Nieweg, Roos

Paans, Wolter

Sermeus, Walter

van der Schans, Cees

Hanze UAS repository

Development of a Measurement Instrument for NursingDocumentation in the Patient RecordWolter PAANS¹, Walter SERMEUS², Roos NIEWEG³ and Cees Van Der SCHANS4¹. Research and Innovation Group in Health Care and Nursing, Hanze University,Applied Sciences, Groningen, The Netherlands and the Catholic University Leuven,Belgium² .School of Public Health, Faculty of Medicine, Center for Health Services andNursing Research, Catholic University Leuven, Belgium³,4. Research and Innovation Group in Health Care and Nursing, Hanze University,Applied Sciences, Groningen, The NetherlandsABSTRACT. Objectives: To develop, validate and test the reliability of a measurement instrument thatmeasures the extent to which records describe essential aspects of nursing care such as the admission report,nursing diagnoses, interventions, and progress and outcome evaluations. Method:. A measurement instrumentwas developed based on the Cat-ch- Ing instrument and the Scale for Degrees of Accuracy in NursingDiagnoses. A record screening was conducted in 7 hospitals in the Netherlands. Content validity was testedby using two Delphi panels. Each of the 250 records was assessed by two reviewers independently. Thereliability of the instrument was tested by calculating Cohen’s weighted Kappa inter-rater reliabilitycoefficient of 250 records and 12 reviewers. Internal consistency was calculated by using  Cronbach’s alpha.Results: The new measurement instrument, named D-Catch, consists of six items. Quantity and qualityvariables were used to judge the accuracy of the nursing documentation. Internal consistency: Cronbach’sAlpha 0.722. The inter-rater reliability coefficients were between 0.397- 1.000. Conclusions andimplications: The D-Catch instrument was estimated to be a valid and reliable measurement instrument fornursing records in hospitals in the Netherlands. An adverse effect on the inter-rater reliability may have beenthat, specifically in long stay situations, documentation forms with diagnoses, interventions and outcomeswere often unstructured and found to be repetitious.Keywords: instrument development, nursing documentation, patient record, nursing process1. IntroductionThe patient record can be seen as essential for adequate nursing care and describesinformation about admission, nursing diagnoses, interventions, progress and outcomeevaluations  [1,3,6,7,10,18-23]. This information should contain the patient’s ongoingstatus and reflect the full range of nursing process [1,3,6]. For that reason the patientrecord is an important instrument to evaluate care performance by nurses and shouldcontain documentation to be able to evaluate the quality, efficiency and effectiveness ofnursing care [1,2,24].Thereby the record is a legal document and may be the only evidence what kind of carewas given [24]. Therefore it is important nursing documentation is accurate andcomplete [1,6,14,16,17].Evaluating the accuracy of the nursing reports in patient records is a possibility to gainknowledge about the quality of these reports and gives information if it is necessary toimprove the way of recordkeeping [1,17,18, 24,25]. However, there is a lack of reliableinstruments to measure the accuracy of nursing reports in the patient record in generalhospital settings [2, 17].Connecting Health and HumansK. Saranto et al. (Eds.)IOS Press, 2009© 2009 The authors and IOS Press. All rights reserved.doi:10.3233/978-1-60750-024-7-2972972. ObjectivesThe purpose of this study was to develop, validate and test the reliability of ameasurement instrument to quantify accuracy of nursing documentation in patientrecords.3. Materials and MethodsA literature search was carried out to be able to identify existing measurementinstruments. The articles were identified through electronic databases CINAHL andMEDLINE and through the citations from published articles from 1980 -2007. Basedon the literature review, members of two Delphi panels (n= 6 per panel) studied threepreselected measurement instruments individually for content, structure, usability andspecificity and discussed these instruments in a group interview. Based on a consensusdiscussion, the panels suggested to integrate The Scale for Accuracy of NursingDiagnoses [14] in a modified Cat-ch-Ing instrument [1] to use in a pilot study. Anassessment of patient records (n= 250) using the new instrument called ‘D-Catch’ wascarried out in a follow-up study in seven general hospitals on different wards (n= 25) inthe Netherlands to be able to analyse the properties of the D-Catch instrument. Each ofthe 250 records was assessed independently by two reviewers. The inter-observerreliability of the instrument was tested by calculating Cohen’s weighted Kappa inter-rater reliability coefficient of 250 records and 12 reviewers. Content validity was testedby two Delphi panels. Internal consistency was calculated by Cronbach’s alpha.4. ResultsThe literature search resulted that six measurement instruments were found:(1) Ziegler’s instrument, The Criteria for Evaluating the Quality of the Nursing Process(ZCEQNP) [4, 25]. (2) The NoGA instrument [20]. (3) The Quality of NursingDiagnosis instrument (QOD) [8]. (4) The Quality of  Diagnoses, Interventions andOutcomes instrument (Q-DIO) [19]. (5) The “Cat-ch -Ing” instrument [1]. (6) The“Scale for Degrees of Accuracy in Nursing Diagnoses” [14].Non of the instruments found in the literature were originally developed to measureaccuracy of nursing documentation in all kind of hospitals, wards and records and nonof these instruments were tested that way.Because the ZCEQNP, QOD and the Scale for Degrees of Accuracy in NursingDiagnoses were only usable for results on the variable ‘reported nursing diagnoses’[4,8,25], the NoGA instrument contains only quantitative rating  possibility’s and noqualitative criteria [20], the Cat-ch-Ing instrument has no possibilities to score theaccuracy of each nursing diagnosis separately in the record and contains specific itemsrelated to Swedish regulations [1], and the Q-DIO includes specific process variablesused in a hospital in Switzerland [19], we concluded that non of these instruments seemto be directly applicable for a record assessment in all kind of hospitals. Based onNANDA-International [21], NIC (Nursing Intervention Classification) [5,11,23] andNOC (Nursing Outcome Classification) [12,18] descriptions of how to documentdiagnoses, interventions and outcomes [3,18, 21] and based on the descriptions of TheDutch Institute for Healthcare Improvement, CBO [6] the new measurementinstrument, named D-Catch, was compiled based on Lunney’s instrument [14] en theCat-ch-Ing instrument [1].W. Paans et al. / Development of a Measurement Instrument for Nursing Documentation298D-catch consists of six items to judge the nursing record. Quantity and quality variableswere used to asses the accuracy. Internal consistency was Cronbach’s Alpha 0.722.The inter-rater reliability coefficients were between 0.397- 1.000.Content validity of the D-catch instrument is considered adequate because the Delphimethod started with items that build upon earlier work in the United States and Swedenwith respect to criteria and information structure. Full agreement among experts on theitems of the new instrument  D-Catch was obtained.5. Conclusion and  DiscussionWith the D-Catch instrument we choose to focus on a specific way to measure eachpresented patient problem (diagnosis) and than, if there is given an intervention. Fromthere on we looked systematically at the process and the outcome evaluations and viceversa.This approach helped us to understand how to categorize and analyse the nursingreports in all kinds of records from patients with all kinds of diseases, treatments andconditions.We estimated the reliability of the D-Catch instrument as satisfactory. An adverseeffect on the inter-rater reliability may have been that, specifically in long-staysituations, documentation forms with diagnoses, interventions and outcomes were oftenunstructured and with reports over more than ten pages. The content of long-staypatient records found to be repetitious with the result of redundant reports.Criteria for  accurate  nursing  documentation  mentioned  in  studies from, for  example,the United States [3,5,10,11,14,15], Sweden [1,7,20] and Switzerland [18,19] seem -notin detail, but over all- rather similar; there is consistency among nurses’  quality criteriain record keeping from different countries,  and over different  studies, which makes thedevelopment of  a  measurement  instrument  for  an  international nursing  audienceplausible [9,21].We  hope that  the development of the items in the D-Catch instrument may  contributeto the development of such an international measurement instrument.References[1] Björvell, C. Nursing Documentation in Clinical Practice, instrument development and evaluation ofa comprehensive intervention programme, Karolinska Institutet, Stockholm; 2002.[2] Bostick, J.E., Riggs, C.J., Rantz, M.J. Quality measurement in nursing, Journal of Nursing CareQuality; 2006,18 (2), 94-104[3] Carpenito, L. J. The NANDA definition of nursing diagnosis. In: Johnnson, C. R. M. (Ed.)Classifications of Nursing Diagnoses,  Proceedings of the Ninth Conference, J.B. LippincottCompany, Philadelphia; 1991.[4] Dobrzyn, J. Components of Written Diagnostic Statements, International Journal of NursingTerminologies and Classifications; 1995, 6, 29-36.[5] Dochterman, J., Bulechek, G.M.(Eds.) Nursing interventions Classification NIC, St. Louis, Mosby;2004.[6] Dutch Institute for Healthcare Improvement, CBO. Herziening Consensus VerpleegkundigeVerslaglegging, CBO, Utrecht, 1999, 5-13[7] Ehrenberg, A., Ehnfors, M., Thorell-Ekstrand, I. Nursing documentation in patient records:experience of the use of the VIPS model. Journal of Advanced Nursing, 1996, 24, 853-867.[8] Florin, J. F., Ehrenberg, A., Ehnfors, M. Quality of Nursing Diagnoses: Evaluation of anEducational Intervention, International Journal of Nursing Terminologies and Classifications, 2005,16 (2), 33-34.W. Paans et al. / Development of a Measurement Instrument for Nursing Documentation 299[9]  Goossen, T.F., Epping, P. J.M.M., Dassen, Th. Criteria for Nursing Information Systems as aComponent of the Electronic Patient Record: An International Delphi Study. Computers in Nursing,1997, 15, (6): 307-315.[10] Gordon, M. Nursing diagnoses process and application: McGraw Publishers, New York; 1994.[11]  Gordon, M. Capturing Patient Problems: Nursing Diagnosis and Functional Health Patterns, in:Naming Nursing ed. Clark, (Ed. Huber, J.H.), Bern; 2003 pp. 87-94,[12] Gordon, M. Implementing nursing diagnoses, interventions and outcomes – Functional healthpatterns: assessment and nursing diagnosis, in ACENDIO 2005, (Ed. Huber, J.H.), Bern; 2005, pp.58-59.[13]  Heartfield, M. Nursing documentation and nursing practice: a discourse analysis Journal ofAdvanced Nursing; 1996, 24, (1), 98-103.[14]  Lunney, M. Critical Thinking and Nursing Diagnoses, Case Studies and Analyses, North AmericanNursing Diagnosis Association; 2001.[15]  Lunney, M. Critical Thinking and Accuracy of Nurses’ Diagnoses, International Journal of NursingTerminologies and Classifications; 2003, 14 (3), 96-107.[16]  Lunney, M. The critical need for accuracy of diagnosing human responses to achieve patient safetyand quality-based services, in: ACENDIO 2007; Oud Consultancy (Ed.), Amsterdam. 2007 pp. 238-239.[17]  Martin, A., Hinds, C., Felix, M. Documentation practices of nurses in long-term care, Journal ofClinical Nursing; 1999, 8; (4):345-52.[18]  Müller-Staub, M., Lavin, M. A., Needham, I., Achterberg, van Th. Nursing diagnoses, interventionsand outcomes – application and impact on nursing practice: systematic review, Journal of AdvancedNursing; 2006, 56 (5), 514-531.[19]  Müller-Staub, M. Evaluation of the implementation of nursing diagnostics, A study on the use ofnursing diagnoses, interventions and outcomes in nursing documentation; 2007 Elsevier / BlackwellPublishing, Print: Wageningen.[20]  Nilsson, B., Willman, A. Evaluation of Nursing Documentation, A Comparative Study Using theInstruments NoGA and Cat-ch-Ing After an Educational Intervention, Scandinavian Journal ofCaring Science; 2000, 14, 199-206.[21]  North American Nursing Diagnosis Association International (NANDA-I) VerpleegkundigeDiagnoses, Definities en Classificaties 2003/2004, Bohn Stafleu, Van Loghum, Houten; 2004.[22] Ozsoy, S. A., Ardahan, M. Research on knowledge sources used in nursing practices, NurseEducation Today; 2007, 27 (5).[23]  Sidani, S., Braden, C. J. Evaluating Nursing Interventions, A Theory-Driven Approach, SagePublications, London; 1998.[24]  Wilkinson, J. M. Nursing Process and Critical Thinking, fourth edition, Pearson, New Jersey; 2007.[25]  Ziegler, S. M. Nursing diagnosis - the state of the art as reflected in graduate students' work. In M.J. Kim, G. K. McFarlane & A.   M. McLane (Eds.) Classification of nursing diagnoses: Proceedingsof the fifth conference. St Louis: C. V. Mosby Company; 1984.Email address for correspondence: w.paans@pl.hanze.nlW. Paans et al. / Development of a Measurement Instrument for Nursing Documentation300

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Development of a measurement instrument for nursing documentation in the patient record...

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