Introduction: In electronic health records (EHRs), standardized nursing terminologies (SNTs), such as nursing diagnoses (NDs), are needed to demonstrate the impact of nursing care on patient outcomes. Unfortunately, the use of NDs is not common in clinical practice, especially in surgical settings, and is rarely included in EHRs. Objective(s): The aim of the study was to describe the prevalence and trend of NDs in a hospital surgical setting by also analyzing the relationship between NDs and hospital outcomes. Methods: A retrospective study was conducted. All adult inpatients consecutively admitted to one of the 15 surgical inpatient units of an Italian university hospital across 1 year were included. Data, including the Professional Assessment Instrument and the Hospital Discharge Register, were collected retrospectively from the hospital's EHRs. Results: The sample included 5,027 surgical inpatients. There was a mean of 6.3 ± 4.3 NDs per patient. The average distribution of NDs showed a stable trend throughout the year. The most representative NANDA-I ND domain was safety/protection. The total number of NDs on admission was significantly higher for patient whose length of stay was longer. A statistically significant correlation was observed between the number of NDs on admission and the number of intra-hospital patient transfers. Additionally, the mean number of NDs on admission was higher for patients who were later transferred to an intensive care unit compared to those who were not transferred. Conclusion: NDs represent the key to understanding the contribution of nurses in the surgical setting. NDs collected upon admission can represent a prognostic factor related to the hospital's key outcomes.

Cesare, M., D'Agostino, F., Maurici, M., Zega, M., Zeffiro, V., Cocchieri, A. (2023). Standardized Nursing Diagnoses in a Surgical Hospital Setting: A Retrospective Study Based on Electronic Health Data. SAGE OPEN NURSING, 9, 1-18 [10.1177/23779608231158157].

Standardized Nursing Diagnoses in a Surgical Hospital Setting: A Retrospective Study Based on Electronic Health Data

Maurici M.;Zeffiro V.;
2023-01-01

Abstract

Introduction: In electronic health records (EHRs), standardized nursing terminologies (SNTs), such as nursing diagnoses (NDs), are needed to demonstrate the impact of nursing care on patient outcomes. Unfortunately, the use of NDs is not common in clinical practice, especially in surgical settings, and is rarely included in EHRs. Objective(s): The aim of the study was to describe the prevalence and trend of NDs in a hospital surgical setting by also analyzing the relationship between NDs and hospital outcomes. Methods: A retrospective study was conducted. All adult inpatients consecutively admitted to one of the 15 surgical inpatient units of an Italian university hospital across 1 year were included. Data, including the Professional Assessment Instrument and the Hospital Discharge Register, were collected retrospectively from the hospital's EHRs. Results: The sample included 5,027 surgical inpatients. There was a mean of 6.3 ± 4.3 NDs per patient. The average distribution of NDs showed a stable trend throughout the year. The most representative NANDA-I ND domain was safety/protection. The total number of NDs on admission was significantly higher for patient whose length of stay was longer. A statistically significant correlation was observed between the number of NDs on admission and the number of intra-hospital patient transfers. Additionally, the mean number of NDs on admission was higher for patients who were later transferred to an intensive care unit compared to those who were not transferred. Conclusion: NDs represent the key to understanding the contribution of nurses in the surgical setting. NDs collected upon admission can represent a prognostic factor related to the hospital's key outcomes.
2023
Pubblicato
Rilevanza nazionale
Articolo
Esperti anonimi
Settore MED/45 - SCIENZE INFERMIERISTICHE GENERALI, CLINICHE E PEDIATRICHE
Settore MED/42 - IGIENE GENERALE E APPLICATA
English
Con Impact Factor ISI
electronic health records
hospital length of stay
intra-hospital patient transfer
nursing diagnoses
patient outcomes
standardized nursing terminologies
surgery
transfer to intensive care unit
https://journals.sagepub.com/doi/epub/10.1177/23779608231158157
Cesare, M., D'Agostino, F., Maurici, M., Zega, M., Zeffiro, V., Cocchieri, A. (2023). Standardized Nursing Diagnoses in a Surgical Hospital Setting: A Retrospective Study Based on Electronic Health Data. SAGE OPEN NURSING, 9, 1-18 [10.1177/23779608231158157].
Cesare, M; D'Agostino, F; Maurici, M; Zega, M; Zeffiro, V; Cocchieri, A
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Utilizza questo identificativo per citare o creare un link a questo documento: https://hdl.handle.net/2108/320844
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