Abstract:

Background: Documentation of nursing care is core to the Nursing profession and to share information on patients/clients with other nurses and between clinical disciplines and care settings, data needs to be recorded and stored in a standardized form. Therefore, to make the care nurses give to be visible, NANDA-I, NIC & NOC was endorsed to be used for documentation.

Purpose: The purpose of the study was to evaluate whether NANDA-I, NIC, & NOC was used for documentation of care at the maternal and infant welfare units of selected Primary Health Centres (PHCs).

Methodology: A retrospective descriptive research design was adopted in this study. Random sampling technique was used to select 5 PHCs. All patient nursing care plan records documented with NANDA-I, NIC & NOC was utilized for data analysis. Data was analyzed using the Statistical Package for Social Sciences (SPSS) version 17.0 for both descriptive and inferential statistics.

Results: Findings revealed that nursing care was documented using NNN. There was no significant difference in the NANDA-I nursing diagnoses, NIC & NOC used as the t calculated value of -1.00 was lesser than the critical value of 1.96, which was not significant at 0.05 alpha levels.

Conclusion: This study has evaluated the documentation of care using NNN in PHCs. It is imperative to state that using NNN for documentation of care is a way of showing evidence-based practice. The researcher therefore recommends that the use and documentation quality of the NNN be evaluated periodically, and corresponding feedbacks given to nurses.

Keywords: Evaluation, Documentation, NANDA-I nursing diagnoses, Nursing Intervention Classification, Nursing Outcome Classification.

References:

[1].    Abreu, M. (2006). NANDA, NOC and NIC linkages in the care of orthopaedic patients in a Brazilian University Hospital. International Journal of Nursing Terminologies & Classifications, 17(10, 19-20.

[2].    Allen, S., Chapman, Y., O Conor, M &Francis, K. (2007). The importance of language for nursing: does it convey commonality of meaning and is it important to do so? Australian Journal of Advanced Nursing Volume 24(4), retrieved March 10, 2009 from http://www.nursingworld.org

[3].    American Nurses Association (2007). ANA Recognized Terminologies and Data Element Sets.

[4].   Available at http.nursingworld.org/npii/terminologies.htm. Accessed August 5, 2009.

[5].    American Nurses Association. (2009). Recognized languages for nursing. Retrieved from
 http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/Nursing

[6].   Standards/DocumentationInformatics/NIDSEC/RecognizedLanguagesforursing.aspx

[7].    Aquillino, M.L. & Keenan, G. (2001). Having our say: nursing’s standardized nomenclatures. The American J Nurs. 2001; 100(7): 33-38. Available from http://www.jstor.org/stable/3521755

[8].    Association of Perioperative Registered Nurses (2016). Perioperative nursing data set. Available from

[9].   http://www.aorn.org/research/

[10].Bakken, S., Holzemer, W. L., Portillo, C., Grimes, R., Welch, J. and Watland, D. (2005). Utility of a standardized nursing terminology to evaluate dosage and tailoring of an HIV/AIDs adherence intervention. Journal of Nursing Scholarship, 37(3), 251-257.

[11].Beyea, S.C. (1999). Standardized language – Making nursing practice count. AORN Journal, 70(5), 834, 837-838.

[12].Bjorwell, C., Thorell-Ekstrand, I., and Wredling, R. (2000). Development of an audit instrument for nursing care plans in the patient record. Quality in Health Care, 9, 6-10.

[13].Bostick, J.E., Riggs, C.J., and Rantz, M.J. (2003). Quality measurement in nursing. Journal of Nursing Care Quality 18(2), 94-10.

[14].Bulechek, G. M., Butcher, H., & Dochterman, J. M. (Eds.). (2008). Nursing interventions classification (NIC) (5th ed.). St. Louis, MO: Mosby Elsevier.

[15].College & Association of Registered Nurses of Alberta (2013). Documentation guidelines for registered nurses. Available at http://www.nurses.ab.ca/content/dam/carna/pdfs/DocumentLi st/Standards/DocumentationStandards_Jan2013.pdf

[16].Criminiello, C., Terjesen, M., & Lunney, M. (2009). Case study: Home nursing care for a 62-year old woman with multiple health problems. International Journal of Nursing Terminologies and Classifications, 20(2), 96-99.

[17].Dochterman, J., and Bulechek, G. M. (2004). Nursing Interventions Classification (NIC) 4^th ed. St. Louis; Mosby.

[18].Erdemir, F., & Algier, L. (2006). Potential nursing diagnoses and interventions in the care of patients in Burn unit: A pilot study. International Journal of Nursing Terminologies & Classifications, 17(1), 30-31.

[19].Gusen, N.J. (2015). Knowledge and utilization of standardized nursing language (NANDA-I, NIC and NOC) among nurses in Jos University Teaching Hospital, Plateau State. A research project submitted to the Nursing & Midwifery Council of Nigeria in partial fulfillment of the award of Registered Nurse (RN) certificate.

[20].Hughes, R. (2006). Identifying and defining the problems, interventions, and outcomes of spinal cord injury in Irish spinal cord injury service using standardized nursing language: A Delphi study. International Journal of Nursing Terminologies & Classifications, 17(1), 38-39.

[21].Johnson, M. (2006). Linking NANDA, NIC, & NOC. International Journal of Nursing Terminologies & Classifications, 17(1), 39-40.

[22].Kautz, D.D., Kuiper, R., Pesut., D.J., & Williams, R. (2006). Using NANDA, NIC, and NOC (NNN) Language for clinical reasoning. International Journal of Nursing Terminologies & Classifications, 17(1), 129-138.

[23].Linch, G. F. C., Müller-Staub, M., & Rabelo, E. R. (2010). Quality of nursing records and standardized language: Literature review. Online Brazilian Journal of Nursing, 9(2), 01–06.

[24].Olaogun, A. & Adejumo, P. (2014). Standardized nursing languages. A power point presentation on the occasion of NANDA-International African network northern zone conference, University of Abuja Teaching Hospital.

[25].Paans, W., Sermeus, W., Nieweg, R., & van der Schans, C. (2010). Determinants of the accuracy of nursing diagnoses: Influence of ready knowledge, knowledge sources, disposition toward critical thinking, and reasoning skills. Journal of Professional Nursing, 26(4), 232–241.

[26].Rogers, E.M. (2003). Diffusion of Innovations, 5^th edn. Free Press, New York, NY.

[27].Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice? Online Journal of Issues in Nursing, 13(1). doi:10.3912/OJIN.Vol13No01PPT05; Retrieved from http://www.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/HealthIT/StandardizedNursingLanguage.html

[28].Saranto, K., & Kinnunen, U. (2009). Evaluating nursing documentation— research designs and methods: Systematic review. Journal of Advanced Nursing, 65(3), 464–476.

[29].Smith, V., & Smith, K. (2007). Supporting evidence based practice through the use of standardized nursing languages. HIMSS webinar, March 28, 2007.

[30].Tastan, S., Linch, G. C. F., Keenan, G. M., Stifter, J., McKinney, D., Fahey, L., Wilkie, D. J. (2014).

[31].Evidence for the existing American Nurses Association-recognized standardized nursing terminologies: A system

[32].Thede, L.Q. & Sewell, J.P. (2012). ANA Recognized Standardized Terminologies that support Nursing Practice.

[33].Thoroddsen, A., & Ehnfors, M. (2007). Putting policy into practice: Pre- and posttests of implementing standardized languages for nursing documentation. Journal of Clinical Nursing, 16(10), 1826–1838.

[34].Vizoso, H., Lyskawa, M., & Couey, P. (2008). Standardized nursing care plan: A case study on developing a tool for clinical research. Western Journal of Nursing Research, 30(5), 578-587.

[35].Wang, N., Hailey D., & Yu, P. (2011). Quality of nursing documentation and approaches to its evaluation: mixed method systematic review. Journal of Advanced Nursing; 67(9):1858–75.

[36].Yang, J. J. (2007). An analysis of nursing outcomes and interventions according to nursing diagnoses for inpatients with brain hemorrhages by undergraduate nursing students. Chonnam Journal of Nursing Science, 12(1), 59–69.

[37].Yom, Y., Chi, S.A., & Yoo, H.S. (2002). Application of nursing diagnoses, interventions, and outcomes to patients undergoing abdominal surgery in Korea. International Journal of Nursing Terminology and Classifications, 13(3), 77-87.

[38].Yun, H. Y. (2002). Development of a nursing intervention protocol based on nursing diagnosis of medical-surgical patients (unpublished master’s thesis). Yonsei University, Seoul.