Abstract
BackgroundAn Austrian Nursing Minimum Data Set (NMDS-AT) has been developed to describe the diversity of patient populations and variability of nursing care based on nursing diagnoses, nursing interventions, and nursing outcomes. The aim of this study is to test the feasibility of using this NMDS-AT by assessing the availability of data needed for the NMDS-AT in routine nursing documentation, and to assess its reliability and usefulness.MethodsData were collected in a general hospital from patient records of 20 patients representing 457 patient days. Availability of needed data was assessed by two raters in a chart review based on an NMDS-AT form. The interrater reliability (n = 20) and intrarater reliability (n = 5) was assessed using Cohen’s kappa coefficient and intraclass correlation coefficient (ICC). Usefulness was assessed by verifying whether typical analysis questions can be answered by the documented NMDS-AT data.ResultsIn the 20 patient records, thirteen nursing diagnoses, 50 nursing interventions, and five nursing outcomes occurred, representing 68 (58.6 %) of the overall 116 data elements of the NMDS-AT. The data were found at different data sources (e.g., electronic nursing record or paper-based fever chart) and in various forms (e.g., standardized or free text).The interrater reliability of the thirteen nursing diagnoses showed kappa values (percentage of agreement) ranging from 0.35 (85 %) to 1.00 (100 %). The 50 nursing interventions showed ICCs ranging from 0.03 to 1.00. All nursing outcomes showed an ICC of 1.00. The intrarater reliability showed 100 % agreement. Performing typical analysis questions showed that the extracted NMDS-AT data are able to answer questions of clinical management, of policy makers, and of nursing science.ConclusionsThe NMDS-AT was found to be feasible: needed data was available in the analysed patient records, data extraction showed good reliability, and typical analysis could be performed and showed interesting results. Before the NMDS-AT can be introduced in healthcare institutions, the following challenges need to be addressed: 1. improve the quality of nursing documentation; 2. reduce fragmentation of documentation; 3. use a standardized nursing classification system; and 4. establish mappings between nursing classification systems and the NMDS-AT.
Highlights
An Austrian Nursing Minimum Data Set (NMDS-AT) has been developed to describe the diversity of patient populations and variability of nursing care based on nursing diagnoses, nursing interventions, and nursing outcomes
Design A chart review of 20 patients of an Austrian hospital was conducted, and data on patient problems, nursing interventions, and nursing outcomes were extracted from routine nursing documentation into the Nursing Minimum Data Sets (NMDS)-AT by two raters
We found that the data needed for the NMDS-AT were partly documented in standardized form and partly as free text
Summary
An Austrian Nursing Minimum Data Set (NMDS-AT) has been developed to describe the diversity of patient populations and variability of nursing care based on nursing diagnoses, nursing interventions, and nursing outcomes. Nursing Minimum Data Sets have been defined as ‘a systematic registration of the smallest possible number of unequivocally coded data, with respect to or for the purpose of nursing practice, making information available to the largest possible group of users according to a broad range of information requirement’ [3]. An NMDS may provide the following benefits: access to comparable nursing care data on a local, regional, national, and international level [4]; description of nursing care in different populations and variety of settings; availability of data for research activities; evaluation of costs and outcomes of nursing care; benchmarking of nursing quality indicators; extrapolation of trends in nursing care; and allocation of resources of hospitals [5, 6]. An NMDS aims at supporting nursing managers, health policy decision makers, public health experts, and nursing researchers [4]
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