Standardized Nursing Diagnoses in a Surgical Hospital Setting: A Retrospective Study Based on Electronic Health Data
Introduction In electronic health records (EHRs), standardized nursing terminologies (SNTs), such as nursing diagnoses (NDs), are needed to demonstrate the impact of nursing care on patient outcomes. Unfortunately, the use of NDs is not common in clinical practice, especially in surgical settings, a...
| Main Authors: | , , , , , |
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| Format: | Article |
| Language: | English |
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SAGE Publishing
2023-02-01
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| Series: | SAGE Open Nursing |
| Online Access: | https://doi.org/10.1177/23779608231158157 |
| _version_ | 1797902734701101056 |
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| author | Manuele Cesare RN, PhD student Fabio D’agostino PhD, RN Massimo Maurici MD Maurizio Zega PhD, RN Valentina Zeffiro PhD, RN Antonello Cocchieri PhD, RN |
| author_facet | Manuele Cesare RN, PhD student Fabio D’agostino PhD, RN Massimo Maurici MD Maurizio Zega PhD, RN Valentina Zeffiro PhD, RN Antonello Cocchieri PhD, RN |
| author_sort | Manuele Cesare RN, PhD student |
| collection | DOAJ |
| description | Introduction In electronic health records (EHRs), standardized nursing terminologies (SNTs), such as nursing diagnoses (NDs), are needed to demonstrate the impact of nursing care on patient outcomes. Unfortunately, the use of NDs is not common in clinical practice, especially in surgical settings, and is rarely included in EHRs. Objective(s) The aim of the study was to describe the prevalence and trend of NDs in a hospital surgical setting by also analyzing the relationship between NDs and hospital outcomes. Methods A retrospective study was conducted. All adult inpatients consecutively admitted to one of the 15 surgical inpatient units of an Italian university hospital across 1 year were included. Data, including the Professional Assessment Instrument and the Hospital Discharge Register, were collected retrospectively from the hospital's EHRs. Results The sample included 5,027 surgical inpatients. There was a mean of 6.3 ± 4.3 NDs per patient. The average distribution of NDs showed a stable trend throughout the year. The most representative NANDA-I ND domain was safety/protection. The total number of NDs on admission was significantly higher for patient whose length of stay was longer. A statistically significant correlation was observed between the number of NDs on admission and the number of intra-hospital patient transfers. Additionally, the mean number of NDs on admission was higher for patients who were later transferred to an intensive care unit compared to those who were not transferred. Conclusion NDs represent the key to understanding the contribution of nurses in the surgical setting. NDs collected upon admission can represent a prognostic factor related to the hospital's key outcomes. |
| first_indexed | 2024-04-10T09:22:23Z |
| format | Article |
| id | doaj.art-b375e51a315a4ff99af176eea4af0ae7 |
| institution | Directory Open Access Journal |
| issn | 2377-9608 |
| language | English |
| last_indexed | 2024-04-10T09:22:23Z |
| publishDate | 2023-02-01 |
| publisher | SAGE Publishing |
| record_format | Article |
| series | SAGE Open Nursing |
| spelling | doaj.art-b375e51a315a4ff99af176eea4af0ae72023-02-20T09:33:45ZengSAGE PublishingSAGE Open Nursing2377-96082023-02-01910.1177/23779608231158157Standardized Nursing Diagnoses in a Surgical Hospital Setting: A Retrospective Study Based on Electronic Health DataManuele Cesare RN, PhD student0Fabio D’agostino PhD, RN1Massimo Maurici MD2Maurizio Zega PhD, RN3Valentina Zeffiro PhD, RN4Antonello Cocchieri PhD, RN5 Department of Biomedicine and Prevention, , Rome, Italy Unicamillus, , Rome, Italy Department of Biomedicine and Prevention, , Rome, Italy , Rome, Italy Department of Biomedicine and Prevention, , Rome, Italy Section of Hygiene, Woman and Child Health and Public Health, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, ItalyIntroduction In electronic health records (EHRs), standardized nursing terminologies (SNTs), such as nursing diagnoses (NDs), are needed to demonstrate the impact of nursing care on patient outcomes. Unfortunately, the use of NDs is not common in clinical practice, especially in surgical settings, and is rarely included in EHRs. Objective(s) The aim of the study was to describe the prevalence and trend of NDs in a hospital surgical setting by also analyzing the relationship between NDs and hospital outcomes. Methods A retrospective study was conducted. All adult inpatients consecutively admitted to one of the 15 surgical inpatient units of an Italian university hospital across 1 year were included. Data, including the Professional Assessment Instrument and the Hospital Discharge Register, were collected retrospectively from the hospital's EHRs. Results The sample included 5,027 surgical inpatients. There was a mean of 6.3 ± 4.3 NDs per patient. The average distribution of NDs showed a stable trend throughout the year. The most representative NANDA-I ND domain was safety/protection. The total number of NDs on admission was significantly higher for patient whose length of stay was longer. A statistically significant correlation was observed between the number of NDs on admission and the number of intra-hospital patient transfers. Additionally, the mean number of NDs on admission was higher for patients who were later transferred to an intensive care unit compared to those who were not transferred. Conclusion NDs represent the key to understanding the contribution of nurses in the surgical setting. NDs collected upon admission can represent a prognostic factor related to the hospital's key outcomes.https://doi.org/10.1177/23779608231158157 |
| spellingShingle | Manuele Cesare RN, PhD student Fabio D’agostino PhD, RN Massimo Maurici MD Maurizio Zega PhD, RN Valentina Zeffiro PhD, RN Antonello Cocchieri PhD, RN Standardized Nursing Diagnoses in a Surgical Hospital Setting: A Retrospective Study Based on Electronic Health Data SAGE Open Nursing |
| title | Standardized Nursing Diagnoses in a Surgical Hospital Setting: A Retrospective Study Based on Electronic Health Data |
| title_full | Standardized Nursing Diagnoses in a Surgical Hospital Setting: A Retrospective Study Based on Electronic Health Data |
| title_fullStr | Standardized Nursing Diagnoses in a Surgical Hospital Setting: A Retrospective Study Based on Electronic Health Data |
| title_full_unstemmed | Standardized Nursing Diagnoses in a Surgical Hospital Setting: A Retrospective Study Based on Electronic Health Data |
| title_short | Standardized Nursing Diagnoses in a Surgical Hospital Setting: A Retrospective Study Based on Electronic Health Data |
| title_sort | standardized nursing diagnoses in a surgical hospital setting a retrospective study based on electronic health data |
| url | https://doi.org/10.1177/23779608231158157 |
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