Irma Nool
Tallinn Health Care College, Estonia
Title: The quality of nursing documentation in Tallinn Children Hospital
Biography
Biography: Irma Nool
Abstract
Statement of the Problem: Growing interest in using NANDA-I nursing diagnoses has been observed in health care facilities due to the fact that it ensures using common terminology for patient’s health assessment and in planning nursing care. Nursing documentation is uneven in quality in Estonia which hinders the availability and continuity of nursing care. Quality standards and indicators are not used for consistent assessment. Nurses are filling nursing records and do not consider them to be part of the entire nursing process. It leads to poor-quality nursing documentation, which prevents communication between simple, structured and focused professionals, which in turn affects the quality of patient care. The aim of the study is to describe the quality of nursing documentation in Tallinn Children Hospital. The research is quantitative, descriptive study.
Methodology & Theoretical Orientation: Sample was taken from nursing records before and after NANDA-I nursing diagnoses training for nurses. The selection criteria’s were: patient had to be in hospital for at least three days and there was individual nursing care plan for the patient. Data collection was done during September 2016 - March 2017. D-Catch instrument, the 4-score Likert scale were used. Data analysis: SPSS 19.0, descriptive statistics, means and t-test were used.
Results: 87 nursing record from 8 departments were evaluated (42 before and 45 after training). The results showed statistically reliable differences in the improvement of the quantity of the structure of nursing record (t(85)=-3.004, p=0.004), quality of nursing anamnesis (t(85)=-2.915, p=0.005), quantity of nursing diagnoses (t(85)=-4.387, p<0.0001), quality of nursing diagnoses (t(85)=-5.768, p<0.0001), quantity of nursing interventions (t(85)=-2.982, p=0.004), quality of nursing interventions (t(85=-4.343, p<0.0001), quantity of assessment (t(85)=-2.439, p=0.017) and quality of assessment (t(85)=-3.209, p=0.002). No statistically reliable differences were found for the quantity of nursing anamnesis and the legibility of documentation.
Conclusion & Significance: The study showed the importance of NANDA training in application of new documentation requirements in nursing practice.