Background: Nurses with good decision-making competencies state more relevant and accurate nursing diagnoses, perform more effective nursing interventions, and achieve better nursing-sensitive patient outcomes. It was reported that the content of nursing records sometimes doesn't match with statements of patients and nurses. Research question: In what extent do the recorded nursing diagnoses, interventions, and outcomes match with observed care situations and patients' statements? Methods: A multiple case study with structured observations, guided interviews, and document analyses was performed. The congruence of nursing diagnoses, interventions, and outcomes between the three data sources was investigated by within- and cross-case-analysis in a sample of 24 patients. Results: In total, 114 nursing diagnoses were identified of which 66 were recorded, 37 were found by observations, and 11 by patient interviews. A high congruence between the three perspectives was determined in 59 % of the recorded nursing diagnoses, in 41 % of nursing interventions, and in 33 % of nursing-sensitive patient outcomes. Almost all documented nursing diagnoses (89 %) were supported by most codes from all three sources. Conclusions: To increase the congruence of the three perspectives, nurses' clinical decision-making competencies should be fostered, so that nurses choose more effective nursing interventions that lead to better nursing-sensitive patient outcomes. Patient participation should be fostered.
|Translated title of the contribution||The congruence of nursing diagnoses, interventions, and outcomes between care observations, patient perceptions, and nursing records: A qualitative multiple case study|
|Number of pages||10|
|Publication status||Published - Feb 2020|
ASJC Scopus subject areas
- Nursing (all)