What patients’ problems do nurses e-chart? Longitudinal study to evaluate the usability of an interface terminology

Juvé‐Udina, Maria‐Eulàlia

doi:10.1016/j.ijnurstu.2013.04.008

Cited by 22 publications

(25 citation statements)

References 53 publications

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“…Additionally, the terminology used by nurses in this study is not as renowned as other nursing language systems, but it offers conceptual coverage for multiple cascade effect problems and for different types of nurses' clinical judgments (Juvé‐Udina, ).…”

Section: Discussionmentioning

confidence: 99%

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Predicting patient acuity according to their main problem

et al. 2019

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Aim To assess the ability of the patient main problem to predict acuity in adults admitted to hospital wards and step‐down units. Background Acuity refers to the categorization of patients based on their required nursing intensity. The relationship between acuity and nurses' clinical judgment on the patient problems, including their prioritization, is an underexplored issue. Method Cross‐sectional, multi‐centre study in a sample of 200,000 adults. Multivariate analysis of main problems potentially associated with acuity levels higher than acute was performed. Distribution of patients and outcome differences among acuity clusters were evaluated. Results The main problems identified are strongly associated with patient acuity. The model exhibits remarkable ability to predict acuity (AUC, 0.814; 95% CI, 0.81–0.816). Most patients (64.8%) match higher than acute categories. Significant differences in terms of mortality, hospital readmission and other outcomes are observed (p < .005). Conclusion The patient main problem predicts acuity. Most inpatients require more intensive than acute nursing care and their outcomes are adversely affected. Implications for nursing management Prospective measurement of acuity, considering nurses' clinical judgments on the patient main problem, is feasible and may contribute to support nurse management workforce planning and staffing decision‐making, and to optimize patients, nurses and organizational outcomes.

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Section: Discussionmentioning

confidence: 99%

“…Despite its conceptual ambiguity, clinical judgment is considered synonymous with decision‐making (Nibbelink & Brewer, ) and for long, nurses' clinical judgments on patient problems have been represented by nursing diagnoses (ND) (Juvé‐Udina, ).…”

Section: Introductionmentioning

confidence: 99%

Predicting patient acuity according to their main problem

et al. 2019

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“…The advantage of the comprehensive nursing assessment is that it is not a separate record but, rather, part of the electronic clinical records of all the hospitals in our organisation (Juve‐Udina, ). Being able to use it to identify the risk of delirium will enable improved recording of this information.…”

Section: Discussionmentioning

confidence: 99%

Nursing assessment as an effective tool for the identification of delirium risk in older in‐patients: A case–control study

Solà-Miravete

López

Martínez-Segura

et al. 2017

Journal of Clinical Nursing

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“…Nurses participating in this study use ATIC terminology. According to Juvé‐Udina () “It is based on six key concepts: Architecture, Terminology, Interface, Information, Nursing (Infermeria) and Knowledge (Coneixement), yielding the acronym ATIC in the Catalan spelling. The ATIC terminology is designed as a nursing concept‐oriented, interface controlled vocabulary.…”

Section: Introductionmentioning

confidence: 99%

Barriers and facilitators involved in standardised care plan individualisation process in acute hospitalisation wards: A grounded theory approach

Castellà-Creus

Delgado‐Hito

Casanovas-Cuellar

et al. 2019

Journal of Clinical Nursing

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Objective To identify and classify the barriers and facilitators of the individualisation process of the standardised care plan in hospitalisation wards. Background The administration of individualised care is one of the features of the nursing process. Care plans are the structured record of the diagnosis, planning and evaluation stages of the nursing process. Although the creation of standardised care plan has made recording easier, it is still necessary to record the individualisation of the care. It is important to study the elements that influence the individualisation process from the nurses' perspective. Design Qualitative study with the grounded theory approach developed by Strauss and Corbin. Methods Thirty‐nine nurses from three hospitals participated by way of theoretical sampling. In‐depth interviews were conducted, as well as participant observation, document analysis and focus group discussion. The analysis consisted of open, axial and selective coding until data saturation was reached. EQUATOR guidelines for qualitative research (COREQ) were applied. Results For both barriers and facilitators, three thematic categories emerged related to organisational, professional and individual aspects. The identified barriers included routines acquired in the wards, the tradition of narrative records, lack of knowledge and limited interest in individualisation. The identified facilitators included holding clinical care sessions, use of standardised care plan and an interface terminology, the nurse's expertise and willingness to individualise. Conclusion The individualisation process of the standardised care plan involves multiple barriers and facilitators, which influence its degree of accuracy. Relevance to clinical practice Implementing strategies at an organisational level, professional level and individual level to improve the way the process is carried out would encourage individualising the standardised care plan in a manner that is consistent with the needs of the patient and family; it would improve the quality of care and patient satisfaction.

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What patients’ problems do nurses e-chart? Longitudinal study to evaluate the usability of an interface terminology

Cited by 22 publications

References 53 publications

Predicting patient acuity according to their main problem

Predicting patient acuity according to their main problem

Nursing assessment as an effective tool for the identification of delirium risk in older in‐patients: A case–control study

Barriers and facilitators involved in standardised care plan individualisation process in acute hospitalisation wards: A grounded theory approach

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