Nursing documentation related to respiratory process: content analysis of portuguese health records
DOI:
https://doi.org/10.37914/riis.v6i1.286Keywords:
Nursing diagnosis, Nursing process, Advanced Practice Nursing, RespirationAbstract
Background: data sharing from clinical practice is crucial to support nurses' decision-making process, improve nursing outcomes, and increase the quality of care. In Portugal, International Classification for Nursing Practice is used to document care being necessary for the standardization of this process preventing information redundancy. Objectives: (1) to identify diagnoses and interventions used by Portuguese nurses related to Respiratory Process, (2) to suggest unified diagnoses and interventions syntaxes. Methodology: qualitative study with a content analysis. The sample included data regarding e-documentation of nursing diagnosis and interventions customized in the nursing public information system until 2019. Results: of the initial sample of 1502 diagnoses aroused 28 and from 2060 interventions emerged 73 as the most relevant. The main findings were: two areas of nursing attention, one related to respiratory function and the other to patient's learning abilities, diversity of diagnoses and interventions to express the same needs resulting from a variety of taxonomic misunderstandings, and lack of standardized language. Conclusions nursing documentation have two dimensions representing the complexity of nursing care. It also shows that using standardized language does not prevent information redundancy resulting in different diagnoses and interventions to express the same needs.
References
Bardin, L. (2012). Análise de Conteúdo. São Paulo: Almedina Brasil.
Clark, J., & Lang, N. (Jul-Aug de 1992). Nursing´s next advance: an internalclassification for nursing practice. International Nursing Review, 109-111.
Cruz, I., Bastos, F., Pereira, F., Silva, A., & Sousa, P. (2016). Analysis of the Nursing Documentation in Use in Portugal - building a clinical data model of nursing centered on the management of treatment regimen. Nursing Informatics, 407-411.
Csoma, B., Vulpi, M. R., Dragonieri, S., Bentley, A., Felton, T., Lázár, Z., & Bikov, A. (2022). Hypercapnia in COPD: Causes, Consequences, and Therapy. Journal of Clinical Medicine, 11. DOI: https://doi.org/10.3390/jcm11113180
Fennelly, O., Grogan, L., Reed, A., & R. Hardiker, N. (2021). Use of standardized terminologies in clinical practice: A scoping review. International Journal of Medical Informatics, 149. DOI: https://doi.org/10.1016/j.ijmedinf.2021.104431
Gilber, H. (2020). Florence Nightingale’s Environmental Theory and its influence on contemporary infection control. Collegian, 626-633. DOI: https://doi.org/10.1016/j.colegn.2020.09.006
Gonçalves, P., Sequeira, C., & Paiva e Silva, M. (2018). Content analysis of nursing diagnoses in mental health records in Portugal. International Nursing Review, 10. DOI: https://doi.org/10.1111/inr.12493
Hak, F., Oliveira, D., Abreu, N., Leuschner, P., Abelha, A., & Santos, M. (2020). An OpenEHR Adoption in a Portuguese Healthcare Facility. Procedia Computer Science. DOI: https://doi.org/10.1016/j.procs.2020.03.075
Hentsch, L., Cocetta, S., Allali, G., Santana, I., Eason, R., Adam, E., & Janssens, J.-P. (2021). Breathlessness and COVID-19: A Call for Research. Respiration, 100, 1016-1026. DOI: https://doi.org/10.1159/000517400
Krueger , R., & Casey, M. (2015). Focus Groups: A Practical Guide for Applied Research. SAGE Publications.
Lee, J., & Park, H. (2017). Development and validation of detaildes clinical models for nursing actiond in perinatal care. International Journal of Medical Informatics, 102. DOI: https://doi.org/10.1016/j.ijmedinf.2017.03.009
Lingtong, M., Tian, Q., Lu, X., Jiye, A., Duan, H., & al, e. (2018). An openEHR based approach to improve the semantic interoperability of clinical data registry. BMC Medical Informatics and Decision Making, 49-56.
McCarthy, B., Fitzgerald, S., O’Shea, M., Condon, C., Hartnett-Collins, G., Clancy, M., Sheehy, A., Denieffe, S., Bergin, M., & Savage, E. (2018). Electronic nursing documentation interventions to promote or improve patient safety and quality care: a systematic review. Journal of Nursing Management. DOI: https://doi.org/10.1111/jonm.12727
Meleis, A. (2012). Theoretical Nursing: Development & Progress. Philadelphia: Wolters Kluwer.
Neves, H., & Parente, P. (2019). A nursing clinical data model for neuromuscular processes: content analysis of the Portuguese nursing customization. 1609-1616. DOI: https://doi.org/10.1590/1413-81232018245.04462019
Oreofe, A. I., & Oyenike, A. M. (2018). Transforming Practice through Nursing Innovative Patient Centered Care: Standardized Nursing Languages. International Journal of Caring Sciences, 1319-1322.
Paiva, A. (2006). Sistemas de Informação em Enfermagem: Uma teoria explicativa da mudança. Porto: Formasau.
Queirós, C., Paiva Silva, Cruz, I., Cardoso, A., & Morais, E. (2021). Nursing diagnoses focused on universal self-care requisites. International Nursing Review, 1-13. DOI: https://doi.org/10.1111/inr.12654
Schenk, E., Scheleyer, R., Jones, C. R., Fincham, S., Daratha, K. B., & Monsen, K. A. (2018). Impact of Adoption of a Comprehensive Eletronic Health Recordon Nursing Work an Caring Efficacy. Computers Informatic Nursing, 331-339. DOI: https://doi.org/10.1097/CIN.0000000000000441
Schrijver, J., Lenferink, A., Brusse-Keizer, M., Zwerink, M., van der Valk, P., van der Palen i, J., & Effing, T. (2022). Self‐management interventions for people with chronic obstructive pulmonary disease. Cochrane Library. DOI: https://doi.org/10.1002/14651858.CD002990.pub4
Silva, A. P., Cardoso, A., Sequeira, C., Morais, E. J., Bastos, F., Pereira, F., & et al. (2014). Análise da parametrização nacional do Sistema de Apoio à Prática de Enfermagem. Escola Superior de Enfermagem do Porto. Aspen Publications.
Sun, B., Zhang, F., Li, J., Yang, Y., Diao, X., Zhao, W., & Shu, T. (2021). Using NLP in openEHR archetypes retrieval to promote interoperability: a feasibility study in China. BMC Medical Informatics and Decision Making, 21. https://doi.org/https://doi.org/10.1186/s12911-021-01554-2 DOI: https://doi.org/10.1186/s12911-021-01554-2
Wang, J., Mallow, J., & Bakken, S. (2019). Models of Collaboration and Dissemination for Nursing Informatics. Nursing Outlook, DOI: https://doi.org/10.1016/j.outlook.2019.02.003. DOI: https://doi.org/10.1016/j.outlook.2019.02.003
Yue, Z., Zhenghong, Y., Zhang, Q., Qin, W., Chun, Y., & Zhang, Y. (2022). Transition to a new nursing information system embedded with clinical decision support: a mixed-method study using the HOT-fit framework. BMC Medical Informatics and Decision Making. DOI: https://doi.org/10.21203/rs.3.rs-1692333/v1
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Copyright (c) 2023 Luis Gaspar, Neuza Reis, Paula Sousa, Abel Paiva e Silva, Natália Machado, Filipe Pereira
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