What factors influence the prevalence and accuracy of nursing diagnoses documentation in clinical practice? A systematic literature review

Research output: Contribution to journalArticleAcademicpeer-review

Abstract

AIM: To identify what determinants influence the prevalence and accuracy of nursing diagnosis documentation in clinical practice.

BACKGROUND: Nursing diagnoses guide and direct nursing care. They are the foundation for goal setting and provide the basis for interventions. The literature mentions several factors that influences nurses' documentation of diagnoses, such as a nurse's level of education, patient's condition and the ward environment.

DESIGN: Systematic review.

METHOD: MEDLINE and CINAHL databases were searched using the following headings and keywords: nursing diagnosis, nursing documentation, hospitals, influence, utilisation, quality, implementation and accuracy. The search was limited to articles published between 1995-October 2009. Studies were only selected if they were written in English and were primary studies addressing factors that influence nursing diagnosis documentation.

RESULTS: In total, 24 studies were included. Four domains of factors that influence the prevalence and accuracy of diagnoses documentation were found: (1) the nurse as a diagnostician, (2) diagnostic education and resources, (3) complexity of a patient's situation and (4) hospital policy and environment.

CONCLUSION: General factors, which influence decision-making, and nursing documentation and specific factors, which influence the prevalence and accuracy of nursing diagnoses documentation, need to be distinguished. To support nurses in documenting their diagnoses accurately, we recommend taking a comprehensive perspective on factors that influence diagnoses documentation. A conceptual model of determinants that influence nursing diagnoses documentation, as presented in this study, may be helpful as a reference for nurse managers and nurse educators.

RELEVANCE TO CLINICAL PRACTICE: This review gives hospital management an overview of determinants for possible quality improvements in nursing diagnoses documentation that needs to be undertaken in clinical practice.

Original languageEnglish
Pages (from-to)2386-2403
JournalJournal of clinical nursing
Volume20
Issue number17-18
DOIs
Publication statusPublished - Sep 2011

Keywords

  • documentation
  • nursing diagnosis

Cite this

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title = "What factors influence the prevalence and accuracy of nursing diagnoses documentation in clinical practice?: A systematic literature review",
abstract = "AIM: To identify what determinants influence the prevalence and accuracy of nursing diagnosis documentation in clinical practice.BACKGROUND: Nursing diagnoses guide and direct nursing care. They are the foundation for goal setting and provide the basis for interventions. The literature mentions several factors that influences nurses' documentation of diagnoses, such as a nurse's level of education, patient's condition and the ward environment.DESIGN: Systematic review.METHOD: MEDLINE and CINAHL databases were searched using the following headings and keywords: nursing diagnosis, nursing documentation, hospitals, influence, utilisation, quality, implementation and accuracy. The search was limited to articles published between 1995-October 2009. Studies were only selected if they were written in English and were primary studies addressing factors that influence nursing diagnosis documentation.RESULTS: In total, 24 studies were included. Four domains of factors that influence the prevalence and accuracy of diagnoses documentation were found: (1) the nurse as a diagnostician, (2) diagnostic education and resources, (3) complexity of a patient's situation and (4) hospital policy and environment.CONCLUSION: General factors, which influence decision-making, and nursing documentation and specific factors, which influence the prevalence and accuracy of nursing diagnoses documentation, need to be distinguished. To support nurses in documenting their diagnoses accurately, we recommend taking a comprehensive perspective on factors that influence diagnoses documentation. A conceptual model of determinants that influence nursing diagnoses documentation, as presented in this study, may be helpful as a reference for nurse managers and nurse educators.RELEVANCE TO CLINICAL PRACTICE: This review gives hospital management an overview of determinants for possible quality improvements in nursing diagnoses documentation that needs to be undertaken in clinical practice.",
keywords = "documentation, nursing diagnosis, verpleegdiagnose, documentatie",
author = "Wolter Paans and Roos Nieweg and {van der Schans}, Cees and Walter Sermeus",
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What factors influence the prevalence and accuracy of nursing diagnoses documentation in clinical practice? A systematic literature review. / Paans, Wolter; Nieweg, Roos; van der Schans, Cees; Sermeus, Walter.

In: Journal of clinical nursing, Vol. 20, No. 17-18, 09.2011, p. 2386-2403.

Research output: Contribution to journalArticleAcademicpeer-review

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T1 - What factors influence the prevalence and accuracy of nursing diagnoses documentation in clinical practice?

T2 - A systematic literature review

AU - Paans, Wolter

AU - Nieweg, Roos

AU - van der Schans, Cees

AU - Sermeus, Walter

N1 - © 2011 Blackwell Publishing Ltd.

PY - 2011/9

Y1 - 2011/9

N2 - AIM: To identify what determinants influence the prevalence and accuracy of nursing diagnosis documentation in clinical practice.BACKGROUND: Nursing diagnoses guide and direct nursing care. They are the foundation for goal setting and provide the basis for interventions. The literature mentions several factors that influences nurses' documentation of diagnoses, such as a nurse's level of education, patient's condition and the ward environment.DESIGN: Systematic review.METHOD: MEDLINE and CINAHL databases were searched using the following headings and keywords: nursing diagnosis, nursing documentation, hospitals, influence, utilisation, quality, implementation and accuracy. The search was limited to articles published between 1995-October 2009. Studies were only selected if they were written in English and were primary studies addressing factors that influence nursing diagnosis documentation.RESULTS: In total, 24 studies were included. Four domains of factors that influence the prevalence and accuracy of diagnoses documentation were found: (1) the nurse as a diagnostician, (2) diagnostic education and resources, (3) complexity of a patient's situation and (4) hospital policy and environment.CONCLUSION: General factors, which influence decision-making, and nursing documentation and specific factors, which influence the prevalence and accuracy of nursing diagnoses documentation, need to be distinguished. To support nurses in documenting their diagnoses accurately, we recommend taking a comprehensive perspective on factors that influence diagnoses documentation. A conceptual model of determinants that influence nursing diagnoses documentation, as presented in this study, may be helpful as a reference for nurse managers and nurse educators.RELEVANCE TO CLINICAL PRACTICE: This review gives hospital management an overview of determinants for possible quality improvements in nursing diagnoses documentation that needs to be undertaken in clinical practice.

AB - AIM: To identify what determinants influence the prevalence and accuracy of nursing diagnosis documentation in clinical practice.BACKGROUND: Nursing diagnoses guide and direct nursing care. They are the foundation for goal setting and provide the basis for interventions. The literature mentions several factors that influences nurses' documentation of diagnoses, such as a nurse's level of education, patient's condition and the ward environment.DESIGN: Systematic review.METHOD: MEDLINE and CINAHL databases were searched using the following headings and keywords: nursing diagnosis, nursing documentation, hospitals, influence, utilisation, quality, implementation and accuracy. The search was limited to articles published between 1995-October 2009. Studies were only selected if they were written in English and were primary studies addressing factors that influence nursing diagnosis documentation.RESULTS: In total, 24 studies were included. Four domains of factors that influence the prevalence and accuracy of diagnoses documentation were found: (1) the nurse as a diagnostician, (2) diagnostic education and resources, (3) complexity of a patient's situation and (4) hospital policy and environment.CONCLUSION: General factors, which influence decision-making, and nursing documentation and specific factors, which influence the prevalence and accuracy of nursing diagnoses documentation, need to be distinguished. To support nurses in documenting their diagnoses accurately, we recommend taking a comprehensive perspective on factors that influence diagnoses documentation. A conceptual model of determinants that influence nursing diagnoses documentation, as presented in this study, may be helpful as a reference for nurse managers and nurse educators.RELEVANCE TO CLINICAL PRACTICE: This review gives hospital management an overview of determinants for possible quality improvements in nursing diagnoses documentation that needs to be undertaken in clinical practice.

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KW - nursing diagnosis

KW - verpleegdiagnose

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JO - Journal of clinical nursing

JF - Journal of clinical nursing

SN - 1365-2702

IS - 17-18

ER -