Software for systematization of nursing care in medical units

Silva, Manoel Gomes da; Araújo, Eliete da Cunha; Moraes, Carlos Ramon Silva; Gonçalves, Lúcia Hisako Takase

doi:10.1590/0034-7167-2016-0386

Cited by 9 publications

(14 citation statements)

References 14 publications

(14 reference statements)

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“…Standardized nursing languages, however, are important at all levels of nursing education, since they have the potential to expand the possibilities for clinical reasoning, ensuring that nurses' professional activity is understood and scientifically grounded (Maia et al, 2014). The use of classifications makes it possible to describe and communicate the nurse's knowledge and practice, and, consequently, to develop knowledge of nursing practice through the extraction and analysis of assessment data, intervention, and outcomes (Gengo e Silva et al, 2018). In addition, the use of nursing classifications ensures harmonization of terms, facilitating the use of nursing data in computerized systems (Peres et al, 2009).…”

Section: Discussionmentioning

confidence: 99%

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Evaluation of the Accuracy of Nursing Diagnoses Determined by Users of a Clinical Decision Support System

Diogo

Gengo

Butcher

et al. 2021

J of Nursing Scholarship

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Purpose To analyze the accuracy of nursing diagnoses determined by users of a clinical decision support system (CDSS) and to identify the predictive factors of high/moderate diagnostic accuracy. Methods This is an exploratory‐descriptive study carried out from September 2017 to January 2018. Participants were nurses, resident nurses, and senior year undergraduates. Two written case studies provided the participants with the clinical data to fill out the assessment forms in the CDSS. The accuracy of the selected diagnostic labels was determined by a panel of experts using the Diagnostic Accuracy Scale, Version 2. Descriptive statistics were used to describe the level of accuracy according to each group of participants. Analysis of variance was used to compare the mean percentages of accuracy categories across groups. A linear regression model was used to identify the predictors of diagnostic accuracy. The significance level was 5%. The study was approved by the Ethics Committee. Results Fifteen undergraduates, 10 residents, and 22 nurses were enrolled in the study. Although resident nurses and students had selected predominantly highly accurate diagnoses (51.8 ± 19.1 and 48.9 ± 27.4, respectively), and nurses had selected mostly diagnoses of moderate accuracy (54.7 ± 14.7), there were no differences in the accuracy level of selected diagnoses across groups. According to the linear regression model, each diagnosis added by the participants decreased the diagnostic accuracy by 2.09% (p = .030), and no experience or a low level of experience using the system decreased such diagnostic accuracy by 5.41% (p = .022). Conclusions The CDSS contributes to decision making about diagnoses of less experienced people. Adding diagnoses not indicated by the CDSS and experience with the system are predictors of diagnostic accuracy. Clinical Relevance In‐service education regarding the use of CDSSs seems to be crucial to improve users’ clinical judgment and decision making.

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Section: Discussionmentioning

confidence: 99%

“…A higher level of experience with PROCEnf-USP applied to clinical practice may be advantageous when selecting more accurate NDs. According to research, it is essential that users be trained in technology, as the respective competence has an impact on efficiency (Silva, Araújo, Moraes, & Gonçalves, 2018).…”

Section: Discussionmentioning

confidence: 99%

Evaluation of the Accuracy of Nursing Diagnoses Determined by Users of a Clinical Decision Support System

Diogo

Gengo

Butcher

et al. 2021

J of Nursing Scholarship

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“…da Silva et al, 2018;Dal Sasso et al, 2013;de Lima et al, 2018;Despins & Wakefield, 2018;Gunningberg et al, 2009;Laukvik et al, 2015Laukvik et al, , 2022Mahler et al, 2007;Rothman et al, 2012;Shiells et al, 2020;von Krogh et al, 2012;Wang et al, 2013). ( 2) care planning systems (Brim & Schoonover, 2014;Castellà-Creus et al, 2019;Wang et al, 2015) and…”

Section: Implementation Of Digital Health Systems Within Nursing Carementioning

confidence: 99%

Clinical decision‐making and the nursing process in digital health systems: An integrated systematic review

Hants,

Bail,

Paterson

2023

Journal of Clinical Nursing

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AimsTo identify how the nursing process (assessment, planning, intervention and outcome evaluation) has been incorporated into digital health systems (electronic medical records, electronic care plans and clinical decision support systems) to gain an understanding of known benefits and challenges posed to nurses' decision‐making processes.BackgroundNursing terminologies, including the International Classification for Nursing Practice (ICNP), and Nursing Minimum Data Set's (NMDS), have been developed to improve standardised language integration of components of nursing care into digital systems. However, there is limited evidence regarding whether the complete nursing process is effectively being incorporated into digital health systems.MethodsAn integrative systematic review following PRISMA guidelines. A search strategy was applied to extract articles from included databases: CINAHL, MEDLINE, SCOPUS and Web of Science Core Collection. Articles were limited to English language and published January 2007–March 2022 and assessed using a pre‐determined eligibility criteria. Quality assessment and a narrative synthesis were conducted.ResultsA total of 3321 articles were identified, and 27 studies included. There were (n = 10) qualitative, (n = 4) quantitative non‐randomised controlled trials, (n = 3) quantitative descriptive studies and (n = 10) mixed methods. Nurse assessment and planning components were the most comprehensive phases incorporated into digital health systems, and interventions and outcome evaluation were scarcely reported.ConclusionsInadequate capture of nursing work is a problem unresolved by digital health systems. This omission may be hindering nurse clinical decision‐making for patient care and limiting the visibility of the nursing role in health care interventions and the associated impact on patient outcomes.Relevance to clinical practiceFurther research is needed on how digital systems can support nurses to apply the full nursing process and to further evaluate patient outcomes. Digital systems can support health‐service level evaluation through capturing missed nursing care and the consequences on patients utilising nurse‐sensitive‐outcomes; however, this is not yet being realised.

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“…ICTs focused on the management field appear to value data collection and analysis of adverse events, that serve as indicators for assessing nursing care; for staff sizing; in the codification of nurses' payments, medication, materials, and analysis of hospital bills (17,21) . In this same dimension, it is considered that their use in these different functions is complementary to the work process performed by nurses (22)(23) .…”

Section: Information and Communication Technologies: Interfaces Of The Nursing Work Processmentioning

confidence: 99%

Information and communication technologies: interfaces the nursing work process

Costa

Silva

et al. 2022

Rev. Bras. Enferm.

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Objectives: to unveil the meanings that nurses attribute Information and Communication Technologies for the nursing work process Methods: qualitative research, theoretically and methodologically based on the Complexity Theory and on the Grounded Theory, respectively. Research with 19 participants, being 12 clinical nurses, and 7 resident nurses. Semi-structured interviews were used for data collection. Results: the results revealed the meanings that clinical nurses attribute to Information and Communication Technologies and, thus, the motivations and limitations for the use of these technologies, pointing out possibilities and strategies that impact the nursing work process, based on the interactions promoted by the official and non-official use of these resources. Final Considerations: the meanings that nurses attribute to Information and Communication Technologies are dependent on their ability to successfully employ those technologies and their importance to the work process developed by the professionals.

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Software for systematization of nursing care in medical units

Cited by 9 publications

References 14 publications

Evaluation of the Accuracy of Nursing Diagnoses Determined by Users of a Clinical Decision Support System

Evaluation of the Accuracy of Nursing Diagnoses Determined by Users of a Clinical Decision Support System

Clinical decision‐making and the nursing process in digital health systems: An integrated systematic review

Information and communication technologies: interfaces the nursing work process

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