Development of an instrument to measure the quality of documented nursing diagnoses, interventions and outcomes: the Q-DIO.
OBJECTIVE
This paper aims to report the development stages of an audit instrument to assess standardised nursing language. Because research-based instruments were not available, the instrument Quality of documentation of nursing Diagnoses, Interventions and Outcomes (Q-DIO) was developed.


BACKGROUND
Standardised nursing language such as nursing diagnoses, interventions and outcomes are being implemented worldwide and will be crucial for the electronic health record. The literature showed a lack of audit instruments to assess the quality of standardised nursing language in nursing documentation.


METHODS
A qualitative design was used for instrument development.


METHODS
Criteria were first derived from a theoretical framework and literature reviews. Second, the criteria were operationalized into items and eight experts assessed face and content validity of the Q-DIO.


RESULTS
Criteria were developed and operationalized into 29 items. For each item, a three or five point scale was applied. The experts supported content validity and showed 88.25% agreement for the scores assigned to the 29 items of the Q-DIO.


CONCLUSIONS
The Q-DIO provides a literature-based audit instrument for nursing documentation. The strength of Q-DIO is its ability to measure the quality of nursing diagnoses and related interventions and nursing-sensitive patient outcomes. Further testing of Q-DIO is recommended.


CONCLUSIONS
Based on the results of this study, the Q-DIO provides an audit instrument to be used in clinical practice. Its criteria can set the stage for the electronic nursing documentation in electronic health records.
Müller-Staub
Maria
M
Pflege PBS, Bern, Switzerland. muellerstaub@bluewin.ch
Lunney
Margaret
M
Odenbreit
Matthias
M
Needham
Ian
I
Lavin
Mary Ann
MA
van Achterberg
Theo
T
D001291:Attitude of Health Personnel; D004282:Documentation / Q000592:standards; D017144:Focus Groups; D006801:Humans; D009726:Nurses / Q000523:psychology; D009731:Nursing Audit / Q000379:methods* / Q000592:standards; D009733:Nursing Diagnosis / Q000592:standards; D015403:Nursing Evaluation Research; D015404:Nursing Methodology Research; D009737:Nursing Records / Q000592:standards; D015588:Observer Variation; D010043:Outcome and Process Assessment, Health Care / Q000379:methods* / Q000592:standards; D010347:Patient Care Planning / Q000592:standards; D010865:Pilot Projects; D011594:Psychometrics; D036301:Qualitative Research; D011787:Quality of Health Care / Q000592:standards; D012680:Sensitivity and Specificity; D018875:Vocabulary, Controlled