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  • Title: Improved quality of nursing documentation: results of a nursing diagnoses, interventions, and outcomes implementation study.
    Author: Müller-Staub M, Needham I, Odenbreit M, Lavin MA, van Achterberg T.
    Journal: Int J Nurs Terminol Classif; 2007; 18(1):5-17. PubMed ID: 17430533.
    Abstract:
    PURPOSE: 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. METHOD: 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. FINDINGS: 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. IMPLICATIONS FOR NURSING PRACTICE: Educational measures support nurses to improve documentation of diagnoses, interventions, and outcomes. The Q-DIO is a useful audit tool.
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