Nursing diagnosis identification by nurses in burn wards: A descriptive cross-sectional study

Area of Science:

• Nursing
• Healthcare Quality
• Patient Safety

Background:

• Accurate identification and documentation of patient care needs are crucial for delivering high-quality healthcare services.
• Burn patient care requires specialized assessments to address unique and complex health challenges.

Purpose of the Study:

• To describe the care needs identified in the nursing records of burn patients.
• To evaluate the extent to which nurses utilize the North American Nursing Diagnosis Association (NANDA) classification for formulating patient care needs.

Main Methods:

• A descriptive, cross-sectional study design was employed.
• 430 nursing records from burn wards were reviewed using a convenient sampling method.
• Data were collected using Gordon's checklist, with established validity and reliability, and analyzed using SPSS v.24.

Main Results:

• The average number of diagnoses per record was 1.94, with 'Safety/Protection' being the most frequent domain.
• The most prevalent nursing diagnoses identified were 'risk for infection' and 'risk for falls'.
• Approximately 83% of identified diagnoses were not aligned with the NANDA classification, suggesting a disconnect in standardized nursing documentation.

Conclusions:

• A significant gap exists in the application of standardized nursing diagnoses (NANDA) in documenting burn patient care needs.
• The findings suggest that nursing care may be primarily physician-directed, with limited evidence of independent nursing assessment and critical thinking in documentation.
• There is a need for improved nursing education and practice to ensure accurate and standardized documentation of patient care needs using established frameworks like NANDA.