Evaluation of the implementation of nursing diagnostics

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Slide 1 : Evaluation of the implementation of nursing diagnosticsA study on the use of nursing diagnoses, interventions and outcomes in nursing documentation Maria Müller Staub, RN, MNS, Phd(c), Bern, CH / Radboud University Nijmegen Promotor Prof. dr. T. van Achterberg University Medical Centre St. Radboud Nijmegen, NL Copromotores Prof. dr. M.A. Lavin, St. Louis University, USA Prof. dr. I. Needham, FHS St. Gallen, CH
Slide 2 : M. Müller Staub, July 9, 2007 2 Background Escalating health costs/legal cases: requirements(Institute of Medicine, 2001) Nursing documentation: quality and legal issues Need for classifications Without classifications:unspecific nursing language, documentation and evaluation
Slide 3 : M. Müller Staub, July 9, 2007 3 Classifications Classifications = Knowledge base Nursing diagnoses(impaired mobility, hopelessness)PES-Format Nursing interventions(exercise therapy, hope instillation/self-modification assistance) Nursing outcomes(enhanced ambulation, hope)
Slide 4 : M. Müller Staub, July 9, 2007 4 Problems Difficulties in classification choice Few studies Nurses not well trained Lack of measurement instruments
Slide 5 : M. Müller Staub, July 9, 2007 5 Research aims Evaluate classifications Investigate effects of application/use of nursing diagnostics Development and testing of instrument Evaluate the initial implementation of nursing diagnoses, interventions and outcomes,and assess the effect of two educational follow-up measures
Slide 6 : M. Müller Staub, July 9, 2007 6 Results 1 - 3 Evaluation of Classifications (ICNP, ICF, NANDA, ZEFP)? NANDA meets most criteria Investigating application/use ? Improvements in documented diagnoses, interventions and outcomes ? Knowledge deficit in accuracy and coherence with interventions/outcomes
Slide 7 : M. Müller Staub, July 9, 2007 7 Results 1 - 3 Development and testing of instrument? Quality of Nursing Diagnoses, Interventions and Outcomes (Q-DIO) Q-DIO: 29 items, 3-5 point scales ? Internal consistency: Cronbach’s alpha < 0.83 ? Intra-Rater reliability: Pearson’s ? = 0.98 ? Interrater reliability: Kappa = 0.94
Slide 8 : M. Müller Staub, July 9, 2007 8 4. Evaluation of initial implementation Pre- posttest study design to evaluate the intervention effect Intervention: Staff education Data analysis: applying measurement instrument Q-DIO
Slide 9 : M. Müller Staub, July 9, 2007 9 Intervention: Introductory class and eight case meetings Nursing Diagnoses PES Choosing nursing interventions Stating and evaluating nursing outcomes Relationships between nursing diagnoses, interventions and nursing outcomes (Odenbreit, 2002a)
Slide 10 : M. Müller Staub, July 9, 2007 10 Sample Six wards, Swiss State Hospital 72 randomly selected, documented nursing diagnoses, interventions, and outcomes
Slide 11 : M. Müller Staub, July 9, 2007 11 Results: Nursing diagnoses
Slide 12 : Nursing interventions and outcomes T- Tests for all sub-scales p < 0.0001
Slide 13 : M. Müller Staub, July 9, 2007 13 Effects of educational follow-up measures Guided clinical reasoning (intervention group)Classic case discussions (control group) Cluster-randomized, experimental intervention study (Duration: 17 months) Evaluation with Q-DIO Sample: 444 nursing diagnoses, interventions and outcomes
Slide 14 : M. Müller Staub, July 9, 2007 14 Results: example Control group Nursing diagnosis “Patient has a decubitus at left heel” Intervention group Nursing diagnosis: Impaired skin integrity: Pressure ulcer, grade II Etiology/related factors Altered circulation Mechanical (pressure, shear, friction) Impaired physical mobility Nutritional deficit Signs/symptoms Destruction of skin layers (dermis) at left heel, 2x3 cm wide, 1mm deep)
Slide 15 : M. Müller Staub, July 9, 2007 15 Results.... Control group Nursing interventions „Change bed position every 4 hours „Change dressing daily”. Intervention group Nursing interventions „Observe wound daily Positioning patient every 3 hours with wedge-pillow Constant pressure-free positioning of heel Aguagel dressing, next change at (date) Mobilize patient 3 times daily for meals Observe and document food and fluid intake (see protocols) Instruction of patient about condition and interventions“
Slide 16 : M. Müller Staub, July 9, 2007 16 Results.... Control group Nursing outcomes “Small tissue damage, skin still red ”. Intervention group Nursing outcomes „Tissue integrity/observable healing with epithelized, dry, irritation- and odorless skin, free of pain Unimpaired mobility of joint Improved self-care ability (patient performs skin observation and care, changes of position, mobility and constant pressure free positioning of heel Patient can explain her condition, the etiology (pressure, immobility, nutritional status and meaning of risk management).
Slide 17 : Results Pre- post-intervention Mean (SD) Nursing diagnosesIntervention group 2.69 (SD = .90) 3.70 (SD = .54) * Control group 3.13 (SD = .89) 2.97 (SD = .80) Nursing interventionsIntervention group 2.33 (SD = .93) 3.88 (SD = .35) * Control group 2.70 (SD = .88) 2.46 (SD = .95 Nursing outcomesIntervention group 1.53 (SD= 1.08) 3.77 (SD = .53) * Control group 2.02 (SD = 1.27) 1.94 (SD = 1.06) Intervention group: t-Tests p < 0.0001
Slide 18 : M. Müller Staub, July 9, 2007 18 Conclusions ? Significant/clinically meaningful quality improvements found (2 studies) ? Guided Clinical Reasoning Nurses need support through educational measures Methodological considerations Further implementation of standardized language

 


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