Quality of Care: Ecological Study for the Evaluation of Completeness and Accuracy in Nursing Assessment

Abstract

Nursing documentation is an important proxy of the quality of care, and quality indicators in nursing assessment can be used to assess and improve the quality of care in health care institutions. The study aims to evaluate the completeness and the accuracy of nursing assessment, analyzing the compilation of pain assessment and nutritional status (body mass index (BMI)) in computerized nursing records, and how it is influenced by four variables: nurse to patient ratio, diagnosis related group weight (DRG), seniority of charge nurse, and type of ward (medical, surgical or other). The observational ecological pilot study was conducted between September and October 2018 in an Italian Tertiary-Level Teaching Hospital. The nursing documentation analyzed for the ‘Assessment’ phase included 12,513 records, 50.4% concerning pain assessment, and 45% BMI. The nurse–patient ratio showed a significant direct association with the assessment of nutritional status (p = 0.032). The average weight DRG has a negative influence on pain and BMI assessment; the surgical units positively correlate with the compilation of nursing assessment (BMI and pain). The nursing process is an essential component for the continuous improvement in the quality of care. Nurses need to be accountable to improve their knowledge and skills in nursing documentation.

Development and Validation of a Meta-Instrument for Nursing Assessment in Adult Hospitalization Units (VALENF Instrument) (Part I)

“…Lindo et al (2016) [ 23 ] reported that more than 60% of the health records audited in three Jamaican hospitals did not include complete nursing assessment data. Iula et al (2020) [ 24 ] indicated that assessments about pain and nutritional status were missing in a sample of 12,513 clinical records that were audited in an Italian hospital. Others show a failure to complete records with instruments that assess functional capacity, falls or pressure ulcers [ 25 , 26 , 27 , 28 ].…”

What should nurses do on post-stroke depression? A global systematic assessment of clinical practice guidelines

“… 8 9 The purpose of nursing assessment is to let nurses perceive the emotional changes of patients in advance, quickly identify the symptoms of depression of patients, and lay a foundation for the formation of nursing diagnosis and nursing plan. 36 In addition, it can promote multidisciplinary collaboration and provide a basis for further detailed assessment and intervention by physicians. At present, the Hamilton Depression Scale is the most widely used assessment tool in clinical practice or research.…”

“…Nurses, as health professionals who have the longest contact time with patients, should make full use of their work advantages, pay attention to observe the psychological state of patients and identify depressive symptoms, especially in patients with acute ischaemic stroke 8 9. The purpose of nursing assessment is to let nurses perceive the emotional changes of patients in advance, quickly identify the symptoms of depression of patients, and lay a foundation for the formation of nursing diagnosis and nursing plan 36. In addition, it can promote multidisciplinary collaboration and provide a basis for further detailed assessment and intervention by physicians.…”

‘It's all about ticks’: A secondary qualitative analysis of nurse perspectives about documentation audit

“…Nursing documentation should reliably represent nursing care (Paterson et al, 2021); however, it cannot realistically capture the nurse's whole role. Complexities in accurate documentation include issues such as time constraints and competing care priorities, compounded by the fact that documentation is inherently biomedically based and often does not accurately capture the holistic care that nurses provide (Charalambous & Goldberg, 2016; de Marinis et al, 2010; Iula et al, 2020; Johnson et al, 2018; Kebede et al, 2017). Therefore, nursing documentation is inadequate to represent all the complexities of the nursing process (assessment, planning, implementation and evaluation), critical thinking, decision‐making; and time spent monitoring and communicating in, and between clinical teams (Bail et al, 2021; Clarke et al, 2010; de Marinis et al, 2010; Fore et al, 2019).…”