AIM: To identify what determinants influence the prevalence and accuracy of nursing diagnosis documentation in clinical practice.BACKGROUND: Nursing diagnoses guide and direct nursing care. They are the foundation for goal setting and provide the basis for interventions. The literature mentions several factors that influences nurses' documentation of diagnoses, such as a nurse's level of education, patient's condition and the ward environment.DESIGN: Systematic review.METHOD: MEDLINE and CINAHL databases were searched using the following headings and keywords: nursing diagnosis, nursing documentation, hospitals, influence, utilisation, quality, implementation and accuracy. The search was limited to articles published between 1995-October 2009. Studies were only selected if they were written in English and were primary studies addressing factors that influence nursing diagnosis documentation.RESULTS: In total, 24 studies were included. Four domains of factors that influence the prevalence and accuracy of diagnoses documentation were found: (1) the nurse as a diagnostician, (2) diagnostic education and resources, (3) complexity of a patient's situation and (4) hospital policy and environment.CONCLUSION: General factors, which influence decision-making, and nursing documentation and specific factors, which influence the prevalence and accuracy of nursing diagnoses documentation, need to be distinguished. To support nurses in documenting their diagnoses accurately, we recommend taking a comprehensive perspective on factors that influence diagnoses documentation. A conceptual model of determinants that influence nursing diagnoses documentation, as presented in this study, may be helpful as a reference for nurse managers and nurse educators.RELEVANCE TO CLINICAL PRACTICE: This review gives hospital management an overview of determinants for possible quality improvements in nursing diagnoses documentation that needs to be undertaken in clinical practice.
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AIM: To obtain an overview of existing evidence on quality criteria, instruments, and requirements for nursing documentation.DESIGN: Systematic review of systematic reviews.DATA SOURCES: We systematically searched the databases PubMed and CINAHL for the period 2007-April 2017. We also performed additional searches.REVIEW METHODS: Two reviewers independently selected the reviews using a stepwise procedure, assessed the methodological quality of the selected reviews, and extracted the data using a predefined extraction format. We performed descriptive synthesis.RESULTS: Eleven systematic reviews were included. Several quality criteria were described referring to the importance of following the nursing process and using standardized nursing terminologies. In addition, some evidence-based instruments were described for assessing the quality of nursing documentation, such as the D-Catch. Furthermore, several requirements for formats and systems of electronic nursing documentation were found that refer to the importance of user-friendliness and development in consultation with nursing staff.CONCLUSION: Aligning documentation with the nursing process, using standard terminologies, and using user-friendly formats and systems appear to be important for high-quality nursing documentation. The lack of evidence-based quality indicators presents a challenge in the pursuit of high-quality nursing documentation.IMPACT: There is uncertainty in nursing practice about which criteria have to be met to achieve high-quality documentation. Aligning documentation with the nursing process, using standard terminologies, and using user-friendly formats and systems appear to be important. These findings can help nursing staff and care organizations enhance the quality of nursing documentation.
BACKGROUND: Patient participation in nursing documentation has several benefits like including patients' personal wishes in tailor-made care plans and facilitating shared decision-making. However, the rise of electronic health records may not automatically lead to greater patient participation in nursing documentation. This study aims to gain insight into community nurses' experiences regarding patient participation in electronic nursing documentation, and to explore the challenges nurses face and the strategies they use for dealing with challenges regarding patient participation in electronic nursing documentation.METHODS: A qualitative descriptive design was used, based on the principles of reflexive thematic analysis. Nineteen community nurses working in home care and using electronic health records were recruited using purposive sampling. Interviews guided by an interview guide were conducted face-to-face or by phone in 2019. The interviews were inductively analysed in an iterative process of data collection-data analysis-more data collection until data saturation was achieved. The steps of thematic analysis were followed, namely familiarization with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and reporting.RESULTS: Community nurses believed patient participation in nursing documentation has to be tailored to each patient. Actual participation depended on the phase of the nursing process that was being documented and was facilitated by patients' trust in the accuracy of the documentation. Nurses came across challenges in three domains: those related to electronic health records (i.e. technical problems), to work (e.g. time pressure) and to the patients (e.g. the medical condition). Because of these challenges, nurses frequently did the documentation outside the patient's home. Nurses still tried to achieve patient participation by verbally discussing patients' views on the nursing care provided and then documenting those views at a later moment.CONCLUSIONS: Although community nurses consider patient participation in electronic nursing documentation important, they perceive various challenges relating to electronic health records, work and the patients to realize patient participation. In dealing with these challenges, nurses often fall back on verbal communication about the documentation. These insights can help nurses and policy makers improve electronic health records and develop efficient strategies for improving patient participation in electronic nursing documentation.
KnowledgeFlows in Marine Spatial Planning - Sharing Innovation in Higher Education(KnowledgeFlows) aims at further enforcing the European higher education community to meet the growing demands for knowledge, skills and innovation within the still emerging field of marine or maritime spatial planning (MSP).Marine Spatial Planning (MSP) is an emerging governmental approach towards a more effective use of the sea. MSP is of great interest in Europe and can be considered a societal process to balance conflicting interests of maritime stakeholders and the marine environment. Many different activities take place at sea, ranging from shipping, fisheries, to offshore wind energy activities. Simultaneously, new and evolving policies focus on strategies to integrate different marine demands in space and resources. MSP is now legally binding in the EU and is much needed approach to manage and organize the use of the sea, while also protecting the environment.KnowledgeFlows will contribute to the development of new innovative approaches to higher education and training on MSP by means of problem-based learning schemes, transdisciplinary collaboration, and advanced e-learning concepts. KnowledgeFlows builds on results from former project outputs (Erasmus+ Strategic Partnership for Marine Spatial Planning SP-MSP), such as the online learning platform MSP Education Arena (https://www.sp-msp.uol.de).The strategic partnership consists of a transnational network of experts both in research and in practice based in the north Atlantic, Baltic Sea and North Sea Regions including Aalborg University (DK, lead partner), The University of Oldenburg (D), the University of Liverpool (U.K.), the University of Nantes (F), the Leibniz Institute for Baltic Sea Research (D), the Breda University of Applied Sciences (NL), University of Ulster (U.K.), and the Finnish Environment Institute (FI). Gothenburg University, also being a higher education organisation, will be associated partner.Furthermore, three international organisations, the Marine Spatial Planning Research Network, the Baltic inter-governmental VASAB and the pan-Nordic Nordregio will be involved in the partnership as associated organisations deeply rooted in the MSP community of practice.The further improvement of curricula, exchange of knowledge and experts, and transparency and recognition of learning outcomes to reach higher qualifications in MSP are key components of KnowledgeFlows. A mutual learning environment for MSP higher education will enable problem-driven innovation among students and their educators from research and governance also involving stakeholders. Related activities on intellectual outputs, multiplier events and lecturing will be carried out by all participating organisations.The intellectual outputs are related to three major contributions to the European higher education landscape:1) an advanced level international topical MSP course (Step-up MSP)2) digital learning facilities and tools (MSP Education Arena)3) designing problem-based learning in MSP (MSP directory)The advanced level inter-institutional topical MSP course will include different teaching and training activities within a problem-based learning environment. Digital learning facilities enabling communication and training will include a further enrichment of the MSP Education Arena platform for students, practitioners and lecturers for including modules forcollaborate learning activities, documentation and dissemination, mobilisation/recruitment, thesis opportunities, placements/internships. Designing problem-based learning in MSP will include topics as; the design of didactics and methods; guidance for lecturers, supervisors and students; evaluation and quality assurance; assessment.Five multiplier events back to back or as part of conferences within the MSP community will be organised to mainstream the outputs and innovative MSP didactics among other universities and institutions.Different teaching and training activities feeds into the intellectual output activities, which will include serious gaming sessions (MSP Challenge (http://www.mspchallenge.info/) and others), workshops, excursions, courses/classes as well as a conference with a specific focus on facilitating the exchange of innovative ideas and approaches among students at bachelor´s, master´s and doctoral level and the MSP community of practice.Project management meetings (twice a year) will assure coherence in project planning and implementation. As the core focus of the strategic partnership is on collaboration, mutual learning, and innovation among educators, students, and practitioners in order to meet actual and future needs regarding knowledge exchange and training within the MSP community, the project will be designed to have long lasting effects.Results
Quality criteria for patient documentation have to be developed based on research evidence. This project addresses the process of gathering patient information, processing information, and using information in the chain of care.
In summer 2020, part of a quay wall in Amsterdam collapsed, and in 2010, construction for a parking lot in Amsterdam was hindered by old sewage lines. New sustainable electric systems are being built on top of the foundations of old windmills, in places where industry thrived in the 19th century. All these examples have one point in common: They involve largely unknown and invisible historic underground structures in a densely built historic city. We argue that truly circular building practices in old cities require smart interfaces that allow the circular use of data from the past when planning the future. The continuous use and reuse of the same plots of land stands in stark contrast with the discontinuity and dispersed nature of project-oriented information. Construction and data technology improves, but information about the past is incomplete. We have to break through the lack of historic continuity of data to make building practices truly circular. Future-oriented construction in Amsterdam requires historic knowledge and continuous documentation of interventions and findings over time. A web portal will bring together a range of diverse public and private, professional and citizen stakeholders, each with their own interests and needs. Two creative industry stakeholders, Yume interactive (Yume) and publisher NAI010, come together to work with a major engineering office (Witteveen+Bos), the AMS Institute, the office of Engineering of the Municipality of Amsterdam, UNESCO NL and two faculties of Delft University of Technology (Architecture and Computer Science) to inventorize historic datasets on the Amsterdam underground. The team will connect all the relevant stakeholders to develop a pilot methodology and a web portal connecting historic data sets for use in contemporary and future design. A book publication will document the process and outcomes, highlighting the need for circular practices that tie past, present and future.
