Effect of standardized nursing language continuing education programme on nurses' documentation of care at University College Hospital, Ibadan

Abstract Aim The study assessed the documentation of nursing care before, during and after the Standardized Nursing Language Continuing Education Programme (SNLCEP). It evaluates the differences in documentation of nursing care in different nursing specialty areas and assessed the influence of work experience on the quality of documentation of nursing care with a view to provide information on documentation of nursing care. The instrument used was an adapted scoring guide for nursing diagnosis, nursing intervention and nursing outcome (Q‐DIO). Design Retrospective record reviews design was used. Methods A total of 270 nursing process booklets formed the sample size. From each ward, 90 booklets were selected in this order: 30 booklets before the SNLCEP, 30 booklets during SNLCEP and 30 booklets after SNLCEP. Results Overall, the study concluded that the SNLCEP had a significant effect on the quality of documentation of nursing care using Standardized Nursing Languages.

diagnoses, development began in 1973 when a group of nurse leaders assembled to identify a system of labels to describe nursing practice (Johnson et al., 2006). According to NANDA-I (2012NANDA-I ( -2014, nursing diagnosis is a clinical judgement that provides the basis for selection of nursing interventions to achieve outcomes for which the nurse are accountable. The Nursing Intervention Classification (NIC), a classification system specific for nursing interventions, was first published in 1992 and included 336 interventions (Iowa Intervention Project, 2008).
An intervention is defined as "any treatment, based upon clinical judgment and knowledge that a nurse performs to enhance patient/client outcomes" (Bulechek, Butcher, Dochterman, & Wagner, 2013. Pg 6), while an individual nurse will have expertise in only a limited number of interventions reflecting on her or his specialty, the entire classification captures the expertise of all nurses.
The Nursing Outcome Classification (NOC) is a nursing classification system with specific labels used to describe outcomes for a client or group of clients. The development of the NOC was first published in 1997 (Iowa Outcomes Project, 2008). An outcome is a measurable individual, family or community, state, behaviour or perception that is measured along a continuum and is responsive to nursing interventions (Moorhead, Johnson, Maas, & Swanson, 2013).
The three components which are NANDA, NIC and NOC make up Standardized Nursing Language (SNL). Hence, SNL is "a structured vocabulary that provides nurses with a common means of communication to describe care" (Beyea, 1999). Hardiker, Hoy, and Casey (2000), argue that terminological standards in nursing (example NOC, NIC and NANDA) are one of the major tools used by the nursing profession to establish its autonomy as well, making nursing visible, given that these standards presents the range of nursing tasks that are over shadow by the works of physicians. The important thing is that these standards are necessary to achieve a system that supports nursing work in a multidisciplinary setting and representation of its outcome in health information systems (Hardiker et al., 2000). Bulechek, Butcher, & Dochterman, 2008 reported that the use of this SNL in nursing documentation can result in better continuity of care by improving communication among nurses (other healthcare providers) and capture more nursing activities as evidence to determine nursing costs, provide standards for improving the quality of nursing care and allow data collection which helps in evaluating the patient outcomes of nursing care. Falk and Bjorvell (2012) stated in a study conducted that, by assessing part of the nursing process it was relatively well documented in the patient record, although the analysis resulting in a nursing diagnosis, in Sweden written in free text format, generating a useful care plan is virtually non-existent. Meanwhile, nursing process and nursing diagnosis have a prominent position in the curricula of most institutions of higher education for nursing; it appears difficult to apply in clinical practice (Carpenito-Moyet, 2010).
According to Muller-Staub, Lavin, Needham, & van Achterberg, 2006, the use of SNLs in documenting care has improved the image of the nursing profession in developed nations. Several studies have been done globally, which are hospital-based care on documentation of care using SNLs (Bakken, 2007;Falk & Bjorvell, 2012;Muller-Staub, Needham, Odenbreit, Lavin, & van Achterberg, 2007; Oginni, Oyedeji, Nnahiwe, & Olatubi, 2011). Koczmara, Jelincic, and Dueck (2005) did a study which examined the accuracy of nursing documentation and inaccuracy of nursing documentation, the conclusion stated that nurses misinterpret thus putting patients in unsafe situations. However, a recent report by Odutayo, Olaogun, Oluwatosin, & Ogunfowokan (2013) stated that public health nurses in Nigeria at a posttest were able to identify actual nursing diagnoses with the signs and symptoms and aetiologies, while in the risk diagnoses they identified the nursing diagnoses with the risk related factors. They also identified NIC activities specific to solving client problems and linked indicators of NOC, which were related to the identified diagnoses and interventions. Bakken (2007) stated that in most developing countries especially sub-Saharan Africa nursing documentation is not at its best; she also noted that large numbers of under qualified nursing staff, lack of incentives such as reimbursement, accreditation among others that are attached to efficient documentation barely exist in developing countries. However, documentation is core to effective use of the nursing process for quality nursing care, but nurses have been noted to be poor in the extent which they document the care they give, especially related to use of appropriate nursing terminologies (Ammenwerth, Mansmann, Iller, & Eichstädter, 2003). Ammenwerth et al. (2003) stated that one of the greatest shortcomings of nursing has been its failure to clearly define and specifically delineate its functions and unique contributions to patient care using a SNL and this is currently the situation among clinical nurses. It is also observed that nursing is at a crossroad and this is no more evident than in discussions around the use of the languages, nursing diagnoses, interventions and outcomes in documentation of client care (Olaogun et al., 2011).
Unfortunately, in Nigeria, many nurses oppose the use of SNLs, stating "It's just another label" while they see no problem with the use of medical labels such as malaria or hip fracture. They feel the use of labels that articulate the unique patient problem from a nurse's perspective is redundant, vague and trivial (Olaogun et al., 2011).
Moreover, Thoroddssen and Ehnfors (2007) introduced SNL, such as NANDA and they stated that this has improved the quality of nursing documentation in the patient record. Odutayo et al. (2013) stated that, without the use of SNLs in documentation, the clinical reasoning and decision-making processes of nursing are obscured. They also said that nurses' risk functioning in a way that is more task driven with little disciplinary focus and makes nursing become hidden in a system that is dominated by medical care, while other healthcare disciplines are focused on advancing their science and the care they deliver, nursing responds by becoming less visible and assuming roles that make care contributions ambiguous and indistinct (Odutayo et al., 2013).
Additionally, despite the training undergone by nursing staff of the University College Hospital, they often expressed difficulties about documenting nursing care according to the standardized terminologies in the nursing process booklets (NPBs). Hence, the researchers considered it worthwhile to measure the effect of standardized nursing language continuing education programme (SNLCEP) on documentation of nursing care at University College Hospital, Ibadan.

| Design
The study employed was a retrospective record review design.

| METHODS
The study was conducted in three wards at University College Hospital (UCH), southwestern Nigeria. UCH is strategically located in Ibadan, the largest city in West Africa, which is the seat of the premier It measures the documentation of nursing diagnosis, nursing interventions and outcomes. The "Nursing diagnoses as process" has 11 items measured on a 3-point Likert-type scale (2-0) with maximum score of 22, while "Nursing diagnoses as a product" has eight items measured on a 5-point Likert-type scale (4-0) with maximum score of 32. Furthermore, "Nursing intervention" has three items measured on a 5-point Likert-type scale (4-0) with maximum score of 12 and "Nursing outcomes" has seven items measured on a 5-point Likert scale (4-0) with maximum score of 28. The total item is 29 and total score is 94. The scoring was rated Low, Medium and High scores: Low-quality documentation (scores from 22-46), Medium-quality documentation (scores from 47-70) and High-quality documentation (scores from 71-94).
The content of SNLCEP provided was through an educational package that was developed by the authors from literature review and learning modules that were produced and used during the 2010 international workshop on NANDA-I diagnostic classification, NOC and NIC (Brokel & Herdman, 2010a, 2010b, 2010cButcher, 2010;Moorhead, 2010). This package is made up of four learning modules.

| Ethics
Ethical clearance was obtained from the Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Nigeria. Approval number NHREC/05/01/2008a. Permission was also taken from the ward coordinators and chief nursing officers of the selected wards. However, informed consent was taken from the nurses involved in documentation. Table 1, 270 nurses attended the SNLCEP, and this same set of nurses documented in the NPBs. The number of NPBs documented in on each ward was 90 each. However, none of the nurses who documented in NPBs had a postgraduate degree in nursing. Their highest nursing education is Diploma in Nursing. The nurses' with 1-5 years of experience documented more in the NPBs. Table 2, the mean score of the documentation after the SNLCEP was 72.28 (SD 14.74). This showed that SNLCEP had an effect on nurses documentation of care. As shown in Table 3, the surgical ward had a mean of 71 (SD 14.97); hence the SNLCEP improved quality of documentation on the surgical ward, followed by psychiatric ward and medical ward. Table 4 shows that there was significant difference in documentation of nursing care among the ward. As shown in Table 5, nurses with 1-5 years of experience had a mean of 65.25 (SD 16.26). However, the nurses with 1-5 years had an improved quality of documentation of nursing care. As shown in the Table 6, the chi-square test result showed that there was no significant difference, with x 2 = 2.57, df = 4 and p value greater than 0.05.  2007) and Criminiello, Terjesen, & Lunney (2009) discovered that before the implementation of NNN, nursing problems were formulated in freestyle without the use of standardized classification. But after SNLCEP, data showed significant improvement in documentation. Abreu (2006) and Hughes (2006) Adeyemo and Olaogun (2013) who reported that the more nurses are knowledgeable, the more their use of nursing process.

| DISCUSSION
T A B L E 2 Documentation of nurses before, during and after standardized nursing language continuing education programme The findings from the study also provided insight into the quality of documentation of nursing care in medical, surgical and psychiatric wards among participants after SNLCEP, which were significant. This is consistent with the study conducted in Ahmadu Bello University Teaching Hospital that showed that there was significant difference in quality of documentation of nursing care in the level of implementation of NPBs across units such as medical, surgical, obstetrics and gynaecology, paediatrics and special units after educational package (Garba et al.,2011as cited by Edet, Mgbekem, & Edet, 2012. It was reflected in the study that the quality of documentation of nursing care among nurses with various work experiences was not significant. This is at variance with report of the study conducted by Sani and Sani (2013  as regard SNLs. Also, there was no significant difference in the quality of documentation of nursing care and nurses work experience.

| CONCLUSION
However, significant efforts have been made to unify SNLs through the taxonomy of NNN. Furthermore, this study has demonstrated that the education of nurses on the nursing process and the implementation of SNLs through the SNLCEPs is a viable way to improve nurse skills in the documentation of care.
The NPBs were difficult to retrieve due to poor record keeping by nurses. The literatures reviewed on studies done on SNLs were based on the available local studies. There is a need for more research in Nigeria and other African nations on how SNLs can be adapted to client care and the effect of SNLs on the quality of nursing care.