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Putting policy into practice: pre- and posttests of implementing standardized languages for nursing documentation.
Asta Thoroddsen1, Margareta Ehnfors
1Orebro University, Orebro, Sweden, and Faculty of Nursing, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland. astat@hi.is
Journal of Clinical Nursing
|September 21, 2007
Summary
Implementing a new documentation policy significantly improved nurses' use of standardized languages for patient care documentation, including nursing assessments, diagnoses, and interventions. This enhances data quality for electronic health records and nursing research.
Area of Science:
- Nursing Informatics
- Healthcare Quality Improvement
- Clinical Documentation
Background:
- Standardized languages in clinical practice are challenging but crucial for nursing knowledge development and performance improvement.
- Nursing records provide essential data for research, quality evaluation, and healthcare policy formulation.
- This study supports a longitudinal project focused on electronic documentation and standardized nursing languages.
Purpose of the Study:
- To evaluate changes in nursing process documentation across inpatient wards after policy implementation.
- To identify differences in documentation practices before and after the new policy.
Main Methods:
- A cross-sectional study design utilized pretest (n=355) and post-test (n=349) nursing record analysis.
- A year-long intervention involved group work, education, and support to facilitate policy adoption.
- Data collection focused on the documentation of nursing assessment, diagnoses, and interventions.
Main Results:
- Statistically significant improvements were observed in the use of Functional Health Patterns for nursing assessments.
- Enhanced documentation of nursing diagnoses using NANDA (North American Nursing Diagnosis Association) was noted.
- Improvements in documenting nursing interventions using the Nursing Interventions Classification (NIC) were statistically significant.
Conclusions:
- Interventions to implement documentation policy improved the daily use of standardized nursing languages at all organizational levels.
- Standardized language is essential for nurses documenting patient care in electronic health records.
- Effective documentation demonstrates nursing contributions and supports evidence-based practice.
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