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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. [ABSTRACT FROM AUTHOR]

The study was planned to determine the most common nursing diagnoses according to NANDA International (NANDA-1) taxonomy and difficulties experienced in using of nursing process in COVID-19 outbreak. The sample of the descriptive cross-sectional study consisted of nurses cared for patients with COVID-19 (n= 114). Average age of nurses is 26.86 ± 6.68. Commonly determined nursing diagnoses according to NANDA-1 taxonomy in patients with COVID-19 were imbalanced nutrition (66.7%), impaired gas exchange (40.4%), insomnia (21.1%), acute confusion (31.6%), hopelessness (96.5%), difficulty playing caregiver (84.2%), anxiety (38.6%) willingness to strengthen religious bond (71.9%), risk for infection (64.9%), nausea (49.1%). Twenty-four-years old and younger, high school graduates, caring for intubated patients, and those who stated that they did not use nursing diagnosis had more difficulty in using nursing process (<0.05). The use of nursing diagnoses and process for patients with COVID-19 is extremely important in ensuring individual and qualified nursing care. [ABSTRACT FROM AUTHOR]

Patient-care data from the electronic health record systems are increasingly in demand for re-use in administration and resource planning. Nursing documentation with coded concepts is expected to produce more reliable data, fulfilling better requirements for re-use. The aim was to ascertain what kind of relation exist between coded nursing diagnoses, nursing interventions, and nursing intensity and to discuss the possibilities for re-using nursing data for workload design. We analysed the retrospective nursing records of 794 patients documented by the Finnish Care Classification and nursing intensity data assessed by the Oulu Patient Classification over a 15-day period in nine inpatient units at a university hospital. Using the generalised linear mixed model, the clear relationship between the number of coded nursing notes and nursing intensity levels were ascertained. The number of coded nursing notes increases when the nursing intensity increases. The outcomes construct a good basis for continuing elaboration of electronic health record data re-use. [ABSTRACT FROM AUTHOR]

East Asia has historically unique concepts of health and well-being and thus is an appropriate setting for exploring the multicultural applicability of the North American Nursing Diagnosis Association’s Nursing Diagnoses (NANDA ND) system. This study aimed to explore how NANDA ND affect the growth and quality of professional nursing from the perspective of Taiwanese nurses. Grounded theory was employed in this interview-based investigation of 53 Taiwan-licensed nursing professionals at various hospitals in Taiwan. Data were analyzed using constant comparative analysis until theoretical saturation was reached. The core concept, Struggling with (the NANDA ND notion that) One Size Fits All, emerged after ongoing analysis of the effects of NANDA ND on good nursing, patient welfare, and professional development. The preliminary theoretical framework developed from this study provides evidence that NANDA ND may be incompatible with the cultural beliefs of the traditional Chinese health care setting in Taiwan, which emphasize holistic harmony and balance. [ABSTRACT FROM PUBLISHER]

Addresses concerns and challenges facing the nursing profession in the U.S., with emphasis on person-centered care. Effort by nurse technologists to promote nursing care based on evidence; Concern over the mechanization of nursing; Concept of person-centered care.