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

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Publication year
2009Source
Journal of Clinical Nursing, 18, 7, (2009), pp. 1027-37ISSN
Publication type
Article / Letter to editor

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Organization
IQ Healthcare
Former Organization
Centre for Quality of Care Research
Journal title
Journal of Clinical Nursing
Volume
vol. 18
Issue
iss. 7
Page start
p. 1027
Page end
p. 37
Subject
NCEBP 6: Quality of nursing and allied health care; ONCOL 4: Quality of CareAbstract
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 operationalized into items and eight experts assessed face and content validity of the Q-DIO. RESULTS: Criteria were developed and operationalized 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.
This item appears in the following Collection(s)
- Academic publications [227864]
- Electronic publications [107344]
- Faculty of Medical Sciences [86218]
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