Development of an instrument to measure the quality of documented nursing diagnoses, interventions and outcomes: the Q-DIO

Authors

  • Maria Müller-Staub,

    1. Authors:Maria Müller-Staub, MNS, PhD, RN, EdN, Director, Pflege PBS, Bern, Switzerland; Margaret Lunney, PhD, RN, Professor, Department of Nursing, College of Staten Island, The City University of New York, Staten Island, NY, USA; Matthias Odenbreit, MNS, RN, EdN, Project Director, SoH Spital Solothurn, Solothurn, Switzerland; Ian Needham, MNS, PhD, RN, EdN, Clinical Nurse Specialist, Department of Education, Consulting and Development, Centre of Psychiatry Rheinau, Rheinau, Switzerland; Mary Ann Lavin, ScD, FAAN, RN, Associate Professor, Saint Louis University School of Nursing, St Louis, MI, USA; Theo van Achterberg, MSc, PhD, RN, Professor, Nursing Science, Centre for Quality of Care Research, University Medical Centre, Nijmegen, The Netherlands
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  • Margaret Lunney,

    1. Authors:Maria Müller-Staub, MNS, PhD, RN, EdN, Director, Pflege PBS, Bern, Switzerland; Margaret Lunney, PhD, RN, Professor, Department of Nursing, College of Staten Island, The City University of New York, Staten Island, NY, USA; Matthias Odenbreit, MNS, RN, EdN, Project Director, SoH Spital Solothurn, Solothurn, Switzerland; Ian Needham, MNS, PhD, RN, EdN, Clinical Nurse Specialist, Department of Education, Consulting and Development, Centre of Psychiatry Rheinau, Rheinau, Switzerland; Mary Ann Lavin, ScD, FAAN, RN, Associate Professor, Saint Louis University School of Nursing, St Louis, MI, USA; Theo van Achterberg, MSc, PhD, RN, Professor, Nursing Science, Centre for Quality of Care Research, University Medical Centre, Nijmegen, The Netherlands
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  • Matthias Odenbreit,

    1. Authors:Maria Müller-Staub, MNS, PhD, RN, EdN, Director, Pflege PBS, Bern, Switzerland; Margaret Lunney, PhD, RN, Professor, Department of Nursing, College of Staten Island, The City University of New York, Staten Island, NY, USA; Matthias Odenbreit, MNS, RN, EdN, Project Director, SoH Spital Solothurn, Solothurn, Switzerland; Ian Needham, MNS, PhD, RN, EdN, Clinical Nurse Specialist, Department of Education, Consulting and Development, Centre of Psychiatry Rheinau, Rheinau, Switzerland; Mary Ann Lavin, ScD, FAAN, RN, Associate Professor, Saint Louis University School of Nursing, St Louis, MI, USA; Theo van Achterberg, MSc, PhD, RN, Professor, Nursing Science, Centre for Quality of Care Research, University Medical Centre, Nijmegen, The Netherlands
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  • Ian Needham,

    1. Authors:Maria Müller-Staub, MNS, PhD, RN, EdN, Director, Pflege PBS, Bern, Switzerland; Margaret Lunney, PhD, RN, Professor, Department of Nursing, College of Staten Island, The City University of New York, Staten Island, NY, USA; Matthias Odenbreit, MNS, RN, EdN, Project Director, SoH Spital Solothurn, Solothurn, Switzerland; Ian Needham, MNS, PhD, RN, EdN, Clinical Nurse Specialist, Department of Education, Consulting and Development, Centre of Psychiatry Rheinau, Rheinau, Switzerland; Mary Ann Lavin, ScD, FAAN, RN, Associate Professor, Saint Louis University School of Nursing, St Louis, MI, USA; Theo van Achterberg, MSc, PhD, RN, Professor, Nursing Science, Centre for Quality of Care Research, University Medical Centre, Nijmegen, The Netherlands
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  • Mary Ann Lavin,

    1. Authors:Maria Müller-Staub, MNS, PhD, RN, EdN, Director, Pflege PBS, Bern, Switzerland; Margaret Lunney, PhD, RN, Professor, Department of Nursing, College of Staten Island, The City University of New York, Staten Island, NY, USA; Matthias Odenbreit, MNS, RN, EdN, Project Director, SoH Spital Solothurn, Solothurn, Switzerland; Ian Needham, MNS, PhD, RN, EdN, Clinical Nurse Specialist, Department of Education, Consulting and Development, Centre of Psychiatry Rheinau, Rheinau, Switzerland; Mary Ann Lavin, ScD, FAAN, RN, Associate Professor, Saint Louis University School of Nursing, St Louis, MI, USA; Theo van Achterberg, MSc, PhD, RN, Professor, Nursing Science, Centre for Quality of Care Research, University Medical Centre, Nijmegen, The Netherlands
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  • Theo Van Achterberg

    1. Authors:Maria Müller-Staub, MNS, PhD, RN, EdN, Director, Pflege PBS, Bern, Switzerland; Margaret Lunney, PhD, RN, Professor, Department of Nursing, College of Staten Island, The City University of New York, Staten Island, NY, USA; Matthias Odenbreit, MNS, RN, EdN, Project Director, SoH Spital Solothurn, Solothurn, Switzerland; Ian Needham, MNS, PhD, RN, EdN, Clinical Nurse Specialist, Department of Education, Consulting and Development, Centre of Psychiatry Rheinau, Rheinau, Switzerland; Mary Ann Lavin, ScD, FAAN, RN, Associate Professor, Saint Louis University School of Nursing, St Louis, MI, USA; Theo van Achterberg, MSc, PhD, RN, Professor, Nursing Science, Centre for Quality of Care Research, University Medical Centre, Nijmegen, The Netherlands
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Maria Müller-Staub, Director, Pflege PBS, Stettlerstrasse 15, CH – 3006 Bern, Switzerland. Telephone: +41 31 351 23 09.
E-mail:muellerstaub@bluewin.ch

Abstract

Aims and objectives.  This paper aims to report the development stages of an audit instrument to assess standardised nursing language. Because research-based instruments were not available, the instrument Quality of documentation of nursing Diagnoses, Interventions and Outcomes (Q-DIO) was developed.

Background.  Standardised nursing language such as nursing diagnoses, interventions and outcomes are being implemented worldwide and will be crucial for the electronic health record. The literature showed a lack of audit instruments to assess the quality of standardised nursing language in nursing documentation.

Design.  A qualitative design was used for instrument development.

Methods.  Criteria were first derived from a theoretical framework and literature reviews. Second, the criteria were operationalised into items and eight experts assessed face and content validity of the Q-DIO.

Results.  Criteria were developed and operationalised into 29 items. For each item, a three or five point scale was applied. The experts supported content validity and showed 88·25% agreement for the scores assigned to the 29 items of the Q-DIO.

Conclusions.  The Q-DIO provides a literature-based audit instrument for nursing documentation. The strength of Q-DIO is its ability to measure the quality of nursing diagnoses and related interventions and nursing-sensitive patient outcomes. Further testing of Q-DIO is recommended.

Relevance to clinical practice.  Based on the results of this study, the Q-DIO provides an audit instrument to be used in clinical practice. Its criteria can set the stage for the electronic nursing documentation in electronic health records.

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