Improved quality of nursing documentation: results of a nursing diagnoses, interventions, and outcomes implementation study.
OBJECTIVE
To evaluate the impact of the quality of nursing diagnoses, interventions, and outcomes in an acute care hospital following the implementation of an educational program.


METHODS
In a pretest-posttest experimental design study, nurses from 12 wards of a Swiss hospital received an educational intervention--an introductory class and consecutive classes, using a case discussion method--to implement nursing diagnoses, interventions, and outcomes. Two sets of 36 randomly selected nursing records were evaluated before and after implementation. The quality of documented nursing diagnoses, interventions, and nursing-sensitive patient outcomes was assessed by 29 Likert-type items with a 0-4 scale instrument, called Quality of Nursing Diagnoses, Interventions, and Outcomes (Q-DIO) and tested using t-tests.


RESULTS
Significant enhancements in the quality of documented nursing diagnoses, interventions, and outcomes were found following the implementation of a planned educational program.


CONCLUSIONS
The implementation of NANDA, NIC, and NOC (NNN) nursing diagnoses, interventions, and outcomes led to higher quality of nursing diagnosis documentation, etiology-specific nursing interventions, and nursing-sensitive patient outcomes.


CONCLUSIONS
Educational measures support nurses to improve documentation of diagnoses, interventions, and outcomes. The Q-DIO is a useful audit tool.
Müller-Staub
Maria
M
Pflege PBS, Stettlerstrasse 15, CH-3006 Bern, Switzerland.
Needham
Ian
I
Odenbreit
Matthias
M
Lavin
Mary Ann
MA
van Achterberg
Theo
T
D004282:Documentation / Q000592:standards*; D004509:Education, Nursing, Continuing / Q000458:organization & administration*; D006801:Humans; D007318:Inservice Training / Q000458:organization & administration; D016347:Medical Records Systems, Computerized; D009731:Nursing Audit; D009733:Nursing Diagnosis / Q000458:organization & administration*; D015402:Nursing Education Research; D015403:Nursing Evaluation Research; D009737:Nursing Records / Q000592:standards*; D009741:Nursing Staff, Hospital / Q000193:education*; D017063:Outcome Assessment, Health Care; D010347:Patient Care Planning / Q000458:organization & administration; D015397:Program Evaluation; D013557:Switzerland; D017749:Total Quality Management; D018875:Vocabulary, Controlled