Nursing diagnosis identification by nurses in burn wards: A descriptive cross‐sectional study

Abstract

Aim To identify and document patients' care needs, it is vital to provide quality care services. This study was aimed to describe care needs derived from records of patients with burn and to evaluate whether nurses employed the North American Nursing Diagnosis Association classification to formulate patients' care needs. Design A descriptive cross‐sectional study. Methods In this study using the convenient sampling method, 430 nursing records reviewed in the burn wards. Data were collected using Gordon's checklist. The validity of the checklist assessed by content validity and the reliability of them calculated with inter‐rater and internal consistency. Data analysed by SPSSv.24. Results The mean number of diagnoses per record was 1.94. The most frequent diagnosis was in the domain of Safety/Protection and the top two prevalent nursing diagnoses in Sina hospital were a risk for infection and risk for falls. From all of the detected diagnostic, about 83% were determinedly not related to one of 247 labels of the North American Nursing Diagnosis Association. Given that nurses provide nursing care as requested by physicians and patient care needs are not assessed and recorded by them, it can be concluded that there was no nursing thinking behind their nursing care.

Nursing process from theory to practice: Evidence from the implementation of "Coming back to existence caring model" in burn wards

“…These studies have reported that the quality of nursing documentation was unsuitable and did not contain necessary information (Rajabpoor et al, 2018;Moghadas & Sedaghati Kesbakhi, 2020;Ghafouri Fard et al, 2012;Tab rizi et al, 2016;Zamanzadeh et al, 2015). Results of this study showed that the top prevalent nursing diagnoses were the risk for infection, which is consistent with the results of Khajehgoodari's study and case study by Vinicius Lino Souza Neto and colleagues (Khajehgoodari et al;Neto et al, 2018)…”

“…A study in Brazil showed that a smaller number of recordings were done in the steps relative to nursing diagnosis and evolution (Reppetto & Souza, 2005 ). A study in the same hospital showed that nurses' awareness of nursing diagnoses was very poor (Khajehgoodari et al., 2020 ). Studies on nursing documentation in Iran have focused more on the quality of nursing documentation.…”

Nursing interventions for patients with COVID‐19: A medical record review and nursing interventions classification study

“…For instance, most nurses do not have enough autonomy to use a nebulizer for patients based solely on their clinical judgment and instead require a specific physician order to do so. Given that nurses provide nursing care according to the orders of physicians and the patient care needs are not planned by nurses, it can be concluded that in this specific context, the documentation of activities reflects physician‐driven interventions rather than a culmination of nurses’ critical thinking and care planning (Khajehgoodari et al., 2020). As it has been recently demonstrated, the quality of nursing diagnoses in Iran is not high enough to provide a nursing care plan (Lotfi et al., 2020).…”

An integrative review of comprehensive nursing assessment tools developed based on Gordon's Eleven Functional Health Patterns

“…Nursing assessment is vital to quality nursing care. However, there is not enough value placed on the role of the assessment in nursing practice, which can be depicted from the lack of its implementation and incomplete patient documentation (Diniz et al 2015;Khajehgoodari et al, 2020). Barriers to conduct nursing assessment have been identified and include lack of nursing role models, and influence on nursing care and on patient outcomes (Douglas et al, 2014).…”

“…Barriers to conduct nursing assessment have been identified and include lack of nursing role models, and influence on nursing care and on patient outcomes (Douglas et al, 2014). The lack of a nursing framework to guide nursing assessment may lead to inaccurate diagnoses of patients' needs from a nursing perspective and invisibility of the nursing profession (Khajehgoodari et al, 2020). Gordon's Eleven FHP (Gordon, 1994) can contribute positively to assist nurses during the continuum of nursing care (Temel & Kutlu, 2015;Türen & Enç, 2020).…”