCTDI has eight scores: the seven scale scores and the total score. anticipating certain results or consequences. trusting oneself to make good judgments. and believing that others trust you as well. 1994. The CCTDI consists of 75 statements and measures respondents’ attitudes toward the use of knowledge and their disposition toward critical thinking. Total scores range from 70 to 420. Inquisitiveness: wanting to be well informed. Systematicity: being orderly and focused. scores ranging from 40 to 60 indicate an increasingly positive disposition. 98 . aiming to correctly map out the situation both in linear and in non-linear problem situations. looking for relevant information. Two lecturers in nursing together with two fourth-year nursing students developed the questionnaire. A total score of less than 280 could be used as a cutoff indicator of overall deficiency in one’s disposition toward critical thinking (Facione 2002). only one answer was correct. Disposition Toward Critical Thinking The California Critical Thinking Disposition Inventory (CCTDI) was used to assess the influence of disposition toward critical thinking on the accuracy of nursing diagnoses. A score of less than 40 shows weakness. no clear expression of either a positive or a negative disposition. scores between 30 and 40 indicate ambivalence. i. being flexible in considering alternatives and opinions. 2. A physician screened the questionnaire for medical correctness. Each scale score ranges from 10 to 60.e. Facione 2000). The questions focused on content of the case presented. The recommended cutoff scores for each scale is 40. 5. The knowledge inventory comprised four case-related multiple-choice questions having four derivatives. The CCTDI consists of seven domains: 1. Maturity: making reflective judgments in situations where problems cannot be properly structured. Scores ranging from 10 to 30 indicate an increasingly negative disposition.Chapter 5 Ready Knowledge A knowledge inventory was used to determine the association between knowledge and the accuracy of nursing diagnoses. 6. 3. The respondents indicated the extent to which they agreed or disagreed with a certain statement on a six-point scale. Truth-seeking: being eager to seek the truth. Analyticity: being alert to potentially problematic situations.

questions. For each of these subscales. We selected the HSRT for our study because its contents were used in a context that is easily recognizable for nurses. and scores from 0 to 3 indicate weak deductive and inductive skills (Facione & Facione 2006). procedures. inference. understanding the significance of experiences. reasons. which is more or less probable on the basis of a finite number of observations. Overall. sources of information. The HSRT subscales use six items to provide a guide for test takers’ abilities in the measured areas of analysis. experiences. Linguistic validation of the CCTDI and the HSRT was done by forward and 99 . the reliability quantified by Cronbach’s alpha was 0. understanding connections between statements. or 10 indicates strong deductive and inductive skills. descriptions or presented convictions. Various studies show a sufficient degree of validity and reliability for the HSRT (Facione & Facione 2006). 3.78 and 0. Kawashima & Petrini 2004. The HSRT test manual is based on the consensus definition of critical thinking that was developed in the Delphi Study (Facione & Facione 2006). 5. Deductive and inductive scales each use 10 items. Reliability was quantified by Cronbach’s alpha and was 0. 2000.81. Reasoning Skills We used the Health Science Reasoning Test (HSRT) to determine the association between reasoning skills and accuracy of nursing diagnoses. b. The HSRT covers the following domains: 1. and a score of 3 or 4 indicates average reasoning skills. For each of these subscales. and opinions that may lead to a conclusion. a score of 5 or 6 indicates strong reasoning skills. opinions. 9.90 for the entire instrument. 2. the correct nursing diagnosis is guaranteed by the reasoning.70 for the seven subscales (n = 1019). for example. and criteria. and to be able to provide convincing arguments for such. The Expert Consensus Statement describes the validation process (Facione 2000). Deductive: ability to refine the truth of a conclusion. ability to reflect on procedures and results. Tiwari et al. 2003. Stewart & Dempsey 2005. a score of < 2 indicates weak reasoning skills.Determinants of the accuracy of nursing diagnoses Various studies show a sufficient degree of validity and reliability for the CCTDI (Kakai 2003.84 for the specific domains (n=444). Analyses (two kinds of meanings): a. Yeh 2002). ranging between 0. varying between 0. Evaluation (two kinds of meanings): a. Smith-Blair & Neighbors. b.60 and 0. Inductive: ability to arrive at a general rule. and evaluation. The HSRT consists of 33 questions and assesses the reasoning capacity of healthcare and nursing professionals (Facione & Facione 2006). convictions. opinions. Inference: ability to formulate assumptions and hypotheses and to consider which information is relevant. and being able to determine relationships. to judge them. 4. experiences. situations. a score of 8. ability to assess the credibility of statements.

Accuracy of Nursing Diagnoses The median (range) score of the accuracy of nursing diagnoses (n= 414) was 4 (2–8). Data Analysis Group means and standard deviations were calculated. along with medians and ranges. Reliability of the Dutch version of the CCTDI quantified by Cronbach’s alpha was 0. The number of relevant diagnoses by each student in group A was significantly higher than that by each student in group B (Table 1). Results Demographic Data Third-year nursing students (n= 42) and fourth-year nursing students (n= 54) were included.5) minutes. and a sample size of 96. and 81% were female. There were no significant differences between the two cases concerning the accuracy of the nursing diagnoses and the number of relevant diagnoses. We were able to determine the length of time by analyzing the videotape record in 36 of 46 cases. The mean (SD) length of time group A students actually used knowledge sources was 4.518.811 and . Their mean (SD) age was 23 (3) years. Differences between the groups were analyzed by Mann-Whitney and Kruskal Wallis tests for ordinal data and Chi-Square test. a SD of 1.6).Chapter 5 backward translation by two independent translators. Based on a mean score of 4. The mean (SD) number of relevant diagnoses for each student was 4 (1.64. The Effect of Knowledge Sources on Diagnoses Accuracy No significant difference was found in the accuracy of the diagnoses between group A (access to knowledge sources) and group B (no access to knowledge sources) (Table 1). Reliability of the Dutch version of the HSRT was 0. The final translation was assessed by a third translator and approved to be relevant in the Dutch nursing context by a panel of nursing scientists (n = 6).73. The association between the accuracy of nursing diagnoses and knowledge was analyzed by Kendall’s Tau.1. also quantified by Cronbach’s alpha (n= 96).5 (3. Both cases—diabetic and COPD cases—included six relevant diagnoses. Cohen’s Kappa inter-rater agreement of the first diagnoses varied between . 100 . the power to detect a minimal difference of 1 was 99%.

0) The Influence of Ready Knowledge on the Accuracy of Diagnoses A very weak.1 (1.0) 4.8.6. The Influence of Disposition Toward Critical Thinking on the Accuracy of Diagnoses The mean (SD) score on each domain of the CCTDI was 42.4. Students scored lowest on the open-mindedness domain. The mean (SD) score on all seven CCTDI domains was 300 (22).258.0 .7.0 .0 (1.0 . a Group B median (range) 2.955 .0 (1.0) P-Valuea . p=.0 .090.0 .0 .4. The median (range) score on the knowledge inventory was 3 (0–4) for groups A and B.0) 4.0) 4. with 9% of all students scoring below 40 (Table 2).041* 2.0 .1).0) 1. *P < .0 (2.6.0) 2. Students scored highest on the inquisitiveness domain.4.0 (2.0) 3.05.Determinants of the accuracy of nursing diagnoses Table 1 Comparison of the number of relevant diagnosis by students with access to knowledge sources (Group A) and without access to knowledge sources (Group B) Group A median (range) Quantitative criteria diagnoses Qualitative criteria diagnoses Accuracy of the diagnoses Number of relevant diagnoses Mann-Whitney test.0 (1. insignificant correlation was found between ready knowledge and the degree of accuracy of the diagnoses.7 (1.0 .2 (1.3 (5.204 . with 57% of all students scoring below the cutoff score of 40. 101 .498 .4. Kendall’s Tau correlation coefficient was .

Chapter 5 Table 2 Percentage of nursing students that scored below the cutoff scores for the CCTDI (N = 96) Scale Truth-seeking Open-mindedness Analyticity Systematicity Self-confidence Inquisitiveness Maturity Total CCTDI % of scores below the cutoff scorea 52 57 19 22 12 9 17 17 Note: CCTDI = California Critical Thinking Disposition Inventory. No significant difference was found on the accuracy of nursing diagnoses of students scoring < 40 and that of students scoring > 40 on the subcategories of the CCTDI (Table 3). a Cutoff score for individual scales of the CCTDI is 40. There were no significant differences in the accuracy of nursing diagnoses and the number of relevant diagnoses between students with total CCTDI scores of less than 280 (cutoff indicator) and students with total CCTDI scores ranging from 280 to 420. cutoff score for the total CCTDI is 280. 102 . No significant differences were found between the CCTDI scores and groups A and B.

cutoff score for the total CCTDI is 280.0 (1-6) >40 4.898 .867 .0 (2-8) 4.0 (2-8) 3.975 P-value .585 P-value .0 (1-6) <280 3.5 (1-6) > 40 4.0 (2-7) 4.0 (1-6) >40 4.426 P-value .0 (2-8) 3.0 (2-8) 3.0 (2-7) 3.262 P-value .9 (2-6) 3. b Median (range).0 (1-6) >280 4.0 (1-6) <40 4.0 (1-6) >40 4.0 (1-6) <40 3. ND = nursing diagnoses.818 Note: CCTDI = California Critical Thinking Disposition Inventory.0 (1-6) >40 4.156 .0 (1-6) < 40 4.0 (2-7) 3.0 (2-8) 3.0 (2-8) 3.428 .0 (1-6) >40 4.0 (2-8) 3.0 (1-6) <40 4.747 P-value .088 P-value .8 (2-5) 5.568 .Determinants of the accuracy of nursing diagnoses Table 3 CCTDI Scores of nursing students: the effect of disposition toward critical thinking on the accuracy of diagnoses Scalea Truth-seeking Accuracy of the ND Number of relevant ND Open-mindedness Accuracy of the ND Number of relevant ND Analyticity Accuracy of the ND Number of relevant ND Systematicity Accuracy of the ND Number of relevant ND Self-confidence Accuracy of the ND Number of relevant ND Inquisitiveness Accuracy of the ND Number of relevant ND Maturity Accuracy of the ND Number of relevant ND Total score Accuracy of the ND Number of relevant ND Students scoring above or below the cutoff scoreb < 40 4.0 (3-5) 4.0 (1-6) <40 3. a Cutoff score for individual scales of the CCTDI is 40.9 (2-7) 3.0 (1-6) <40 3.818 .0 (2-8) 4.0 (1-6) P-value .724 .0 (1-6) >40 4.886 P-value . 103 .588 .7 (2-7) 3.

p= . No significant differences were found in the accuracy of diagnoses of students that scored low.013) than students that scored low on the analysis domain. or strong on the HSRT (N=96) Scale Analysis Inference Evaluate Deductive Inductive Weak (%) 35 41 1 28 0 Average (%) 49 51 34 60 46 Strong (%) 16 8 65 12 54 Note: HSRT = Health Science Reasoning Test.Chapter 5 The Influence of Reasoning Skills on the Accuracy of Diagnoses On average. average. or high on the other subcategories of the HSRT (Table 5). average. Students that scored high on the analysis domain of the HSRT scored significantly higher on the accuracy of their diagnoses (5 vs. No significant differences were found between the HSRT domains and groups A and B. Table 4 Percentage of nursing students that scored weak. 4. 104 . Students scored lowest on the analysis and inference domains (Table 4). students scored highest on the evaluate and inductive domains of the HSRT.

0 (1-6) Strong 5.0 (1-6) Weak 2.0 (2-6) 3.0 (1-6) Weak 4.8 (2-3) 6.973 P-value .0 (1-6) Average 4 .0 (1-6) Strong 4.013* .05.0 (2-6) 4.158 . ND = nursing diagnoses.0 (6-6) Weak — — Weak 4.0 (2-8) 3.0 (2-6) 3.518 P-value .0 (1-6) Average 4.9 (2-5) 5.0 (1-6) Strong 3.0 (1-6) Average 4.0 (3-8) 3.0 (2-6) 4. 105 .0 (1-5) P-value .Determinants of the accuracy of nursing diagnoses Table 5 HSRT scores of nursing students: the effect of reasoning skills on the accuracy of diagnoses Scale Analysis Accuracy of the ND Number of relevant ND Inference Accuracy of the ND Number of relevant ND Evaluate Accuracy of the ND Number of relevant ND Inductive Accuracy of the ND Number of relevant ND Deductive Accuracy of the ND Number of relevant ND Weak 4.662 .0 (2-8) 3.0 (1-6) Average 4. a Median (range).902 Note: HSRT = Health Science Reasoning Test. *P < .607 P-value .0 (1-6) Strong 4.977 .8 (2-6) 4.0 (2-8) 4.0 (2-6) 4.0 (2-7) 3.0 (2-6) 3.0 (1-6) HSRT Scoresa Average 3.0 (1-6) Strong 4.113 P-value .763 .

Chapter 5 Discussion and conclusion Methods This pilot study was feasible. Our findings are supported by those of Ronteltap (1990). and HSRT have proven to be useful within the framework of the study. This may be due to the fact that the assessment format and the handbooks have a structure based on categorized problem labels. the recorded diagnoses were incomplete and poorly formulated. knowledge of the problem area might lead to an accurate diagnosis only if the students had had sufficient skills to formulate diagnoses. The instruments D-Catch. resulted in a higher number of recorded relevant diagnoses. and Müller-Staub (2007). The 106 . CCTDI. Smith-Blair & Neighbors. The students that participated in our study may have not yet been sufficiently prepared to use available tools. The Influence of Ready Knowledge on the Accuracy of Diagnoses The finding that ready knowledge did not correlate with the accuracy of nursing diagnoses could be explained by the fact that the students did not possess skills needed to derive accurate diagnosis. Scores of the current sample are not very different from scores of other samples of nursing students. The simulation patients generally acted in accordance with the case and the script. 2000. Wan et al. 2006). These authors differentiated caserelated knowledge from diagnostic knowledge as two essential separate bases of ready knowledge and found that both types of knowledge are needed to report accurate diagnoses. however. 2005). Even if students had access to knowledge sources. In this study. which may have guided students during the interview. One possible explanation for the relatively low accuracy of the recorded diagnoses is that students may have not been familiar with the knowledge sources in the NANDA-I classification. causing them to formulate more focused and complete questions about the problem (Carpenito 1991. The Influence of Disposition Toward Critical Thinking on the Accuracy of Diagnoses Our students scored relatively low on the CCTDI truth-seeking and openmindedness domains. Christensen 2003. Even if students were familiar with the NANDA-I classification. Four other samples had similarly low subscale scores in the area of truth-seeking and open-mindedness (Colucciello 1997. Gulmans (1994). Nokes et al. knowledge inventory. Access to knowledge sources. to help them make standardized diagnoses. Gordon 1994). they may have been unable to apply this information to the context of an assessment interview. 2000. Various methods to help nurses apply standardized diagnoses in practice are still under development (Brunt 2005. such as knowledge sources. Müller-Staub et al. The Effect of Knowledge Sources on the Accuracy of Diagnoses Access to knowledge sources did not improve the accuracy of diagnoses. as far as the methods employed were concerned.

Understanding information and connections between statements is the first analytical step toward formulating accurate diagnoses (Gulmans 1994. hypothesis testing. the analysis of the accuracy of diagnoses was based on what the students recorded. this hypothetico-deductive. the CCTDI scores of older and more experienced individuals may contribute to a higher accuracy of diagnoses. The failure to apply analytical skills when doing problem inventories is called the “non-analytical process” or “intuitive process” (Benner. Nevertheless.Determinants of the accuracy of nursing diagnoses age and experience of individuals seems to be an important factor (ProfettoMcGrath 2003). 1994). and Gulmans 1994 suggested that a diagnosis based on the used of analytical skills is more accurate as opposed to a diagnosis based on experience and intuition alone. Dreyfus and Dreyfus (1986) and Benner and Tanner (1987) suggested that intuition forms the major core of diagnostic practice in nursing. Perhaps. 2006). Gulmans 1994. students were included and no significant relationship was found between a disposition for critical thinking and the accuracy of diagnoses. It is possible that some of the students used their analytical skills as a first step toward formulating accurate diagnoses. From a phenomenological perspective. In the present study. In the present study. (1982). Higher CCTDI scores were found in samples composed of older and more experienced nurses with nursing degrees (Nokes et al. because they lacked experience. we assumed that the students were unable to rely on their intuition. Barrows et al. Facione et al. In our study. 2005. obviously inexperienced. In spite of the fact that we did not find a significant relationship between the accuracy of diagnoses and the inference domain. However. but significant. based on a weak. students scored poorly on the HSRT domains analyses and inference. association. Substantiating the presupposition that the accuracy of diagnoses is determined by a nurse’s age and experience will require additional research. Gordon. we presume that students with strong analysis scores did stand out in the accuracy of their diagnoses. not on what they thought or what they might have meant. 2001. Gordon 2003. (1982) found that the ability to analyze and substantiate information relating to a patient is prerequisite for formulating an accurate diagnosis. rational. 2003). Their ability to express themselves in writing diagnoses was found to be moderate. In our study. This process is based on one’s recognition of situations and on making the most obvious choices based on one’s recognition (Benner 2001. still there may be a plausible connection between the quality of analytical thinking. and the way students record diagnoses (Facione 2000. no studies offer conclusive explanations of how intuitive reasoning directs accurate nursing diagnoses (Lee et al. only young. Gordon 1994). Gordon (1994). and analytic approach is argued. Gordon (1994) and Ronteltap (1990) suggested that hypothesis testing is a key component of the diagnostic process and is required for an individual to be able to express the outcomes of clinical judgment in an accurate way. whereas most of the 107 . The Influence of Reasoning Skills on the Accuracy of Diagnoses Although. Barrows et al. Pesut & Herman 1998). Paley 1996). In a study of physicians.

Improving nursing students’ skills in using knowledge sources and in reasoning could be a step forward to improving the accuracy of nursing diagnoses. Implications The results of this study have possible implications for nursing education. This could be a starting point for a follow-up study. such as analytical and inference skills. The influence of these skills on the accuracy of nursing diagnoses may be more apparent when a student is specifically asked to use these skills consciously and actively when deriving diagnoses (Pesut & Herman 1999. Follow-up research must examine this assumption in greater depth.Chapter 5 students failed to use indispensable inference and deductive skills when deriving diagnoses. The present study can be viewed as a starting point for developing more stimulating knowledge sources. 108 . for encouraging the use of specific reasoning skills. Whether the use of such diagnoses report forms as a tool to support the diagnostic reasoning process would improve the accuracy of diagnoses is unknown. and for cultivating an open-minded and truthseeking disposition. Nurses may benefit by pre-structuring the diagnoses report form to specifically include these factors and characteristics. This could be achieved by training students in reason-giving and fact-finding analytical skills and by asking them specific questions related to the aetiology (related factors) and signs and symptoms (defining characteristics) of health care problems (Müller-Staub 2007). Worrell & Profetto-McGrath 2007).

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van der Schans. Nieweg. Cees P. Walter Sermeus. Krijnen. 113 . This chapter is submitted for publication. Roos M.B.Accuracy of nursing diagnoses: a randomised study CHAPTER 6 The effect of a predefined record structure and knowledge sources on the accuracy of nursing diagnoses: a randomised study Wolter Paans. 2010. Wim P.

Nevertheless. Based on a comparison of four classification systems. 2003. 2005. and clinical pathways. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable” (NANDAI 2004. Müller-Staub et al. Reed & Lawrence 2008). 2006. assessment formats. Wilkinson 2007). Knowledge sources may help nurses derive diagnoses that are more accurate than those derived without the use of such resources (Goossen 2000. and related factors and poorly documented details of interventions and outcomes (Ehrenberg et al. A distinction between ‘ready knowledge’ and ‘knowledge obtained through the use of knowledge sources’ can be made. Lunney 2007). Ozsoy & Ardahan 2007). Lunney 2008). Describing a problem solely in terms of its label in the absence of related factors and defining characteristics can lead to misinterpretation (Lunney 2001. pre-structured data sets. 2007. 2008). 22). Imprecise wording. Hasegawa et al.Chapter 6 Introduction Nurses constantly make knowledge. prestructured record forms. 2008). Müller-Staub (2007. 2008. related factors (aetiology).and skill-based decisions on how to manage patients’ responses to illness and treatment. pertinent signs and symptoms. several authors have reported that patient records contained relatively few precisely formulated diagnoses. Lunney 2001). protocols. Moloney & Maggs 1999. Accurate formulation of nursing diagnoses is essential. Their diagnoses should be founded on the ability to analyse and synthesize patients’ information. p. Background Numerous aspects related to cognitive capabilities and knowledge influence diagnostic processes (Smith et al. clear language (Gordon 1994. Spenceley et al. and defining characteristics (signs and symptoms) in an unequivocal. Knowledge obtained through knowledge sources is acquired through the use of handbooks. Ready knowledge is previously acquired knowledge that an individual can recall to mind. since nursing diagnoses guide intervention (Gordon 1994. Knowledge about a patient’s history and about how to interpret relevant patient information is a central factor to derive accurate diagnoses (Cholowski & Chan 1992. An accurate diagnosis describes a patient’s problem (label). The definition of ‘nursing diagnosis’ is: “A clinical judgment about individual. classification is the best-researched and internationally most widely implemented classification system. and expression of patient problems in terms of an incomprehensible diagnosis could have an undesirable effect on the quality of patient care and patient well-being (Kautz et al. lack of scrutiny. p. 22-39) concluded that the NANDA-I (North American Nursing Diagnoses Association International). family or community responses to actual and potential health problems/ life processes. Ready knowledge is achieved through education programmes and experience in situations in different nursing contexts (Gulmans 1994. 2006¹). The purpose of using assessment formats based on Functional Health Patterns and standard nursing 114 . 1996. Lunney 2001.

truth-seeking. but are not completely informative with respect to the truth of the conclusion (Bandman & Bandman 1995). Tanner 2005). What is the influence of reasoning skills? Methods A randomised. factorial design was used to determine whether knowledge sources and a predefined record structure affect the accuracy of nursing diagnoses. 115 . inquisitiveness. the accuracy of nursing diagnoses. and evaluation. Reasoning skills comprise induction and deduction. What is the influence of ready knowledge? 3. Stewart & Dempsey 2005. as included in the Handbook of Nursing Diagnoses (Carpenito 1991. Clinical nurses were invited to derive diagnoses based on an assessment interview with a simulation patient (a professional actor) using a standardized script. (2) to determine whether knowledge. In an inductive (diagnostic) argument the premises provide some evidence. Research Questions We addressed the following research questions about the accuracy of nursing diagnoses: 1. systematicity. Although. or can explain. Steward & Dempsey 2005). Dispositions towards critical thinking include open-mindedness. 2002). inference. or hypothesis) supply complete evidence for the conclusion so that the conclusion necessarily follows from the premises. The study Aim The aim of the study was twofold: (1) to determine whether the use of a predefined record structure and knowledge sources does affect the accuracy of nursing diagnoses. Other factors influencing the accuracy of nursing diagnoses are nurses’ disposition towards critical thinking and reasoning skills. What is the influence of dispositions towards critical thinking? 4. In a deductive argument the premises (foundation. What is the effect of a predefined record structure and knowledge sources? 2. several studies focused on nurses’ dispositions for critical thinking. Fesler 2005. There are two kinds of diagnostic arguments: deductive and inductive. as well as analysis. These skills are vital for the diagnostic process (Facione and Facione 2006. and maturity (Facione & Facione 2006). or reasoning skills are associated with. disposition towards critical thinking.Accuracy of nursing diagnoses: a randomised study diagnoses. analyticity. is to attain higher accuracy in diagnoses. these yielded little information about nurses specific reasoning skills to attain high levels of accuracy of nursing diagnoses (Edwards 2003. idea.

and D. Possible determinants—knowledge. notebook. None of the participants had any specific training in using NANDA-I diagnoses as a part of this study. the nurses were told that part of the study would be experimental. We requested at least 20 registered nurses per hospital to participate. The researchers were unaware of group allocation. C. they acted as a control group. or D. only one director refused to cooperate. group B could use a predefined record structure (hereafter referred to as the “PES-format”). and group C could use both knowledge sources and a predefined record structure Group D used neither knowledge sources nor the predefined record structure. nurses could subscribe voluntarily for participation. Sample Of all 94 medical centres (86 general hospitals and 8 university hospitals) in the Netherlands in 2007. The hospital directors approached the heads of nursing staff to participate. and reasoning skills—that could influence the accuracy of nursing diagnoses were measured by the following questionnaires: (1) a knowledge inventory. by choosing one of four sealed envelopes. Seventy nurses were allocated to the control group D. that they would be asked to complete questionnaires. By using the registration form. Facione 2000). distributed in wards. and (3) the Health Science Reasoning Test (HSRT) (Facione & Facione 2006). Five hospital directors declined to participate. To replace these. and paper. The entire procedure—starting from preparing for the assessment interview to writing the diagnoses—was recorded both on film and audiotape. an observer noted whenever the simulation patient failed to adhere to the script. a questionnaire that maps disposition towards critical thinking (Facione et al. using stratification by province. we randomly selected 11 hospitals. The form inside each envelope indicated allocation to group A. disposition towards critical thinking. without knowledge sources. B. Group A could use knowledge sources (an assessment format with Functional Health Patterns and standard nursing diagnoses (labels) and handbooks nursing diagnoses). Data collection First. Out of the latter. Nurses in this group were given only a pen. we requested six additional hospital directors from the same region to participate. Group A nurses (n= 49) 116 . (2) the California Critical Thinking Disposition Inventory (CCTDI). C. We did not test whether the participating nurses had on before hand knowledge of the NANDA classification or experience in the use of a PES-format.e. 1994. B.5 hours of their time. and free text format (blank paper). Nurses allocation to each of the four groups took place by randomization i. Each of the participating nurses (n= 249) gave informed consent. The heads of staff were asked to distribute registration forms to nurses to enrol in the study.Chapter 6 Participants were randomly allocated to one of four groups—group A. During the interviews. and that the entire study would take about 2. It was guaranteed that participation was during work time.

Based on video recordings. The Handbook of Nursing Diagnoses and NANDA-I classification (NANDA-I 2004). and the last section consisted of ‘signs and symptoms’ (S. The example was not related to the case histories. and paper. it was made possible for nurses to complete information about P. and hobbies. or a Crohn’s disease patient (n= 93).. and the formulation of diagnoses: 1. gender. Each nurse was directed to an admission room and instructed to prepare for 10 minutes an assessment interview with either a simulated diabetes mellitus type 1 patient (n= 71). Nurses in groups B and C wrote their findings in the PES-format. Crohn’s disease or diabetes mellitus type 1. family situation. Based on the information in the script.. One section of this document consisted of the ‘problem label’ (P. 2.). data of two control group nurses.). It was required that the participants did state the problem label. For all groups. medical history. They did not have access to the aforementioned reference material.Accuracy of nursing diagnoses: a randomised study were allowed to review the following knowledge sources as they prepared for the assessment interview. notebook. the nurses were given 10 minutes to formulate their diagnoses. they had the opportunity to use a document with pre-structured sections to write down their diagnostic findings. three group B nurses. Nurses in groups A and D documented their findings on blank paper. a chronic obstructive pulmonary disease (COPD) patient (n= 84). Instead. 3. the current medical diagnosis. reason for hospital admission and description of the current situation. the next section consisted of ‘related factors or aetiology’ (E. profession. Nurses were asked to derive accurate diagnoses based on the assessment interview and to note these on paper. two group A nurses. An assessment format with Functional Health Patterns and standard nursing diagnoses (labels) as described in the Handbook of Nursing Diagnoses (Carpenito 2002). Seventy-nine nurses were allocated to Group B. and one group C nurse were excluded for the reason that the actors did 117 . They could take notes during the interview. age and address. all items were within reach on the table.. represented by the actors. After the interviews. The PES-format used by group B nurses listed one example of a nursing diagnosis noted in the PES-format and a brief introduction related to the example and ended with the following request: “Please note your diagnostic findings in the PESformat”.. fill in. as these matched with the patient situation... Preparing for the assessment interviews. all nurses were given the following written information about the patient: name. related factors (aetiology) and the signs/ symptoms or defining characteristics.). Each participant assessed one professional actor representing a patient suffering from COPD. The 51 nurses in group C were allowed to review the knowledge sources along with the PES-format. The Handbook of Nursing Diagnoses (Carpenito 2002). Each of the three actors’ scripts contained six nursing diagnoses which should be identified by the nurses based on the assessment interview. E and S per diagnosis. including pen. fill in. fill in.

lecturers and students questioned the simulation patients during testing rounds after which their answers were assessed for script consistency. D. 47 in group A. the script was considered to be fully consistent and was adopted for the study. This was based on the Guidelines for Development of Written Case Studies (Lunney 2001). 82 assessed a COPD patient.Chapter 6 not strictly adhere to the script in these cases. The script was also assessed for clarity (clear language and sentence structure) specificity as well as nursing relevance. All the four actors involved. had over five years of professional experience as simulation patients in nursing or medical education. and 50 in group C. Instrumentation Case development Three case scenarios were developed. One of the Delphi panels consisted of lecturers with a master’s degree in nursing science (n= 6) and fourth-year bachelor’s degree nursing students (n= 2). The cases were assessed by two external Delphi panels using a semi-structured questionnaire. Of the 241 nurses. 68 assessed a diabetes patient. 118 . Subsequently. 76 in group B. Their acting was attuned with respect to behaviour according to the script. The testing rounds were recorded both on film and tape and analysed by two lecturers and two bachelor’s students for script consistency and behaviour during the interviews. A physician screened the case scenarios for medical correctness. adequately responding patients to questions posed. For ethical reasons. data of 241 nurses were analysed: 68 in the control group. The other Delphi panel consisted of experienced nurses working in clinical practice that had either a post-graduate specialization or a master’s degree in nursing science (n= 6). They were instructed to act like introverted. the participants were acknowledged that all information would be used for research purposes only and that data would be anonimized. The interviews lasted maximum 30 minutes (range: 10 – 30 minutes). Finally. all were asked to keep the contents and methods of the investigation confidential and to sign a corresponding agreement. After the last practice rounds. Any nursing diagnosis not belonging to the script was considered to be incorrect. and 91 assessed a patient with Crohn’s disease (Figure 1). To ensure that participants could not prepare themselves or discuss any details of the study with others.

HSRT (Health Science Reasoning Test) N= 241 (1) Effect of knowledge sources on the accuracy of nursing diagnoses (2) Influence of dispositions of critical thinking and reasoning skills on the accuracy of the nursing diagnoses 147 119 .After the last practice rounds. CCTDI (California Critical Thinking Disposition Inventory) 3. the script was considered to be fully consistent and was adopted for the study. Accuracy of nursing diagnoses: a randomised study Figure 1 Research design Research design Randomisation of participants (n = 249) into four groups and three case histories Group A Handbooks & Assessment format Goup B PES format Group C PES format & Handbooks & Assessment format n= 51 Case history: -Diabetes: n= 19 -COPD: -Crohn: n= 15 n= 16 Group D Control Group (no sources / no PES format) n= 49 Case history: -Diabetes: n= 18 -COPD: -Crohn: n= 15 n= 14 n= 79 Case history: -Diabetes: n= 14 -COPD: n= 24 -Crohn: n= 38 n= 70 Case history: -Diabetes: n= 17 -COPD: -Crohn: n= 28 n= 23 Excluded: n= 2 Excluded: n= 3 Excluded: n= 1 Excluded: n= 2 n= 47 Questionnaires: n= 76 n= 50 n= 68 1. Knowledge Inventory based on case history 2.

Open-mindedness: being tolerant of divergent views with sensitivity to the possibility of one’s own bias.4). The CCTDI consists of seven domains: 1. with one correct answer. and linguistic correctness?” (scale: 1. an instrument that quantifies the degree of accuracy in written diagnoses (Paans et al. the sum of the quantity and quality criteria score was computed. The number of relevant diagnoses documented for each participant was determined out of six in total in each script. 4. Ready knowledge A knowledge inventory was used only to determine the association between casebased conceptual. 120 . 2002) was used to assess the influence of disposition towards critical thinking on the accuracy of nursing diagnoses. For each diagnosis (out of six available) documented by each nurse. the mean was taken and in the sequel will be referred to as diagnoses accuracy score. Self-confidence: to be trusted upon for making adequate judgments. 6. The knowledge inventory comprised of four case-related multiple-choice questions each consisting of four alternatives. From the six possible sum scores. 3. 5.Chapter 6 Accuracy of the nursing diagnoses For measuring the accuracy of the nursing diagnoses. After assessors’ agreement was reached. The questions focused on content of the case presented. anticipating certain results or consequences. On a six-point scale.4) and (2) Quality. Disposition towards critical thinking The CCTDI. Facione 2000. unambiguity. respondents indicate the extent to which they (dis)agree with a certain statement. Analyticity: being alert to potentially problematic situations. validated in a nursing context (Facione et al. The CCTDI consists of 75 statements and measures respondents’ attitudes towards the use of knowledge and their disposition towards critical thinking. 2. Systematicity: being orderly and focused. which addresses: “Are the components of the diagnosis present?” (scale: 1. 1994. Maturity: making reflective judgments in situations where problems cannot be properly structured. 2010). the D-Catch was used. Inquisitiveness: wanting to be well informed as well as having a desire to know how things work and fit together. 2005) was used as a guideline for development. 7. The Handbook of Enquiry & Problem Based Learning (Barrett et al. which addresses: “What is the quality of the description with respect to relevancy. This instrument consist of two sections: (1) Quantity. Insight Assessment. Truth-seeking: being flexible in considering alternatives and opinions. aiming to correctly map out the situation both in linear and in non-linear problem situations. ready knowledge and the accuracy of nursing diagnoses. the questions were adopted to the inventory.

experiences. and criteria. 4. The score indicates the degree of which nurses have a disposition toward critical thinking. Deduction: ability to refine the truth of a conclusion. Stewart & Dempsey 2005. procedures. a score of < 2 121 . The HSRT was selected because its contents are usable in a context that is easily recognizable for nurses. and to be able to determine relationships. opinions. expression of positive or negative disposition). A score of less than 40 reveals weakness (Facione 2002). reasons. ability to assess the credibility of statements. sources of information. The final translation to the Dutch language was assessed by a third translator and approved to be relevant in the Dutch nursing context by a panel of nursing scientists (n= 6). the correct nursing diagnosis is guaranteed by the reasoning. 3. Linguistic validation of the CCTDI was done by forward and backward translation by two independent translators. Inference. For each of these subscales. situations.e. 2006). The recommended cut-off score for each scale is 40. Kawashima & Petrini 2004. and Evaluation. 2003. Tiwari et al. which is more or less probable on the basis of a finite number of observations. Smith-Blair & Neighbors 2000. Reasoning skills We used the HSRT to measure reasoning skills. ability to reflect on procedures and results. Evaluation: a. The HSRT consists of 33 questions and assesses the reasoning capacity of healthcare and nursing professionals (Facione & Facione. Analysis: a. experiences. The HSRT covers the following domains: 1. Inference: ability to formulate assumptions and hypotheses and to evaluate the relevancy of the information. convictions. Various studies have demonstrated the CCTDI scales to have a sufficient degree of reliability and validity (Kakai 2003. Facione (2002) found scores ranging from 10 to 30 to indicate an increasingly negative disposition. scores ranging from 40 to 60 to indicate an increasingly positive disposition. 2. and to be able to provide convincing arguments for such. and opinions that may lead to a conclusion.74 (n= 241).Accuracy of nursing diagnoses: a randomised study The scores of the CCTDI scales range from 10 to 60. to judge them. for example. questions. Yeh 2002). opinions. understanding the significance of experiences. scores between 30 and 40 to indicate ambivalence (i. The HSRT subscales consist of six items to provide a guide for test takers’ abilities in the measured areas of Analysis. descriptions or presented convictions. b. b. Induction: ability to arrive at a general rule. understanding connections between statements. 5. a score of 5 or 6 indicates strong reasoning skills. Reliability of the Dutch version of the CCTDI quantified by Cronbach’s alpha was 0.

a score of 8. and scores from 0 to 3 indicate weak deductive and inductive skills (Facione & Facione. To estimate the amount of explained variance for accuracy of nursing diagnoses (depended variable) we used linear regression taking as independent variables the CCTDI domains and the HSRT scales as the knowledge inventory. 9. The intra-class correlation coefficient based on analysis of variance of the ratings gives the proportion of variance attributable to the objects of measurement (McGraw & Wong 1996). 2006). Inter-observer agreement of the D-Catch was estimated by Cohen’s quadratic weighted kappa. 64% had over 10 years of nursing experience. For the following statistics we used R version 2.1 (R Development Core Team 2009). reliability of the Dutch version of the HSRT was 0. and a score of 3 or 4 indicates average reasoning skills. For each of these subscales. Their mean (SD) age was 38 (10) years. 2006). quantified by Cronbach’s alpha (n= 241). The main and interaction effects of knowledge sources and PES-format on accuracy of nursing diagnoses were estimated by two-way analysis of variance (ANOVA). and bachelor’s degree nurses (n= 68). The association between accuracy of diagnoses and knowledge (knowledge inventory) dispositions towards critical thinking (CCTDI) and reasoning skills (HSRT). Insight Assessment / The California Academic Press are the distributors of the CCTDI and HSRT. and 212 (88%) were female.72.0 and summarised by group means and standard deviations. hospital-trained nurses (n= 120). The final translation was assessed by a third translator and approved to be relevant in the Dutch nursing context by a panel of nursing scientists (n= 6).Chapter 6 indicates weak reasoning skills. Statistical analyses Demographic data were calculated by using SPSS version 14. Results Demographic data Licensed practical nurses (n= 53). The scale scores of the CCTDI and HSRT were computed by Insight Assessment. was estimated by Kendall’s tau. 92% Of the nurses worked at least 50% of full-time employment. registered nurses were included in our study. all working as qualified. or 10 indicates strong deductive and inductive skills. along with percentages. is based on the consensus definition of critical thinking that was developed in the Delphi study described in the Expert Consensus Statement of Facione (2000). The HSRT test manual “The Health Sciences Reasoning Test” (Facione & Facione.10. Deductive and inductive scales consist of 10 items. Cohen’s kappa with quadratic weighting was used to measure the proportion of agreement greater than that expected by chance. presence of PES-format. Based on our study. intra-class correlation coefficient and Pearson’s product moment correlation coefficients of the first diagnoses listed by all of the participants. 122 . knowledge sources and age of the participants.

75. . .91) .61. No significant differences were found between the CCTDI scores. 2001). The values of the coefficients as well as their confidence intervals are highly similar. No significant differences were found between the three cases concerning the accuracy of the nursing diagnoses (p = 0.76 (.83) . .79 (.75 (.73 (.83) . We conclude that the inter-rater agreement is substantial (Fleiss et al. .69. . .86) . . .84) .73 (.75 (. .89) .85) .72.63.62. All of the coefficients are larger than . B. .76 (.91) . as well as their 95% confidence intervals are presented in Table 1.73 (.55.86) .76 (.70.. and groups A.90) .75 (.679).739).57.80 (.88) .75 (.72. .Accuracy of nursing diagnoses: a randomised study Internal validity and reliability We did not find significant differences between the four simulation patients on the accuracy of nursing diagnoses using two-way analysis of variance (p = 0.73 (.70 and have their left boundary of the confidence interval greater than .59. .59.61.74. Cohen’s weighted kappa.546).53. the intra-class correlation coefficient and Pearson’s product moment correlation coefficient.72 (.73 (. C. or on the number of relevant diagnoses (p = 0.89) .83) .91) . the HSRT scores. .90) .63.156).87) . .85) .75 (. . . intra class correlation coefficient and Pearson’s product moment correlation coefficient with 95% confidence intervals of quantity and quality criteria of the first diagnosis of each participant Raters Objects Na Kw Intra Class Correlation Pearson’s Correlation Coefficient Quantity 1 vs 2 3 vs 4 2 vs 4 5 vs 6 7 vs 8 Quality 1 vs 2 3 vs 4 2 vs 4 5 vs 6 7 vs 8 a 61 60 57 38 25 61 60 57 38 25 .80 (.83 (.82 (. .84 (. 87) .56.85) . .68.74 (. We found no significant differences in the pairs of reviewers (n = 5).53.82 (. 91) ..50. .55. .90) .55.83 (.57. . . .84) .85) .82 (.83) .82 (65.63.196).89) . in the accuracy of the nursing diagnoses (p = 0.59.59.89) .74 (.60. . .83 (.73.083) and the number of relevant diagnoses (p = 0.82 (.88) .76 (. 90) Quality and quantity criteria of the accuracy measurement based on the D-Catch instrument 123 .84) . . These results are in line with the random assignment of nurses to groups. Table 1 Inter-rater agreement measured Cohen´s Kappa with quadratic weighting.83) . .75 (.58.51. and D. nor on the number of relevant diagnoses (p = 0. .

In order to estimate the degree of association between the dependent variable ‘Diagnoses Accuracy’ and the independent variables from the CCTDI and HSRT scales and the knowledge inventory. neither its estimated size nor its corresponding main effects are significant. and the HSRT scales Analysis. Following the custom of using 0. There is no significant main effect of PES-format or Handbooks/ Assessment format on any of the CCTDI or HSRT domains on the number of relevant diagnoses.237. p = 0. 124 . Inference. That is.05 as cut-off value for significance. There is no significant effect for Handbooks/Assessment format (F= 0. More specifically. p = < 0.7795) nor any significant interaction effects. these scales have a positive association with diagnoses accuracy in the sense that an increase on either of these scales would result in an increase of accuracy of nursing diagnoses. and Deduction. Table 2). Kendall’s tau coefficients were computed.025. For these reasons we refrain from interpreting this effect.0001). Ready knowledge correlates with the main effect of handbooks and the assessment format because of higher mean scores as no handbooks or assessment format were available (P= 0.5079. The only exception to this is a significant interaction effect for Systematicy (CCTDI) but. the significance of these are measured by the P-values.Chapter 6 The influence of knowledge. handbooks/assessment format reasoning skills and the PES-format on the accuracy of diagnoses In order to facilitate the interpretation of two-way ANOVA the means of the (in)dependend variables over the experimental groups with PES-format and without PES-format are presented in Table 2. The resulting coefficients are presented in Table 3 together with the corresponding P-values. the PES-format has an estimated increasing effect of 1. Induction. df= 1.0786. it can be inferred from the P-values that there is a positive association between diagnoses accuracy and the CCTDI scales Systematicity and Maturity.237. These means correspond to the main effects in two-way ANOVA.5 on mean diagnosis accuracy. A significant PES-format effect was found on accuracy of nursing diagnoses (F= 118. df= 1.

1) 7.521 0.2 (5.1) 44.1 (1.0) 7.8 (1.174 0.2 (4.8 (1.8) 43.6) 48.0 (1.Table 2 Group means (SD) and P-values from two-way ANOVA Experimental conditions B&C PES-Format No Handbooks and no Assessment Handbooks & Assessment format Main effect PES.8 (2.760 Accuracy of ND Number of relevant ND Knowledge Inventory CCTDI Truth-seeking Open-Mindedness Analyticity Systematicity Self-confidence Inquisitiveness Maturity HSRT Analysis Inference Evaluation Induction Deduction 41.5 (5.067 0.8 (4.1) 40.2) 2.7 (1.0 (1.1) a b Accuracy of nursing diagnoses: a randomised study 125 Mean (SD) Group A had the opportunity to use handbooks and assessment format and free text format (blank paper) Group B had the opportunity to use a predefined record structure (PES-Format) Group C had the opportunity to use handbooks and assessment format and a predefined record structure (PES-Format) Group D did not have the opportunity to use handbooks and assessment format or PES-Format at all (control group) c ANOVA * < P= 0.2) 2.754 0.1) 37.3) 47.2 (5.9 (5.6 (1.936 0.4 (4.7 (5.545 0.780 0.4) 4.320 0.2) <0.3 (5.0) 7.7 (2.2 (5.9) 37.1) 44. HSRT = Health Science Reasoning Test .2) 4.5 (1.7 (1.612 0.8 (5.9 (1.148 0.1) 3.135 0.2 (4.3) 3.0 (6.956 0.4) 2.879 0.891 0.001* 0.259 0.8 (1.4) 2.5) 37.1) 43.3) 3.268 0.3 (4.1) 7.9 (3.553 0.3) 47.065 0.format P-Valuec Main effect HandBooks & Assessment format P-Valuec 0.0) 2.4) 2.8 (1.311 0.1) 4.025* 0.8) 44.0 (1.693 0.5) 4.8 (1.0) 47.6 (2.0) 44.4) 40.553 0.2 (5.6) 46.186 0.7) 45.3 (5.8 (6.0 (1.3) 3.441 0. CCTDI = California Critical Thinking Disposition Inventory.173 0.7) 44.4) 4.3) 3.9 (1.1) 4.308 0.2 (1.9) 44.3) 4.9 (5.9 (1.4) 0.4 (6.0) 3.063 0.05 Note: ND = nursing diagnoses.207 0.2) 3.8 (1.4 (4.949 0.5 (4.5) 44.617 0.507 0.373 B&D A&C Interaction effect P-Valuec Scalea Groups b A&D Dependent Variable No PES-Format 4.4 (1.5 (4.6) 3.504 0.683 0.956 0.4 (5.5) 4.2) 4.7 (1.2) 44.0 (5.217 0.6 (1.2) 4.2) 41.953 0.0 (6.9 (1.6 (6.7) 43.9) 37.0 (1.303 0.039* 0.3 (1.2) 3.4) 4.2 (1.5) 44.438 0.8 (1.4 (1.693 5.168 0.553 0.3 (5.6 (2.7) 45.3) 44.

0001* < 0.05.4923. the CCTDI and the HSRT scales Variable Knowledge inventory CCTDI Truth-seeking Open-Mindedness Analyticity Systematicity Self-Confidence Inquisitiveness Maturity HSRT Analysis Inference Evaluation Induction Deduction 0.11 0.0001* 0. handbooks/assessment format. To obtain a parsimonious linear regression model we used the stepwise approach according to Akaike’s information criterion and proceeded by manually dropping non-significant coefficients (Venables & Riply 2002.07 0.121 0.0001* 0. presence 1). age.076 0.016* Kendall’s tau 0. resulted in one and the same model.01 0.24 < 0. HSRT = Health Science Reasoning Test Relationship of PES-format.003* 0.099 0.04 P-value* 0. 175).08 0.899 0.002* <0. and the continuous variables age and the 126 . ready knowledge and diagnoses accuracy By a regression analysis we investigated the degree in which variation in diagnoses accuracy can be explained by the variables age.756 0.16 0.07 -0.01 0.19 0.08 0. CCTDI and HSRT scales. -We merely note that doing this in different orders. p. Note: CCTDI = California Critical Thinking Disposition Inventory. reported in Table 4.135 0. but also in a non-parsimonious model with several non-significant beta coefficients.The resulting estimated linear model contains the dichotomized variable presence of PES-format. as well as the knowledge inventory and the dichotomized variables PES-format and Handbooks/Assessment format (absence 0.. Using these (15) independent variables resulted in a multiple squared correlation of 0.13 0.Chapter 6 Table 3 Kendall’s tau coefficients with corresponding P-values between mean diagnoses accuracy and the knowledge inventory.401 *P < .15 0. the CCTDI and HSRT scales.

0113 t P-Valueb * Dependent variable: accuracy of nursing diagnosis a AIC: Akaike’s Information Criterion b P < .05 Note: HSRT = Health Science Reasoning Test 127 . for age (23-62). see Table 4.3202 0.0001 < 0.13 if deduction increases by one scale point.0251 0.0564 12.0347 0.4702 and.0063 0. according to the model.5 (20 times 0. therefore.Analysis domain B 4.0001 < 0.00 3.0574 1. nurse age and reasoning skills deduction and analysis. The model has a multiple squared correlation of 0.67 11.0001 0.5 and an increase of analysis skills by 3 scale points yields an increase of mean accuracy by 0. Almost half of the variance of diagnoses accuracy is explained by the presence of PES-format. and an increase by . Similarly. an increase by .1442 SE 0.3658 -0.Accuracy of nursing diagnoses: a randomised study reasoning skills Deduction and Analysis (HSRT). For a proper interpretation of these effects it is relevant to keep in mind the range of the (in)dependent variables.025 if age increases by one year.1272 0. a nurse being 20 years younger has a larger mean accuracy of .37 if PES-format is present. explains 47. This is for diagnoses accuracy (28).1213 0. More specifically. for deduction (0-10) and for analysis (0-6). Thus.43.26 -4.0003 0. Table 4 Model found by stepwise AICa followed by dropping non-significant coefficients* Model Unstandardized Coefficients Variables (Intercept) PES-format Age HSRT Deduction domain HSRT. an increase of deduction skills by 4 scale points yields an increase of mean diagnoses accuracy of 0. a decrease of . the resulting model (Table 4) implies an increase of diagnoses accuracy by 1.14 if analysis increases by one point. Visual inspection of the fitted values by residuals as well as the normal quantile-quantile plot of residuals reveals that the latter is normally distributed with constant variance (normality is not rejected by the Shapiro-Wilk test).02% of the variance in the independent variable diagnoses accuracy.66 2.55 < 0.025).

Wan et al. 2003. to aim to correctly map out situations. since handbooks might be a knowledge stimulant and therefore. Our findings are supported by Ronteltap (1990) and Müller-Staub (2006². Ready knowledge did significantly correlate with the main effect of handbooks and the assessment format because of higher scores if no handbooks or assessment format were available. inference and deductive scores did stand out in 128 . It is unknown if this explanation is correct. this may explain that age was a significant predictor. 2009). 2007) who differentiated caserelated knowledge from diagnostic skills as two essential aspects needed to report accurate diagnoses (Gulmans 1994). it might be possible that nurses are in retrospect more activated to use ready knowledge due to the absence of handbooks and the assessment format. knowledge looked up in handbooks might have given a positive effect on the latter inventory scores. caused by multiple testing. Reasoning skills Nurses with strong analysis. Cruz et al. to be orderly and focused. ProfettoMcGrath et al. or if our finding is coincidental. 2002. A possible explanation why PES did not affect the number of relevant diagnoses is that this format primarily guides the reasoning process of nurses. and to look in more depth for relevant diagnostic information. helping them to differentiate and document accurately.Chapter 6 Discussion Because the PES-structure is taught in nursing education programs in the Netherlands from the mid 1990’s. Smith-Blair & Neighbors 2000. Nurse educators may need to teach students to reflect on dispositions. Ready knowledge The finding that ready knowledge did not correlate with accuracy of nursing diagnoses can be explained by the fact that the participants did not possess sufficient diagnostic skills needed to derive accurate diagnoses. Several studies have reported that nurses trained in analytical skills score relatively high on the CCTDI (Colucciello 1997. knowledge of the problem area might have lead to more accurate diagnoses if the nurses had sufficient diagnostic skills to formulate these. Profetto-McGrath 2003. We did not find a significant main effect of using knowledge sources and the PESformat and the number of relevant diagnoses (Table 2). On the other hand. we assume nurses may need to be more aware of the importance of being sensitive to one’s potential bias and being alert to potentially problematic situations (Alfaro-LeFevre 2004). 2005). younger nurses had higher accuracy scores than older nurses. Disposition towards critical thinking Based on our findings. In this study. Nokes et al. 2000. This significant finding was unexpected. Therefore nurses as well as lecturers may have to focus more on thinking dispositions in daily hospital practice and in diagnostic training programs (Björvell et al.

Conclusion Based on the results of this study it can be concluded that the PES-format has a main positive effect on the accuracy of the nursing diagnoses. Almost half of the variance of diagnoses accuracy is explained by the presence of PES-format. The relatively high scores on the inductive domain of the HSRT suggest that the nature of nurses’ reasoning is. As far as we know this result is new and puts pre-structured formats and reasoning skills in a new perspective. could be a step forward to improving the accuracy of nursing diagnoses. and encouraging them to use the PES-structure. Personal knowledge. This way of sampling may have introduced a selection bias. The results of this study should have implications for nursing practice and education. nurses may use their inductive skills as well as their deductive and analytical skills (Lee 2005). 129 . since a number of nurses in our sample might have been more focussed on nursing diagnoses. 1982) and physical therapists (Ronteltap 1990) suggest that a diagnosis based on the use of deductive skills is more accurate as opposed to a diagnosis based on knowledge and experience alone. To properly determine which previous empirical information is relevant for a given clinical situation. to a certain extent.Accuracy of nursing diagnoses: a randomised study the accuracy of their diagnoses. Limitations Nurses in our sample did voluntarily participate in a study in diagnostics. More analytical and deductive reasoning needs to be taught to accurate use the PES-structure. improving nurses’ reasoning skills. even though they were uncertain of what to expect in the case history contents and questionnaires. Improving nurses’ disposition towards critical thinking. Lunney 2006). Previous studies in physicians (Barrows et al. inductive. Part of the 53% unexplained variance is likely to be random in the sense that it cannot be explained by systematic variance from independed variables. experience. nurse age and reasoning skills deduction and analysis. and (subjective) individual reflections are part of nurses’ diagnostic process as well (Benner & Tanner 1989. Cutler 1979.

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Chapter 6 134 .

General Discussion and Recommendations CHAPTER 7 GENERAL DISCUSSION AND RECOMMENDATIONS 135 .

and signs and symptoms or defining characteristics. The purpose of the interview is to exchange appropriate information that will be used for planning and delivering daily care in hospital practice (Johnson et al. with reference to an attainable nursing intervention. It offers them information on nursing diagnoses. clarifying the diagnostic domain called ‘the diagnostic label’. 2007. disrupting 136 . Patient data are supposed to be documented in the patient record so that colleagues and other health professionals can inform themselves. NANDA 2004). our studies evaluated factors influencing the accuracy of the nursing diagnosis documentation. A well-structured and unambiguous report should therefore facilitate efficient information transfer and is directly available for use (Eggland & Heineman 1994). If we focus on the key component of the nursing process—the nursing diagnosis— the use of the NANDA-I classification implies that classification criteria for the documentation of nursing diagnoses are to be found in the patient record (Lavin et al. it provides information about the results of the care delivered in terms of outcome (Doenges & Moorhouse 2008). nursing documentation has gained increased attention from policy makers and hospital managers (McCormick 2007. and specific influencing factors: knowledge sources. whose focus is mainly on the development and implementation of electronic documentation devices (Ball et al. Thereby. We distinguished two classes of factors that influence nursing documentation: (1) general factors that influence the reasoning and documentation process in general. also known as the PES structure (Gordon 1994.Chapter 7 Introduction The nurses’ admission interview usually represents the start of a patient-tonurse relationship. This information is vital for continuity of care as well as for patient safety (World Alliance for Patient Safety 2008). The contributions of these studies to the domain of nursing diagnoses and nursing documentation can be summarised as follows. Examples of general factors that influence nursing documentation include work procedures. critical thinking dispositions. and reasoning skills and whether they affect the accuracy of nursing diagnosis documentation. Over the last two decades. as a result of the systematic literature review. Wilkinson 2007). work allocation. we proposed a conceptual basis to explain the reasons for (in)accurate diagnoses and intervention documentation. By using several methodological designs. A nursing diagnosis should be documented in terms of a definition. the prevalence of accurate nursing documentation in hospital patient records. and interventions previously carried out. and (2) specific factors that specifically influence the prevalence and accuracy of nursing diagnosis documentation. the current status of the quality of nursing documentation in the patient record and influences on the accuracy of documentation were not studied intensively during this period (Gunningberg et al. 2005). Welton et al. planned interventions. 2009). 1999). Nevertheless. First. Part of the diagnosis documentation is the listing of aetiology or related factors. 2003). The nursing care plan is the main legal source of information for nurses.

and (4) hospital policy and environment. we established that nursing documentation was mainly chronological instead of systematic and hardly problem or diagnoses based. motivation. and we decided to focus on pre-structured record forms and the use of classification structure i. We selected the following determinants out of the Diagnostician domain: diagnostic reasoning skills and case related and diagnostic knowledge. based on the results of the systematic review. we recommend an in depth. Second. Therefore we chose to the nurse related determinants for further research. (3) complexity of a patient’s situation. (2) diagnostic education and resources. Third. conflicting personal values. As we did not find a psychometrically tested measurement instrument for assessing the accuracy of nursing documentation. Furthermore. Based on our record review. on the basis of a cross-sectional record review and using the D-Catch instrument. or international levels. as presented in this dissertation. but that these influences were not further researched in depth. Using the D-Catch instrument as a measurement tool for accuracy of 137 . Based on a study of 245 patient records in 25 wards in seven hospitals. the D-Catch was found to be a feasible and reliable instrument for use in a general hospital context. related to the domain. to determine whether nursing documentation in clinical practice is accurate. may be helpful for nurse managers and nurse educators to use as a reference. we showed that nursing diagnoses were poorly documented according the PES structure. the second group used a PES-format. it was unclear what factors influence accurate and inaccurate documentation. it can be used on regional. NANDA-I. and staff development. Diagnostic education and resources in nursing practice.e. integrative view of factors that influence diagnoses documentation. in which we compared four groups of hospital nurses (n= 241). We performed a study based on a randomised factorial experimental design. and NOC as a conceptual basis (Johnson et al. 2007). the D-Catch may in future research facilitate the review of patient records for determining the accuracy of nursing documentation. NIC. The fourth group acted as control group.General Discussion and Recommendations work conditions. A conceptual model of determinants that influence nursing diagnosis documentation. we concluded that important influences were described toward nurses themselves. Fourth. Even though NANDA-I criteria were incorporated into almost all nursing school curricula in the Netherlands since the mid 1990s. For clinical purposes at the hospital ward level. we developed a new instrument: the D-Catch. One group used handbooks and an assessment format. we used the NANDA-I. Specific influencing factors were subdivided into four conceptual domains: (1) the nurse as a diagnostician. we found that documented nursing interventions were mainly unrelated to documented nursing diagnoses. Because the D-Catch is based on international nursing standards. To support nurses in documenting their diagnoses accurately. knowing the patient. the third group used a PES-format and handbooks and an assessment format. national.

accuracy of diagnoses is to be judged as ordinal. Nevertheless. the level of evidence. we missed several papers. Methodological considerations Factors influencing the prevalence and accuracy of nursing diagnosis documentation in hospital practice The conceptual definition of accuracy of a nursing diagnosis and a description of the characteristics of accuracy emphasise the relativistic nature of the concept (Lunney 2008. Therefore. we are convinced that the overview of influencing factors on diagnoses accuracy is important for hospital managers. since the measurement instruments and methods described in the reviewed articles differed. we found that the use of a PES format had a significant positive effect on the accuracy of nursing diagnosis documentation. and factors that influence diagnoses. the data collection. This means that “accuracy of nurses diagnoses of human responses is too complex and relative to be considered as a dichotomous (i. We propose a conceptual model comprising four domains of factors that influence diagnoses documentation accuracy. the research design. We used the Oxford Levels of Evidence as a reference guide for assessing study validity. Instead. and so we modified these levels. Designs. As we included papers written in English only. It was impossible to aggregate data by performing statistical procedures. we presume that our model is consistent and contains the foremost influencing factors described in the literature. The information we found in English abstracts related to these articles was in many cases insufficient to obtain enough clarity addressing the focus of the study. we assessed papers qualitatively and were thus unable to associate the influencing factors or to distinguish major influences from minor ones. and methods were assessed. because there seems to be a web of relationships between various independent variables and the dependent variable ‘nursing diagnosis accuracy’. as the D-Catch instrument provides. The opportunity to use handbooks on nursing diagnoses or a pre-structured assessment format did not significantly affect the accuracy of diagnoses. mostly published in Spanish. Our modification of the Oxford Centre criteria was not further validated.e.Chapter 7 nursing diagnoses. these levels of evidence do not accommodate fully the wide range of qualitative research we found. Although we might have overlooked some papers due to the search strategy or database filters used. Therefore we decided not to include these papers. sample sizes. 2009). Accuracy in nursing diagnoses is also considered to be relativistic in nature. Although our review has its limitations. p. These results suggest that knowledge and reasoning skills acquired in previous educational programmes do not automatically result in the use of this knowledge and these skills without specific sources. 138 .. either / or) variable” (Lunney 2009. We found that nurses who scored low on critical thinking dispositions and reasoning skills documented diagnoses with lower accuracy than nurses who scored higher on these dispositions and skills. Portuguese or Japanese. 28).

we present evidence that the cause of low accuracy in nursing diagnosis documentation in clinical practice is multi-factorial. At the time we had carried out the review toward the instruments available from the literature and had started a pilot study using the D-Catch instrument (2007). To move forward in developing strategies for accuracy in diagnoses documentation. there may be similarities between the hospital context and other healthcare settings related to the model as well. Although single implementations might have short-term effects.General Discussion and Recommendations nurse educators. Therefore. Completion of an additional review of the literature toward influencing factors in other settings can provide the basis to evaluate the model representing the hospital context. their long-term effects are often uncertain. environmental and cultural aspects as well as patient characteristics may differ from the hospital situation with other influencing factors as result. Nevertheless. as the ultimate aim is to positively influence the quality of care and to decrease the amount of adverse events in clinical practice by providing accurate nursing documentation. Also. we performed an exhaustive literature search for quantitative measurement instruments used in hospitals. such as training in deriving diagnoses or computer tools in nursing documentation. we were unable to calculate consensus scores or agreement rates. 139 . instead of carrying out only single-issue implementations. Akins 2005). However. a management approach with the aim of improving diagnoses documentation should be integrative in nature. we determined the content of the D-Catch instrument. Policy. despite limitations. On the basis of the content of two measurement instruments and by using Delphi panel techniques. it is necessary to address the whole field of influencing factors. we found that interactions among the panellists throughout consensus discussions yielded valuable opinions that were used to decide on the ultimate criteria of the D-Catch instrument. with the aim to develop a model for use more general. Therefore. We found that none of the instruments were psychometrically tested for use in general hospitals. the qualitative Delphi panel approach of two small panels we used has limitations for content validity testing (Lynn 1986. We assume that our overview of instruments represents the foremost instruments published. who are all accountable for continuity and quality of care and patient safety. The prevalence of accurate nursing documentation in hospital patient records in the Netherlands To get an idea of available instruments that have been used to assess nursing documentation. this model may not be transferrable to other health care settings as for instant nursing homes. On the basis of our review. Reflecting on this qualitative approach. and staff nurses. As we focus on the model containing determinants that influence the prevalence and accuracy of nursing diagnosis documentation as developed based on the results of the literature review. single implementations could be a disinvestment.

since we did not assess patients in our prevalence study. and the nursing staff’s educational background and years of experience. the issue ‘relevant’ in the quality criteria of the D-Catch may be a cause of subjectivity. such as the Cat-ch-Ing (Björvell 2000) and the Q-DIO (Müller-Staub 2007. were not assessed in our study and might have influenced accuracy scores. nurse educators. Standards for nursing documentation are equal in all settings. has a negative effect on the quality of care and could be a cause of severe adverse events hampering patient safety (Zeegers 2009). we believe that our sampling method did not affect representativeness due to selection bias. These contacts were helpful and positively influenced the simultaneous procedure of development and testing of the D-Catch. As we were not able to review whether the documentation was relevant related to the actual or potential existence of nursing diagnoses in that particular patient situation at that time. Twelve pairs of reviewers assessed the nursing documentation. therefore the D-Catch instrument may be suitable to 140 . We reviewed nurses’ documentation (341 patient records) in 10 hospitals and seven specialties (35 wards) that differed in the conditions of the patients. as found in this dissertation. The D-Catch was used to measure accuracy in nursing documentation in a prevalence study. with the result that the inter-rater reliability was acceptable and raters had comparable understanding whether the information was relevant in the context of the additional content of the documentation. nurse educators and staff nurses in a hospital context could benefit from the D-Catch instrument. A record review was carried out using a random sample from 6 of 10 general hospitals. We assume that the data acquired with the D-Catch instrument resulted in reliable information on the accuracy of nursing documentation and should seriously be taken into consideration by hospital managers. The understanding of relevancy of documented nursing diagnoses in patient records was a particular subject of consideration in the training session ahead of the measurement in hospital practice. and staff nurses. Therefore. the patient-to-staff ratio.Chapter 7 concurrently the amount of publications toward measurement instruments was increasing. 2008). Not only hospital managers. We found no significant differences between the nursing documentation accuracy scores of the four replacement hospitals and those of the randomly selected hospitals. This approach was feasible in hospital practice despite differences in documentation formats and patient records. Still. Müller-Staub et al. since low accuracy in nursing documentation. We replaced the hospitals that declined participation by approaching hospital managers in the same region as those that declined. such as interdisciplinary or environmental characteristics of the ward. this can be seen as a limitation of the study. These and other factors. We had several contacts with some of the researchers developing instruments for research in the same area.

“The advantage of the simulated patient technique is that it directly assesses nurses’ communication skills that are important during the daily performance in nursing practice”. Williams & Gossett 2001. Most of the assessment interviews were videotaped and reviewed for reliability reasons. however. As the documentation approach and documentation systems in other settings may be different compared to the hospital setting. interpret. It may seem that providing a PES-format for diagnoses documentation is receiving diagnostic results in a PES-format. despite costs and time-consuming face-to-face acting. Retrospectively. However. we conclude that script consistency was satisfactory. questions in order to be able to analyse. and that the structure was ignored completely. for instance. reliability and validity testing of the D-Catch instrument seems to be required in case of use in other settings. actors are not the same as patients. Based on the analysis of the documentation in the PES-format in our experiment. it is essential in an experimental environment as well. (2001) stated. related 141 . we found that 8 (6%) of the 126 participants did not use the format as it was purposed. we took time to intensively rehearse the case histories and script. The effect of knowledge sources and predefined record structure on the accuracy of nursing diagnoses We were able to provide evidence based on a randomised factorial design that a predefined record structure and reasoning skills (deductive and analytical skills) significantly contribute to the accuracy of nursing diagnoses. Jeffries 2005). describe the relationship between the accuracy of nursing diagnoses and critical thinking and reasoning. Otherwise this may hamper generalisation of the results to clinical practice. working with actors provided us with natural nurse-to-patient interactions. and therefore was easier to assess. None of these studies. Several studies associate critical thinking and reasoning to diagnostic inference. and document patients’ information in terms of nursing diagnoses. Compared to pre-produced video cases. As this relationship or ‘connection’ is required for deriving accurate nursing diagnoses in clinical practice. On the other hand. A patient-to-nurse relationship is essential for deriving diagnoses (Wilkinson 2007). Using actors as simulation patients. feasibility. Thereby we were able to work with the same four actors from the pilot study in the follow-up study. preferable in researching the effect of nurse-to-patient interactions (Cioffi 2001. the documentation was descriptive in nature and problem label. Nurses have to use their expertise to ask patients relevant. we were able to create an experimental environment that closely resembled the participants’ work setting. To limit bias. We have to consider the possibility that the information presented by the actors had more internal coherence than information obtained from real patient situations. in depth. Kruijver et al. real-life simulations are.General Discussion and Recommendations evaluate the accuracy of the documentation in other settings as well.

In almost all cases. For some nurses it seemed to be complex to use the format appropriately and to document their findings correctly in the format.Chapter 7 factors and signs and symptoms were not accurately documented. The estimated time needed to do the assessment interview and to document the diagnoses seemed to be sufficient. Therefore no scores for inter-rater reliability calculation were noted in the case of the six diagnoses from the fixed scripts. Therefore their scores were < 4 (2-8). Nearly all participants stated that the environment and the performance of the simulation patients were natural and did not hamper their interviewing. Independent raters (n= 8. Out of the 115 participants allocated in groups without the possibility to use a PESformat. However. four registered nurses and four fourth year bachelor students in nursing) scored in pairs whether the diagnosis was considered to be relevant or not based on the listed six diagnoses after they had received a 20 hour training in reviewing accuracy and relevancy of nursing diagnoses. Any actual nursing diagnosis not fitting the script was considered to be irrelevant. the raters’ scores of relevant or irrelevant diagnosis lead to no discussion and the scores were found to be equal. because it was apparent whether it was relevant related to the six actual diagnoses in the script. 142 . The scripts were specifically designed to represent exactly six actual nursing diagnoses. we have to take into account that the results in our study may be. raters gave a definite score. To be able to analyse whether nurses derived relevant diagnoses (accurate content). which is hardly to avoid in this type of experimental designs. each of the three actors’ scripts contained six actual nursing diagnoses which should be identified based on the assessment interview (Table 1). Participants did not report lack of time. We paid attention to relevancy of the nursing diagnosis in the experimental studies. Based on a consensus discussion. if necessary. caused by an overlap between intervention and outcome measure. 17 (15%) participants used the PES-structure and scored > 5 (2-8) and 53 (46%) participants scored < 4 (2-8) in these groups. we found that providing a PES-format offered results significantly positive: 90 (71%) participants out of 126 scored > 5 (2-8) in these groups. to some extent. Although the use of a PESformat is not obviously resulting in higher accuracy scores in all cases.

We used the CCTDI and the HSRT to estimate the association between critical thinking dispositions and diagnoses accuracy. Application to Clinical Practice. 66) Anxiety (death anxiety) or fear (p. The HSRT test manual is based on the consensus definition of critical thinking that was developed in a Delphi Study (Facione & Facione 2006). 253) 2 Grieving (p. 266) Disturbed sleep pattern (p. 88) 1 Diagnostic labels1 incorporated in the case history and script COPD patient Activity intolerance (p. 471) 4 Inactive self-health management (p. Lippincott Williams & Wilkins. 72 / p. 260) Deficient fluid volume (p. Edition 13. and reasoning skills on the accuracy of nursing diagnoses A number of student nurses and registered nurses in our samples may have been especially interested in nursing diagnoses. since students and nurses in our samples were invited to voluntarily participate in our study. as compared to those who did not participate.General Discussion and Recommendations Table 1 Nursing diagnoses in actors’ script Diagnostic labels1 incorporated in the case history and script Diabetes patient 1 Fatigue (p. 253) Ineffective activity planning (p. 511) Diagnostic labels1 incorporated in the case history and script Crohn’s disease patient Chronic pain (p. This may have introduced a selection bias and a restriction of variance. 145) Diarrhea (p. 579) 5 Ineffective activity planning (p. 516) Ineffective airway clearance (p. 199) Stress overload (p. 71) Ineffective coping (p. Linguistic validation of the CCTDI and the HSRT was done by forward and backward translation by two independent translators. Carpenito-Moyet (2010). 602) Impaired gas exchange (p. 225) Fatigue (p. The influence of ready knowledge. 464 / p. The final translation was assessed by a third translator and approved to be relevant in the Dutch nursing context by a 143 . dispositions towards critical thinking. 647) Diagnostic labels as published in: Nursing Diagnosis. 280) 3 Impaired tissue or skin integrity (p. 71) 6 (Risk for) unstable blood glucose (p.

the research design and the use of the D-Catch. also quantified by Cronbach’s alpha (n= 96). On the basis of our findings from the two studies in which we used the knowledge inventory.73. critical thinking. Based on the experiment toward students we found a weak. association between the Analysis domain of the HSRT and the accuracy in nursing diagnoses documentation. Although we found significance in this domain as well as in the experiment of hospital nurses. and reasoning skills need to be taught and assessed comprehensively in nursing schools and in postgraduate education programmes if nurses are to avoid inaccurate diagnoses and incorrect interventions in clinical practice. we concluded that case-related knowledge. and the HSRT. since after Bonferroni correction this finding does not fall below 0. 144 . (p= 0. in general. the CCTDI.05 significant level. We found the sampling.Chapter 7 panel of nursing scientists (n = 6). but significant.013). and the HSRT instruments to be useful within the framework of this study. the CCTDI. students’ reasoning skills influence the accuracy of nursing diagnoses. the knowledge inventory. Reliability of the Dutch version of the HSRT was 0. Reliability of the Dutch version of the CCTDI quantified by Cronbach’s alpha was 0. This significant result may be due to multiple testing.64. we can not conclude that.

The evidence for the relationship between specific reasoning skills and accuracy in nursing diagnoses is new and may contribute to the development of nursing education programs and assessments addressing these reasoning skills in several countries in which these skills have less attention. A distinction between general and specific factors of influence can be made. in general. may be helpful for nurses. deductive reasoning skills. influence accuracy of nursing diagnoses positively. • On the basis of a systematic review it was concluded that the cause of low accuracy in nursing diagnosis documentation in clinical practice is multifactorial. • The PES-format as a tool may be beneficial for use in electronically patient records. provided in this dissertation. • Particularly the accuracy of the documentation of nursing diagnoses and interventions. 145 . since this format proved to be helpful in requiring accurate nursing diagnoses documentation. • In general. and that several factors are influencing the accuracy of nurses’ (diagnosis) documentation. administrators and record designers. were found to be poor to moderate in the Netherlands.General Discussion and Recommendations Conclusion This study shows that the accuracy of the nursing documentation. These findings are comparable with several findings in other countries. A conceptual model of influencing factors. a positive critical thinking disposition and well developed reasoning skills. needs improvement. It seems that an international approach is required for further developing international documentation standards and accuracy in nursing documentation. Further research is needed to distinguish minor from major influences. This instrument may be of use in an international context as well. facilitators. The following findings are concluded: • The D-Catch instrument proved to be a reliable and valid instrument for measuring the accuracy of nursing documentation in the patient record. in particular analytical.

and experience and training in the specialty area in which the nurse is employed. Lunney 2009). nurses. In our study we provide evidence that a nurse’s dispositions towards critical thinking and diagnostic reasoning skills are vital for obtaining accurate nursing diagnoses. Ongoing critical evaluation of what is expected from nurses. Hospital managers. what nurses ought to recall to mind depends on several determinants. Knowledge. and consequently. Nurses are employed in numerous specialty areas. and nurse educators in hospital practice are accountable for patient safety and quality of care. 2002. Also. It 146 . Nurses may need to be more aware of being sensitive to one’s potential bias. and being able to anticipate certain results or consequences that influence their diagnoses (Alfaro-LeFevre 2004). Cruz et al. related to their tasks and responsibilities in clinical practice. the complexity of patient situations that nurses have to deal with in daily practice differs. Therefore. 2009). a lower overall report-mark for the nursing and medical record is associated with a higher rate of adverse events. Teaching nursing students and registered nurses how to employ strategies on using ready knowledge and knowledge sources (‘on-paper-knowledge’ or ‘databaseknowledge’) is an important objective for nursing faculty. being alert to potentially problematic situations. However. Thus. such as their responsibilities relating to their individual diagnostic inference as members of a multidisciplinary team. Therefore. This study confirms the need to develop students’ critical thinking dispositions and reasoning skills in nursing schools to enhance the accuracy of nursing diagnosis documentation (Björvell et al. The results of the study of Zeegers (2009) and the results of our study on accurate nursing documentation show the importance of taking action in clinical practice. reported by Zeegers (2009) revealed that “inadequate content in patient records is associated with higher rates of adverse events.Chapter 7 Implications for practice This study provides instruments and methods to investigate the prevalence of accurate documentation as well as factors that influence nursing diagnosis documentation. they have to find strategies to improve nursing documentation in clinical practice. Cruz et al. the adequacy of patient record contents seems to be a predictor of the quality of health care”. and reasoning in nursing The first step to improving the accuracy of nursing diagnosis documentation is to create awareness of the need to make reflective judgements in complex situations. Nurses as well as teachers have to focus more on critical thinking dispositions in daily clinical practice and in diagnostic training programmes (Björvell et al. 2002. the level of knowledge needed in specific patient situations. 2009. might deliver essential information on what knowledge is lacking or on what knowledge sources might be needed in specific nursing areas. patient situations in nursing are diverse. The result of an international record review of 7926 randomly selected hospital records. critical thinking.

Kurashima et al. and the most observed outcomes. and progress and outcome evaluations. the most successful interventions. (2008) found that time needed to obtain a diagnosis is significantly shorter when nurses use a computer aid. The implementation of such systems ought to be supported by experts in nursing diagnoses education and in critical thinking and diagnostic reasoning. and using knowledge sources will likely be a step forward in improving the accuracy of nursing diagnoses. are helpful in combination with electronic resources to provide accurate diagnoses documentation (Smith Higuchi et al. 2009). Improving nurses’ disposition towards critical thinking. As educators focus on developing critical thinking disposition and reasoning skills in aspiring nurses. useless redundancies. improving nurses’ reasoning skills. may support nurses in their administrative work (Smith Higuchi et al. what goes into the system must be relevant and precise. 1999. (2008). This finding is important for software designers and implementers of electronic documentation systems. such as the NANDA-I classification (Thoroddsen & Ehnfors 2006). related interventions. deriving and documenting nursing diagnoses should be part of all nursing education programmes. The use of electronic information systems designed to achieve systematically and logically structured information that is directly available to all health care professionals may overcome the time-consuming. Nevertheless. Computer tools and software can increase the efficiency in exchanging patient information on an inter-institutional level. Experts in nursing diagnoses education have to offer training intended for the nursing staff in clinical practice in how to use the PES format in an electronic documentation system. As mentioned by Keenan et al. 147 . Resources to reduce the lack of precision of diagnostic reports as. mostly handwritten documentation systems. 2008). All staff nurses are individually accountable for deriving and documenting accurate nursing diagnosis.General Discussion and Recommendations is also imperative to cultivate these skills in nursing staff in clinical practice. 1999). detailed computer-generated standardised nursing care plans. The development and implementation of electronic documentation resources and pre-formulated templates have positive influences on the frequency of diagnoses documentation (Smith Higuchi et al. Classification structures. 1999). for instance. Documentation resources This dissertation gives evidence that using the PES format increases accuracy in nursing diagnosis. since care plan information documented in the system needs to be reliable. Gunningberg et al. as the ones we found in chronologically. software that quantify data in electronic documentation systems can address evaluative questions about what are the most prevalent problems. Electronic nursing documentation also helps nurses in systematically evaluating the care plans based on a structured and legible documented patient history (Keenan et al. The use of the PES format should be incorporated into all digital nursing documentation systems.

and abilities that all nurse educators must possess if they are to teach courses on nursing and diagnoses documentation and electronic documentation systems. populations. Keenan et al. 2008). Since health care expenditures vary greatly because of different health care settings. Nursing documentation in education programmes Some authors are concerned on whether there are an adequate numbers of wellprepared and capable nurse educators to teach the nursing process (Davies et al. Hinshaw 2001). diseases. even as a fit between nursing workflow and the functionality of a digital nursing documentation system. Coaching and support are needed. Standardized nursing language facilitates the collection and use of data for measuring and monitoring quality of care. 2005. accurate nursing documentation would show the full range of nursing practice. (2002). Therefore. we highly recommend the implementation of computer tools for digital care plan documentation in clinical practice and in nursing schools. and conditions. 2008). simply adopting electronic health records is likely to be insufficient. Improvements in nursing documentation that use an internationally acknowledged classification system offer opportunities to establish a nationwide or state-wide database that incorporates medical and nursing data. (2010) suggest that “to drive substantial gains in quality and efficiency. Thereby. Hospital policy and management For hospital management. especially to nurses educated before the mid 1990s. the findings of DesRoches et al. These tools must be based on nursing standards and software resources that will help nurses to use these standards. Instead. mainly because the use of classification principles and the PES format may be unfamiliar to a number of nurses. skills. when implementing computer tools. Nevertheless. These data can be used for the retrospective analysis of quality and safety issues as well as costs. Nurse educators that are experts in nursing diagnosis derivation and documentation are a prerequisite for accurate nursing documentation in clinical practice. Accurate nursing diagnosis 148 . policies are needed that encourage the use of electronic health records in ways that will lead to improvements in care”. Furthermore standardized language not only facilitates the development of practice standards at the unit level but they also do so at larger levels.Chapter 7 Taking all aforementioned issues into consideration. there may be cost controlling reasons from a political perspective for implementing standardised language in nursing. Software for use in nursing education programmes can assist educators to teach students how to plan their care in a consistent way while using standardisation (Keenan et al. as was found by Ammenwerth et al. we recommend the development of a competency statement that lists the essential core knowledge. it is important to consider whether nurses agree to use electronic care plans in their wards. including how nursing contributes to health promotion and prevention of illness (Clark 1997.

to adopt quality indicators in international accreditation programmes based on nursing documentation standards is highly recommendable. Hospital benchmark research positively influences quality of care and patient safety (Donaldson et al. Using incomplete or incorrect accreditation criteria in nursing documentation might put forth a counterfeit image of documentation accuracy that misleads hospital management and that results in the perpetuation of low documentation accuracy. there is no single determinant that solely can attribute to the accuracy of nursing diagnosis documentation. critical thinking dispositions. by benchmarking hospital expenditures. we found that several factors that influence diagnoses documentation were investigated as a single influencing factor. On the basis of our findings. since we found that in many cases nursing documentation was inaccurate. experience. It gives hospital management an indication of possible quality improvements that need to be undertaken. Previously obtained case-related diagnostic knowledge. 2005). However.General Discussion and Recommendations documentation can open up possibilities for exploring the nature of the costs of nursing care. Thus. and environmental 149 . and protocols in a variety of indicators. for instance. For reliable data on quality and efficiency. and cultural characteristics. The combination of factors presumed to affect the accuracy of nursing diagnosis documentation has to be taken into consideration as a topic for further research. both procedures and the quality of documentation content must be measurable and audited. This might stimulate them to improve documentation procedures as well as the content of the documentation. We are convinced that this will make a real difference between safe and unsafe patient situations in clinical practice. we presume that hospital accreditation is awarded based on incomplete accreditation standards in nursing documentation. In this manner. Probably. Accreditation based on uniform standardised accreditation criteria gives hospital management the exact direction for improvements. reasoning skills. processes. External hospital accreditation is not only valuable for receiving an independent quality and efficiency statement. external hospital accreditation is increasingly important for hospital management. with the opportunity to do hospital benchmark research. hospital policy. Thus. instructions. accreditation reflects the origins of systematic assessment of hospitals against explicit standards (Shaw 2000). Future research Paradigm shift in nursing diagnosis research In the literature. Audit staffs observe mostly documentation procedures. the use of diagnostic resources. it is also valuable for achieving compliance with safety requirements. the development of uniform accreditation criteria in nursing documentation provides hospital management and nursing staff with a tool for measuring identically documentation quality in several hospitals.

and institutional. and Iceland. This may be a reason why nurses write about observations and responses in a chronological and passive manner. But nurses’ general inductive and evaluative thinking with their focus on patient’s possibilities as alternative ways of analysing the problems of patients may cause nurses to become dissatisfied with the use of nursing diagnoses and to resist systematic data documentation (Henderson & Nite 1978. p. Alfaro-LeFevre 2004. Since the 1980’s nurses are developing a more flexible use of the nursing process (Pesut & Herman 1998. Benner & Tanner 1987. Tanner 2005) versus the cognitive. Sweden.Chapter 7 aspects will result in additional knowledge that will serve as a useful basis for future documentation improvement strategies. it might be that the current dichotomy—the non-analytical and humanistic stance (Benner 2001. what health problems nurses actually are engaged in. most of the instruments 150 . we presume that the basic principles defining accurate nursing documentation are quite similar. these factors could be an option for further research. thus. A third stance—the pluralistic diagnoses accuracy paradigm. dichotomizing objective and subjective elements as signs and symptoms. legal. For instance. Benner & Tanner 1987. positivistic stance related to the conceptual basis of Gordon (1994). when studied concurrently in a multifactorial design. 2006) —has to be abandoned as a conceptual distinction for researching the accuracy of nursing diagnoses documentation. hospital policy. 199-212). Switzerland. Henderson mentioned in 1980 that the role of subjective or intuitive aspects of nursing and the role of experience. Heartfield 1996). Doering 1992. in clinical practice is unclear. empiricists’ view on nursing care. Carpenito-Moyet (2008). Wilkinson 2007). and therefore. logic and expert opinion as the basis for nursing practice may be ignored by using the nursing process with the purpose of problem-solving (Halloran 1995. The contemporary view is that nursing documentation must be logically written. Dreyfus & Dreyfus 1986. and hospital environmental attributes—might offer a new focus for researching the accuracy of nursing diagnoses. Facione (2000. Research collaboration The instruments and the methods used in the studies reported in this dissertation might be useful in other research designs as pre. Therefore. The results of our study emphasise that positive critical thinking dispositions and extended reasoning skills (especially analytical and deductive reasoning skills) are positively associated with the accuracy of nursing diagnosis documentation. As we focus on the content of the instruments used to measure the accuracy of nursing documentation in several countries such as the USA.and post-tests to measure the outcome of implementations such as electronic documentation systems. 371. the reality of nursing remains hidden and will not be recorded as suggested by Heartfield (1996). p. according to the ethical. which combines aspects of the aforementioned paradigms with cultural characteristics.

2008). there might be an association between nurses’ level of education.General Discussion and Recommendations use the NANDA-I and the PES structure as their conceptual basis for accuracy measurement in nursing diagnoses. Moreover. streamlining information. other sources need to be researched as well. Although these suggestions are based on research on physician-to-physician communication during patient handoffs (Solet et al. future research has to be carried out on nursing hand-over effectiveness relative to the accuracy of nursing documentation. Lunney 2007). However. in order to support our recommendation. and providing patients with the opportunity to read their own medical record as a patient safety strategy (World Health Organization 2007). nurses’ reasoning skills. 2005). automated medication reconciliation. and availability of resources (paper and electronic) and accuracy in diagnostic documentation. In order to determine whether omissions in patient records affect patient safety and adverse events. and patient safety (Urquhart & Currell 2005. The impact of inaccurate and accurate nursing documentation on patient safety Research is lacking on the effects of inaccurate and accurate nursing diagnosis documentation on the continuity of care. quality of care. International collaboration in the field of accuracy measurement might provide additional information on minor and major factors that influence the accuracy of nursing documentation and on essential interventions that can enhance documentation accuracy. or the prevalence of adverse events. 151 . this possible association is still unclear and needs to be investigated. The World Health Organization’s advice (2007) is to explore technologies and methods that can improve hand-over effectiveness. Additional research outcomes that link the quality of information in patient records to causes of adverse events will provide information that may stimulate documentation improvements (Zeegers 2009). quality of care. For instance. using a common (standardised) language for communicating critical information. future research is needed to show how the use of documentation standards affects length of stay. nurse staffing. on the basis of our results we recommend that this advice should also be applied to the nursing context as it relates to nursing and interdisciplinary hand-over effectiveness (Wong et al. such as databases for specific documentation of causes of adverse events in hospitals. such as electronic medical records. since patient records may not provide enough pertinent information for reliable research data. Nevertheless. The development of an instrument for accuracy measurement in nursing documentation in an international context could serve as a launching point for further international research on the prevalence of accurate nursing documentation.

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In clinical practice, documentation in the patient record is part of each nurse’s daily routine. It is considered to be essential for adequate, safe, and efficient nursing care. Inaccurate nursing documentation can be a cause of nurses’ misinterpretations and may cause unsafe patient situations. Therefore, the World Alliance for Patient Safety recommends further research on medical and nursing documentation so that they can identify and report potential areas for improvement. The introduction of the nursing process to hospitals in the USA and Europe, combined with information on the value of nursing diagnoses from NANDA in the early 1980s, prompted nurses to think seriously about the importance of systematic, standardised, and accurate nursing reports in the patient record. From then on, nursing diagnoses became progressively more important as an element of nursing documentation. Therefore, how to derive and how to document nursing diagnoses received priority attention in nursing education programmes. Nursing diagnoses provide the bases for selecting nursing interventions that achieve outcomes for which nurses are accountable. Nursing diagnosis is defined as “a clinical judgment about individual, family or community responses to actual and potential health problems/life processes. (NANDA-I 2004, p. 22). An accurate diagnosis describes a patient’s problem (label), related factors (aetiology), and defining characteristics (signs and symptoms) in unequivocal, clear language. This way of documenting diagnostic findings is called the PES structure (P = problem label, E = aetiology (related factors) and S = signs/symptoms). Describing a problem solely in terms of its label in the absence of related factors and defining characteristics could lead to misinterpretation. Although certain aspects of nursing documentation and diagnoses have been researched, gaps remain in the field of (1) measurement instruments for reviewing nursing documentation in the patient record, (2) the prevalence of accurate nursing documentation, and (3) factors influencing nursing diagnosis documentation. This dissertation had two main objectives. The first was to describe factors that influence the accuracy of documented nursing diagnosis. The second objective was to describe the prevalence of accurate nursing documentation in the patient record. The aim of the first study was to review factors that influence the prevalence and accuracy of nursing diagnosis documentation in hospital practice. To accomplish this aim, we performed a systematic literature search of the electronic databases MEDLINE and CINAHL of articles published between January 1995 and October 2009. Twenty-four articles that examined factors that influence the prevalence and accuracy of nursing diagnosis documentation were included in the review. Four domains were identified: (1) the nurse as a diagnostician, (2) diagnostic education and resources, (3) complexity of a patient’s situation, and (4) hospital policy and environment. The aim of the second study presented was (1) to develop a measurement instrument to assess nursing documentation—which includes record structure, admission

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data, nursing diagnoses, interventions, progress data, and outcome evaluations— in various hospitals and wards, and (2) to test the validity and reliability of this instrument. The aim of the third study was to describe the accuracy of nursing documentation in patient records in hospitals. The D-Catch instrument was used to measure the accuracy of nursing documentation in 341 patient records of 10 randomly selected hospitals and 35 wards in the Netherlands. We found that, in general, the quality of nursing diagnoses and the documentation of nursing interventions was moderate to poor. The aim of the fourth study was to determine how knowledge sources, ready knowledge, and disposition towards critical thinking, and reasoning skills influence the accuracy of student nurses’ diagnoses. This pilot study, which used a two-group randomised design, examined our methodological approach to studying how nursing students (n= 100) document diagnoses. The aim of the fifth study, which used a four-group randomised factorial design and included registered hospital nurses (n= 249), was to determine the effect of knowledge sources and a predefined record structure (problem label, aetiology, signs/symptoms [PES] format) on the accuracy of nursing diagnoses, and to determine the association between ready knowledge, dispositions towards critical thinking, and reasoning skills and the accuracy of nursing diagnoses. Based on the results of this study, it can be concluded that the PES format mainly has a positive effect on the accuracy of the nursing diagnoses. Almost half of the variance in diagnosis accuracy was explained by the presence of the PES format; nurses’ age; and nurses’ reasoning skills, deduction, and analysis. As far as we know, this result is new and places pre-structured formats and reasoning skills in a new perspective. To use the PES structure more accurately, nurses need to enhance their analytical and deductive reasoning skills. This could be achieved through specialized courses geared towards building these skills. Part of the 53% unexplained variance was likely to be random in the sense that it cannot be explained by systematic variance from independent variables. Personal knowledge, experience, and (subjective) individual reflections are part of nurses’ diagnostic process as well. The results of this study have implications for nursing practice and education. Improving nurses’ disposition towards critical thinking, improving nurses’ reasoning skills, and encouraging them to use the PES structure could be a step forward to improving the accuracy of nursing diagnoses. The results of this research project contributed to the research domain of nursing documentation and to the domain of nursing diagnoses. We developed a measurement instrument intended to measure the prevalence of accurate nursing documentation, and we added information on the prevalence of nursing documentation in the Netherlands. As a result, we developed a conceptual model of factors that influence nursing diagnosis documentation and that can

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This kind of research is required for evidence-based organisation enhancement in clinical practice. Research is lacking on the effects of accurate and inaccurate nursing diagnosis documentation on the continuity of care and patient safety. we stress to health care leaders and educators the importance of investing in appropriate nursing documentation. The testing of an instrument that measures the accuracy of nursing documentation in an international context could be a start for further international research on the prevalence of accurate nursing documentation and for defining international nursing standards in nursing documentation. As we merge our findings to the findings of recently published research on the negative influence of inaccurate nursing documentation on patient safety and quality of care. For instance. 160 . Additional research outcomes that link the quality of information in patient records to causes of adverse events will provide knowledge that may stimulate documentation improvements and may have a positive influence on the quality of care. Moreover. We presume that the basic principles defining accurate nursing documentation are quite similar internationally. internationally the NANDA-I and the PES structure are well-known conceptual bases for accurate measurements in nursing diagnoses.be used by hospital managers and nurse educators as a reference guide for developing management and educational strategies for improving nursing documentation. we demonstrated that pre-structured record forms and analytical reasoning skills are factors that positively influence nursing diagnosis documentation.

Samenvatting Samenvatting (Dutch Summary) 161 .

Daarbij behoort een verpleegkundige diagnose zo omschreven te zijn dat er een verpleegkundige actie (interventie) op voorgeschreven kan worden. Deze probleemaanpak behoort evalueerbaar te zijn in termen van uitkomsten of effecten van de zorgverlening.Verpleegkundigen rapporteren dagelijks. hun bevindingen in het patiëntendossier. Vanuit het oogpunt van patiëntveiligheid wordt dan ook nationaal en internationaal aangedrongen op onderzoek naar de kwaliteit van de medische en verpleegkundige rapportage om mogelijkheden tot verbeteringen op te kunnen sporen. Amerika en Azië gedoceerd en geëxamineerd. S= Symptomen / Signs (aanwijsbare kenmerken). gepland en uitgevoerd. is de basis geweest voor het denken over systematische rapportagemogelijkheden en het toepassen van gestandaardiseerde verpleegkundige taal. De introductie van het verpleegkundig proces in de Verenigde Staten van Amerika en in verschillende landen van Europa in de jaren 1980-1990. en (2) de prevalentie van accurate verpleegkundige documentatie in patiëntendossiers in ziekenhuizen in Nederland. De verpleegkundige rapportage wordt gezien als een essentieel element voor veilige en goed communiceerbare zorgverlening. Op basis van een verpleegkundige diagnose worden passende interventies voorgesteld. in veel gevallen zelfs meerdere malen per dag. De eerste studie betreft een systematisch uitgevoerde literatuurstudie naar factoren die de verpleegkundige diagnose in de klinische praktijk van het ziekenhuis beïnvloeden. Op basis van deze literatuurstudie kunnen vier domeinen in een conceptueel model worden ondergebracht. In de verpleegkunde is de structuur van documenteren bekend onder de term ‘PESstructuur’ (P= probleemlabel. Binnen het domein (1) ‘Invloed door de complexiteit van de patiëntensituatie’ valt ondermeer de mate waarin de patiënt 162 . psychische of sociaal-maatschappelijke) opzichten belemmert. Conform de richtlijn van de North American Nursing Diagnosis Association International (NANDA-I) behoort een verpleegkundige diagnose een kernprobleem van de patiënt te beschrijven dat deze patiënt in het dagelijks leven in bepaalde (fysieke. maar ook in verschillende andere landen van Noordwest Europa. Vanaf medio 1990 wordt het vaststellen en het documenteren van de verpleegkundige diagnose in vrijwel alle verpleegkundige opleidingen in Nederland. dienen daarbij genoteerd te worden. De verpleegkundige diagnose maakte onder invloed van de North American Nursing Diagnoses Association (NANDA) in de Verenigde Staten van Amerika in de jaren 1970 en 1980 een ontwikkeling door die ook internationaal haar weerslag heeft gekregen. Oorzakelijke factoren of gerelateerde factoren en de kenmerken waaruit het bestaan van het probleem blijkt. een concrete probleemaanpak. E= etiologie (oorzakelijke factoren / gerelateerde factoren). Verpleegkundigen hebben de taak de problemen die het gevolg zijn van ziekte en die het algemeen dagelijks functioneren van een patiënt belemmeren in kaart te brengen in termen van een verpleegkundige diagnose. Deze studie bevat twee hoofdthema’s: (1) de factoren die van invloed zijn op de documentatie van de verpleegkundige diagnose.

Het D-Catch instrument bestaat uit 10 onderdelen die gerelateerd zijn aan de fasen van het verpleegkundig proces en een Likert-schaal die onderverdeeld is in kwantiteitscriteria en kwaliteitscriteria. Het doel van de derde studie is het beschrijven van de accuraatheid van de verpleegkundige documentatie in ziekenhuizen in Nederland. In minder dan 50 procent van de dossiers sluiten de interventies aan op de genoteerde diagnosen.Samenvatting in staat is zijn gezondheidsproblemen te uiten. is in meer dan 50 procent van de bestudeerde dossiers incompleet en niet in de PES-structuur geformuleerd. bruikbaar en valide beoordeeld op basis van de resultaten van interbeoordelaar-betrouwbaarheidsberekeningen. Binnen het domein (2) ‘De invloed van de verpleegkundige als diagnosticus’ is de houding van verpleegkundigen ten opzichte van kritisch denken en diagnosticeren opgenomen. tot vaag beschreven. Het domein (4) ‘Ziekenhuisomgeving en ziekenhuiscultuur’ omvat (randvoorwaardelijke) omgevingsfactoren en beleidsmatige en bestuursmatige aspecten die van invloed zijn zoals het aantal patiënten waarvoor een verpleegkundige zorg moet dragen binnen een dienst en de mate waarin leidinggevenden en medici verpleegkundigen ondersteunen en stimuleren in het gebruik van verpleegkundige diagnostiek. is vastgesteld dat de D-Catch bruikbaar is in een ziekenhuiscontext.en uitkomstrapportages op basis van een dossieronderzoek in ziekenhuizen en (2) het testen van de betrouwbaarheid en validiteit van dit instrument. de opnamegegevens. Het domein (3) ‘Opleiding en gebruik van hulpmiddelen’ betreft factoren zoals het volgen van bij. De resultaten van dit prevalentieonderzoek wijzen uit dat de opnamegegevens van de patiënt over het algemeen volledig genoteerd worden in het patiëntendossier. op basis van 341 patiëntendossiers te beoordelen. De diagnostische notities van verpleegkundigen zijn niet eenduidig. Dat wil zeggen dat in meer dan de helft van de bestudeerde dossiers. Het doel van de tweede studie is (1) het ontwikkelen van een instrument om de prevalentie van accurate verpleegkundige documentatie in kaart te kunnen brengen. de interne consistentie en de consensusuitkomsten van twee Delphipanels aangaande de inhoudsvaliditeit. het volgen van trainingen in redeneervaardigheden en het gebruik van computerapplicaties en een diagnostische classificatiestructuur. Het instrument is als betrouwbaar. Ook de invloed van verschil in culturele achtergrond tussen patiënten en verpleegkundigen komt naar voren. Op basis van een pilotstudy waarin 245 patiëntendossiers van zeven ziekenhuizen en 25 verpleegafdelingen werden bestudeerd. 163 . De studie werd uitgevoerd door de accuraatheid van de verpleegkundige rapportage op 35 verpleegafdelingen in 10 ziekenhuizen met een spreiding over Nederland. De verpleegkundige diagnose echter. verpleegkundige interventies genoteerd staan waarvan de reden of de aanleiding onduidelijk is. de verpleegkundige diagnosen. Ook diagnostische vaardigheden en verpleegkundige werkervaring blijken van invloed te zijn. Het instrument (D-Catch) kwantificeert het oordeel over de structuur van het dossier.en nascholingscursussen die betrekking hebben op het toepassen van verpleegkundige diagnostiek. de verpleegkundige interventies en de evaluatieve voortgang.

Een pilotstudy werd uitgevoerd onder 100 derde. door gebruik te maken van een experimenteel gerandomiseerd design en vragenlijsten. de houding ten opzichte van kritisch redeneren en redeneervaardigheden. We brachten de prevalentie in kaart van accurate verpleegkundige documentatie. gebaseerd op een analyse van de HSRT. We ontwikkelden een instrument om de accuraatheid van de verpleegkundige documentatie op basis van verpleegkundige standaarden in kaart te brengen. dat met specifieke hulpmiddelen (PES-format). de leeftijd van de verpleegkundige evenals deductieve en analytische redeneervaardigheden. Aangetoond is. Hen werd gevraagd een opnamegesprek met een simulatiepatiënt te voeren om op basis daarvan de relevante verpleegkundige diagnosen zo accuraat mogelijk te noteren. een positieve kritische denkhouding en ontwikkelde (analytische en deductieve) redeneervaardigheden een hogere accuraatheid van de verpleegkundige diagnose te verkrijgen is. Deze studie had ondermeer als doel het bestuderen of de methode van onderzoek uitvoerbaar en passend zou zijn. De CCTDI bestaat uit 75 stellingen die de gezindheid ten opzichte van kritisch denken in kaart brengen en de HSRT betreft een test die 33 vragen omvat die het diagnostisch redeneervermogen in kaart brengen. in vertaalde versie: Gezondheidswetenschappelijke Redeneertest). De bijdragen van dit onderzoek binnen het onderzoeksdomein van de verpleegkundige diagnose zijn divers. Op basis van een regressieanalyse blijkt dat 47% van de variantie op de afhankelijke variabele ‘Accuraatheid van de verpleegkundige diagnose’ verklaard kan worden door het PES-format. de California Critical Thinking Disposition Inventory (CCTDI. al dan niet met de mogelijkheid gebruik te maken van een voorgestructureerd dossierformulier (structuur volgens ‘PES’).De vierde en vijfde studie zijn experimenteel van aard en beschouwen twee aspecten van de verpleegkundige diagnose: (1) het effect van hulpmiddelen die de diagnostiek en de documentatie van diagnosen kunnen ondersteunen en (2) de invloed van (parate) kennis. Aansluitend werd de verpleegkundigen gevraagd drie vragenlijsten in te vullen: een kennisinventarisatielijst. Het blijkt dat het PES-format significante verhoging van de accuraatheid van de verpleegkundige diagnose tot gevolg heeft.en vierdejaars studenten van de hogere beroepsopleiding voor Verpleegkunde. De kennisinventarisatielijst bevat vier meerkeuzevragen. in vertaalde versie: Inventarisatie van de Kritische Denkhouding) en de Health Science Reasoning Test (HSRT. Deze onderzoeksresultaten tonen het belang aan van onderwijs in de 164 . Deze studenten werden willekeurig ingedeeld in een van beide groepen. Dit in tegenstelling tot het gebruik van handboeken over verpleegkundige diagnostiek en een voorgestructureerd opnameformulier. waaraan zij mochten deelnemen in werktijd. Het onderzoek vond plaats in het ziekenhuis waar de deelnemers werkzaam waren als verpleegkundige. handboeken verpleegkundige diagnostiek en een voorgestructureerd opnameformulier (structuur volgens 11 gezondheidspatronen). Aansluitend werd een experimentele studie in een gerandomiseerd factorieel design in vier groepen met 249 gediplomeerde verpleegkundigen in 11 ziekenhuizen uitgevoerd. generaliseerbaar naar landelijk niveau. De verpleegkundigen schreven zich vrijwillig in voor het onderzoek.

culturele en omgevingsfactoren evenals factoren aangaande het ziekenhuisbeleid een plaats hebben. Vervolgonderzoek is gewenst om aanvullende kennis te verwerven over de mate waarin verschillende factoren van invloed zijn op de accuraatheid van de verpleegkundige diagnose. Om het brede palet van beïnvloedende factoren op de accuraatheid van de verpleegkundige diagnose te kunnen overzien lijkt een pluralistische visie op verpleegkundige diagnostiek aanbevelenswaardig. 165 . diagnostische redeneervaardigheden en het gebruiken van kennishulpmiddelen.Samenvatting basisopleiding tot verpleegkundige en in specialistische vervolgopleidingen in het ontwikkelen van een kritische denkhouding. Ook kunnen de resultaten van belang zijn voor ontwikkelaars van software voor elektronische patiëntendossiers. een visie waarbij individuele. Recent internationaal onderzoek heeft uitgewezen dat er een relatie bestaat tussen inaccurate verpleegkundige documentatie en fouten die gemaakt worden in de zorgverlening waardoor de patiëntveiligheid in gevaar komt. gecombineerd met de resultaten van deze studie geven aan dat verpleegkundigen. Dit zou de verdere ontwikkeling van eenduidige en accurate verpleegkundige documentatie positief kunnen beïnvloeden. De ontwikkeling van een internationale gouden standaard voor accurate verpleegkundige documentatie in het patiëntendossier vraagt om internationale samenwerking in theorievorming en onderzoek om tot instrumentontwikkeling te komen voor de evaluatie van patiëntendossiers in internationaal verband. ziekenhuismanagers en verpleegkundig opleiders actie zouden moeten ondernemen om de verpleegkundige documentatie in ziekenhuizen te verbeteren. De uitkomsten van dat onderzoek. Zij zijn medeverantwoordelijk voor het scheppen van voorwaarden voor hoogwaardige kwaliteit van zorg en patiëntveiligheid.

166 .

Curriculum vitae Curriculum Vitae Wolter Paans 167 .

in Eindhoven. After military service as a paramedic in 1986-1987. Department of Demography and the Hanze University of Applied Sciences Groningen). He is also a scholar of the European Academy of Nursing Sciences (EANS). His master’s dissertation was entitled. In 1999 he obtained a Master of Science degree in nursing at the University of Wales. which focussed on developing. and the Research Initiative for Qualitative Studies in Healthcare and Aging (RIQSHA. primary health care. In 2006 he commenced his PhD studies on the accuracy of nursing diagnoses at the Catholic University Leuven. the Netherlands. Wolter is a member of the Research and Education Committee of the North American Nursing Diagnosis Association International (NANDA-I). School of Nursing. he studied to become a teacher in nursing while working as a nurse in hospital practice in several wards. UK. the Rho Chi Chapter of Sigma Theta Tau International (STT-I). From 1999 to 2005 he was manager and team leader of Company Trainings. he became a member of the Research and Innovation Group in Health Care and Nursing. a nursing school in Groningen. In 2002. a collaboration of the University of Groningen. the Netherlands. and implementing postgraduate educational programmes in nursing. In addition to his PhD studies. 168 . from 1988 to 1990. Hanze University of Applied Sciences. 1964. Hanze Connect Department. ‘The relationship between self-management and innovativeness in teams in nursing’. certificate as a health care educator. Wolter has been working as a lecturer at the Hanze University of Applied Sciences. In 1986 he received his degree as a hospital-trained nurse in Elkerliek Hospital. At that time Wolter developed and provided several educational programmes in nursing process application and implementation for postgraduate staff nurses and nurse administrators. From 1990 to 1999 he taught nursing students in hospital training programmes at de Wierde. Hanze University of Applied Sciences. Hanze University of Applied Sciences. at VU University. Belgium. Groningen. and paramedical care (Noorderpoort Training & Advies. providing. Groningen). Groningen. Amsterdam. and the Research and Innovation Group in Health Care and Nursing. Helmond-Deurne. and in 1993 he received his first professional degree. In 1990 he received his certificate as a nurse educator at Hogeschool Utrecht.Wolter Paans was born on November 26.