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Objectives: This study explores the evidence available on Nursing Minimum Data Sets (NMDSs) by summarising: (a) the main methodological and reporting features of the reviews published in this field to date; (b) the recommendations developed and published in such reviews regarding the NMDSs, and (c) the categories and items that should be included in the NMDSs according to the available reviews. Methods: An Umbrella Review was performed. A search of secondary studies published up to November 2021 that were focused on NMDSs for adult hospitalised patients was conducted using MEDLINE (via PubMed), CINAHL and Scopus databases. The included studies were critically evaluated by using the Checklist for Systematic Review and Research Syntheses. The full review process was performed according to the Preferred Reporting Items for Systematic reviews and the Meta-Analyses statement. Results: From the initial 1311 studies that were retrieved, a total of eight reviews published from 1995 to 2018 were included. Their methodological quality was variable; these reviews offered four types of recommendations, namely at the overall, clinical, research and management levels. Additionally, seven NMDSs emerged with different purposes, elements, target populations and taxonomies. A list of categories and items that should be included in NMDSs have been summarised. Conclusions: Nurses are daily involved in the nursing care documentation; however, which elements are recorded is mainly defined at the local levels and relies on paper and pencil. NMDS might provide a point of reference, specifically in the time of health digitalisation. Alongside other priorities as underlined in available recommendations, and the need to improve the quality of the reviews in this field, there is a need to develop a common NMDS by establishing its core elements, deciding on a standardised language and identifying linkages with other datasets.

ICN anticipates that ICNP® users will develop more catalogues as more nurses use ICNP® in electronic health records and digital communication devices. Nurses who use ICNP® in the documentation of their practice should know the core data elements for their specialty or setting. The following questions needed to be answered: “What nursing diagnoses are most commonly used?”, “What nursing interventions are used?” and “What care recipient outcomes are used in that specialty or setting?” Since ICNP® was first released in 2005, many pre-coordinated statements have been added to the terminology and more catalogues have been developed by nurse experts and published by ICN. The critical need for continued development of ICNP® is the use of the terminology in clinical settings so that the collection of standardized data is available for analysis and research. In this way, nursing will be described. Nurses will then be able to say: “these are our most common diagnoses and interventions” and “these are the best or most-preferred care recipient outcomes.”

Aims To measure the inter-rater reliability of the Oulu Patient Classification (OPCq) and to discuss existing methods of reliability testing. Background The OPCq, part of the RAFAELA® System, has been developed to assist nursing managers with the proper allocation of nursing resources. Due to the increased intensity of inpatient care during recent years, there is a need for the reliability testing of the classification, which has been in clinical use for 20 years. Design Retrospective statistical study. Methods To test inter-rater reliability, a pair of nurses classified the same patients, without knowledge of each other's ratings, as a part of annually conducted standardization. Data on the parallel classifications (n = 19,997) was obtained from inpatient units (n = 32) with different specialties at a university hospital in Finland during 2010–2015. Parallel classification practices were also analysed. The reliability of the overall classification and its subareas were calculated using suitable statistical coefficients. Results Inter-rater reliability coefficients were a reliable or almost perfect means of considering the nursing intensity category and various practices, but there were detectable differences between subareas. The lowest agreement levels occurred in the subareas ‘Planning and Coordination of Nursing Care’ and ‘Guiding of Care/Continued Care and Emotional Support’. Conclusions There is a need to develop the descriptions of subareas and to clarify the related concepts. Precise nursing documentation can promote a high level of agreement and reliable results. The traditional overall proportion of agreement does not provide an adequate picture of reliability –weighted kappa coefficients should be used instead. This article is protected by copyright. All rights reserved.

Background Oncological diseases affect the biopsychosocial aspects of a person's health, resulting in the need for complex multidisciplinary care. The quality and outcomes of healthcare cannot be adequately assessed without considering the contribution of nursing care, whose essential elements such as the nursing diagnoses (NDs), nursing interventions (NIs), and nursing activities (NAs) can be recorded in the Nursing Minimum Data Set (NMDS). There has been little research using the NMDS in oncology setting. Objective The aim of this study was to describe the prevalence and distribution of NDs, NIs, and NAs and their relationship across patient age and medical diagnoses. Methods This was a prospective observational study. Data were collected between July and December 2014 through an NMDS and the hospital discharge register in an Italian hospital oncology unit. Results On average, for each of 435 enrolled patients, 5.7 NDs were identified on admission; the most frequent ND was risk for infection. During the hospital stay, 16.2 NIs per patient were planned, from which 25.2 NAs per day per patient were delivered. Only a third of NAs were based on a medical order, being the highest percentage delivered on nursing prescriptions. The number of NDs, NIs, and NAs was not related to patient age, but differed significantly among medical diagnoses. Conclusions An NMDS can depict patient needs and nursing care delivered in oncology patients. Such data can effectively describe nursing contribution to patient care. Implications for practice The use of an NMDS raises the visibility of nursing care in the clinical records. Such data enable comparison and benchmarking with other healthcare professions and international data.

Background There is a general belief that the markers of nursing home quality do not aggregate easily. Identifying consistent and coherent dimensions of quality that usefully summarize the multiplicity of nursing home quality measures is an important goal. It would simplify interpretation and help consumers, their families and advocates to choose nursing facilities. Objectives This study uses quality indicators (QIs) from a state nursing home report card to explore the dimensionality of quality in nursing homes and to determine whether aggregation at the resident versus facility level yields the same underlying dimensions. Design Cross-sectional study. Setting 382 Medicare- and/or Medicaid-certified nursing homes in Minnesota. Participants Residents admitted to the nursing homes during 2011–2012. Measurements 16 QIs obtained from the Minimum Data Set 3.0 assessment instrument between 2011 and 2012 were used in the exploratory factor analysis. Results Factor analysis results suggest four main factors or dimensions to characterize facility performance: continence care (including 4 QIs), restraints and behavioral symptoms (including 3 QIs), care for specific conditions (including 6 QIs), and physical functioning (including 3 QIs). The resident-level and facility-level results generally agreed for 11 QIs. Conclusion Nursing home quality of care can be captured in summary measures, which can be used by consumers, providers and researchers. Reporting at the resident or facility level will depend on the purpose. These summary measures can be used by policy-makers to identify and reward high-performing facilities and by families to choose nursing facilities for care.

Big data are large volumes of digital data that can be collected from disparate sources and are challenging to analyze. These data are often described with the five "Vs": volume, velocity, variety, veracity, and value. Perioperative nurses contribute to big data through documentation in the electronic health record during routine surgical care, and these data have implications for clinical decision making, administrative decisions, quality improvement, and big data science. This article explores methods to improve the quality of perioperative nursing data and provides examples of how these data can be combined with broader nursing data for quality improvement. We also discuss a national action plan for nursing knowledge and big data science and how perioperative nurses can engage in collaborative actions to transform health care. Standardized perioperative nursing data has the potential to affect care far beyond the original patient.

The electronic health record is a potentially rich source of data for clinical research in the intensive care unit setting. We describe the iterative, multi-step process used to develop and test a data abstraction tool, used for collection of nursing care quality indicators from the electronic health record, for a pragmatic trial. We computed Cohen’s kappa coefficient (κ) to assess interrater agreement or reliability of data abstracted using preliminary and finalized tools. In assessing the reliability of study data ( n = 1,440 cases) using the finalized tool, 108 randomly selected cases (10% of first half sample; 5% of last half sample) were independently abstracted by a second rater. We demonstrated mean κ values ranging from 0.61 to 0.99 for all indicators. Nursing care quality data can be accurately and reliably abstracted from the electronic health records of intensive care unit patients using a well-developed data collection tool and detailed training.

Aim: Documentation is a critical element in the function of the nursing team, and cannot be separated from high-quality, patient-centered care. The aim of this study was to compare the quality of nursing documentation in electronic and paper-based systems. Method: A retrospective descriptive study was designed to compare the quality of nursing documentation in electronic health records (EHR) versus paper-based documentation systems before and after the application of the electronic system. Results: Analysis of data found a significant difference in the quality of nursing documentation in the two hospitals both before and after the implementation of an EHR system (p < 0.001).Quality of nursing documentation in the electronic system was significantly better than that of paper-based documentation systems. Conclusion: Vocal-electronic systems help to improve quality of nursing documentation, suggesting this aspect may be essential to implementing a successful system in local settings.

Aim The aim of the present study was to develop a comprehensive understanding of the concept ‘workload’ within the nursing profession in order to arrive at a clear definition of nursing workload based on the evidence in existing literature. Background Nursing workload is a common term used in the health literature, but often without specification of its exact meaning. Concept clarification is needed to delineate the meaning of the term ‘nursing workload’. Method A concept analysis was conducted using Walker and Avant's method to clarify the defining attributes of nursing workload. As the subject matter was nursing focused, only one database was searched, the Cumulative Index for Nursing and Allied Health Literature (CINAHL). Articles that did not use ‘workload’ in the title or abstract were excluded. A model case, contrary case, related case and empirical referents were constructed to clarify the concept and to demonstrate how the workload is captured by the main attributes. Results The attributes of nursing workload found in the literature fall into five main categories: the amount of nursing time; the level of nursing competency; the weight of direct patient care; the amount of physical exertion; and complexity of care. The attributes were organised according to the leading antecedents, which were identified as the patient, nurse and health institution. Implications for Nursing Management Nurse managers need to address the workload issues with regard to the real nature of nursing work; this could increase nurses' productivity, nurses' satisfaction, turnover, work stress and provide sufficient staffing to patient care needs. Conclusion The concept analysis demonstrated clearly the complexity of the concept and its implications for practice and research. It is believed that the current concept analysis will help to provide a better understanding of nursing workload and contribute towards the standardisation of the nursing workload and the development of a valid and reliable measurement system.

El colectivo enfermero español no redacta de forma generalizada ningún Informe de Cuidados de Enfermería al Alta (ICEA) tras la atención hospitalaria del paciente que permita la continuidad de los cuidados. Desde que el Ministerio de Sanidad, Política Social e Igualdad presentara el Plan de Calidad para el Sistema Nacional de Salud (2006) donde se enmarcó el proyecto Historia Clínica Digital, diferentes grupos de trabajo han definido los Informes del Conjunto Mínimo de Datos, entre los que se incluye el Informe de Cuidados de Enfermería. Tomando una muestra aleatoria de enfermeras de los hospitales correspondientes a las nueve áreas de salud de la Región de Murcia, se analizan las capacidades científicas, las capacidades tecnológicas, el nivel de conocimientos y el acceso a la formación continuada que tienen sobre el contenido del ICEA. Los datos muestran que es necesaria una importante consolidación teórica y metodológica de las enfermeras hospitalarias más veteranas de la Región de Murcia, en diagnósticos NANDA, intervenciones recogidas en las NIC y medición de resultados enfermeros (NOC) que les permita redactar el ICEA., The Spanish nursing profession does not write any report widely to Alta Care Nurse after the patient's hospital care will allow for continuity of care. Since the Ministry of Health, Social Affairs and Equal submit the Quality Plan for the National Health System (2006) which framed the Medical Records project, various working groups have defined the reports of the Minimum Data Set, among which are included, the Nursing Care Report. We taking a random sample of nurses from hospitals for the nine health areas in the region of Murcia, discusses the scientific, technological capabilities, the level of knowledge and access to ongoing training with the nurses on the content of the discharge nurse. These data show that consolidation needs major theoretical and methodological most senior hospital nurses in the region of Murcia, in matters of NANDA diagnoses, interventions included in the NIC and measurement of nursing outcomes (NOC) to allow them to draft the Report of High Nursing.

OBJECTIVE: To identify all published nutritional screening instruments that have been validated in the adult population in primary healthcare settings and to report on their psychometric validity.INTRODUCTION: Within health care, there is an urgent need for the systematic collection of nursing care data in order to make visible what nurses do and to facilitate comparison, quality assurance, management, research and funding of nursing care. To be effective, nursing records should accurately and comprehensively document all required information to support safe and high quality care of patients. However, this process of documentation has been criticized from many perspectives as being highly inadequate. A Nursing Minimum Data Set within the nutritional area in primary health care could therefore be beneficial in order to support nurses in their daily documentation and observation of patients.INCLUSION CRITERIA: The review considered studies that included adults aged over 18 years of any gender, culture, diagnosis and ethnicity, as well as nutritional experts, patients and their relatives. The concepts of interest were: the nature and content of any nutritional screening tools validated (regardless of the type of validation) in the adult population in primary healthcare; and the views and opinions of eligible participants regarding the appropriateness of nutritional assessment were the concept of interest. Studies included must have been conducted in primary healthcare settings, both within home care and nursing home facilities.METHODS: This scoping review used a two-step approach as a preliminary step to the subsequent development of a Nursing Minimum Data Set within the nutritional area in primary healthcare: i) a systematic literature search of existing nutritional screening tools validated in primary health care; and ii) a systematic literature search on nutritional experts opinions on the assessment of nutritional nursing care of adults in primary healthcare as well as the views of patients and their relatives. Multiple databases (PubMed, CINAHL, Embase, Scopus, Swemed+, MedNar, CDC, MEDION, Health Technology Assessment Database, TRIP database, NTIS, ProQuest Dissertations and Theses, Google Scholar, Current Contents) were searched from their inception to September 2016.RESULTS: The results from the studies were extracted using pre-developed extraction tools to all three questions, and have been presented narratively and by using figures to support the text. Twenty-nine nutritional screening tools that were validated within a primary care setting, and two documents on consensus statements regarding expert opinion were identified. No studies on the patients or relatives views were identified.CONCLUSIONS: The nutritional screening instruments have solely been validated in an over-55 population. Construct validity was the type of validation most frequently used in the validation process covering a total of 25 of the 29 tools. Two studies were identified in relation to the third review question. These two documents are both consensus statement documents developed by experts within the geriatric and nutritional care field. Overall, experts find it appropriate to: i) conduct a comprehensive geriatric assessment, ii) use a validated nutritional screening instrument, and iii) conduct a history and clinical diagnosis, physical examination and dietary assessment when assessing primarily the elderly's nutritional status in primary health care.

There is no consistent, standardized, concise method for nurses to record information about their patients and clients that is conducive to store, retrieve, and use in patient and client care; to improve professional self-development; and to use in collaboration with patients and clients, their families, other nurses, doctors, hospitals, and health systems. Nurses gauge the health status of their patients and clients every day and are now in a position both to record their impressions for their own use and to share them with colleagues who care for the same patients and clients. What is now needed is a way to record these clinical impressions within an authoritative format that is related to the depth and breadth of the clinical literature related to nursing and the needs of the patients and clients nurses serve. The International Council of Nurses' Nurse-Patient Summary is proposed here to fill the gulf between narrative nurses' notes, proprietary and widely varying electronic health record systems, and information from nurses about their patiens and clients human needs. The International Council of Nurses' Nurse-Patient Summary could replace nursing diagnosis items in the Nursing Minimum Data Set and serve as a substitute for the World Health Organization's International Classification of Function, Disability and Health, a seldom used instrument derived from the International Council of Nurses' Basic Principles of Nursing Care.

REVIEW QUESTION / OBJECTIVE The primary objective of the scoping review is to identify all published nutritional screening instruments that have been validated in the adult population in primary healthcare settings and to report on their psychometric validity. The scoping review will also seek to include published evidence from the perspective of relevant experts in the field as to what is viewed as appropriate to assess in relation to nutritional care for adults in primary healthcare. Furthermore, published evidence of adult patients’ and their relatives’ views of nutritional assessment and documentation will also be sought for inclusion. Review question 1: What nutritional screening instruments have been validated for use for the adult population in primary healthcare settings? Review question 2: What is the psychometric validity of these nutritional screenings tools? Review question 3: What do nutritional experts, patients and their relatives find appropriate to assess in relation to the nutritional status of adults in primary healthcare? In this scoping review, the term “appropriate” refers to what patients, their relatives and experts consider as “suitable” or “meaningful” to assess in relation to the nutritional status of adults. INCLUSION CRITERIA Types of participants For Question 1 and 2, this scoping review will seek to include studies with participants who are adults (aged 18 years and over) of any sex, culture, diagnoses and ethnicity. For Question 3, studies will be sought that report on the views and opinions of nutritional experts as well as the views of patients (defined above) and their relatives.TRUNCATED AT 250 WORD

This article describes the development and early application of the Scottish Community Nursing Workload Measurement Tool, part of a suite of tools aiming to ensure a consistent approach to measuring nursing workload across NHS Scotland. The tool, which enables community nurses to record and report their actual workload by collecting information on six categories of activity, is now being used by all NHS boards as part of a triangulated approach. Data being generated by the tool at national level include indications that approximately 50% of band 6 district nurses' time is spent in face-to-face and non-face-to-face contact and planned sessions with patients, and that over 60% of face-to-face contacts are at ‘moderate’ and ‘complex’ levels of intervention (2012 data). These data are providing hard evidence of key elements of community nursing activity and practice that will enable informed decisions about workforce planning to be taken forward locally and nationally. The article features an account of the early impact of the tool's implementation in an NHS board by an associate director of nursing. Positive effects from implementation include the generation of reliable data to inform planning decisions, identification of issues around nursing time spent on administrative tasks, clarification of school nursing roles, and information being fed back to teams on various aspects of performance.

SummaryBackground: Nursing care is facing exponential growth of information from nursing documentation. This amount of electronically available data collected routinely opens up new opportunities for secondary use.Objectives: To present a case study of a nursing intelligence system for reusing routinely collected nursing documentation data for multiple purposes, including quality management of nursing care.Methods: The SPIRIT framework for systematically planning the reuse of clinical routine data was leveraged to design a nursing intelligence system which then was implemented using open source tools in a large university hospital group following the spiral model of software engineering.Results: The nursing intelligence system is in routine use now and updated regularly, and includes over 40 million data sets. It allows the outcome and quality analysis of data related to the nursing process.Conclusions: Following a systematic approach for planning and designing a solution for reusing routine care data appeared to be successful. The resulting nursing intelligence system is useful in practice now, but remains malleable for future changes.Citation: Hackl WO, Rauchegger F, Ammenwerth E A Nursing Intelligence System to Support Secondary Use of Nursing Routine Data. Appl Clin Inform 2015; 6: 418–428http://dx.doi.org/10.4338/ACI-2015-04-RA-0037

Aim and Objective To assess and compare the quality of paper-based and electronic-based health records. The comparison examined three criteria: content, documentation process, and structure. Background Nursing documentation is a significant indicator of the quality of patient care delivery. It can be either paper-based or organized within the system known as the Electronic Health Records (EHRs). Nursing documentation must be completed at the highest standards, in order to ensure the safety and quality of health care services. However, the evidence is not clear on which one of the two forms of documentation (paper-based versus EHRs) is more qualified. Methods A retrospective, descriptive, comparative design was utilized to address the study's purposes. A convenient number of patients’ records, from two public hospitals, were audited using the Cat-ch-Ing Audit Instrument. The sample size consisted of 434 records for both paper-based health records and EHRs from medical and surgical wards. Results EHRs were better than paper-based health records in terms of process and structure. In terms of quantity and quality content, paper-based records were better than EHRs. The study affirmed the poor quality of nursing documentation and lack of nurses’ knowledge and skills in the nursing process and its application in both paper-based and electronic-based systems. Conclusion Both forms of documentation revealed drawbacks in terms of content, process, and structure. This study provided important information, which can guide policymakers and administrators in identifying effective strategies aimed at enhancing the quality of nursing documentation. Relevance to Clinical Practice Policies and actions to ensure quality nursing documentation at the national level should focus on improving nursing knowledge, competencies, practice in nursing process, enhancing the work environment and nursing workload, as well as strengthening the capacity building of nurses practice to improve the quality of nursing care and patients’ outcomes. This article is protected by copyright. All rights reserved.

Purpose The purpose of this paper is to develop a nursing quality indicator (NQI) framework and provide a comprehensive reporting mechanism for nursing care. Design/methodology/approach Mixed method, including patient records audit, patient experience questionnaire, nurse self-report questionnaire and collecting ward-level information. The sample was 53 patients and 22 nurses. Findings Outputs from the NQI framework domains offer a more comprehensive understanding of nursing quality compared to when domains are analysed separately. The NQI framework also provides a more inclusive mechanism for assuring nursing care. Research limitations/implications Sample size was limited to 53 English-speaking patients who consented to participating in the study. Originality/value One design strength was the ability to describe individual patient care across the four domains and subsequently show relationships between nursing knowledge, nursing interventions and patient outcomes/experiences. Additionally, corroborated information from three sources (documentation review, patient and nurse responses) strengthened the conclusion that the NQI framework could provide more comprehensive assurances on nursing quality and identify care improvements.

Aim This study examined nurses’ work, comparing nursing interventions and locations across three units in a United States hospital using Omaha System standardized terminology as the organizing framework. Background The differences in nurses’ acute-care work across unit types are not well understood. Prior investigators have used time–motion methodologies; few have compared differences across units, nor used standardized terminology. Methods Nurse-observers recorded locations and interventions of nurses on three acute-care units using hand-held devices and web-based TimeCaT™ software. Nursing interventions were mapped to Omaha System terms. Unit-differences were analysed. Results Nurses changed locations approximately every 2 min, and averaged approximately one intervention/minute. Unit differences were found in both the interventions performed and the locations. Most interventions were case-management related, demonstrating the nurses’ patient management/coordination role. Conclusions Unit differences in nursing interventions and location were found among three unit types. Omaha System terminology, as well as the observational method used, were found to be feasible and practical. Implications for Nursing Management Nursing work varies by unit, yet managers have not been armed with empirical data with which to make more informed decisions about nurses’ work priorities, clinical outcomes, patient satisfaction, staff satisfaction and cost. The results from this study will help them to do so.

Aim To define the concept of patient-related complexity of nursing care in acute care hospitals and to operationalize it in a questionnaire. Background The concept of patient-related complexity of nursing care in acute care hospitals has not been conclusively defined in the literature. The operationalization in a corresponding questionnaire is necessary, given the increased significance of the topic, due to shortened lengths of stay and increased patient morbidity. Design Hybrid model of concept development and embedded mixed-methods design. Methods The theoretical phase of the hybrid model involved a literature review and the development of a working definition. In the fieldwork phase of 2015 and 2016, an embedded mixed-methods design was applied with complexity assessments of all patients at five Swiss hospitals using our newly operationalized questionnaire ‘Complexity of Nursing Care’ over a one-month period. These data will be analysed with structural equation modelling. Twelve qualitative case studies will be embedded. They will be analysed using a structured process of constructing case studies and content analysis. In the final analytic phase, the quantitative and qualitative data will be merged and added to the results of the theoretical phase for a common interpretation. Cantonal Ethics Committee Zurich judged the research program as unproblematic in December 2014 and May 2015. Discussion Following the phases of the hybrid model and using an embedded mixed-methods design can reach an in-depth understanding of patient-related complexity of nursing care in acute care hospitals, a final version of the questionnaire and an acknowledged definition of the concept. This article is protected by copyright. All rights reserved.

Hintergrund: Um den prognostizierten Wandel im Pflegebereich begleiten zu können, wird seit langem die Forderung nach einer einheitlichen Datenbasis gestellt, auf deren Grundlage Pflegedaten von Leistungsanbietern transparent abgebildet werden können. In Österreich fehlt bis dato eine Empfehlung, welche Pflegedaten als «Basisdaten» dokumentiert werden müssen, wodurch eine nationale Vergleichbarkeit von Pflegedaten erschwert wird. Internationale Entwicklungen von Nursing Minimum Data Sets (NMDS) weisen darauf hin, dass Pflegedaten adäquat abgebildet werden können. Ziel der vorgestellten systematischen Literaturanalyse ist es, den aktuellen Wissensstand über NMDS zu erheben und eine strukturierte Beschreibung von NMDS zu entwickeln, welche vor allem die erfassten Datenelemente und die zugehörigen Zielsetzungen der NMDS-Verwendung dokumentieren kann. Ergebnisse: Insgesamt wurden 70 Publikationen zum Thema NMDS in die Literaturübersicht eingeschlossen. Die Analyse der vorgestellten acht NMDS ergab sechs zentrale Zielsetzungen und sechs übergeordnete Datenelemente. Zu den identifizierten sechs Zielsetzungen gehören: Beschreibung der Pflegepraxis, Verteilung finanzieller Mittel, Benchmarking, Personaleinsatzplanung, Trendanalysen und Qualitätssicherung. Die identifizierten sechs Datenelemente umfassen betriebliche Daten, demografische Daten, Pflegediagnosen, -interventionen, -ergebnisse (Qualitätsindikatoren) und Pflegeintensität (klinische Daten). Diskussion: Es hat sich gezeigt, dass kein klarer Zusammenhang zwischen den Zielsetzungen und Datenelementen der untersuchten minimalen Pflegedatensätzen vorliegt.

Aim To report a concept analysis of nursing-sensitive indicators within the applied context of the acute care setting. Background The concept of ‘nursing sensitive indicators’ is valuable to elaborate nursing care performance. The conceptual foundation, theoretical role, meaning, use and interpretation of the concept tend to differ. The elusiveness of the concept and the ambiguity of its attributes may have hindered research efforts to advance its application in practice. Design Concept analysis. Data sources Using ‘clinical indicators’ or ‘quality of nursing care’ as subject headings and incorporating keyword combinations of ‘acute care’ and ‘nurs*’, CINAHL and MEDLINE with full text in EBSCOhost databases were searched for English language journal articles published between 2000–2012. Only primary research articles were selected. Methods A hybrid approach was undertaken, incorporating traditional strategies as per Walker and Avant and a conceptual matrix based on Holzemer's Outcomes Model for Health Care Research. Results The analysis revealed two main attributes of nursing-sensitive indicators. Structural attributes related to health service operation included: hours of nursing care per patient day, nurse staffing. Outcome attributes related to patient care included: the prevalence of pressure ulcer, falls and falls with injury, nosocomial selective infection and patient/family satisfaction with nursing care. Conclusion This concept analysis may be used as a basis to advance understandings of the theoretical structures that underpin both research and practical application of quality dimensions of nursing care performance.

Purpose The purposes of this study were to (a) develop and implement a standardized nursing languages-based electronic nursing documentation system in Korea, and (b) explore nurses' experience with NANDA-I, Nursing Interventions Classification, and Nursing Outcomes Classification languages in relation to nursing workflow. Methods The system was developed by the research team and implemented in a tertiary hospital in Korea. Ten nurses used the system and interviews were conducted to explore nurses' experiences with the standardized nursing languages. Findings The most frequently used NANDA-I, Nursing Interventions Classification, and Nursing Outcomes Classification were identified. Nurses' experiences with standardized nursing languages and how they impact nursing workflow were analyzed. Conclusions and Implications Obtaining valid and comparable data from this system will be critical in improving patient safety, quality, and evidence-based practice.

Purpose To synthesize evidence related to the use of the Nursing Interventions Classification in order to identify nursing workload. Method An integrative literature review was conducted in June 2013. Findings The search strategy yielded a total of 111 references, 18 of which were retrieved, read, and evaluated for relevance. A set of 10 articles met the selection criteria. Conclusion A review of papers regarding the Nursing Interventions Classification and workload revealed the following themes: the identification of nursing interventions in areas of expertise and estimated times for their completion, the distribution of interventions in direct and indirect care, and the prevalence of the type of care in a given healthcare setting.

Nursing administration requires a large volume of wide-ranging information, and nurse administrators are limited in their ability to compile and analyze information for nursing administration. The purpose of this study is to create methodology for developing a nursing administration analysis system to aid nurse administrators in performing outcome analysis. In this methodology, information required for nursing administration in the PSYCHOMS&#174 (Psychiatric Outcome Management System, registered trademark) database is analyzed according to the individual needs of nurse administrators. It features a combination of a classification method and an extraction method for obtaining quantitative and qualitative data as information required for nursing administration, and enables nurse administrators to easily obtain analysis results that they directly need. This methodology converts the time required nurse administrators to collect and organize information into time for making considerations in order to devise strategies for improving the quality of nursing care services, and can improve the quality and efficiency of nursing administration. This may lead to an increase of the quality of nursing care services at psychiatric hospitals. This methodology is highly versatile as it can be applied in information management, not only for nursing, but for the entire psychiatric hospital.

Review question/objective The objective of this systematic review is to critically appraise and synthesize the best available evidence on the effectiveness of team nursing compared to total patient care on staff wellbeing when organizing nursing work in acute care ward settings. This review will seek to answer the following question: Is a team nursing or a total patient care approach the most effective model of care when organizing nursing work to achieve desired staff wellbeing (defined by outcomes of staff satisfaction, stress, burnout, absenteeism and turnover) in a general ward setting? Inclusion criteria Types of participants This review will consider studies that include all nurses working on general wards in the acute care hospital sector. This includes registered general nurses or the international equivalent such as staff nurses and professional nurses, enrolled nurses or the international equivalent such as licensed vocational nurses or licensed practical nurses and unlicensed personnel such as nursing assistants or the international equivalent such as nurse’s aides and auxiliary nurses. This will review will exclude: Nursing staff working on specialized wards and areas for example intensive/critical care areas, oncology wards, pediatrics, midwifery, mental health, primary care and aged care sectors, as they utilize specific models of care for their scope of practice. Types of intervention(s) This review will consider studies that investigate the use of a team nursing model when organizing nursing work. The comparator will be utilization of a total patient care model. Types of outcomes The outcome of interest to this review will be staff wellbeing. Methodology for data collection will be grouped from the primary research papers based on the types of outcomes measures or tools that were used to promote homogeneity of pooled data. Data collection tools that have been used in initial searches of papers have included questionnaires for the collection of responses for staff satisfaction. The measurement tools considered for inclusion must be validated and reliable, examples of these tools are the Nursing Work Index tool which measures nursing values in relation to job satisfaction and productivity. This tool has been modified and used in various countries including Australia where it is referred to as the Nursing Work Index – Revised: Australian Tool, (NWI-R:A tool).23 Another reliable tool is the McCloskey/Mueller Satisfaction Scale (MMSS) which is a multidimensional questionnaire designed for hospital staff nurses. There are 31 items; the response format is a five-point Likert scale. The Nurse Satisfaction Scale (NSS) is also a validated tool which measures job satisfaction among nurses. The questionnaire is multidimensional and has 24 items. The response format is a seven-point Likert scale.24 Maslach Burnout Inventory tool has been utilized to measure staff burnout and stress levels other tools that measure staff burnout and stress will be considered for inclusion, providing it is a validated and tested tool for measuring staff burnout and stress levels. Nursing turnover and absenteeism rates will be extracted from included papers. Patient clinical outcomes will be excluded from the review.

In psychiatric hospitals, the ratios between patients versus physician and patients versus nurse are low as compared to those in general hospitals. Furthermore, usages of electronic medical records are also low so that nurse administrators are limited in their ability to compile, analyze, and generate patient care staffing information for their administrative use. Psychiatric nurse administrators anticipate the development of a nursing administration analysis system that could perform personnel data simulation, manage information on nursing staff, and manage ward/ practice operations. Responding to this situation, the authors developed a nursing administration analysis system utilizing formulae from the Psychiatric Outcome Management System, PSYCHOMS® to aid nurse administrators. Such formulae are awaiting patent approval. The purpose of this study was to examine the validity of the formulae and the Structured Query Language (SQL) statement, and its practical effectiveness of analyzing data. The study findings showed that two kinds of computation expressions—a classification and extraction were able to display required information desired by nurse administrators. Moreover, significant information critical to assigning staff was validated to ensure high quality of nursing care according to the function and characteristic of the hospital ward.

Aim The aim of this study was to explore the potential for one set of patient information for nursing handover and documentation. Background Communication of patient information requires two processes in nursing: a verbal summary of the patients' care and another report within the nursing notes, creating duplication. Introduction Advances in speech recognition technology have provided an opportunity to consider the practicality of one set of information at the nursing end-of-shift. Methods We used content analysis to compare transcripts from 162 digitally recorded handovers and written nursing notes for similar patients within general medical-surgical wards from two metropolitan hospitals in Sydney Australia. Findings Using the Nursing Handover Minimum Dataset analysis framework similar content [n = 2109 (handover) n = 1902 (nursing notes)] was found within the handovers and notes at the end-of-shift (7:00 am and 2:00 pm). Analysis of the overarching categories demonstrated the emphasis within the differing data sources as: patient identification (31%), care planning or interventions (25%), clinical history (13%), and clinical status (13%) for handover, vs. care planning (47%), clinical status (24%), and outcomes or goals of care (12%) for nursing notes. Discussion This study has demonstrated that similar patient information is presented at handover and within documentation. Major categories are consistent with international nursing minimum datasets in use. Conclusion We can use one set of patient information (within some limitations) for two purposes with system design, practice change and education. Experiments are currently being conducted trialling speech recognition within laboratory and clinical settings. Implications for Nursing and Health Policy One set of patient information, verbally generated at handover delivering electronic documentation within one process, will transform international nursing policy for nursing handover and documentation.