Accuracy of nursing diagnoses: knowledge, knowledge sources, reasoning skills and the use of Big Data in nursing documentation

Transcription

1 Accuracy of nursing diagnoses: knowledge, knowledge sources, reasoning skills and the use of Big Data in nursing documentation An overview of studies of the Research Group in Nursing Diagnostics, Hanze University of Applied Sciences Dr. Wolter Paans New-Net Network European Ways of Nursing Education and Training Europäisches Pflegesymposium Oldenburg

2 The Beginning Davon ausgehen, dass Pflegediagnosen in Deutschland so gut wie gar nicht bekannt sind. : New-Net Network European Ways of Nursing Education and Training Europäisches Pflegesymposium Oldenburg

3 Kurz vorstellen System der Pflegediagnosen kurz vorstellen am besten anhand von konkreten Beispielen Woher kommen die Pflegediagnosen? Wie sind sie entstanden, wie werden sie entwickelt und durch wen? Welche Bedeutung haben Pflegediagnosen für die Profession Pflege und den Pflegeprozess? Wie sind Pflegediagnosen aufgebaut? Wie wird in der Praxis mit Pflegediagnosen gearbeitet? Wie ist der Forschungstand zu Pflegediagnosen (Effekte von Pflegediagnosen auf die Patientenversorgung) New-Net Network European Ways of Nursing Education and Training Europäisches Pflegesymposium Oldenburg

4 Entwicklung Wo stehen die Niederlande und Deutschland in Bezug auf die Implementierung der Pflegediagnosen? Was sind Möglichkeiten zur weiteren Entwicklung der Pflegediagnosen? Bitte denkt daran, dass das Thema Pflegediagnosen in Deutschland nicht verbreitet ist. Lieber weniger Theorie und mehr Diskussion! New-Net Network European Ways of Nursing Education and Training Europäisches Pflegesymposium Oldenburg

5 Thema Pflegediagnosen Health Problems Difference MD: ND; all about the influence and effect of diseases and illness on individuals, groups and the social network

6 Example Risk diagnoses: -Risk for falls -Risk for imbalanced fluid volume -Ris for suicide Acute diagnoses: - Acute (abdominal) pain - Anxiety - Imbalanced nutrition New-Net Network European Ways of Nursing Education and Training Europäisches Pflegesymposium Oldenburg

7 GOAL To plan accurate and measurable interventions (efficient / effective). To come to patient s self management.

8 GOAL To structure and document nursing knowlegde and the relationship between interventions. To develop reasoning tools and documentation tools (in the electronic health record) New-Net Network European Ways of Nursing Education and Training Europäisches Pflegesymposium Oldenburg

9 GOAL To make nursing care, and nursing outcomes (the importance of nursing) measurable New-Net Network European Ways of Nursing Education and Training Europäisches Pflegesymposium Oldenburg

10 Conceptual basis of nursing diagnosis A nursing diagnosis: - is based on patients individual physical, social and psychosocial response to an illness or health problem that have an impact on activities of daily living; - describe a patient s problem - include related factors (etiology of the problem) - include defining characteristics (signs and symptoms) - is related to nurses (potential) interventions

11 Conceptual basis of nursing diagnosis continued An accurate actual nursing diagnosis is documented in the PES-Structure and related to an (potential) nursing interventions (I). - (P) = Problem label - (E) = Etiology (related factors) - (S) = Signs / Symptoms - (I) = Intervention

12 Background of studies Over 20 years nursing diagnosis as a topic in nursing education. Inaccurate nursing diagnoses may have negative influences on patient safety. The prevalence and accuracy of nursing diagnoses in clinical practice was not yet determined in the Netherlands.

13 Research questions (1) What is the prevalence of accurate nursing documentation in patient records? (2) What factors influence the accuracy of nursing diagnosis? (3) Do knowledge sources and a predefined record structure affect the accuracy of nursing diagnoses?

14 Research questions continued (4) Does ready knowledge influence the accuracy of nursing diagnoses? (5) Do dispositions towards critical thinking influence the accuracy of nursing diagnoses? (6) Does reasoning skills influence the accuracy of nursing diagnoses? (7) What is the predictive power of ND-documentation?

15 1) Development and testing of the D-Catch instrument study 1 Nursing documentation should contain the following key components: 1) Patient s personal information 2) Accurate description of the admission data 3) Accurate nursing diagnoses 4) Accurate nursing interventions 5) Accurate report of the progress & outcomes evaluations 6) Legible handwriting or typed reports

16 1) Development and testing of the D-Catch instrument continued Quantity criteria address the question Are the components of the documentation present? Measurement: quantity criteria can be scored as follows: complete = 4 points; partially complete = 3 points; incomplete = 2 points; none = 1 point.

17 1) Development and testing of the D-Catch instrument continued Quality criteria of the D-Catch instrument address the question: What is the quality of the description with respect to relevancy, unambiguity, and linguistic correctness? Measurement: Quality criteria can be scored as follows: very good = 4 points; good = 3 points; moderate = 2 points; poor = 1 point.

18 1) Development and testing of the D-Catch instrument continued Example of quantity measurement accuracy of nursing diagnoses 4 points: (P+E+S) (I) 3 points: (P)+(E)+(S) (?) or (P)+(E)+(?) (I) or (P)+(?)+(S) (I) 2 points: (P)+(?)+(?) (I) or (P)+(E)+(?) (?) or (P)+(?)+(S) (?) 1 point: (P)+(?)+(?) (?) Complete Incomplete on 1 aspect Incomplete on 2 aspects Incomplete on 3 aspects

19 1) Development and testing of the D-Catch instrument continued Sample - Of 94 medical centers in the Netherlands, seven hospitals were randomly selected patient records from 25 wards were assessed with the D-Catch instrument.

20 1) Development and testing of the D-Catch instrument continued Reliability - Internal consistency as determined by Cronbach s alpha was Inter-rater reliability of the D-Catch was calculated using eight pairs (n= 245 records) resulting in a K w between and The results show that the D-Catch instrument had acceptable validity and reliability when used in general hospital settings

21 (2) Prevalence of accurate nursing documentation study 2 Sample - 10 hospitals, were randomly selected, stratification by province was applied. - Included: 341 patient records in 35 wards and seven specialties. - Specialties and n of wards: Internal medicine (11), Intensive care (2), Neurology (6), Obstetrics (1), Orthopedics (4), Pediatric care (1), Surgery (10)

22 (2) Prevalence of accurate nursing documentation continued Sample Hospital category n of Hospitals n of Wards n of Records n of Diagnoses Sub-total General University Total General & university

23 (2) Prevalence of accurate nursing documentation continued Results Found good very good: - Record structure: 62% - Admission information: 80% - Nursing diagnoses: 24% - Nursing interventions: 5% - Progress and Outcome: 64% - Legibility: 67% - Nature of nurses documentation: descriptive & chronological - Unstructured and redundant documentation in long-stay situations

24 Study 3: Influencing factors on ND Hospital policy and diagnostic environment -Number of patients -Workload level -Information structure -Medical model Patients complexity -Cultural differences in patients expressing severe diagnoses -Severe medical diagnoses -Patients way of expressing diagnoses Influencing factors on ND Education & Resources -Clinical reasoning -Educational background -Structured forms -Classification structure -Computer tools Diagnosticians -Disposition toward diagnoses -Experience -Diagnostic knowledge -Reasoning skills

25 Study 4: Accuracy of ND: a randomised study Method Randomisation of participants (n= 249) into four groups and three case histories Group A n= 47 Handbooks & assessment format Group B n= 76 PES-format Group C n= 50 Handbooks & Assessment format & PES-format Group D n= 68 Control group Case history: Diabetes: n= 68, COPD: n= 82, Crohn: n= 91 Questionnaires: 1) Knowledge Inventory based on case history 2) California Critical Thinking Disposition Inventory (CCTDI) 2) Health Science Reasoning Test (HSRT)

26 Accuracy of ND: a randomised study (continued) Results Main positive effect of: PES-format on the accuracy of nursing diagnoses No significant effect of handbooks and assessment format on the accuracy of nursing diagnoses

27 Results study 4 Positive influencing factors: - Young, higher educated nurses - Reasoning skills (deduction and analysis) Implications for nursing practice Electronic record designers use of PES-format Critical reasoning and reasoning skills in education programs

28 Nursing diagnosis (n=199) Predictive power of ND on LOS: Study 5 %, (n) Mean LOS N= 300 hip fracture patients Mean (standard deviation) p-value* Diagnosed Not diagnosed Pain 79,90 (159) 10,92 (6.589) 7,35 (3,207) 0,005* Disordered / Distressed 48,24 (96) 11,42 (7,564) 9,07 (4,382) 0,000* Pressure ulcer 21,61 (43) 14,72 (8,833) 8,96 (4,594) 0,000* Nausea 35,18 (70) 11,86 (7,703) 9,30 (5,060) 0,018* Obstipation 22,61 (45) 12,73 (7,958) 9,46 (5,428) 0,023* Delirium 7,54 (15) 12,67 (5,038) 10,00 (6,279) 0,840 Anxiety 17,59 (35) 12,23 (7,585) 9,77 (5,828) 0,118 Imbalanced Nutrition /less than body requirements Imbalanced fluid volume / deficient fluid volume 15,58 (31) 14,23 (9,615) 9,46 (5,074) 0,000* 14,07 (28) 15,57 (10,265) 9,32 (4,779) 0,000* Impaired tissue perfusion 19,10 (38) 15,34 (9,382) 8,99 (4,451) 0,000* New-Net Network European Ways of Nursing Education and Training Europäisches Pflegesymposium Oldenburg

29 Conclusion - Nursing diagnoses did not comprise the core element of the nursing documentation. - Accuracy in nursing documentation appears to be heterogeneous. - Nursing documentation needs to be improved in order to promote patient safety. - The implementation and use of electronically produced documentation and resources might be helpful to organize nurses notes more accurately. - ND and predictive power studies / Big Data research are key for the nursing discipline as well as for the quality of care and patient safety.

30 Nursing Diagnosis, & Technique: Future Research Paans, W., Wijkamp, J.S., Wolfensberger M.V.C. (2014). What establishes an excellent nurse? A focus group and Delphi panel approach, Journal of Nursing Scholarship (In Review).

31 BIG DATA International Master Program Sensor Techniques in Healthcare (Hanze University of Applied Siences) (PES: signs sensor detectors)

32 Stimmen Sie zu?(i) Pflegediagnosen (Nursing Diagnosis) sind der Herzschlag der pflegerischen Profession Ohne Pflegediagnosen keine professionelle Pflege Nursing Diagnosis (ND) must be seen as the beating heart of nursing as a profession -No ND no Professional Nursing New-Net Network European Ways of Nursing Education and Training Europäisches Pflegesymposium Oldenburg

33 Stimmen Sie zu?(ii) Die Nutzung von Pflegediagnosen muss international entwickelt und vorangetrieben werden, da durch die Pflegediagnosen pflegerisches Handeln begründet wird - ohne Pflegediagnose ist keine stichhaltige Intervention möglich The use of Nursing Diagnostics needs to be developed internationally as it reflects nurses motivation for interventions -No valid intervention is possible without a diagnosis New-Net Network European Ways of Nursing Education and Training Europäisches Pflegesymposium Oldenburg

34 Stimmen Sie zu?(iii) Ohne Pflegediagnosen ist der Effekt von Pflege nicht messbar Wenn die Pflegeintervention nicht in Verbindung mit einer Pflegediagnose steht, können die Effekte der Interventionen niemals gemessen werden. Without a Nursing Diagnosis, the effect of nursing is not measurable -If you do not relate the problem to the intervention, you can never measure effects New-Net Network European Ways of Nursing Education and Training Europäisches Pflegesymposium Oldenburg

35 Stimmen Sie zu?(iv) In 2025 in Deutschland ist das System der Pflegediagnosen ausreichend entwickelt und als Schlüsselelement im Pflegeprozess anerkannt Pflegekräfte sind Professionelle, die Pflege leitet eigenständig Diagnosen ab und erstellt ihren Pflegeplan auf Basis exakter diagnostischer Begründungen In Germany in 2025 Nursing Diagnostics are sufficient developed and accepted as the key item in the nursing process -The nurse is a professional, nurses derive diagnoses themselves and make there care plan on accurate diagnostic reasoning New-Net Network European Ways of Nursing Education and Training Europäisches Pflegesymposium Oldenburg

36 Was schlagen Sie vor? Für die Pflegepraxis? Für die Pflegeaus-/fort-/weiterbildung? Für die Pflegeforschung? Was können wir und Sie in Deutschland tun? New-Net Network European Ways of Nursing Education and Training Europäisches Pflegesymposium Oldenburg

37 Keenan, G., Yakel, E., Dunn Lopez, K., Tschannen, D., & Ford, Y. B. (2012). Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information. Journal of the American Medical Informatics Association : JAMIA. doi: /amiajnl Keenan, G., Yakel, E., Dunn Lopez, K., Tschannen, D., & Ford, Y. B. (2013). Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information. [Multicenter Study Research Support, U.S. Gov't, P.H.S.]. Journal of the American Medical Informatics Association : JAMIA, 20(2), doi: /amiajnl Müller-Staub, M., Lavin, M. A., Needham, I., & van Achterberg, T. (2006). Nursing diagnoses, interventions and outcomes - Application and impact on nursing practice: A systematic literature review. Journal of Advanced Nursing, 56(5), Lunney, M. (2008). Critical Need to Address Accuracy of Nurses Diagnoses. OJIN: The Online Journal of Issues in Nursing, 13(1). Lunney, M. (2009). Critical thinking to achieve positive health outcomes (2 ed.). Ames, IA: Wiley-Blackwell. Paans, W., Muller-Staub, M., & Nieweg, R. (2013). The influence of the use of diagnostic resources on nurses' communication with simulated patients during admission interviews. International journal of nursing knowledge, 24(2), doi: /j x Paans, W., Müller-Staub, M., & Nieweg, R. (2013). The Influence of the Use of Diagnostic Resources on Nurses' Communication With Simulated Patients During Admission Interviews. International journal of nursing knowledge. doi: /j x Paans, W., Sermeus, W., Nieweg, M.B., Krijnen, W.P., Schans, van der, C.P. (2012). Do knowledge, knowledge sources and reasoning skills affect the accuracy of nursing diagnoses? a randomized study. Biomed Central, Nursing (BMC-N) free text Paans, W., Müller-Staub, M.M. (2012) Standards in Multi-professional Digital Documentation IT for Health, CH/News/2012/08/07/Standards-in-Multi-professional-Digital-Documentation.aspx Paans, W., Sermeus, W., Nieweg, R. M., & van der Schans, C. P. (2010a). D-Catch instrument: development and psychometric testing of a measurement instrument for nursing documentation in hospitals. Journal of Advanced Nursing, 66(6), doi: /j x Paans, W., Sermeus, W., Nieweg, R. M., & van der Schans, C. P. (2010b). Prevalence of accurate nursing documentation in patient records. Journal of Advanced Nursing, 66(11), doi: /j x Paans, W., Nieweg, M.B., Schans, van der C.P., Sermeus, W. (2010). What factors influence the prevalence and accuracy of nursing diagnoses documentation in clinical practice? A systematic literature review. Journal of Clinical Nursing; 20(17-18): doi: /j x. Richtlijn Verpleegkundige Verslaglegging, (2011), V&VN, Nu 91, Wilkinson, J.M., Kritisch denken binnen het verpleegkundig proces, book editing for Dutch release of the fifth edition of Critical Thinking in the Nursing Process, Pearson, Amsterdam New-Net Network European Ways of Nursing Education and Training Europäisches Pflegesymposium Oldenburg