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What factors influence the prevalence and accuracy of nursing diagnoses documentation inclinical practice? A systematic literature reviewPaans, W.; Nieweg, R.M.B.; van der Schans, C.P.; Sermeus, W.

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REVIEW

What factors influence the prevalence and accuracy of nursing diagnoses

documentation in clinical practice? A systematic literature review

Wolter Paans, Roos MB Nieweg, Cees P van der Schans and Walter Sermeus

Aim. To identify what determinants influence the prevalence and accuracy of nursing diagnosis documentation in clinical

practice.

Background. Nursing diagnoses guide and direct nursing care. They are the foundation for goal setting and provide the basis for

interventions. The literature mentions several factors that influences nurses’ documentation of diagnoses, such as a nurse’s level

of education, patient’s condition and the ward environment.

Design. Systematic review.

Method. MEDLINE and CINAHL databases were searched using the following headings and keywords: nursing diagnosis,

nursing documentation, hospitals, influence, utilisation, quality, implementation and accuracy. The search was limited to

articles published between 1995–October 2009. Studies were only selected if they were written in English and were primary

studies addressing factors that influence nursing diagnosis documentation.

Results. In total, 24 studies were included. Four domains of factors that influence the prevalence and accuracy of diagnoses

documentation were found: (1) the nurse as a diagnostician, (2) diagnostic education and resources, (3) complexity of a patient’s

situation and (4) hospital policy and environment.

Conclusion. General factors, which influence decision-making, and nursing documentation and specific factors, which influence

the prevalence and accuracy of nursing diagnoses documentation, need to be distinguished. To support nurses in documenting

their diagnoses accurately, we recommend taking a comprehensive perspective on factors that influence diagnoses documen-

tation. A conceptual model of determinants that influence nursing diagnoses documentation, as presented in this study, may be

helpful as a reference for nurse managers and nurse educators.

Relevance to clinical practice. This review gives hospital management an overview of determinants for possible quality

improvements in nursing diagnoses documentation that needs to be undertaken in clinical practice.

Key words: literature review, nursing diagnosis, nursing documentation, nursing process

Accepted for publication: 17 August 2010

Introduction

Accurate documentation of nursing diagnoses is vital to

nurses in daily hospital practice. The aim of diagnoses

documentation is to help nurses to correctly plan, intervene

and evaluate nursing care for individuals and to accomplish

optimal continuity of care and patient safety (Needleman &

Buerhaus 2003).

Several authors have reported that patient records contain

relatively few formulated nursing diagnoses, related factors

Authors: Wolter Paans, MScN, RN, PhD Candidate, Research and

Innovation Group in Health Care and Nursing, Hanze University of

Applied Sciences, Groningen, The Netherlands and the Catholic

University Leuven, Leuven, Belgium; Roos MB Nieweg, MScN, RN,

Assistant Professor, Research and Innovation Group in Health Care

and Nursing, Hanze University of Applied Sciences; Cees van der

Schans, PhD, PT, CE, Professor, Research and Innovation Group in

Health Care and in Nursing, Hanze University of Applied Sciences,

Groningen, The Netherlands; Walter Sermeus, PhD, RN, Professor,

School of Public Health, Faculty of Medicine, Centre for Health

Services and Nursing Research, Catholic University Leuven, Leuven,

Belgium

Correspondence: Wolter Paans, PhD Candidate, Research and

Innovation Group in Health Care and Nursing, Hanze University

of Applied Sciences, Groningen, The Netherlands and the Catholic

University Leuven, Leuven, Belgium. Telephone: +31 (0) 505953635.

E-mail: [email protected]

2386 � 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2386–2403

doi: 10.1111/j.1365-2702.2010.03573.x

and pertinent signs and symptoms (Bjorvell et al. 2002,

Florin et al. 2005, Muller-Staub et al. 2007). Furthermore,

the accuracy of nursing diagnoses documentation has been

found to be moderate to poor (Ehrenberg et al. 1996,

Moloney & Maggs 1999, Muller-Staub et al. 2006). Several

studies have shown that the prevalence and accuracy of

nursing diagnoses have an indirect impact on the decision-

making processes and documentation of nurses (Brunt 2005,

Banning 2007). The nurses’ decision-making process is

determined by work procedures, allocation of work, dis-

rupted working conditions and time pressures (Coiera &

Tombs 1998, Bjorg & Kirkevold 2000, Hedberg & Satterl-

und-Larsson 2004); doctors’ treatment orders, ward proto-

cols and policies; conflicting personal values; and ‘knowing

the patient’ (Radwin 1995, 1998, Bucknall & Thomas 1997,

Bucknall 2000, Currey & Worrall-Carter 2001). Nurses’

daily documentation in the patient’s record is negatively

influenced by several factors, such as being disrupted during

documentation activities, nurses’ limited competence regard-

ing documenting, lacking motivation to enter information

into the patient record and receiving inadequate supervision

(Cheevakasemsook et al. 2006). A positive influence on the

documentation in the patient record is the use of electronic

nursing process documentation systems (Ammenwerth et al.

2001). These studies evaluated the general impact of these

factors on the decision-making process and the documenta-

tion process. However, how these various factors affect the

prevalence and accuracy of nursing diagnoses documentation

is less known. Thus, the aim of this review was to study the

factors that determine the frequency and accuracy of nursing

diagnoses documentation.

Background

In the 1970s, the nursing process was introduced into nursing

educational programmes and hospital nursing practice

worldwide as a systematic method of planning, evaluating

and documenting nursing care (Gordon 1994). The nursing

process facilitates problem solving, reflective judgement and

decision-making, which in turn results in a desired outcome.

Nurses are trained to document their knowledge and judg-

ements explicitly according to the nursing process (Warren &

Hoskins 1990, Lee et al. 2006). A central element of the

nursing process is how nurses derive a nursing diagnosis

based on clinical assessments, interviews and observations

(Wilkinson 2007). In 1990, the North American Nursing

Diagnosis Association (NANDA) defined nursing diagnosis

as ‘a clinical judgement about individual, family, or commu-

nity responses to actual or potential health problems/life

processes’ (NANDA 2004). Diagnoses contain a problem

label (P), a concise term or phrase that represents a pattern of

related cues; an aetiology or related factors (E) and signs/

symptoms (S). This diagnostic structure is known as the ‘PES

structure’ (Gordon 1994). Nurses have to analyse a patient’s

responses to health problems using interviews and obser-

vations. These analyses can be complex as there is a large

variety in responses to illness and diseases (Muller-Staub

et al. 2006).

Although nursing educators acknowledge the importance

of developing skills in diagnostic reasoning, the majority of

graduate and undergraduate programmes in nursing educa-

tion do not focus on factors that affect reporting diagnostic

inferences in the ward in daily practice (Smith Higuchi et al.

1999). From the mid 1990s, nurse researchers have increas-

ingly studied factors that influence nursing diagnoses, such as

education programmes and electronic documentation devices

to improve diagnoses documentation (Kurashima et al.

2008). Evidence shows that educational programmes geared

to improving diagnostic-reasoning skills significantly increase

the prevalence and accuracy of documented nursing diagno-

ses (Bjorvell et al. 2002, Muller-Staub et al. 2006, Cruz et al.

2009, Saranto & Kinnunen 2009). Moreover, the develop-

ment and implementation of electronic documentation

resources and preformulated templates have been demon-

strated to positively influence the frequency of diagnoses

documentation (Smith Higuchi et al. 1999, Gunningberg

et al. 2009).

The study

Aim

The aim of this study was to review what factors influence

the prevalence and accuracy of nursing diagnosis documen-

tation in hospital practice.

Methods

We conducted a systematic literature search of the electronic

databases MEDLINE and CINAHL for relevant articles

published between January 1995–October 2009. We used

MeSH terms for the MEDLINE search and thesaurus terms

for the CINAHL search. Four sets (I, II, III and IV) of search

terms were used. The sets were subdivided into two groups:

Sets I and III (MEDLINE) and sets II and IV (CINAHL)

(Fig. 1). Our search returned 1032 titles. We applied the

following inclusion criteria to the articles: (1) published

in English, (2) primary research, (3) addressed factors

influencing the prevalence and accuracy of the documenta-

tion of nursing diagnoses and (4) related to registered nurses

Review Factors influencing the prevalence and accuracy of nursing diagnoses

� 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 2386–2403 2387

in hospital practice. We excluded studies conducted in non-

hospital environments or those involving nursing students

and studies on diagnostic inferences in emergency room

triage situations. Studies on the decision-making process or

reasoning process were included only if a clear connection to

nursing diagnoses documentation was described. Studies

describing the validation or evaluation of measurement

instruments or guidelines dealing with the accuracy of

nursing diagnoses in patient records were included if influ-

ences on the documented nursing diagnoses were described.

We excluded studies that discussed possible influencing

factors without research-based evidence (Fig. 2). In total,

63 articles were retained for full-text analysis. To assess the

quality of the selected studies, we followed the meta-synthesis

approach of Paterson et al. (2001).

While examining the included articles, two independent

reviewers systematically abstracted the focus of the studies,

design, sample size, data analysis and general and key findings

concerning factors that influence the prevalence and/or accu-

racy of nursing diagnoses in patient records. In addition, two

reviewers assessed the methodology used in each study. For

instance, reports of randomised, controlled trials were assessed

according to the recommendations of the Consolidated Stan-

dards of Reporting Trials (CONSORT) statement (Moher

et al. 2001). For the assessment of reports of non-randomised

studies, the Transparent Reporting of Evaluations with Non-

randomised Designs statement was used (Des Jarlais et al.

2004). For cohort or case–control studies, Strengthening the

Reporting of Observational Studies in Epidemiology

(STROBE) was applied (Vandenbroucke et al. 2007).

In our appraisal, we categorised each article according to

the level of evidence contained in the article. For this purpose,

we used the updated version of the Oxford Levels of

Evidence, as published by the Centre for Evidence Based

Medicine (Phillips et al. 2009). Based on Muller-Staub et al.

(2006), slight adaptations were made for research in nursing

or studies with qualitative research methods. The following

categories were used:

• Level 1. Randomised trials

• Level 2. Cohort studies, cross-sectional designs, pretest/

post-test designs, quasi-experimental designs, record

reviews

• Level 3. Case-controlled studies

• Level 4. Observational studies, database research, quali-

tative interviews, systematic analyses of qualitative studies

• Level 5. Expert opinions.

Critical appraisal revealed that the design of most of the

research papers included in our review did not employ

highest level of evidence. There were three Level 1 studies, 16

Level 2 studies, one Level 3 study and four Level 4 studies.

We excluded Level 5 studies. The Level 1 studies were

clinically relevant randomised studies. The Level 2 studies

used a variety of designs and were described in papers

examining nursing diagnoses documentation; these Level 2

studies used pretest/post-test designs, quasi-experimental

designs, cross-sectional designs, exploratory study methods

and record reviews. The Level 3 study was a case-controlled

• I: MEDLINE (‘nursing diagnosis’[MeSH Terms] OR ‘nursing diagnosis’[All Fields])

AND ‘nursing documentation’[All Fields] AND (‘hospitals’[MeSH Terms] OR

‘hospitals’[All Fields] OR ‘hospital’[All Fields])

• II: CINAHL: MH nursing diagnosis AND nursing documentation AND hospital

• III: MEDLINE: (‘nursing diagnosis’[MeSH Terms] OR ‘nursing diagnosis’[All Fields])

AND (Influence OR influenceable OR influenced OR influences OR

‘utilization’[Subheading] OR quality OR implementation[All Fields] OR accuracy[All

Fields])

• IV: CINAHL: MH nursing diagnosis AND (influenc* or utili?ation or quality or accuracy

or implementation)

Figure 1 Database search.

Perceived to be relevant to the study based on title and abstract and

included for full-text assessment n = 63

Papers excluded based on title and abstract n = 969

Papers excluded based on full-text analysis

n = 39

Total papers included

n = 24

Analysis of full text n = 63

Set I, II, III and IV after duplicates removed n = 1032

Excluded:

Published 1995 to October 1, 2009 n = 454

Non-English language n = 173

Nursing students/professions other than nurses n = 21

Non-hospital settings/triage settings n = 51

Influences on reasoning/decision making/attitudes n = 122

Validation and/or evaluation of instruments and guidelines n = 93

Level of evidence: 5 n = 55

Set II & Set IV

After duplicates removed

n = 615

Set I & Set III

After duplicates removed

n = 567

MEDLINE (Set I)

n = 18

MEDLINE (Set III)

n = 556

CINAHL (set II)

n = 9

CINAHL (set IV)

n = 613

Figure 2 Search strategy and number of records identified through

database search.

W Paans et al.


study. The Level 4 studies used qualitative interview methods

and qualitative descriptive designs, representing more than

expert opinion. The Level 1, 2 and 3 studies used adequate

sample sizes and an acceptable reference standard/clinical

decision rule. Based on the quality analysis, 24 articles were

included for further analysis.

Next, we performed an in-depth analysis of the papers’

contents using the approach of Paterson et al. (2001) and

Cooper (1998), where papers were re-read purposively to

identify influencing factors. To categorise the factors influ-

encing the prevalence and accuracy of nurses’ diagnoses

documentation, two reviewers qualitatively structured the

factors independently into ‘themes’. To compose a more

distinct categorisation of influencing factors, the reviewers

compared and discussed their themes until they reached

consensus. The consensus discussions enabled us to construct

a categorisation of domains, which in turn enabled us to

present a conceptual framework of determinants that influ-

ence the prevalence and accuracy of nursing diagnoses, as

described in the literature.

Reliability and validity

We identified various instruments previously used to measure

factors that influence the prevalence and accuracy of nursing

diagnoses documentation: the Cat-ch-Ing instrument (Bjorv-

ell et al. 2002, Darmer et al. 2006); the PES format of

Gordon (1976) (Thoroddsen & Thorsteinsson 2002, Thor-

oddsen & Ehnfors 2006); the Quality of Nursing Diagnoses

(QOD) (Florin et al. 2005); the Scale for Degrees of Accuracy

compiled by Lunney (2001) (Kurashima et al. 2008, Cruz

et al. 2009); and the Quality of Nursing Diagnoses Interven-

tions and Outcomes (Q-DIO) (Muller-Staub et al. 2006).

These studies reported on aspects of content validity and

reliability. Inter-rater reliability outcomes were described for

all of the aforementioned instruments. Reported over all

inter-rater reliability scores were 0Æ61 or higher and there-

fore, according to Fleiss et al. (2003), acceptable.

All the aforementioned instruments included the PES

structure as the theoretical basis for quantifying accuracy of

diagnoses, even though the PES structure was used in various

scoring ranges and scales. In studies that used questionnaires

in surveys, validity and reliability were often unclear or not

mentioned at all.

Results

We included 24 articles that examined factors that influence

the prevalence and accuracy of nursing diagnoses documen-

tation. Four domains were identified: (1) the nurse as a

diagnostician, (2) diagnostic education and resources, (3)

complexity of a patient’s situation and (4) hospital policy

and environment. These four themes were subdivided into

18 sub-themes that influence diagnoses documentation

(Fig. 3).

The nurse as a diagnostician

In the literature, we identified four sub-themes related to the

individual nurse as a diagnostician as a factor that influences


tation: (1) attitude and disposition towards diagnosis, (2)

diagnostic experience and expertise, (3) case-related and

diagnostic knowledge and (4) diagnostic reasoning skills.

The attitude or disposition of nurses towards nursing

diagnoses and the critical-thinking approach of nurses may

influence the way they document diagnostic findings. Based

on the findings of Armitage (1999) and Hasegawa et al.

(2007), it seems that nurses do not examine how they should

reflect on their critical-thinking approach and their diagnostic

findings in clinical practice. Smith Higuchi et al. (1999)

suggest that to be able to document diagnoses accurately and

to perform at satisfactory levels of diagnostic competency,

nurses may have to learn how to examine their critical-

thinking disposition in areas such as open-mindedness. The

development of such disposition can be explored by provid-

ing a formal education programmes in hospital practice,

because nurses do not document nursing diagnoses on their

own initiative (Smith Higuchi et al. 1999).

In hospital practice, the degree of nurses’ experience in

diagnosing significantly and positively influences the accuracy

of nursing diagnoses documentation (Reichman & Yarandi

2002, Hasegawa et al. 2007). Using a qualitative research

approach, Armitage (1999) and Axelsson et al. (2005) also

reported that diagnostic experience positively influences the

prevalence of accurate diagnoses. Several factors affect

nurses’ knowledge and experience: the presence of case-

related knowledge and reasoning skills acquired in formal

education programmes (Smith Higuchi et al. 1999); the

motivation to learn diagnostic tasks (Whitley & Gulanick

1996); and the frequency of studying diagnostics (Hasegawa

et al. 2007, Cruz et al. 2009).

Diagnostic education and resources

From the included articles, we extracted five educational or

resources-related sub-themes that influence the accuracy of

nursingdiagnosisdocumentation: (1)guidedclinical reasoning,

(2) nurses’ educational background in nursing process appli-

cation, (3) prestructured record forms, (4) implementation



of classification systems, such as NANDA and (5) computer-

generated care plans and patient records.

Nursing process education (Bjorvell et al. 2002, Florin

et al. 2005 Cruz et al. 2009) and guided clinical reasoning

(Muller-Staub et al. 2006, 2008) are examples of educational

programmes for registered nurses which intended to improve

the accuracy of diagnoses documentation significantly. Con-

sistent theoretical teaching and practical training in ongoing

educational programmes may offer procedural and concep-

tual knowledge as a basis for accurate diagnostic documen-

tation (Muller-Staub et al. 2006, Cruz et al. 2009).

Educational programmes related to patient populations are

needed to educate nurses on how to derive and report

diagnoses in the actual hospital information structure where

they work (Darmer et al. 2006). Educational programmes

intended for both novice and experienced nurses can give

both the opportunity to reflect on how to document diagno-

ses in the present hospital environment of their own ward

(Kawashima & Petrini 2004, Turner 2005). This approach

has a significant positive effect on the accuracy of nursing

diagnoses documentation (Bjorvell et al. 2002, Lee 2005,

Muller-Staub et al. 2006). Resources that reduce the lack of

clarity in diagnostic statements – for instance, specific

computer-generated standardised nursing care plans – may

support nurses in their administrative work (Smith Higuchi

et al. 1999). Kurashima et al. (2008) found that the time

Workload level and time to spend on diagnostic task

Number of patients per

nurse

Hospital policy and diagnostic environment

Number of administrative

tasks

Physician’s disposition towards nursing

diagnoses

Nurse as diagnostician

Complexity

of a

patient’s

situation

Cultural/racial differences in

expressing patients’ needs and in naming

diagnoses

Patients’ expressing severe diagnoses

Guided clinical reasoning

Diagnostic

education

and

resources

in

nursing

practice

Attitude and disposition

towards diagnosis

Diagnostic experience and

expertise Case-related and diagnostic knowledge

Diagnostic reasoning skills

Used information structure

Nursing

Diagnosis

Documentation

Severe medical diagnoses in

specialty areas

Implementation of classification structure, i.e., NANDA

Educational background in nursing process

application

Pre-structured record forms

Computer-generated care plans & patient records

Medicalmodel

Figure 3 Determinants that influence the prevalence and accuracy of nursing diagnosis documentation.

W Paans et al.


needed to derive a diagnosis was significantly shorter when

nurses used a computer aid. Classification structures, e.g.,

NANDA-I classification (Thoroddsen & Ehnfors 2006) and

new forms for recording in the PES format (Florin et al.

2005, Darmer et al. 2006) in combination with applicable

electronic resources facilitate more accurate diagnoses doc-

umentation (Smith Higuchi et al. 1999).

Complexity of a patient’s situation

Factors that indicate the complexity of a patient’s situation in

clinical practice may influence the accuracy of the nursing

diagnosis documentation. These factors, as the current

literature indicates, can be categorised into three themes:

(1) cultural differences in expressing patients’ needs, (2)

patients’ severe medical diagnosis in specialty areas and (3)

patients’ way of expressing severe diagnoses.

Kilgus et al. (1995) and Hamers et al. (1996) stated that,

especially in complex patient situations or in specialty areas,

it is important for nurses to be aware of their subjectivity in

diagnostic judgements and to develop mental abilities that

reflect this subjectivity. Hamers et al. (1996) showed in a

study of newborns that nurses attributed the highest pain

score to a child when the medical diagnosis was severe and

the child vocally expressed his/her pain. On the basis of a

record review, Kilgus et al. (1995) found significant cultural

differences in the discharge diagnoses of adolescents hospi-

talised for psychiatric disorders. The authors of this study

pointed out that some of these differences may reflect

ethnocentric clinician bias in the diagnostic assessment of

youths with different cultural backgrounds.

There may be an association between length of stay, severe

medical diagnosis in specialty areas and complexity of the

patient situation, as Thoroddsen and Thorsteinsson (2002)

suggested, although, based on the results of their study, this

association was not clear. Nevertheless, length of stay seems

to be an influencing factor with respect to the number of

documented diagnoses, as was reported by Thoroddsen and

Thorsteinsson (2002).

In complex patient situations nurses’ confidence in the

diagnostic task in cases of severe diagnoses, interpretation

difficulties of cues and difficulties in analysing diagnoses in

specialty areas are factors influencing nursing diagnosis

documentation as well (Whitley & Gulanick 1996, Armitage

1999).

Hospital policy and environment

We identified six sub-themes concerning the influence of the

hospital environment on nursing diagnoses: (1) the number of

patients per nurse, (2) nurses’ workload level and time to

spend on diagnostic tasks, (3) the use of a medical model,

(4) the number of administrative tasks nurses have to carry

out, (5) physicians’ disposition towards nursing diagnoses

and (6) the information structure used in the ward.

The medical-situational context appears to be one of the

important factors that influences the prevalence and accuracy

of nursing diagnoses documentation. According to Griffiths

(1998), the way nurses process the diagnostic opinions of

physicians is a factor that influences how nurses document

their own diagnostic findings. Nurses appear to adopt

medical language instead of nursing language. Physicians’

objections or rejections toward the implementation of nurs-

ing diagnoses, as mentioned by (Whitley & Gulanick 1996),

can obstruct, or at least hinder the implementation of nursing

education courses or resource innovations in documentation.

Martin (1995) and Paganin et al. (2008) identified the

number of administrative tasks, lack of administrative

support, lack of time and workload level as the main barriers

nurses face when documenting nursing diagnoses. One

possible measure providing administrative support is the

implementation of a prestructured information approach,

because prestructuring information by using, for instance,

prestructured care plans or schemes appears to be helpful

(Bjorvell et al. 2002, Brannon & Carson 2003, Muller-Staub

et al. 2006).

Discussion

Factors that influence diagnoses documentation

We identified four themes that characterise factors that

influence the prevalence and accuracy of nursing diagnoses

documentation. However, our review of the literature failed

to identify arguments distinguishing major and minor factors

of influence. It seems that each domain comprises important

influencing factors.

Different designs and sample sizes were used in various

studies; however, no major contradictions in outcomes were

found. We found representative record reviews that reported

factors influencing diagnoses documentation: 1103 charts

(Thoroddsen & Thorsteinsson 2002); 427 charts (Smith

Higuchi et al. 1999); 352 records (Kilgus et al. 1995); 225

records (Muller-Staub et al. 2006); and 600 journals

(Darmer et al. 2006). We found results from qualitative

research to be comparable to those obtained from

quantitative methods. For instance, both Armitage (1999)

and Reichman and Yarandi (2002) arrived at the same

conclusion–nurses’experienceisanimportantfactor that influ-

ences the accuracy of nursing diagnoses documentation –



even though the former study was based on in-depth

interviews of 10 nurses and the latter was based on analysis

of 184 written patient simulations.

We only included studies that had examined nursing

diagnosis documentation as a research topic. In our analyses,

however, we distinguished two classes of factors that

influence nursing documentation: (1) general factors, which

influence the reasoning and documentation process in

general; and (2) specific factors, which specifically influence


tation, as stated in a conceptual framework (Fig. 3), which is

based on the influencing factors mentioned in the included

papers (Table 1). Examples of general factors that influence

nursing decision-making procedures and documentation

include work procedures, allocation of work, disrupted work

conditions, conflicting personal values, knowing the patient,

motivation and staff development. The differentiation of

general versus specific factors that influence diagnoses doc-

umentation may have common characteristics that need to be

investigated more intensely, because the terms used in the

literature denote subjective notions. For example, a clear and

uniform definition or consistent description of the meaning of

‘knowing the patient’, ‘intuition’, ‘motivation’, ‘inadequate

staff development’ was not found. As a result, a comprehen-

sible description of activities that disrupt nurses as they

document diagnoses was missing. Also missing was informa-

tion about the background of conflicting personal values. We

hypothesise that there might be several underlying issues that

influence nurses’ decision-making and diagnoses documenta-

tion. These issues need to be investigated in more depth in

future research.

With regard to specific factors that influence diagnoses

documentation, we hypothesise that the influencing factors

positioned in the four domains may be inter-related. For

instance, the knowledge of individual nurses partly depends

on education programmes provided in hospital practice. The

provision of these programmes depends on a hospital’s policy

on offering educational courses and resources. These courses

and resources may only be successful if there are restrictions

in workload, clear diagnostic expectations regarding docu-

menting accurate nursing diagnoses and interdisciplinary

support to give nurses the opportunity to learn and to carry

out their diagnostic tasks. Consequently, we assume that a

single innovation, such as an education programme dealing

with diagnostics or a computerised care plan, without taking

other factors that influence diagnoses documentation into

account, may not be as effective as it could be in the long

term.

The distinction between medical diagnoses and nursing

diagnoses appears to be unclear for both physicians and

nurses (Whitley & Gulanick 1996). Therefore, healthcare

professionals may not fully accept a nurse’s responsibility to

make diagnoses. Still, in general, there may be no interdis-

ciplinary agreement on what an accurate nursing diagnosis is

and what it is not. In hospital practice, nurses usually do not

perceive a sharp distinction between ‘diseases’ and ‘levels of

wellness’ (Bandman & Bandman 1995, Hasegawa et al.

2007).

Being unfamiliar with the nursing diagnosis domain and

the diagnostic language used by nurses may lead to

uncertainties and misunderstandings both for nurses and

physicians. In contrast, knowledge and a positive attitude

towards the use of diagnoses by nurses, physicians and the

hospital administration may stimulate nurses to derive

accurate diagnoses (Whitley & Gulanick 1996, Bjorvell

et al. 2002). Reducing the nurse-to-patient ratio and

limiting additional administrative tasks to give nurses

enough time to accomplish their diagnostic tasks creates

limits in the hospital environment and will give nurses the

notion that hospital management supports them in their

diagnostic responsibilities. Nurses’ impression of the hos-

pital policy in the case of diagnostic tasks may sometimes

reflect their motivation for learning how to document and

for documenting nursing diagnoses (Whitley & Gulanick

1996).

In the ‘nurse as a diagnostician’ context, Hamers et al.

(1996) and Shapiro (1993) found that nurses’ perceptions or

misperceptions of a newborn’s pain affected how much

analgesics they gave the newborn. This observation suggests

that nurses’ ‘misperceptions’ could affect their diagnoses

and ultimately the amount of medication dispensed. Indeed,

in the Hamers et al. (1996) and Shapiro (1993) studies,

nurses’ ‘misperceptions’ caused newborns to receive inade-

quate pain medication. Research on nurse’s interpretation

and judgement of frequently documented or severe diagno-

ses, such as pain, is rare, and further research is required.

Educational programmes, as suggested by Muller-Staub

et al. (2006) and Cruz et al. (2009) that focus on recogn-

ising the signs and symptoms of severe diagnoses may help

nurses to avoid diagnostic misperceptions, as education in

diagnostic documentation skills can enhance the quality of

documented nursing diagnoses. Higher quality of diagnoses

documentation correlates with qualitative improvements in

the documentation of nursing-sensitive patient outcomes, as

mentioned in the implementation study of Muller-Staub

et al. (2007). However, studies discussing the possible

effects of education programmes intended for accurate

diagnostic documentation in terms of patient safety and

quality of care are lacking and may be needed as well

(Lunney 2007).

W Paans et al.


Table

1Fact

ors

that

influen

ceth

epre

vale

nce

and

acc

ura

cyof

nurs

ing

dia

gnose

sdocu

men

tati

on

Ref

eren

ceFocu

s

Res

earc

hdes

ign/l

evel

of

evid

ence

(LE

)D

ata

collec

tion/s

am

ple

size

Key

findin

gs

Fact

ors

that

influen

cedia

gnose

s

Arm

itag

e(1

999)

Tit

le:

Nurs

ing

ass

essm

ent

and

dia

gnosi

sof

resp

irato

rydis

tres

sin

infa

nts

by

childre

n’s

nurs

es

The

nurs

ing

ass

essm

ent

of

resp

irato

rydis

tres

s

inin

fants

Cro

ss-s

ecti

onal

des

ign

usi

ng

qualita

tive

inte

rvie

ws

and

a

surv

ey

LE

:4

Qual

ified

childre

n’s

nurs

es

(n=

10)

com

ple

ted

ques

tionnair

esand

part

ook

in

quali

tati

ve

inte

rvie

ws

Nurs

es’

ass

essm

ent

was

influen

ced

by

the

med

ical

model

The

conce

pt

‘nurs

ing

dia

gnosi

s’

was

poorl

yunder

stood

Med

ical

model

Nurs

es’

dia

gnost

icex

per

ience

Axel

sson

etal

.(2

005)

Tit

le:

Sw

edis

hre

gis

tere

d

nurs

es’

ince

nti

ves

to

use

nurs

ing

dia

gnose

s

inpra

ctic

e

Ince

nti

ves

for

usi

ng

nurs

ing

dia

gnose

s

incl

inic

al

pra

ctic

e

Qualita

tive,

des

crip

tive

des

ign

LE

:4

Qual

itati

ve

inte

rvie

ws

of

regis

tere

d

nurs

es(n

=12)

Ince

nti

ves

for

usi

ng

nurs

ing

dia

gnose

sori

gin

ate

dfr

om

effe

cts

gen

erate

dfr

om

per

form

ing

a

dee

per

analy

sis

of

the

pati

ent’

s

nurs

ing

nee

ds

Moti

vati

on

topro

vid

ein

div

idual

and

holi

stic

nurs

ing

care

Exper

ienci

ng

that

dia

gnose

s

faci

lita

tedec

isio

ns

inte

rms

of

act

ions

Rec

ord

ednurs

ing

dia

gnose

s

per

ceiv

edas

tim

esa

vin

g

Exper

ienci

ng

that

dia

gnose

s

faci

lita

teev

alu

ati

on

of

nurs

ing

care

Support

from

the

managem

ent

in

usi

ng

dia

gnose

s

Bjo

rvel

let

al.

(2002)

Tit

le:

Long-t

erm

incr

ease

in

quali

tyof

nurs

ing

docu

men

tati

on:

effe

cts

of

aco

mpre

hen

sive

inte

rven

tion

Long-t

erm

effe

cts

of

anurs

e-

docu

men

tati

on

inte

rven

tion

Quasi

-exper

imen

tal

longi

tudin

al

des

ign

LE

:2

A2-y

ear

inte

rven

tion

com

pose

dof

theo

reti

cal

train

ing,

super

vis

ion,

exch

ange

of

info

rmati

on

duri

ng

confe

rence

s,and

org

anis

atio

nal

support

regard

ing

nurs

ing

docu

men

tati

on

base

don

the

Sw

edis

hV

IPS

Model

,fo

llow

ed

by

are

cord

revie

wof

269

reco

rds

inth

ree

acu

te-c

are

war

ds

inone

hosp

ital

usi

ng

the

Cat-

ch-I

ng

inst

rum

ent

Aco

mpre

hen

sive

inte

rven

tion

of

nurs

ing

docu

men

tati

on

signifi

cantl

yim

pro

ved

the

quality

of

nurs

ing

dia

gnose

s

docu

men

tati

on

inth

esh

ort

term

and

the

long

term

Theo

reti

cal

train

ing

in

docu

men

tati

on

of

dia

gnose

s

Indiv

idual

super

vis

ion

and

support

Info

rmati

on

exch

ange

Dev

elopm

ent

of

stru

cture

dfo

rms

and

standard

ised

care

pla

ns



Table

1(C

onti

nued

)

Ref

eren

ceFocu

s

Res

earc

hdes

ign/l

evel

of

evid

ence

(LE

)D

ata

coll

ecti

on/s

am

ple

size

Key

findin

gs

Fact

ors

that

influen

cedia

gnose

s

Bra

nnon

and

Cars

on

(2003)

Tit

le:

Nurs

ing

exper

tise

and

info

rmat

ion

stru

cture

influen

cem

edic

al

dec

isio

n-m

akin

g

The

influen

ceof

nurs

ing

exper

tise

and

info

rmat

ion

stru

cture

on

cert

ain

tyof

dia

gnost

ic

dec

isio

n-m

akin

g

Quas

i-ex

per

imen

tal/

case

-contr

oll

eddes

ign

LE

:3

Nurs

es(e

xper

ts),

studen

tnurs

es

(novic

es),

and

non-n

urs

e(n

aiv

e)

part

icip

ants

(n=

216)

read

pati

ent

scen

ari

os

eith

erhig

hin

info

rmat

ion

stru

cture

or

low

in

info

rmat

ion

stru

cture

and

rate

d

thei

rce

rtain

tyabout

what

the

pote

nti

al

dia

gnosi

sm

ight

be

Aft

erw

ard

s,ea

chpart

icip

ant

was

ask

edto

gen

erate

adia

gnosi

sand

rate

thei

rle

vel

of

confiden

cein

thei

row

ndia

gnosi

sfr

om

0–100%

By

usi

ng

pre

-exis

ting

cognit

ive

schem

ata

for

pro

cess

ing

pati

ent

info

rmati

on,

part

icip

ants

wer

e

more

cert

ain

about

thei

r

dec

isio

n-m

akin

gw

hen

usi

ng

stru

cture

din

form

ati

on

than

they

wer

eabout

usi

ng

unst

ruct

ure

d

info

rmati

on

Nurs

es’

dia

gnost

icex

per

tise

Use

of

stru

cture

din

form

atio

n

Cru

zet

al.

(2009)

Tit

le:

Impro

vin

gcr

itic

al

thin

kin

gand

clin

ical

reaso

nin

gw

ith

a

conti

nuin

ged

uca

tion

cours

e

Conti

nuin

g

educa

tion

cours

es

rela

ted

tocr

itic

al

thin

kin

gand

clin

ical

reaso

nin

g

Pre

test

/post

-tes

tdes

ign

LE

:2

Nurs

esco

mple

ted

apre

test

and

a

post

-tes

tco

nsi

stin

gof

two

wri

tten

case

studie

sdes

igned

to

mea

sure

the

acc

ura

cyof

nurs

es’

dia

gnose

s(n

=39)

Sig

nifi

cant

dif

fere

nce

sw

ere

found

inacc

ura

cyon

the

pre

test

and

the

post

-tes

tbec

ause

of

the

educa

tion

cours

esre

late

dto

crit

ical

thin

kin

gand

clin

ical

reaso

nin

g

Conti

nuin

ged

uca

tion

cours

es

(16

hours

)re

late

dto

crit

ical

thin

kin

gand

clin

ical

reaso

nin

g

Darm

eret

al.

(2006)

Tit

le:

Nurs

ing

docu

men

tati

on

audit

–th

eef

fect

of

a

VIP

Sim

ple

men

tati

on

pro

gra

mm

ein

Den

mark

Nurs

es’adher

ence

to

the

VIP

Sm

odel

,a

syst

emati

cm

ethod

of

nurs

ing

docu

men

tati

on

to

impro

ve

the

acc

ura

cyof

the

nurs

ing

report

Longit

udin

al

retr

osp

ecti

ve

nurs

ing

journ

al

revie

w

LE

:2

Nurs

ing

docu

men

tati

on

(journ

als

,

n=

50)

of

four

dep

art

men

tsw

ere

random

lyse

lect

edand

audit

ed

annuall

yfo

r3

yea

rsusi

ng

the

Cat-

ch-I

ng

inst

rum

ent

(n=

600)

Nurs

ing

docu

men

tati

on

impro

ved

sign

ifica

ntl

yduri

ng

the

cours

eof

the

study

Apra

gm

ati

cappro

ach

:re

ver

sed

‘pro

ble

ms’

and

conse

quen

ces

and

reduce

ddia

gnost

icst

ate

men

tsto

pro

ble

m,

aet

iolo

gy,

des

crip

tion

of

signs

and

sym

pto

ms

inth

e

nurs

ing

statu

s

W Paans et al.


Table

1(C

onti

nued

)

Ref

eren

ceFocu

s

Res

earc

hdes

ign/lev

elof

evid

ence

(LE

)D

ata

coll

ecti

on/s

ample

size

Key

findin

gsFact

ors

that

influen

cedia

gnose

s

Flo

rin

etal

.(2

005)

Tit

le:

Qual

ity

of

nurs

ing

dia

gnose

s:ev

alu

atio

n

of

an

educa

tional

inte

rven

tion

Eff

ects

of

educa

tion

on

the

nurs

ing

pro

cess

and

imple

men

tati

on

of

new

form

sfo

r

reco

rdin

gon

the

quali

tyof

nurs

ing

dia

gnost

ic

state

men

tsin

pati

ent

reco

rds

Pre

test

/post

-tes

tdes

ign

LE

:2

The

inte

rven

tion

consi

sted

of

a

3-h

our,

five-

mee

ting

educa

tional

pro

gra

mm

es

Random

lyse

lect

edpati

ent

reco

rds

wer

ere

vie

wed

bef

ore

and

aft

er

the

inte

rven

tion

Data

analy

ses

usi

ng

a

mea

sure

men

tsc

ale

wit

h14

chara

cter

isti

csper

tain

ing

to

nurs

ing

dia

gnose

snam

ed:

quality

of

nurs

ing

dia

gnosi

suse

din

two

exper

imen

tal

unit

s(n

=70)

and

one

contr

ol

unit

(n=

70)

Quali

tyof

nurs

ing

dia

gnost

ic

state

men

tsim

pro

ved

signifi

cantl

y

inth

eex

per

imen

tal

unit

s,

wher

eas

no

impro

vem

ent

was

found

inth

eco

ntr

ol

unit

Educa

tion

inth

enurs

ing

pro

cess

and

imple

men

tati

on

of

new

form

sfo

rre

cord

ing

mig

ht

impro

ve

RN

s’sk

ills

inex

pre

ssin

g

nurs

ing

dia

gnose

s

Imple

men

tati

on

of

new

form

sfo

r

reco

rdin

g

Educa

tion

inth

enurs

ing

pro

cess

Gri

ffith

s(1

998)

Tit

le:

An

inves

tigati

on

into

the

des

crip

tion

of

pati

ents

pro

ble

ms

by

nurs

es

usi

ng

two

dif

fere

nt

nee

ds-

base

dnurs

ing

model

s

Des

crip

tion

of

pati

ents

’pro

ble

ms

by

nurs

esusi

ng

two

dif

fere

nt

nee

ds-

base

dnurs

ing

model

s

Qual

itati

ve,

des

crip

tive

study

des

ign

and

lite

ratu

rere

vie

w

LE

:4

Tw

ow

ard

sw

ere

inves

tigate

din

one

hosp

ital;

Ward

Ause

dth

e

nurs

ing

model

of

Roper

Logan

and

Tie

rney

(1980),

wher

eas

Ward

Buse

dth

em

odel

of

Doro

thea

Ore

m(1

980)

Data

coll

ecte

dw

ere

subje

cted

to

conte

nt

analy

sis

usi

ng

Gord

on’s

Funct

ional

Hea

lth

Patt

erns

to

ord

erth

edata

Nurs

esm

ost

com

monly

use

d

med

ical

dia

gnose

sor

the

med

ical

reaso

ns

for

adm

issi

on

Pati

ents

’pro

ble

ms

iden

tified

pre

dom

inate

lyaddre

ssed

bio

psy

chic

al

nee

ds

Med

ical

dia

gnose

s

Med

ical

reaso

ns

for

adm

issi

on

Gunnin

gber

get

al.

(2009)

Tit

le:

Impro

ved

quali

tyand

com

pre

hen

siven

ess

in

nurs

ing

docu

men

tati

on

of

pre

ssure

ulc

ers

aft

er

imple

men

ting

an

elec

tronic

hea

lth

reco

rdin

hosp

ital

care

The

quali

tyand

com

pre

hen

siven

ess

of

nurs

ing

docu

men

tati

on

of

pre

ssure

ulc

ers

bef

ore

and

aft

er

imple

men

tati

on

of

an

elec

tronic

hea

lth

reco

rdand

the

use

of

pre

form

ula

ted

tem

pla

tes

for

pre

ssure

ulc

er

reco

rdin

g

Cro

ss-s

ecti

onal

retr

osp

ecti

ve

revie

wof

hea

lth

reco

rds

LE

:2

Analy

sis

of

reco

rded

data

on

pre

ssure

ulc

ers

Paper

-base

dre

cord

s(n

=59)

iden

tified

by

note

son

pre

ssure

ulc

ers

and

elec

tronic

hea

lth

reco

rds

(n=

71)

wit

hpre

ssure

ulc

erre

cord

ings

wer

e

retr

osp

ecti

vel

yre

vie

wed

Ele

ctro

nic

pati

ent

reco

rds

show

ed

signifi

cantl

ym

ore

dia

gnost

ic

note

son

pre

ssure

ulc

ergra

de

Pre

form

ula

ted

tem

pla

tes

in

elec

tronic

hea

lth

reco

rds



Table

1(C

onti

nued

)

Ref

eren

ceFocu

s

Res

earc

hdes

ign/l

evel

of

evid

ence

(LE

)D

ata

coll

ecti

on/s

am

ple

size

Key

findin

gs

Fact

ors

that

influen

cedia

gnose

s

Ham

ers

etal

.(1

996)

Tit

le:

The

influen

ceof

childre

n’s

voca

l

expre

ssio

ns,

age,

med

ical

dia

gnosi

sand

info

rmati

on

obta

ined

from

pare

nts

on

nurs

es’

pain

ass

essm

ents

and

dec

isio

ns

regard

ing

inte

rven

tions

The

influen

ceof

task

-rel

ate

dfa

ctors

on

nurs

es’

pain

ass

essm

ents

and

dec

isio

ns

regard

ing

inte

rven

tions

Random

ised

exper

imen

tal

des

ign

LE

:1

Paed

iatr

icnurs

es(n

=202)

from

11

hosp

itals

wer

era

ndom

ised

into

four

gro

ups

Each

gro

up

was

expose

dto

four

sequen

tial

case

s,ea

chof

whic

h

consi

sted

of

avig

net

teand

a

vid

eota

pe

wit

hdif

fere

nt

fact

ors

The

child’s

expre

ssio

ns

wer

e

oper

ati

onali

sed

via

vid

eota

pes

of

the

sam

ech

ild

Data

collec

tion

took

pla

ceduri

ng

15-m

inute

sess

ions

base

don

vig

net

tes;

nurs

esra

ted

thei

r

answ

ers

on

avis

ual

analo

gue

scale

Paed

iatr

icnurs

esatt

ribute

dm

ore

pain

toand

wer

em

ore

incl

ined

to

adm

inis

ter

non-n

arc

oti

c

anal

ges

ics

toch

ildre

nw

ho

voca

lly

expre

ssed

thei

rpain

than

toch

ildre

nw

ho

wer

ele

ss

expre

ssiv

e

Nurs

esals

oatt

ribute

dth

em

ost

pain

toa

chil

dw

hen

the

dia

gnosi

sw

as

sever

e

Voca

lly

expre

ssin

gpain

Sev

ere

med

ical

dia

gnosi

s

Hase

gaw

aet

al.

(2007)

Tit

le:

Mea

suri

ng

dia

gnost

ic

com

pet

ency

and

the

anal

ysi

sof

fact

ors

influen

cing

com

pet

ency

usi

ng

wri

tten

case

studie

s

Nurs

es’

dia

gnost

ic

com

pet

enci

esby

usi

ng

wri

tten

case

studie

sand

the

fact

ors

influen

cing

thes

eco

mpet

enci

es

Cro

ss-s

ecti

onal

study

des

ign

base

don

wri

tten

case

studie

s

LE

:2

Tw

ow

ritt

enca

sest

udie

sw

ere

use

d

tom

easu

reth

edia

gnost

ic

com

pet

enci

esof

the

subje

cts

Aco

nven

ience

sam

ple

of

376

nurs

espra

ctic

ing

inm

edic

al-

surg

ical

nurs

ing

posi

tions

was

obta

ined

from

nin

edif

fere

nt

hosp

itals

Japanes

enurs

esin

the

sam

ple

,in

gen

eral,

did

not

per

form

sati

sfact

ory

level

sof

dia

gnost

ic

com

pet

ency

Len

gth

of

clin

ical

exper

ience

Dec

isio

n-m

akin

gre

sponsi

bil

ity

Fre

quen

cyof

studyin

gnurs

ing

dia

gnosi

s

Kil

gus

etal

.(1

995)

Tit

le:

Influen

ceof

race

on

dia

gnosi

sin

adole

scen

t

psy

chia

tric

inpat

ients

Influen

ceof

race

on

dia

gnose

s

Rec

ord

revie

w

LE

:2

Data

wer

eabst

ract

edfr

om

pati

ents

’re

cord

sand

nurs

ing

inci

den

tre

port

s

DSM

-III

-Rdis

char

ge

dia

gnose

s

wer

eass

igned

tofive

non-

mutu

all

yex

clusi

ve

gro

ups

Hosp

ital

med

ical

reco

rds

(n=

352);

whit

es(n

=251),

Afr

ican

Am

eric

ans

(n=

101)

in

one

hosp

ital

Sig

nifi

cant

raci

aldif

fere

nce

sw

ere

found

inth

edis

charg

edia

gnose

s

of

adole

scen

tshosp

italise

dfo

r

psy

chia

tric

dis

ord

ers

Org

anic

/psy

choti

cdia

gnose

sw

ere

much

more

freq

uen

tin

Afr

ican

Am

eric

ans,

wher

eas

whit

esw

ere

alm

ost

twic

em

ore

likel

yto

rece

ive

mood/a

nxie

tydia

gnose

s

Subst

ance

abuse

was

more

oft

en

dia

gnose

din

whit

es

Som

eof

thes

edif

fere

nce

sm

ay

reflec

tet

hnoce

ntr

iccl

inic

ian

bia

s

inth

edia

gnost

icass

essm

ent

of

youth

sfr

om

dif

fere

nt

cult

ura

l

and

raci

al

back

gro

unds

Raci

al

dif

fere

nce

sin

pati

ents

Cult

ura

lback

gro

unds

in

pati

ents

W Paans et al.


Table

1(C

onti

nued

)

Ref

eren

ceFocu

s

Res

earc

hdes

ign/l

evel

of

evid

ence

(LE

)D

ata

collec

tion/s

am

ple

size

Key

findin

gsFact

ors

that

influen

cedia

gnose

s

Kura

shim

aet

al.

(2008)

Tit

le:

Acc

ura

cyand

effici

ency

of

com

pute

r-aid

ed

nurs

ing

dia

gnosi

s

Whet

her

a

com

pute

r-aid

ed

nurs

ing

(CA

N)

dia

gnosi

ssy

stem

impro

ves

dia

gnost

icacc

ura

cy

and

effici

ency

Random

ised

cross

ove

r

tria

l

LE

:1

Reg

iste

red

nurs

es(n

=42)

wer

e

div

ided

into

gro

ups:

one

usi

ng

the

CA

Ndia

gnosi

ssy

stem

and

the

oth

erusi

ng

ahandbook

of

nurs

ing

dia

gnosi

s

Deg

ree

of

acc

ura

cyw

as

judge

dby

usi

ng

Lunney

’sse

ven

-poin

t

inte

rval

scale

,w

hil

eef

fici

ency

was

evalu

ate

dacc

ord

ing

toth

e

tim

ere

quir

edfo

rdia

gnosi

s

No

sign

ifica

nt

dif

fere

nce

was

found

bet

wee

nth

etw

ogro

ups

in

term

sof

dia

gnost

icacc

ura

cy

Tim

ere

quir

edfo

rdia

gnosi

sw

as

signifi

cantl

ysh

ort

erfo

rsu

bje

cts

who

use

dth

eC

AN

dia

gnosi

s

syst

emth

an

for

those

who

did

not

Usi

ng

aco

mpute

raid

signifi

cantl

y

short

ens

the

tim

enee

ded

to

der

ive

dia

gnosi

s

Lee

(2005)

Tit

le:

Nurs

ing

dia

gnose

s:

fact

ors

aff

ecti

ng

thei

r

use

inch

art

ing

standard

ised

care

pla

ns

Fact

ors

that

may

aff

ect

nurs

es’use

of

nurs

ing

dia

gnose

s

inch

art

ing

standard

ised

nurs

ing

care

pla

ns

inth

eir

dail

y

pra

ctic

e

One-

on-o

ne,

in-d

epth

inte

rvie

ws

LE

:4

Cli

nic

al

nurs

es(n

=12)

at

a

med

ical

centr

eunder

wen

tone-

on-o

ne,

in-d

epth

inte

rvie

ws

Dat

aanaly

sis

was

base

don

Mil

es

and

Huber

man’s

(1994)

data

reduct

ion,

data

dis

pla

y,and

concl

usi

on-v

erifi

cati

on

pro

cess

to

inves

tigate

the

chart

ing

pro

cess

Nurs

esdo

not

regula

rly

use

obje

ctiv

edata

tore

cord

pati

ents

’

condit

ion

Use

of

standard

ised

care

pla

ns

Mart

in(1

995)

Tit

le:

Nurs

epra

ctit

ioner

suse

of

nurs

ing

dia

gnosi

s

The

indep

enden

t

nurs

ing

role

of

nurs

epra

ctit

ioner

s

(NPs)

and

the

advanta

ges

and

barr

iers

of

usi

ng

nurs

ing

dia

gnosi

s

inN

Ppra

ctic

e

Cro

ss-s

ecti

onal

study

des

ign

base

don

a

surv

ey

LE

:2

Sel

f-adm

inis

tere

dques

tionnair

es

(n=

181)

incl

uded

bio

graphic

al

data

and

forc

edch

oic

eques

tions

about

know

ledge

of

nurs

ing

dia

gnosi

s

No

stati

stic

al

sign

ifica

nce

was

seen

bet

wee

nN

Ps’

know

ledge

and

use

of

nurs

ing

dia

gnose

sand

thei

r

educa

tional

back

gro

und,

spec

ialt

y,

yea

rsof

pra

ctic

eas

a

NP,

and

pra

ctic

ese

ttin

g

85%

of

NPs’

surv

eyed

report

ed

they

did

not

use

nurs

ing

dia

gnose

sin

thei

rcl

inic

alpra

ctic

e

Lack

of

tim

e

Lack

of

clari

tyof

dia

gnost

ic

state

men

ts

Lack

of

adm

inis

trati

ve

support

for

wri

ting

nurs

ing

dia

gnosi

s

Muller

-Sta

ub

etal

.

(2007)

Tit

le:

Impro

ved

quali

tyof

nurs

ing

docu

men

tati

on:

resu

lts

of

aN

urs

ing

Dia

gnose

s

Inte

rven

tions

and

Outc

om

es

Imple

men

tati

on

study

Evalu

ati

on

of

the

effe

cts

of

the

Nurs

ing

Dia

gnost

ics

Educa

tional

Pro

gra

mm

e

(ND

EP)

Pre

test

/post

-tes

tdes

ign

LE

:2

Nurs

esof

hosp

ital

ward

s(n

=12)

of

one

hosp

ital

rece

ived

an

educa

tional

inte

rven

tion

called

ND

EP

Bef

ore

and

aft

erth

ein

terv

enti

on,

ato

tal

of

72

random

lyse

lect

ed

nurs

ing

reco

rds

wer

eev

alu

ate

d

The

inst

rum

ent

Quali

tyof

Nurs

ing

Dia

gnose

s,In

terv

enti

ons,

and

Outc

om

esw

asuse

dto

mea

sure

the

quality

of

the

nurs

ing

dia

gnose

s

The

guid

edcl

inic

al

reaso

nin

g

pro

gra

mm

esi

gnifi

cantl

y

impro

ved

the

form

ula

tion

of

nurs

ing

dia

gnost

icla

bel

sand

iden

tifica

tion

of

signs/

sym

pto

ms

and

corr

ect

aet

iolo

gie

s

Post

-tes

tdata

show

edalm

ost

no

nurs

ing

dia

gnose

sw

ithout

sign

s/

sym

pto

ms

inco

mpari

son

wit

h

the

pre

test

ND

EP

Guid

edcl

inic

al

reaso

nin

g



Table

1(C

onti

nued

)

Ref

eren

ceFocu

s

Res

earc

hdes

ign/l

evel

of

evid

ence

(LE

)D

ata

collec

tion/s

am

ple

size

Key

findin

gs

Fact

ors

that

influen

cedia

gnose

s

Mull

er-S

taub

etal

.

(2008)

Tit

le:

Imple

men

ting

nurs

ing

dia

gnost

ics

effe

ctiv

ely:

clust

erra

ndom

ised

tria

l

The

effe

ctof

guid

ed

clin

ical

reaso

nin

g

on

nurs

ing

dia

gnose

s,

inte

rven

tions,

and

outc

om

es

Clu

ster

-random

ised

contr

oll

ed

exper

imen

tal

study

in

apre

test

/post

-tes

t

des

ign

LE

:1

Nurs

esfr

om

thre

ew

ard

sre

ceiv

ed

guid

edcl

inic

al

reaso

nin

gtr

ain

ing

Nurs

esof

thre

eoth

erw

ard

s

part

icip

ate

din

class

icca

se

dis

cuss

ions

and

funct

ioned

as

a

contr

ol

gro

up

The

quality

of

225

random

ly

sele

cted

nurs

ing

reco

rds,

conta

inin

g444

docu

men

ted

nurs

ing

dia

gnose

sco

rres

pondin

g

toin

terv

enti

ons

and

outc

om

es,

was

evalu

ate

dby

apply

ing

18

Lik

ert-

type

item

sof

the

Q-D

IO

The

mea

nsc

ore

sof

nurs

ing

dia

gnose

sin

crea

sed

sign

ifica

ntl

y

inth

ein

terv

enti

on

gro

up

Guid

edcl

inic

al

reaso

nin

gle

dto

sign

ifica

ntl

yhig

her

quality

of

nurs

ing

dia

gnosi

sdocu

men

tati

on

toaet

iolo

gy-s

pec

ific

inte

rven

tions

and

toen

hance

nurs

ing-s

ensi

tive

pati

ent

outc

om

es

Inth

eco

ntr

olgro

up,th

equality

of

the

dia

gnose

sw

as

not

sign

ifica

ntl

ych

anged

Guid

edcl

inic

al

reaso

nin

g

Paganin

etal

.(2

008)

Tit

le:

Fact

ors

that

inhib

itth

e

use

of

nurs

ing

language

The

impact

of

inst

ituti

onal,

pro

fess

ional

and

per

sonal

fact

ors

on

nurs

esand

on

thei

r

effo

rts

toder

ive

nurs

ing

dia

gnose

s

Cro

ss-s

ecti

onal

study

des

ign

base

don

a

surv

ey

LE

:2

Res

ponse

sof

21

nurs

esfo

rea

ch

gro

up

of

fact

ors

(inst

ituti

onal,

per

sonal,

and

pro

fess

ional

)w

ere

evalu

ate

dand

score

don

asc

ale

of

0(n

one

of

the

impact

para

met

ers

iden

tified

)to

100

(all

impact

para

met

ers)

Dat

aw

ere

coll

ecte

dusi

ng

acl

ose

d,

stru

cture

dques

tionnair

eduri

ng

the

work

shif

tof

21

nurs

es

The

pro

fess

ionalfa

ctor

score

sw

ere

sign

ifica

ntl

ylo

wer

am

ong

nurs

es

wit

hpre

vio

us

theo

reti

cal

train

ing

innurs

ing

dia

gnosi

sco

mpare

dto

those

wit

hno

pre

vio

us

theo

reti

cal

train

ing

The

reco

gnit

ion

of

thes

efa

ctors

and

impro

ved

inst

ituti

onal

support

may

faci

lita

teth

e

imple

men

tati

on

of

nurs

ing

dia

gnose

s

Work

load

level

Num

ber

of

pati

ents

per

nurs

e

Num

ber

of

adm

inis

trat

ive

task

s

Pre

vious

nurs

ing

dia

gnosi

s

exper

ience

Pre

vious

theo

reti

cal

train

ing

Rei

chm

an

and

Yara

ndi

(2002)

Tit

le:

Cri

tica

lca

re

card

iovasc

ula

rnurs

e

exper

tand

novic

e

dia

gnost

iccu

e

uti

lisa

tion

Dia

gnost

iccu

e

uti

lisa

tion

bet

wee

n

exper

tand

novic

e

crit

ical

care

card

iovasc

ula

r

nurs

es(C

CC

V)

Exper

imen

tal

des

ign

LE

:2

Fiv

ew

ritt

enpati

ent

sim

ula

tions

(WPSs)

serv

edas

inst

rum

ents

in

the

study

Ver

bal

reca

lls

of

the

resp

onden

ts

wer

eaudio

taped

for

anal

ysi

s;

exper

t(n

=23)

and

novic

e

(n=

23)

nurs

esw

ere

test

ed

Of

the

184

WPSs

that

wer

e

dia

gnose

d,

88

wer

eacc

ura

te

Of

the

88

acc

ura

tedia

gnose

s,63

(72%

)w

ere

made

by

CC

CV

nurs

eex

per

ts,

while

25

(28%

)

wer

em

ade

by

nurs

enovic

es

Lev

elof

exper

ience

Nurs

es’

back

gro

und

as

an

exper

t

W Paans et al.


Table

1(C

onti

nued

)

Ref

eren

ceFocu

s

Res

earc

hdes

ign/l

evel

of

evid

ence

(LE

)D

ata

collec

tion/s

am

ple

size

Key

findin

gsFact

ors

that

influen

cedia

gnose

s

Sm

ith

Hig

uch

iet

al.

(1999)

Tit

le:

Fact

ors

ass

oci

ate

dw

ith

nurs

ing

dia

gnosi

s

uti

lisa

tion

inC

anada

Fact

ors

ass

oci

ate

d

wit

hnurs

ing

dia

gnosi

s

uti

lisa

tion

Cro

ss-s

ecti

onal

study

des

ign

base

don

a

surv

eyand

a

retr

osp

ecti

vech

art

revie

w

LE

:2

Att

itude

surv

eyin

cluded

47

Lik

ert-

scale

item

sand

2open

-ended

ques

tions

All

nurs

es(n

=65)

from

four

hosp

itals

that

care

dfo

rpati

ents

wit

hre

spir

ato

ryco

ndit

ions

wer

e

invit

edto

part

icip

ate

inth

est

udy

Inaddit

ion,

are

trosp

ecti

ve

chart

audit

of

dis

charg

edpati

ents

(n=

427)

was

conduct

ed

Intw

ohosp

itals

inw

hic

hnurs

ing

dia

gnosi

sim

ple

men

tati

on

pro

gra

mm

esw

as

not

imple

men

ted,

none

of

the

22

nurs

esdocu

men

ted

nurs

ing

dia

gnose

s

Inth

etw

ohosp

itals

inw

hic

h

nurs

ing

dia

gnosi

sw

asfo

rmal

ly

imple

men

ted

thro

ugh

hosp

ital

educa

tional

pro

gra

mm

es,

37

of

43

nurs

es(8

6%

)docu

men

ted

nurs

ing

dia

gnose

s

Att

itude

tow

ard

sdia

gnosi

s

uti

lisa

tion

Know

ledge

Nurs

ing

adm

inis

trat

ion

expec

tati

ons

Pre

sence

of

form

alhosp

ital

educa

tional

pro

gra

mm

esin

nurs

ing

dia

gnost

ics

Com

pute

r-gen

erate

dnurs

ing

care

pla

ns

Tak

ahash

iet

al.

(2008)

Tit

le:

Dif

ficu

ltie

sand

faci

liti

es

poin

ted

out

by

nurs

es

of

auniv

ersi

tyhosp

ital

when

apply

ing

the

nurs

ing

pro

cess

Dif

ficu

ltand

easy

asp

ects

of

per

form

ing

the

dif

fere

nt

stages

of

the

nurs

ing

pro

cess

,acc

ord

ing

toth

ere

port

sof

nurs

es

Cro

ss-s

ecti

onal

study

des

ign

base

don

a

surv

ey

LE

:2

Eig

hty

-thre

enurs

esfr

om

20

dif

fere

nt

hosp

ital

unit

sin

whic

h

the

nurs

ing

pro

cess

was

regula

rly

imple

men

ted

answ

ered

stru

cture

dre

searc

h

ques

tionnair

es

Nurs

eshad

most

dif

ficu

ltie

sw

ith

the

phase

snurs

ing

dia

gnose

sand

evalu

ati

ons

Most

of

the

dif

ficu

ltand

easy

asp

ects

report

edw

ere

rela

ted

to

the

nurs

es’

theo

reti

cal

and

pra

ctic

al

know

ledge

nee

ded

to

per

form

the

phase

sof

the

pro

cess

Lack

of

theo

reti

cal

know

ledge

Lack

of

pra

ctic

al

exer

cise

Thoro

ddse

nand

Ehnfo

rs(2

006)

Tit

le:

Putt

ing

policy

into

pra

ctic

e:pre

-and

post

-

test

sof

imple

men

ting

standard

ised

languages

for

nurs

ing

docu

men

tati

on

Dif

fere

nce

sin

docu

men

ted

nurs

ing

dia

gnose

s,

signs

and

sym

pto

ms

and

aet

iolo

gic

al

fact

ors

bef

ore

and

aft

eran

educa

tional

effo

rt

Pre

test

,post

-tes

t,cr

oss

-

sect

ional

study

des

ign

LE

:2

For

the

pre

test

,355

nurs

ing

reco

rds

ina

hosp

ital

wer

e

revie

wed

Aft

erth

eim

ple

men

tati

on

of

the

Funct

ional

Hea

lth

Patt

erns

for

ass

essm

ent

docu

men

tati

on

and

the

NA

ND

Acl

ass

ifica

tion

for

nurs

ing

dia

gnose

s,a

post

-tes

tw

as

conduct

edin

whic

h349

reco

rds

wer

ere

vie

wed

The

num

ber

of

dia

gnose

sper

pati

ent

incr

ease

d,

inco

mple

te

dia

gnose

sdec

rease

dalo

ng

wit

h

the

use

of

med

icaldia

gnose

s,and

the

docu

men

tati

on

of

signs

and

sym

pto

ms

incr

ease

d

Imple

men

tati

on

of

the

NA

ND

A

class

ifica

tion

for

nurs

ing

dia

gnose

s



Table

1(C

onti

nued

)

Ref

eren

ceFocu

s

Res

earc

hdes

ign/l

evel

of

evid

ence

(LE

)D

ata

coll

ecti

on/s

am

ple

size

Key

findin

gs

Fact

ors

that

influen

cedia

gnose

s

Thoro

ddse

nand

Thors

tein

sson

(2002)

Tit

le:

Nurs

ing

dia

gnosi

s

taxonom

yacr

oss

the

Atl

anti

cO

cean:

congru

ence

bet

wee

n

nurs

es’

chart

ing

and

the

NA

ND

A

taxonom

y

Expre

ssio

ns

or

term

s

use

dby

nurs

esto

des

crib

epati

ent

pro

ble

ms

Ret

rosp

ecti

ve

chart

revie

w

LE

:2

The

pati

ent

reco

rds

in1103

chart

s

from

a400-b

edacu

te-c

are

hosp

ital

wer

eanaly

sed

Nurs

ing

dia

gnose

sst

ate

men

ts

(n=

2171)

inch

art

sw

ere

anal

yse

dbase

don

the

PE

Sfo

rmat

Nurs

esfa

iled

todocu

men

tth

e

pro

ble

ms

of

pati

ents

inabout

40%

of

the

reco

rds

The

NA

ND

Ata

xonom

yse

ems

to

be

cult

ura

lly

rele

vant

for

nurs

es

indif

fere

nt

cult

ure

s

Pati

ent

length

of

stay

isass

oci

ate

d

wit

hth

enum

ber

of

dia

gnose

s

Whit

ley

and

Gula

nic

k

(1996)

Tit

le:

Barr

iers

toth

euse

of

nurs

ing

dia

gnosi

s

language

incl

inic

al

sett

ings

The

curr

ent

statu

s

regard

ing

uti

lisa

tion

of

nurs

ing

dia

gnosi

s

and

the

inte

rest

in

educa

tional

consu

ltati

on

sess

ions

that

wer

e

pro

vid

edby

the

nurs

ing

dia

gnosi

s

counci

l

Cro

ss-s

ecti

onal

study

des

ign

base

don

a

surv

ey

LE

:2

Asu

rvey

inst

rum

ent

was

mail

edto

all

hosp

itals

(n=

239)

inth

est

ate

of

Illi

nois

,U

SA

The

surv

eyin

stru

men

tsw

ere

com

ple

ted

and

retu

rned

by

139

agen

cies

Nurs

ing

dia

gnose

sw

ere

per

form

ed

in109

of

the

139

resp

ondin

g

hosp

itals

Of

the

109

resp

onden

tsw

ho

per

form

ednurs

ing

dia

gnose

s,

88%

incl

uded

nurs

ing

dia

gnosi

s

inan

ori

enta

tion

pro

gra

mm

e,

and

alm

ost

all

use

dN

AN

DA

term

inolo

gy

(95%

)

Lim

ited

ongoin

ged

uca

tion

Lack

of

moti

vati

on

tole

arn

Dif

ficu

ltie

sin

usi

ng

dia

gnose

sin

spec

ialt

yare

as

Physi

cian

obje

ctio

ns

or

resi

stan

ce

NA

ND

A,

Nort

hA

mer

ican

Nurs

ing

Dia

gnosi

sA

ssoci

ati

on.

W Paans et al.


Limitations

The present review is limited in several respects. We only

included papers published in English. Therefore, we focused

more on papers written by authors who carried out their

research in the North American and north-western European

context. Despite the advanced literature search, we may have

overlooked some papers because of the search strategy or

database filters used. We assessed papers qualitatively. No

statistical procedures to aggregate data were used, as the

instruments and methods described in the reviewed articles

differed. Therefore, it was not feasible to perform statistical

procedures on the aggregated data.

Conclusion

Despite the lack of knowledge about factors that influence

diagnoses documentation, we conclude that nursing diagnosis

documentation is not limited to classification in an autono-

mous nursing domain but is limited to inference to an

individual process influenced by several internal and external

factors (Bandman & Bandman 1995, Wilkinson 2007). The

outcomes of an individual diagnostic process ought to be

documented by nurses in such a way that patients, colleagues,

physicians and other healthcare workers can understand it

and can rely on the content of the documentation. Also

lacking is research about the influences of interdisciplinary

exchange of knowledge concerning the essentials of medical

and nursing diagnosis. Moreover, there might be an associ-

ation between a nurse’s level of education, nurse staffing in

hospitals and accuracy in diagnostic documentation. How-

ever, this possible association is still unclear and needs to be

researched.

Acknowledgements

We thank Brink& Research and Development Association,

Utrecht, the Netherlands, for additional funding.

Contributions

Study design: WP, RN, WS, CS; data collection and analysis:

WP, RN and manuscript preparation: WP, RN, CS, WS.

Conflict of interest

Brink& Research and Development Association, Utrecht, the

Netherlands financially funded the study and had no role in

study design, in the collection, analyses and interpretation of

data, in the writing of the report or in the decision to submit

the paper for publication.

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