Background. Nursing documentation has long traditions and represents core element of nursing, but the documentation is often criticized of being incomplete. Nursing diagnoses are an important research topic in nursing in terms of quality of nursing assessment, interventions, and outcome in addition to facilitating communication and continuity. Aim. The aim of this study was to explore the nurses' and nursing students' experiences after implementing free text format nursing diagnoses in a medical department. Method. The study design included educational intervention of free text nursing diagnoses. Data was collected through five focus group interviews with 18 nurses and 6 students as informants. The data was analyzed using qualitative content analysis. Results. The informants describe positive experiences concerning free text format nursing diagnoses' use and usefulness; it promotes reflection and discussion and is described as a useful tool in the diagnostic process, though it was challenging to find the diagnosis' appropriate formulation. Conclusion. Our findings indicate a valid usability of free text format nursing diagnoses as it promotes the diagnostic process. The use seems to enhance critical thinking and may serve as valuable preparation towards an implementation of standardized nursing diagnoses. Use and support of key personnel seem valuable in an implementation process.
Nurses often hold key positions on interdisciplinary collaboration; therefore, they must develop the communicative skills required in this position to be able to improve the quality of patient care in hospitals, related to nurses' experiences and skills.
Discussions on how nursing documentation should be carried out have been ongoing for the last decade. In this study, free-text format for nursing diagnoses was introduced to nursing staff at a university hospital in Norway. The aim of the study was to investigate the impact of an education intervention introducing nursing diagnoses in a free-text format following a problemetiology-symptom structure. A pretest-posttest design was performed to assess changes in quality and quantity in the nursing documentation using the audit instrument N-Catch II. Several elements in the nursing documentation had statistically significant changes; the largest was found for quantity in nursing diagnoses. Education interventions aimed to improve nurses' documentation in the electronic health record may have an effect on more complete and accurate nursing documentation. The presented education intervention showed a significant impact of more accurate nursing diagnoses and significant improvements in nursing documentation.
Management 24, E175-E182.
Exploring nursing staffs communication in stressful and non-stressful situationsAim To explore the factors that characterise the work environment, focusing on communication among nurses in stressful and non-stressful situations. Background Nursing is often described as a stressful occupation. Implementation of change may be an additional stress factor. Methods Nurses and assistant nurses completed a questionnaire from two different perspectives, 'communication in non-stressful situations' and 'communication under stress'. The Systematising Person-Group Relations method was used to gather and analyse the data. Results When the two perspectives, 'communication in non-stressful situations' and 'communication under stress', were compared, there were significant differences in 8 of the 12 factors. The stressful situations were characterised by low values in task orientation, caring, criticism, loyalty, acceptance, engagement and empathy; only the factor creativity had higher scores. Conclusion The stressful situations were characterised by creative and spontaneous behaviour, not by task orientation and engagement, indicating a potential patient safety risk. Implications for nurse management There is a need to help health-care workers develop more mature analytical and task-oriented behaviours related to both independent work and collaboration in stressful situations. Nursing leadership and organisation must focus on healthy work environments to promote engaged communication in stressful situations, ultimately increasing patient safety.
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