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Volume 3 Advanced Practices in Nursing
ISSN: 2573-0347 Advanced Nursing Research 2018
June 14-15, 2018
June 14-15, 2018 | Dublin, Ireland
48th World Congress on
Advanced Nursing Research
The quality of nursing documentation in Tallinn Children Hospital
Irma Nool, Mare Tupits and Eha Hõrrak
Tallinn Health Care College, Estonia
Statement of the Problem: Growing interest in using NANDA-I nursing diagnoses has been observed in health care facilities
due to the fact that it ensures using common terminology for patient’s health assessment and in planning nursing care. Nursing
documentation is uneven in quality in Estonia which hinders the availability and continuity of nursing care. Quality standards
and indicators are not used for consistent assessment. Nurses are filling nursing records and do not consider them to be part
of the entire nursing process. It leads to poor-quality nursing documentation, which prevents communication between simple,
structured and focused professionals, which in turn affects the quality of patient care. The aim of the study is to describe the
quality of nursing documentation in Tallinn Children Hospital. The research is quantitative, descriptive study.
Methodology&Theoretical Orientation: Samplewas taken fromnursing records before and afterNANDA-I nursing diagnoses
training for nurses. The selection criteria’s were: patient had to be in hospital for at least three days and there was individual
nursing care plan for the patient. Data collection was done during September 2016 - March 2017. D-Catch instrument, the
4-score Likert scale were used. Data analysis: SPSS 19.0, descriptive statistics, means and t-test were used.
Results: 87 nursing record from 8 departments were evaluated (42 before and 45 after training). The results showed statistically
reliable differences in the improvement of the quantity of the structure of nursing record (t(85)=-3.004, p=0.004), quality
of nursing anamnesis (t(85)=-2.915, p=0.005), quantity of nursing diagnoses (t(85)=-4.387, p<0.0001), quality of nursing
diagnoses (t(85)=-5.768, p<0.0001), quantity of nursing interventions (t(85)=-2.982, p=0.004), quality of nursing interventions
(t(85=-4.343, p<0.0001), quantity of assessment (t(85)=-2.439, p=0.017) and quality of assessment (t(85)=-3.209, p=0.002). No
statistically reliable differences were found for the quantity of nursing anamnesis and the legibility of documentation.
Conclusion & Significance: The study showed the importance of NANDA training in application of new documentation
requirements in nursing practice.
Biography
Irma Nool is affiliated to Tallinn Health Care, Estonia. Irma Nool has her expertise in critical thinking in nursing practice, enhancing the quality of nursing care. She has
completed her Master of Public Health at University of Tartu from 2003-2006, Bachelor of Nursing at University of Tartu from 2003-2006 and Nurse Tallinn Medical School
from 1992-1993.
Irma Nool et al., Adv Practice Nurs 2018, Volume 3
DOI: 10.4172/2573-0347-C2-020