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

Author

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  • Wolter Paans
  • Roos MB Nieweg
  • Cees P van der Schans
  • Walter Sermeus

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.

Suggested Citation

  • 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.
  • Handle: RePEc:wly:jocnur:v:20:y:2011:i:17-18:p:2386-2403
    DOI: 10.1111/j.1365-2702.2010.03573.x
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    Cited by:

    1. 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.
    2. Gianfranco Sanson & Ercole Vellone & Mari Kangasniemi & Rosaria Alvaro & Fabio D'Agostino, 2017. "Impact of nursing diagnoses on patient and organisational outcomes: a systematic literature review," Journal of Clinical Nursing, John Wiley & Sons, vol. 26(23-24), pages 3764-3783, December.
    3. Fatjona Kamberi, 2018. "Knowledge and Attitudes of Nurses toward the Use of Nursing Diagnosis in Clinical Practice," Eastern-European Journal of Medical Humanities and Bioethics, Editura Lumen, vol. 2(2), pages 43-55, December.
    4. Elisabeth Østensen & Nicholas R. Hardiker & Line Kildal Bragstad & Ragnhild Hellesø, 2020. "Introducing standardised care plans as a new recording tool in municipal health care," Journal of Clinical Nursing, John Wiley & Sons, vol. 29(17-18), pages 3286-3297, September.

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    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.;
    All these keywords.

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