Cent Eur J Nurs Midw 2014, 5(3):117-126 | DOI: 10.15452/CEJNM.2014.05.0006

The use of nursing diagnoses in clinical practice

Eva Mynaříková1,*, Katarína Žiaková2
1 Division of Nursing Care, University Hospital Ostrava, Czech Republic
2 Department of Nursing, Jessenius Medical Faculty in Martin, Comenius University in Bratislava, Slovakia

Aim: The aim was to determine the error rate and frequency of nursing diagnoses used in clinical practice by the means of analysis of available literature, and to reveal the factors influencing the accuracy and occurrence of nursing diagnoses.

Methods: The following databases (1993-2013) were used as the data source for the performed analysis: PubMed, ProQuest and Google Scholar. A total of thirty-nine data sources were utilized for data processing: predictive correlational studies (9), retrospective studies using patient data (7), cross-sectional studies (4), systematic reviews (3), cohort studies (3), a randomized trial (1), and a longitudinal analysis (1). The data were also obtained from educational texts (7), review articles (2) and expert disputations (2).

Results: Identical problems in formulation as well as accuracy of the nursing concepts have been repeatedly observed during the monitoring of occurrence of the error rate in nursing diagnoses. Noted imperfections concerned identification of determining characters, and especially related factors. Diagnoses regarding dysfunctional physical needs prevailed, whereas diagnoses in the psychosocial and spiritual areas were absent. The analysis of literature data showed that the factors influencing the accuracy and occurrence of nursing diagnoses in practice include the nurses and their education and experience in nursing diagnostics, the way the nursing care is organized, technologies of the nursing documentation and institutional support, especially in the form of adequate staffing.

Conclusion: In order to be able to provide beneficent, effective and safe care, it is necessary for managers of individual healthcare establishments to target the strategy on the system as a whole, that is, on mutual interconnection of individual components: the people, environment, process and technologies.

Keywords: nursing diagnosis, accuracy, frequency, education, influencing factors, clinical practice

Received: March 25, 2014; Accepted: July 27, 2014; Published: September 30, 2014  Show citation

ACS AIP APA ASA Harvard Chicago Chicago Notes IEEE ISO690 MLA NLM Turabian Vancouver
Mynaříková E, Žiaková K. The use of nursing diagnoses in clinical practice. Central European Journal of Nursing and Midwifery. 2014;5(3):117-126. doi: 10.15452/CEJNM.2014.05.0006.
Share...
Download citation
  • BibTeX (.bib)
  • Bookends (.ris)
  • EasyBib (.ris)
  • EndNote (.enw)
  • EndNote 8 (.xml)
  • ISI WoS (.isi)
  • Medlars (.medlars)
  • Mendeley (.ris)
  • MODS (.xml)
  • Papers (.ris)
  • RefWorks (.txt)
  • RefManager (.ris)
  • RIS (.ris)
  • MS Word (.xml)
  • Zotero (.ris)
    • Open full article

    References

    1. Brokel J, Heath, C. Hodnota ošetřovatelských diagnóz v elektronických záznamech. In: NANDA International. Ošetřovatelské diagnózy: definice a klasifikace 2009 - 2011. Praha: Grada; 2010. p. 26-29. (in Czech)
    2. Bostick JE, Rantz MJ, Flesner MK, Riggs CJ. Systematic review of studies of staffing and quality in nursing homes. Journal of the American Medical Directors Association. 2006;7(6): 366-376. Go to original source... Go to PubMed...
    3. Bulechek GM, Butcher HK, Dochterman MJ. Nursing Interventions Classifications (NIC). 5th ed. St. Louis: Mosby; 2008.
    4. Brannon LA, Carson KL, The representative heuristic: influence on nurses' decision making. Applied Nursing Research. 2003;16(3): 201-204. Go to original source... Go to PubMed...
    5. Carnevali DL, Thomas MD. Diagnostic Reasoning and Treatment Decision Making in Nursing. Philadelphia: Lippincott; 1993.
    6. Carpenito-Moyet LJ. Invited paper: Teaching nursing diagnosis to increase utilization after graduation. International Journal of Nursing Terminologies and Classifications. 2010;21(3):124-133. Go to original source... Go to PubMed...
    7. Cruz DM, Pimenta CM, Lunney, M. Improving critical thinking and clinical reasoning with a continuing education course. The Journal of Continuing Education in Nursing. 2009;40 (3):121-127. Go to original source... Go to PubMed...
    8. Czech. Ministerstvo zdravotnictví. Vyhláška č. 55 ze dne 1. března 2011 o činnostech zdravotnických pracovníků a jiných odborných pracovníků. In: Sbírka zákonů České republiky. 2011, částka 20, p. 482-544. (in Czech)
    9. Czech. Ministerstvo zdravotnictví. Vyhláška č. 98 ze dne 22. března 2012 o zdravotnické dokumentaci. In : Sbírka zákonů České republiky. 2012, částka 39, p. 1666-1685. (in Czech)
    10. Czech. Ministerstvo zdravotnictví. Vyhláška č. 99 ze dne 22. března 2012 o požadavcích na minimální personální zabezpečení zdravotních služeb. In: Sbírka zákonů České republiky. 2012, částka 39, p. 1686-1730. (in Czech)
    11. Červinková L, Marečková J. Zkušenosti s výukou ošetřovatelské diagnostiky na střední zdravotnické škole. (In: Bužgová R, Jarošová D. Ošetřovatelská diagnostika a praxe založená na důkazech. Ostrava; 2007. p. 40-44. (in Czech)
    12. Doenges ME, Moorhouse MF. Application of Nursing Process and Nursing Diagnosis. An Interactive Text for Diagnostic Reasoning. 4th ed. F. A. Davis Company: Philadelphia; 2003.
    13. Dolák F, Scholz P, Tóthová V. Postoj sester k ošetřovatelským klasifikačním systémům. Kontakt. 2012;14(4):434-443. (in Czech) Go to original source...
    14. Gordon M. Nursing Diagnosis: Process and Application. 3th ed. St. Louis: Mosby; 1994.
    15. Florin J, Ehrenberg A, Ehnfors M. Quality of nursing diagnoses: evaluation of an educational intervention. International Journal of Nursing Terminologies and Classifications. 2005;16(2): 33-43. Go to original source... Go to PubMed...
    16. Hedberg B, Larsson US. Environmental elements affecting the decision-making process in nursing practice. Journal of Clinical Nursing. 2004;13(3):316-324. Go to original source... Go to PubMed...
    17. Hendrich A, Chow M, Skierczynski BA, Lu Z. A 36-hospital time and motion study: how do medical-surgical nurses spend their time? The Permanente Journal. 2008;12(3):25-34. Go to original source... Go to PubMed...
    18. Cheevakasemsook A, Chapman Y, Francis K, Davies C. The study of nursing documentation complexities. International Journal of Nursing Practice. 2006;12(6): 366-374. Go to original source... Go to PubMed...
    19. Jarošová D. Ověřování souboru ošetřovatelských diagnóz a intervencí pro domácí péči. In: Jarošová D, editor. Využitelnost ošetřovatelských klasifikací NANDA International a NIC v domácí péči. Ostrava: OU v Ostravě, LF; 2012. p. 86-99. (in Czech)
    20. Jerant AF, Azari R, Nesbitt TS. Reducing the cost of frequent hospital admissions for congestive heart failure: a randomized trial of a home telecare intervention. Medical Care. 2001;39(11):1234-1245. Go to original source... Go to PubMed...
    21. Lavin MA, Avant K, Craft-Rosenberg M, Herdman TH, Gebbie K, Michel J, de Barros A, Apalategui MU. Context for the study of the economic influence of nursing diagnoses on patient outcomes. International Journal of Nursing Terminologies and Classifications. 2004;15(2): 39-47. Go to original source... Go to PubMed...
    22. Levin HM, McEwan PJ. Cost-Effectiveness Analysis: Methods and Applications. 2nd ed. Thousand Oaks: Sage Publications; 2001.
    23. Lucena AF, Barros ALBL. Nursing diagnoses in a Brazilian intensive care unit. International Journal of Nursing Knowledge. 2006;17(3):139-146. Go to original source...
    24. Lunney M. Critical need to address accuracy of nurses' diagnoses. The Online Journal of Issues in Nursing. 2008;13(1) Go to original source...
    25. Lunney M. Hodnocení, klinické posouzení a ošetřovatelské diagnózy: jak určit přesnou diagnózu. In : NANDA International. Ošetřovatelské diagnózy: definice a klasifikace 2009 - 2011. Praha: Grada; 2010. p. 3-15. (in Czech)
    26. Macková H, Zeleníková R. Faktory ovlivňující používání ošetřovatelských diagnóz v praxi. Ošetřovatelství a porodní asistence. 2012;3(2): 390-397. (in Czech)
    27. Marečková J, Stefanová P, Mazalová L, Bocková S. Přehled informací k mezinárodním terminologickým systémům v ošetřovatelství. In: Jarošová D, editor. Využitelnost ošetřovatelských klasifikací NANDA International a NIC v domácí péči. Ostrava: OU v Ostravě, LF; 2012. p. 7-24. (in Czech)
    28. Marečková J, Tománková I. Diagnostické prvky NANDA International u bezvědomých pacientů. In : Bužgová R, Jarošová D, editors. Ošetřovatelská diagnostika a praxe založená na důkazech. Ostrava; 2007. p. 58-64. (in Czech)
    29. McCabe C. Nurse-patient communication: an exploration of patients' experiences. Journal of Clinical Nursing. 2004;13(1): 41-49. Go to original source... Go to PubMed...
    30. Munhall PL. "Unknowing": toward another pattern of knowing in nursing. Nursing Outlook. 1993;41(3):125-128.
    31. Munyisia EN, Yu P, Haley D. Does the introduction of an electronic nursing documentation system in nursing home reduce time on documentation for nursing staff? International Journal of Medical Informatics. 2011;80(11):782-792. Go to original source... Go to PubMed...
    32. Müller-Staub M, Lavin MA, Needham I, Van Achterberg T. Nursing diagnoses, interventions and outcomes - application and impact on nursing practice: systematic review. Journal of Advanced Nursing. 2006;56(5):514-531. Go to original source... Go to PubMed...
    33. Müller-Staub M, Needham I, Odenbreit M, Lavin MA, Van Achterberg T. Improved quality of nursing documentation: results of a nursing diagnoses, interventions, and outcomes implementation study. International Journal of Nursing Terminologies and Classifications. 2007;18(1):5-17. Go to original source... Go to PubMed...
    34. Ogasawara, C, Hasegawa T, Kume Y, Takahashi I, Katayama Y, Furuhashi Y, Andoh M, Yamamoto Y, Okazaki S, Tanabe M. Nursing diagnoses and interventions of Japanese patients with end-stage breast cancer admitted for different care purposes. International Journal of Nursing Terminologies and Classifications. 2005;16(3-4):54-64. Go to original source... Go to PubMed...
    35. Paans W, Nieweg RMB, Van der Schans CP, Sermeus W. What factors influence the prevalence and accuracy of nursing diagnoses documentation in clinical practice? A systematic literature review. Journal of Clinical Nursing. 2011;20(17-18):2386-2403. Go to original source... Go to PubMed...
    36. Paganin A, Moraes MA, Pokorski S, Rabelo ER. Factors that inhibit the use of nursing language. International Journal of Nursing Terminologies and Classifications. 2008;19(4):150157. Go to original source... Go to PubMed...
    37. Pavelová L, Nádaská I, Mesárošová J, Peťková J. Sesterská diagnostika v ošetrovateľskom procese u pacientov v kritickom stave. In: Ošetrovateľstvo 21. storočia v procese zmien. Univerzita Konštantína Filozofa v Nitre. Fakulta sociálnych vied a zdravotníctva, Katedra ošetrovateľstva; 2005. p. 343-346. (in Slovak)
    38. Pospíšilová A, Kyasová M, Juřeníková, P. Knowledge of NANDA International, NIC and NOC concepts in terms of education of general nurses. Kontakt. 2012;14(4): 421-433. Go to original source...
    39. Tanner CA. Thinking like a nurse: a research-based model of clinical judgment in nursing. Journal of Nursing Education. 2006;45(6):204-211. Go to original source... Go to PubMed...
    40. Thoroddsen A, Thorsteinsson HS. Nursing diagnosis taxonomy across the Atlantic Ocean: congruence between nurses' charting and the NANDA taxonomy. Journal of Advanced Nursing. 2002;37(4):372-381. Go to original source... Go to PubMed...
    41. Thoroddsen A, Ehnfors M, Ehrenberg A. Nursing specialty knowledge as expressed by standardized nursing languages. International Journal of Nursing Terminologies and Classification. 2010;21(2):69-79. Go to original source... Go to PubMed...
    42. Žiaková K, Holmanová E, Čáp J. Reflexia aplikácie ošetrovateľských diagnóz vo vzdelávaní. In: Bužgová R, Jarošová D, editors. Ošetřovatelská diagnostika a praxe založená na důkazech. Ostrava; 2007. p. 100-105. (in Slovak)
    43. Žiaková K, Holmanová E, Čáp J. Problematika odbornej terminologie v ošetrovateľstve. In: Bužgová R, Sikorová L, editors. Ošetřovatelská diagnostika a praxe založená na důkazech II. Ostrava; 2008. p. 83-86.
    44. Žiaková K, Gurková E, Šerfelová R, Čáp J. Stimuly a bariéry vo využívaní ošetrovateľských diagnóz. Ošetřovatelství a porodní asistence. 2013;4(3):601-608. (in Slovak)

    This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0), which permits non-comercial use, distribution, and reproduction in any medium, provided the original publication is properly cited. No use, distribution or reproduction is permitted which does not comply with these terms.


    Return to the content