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Implementation of Free Text Format Nursing Diagnoses at a University Hospital’s Medical Department. Exploring Nurses’ and Nursing Students’ Experiences on Use and Usefulness. A Qualitative Study

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  • Sigrun Aasen Frigstad
  • Torunn Hatlen Nøst
  • Beate André

Abstract

Background . Nursing documentation has long traditions and represents core element of nursing, but the documentation is often criticized of being incomplete. Nursing diagnoses are an important research topic in nursing in terms of quality of nursing assessment, interventions, and outcome in addition to facilitating communication and continuity. Aim . The aim of this study was to explore the nurses’ and nursing students’ experiences after implementing free text format nursing diagnoses in a medical department. Method . The study design included educational intervention of free text nursing diagnoses. Data was collected through five focus group interviews with 18 nurses and 6 students as informants. The data was analyzed using qualitative content analysis. Results . The informants describe positive experiences concerning free text format nursing diagnoses’ use and usefulness; it promotes reflection and discussion and is described as a useful tool in the diagnostic process, though it was challenging to find the diagnosis’ appropriate formulation. Conclusion . Our findings indicate a valid usability of free text format nursing diagnoses as it promotes the diagnostic process. The use seems to enhance critical thinking and may serve as valuable preparation towards an implementation of standardized nursing diagnoses. Use and support of key personnel seem valuable in an implementation process.

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  • Sigrun Aasen Frigstad & Torunn Hatlen Nøst & Beate André, 2015. "Implementation of Free Text Format Nursing Diagnoses at a University Hospital’s Medical Department. Exploring Nurses’ and Nursing Students’ Experiences on Use and Usefulness. A Qualitative Study," Nursing Research and Practice, Hindawi, vol. 2015, pages 1-11, May.
  • Handle: RePEc:hin:jnlnrp:179275
    DOI: 10.1155/2015/179275
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    References listed on IDEAS

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    1. Wolter Paans & Roos MB Nieweg & Cees P van der Schans & Walter Sermeus, 2011. "What factors influence the prevalence and accuracy of nursing diagnoses documentation in clinical practice? A systematic literature review," Journal of Clinical Nursing, John Wiley & Sons, vol. 20(17‐18), pages 2386-2403, September.
    2. Edith R Gjevjon & Ragnhild Hellesø, 2010. "The quality of home care nurses’ documentation in new electronic patient records," Journal of Clinical Nursing, John Wiley & Sons, vol. 19(1‐2), pages 100-108, January.
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    1. Beate André & Torunn H Nøst & Sigrun A Frigstad & Endre Sjøvold, 2017. "Differences in communication within the nursing group and with members of other professions at a hospital unit," Journal of Clinical Nursing, John Wiley & Sons, vol. 26(7-8), pages 956-963, April.
    2. David Luna-Aleixos & Irene Llagostera-Reverter & Ximo Castelló-Benavent & Marta Aquilué-Ballarín & Gema Mecho-Montoliu & Águeda Cervera-Gasch & María Jesús Valero-Chillerón & Desirée Mena-Tudela & Lau, 2022. "Development and Validation of a Meta-Instrument for Nursing Assessment in Adult Hospitalization Units (VALENF Instrument) (Part I)," IJERPH, MDPI, vol. 19(22), pages 1-15, November.

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