Investigating nursing documentation quality using Q-DIO: A multilevel regression analysis

PurposeTo investigate the factors influencing the completion quality of nursing documentation (NDoc) in Romania using multilevel modeling.DesignRetrospective descriptive study.MethodA mixed-effect logistic regression analysis was conducted to identify factors affecting the completion of NDoc by using the Q-DIO instrument. A total of 395 NDocs were selected by probabilistic sampling.FindingsThe study identified significant correlations among the Q-DIO sub-concepts. Specifically, "Nursing Diagnoses as Process" was significantly correlated with both "Nursing Diagnoses as Product" and "Nursing-Sensitive Patient Outcomes." Additionally, "Nursing Diagnoses as Product" is correlated with "Nursing Interventions." Among the external factors, the number of nurses involved in documentation was significantly linked to the completeness of both "Nursing Diagnoses as Product" and "Nursing Interventions." Documentation quality also varied by hospital specialty, whereas the length of stay did not show any significant correlation with the Q-DIO sub-concepts.ConclusionsThe relationships between Q-DIO sub-concepts underscore the importance of addressing every phase of the nursing process for meaningful nursing-sensitive patient outcomes. External factors significantly affect documentation completion, requiring the consideration of organizational aspects when implementing NDoc.Implications for Nursing PracticeThis study highlights the need for nurses to systematically collect and document data across all phases of the nursing process. Training and support should be provided to improve the accuracy and completeness of nursing diagnoses and their linkage to interventions and outcomes. Additionally, organizational factors, such as staffing levels and the type of hospital specialty, should be carefully considered when implementing documentation innovations, as they significantly impact the quality and completeness of NDoc.