Nursing Documentation Research Articles

Sedation in palliative care - step by step

Sedation in palliative care, also called "palliative sedation", is an important treatment option for patients who experience unbearable suffering from treatment-refractory symptoms at the end of life. The aim is to reduce this suffering as far as possible by reduction of the patient's consciousness. Good communication between all people involved is crucial for these clinically and ethically challenging situations. This article presents definitions of key terms and of different types of sedation. It then describes the process of sedation step by step: 0. Pre-emptive discussion of the option of sedation (in the context of advance care planning); 1. indication and decision making; 2. information and informed consent; 3. documentation when starting sedation; 4. start of sedation; 5. monitoring and adaption of sedation; 6. medical and nursing care and documentation during sedation; 7. care and processes after the death of the patient (if applicable).

Patient participation in electronic nursing documentation: an interview study among community nurses

BackgroundPatient participation in nursing documentation has several benefits like including patients’ personal wishes in tailor-made care plans and facilitating shared decision-making. However, the rise of electronic health records may not automatically lead to greater patient participation in nursing documentation. This study aims to gain insight into community nurses’ experiences regarding patient participation in electronic nursing documentation, and to explore the challenges nurses face and the strategies they use for dealing with challenges regarding patient participation in electronic nursing documentation.MethodsA qualitative descriptive design was used, based on the principles of reflexive thematic analysis. Nineteen community nurses working in home care and using electronic health records were recruited using purposive sampling. Interviews guided by an interview guide were conducted face-to-face or by phone in 2019. The interviews were inductively analysed in an iterative process of data collection–data analysis–more data collection until data saturation was achieved. The steps of thematic analysis were followed, namely familiarization with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and reporting.ResultsCommunity nurses believed patient participation in nursing documentation has to be tailored to each patient. Actual participation depended on the phase of the nursing process that was being documented and was facilitated by patients’ trust in the accuracy of the documentation. Nurses came across challenges in three domains: those related to electronic health records (i.e. technical problems), to work (e.g. time pressure) and to the patients (e.g. the medical condition). Because of these challenges, nurses frequently did the documentation outside the patient’s home. Nurses still tried to achieve patient participation by verbally discussing patients’ views on the nursing care provided and then documenting those views at a later moment.ConclusionsAlthough community nurses consider patient participation in electronic nursing documentation important, they perceive various challenges relating to electronic health records, work and the patients to realize patient participation. In dealing with these challenges, nurses often fall back on verbal communication about the documentation. These insights can help nurses and policy makers improve electronic health records and develop efficient strategies for improving patient participation in electronic nursing documentation.

Palliative Integration Into Ambulatory Oncology: An Advance Care Planning Quality Improvement Project

Advance care planning (ACP) is essential to ensuring that patient-centered end-of-life goals are respected if a health crisis occurs. Advanced practitioner barriers to ACP include insufficient time and limited confidence in discussions. The purpose of this quality improvement project was to increase advanced cancer patients’ electronic health record (EHR) documented surrogate decision maker and ACP documentation by 25% over 8 weeks. A secondary aim was to decrease patients’ decisional conflict scores (DCS) related to life-sustaining treatment preferences after a clinical nurse specialist (CNS)-led ACP session. Using the define, measure, analyze, improve, and control (DMAIC) process of quality improvement methodology, an interprofessional team led by a palliative CNS fostered practice change by (a) incorporating a patient self-administered Supportive Care and Communication Questionnaire (SCCQ) to standardize the ACP assessment, (b) creating an EHR nursing and provider documentation template, (c) offering advanced cancer patients a palliative CNS consultation for ACP review and advance directive completion, and (d) evaluating patients’ DCS through the four-item SURE tool. Of 126 participants provided with the SCCQ, 90 completed the document, resulting in a 71% return rate. Among the completed SCCQs, 37% (n = 33) requested a CNS consultation, with 76% (n = 25) returning for the ACP session. The CNS intervention yielded an average reduction of 1.4 points in SURE tool findings, a statistically significant decrease determined by a paired sample t-test. The project’s interprofessional collaboration promoted a system-wide standardized ACP process throughout ambulatory, acute, and post-hospital settings.

Validation of nursing documentation regarding in-hospital falls: a cohort study

BackgroundIn-hospital fall incidents are common and sensitive to nursing care. It is therefore important to have easy access to valid patient data to evaluate and follow-up nursing care. The aim of the study was to validate the nursing documentation, using a specific term in the registered nurses´ (RNs´) discharge note, regarding inpatient falls according to the outcome of a digitalized data extraction tool and the discharge note itself.MethodsAt a teaching hospital, 31,571 episodes of care were eligible for inclusion in this retrospective cohort study. A stratified sampling including five groups was used, two with random sampling and three with total sampling. In total, 1232 episodes of care were reviewed in the electronic patient record using a study-specific protocol. Descriptive statistics were used.ResultsIn total, 590 episodes of care in the study cohort included 714 falls. When adjusted for the stratified sampling the cumulative incidence for the study population was 1.9%.The positive predictive value in total for the data extraction tool regarding the presence of any fall, in comparison with the record review, was 87.4%. Discrepancies found were, for example, that the RNs, at discharge, stated that the patient had fallen but no documented evidence of that could be detected during admission. It could also be the opposite, that the RNs correctly had documented that no fall had occurred, but the data extraction tool made an incorrect selection. When the latter had been withdrawn, the positive predictive value was 91.5%.Information about minor injuries due to the fall was less accurate. In the group where RNs had stated that the patient had fallen without injury, minor injuries had actually occurred in 28.3% of the episodes of care.ConclusionsThe use of a specific term regarding fall in the RNs´ discharge note seems to be a valid and reliable data measurement and can be used continuously to evaluate and follow-up nursing care.

A systematic review of the implementation of electronic nursing documentation toward patient safety

We find out the implementation of electronic nursing documentation toward patient safety. A systematic review of 15 articles were using PRISMA from five online database: Science Direct, ProQuest, Scopus, Wiley Online, and Emerald Insight. The keywords used are "nursing documentation," "electronic health record," and "patient safety). The implementation of EHR has an effect on patient safety i.e. improving identify patients correctly, improve effective communication, improve the safety of high-alert medications, ensuring the correct location of surgery, and reducing the risk of infection. In addition, it also reduces the risk of patient injury due to falls by helping with falling risk screening process. Optimizing the implementation of electronic nursing documentation affects the quality of nursing documentation and patient safety. The result of this study may impact nursing managers while improving integrated EHR with nursing documentation.

Pain Management Education Initiative: Creating S.T.A.R.S. (Specialized Treatment Approach Requires a Skill-set)

Effective pain management is a key component of patient care on a surgical unit. It was identified that there was an opportunity to improve nurse adherence and compliance with clinical practice guidelines and best practice in pain management. A pain education program was created by a pain certified nurse and nurse educator. Outcomes showed a positive trend in nurse confidence, knowledge, documentation compliance, and nurse-driven non-pharmacological interventions; pain HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores improved. The EBP (evidence-based practice) process was implemented to identify best pain management practices for clinical nurses. Problem identification, literature search, critical appraisal and synthesis of relevant sources were completed. A gap analysis was conducted using an online survey to assess nurses' knowledge and confidence with pain management assessments, opioid administration, and non-pharmacological interventions. Based on learning needs identified, an educational program was designed and implemented. Post implementation, audits were completed monthly to trace nurses' knowledge, confidence, documentation, and use of non-pharmacological interventions, and HCAHPS scores. Post implementation improvement consecutively for three months showed the nurse-driven non-pharmacological interventions (9% to 55%), pain assessments (33% to 52%), and use of pain management in nursing care plans (45% to 52%). HCAHPS scores (“staff discussion regarding pain”) improved from 70.5 to 72.1%, 95 to 96 percentiles. Enhanced nurses' pain management education showed marked improvement in pain management strategies and patient outcomes. This EBP initiative opened the door for a future role of a Pain Management Nurse Scholar facility wide resource to maintain outcomes and relevant ongoing education initiatives in pain management.

574 A Nurse Educational Program to Promote Spiritual Care Delivery: Development and Pilot Testing

Abstract Introduction Spiritual Care (SC) is crucial for the holistic care of patients. Findings from a needs assessment conducted on an 8-bed burn Intensive Care Unit (ICU) (n=34, 88% response rate) revealed 90.3% of nurses believed SC was important for the overall care of their patient, but only 13% felt confident to provide the religious care. Of the respondents, 77% had come across a time when they were unable to obtain SC for their patients. The survey revealed 39% were interested in obtaining education to enhance their provision of holistic care. Based on this data, we developed and pilot tested an innovative SC educational course to examine feasibility, learning, and preliminary outcomes. Methods The IRB-approved study involved a two-hour evidence-informed class developed by a burn nurse and chaplain. The course was offered on a voluntary basis for all nurses in the critical care division (5 units overall). The class consisted of PowerPoint presentation, case studies and practice utilizing spiritual care assessment tools. Data was collected before and after the class at one- and two-months post class completion. Results Participants (n=12) were mostly female (82%), Bachelors prepared (82%), affiliated as Christian (73%) and had not had spiritual education in the past (73%). Nurses also agreed the spiritual assessment tools were useful and they were confident using them. Mean total score for Nurses’ Spiritual Care Practice increased 14% over time. Practices with the largest increases included reading/offering spiritual writings to patients (67/57%) and documentation of meeting spiritual needs (40%). The Spiritual Care Perspective scale increased 7% overall with changes in the beliefs of SC being a significant part of Advanced Nursing Practice (ANP) (10% increase), the domain of APN includes SC (15% increase) and nurses should assist a patient in using his/her spiritual resources to cope with illness (9% increase). At 2-months post training, participants felt comfortable (4.25/5.0 and confident (4.0/5.0) providing SC. Conclusions SC is an essential element of holistic nursing practice that has become even more relevant in this pandemic year. Our 2-hour educational class was considered well organized, provided relevant education and tools for use, and increased nurses confidence, comfort, and documentation of providing SC to their patients.

Equitable academic preparation: A structured onboarding program for incoming graduate nursing students

Background and objective: Nurses who return to school to obtain higher education come with varying levels of professional, educational and technological competencies. Some are new graduates, others have not been in school for a decade, and several find educational technology difficult to navigate. Returning to school can be challenging because graduate programs require complex skills in order for students to succeed. Onboarding, the process of organizational socialization, also known as the orientation process, is a relevant element in the retention and progression of students in graduate education. Onboarding differs from school to school, ranging from half a day to a weeklong on-campus orientation. This research is about a structured onboarding program built into a graduate nursing course and specifically addresses the needs of students in order to succeed in their studies. This research presents insights into the Graduate Student Onboarding – Professional Development Program (GSO-PDP), a structured onboarding designed to assist graduate nursing students with their adjustment back to school, enhance their learning, and achieve their graduate degree successfully. It is built into the Nursing Informatics class and is a month-long process. The research offers some understanding of the usefulness of the GSO-PDP to incoming graduate nursing students.Methods: The study uses the qualitative paradigm, in particular, a case study design. This is an examination of the four modules of the GSO-PDP: Elements of Research, Scholarly Writing and Nursing Documentation, Academic Support Services, and Student Life. Student volunteers participated in focus group interviews to evaluate the program. Results: The following were recurring themes identified from focus group interviews: “APA Refresher Overload,” “Bridging the Gap,” “Relearning English Grammar,” “Navigating the Learning and University Maze,” and “Not Really Computer Savvy.” It is evident that most of the elements of the GSO-PDP are beneficial to students in enhancing their adjustment and return to school for further education. The onboarding program also facilitates and enhances student learning. Focus group participants offered some helpful recommendations to improve the program.Conclusions & Implications: This is an innovative and structured onboarding approach to help students with diverse backgrounds to succeed in the Master’s program. Participants generally described the program favorably, but did make suggestions for improvement.

Documented diabetes care among older people receiving home care services: a cross\u2010sectional study

BackgroundHome care services plays an important role in diabetes management, and to enable older adults remain home-dwellers. Adequate follow-up and systematic nursing documentation are necessary elements in high quality diabetes care. Therefore, the purpose of this study was to examine the diabetes treatment and management for older persons with diabetes receiving home care services.MethodsA cross-sectional study was used to assess the diabetes treatment and management in a Norwegian municipality. Demographic (age, sex, living situation) and clinical data (diabetes diagnose, type of glucose lowering treatment, diabetes-related comorbidities, functional status) were collected from electronic home care records. Also, information on diabetes management; i.e. follow-up routines on glycated haemoglobin (HbA1c), self-monitoring of blood glucose, insulin administration and risk factors (blood pressure, body mass index and nutritional status) were registered. HbA1c was measured upon inclusion. Descriptive and inferential statistics were applied in the data analysis.ResultsA total of 92 home care records from older home-dwelling persons with diabetes, aged 66–99 years were assessed. Only 52 (57 %) of the individuals had the diabetes diagnosis documented in the home care record. A routine for self-monitoring of blood glucose was documented for 27 (29 %) of the individuals. Only 2 (2 %) had individual target for HbA1c documented and only 3 (3 %) had a documented routine for measuring HbA1c as recommended in international guidelines. Among 30 insulin treated older individuals, a description of the insulin regimen lacked in 4 (13 %) of the home care records. Also, documentation on who performed self-monitoring of blood glucose was unclear or lacking for 5 (17 %) individuals.ConclusionsThe study demonstrates lack of documentation in home care records with respect to diagnosis, treatment goals and routines for monitoring of blood glucose, as well as insufficient documentation on responsibilities of diabetes management among older home-dwelling adults living with diabetes. This indicates that home care services may be suboptimal and a potential threat to patient safety.

Is nursing and midwifery clinical documentation a burden? An empirical study of perception versus reality.

To measure time spent on clinical documentation and nurses and midwives' perceptions of this aspect of their role. Nurses and midwives rely on accurate documentation when planning care. However, documenting and communicating care can be onerous, time-consuming and at times duplicated or redundant. While documentation provides a record and means of communicating care, it should not detract from the delivery of care. An observational time and motion study and survey design reported using the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. The study was conducted with Western Australian nurses and midwives working in a private not-for-profit hospital from July-October 2019. An observational study was undertaken to measure the practice of documentation on each shift. Participants' perceptions of clinical documentation were measured using a self-report survey. A total of 120hr of observation were undertaken. Total observed time spent on documentation was 28.1% on morning shifts, 22.7% on afternoon shifts and 20.9% on night duty. The mean self-reported time for clinical documentation was 50.4% on morning shifts, 40.7% on afternoon shifts and 37.9% on night duty. Issues with duplication and unnecessary paperwork were identified. Although participants tended to overestimate time spent on documentation, it still consumed a significant proportion of time. Frustrations with paperwork may amplify nurses' negative perceptions of documentation. Clinical documentation needs to be reviewed, revised and reduced to release time back to direct patient care and reduce clinician dissatisfaction. Clinical documentation is required in all areas of clinical practice and forms an important legal record. Understanding the demands of clinical documentation can assist in reviewing and improving documentation to release time back to direct patient care.

Abstract P854: Lean A3 Project in a Primary Stroke Center Results in Improved Dysphagia Screening Compliance for Stroke

Introduction: Dysphagia is a common comorbidity after stroke linked to increased morbidity and mortality. Evidence-based guidelines recommend a bedside dysphagia screen before oral intake to reduce the risk of aspiration pneumonia in stroke patients. Prior studies have reviewed barriers to dysphagia screens being completed or documented timely on stroke patients before giving oral intake. Through Lean A3 process, we aimed to improve overall nursing documentation, including dysphagia screen, for stroke patients in the Emergency Department (ED) at an established Primary Stroke Center. Methods: The ED Charge Nurses and the Stroke Coordinator began an A3 project in May 2019 which focused on ED nurse documentation for stroke patients. Data included was 7 months prior to A3 implementation and 8 months post-implementation using Get With The Guidelines quality “Dysphagia Screen” measure. Lean A3 process involved changes to the computer system and re-education of nursing staff in July 2019 by the charge nurses and Stroke Coordinator. The post-A3 measurement period was between August 2019 and March 2020. Chi square tests were used to assess proportion differences in completed dysphagia screen and proportion of meeting or exceeding goal before and after the A3. Results: Overall compliance of patients screened for dysphagia was 87.3% (n = 379/434). After the A3 project, compliance for dysphagia screening was significantly higher than prior to the A3 implementation ((91.9% (n = 228/248) vs. 81.2% (n = 151/186), OR = 2.64 [95%CI 1.47-4.75], p < 0.001). In addition, the 90% goal for dysphagia screen compliance was achieved only 1 month of 7 (14.3%) prior to A3, but was achieved in 6 months of 8 post-A3 (75%), p = 0.04. Conclusion: In conclusion, we found that dysphagia screening documentation by ED nurses improved due to the Lean A3 process improvement project conducted in the ED.

Abstract P824: Ready, Set, Go! Covid-19 Pandemic Drives Creation of Fast Track Alteplase Protocol

Background: In response to the pandemic, our facility recognized the need to safely decompress ICUs to create space for critically ill COVID-19 patients. Stroke leadership identified select recipients of Alteplase to have care safely de-escalated from ICU to stepdown status earlier than the traditional protocol allowed. Per previous protocol, all stroke patients recovered in ICU for 24 hours post-Alteplase with 36 neurological and vital sign assessments completed. Acting upon the need to ensure patient safety and create inpatient ICU bed availability, the multidisciplinary stroke leadership team created the Fast Track Alteplase Protocol. Goals: Project goals included decreasing ICU utilization and minimizing nursing encounters at the patient bedside to decrease potential COVID-19 exposures. Methods: Protocol qualifications include both pre-Alteplase NIH Stroke Scale scores less than 10 and no large vessel occlusions or flow limiting stenosis present on imaging. Once in the protocol, to qualify for transfer out of ICU, an NIH Stroke Scale score less than 10 throughout ICU stay, non-contrast head CT or MRI to evaluate infarct burden, not require continuous anti-hypertensive medications to maintain systolic blood pressure cap, and not demonstrate hemodynamic or respiratory concerns must be achieved and completed. We developed education for nurses and physicians in ED, ICU, and stepdown patient care areas and tip sheets to guide nursing care and documentation associated with the new protocol. Electronic orders were quickly developed and integrated as a new subphase specific to the Fast Track Alteplase Protocol within an existing stroke order set. Results: The protocol decreased the number of encounters between nursing and patients from 36 to 12 interactions (66.7%) and planned time in the ICU from 24 to 12 hours (50%). The median time comparison of ICU length of stay for Fast Track vs. traditional protocol was 12 hours and 26 min vs 35 hours and 15 minutes respectively. Conclusion: The protocol achieved both goals of decreasing the amount of time stroke patients are in the ICU and number of nursing encounters reducing the possibility of patient and staff exposure to COVID-19.

Organizational learning in hospitals: Evaluation of the implementation of IT-supported nursing documentation

BackgroundThe present paper explores the introduction of computer-based nursing documentation in a hospital as an example of organizational learning viewed through the lens of organizational education. It provides insights into existing routines and patterns of nursing practice within the organization and seeks, in understanding them, to support organizational learning in hospital settings. The focus of this article is on the analysis of patterns of practice specific to the organization in order to derive the specific need for support of organizational learning for the hospital as an organization. MethodsA mixed-methods approach was used to record data, combining qualitative and quantitative techniques. Its theoretical focus draws on organizational education in examining organizational learning – a context in which the use of mixed-methods approaches, triangulation and multiperspectivity appeared to be best suited for the task. ResultsThe results demonstrate that the practical implementation of computer-based nursing documentation calls, alongside technical adaptations, for the consideration of organizational learning, defined as learning undertaken by a social unit comprising a range of groups with distinct interests. The key challenge to organizational learning consists in disrupting long established routines and standardizing new patterns of practice. Success in this endeavor requires time and space for employees’ dialog-based, cooperative exploration of the patterns previously in place. Conclusion/OriginalityThe literature on organizational learning provides numerous examples of members of organizations rupturing previous patterns and routines, yet few examples aimed at creating an understanding of existing practices, particularly in relation to hospital settings. This paper fills this lacuna by describing extant practices in such a setting and seeks to support organizational learning processes in this context.

Nurse Documentation of Child Weight-Related Health Promotion at Age Four in Sweden.

(1) Background: Overweight and obesity in children have increased worldwide and tend to persist into adolescence and adulthood. The Child Health Service (CHS) has an important role in providing health-promotive interventions, and such interventions are required to be documented in a child’s health record. The aim of the study was to investigate Child Health Care (CHC) nurses’ documentation of weight-related, health-promotive interventions in the Child Health Care Record (CHCR) regarding lifestyle habits in connection to the four-year visit. (2) Methods: A record review of 485 CHCRs using a review template was accomplished. Of the included CHS units, four used electronic records and two used paper records. Chi-square tests and Spearman’s rank-order correlations were used to analyse data. (3) Results: The results showed that CHC nurses document interventions regarding lifestyle habits to a low extent, although children with overweight/obesity seemed to undergo more interventions. There was also a difference between electronic and paper records. (4) Conclusions: The consequences of not documenting the interventions in the CHCR make it difficult to follow up and demonstrate the quality of the CHC nurse’s work. There is a need for more research to gain a deeper understanding of the reasons that the work of CHC nurses is not visible in children’s health records.

Improving nursing documentation for surgical patients in a referral hospital in Freetown, Sierra Leone: protocol for assessing feasibility of a pilot multifaceted quality improvement hybrid type project

BackgroundThere is an urgent need to improve quality of care to reduce avoidable mortality and morbidity from surgical diseases in low- and middle-income countries. Currently, there is a lack of knowledge about how evidence-based health system strengthening interventions can be implemented effectively to improve quality of care in these settings. To address this gap, we have developed a multifaceted quality improvement intervention to improve nursing documentation in a low-income country hospital setting. The aim of this pilot project is to test the intervention within the surgical department of a national referral hospital in Freetown, Sierra Leone.MethodsThis project was co-developed and co-designed by in-country stakeholders and UK-based researchers, after a multiple-methodology assessment of needs (qualitative, quantitative), guided by a participatory ‘Theory of Change’ process. It has a mixed-method, quasi-experimental evaluation design underpinned by implementation and improvement science theoretical approaches. It consists of three distinct phases—(1) pre-implementation(project set up and review of hospital relevant policies and forms), (2) intervention implementation (awareness drive, training package, audit and feedback), and (3) evaluation of (a) the feasibility of delivering the intervention and capturing implementation and process outcomes, (b) the impact of implementation strategies on the adoption, integration, and uptake of the intervention using implementation outcomes, (c) the intervention’s effectiveness For improving nursing in this pilot setting.DiscussionWe seek to test whether it is possible to deliver and assess a set of theory-driven interventions to improve the quality of nursing documentation using quality improvement and implementation science methods and frameworks in a single facility in Sierra Leone. The results of this study will inform the design of a large-scale effectiveness-implementation study for improving nursing documentation practices for patients throughout hospitals in Sierra Leone.Trial registrationProtocol version number 6, date: 24.12.2020, recruitment is planned to begin: January 2021, recruitment will be completed: December 2021.

Implementation of Effective Nurse Communication in Hospital Through Electronic Nursing Documentation (END)

Introduction: The low quality of documented information becomes the main cause of failure in conductingeffective communication. The implementation of electronic nursing documentation improves the quality ofinformation so that it facilitates the implementation of effective communication. Objective: To identify theimplementation of effective communication of nurses in hospitals through electronic nursing documentation.Method: A cross sectional design with 243 nurses as total sample. The effective communication instrumentconsists of 52 statements. The validity test result is in the range of 0.396-0.946 and the reliability testresult is Cronbach’s alpha 0.965. The data are collected online using Google form application. Results:Implementation of effective communication of nurses was 80.18% of the maximum value. The highesteffective communication occurred on patient discharge while the lowest conducted in receiving messages byphone. The implementation of effective communication during the nursing process is 78.70%. Conclusion:The implementation of electronic nursing documentation could facilitate the implementation of effectivecommunication for nurses in hospitals. However, effective communication during the nursing process ispotentially requiring more improvement. The recommendation is that the nursing manager should encouragethe implementation of effective communication through the utilization of electronic nursing documentation.

EFFECTIVENESS OF COMPUTER-BASED NURSING DOCUMENTATION IN NURSING CARE IN HOSPITAL – A LITERATURE REVIEW

Background: Nurse population in hospitals has a greater proportion than other health workers. Nearly 60-70% of the total human resources available, occupied by nurses. In fact, 90% of the health services provided are a form of nursing service. Therefore, nursing service is a form of professional service that is the biggest indicator in realizing the quality of hospital services. One of the duties of nurses in providing nursing services in accordance with standards is to document all nursing care provided. Objective: To review journals about documenting computer-based nursing care in hospitals for the effectiveness of the preparation of nursing care. Methods: Quantitative, mixed-methods, and qualitative reviews that aim to evaluate the influence of computerized nursing documentation (eg, management, computerized decision support systems and information systems) on nursing care were included. We used the nursing care performance framework as an extraction grid and analytical tool. This model illustrates how the interplay between nursing resources and nursing services can produce changes in patient conditions. The primary outcomes included nurses' practice environment, nursing processes, professional satisfaction, and nursing-sensitive outcomes. The secondary outcomes included satisfaction or dissatisfaction with computerized nursing documentation according to nurses 'and patients' perspectives. Reviews published in English, French, or Spanish from January 1, 2000 to December 15, 2019, were considered.
 Results: A total of 5515 titles or abstracts were assessed for eligibility and full-text papers of 72 articles were retrieved for detailed evaluation. It was found that 22 reviews published between 2002 and 2015 met the eligibility criteria. Many nursing care themes (ie, indicators) were influenced by the use of computerized nursing documentation, including time management; time spent on patient care; documentation time; information quality and access; quality of documentation; knowledge updating and utilization; nurse autonomy; intra and interprofessional collaboration; nurses' competencies and skills; nurse-patient relationship; assessment, care planning, and evaluation; teaching of patients and families; communication and care coordination; perspectives of the quality of care provided; nurses and patients satisfaction or dissatisfaction with computerized nursing documentation; patient comfort and quality of life related to care; empowerment; and functional status.

The effect of early adoption of an academic electronic health record system in nursing education: A pilot outcome study

Objective: This study aimed to explore the faculty’s and students’ perceptions of an academic electronic health record system (AEHRs) for teaching/learning electronic nursing documentation and to assess the outcomes of the AEHRs on nursing students’ competency with electronic nursing documentation.Methods: With a mixed-method pilot study, a convenience sample of 41 undergraduate nursing students and a purposive sample of 7 faculty and 9 students were used. Two groups of student participants for the quantitative data were compared for their competency with electronic nursing documentation. For the qualitative data, an in-depth, exploratory approach to data collection was taken for the nursing faculty and the intervention group.Results: For the quantitative findings, the early adoption of an AEHRs could help students to collect a patients’ health information through the system even though it may not impact their critical thinking on a patient’s care. For the qualitative findings, three key themes were shared by the faculty and students: (1) benefits and challenges, (2) impact of the AEHRs, and (3) recommendations for future adoption.Conclusions: This study revealed that the successful adoption of an AEHRs includes many steps that can be used to create positive improvements. These findings were beneficial to prepare students and nursing educators for the future of health information technology. Meaningful adoption of an AEHRs will help in building the competence of undergraduate nursing students in electronic nursing documentation and improve patient care.

Factors associated with aggressive behaviour in persons with cognitive impairments using home care services: A retrospective cross-sectional study.

AimThis study aimed to investigate the frequency of documented aggression, on the part of cognitively impaired individuals, against health professionals in home care services and to highlight related factors.DesignA retrospective cross‐sectional study was conducted using data obtained from the nursing documentation of six home care service organizations in Switzerland.MethodsWe analysed the nursing documentation of 1,186 clients in six home care services, between July 2019–September 2019, using the Cohen‐Mansfield Agitation Inventory. We conducted a factor analysis as well as a descriptive data analysis and logistic regression using IBM SPSS Statistics.ResultsA factor analysis revealed in five factors, of which three represented aggressive behaviour in the sample. These factors were physically aggressive behaviour, verbally aggressive behaviour and importunate behaviour. Aggressive incidents, documented in the nursing records of 14.7% of clients in our sample, tended to be associated with cognitive, communication and mobility difficulties.Impact statement This retrospective cross‐sectional survey gives an overview of the frequency and forms of documented aggressive behaviour on the part of persons with cognitive impairments towards health professionals in home care services.One of the motivating factors for this study was the awareness that aggressive behaviour on the part of clients may stress health professionals in various ways which in turn may have an impact on the quality of care provided.The study revealed that healthcare specialists, rather than more qualified general or psychiatric nurses, were routinely assigned to assisting such clients and therefore specific educational and training interventions for these specific group of staff are indicated.

Screening and detection of delirium in an adult critical care setting: a best practice implementation project.

To assess compliance with evidence-based practice regarding screening and detection of delirium in adult patients at the ICU from a university hospital. The compliance rates were evaluated using the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice audit and feedback tool. This strategy was designed in three phases: (1) establishing a team and conducting a baseline audit based on criteria informed by the evidence; (2) reflecting on the results of the baseline audit and designing and implementing strategies to address noncompliance found in the baseline audit informed by the JBI Getting Research into Practice framework; and (3) conducting a follow-up audit to assess the outcomes of the interventions implemented to improve practice and identify future practice issues to be addressed in subsequent audits. The implementation protocol was designed based on the primary barriers and facilitators identified in the baseline audit, allied to a training program and electronic medical records changes. Nursing documentation available in medical records from patients admitted in the ICU was used to assess the baseline and follow-up audit compliance rates. None of the medical records evaluated before the implementation protocol showed compliance with the following audit criteria: a valid and reliable instrument is accessible in the ward environment (0%), the nursing care documentation supports that the Confusion Assessment Method for the Intensive Care Unit instrument is being used (0%) and population assessed for delirium includes all adults over the age of 65, cognitive impairment, dementia, or both, current hip fracture and severe illness (0%). After the evidence-based practice implementation, the follow-up audit revealed up to 100% compliance rates with those criteria, showing that all patients under risk were screened and assessed for delirium. The only exception was the Confusion Assessment Method for the Intensive Care Unit use, whose compliance was observed in 80.95% of the medical records. These findings support that baseline and follow-up audits allied to a delirium training program, and changes in the electronic nursing records increase the compliance rates related to the evidence-based practice for screening patients under risk and assessing delirium.