Laura Elena Gligor MSc, RN, Horațiu Rusu PhD, Carmen Daniela Domnariu PhD, DR, Maria Müller-Staub PhD, MNS, EdN, RN, FNI, FEANS
{"title":"用Q-DIO测量罗马尼亚护理文献中护理诊断、干预和结果的质量：一项横断面研究。","authors":"Laura Elena Gligor MSc, RN, Horațiu Rusu PhD, Carmen Daniela Domnariu PhD, DR, Maria Müller-Staub PhD, MNS, EdN, RN, FNI, FEANS","doi":"10.1111/2047-3095.12446","DOIUrl":null,"url":null,"abstract":"<div>\n \n \n <section>\n \n <h3> Purpose</h3>\n \n <p>To assess the quality of the nursing process in Romania by evaluating nursing documentations with the quality of diagnoses, interventions and outcomes (Q-DIO) measurement instrument.</p>\n </section>\n \n <section>\n \n <h3> Methods</h3>\n \n <p>A quantitative cross-sectional research design was employed using probabilistic sampling to select nursing documentations from a Romanian university hospital. The data were analyzed using the Q-DIO measurement instrument.</p>\n </section>\n \n <section>\n \n <h3> Findings</h3>\n \n <p>Low quality levels of nursing process documentation were found. The Q-DIO subscale “Nursing diagnoses as process” (assessment) revealed a mean = 1.36 (SD 0.52) of maximum 2. Nurses collected lots of data but did not use these to state nursing diagnoses. “Nursing diagnoses as product” showed inaccurate diagnoses; mean = 1.24 (SD 0.48) of maximum 4. Nursing interventions were planned and documented, but their impact on the etiology of nursing diagnoses was low; mean = 0.76 (SD 0.18). The quality of nursing outcomes mean was 0.57 (SD 0.29).</p>\n \n <p>Nurses failed making connections between nursing assessment, diagnoses, interventions, and outcomes, and standardized nursing languages (SNLs) were not used. Statistically significant differences were found among all Q-DIO sub-concepts except for “Nursing diagnoses as process.”</p>\n </section>\n \n <section>\n \n <h3> Conclusions</h3>\n \n <p>The documentation was structured but did not support the nursing process and its documentation, and SNLs were not implemented. There was an underutilization of data to state nursing diagnoses, and nursing interventions were mostly ineffective, leading to low nursing outcomes.</p>\n </section>\n \n <section>\n \n <h3> Implications for nursing practice</h3>\n \n <p>This study provides new insights on the nursing process and its documentation in Romania and a baseline for future research. Policymakers, administrators, and educators should consider educating nurses to use standardized nursing languages and apply the <i>Advanced Nursing Process</i>.</p>\n </section>\n </div>","PeriodicalId":49051,"journal":{"name":"International Journal of Nursing Knowledge","volume":"35 3","pages":"298-307"},"PeriodicalIF":1.4000,"publicationDate":"2023-09-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"The quality of nursing diagnoses, interventions, and outcomes in Romanian nursing documentation measured with the Q-DIO: A cross-sectional study\",\"authors\":\"Laura Elena Gligor MSc, RN, Horațiu Rusu PhD, Carmen Daniela Domnariu PhD, DR, Maria Müller-Staub PhD, MNS, EdN, RN, FNI, FEANS\",\"doi\":\"10.1111/2047-3095.12446\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<div>\\n \\n \\n <section>\\n \\n <h3> Purpose</h3>\\n \\n <p>To assess the quality of the nursing process in Romania by evaluating nursing documentations with the quality of diagnoses, interventions and outcomes (Q-DIO) measurement instrument.</p>\\n </section>\\n \\n <section>\\n \\n <h3> Methods</h3>\\n \\n <p>A quantitative cross-sectional research design was employed using probabilistic sampling to select nursing documentations from a Romanian university hospital. The data were analyzed using the Q-DIO measurement instrument.</p>\\n </section>\\n \\n <section>\\n \\n <h3> Findings</h3>\\n \\n <p>Low quality levels of nursing process documentation were found. The Q-DIO subscale “Nursing diagnoses as process” (assessment) revealed a mean = 1.36 (SD 0.52) of maximum 2. Nurses collected lots of data but did not use these to state nursing diagnoses. “Nursing diagnoses as product” showed inaccurate diagnoses; mean = 1.24 (SD 0.48) of maximum 4. Nursing interventions were planned and documented, but their impact on the etiology of nursing diagnoses was low; mean = 0.76 (SD 0.18). The quality of nursing outcomes mean was 0.57 (SD 0.29).</p>\\n \\n <p>Nurses failed making connections between nursing assessment, diagnoses, interventions, and outcomes, and standardized nursing languages (SNLs) were not used. 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The quality of nursing diagnoses, interventions, and outcomes in Romanian nursing documentation measured with the Q-DIO: A cross-sectional study
Purpose
To assess the quality of the nursing process in Romania by evaluating nursing documentations with the quality of diagnoses, interventions and outcomes (Q-DIO) measurement instrument.
Methods
A quantitative cross-sectional research design was employed using probabilistic sampling to select nursing documentations from a Romanian university hospital. The data were analyzed using the Q-DIO measurement instrument.
Findings
Low quality levels of nursing process documentation were found. The Q-DIO subscale “Nursing diagnoses as process” (assessment) revealed a mean = 1.36 (SD 0.52) of maximum 2. Nurses collected lots of data but did not use these to state nursing diagnoses. “Nursing diagnoses as product” showed inaccurate diagnoses; mean = 1.24 (SD 0.48) of maximum 4. Nursing interventions were planned and documented, but their impact on the etiology of nursing diagnoses was low; mean = 0.76 (SD 0.18). The quality of nursing outcomes mean was 0.57 (SD 0.29).
Nurses failed making connections between nursing assessment, diagnoses, interventions, and outcomes, and standardized nursing languages (SNLs) were not used. Statistically significant differences were found among all Q-DIO sub-concepts except for “Nursing diagnoses as process.”
Conclusions
The documentation was structured but did not support the nursing process and its documentation, and SNLs were not implemented. There was an underutilization of data to state nursing diagnoses, and nursing interventions were mostly ineffective, leading to low nursing outcomes.
Implications for nursing practice
This study provides new insights on the nursing process and its documentation in Romania and a baseline for future research. Policymakers, administrators, and educators should consider educating nurses to use standardized nursing languages and apply the Advanced Nursing Process.
期刊介绍：
The International Journal of Nursing Knowledge, the official journal of NANDA International, is a peer-reviewed publication for key professionals committed to discovering, understanding and disseminating nursing knowledge.
The Journal aims to clarify the knowledge base of nursing and improve patient safety by developing and disseminating nursing diagnoses and standardized nursing languages, and promoting their clinical use. It seeks to encourage education in clinical reasoning, diagnosis, and assessment and ensure global consistency in conceptual languages.
The International Journal of Nursing Knowledge is an essential information resource for healthcare professionals concerned with developing nursing knowledge and /or clinical applications of standardized nursing languages in nursing research, education, practice, and policy.
The Journal accepts papers which contribute significantly to international nursing knowledge, including concept analyses, original and applied research, review articles and international and historical perspectives, and welcomes articles discussing clinical challenges and guidelines, education initiatives, and policy initiatives.
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