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Impact of an Educational Program on the Use of

Standardized Nursing Languages for Nursing
Documentation Among Public Health Nurses
in Nigeria
Patience Omonigho Odutayo, MSc (Nursing), RN, RM, RPHN, RNE, Adenike Ayobola Olaogun, PhD, RN, RM, RPHN,
Abimbola Oyeninhun Oluwatosin, PhD, RN, RM, FWACN, and
Adesola Adenike Ogunfowokan, PhD, RN, RM, RPHN, FWACN
Patience Omonigho Odutayo, MSc (Nursing), RN, RM, RPHN, RNE, is the Principal at the School of Nursing, Ijebu-Ode, Ogun
State, Nigeria; Adenike Ayobola Olaogun, PhD, RN, RM, RPHN, is an Associate Professor at the Department of Nursing
Science, College of Health Sciences, Obafemi Awolowo University, Ile Ife, Nigeria; Abimbola Oyeninhun Oluwatosin, PhD,
RN, RM, FWACN, is a Senior Lecturer at the Department of Nursing Science, College of Medicine, University of Ibadan,
Ibadan, Nigeria; and Adesola Adenike Ogunfowokan, PhD, RN, RM, RPHN, FWACN, is a Senior Lecturer at the Department of
Nursing Science, College of Health Sciences, Obafemi Awolowo University, Ile Ife, Nigeria.

Search terms: PURPOSE: To measure the effect of an educational package on documentation

Clients’ documentation, public of care among public health nurses (PHNs).
health nurse, standardized nursing METHOD: A quasi-experimental design was adopted. Forty PHNs working in
language primary healthcare settings were selected. Education was given through a 5-day
workshop. Documentation of care was assessed using a modified “Muller-Staub
Q-DIO instrument.” Data were analyzed using t test third and twelfth months
Author contact:
postintervention.
adenikeolaogun@gmail.com, with a FINDINGS: There was a significant improvement on documentation of care at
copy to the Editor: p = .0001.
journal@nanda.org CONCLUSION: Educating PHNs and providing them with standardized nursing
care plans enhance documentation of care.
IMPLICATION TO PRACTICE: A combination of education on the use of stan-
dardized nursing languages and standardized nursing care plans can enhance
documentation of care. There is a need for more research on the use of standard-
ized nursing languages in developing nations.

Globally, nurses form an integral part of the healthcare
system, but their contributions, particularly in the develop-
ing nations, have been largely invisible because of poor
documentation of care (Allen, Chapman, O’Connor, &
Francis, 2007). According to Bostick, Riggs, and Rantz
(2003), nurses’ documentation of the care that they give to
clients, interventions used to treat the diagnoses, and the
resulting outcome/responses are necessary for evaluation
of care. Standardized nursing languages (SNLs) started
with the development of NANDA-I diagnostic classifications.
SNLs were developed to give the phenomena that represent
the nursing process a name or label to make them visible
(Farren, 2010). They provide uniform nomenclature for
diagnosis, intervention, and evaluation components of the
nursing process. When nurses are familiar with and are
educated on the use of nursing classifications in documen-
tation, client care that is unique to nursing can be better
described and outcomes more clearly communicated.
According to Dochterman and Bulechek (2004), SNLs have
implications for competency evaluation, reimbursement for
services, and curriculum design. They hold the potential to
improve the quality of nursing care, guide policy, and assist
nurses in articulating how their actions contribute to posi-
tive health outcomes. However, in spite of the benefits of
SNLs, Thoroddsen and Ehnfors (2007) observed that many
nurses had not been taught to use them. Deficiencies in
accurately stating and documenting nursing diagnoses, and
relating them to nursing interventions and outcomes, have
also been reported by Florin, Ehrenberg, and Ehnfors
(2005).
A lot of work has been done globally on the use of SNLs
in hospital-based care (Muller-Stuab, Needham, Odenbreit,
Lavin, & Achterberg, 2007; Olaogun, Oginni, Oyedeji,
Nnahiwe, & Olatubi, 2011). According to Neufeld and

108 © 2013, The Authors

International Journal of Nursing Knowledge © 2013, NANDA International
International Journal of Nursing Knowledge Volume 24, No. 2, June 2013
P. O. Odutayo et al.
Harrison (1995), there are conflicting views about the utility
of nursing diagnosis in the community setting due to large
client populations available in such settings. The use of
SNLs in the primary healthcare settings has been at its low
ebb in many parts of the world, including Nigeria
(Ogunfowokan, Oluwatosin, Olajubu, Alao, & Faremi, 2013),
and many initiatives have been developed to facilitate their
use in the context of primary health care (PHC) (Mañá
González & Mesas Sáez, 2002; Trigueros Aguado, San
Martín Aparicio, Ballesteros Álvaro, & López Merino, 2003).
However, a recent report by Rivas, García, Arenas, Lagos,
and López (2012) showed that nurses in the PHC settings
have effectively incorporated the nursing process as a work
methodology in their caregiving practices, significantly
improving their nursing care (Rivas et al., 2012).
Public health nurses (PHNs) working at the PHC settings
are the first skilled care providers that a majority of clients
relate to at the community level. They serve very important
roles in ensuring health promotion and health maintenance,
as well as in treating minor ailments for individuals, families,
and communities. It is pertinent to note that documentation
of care among this group of nurses is essential and would
further enhance nursing as a profession. Documentation of
care at this level would also enhance referral of clients to a
higher level of care when there is a need. Such documen-
tation would provide clearer information that will be useful
in the referral process. In view of the aforementioned, the
researchers considered it worthwhile to conduct an inter-
vention study on the use of SNLs among PHNs working in
primary healthcare settings.
Objective of the Study
The main objective of this research was to develop and
implement an educational package on the use of SNLs in
client care among PHNs.
Research Methodology
A quasi-experimental design was adopted.
Research Setting/Location
Nigeria is divided into 36 states and the federal capital
territory. Each state is further divided into local govern-
ment areas (LGAs). The study was conducted in two LGAs in
Ogun State, southwestern Nigeria. These are the Ijebu Ode
and Odogbolu LGAs. Twenty-one PHCs in the two selected
local governments were used for the study. Services avail-
able at these centers were immunization, treatment of
minor ailments, and reproductive, school, and environmen-
tal health.
Sampling Technique and Sample Selection
A multistage sampling method was used. There are 20
LGAs in Ogun State, and using simple random sampling
Public Health Nurses’ Documentation of Care
(picking of ballot), two LGAs (Ijebu Ode and Odogbolu) were
selected. Half of the 42 PHCs in the two LGAs were selected
(10 from Odogbolu and 11 from Ijebu Ode). Convenience
sampling technique was later used to select 40 PHNs from
the PHCs who were assigned into an experimental group
(20 PHNs from Ijebu Ode LGAs) and a control group (20
PHNs from Odogbolu LGAs).
Instrument for Data Collection
Three instruments were used for data collection: (a) An
18-item, self-administered questionnaire adapted from
“Study Temple” (an online standard questionnaire) was
used to measure a PHN’s knowledge of the nursing process
and SNLs. (b) A checklist for assessment of nurses’ docu-
mentation of care was modified from Muller-Staub et al.’s
(2007) quality of nursing diagnoses, interventions, and out-
comes (Q-DIO). It measures the documentation of nursing
diagnosis, nursing interventions, and outcomes through 29
items on a 3-point Likert scale. This 3-point scale distin-
guishes between comprehensive documentation (3), partial
documentation (2), and missing documentation (1). In
scoring the standardized nursing care plans (SNCPs) used
in the study, the minimum attainable score is 29 (no docu-
mentation) and the maximum score is 87. (c) A health edu-
cation package was developed from literature review, and
learning modules were produced and used during the 2010
international workshop on NANDA-I diagnostic classifica-
tions, Nursing Outcome Classification (NOC), and Nursing
Intervention Classification (NIC) (Brokel & Herdman, 2010a,
2010b, 2010c; Butcher, 2010; Moorhead, 2010). This package
is made up of five learning modules:
• Module 1—Historical development of SNLs
• Module 2—Introduction to the concepts of NANDA-I
nursing diagnoses, NOC, and NIC (NNN)
• Module 3—Linkages between the NNN
• Module 4—Documentation of care using NNN and the
SNCPs
• Module 5—Advantages of using NNN in documentation
Procedure for Data Collection
There were three phases in this study.
Phase 1: This was the phase for mobilization of the PHNs
and pretest. Three major events took place during
this phase:
1. In each LGA selected, a meeting was held with
the selected PHNs at one of the PHCs, and
information about the purpose of the study, the
course it will take, and its potential benefits to
nursing were discussed. PHNs were given the
self-administered questionnaires to fill out.
2. One of the researchers later visited the
selected PHCs to assess the documentation of
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Public Health Nurses’ Documentation of Care P. O. Odutayo et al.

the client care. At this level, it was discovered inferential statistics. t test was used to compare the pre-
that none of the facilities had nursing docu- and postintervention in between groups and between the
ments for the nursing process and nursing care intervention group posttest scores.
plan. The PHNs document the care given to
their clients in small booklets using the medical Results
diagnoses. These booklets were studied, and
frequently occurring health problems were Professional Characteristics
identified, including malaria, malnutrition, gas-
troenteritis, teenage pregnancies, poor school As reflected in Table 1, 80% of the experimental group
attendance, drug abuse, and rape. and 85% of the control group were females. None had a
3. Results from this phase were used to modify university degree in nursing. Their highest nursing educa-
the educational package to enhance the tion was a diploma in public health nursing. Each female had
nurses’ understanding in preparation for the been educated and licensed with the Nursing and Midwifery
intervention. Nursing diagnoses related to Council of Nigeria as a registered nurse (RN), registered
the commonly occurring health problems were midwife (RM), and registered public health nurse (RPHN),
identified. These included hyperthermia, imbal- while the males were RN and RPHN. The participants’
anced nutrition (less than body requirements), ranges of years of service in the profession were 5–25
deficient fluid volume, anxiety, situational low years, with a mean of 12 ⫾ 7.1 years (experimental), and
self-esteem, rape–trauma syndrome, risk for 5–25 years with a mean of 12 ⫾ 7.5 years (control). For
violence, and impaired parenting. These current professional status, the experimental group had
nursing diagnoses were used in developing public health officer 1 (PHNO) (25%), PHNO 11 (45%), assis-
SNCPs by a team of MSc nursing students who tant chief nursing officers (ACNOs) (25%), and chief
were studying a course on “Advanced Study of nursing officer (5%), while the control group had PHNO I
the Nursing Process,” and their lecturer who (50%), PHNO II (20%), ACNOs (25%), and chief nursing
has a PhD and has undergone a postdoctoral officer (5%). In addition, for the experimental group, 30%
study on the NNN at the College of Nursing, were working in antenatal care unit, 30% in the reproduc-
University of Iowa.
Phase 2: A 5-day training workshop was held with the PHNs
in the intervention group using one of the PHCs. Table 1. Professional Status and Area of Functioning of
During the workshop, the modules were used for Public Health Nurses
teaching, and client studies were presented at
practical sessions. The SNCPs were introduced to Experimental Control
the PHNs, and their use was monitored in each of Frequency % Frequency %
the PHCs of the participating PHNs by the first
author on a monthly basis. Sex
Phase 3: At the end of 12 weeks, the first posttest was Male 4 20 3 15
Female 16 80 17 85
conducted using the same instruments used at
Total 20 100 20 100
pretest. One hundred SNCPs were selected ran- Length of time in the
domly from the PHCs and were assessed using the profession (in years)
modified Muller-Staub et al. (2007) Q-DIO check- 1–5 6 30 7 35
list. A second posttest was done at the end of 12 6–10 5 25 4 20
11–15 3 15 3 15
months (a year) of postintervention to assess 100 16–20 3 15 3 15
randomly selected SNCPs from the experimental 21 and above 3 15 3 15
group. Total 20 100 20 100
Current professional
Ethical Consideration status
CNO 1 5 1 5
ACNO 5 25 5 25
Ethical clearance was obtained from the Research Ethics PHNO I 5 25 4 20
Committee of Ministry of Health, Abeokuta, Ogun State. PHNO II 9 45 10 50
Permission was also taken from the PHC co-coordinators Total 20 100 20 100
Unit of duty
and chief nursing officers of the PHCs. Each participant was Antenatal 6 30 6 30
informed and provided consent. Immunization 4 20 4 20
Reproductive health 5 25 6 30
Method of Data Analysis School health 5 25 4 20
Total 20 100 20 100
Data were analyzed using the Statistical Package for ACNO, assistant chief nursing officer; CNO, chief nursing officer;
Social Sciences (SPSS) version 17.0 for both descriptive and PHNO, public health nursing officer.

110
P. O. Odutayo et al.
tive health unit, 20% in school health unit, and 20% in the
immunization unit. For the control, 30% were working in
antenatal care unit, 20% in immunization unit, 25% in
school health, and 25% in reproductive health unit.
Knowledge of Nursing Process and SNLs, and
Documentation of Client Care
Results on the participants’ knowledge of nursing
process (NP) and SNLs revealed that 70% of experimental
and 65% of control had theoretical training on the NP
during their schooling, but none of the participants have
heard of the NOC and NIC. The percentage scores for the
experimental group ranged from 0 to 50, with a mean per-
centage of 18.75 ⫾ 15.1, while the control group percentage
scores ranged from 0 to 40, with a mean percentage of
18.25 ⫾ 3.6. At posttest, the experimental group scored
from 50% to 70%, with a mean percentage of 48.25 ⫾ 6.9,
while the control scored from 0% to 45%, with a mean
percentage of 17 ⫾ 13.0. There was a significant difference
in the pretest and posttest mean scores of the experimental
group, with t value of 18.3, d.f. 19, and p = .0001, but no
significant difference in the pre- and posttest mean scores
of the control group, with t value of 5.9, d.f. 19, and p = 1.15.
Scrutinizing the documents used for client care at
pretest, findings revealed that PHNs were not documenting
client care using NANDA-I nursing diagnoses, nursing out-
comes, and nursing interventions. Treatment given to
patients/clients was based on medical diagnosis and was
recorded in notebooks. Therefore, both groups had mean
score of 29 ⫾ 0.00. At posttest, the control group was using
the notebooks, but the experimental group was using the
SNCPs. The scores on documentation for the control was 29
⫾ 0.00 at the first and second posttest, while the experi-
mental group had scores ranging from 58 to 72, with a
mean of 60.9 ⫾ 2.3 (first posttest), and at the second post-
test, it ranged from 58 to 87, with a mean of 78.77 ⫾ 6.0. As
shown in Table 2, the t-test results showed a significant
difference in the mean scores of the control group when
compared with the experimental group at first posttest
(t value = -140.09, d.f. 99, p = .0001) and at second posttest
(t value = -82.52, d.f. 99, p = .0001). There was also signifi-
cant difference in the pretest and first posttest mean scores
of the experimental group (t value -140.09, d.f. 99, p =
.0001). Comparing the mean scores of the first posttest and
second posttest of the experimental group revealed signifi-
cant difference, with t value = -27.61, d.f. 99, p = .0001.
Table 2. Pretest and Posttest Mean Scores of Documentation of Client Care Using the Standardized Nursing
Care Plans
Control
Pretest 29.00 ⫾ 0.00
First posttest 29.00 ⫾ 0.00
Second posttest 29.00 ⫾ 0.00
For first and second posttest scores of the experimental group, t = -27.60 at p = .0001.
Public Health Nurses’ Documentation of Care
Discussion of Findings
In Nigeria, nursing process and the use of NANDA-I
nursing diagnoses have been incorporated into nursing
education since the 1980s, but the concepts of NOC and NIC
are relatively new. These concepts were introduced into the
country through an international workshop hosted by the
NANDA-I African Network-Nigeria Chapter, NANDA-I, and
the Center for Nursing Classification and Clinical Effective-
ness of the College of Nursing, University of Iowa, in 2010.
This study is a by-product of this workshop. As reported by
Muller-Staub, Needham, and Lavin (2007), von Krogh and
Nåden (2008), and Muller-Staub (2009) in similar research
conducted on the use and documentation of SNLs, with the
introduction of adequate education and resources, nursing
documentation increases with use of SNLs.
Muller-Staub et al. (2007) and Criminiello, Terjesen, and
Lunney (2009) discovered that before the implementation
of NNN, nursing problems were formulated in freestyle
without the use of standardized classification. But
postimplementation, data showed significant improvement
in documentation. Abreu (2006) and Hughes (2006) also
reported the use of NNN in documenting the care of ortho-
pedic and spinal cord injury patients in Brazil and Ireland.
NNN linkages are, therefore, an important step in the orga-
nization of nursing information.
The low scoring of the PHNs on documentation of care
using the Muller-Staub checklist at pretest supported the
findings of Ogunfowokan et al. (2013) that PHNs in Nigeria
are not using the SNLs for client care in the community
setting. This poor documentation among the PHNs is
reflected in the lack of documentation of client care using
NANDA-I nursing diagnoses, nursing outcomes, and nursing
interventions. They also based their treatment on medical
diagnosis and recorded their care in notebooks. Most Nige-
rian clinical nurses have poor knowledge of the concept of
nursing process, and that serves as a hindrance to the
effective use of the SNLs (Momoh & Chukwu, 2010; Olaogun
et al., 2011). At posttest, the PHNs in this study were able to
identify actual nursing diagnoses with the signs and symp-
toms and etiologies, while in the risk diagnoses they iden-
tified the nursing diagnoses with the related factors. They
also identified NIC activities specific to solving client prob-
lems and linked indicators of NOC, which were related to the
identified diagnoses and interventions. The American
Nurses Association (2007) stated that nurses would acquire
adequate knowledge when trained consistently through
Experimental t value d.f. Sign
29.00 ⫾ 0.00
60.86 ⫾ 2.27 -140.09 99 0.0001
78.77 ⫾ 6.03 -82.52 99 0.0001
111
Public Health Nurses’ Documentation of Care
seminars/workshops, in-service training, and higher educa-
tion. Similarly, Rogers (2003) suggests that individuals and
groups make decisions to adopt new technology, ideas, and
practices when they obtain knowledge and develop apti-
tude. Therefore, practitioners, including nurses, would
accept and implement new ideas and practices, such as the
use of SNCPs, if they are informed, educated, and have a
better understanding of the relevant concepts.
The improved documentation of nursing diagnoses,
interventions, and outcomes in the experimental group
through the use of the SNCPs has implication for NP. There
is the need to ensure regular in-service training for nurses
to improve their knowledge of SNLs and ensure availability
of SNCPs in every PHC setting. Consequently, there is
bound to be improved documentation, which will result in
quality nursing care. This is the first reported empirical
study using NNN in client care in Nigeria. It is anticipated
that future research will be conducted in hospital and non-
hospital settings here to test the effect of the NNN on the
quality of nursing care and its documentation.
Conclusion
Significant efforts have been made to unify SNLs
through the taxonomy of NNN. This study has demon-
strated that education of nurses on the nursing process and
the implementation of SNLs through the SNCPs is a viable
way to improve nurse skills in documentation of care. There
is a need for more research in Nigeria and other African
nations on how SNLs can be adapted to client care and the
effect of SNLs on the quality of nursing care.
Acknowledgment. The authors acknowledge the contribu-
tions of the coordinator and the staff of the primary health-
care centers of Ijebu Ode LGA, Ogun State, Nigeria, in the
conduction of this project.
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