Nordic Journal of Nursing Research

Empirical identification of nursing diagnoses by collection of terms naming patient problems from a nursing perspective can be compared with both field studies of anthropologists depicting folk classifications of animals or plants and cognitive psychologists studying categories of the mind. This article purports to report on an attempt to transforming theoretical and methodological inspiration from anthropology and cognitive psychology into empirical practice in the field of nursing. Of particular interest to nursing is the hypothesis in antropology and cognitive psychology of the existence of a basic level of diagnostic categories challenging basic assumptions of traditional views about classification.

Results reported in this article do not demonstrate the existence of a basic level of diagnostic categories in nursing but provide usefull motivation for using nursing terminology from clinical practice as a means of identifying nursing diagnoses as an important supplement to nursing diagnoses derived from the terms of nursing theorists.

The documentation and comprehensiveness of the recording of individual patient problems in 140 records from seven hospital wards was reviewed. The aims was to explore what patient problems nurses describe in patient records and whether these could be represented by the keywords of nursing status in the VIPS-model and by the NANDA diagnoses respectively, was also reviewed. Two instruments based on the VIPS-model and developed in earlier studies were used; the VIPS-Review Instrument and the CNRP-instrument. Validity and reliability are discussed. Observer-agreement tests were calculated as Cohens kappa values with good result for both instruments. The result showed that the 410 patient problems or nursing diagnoses recorded were expressed mainly on a general level, they could be categorized under the keywords of nursing status in the VIPS-model and in the NANDA diagnoses. For slightly more than half of the problems there was information in the records on the solution of the problem or on the outcome of nursing care.

An important part of the daily work is the nursing documentation. The purpose of this study was to describe how the nursing documentation and the informal oral report changed at a pediatric ward, when a systematic model based on the nursing process model with keyword was introduced. The nursing record and the informal oral report were studied before and after the intervention. A questionary was to be answered by the nurses after the intervention. A comparison of data showed an enhanced documentation of the nursing process. The four steps: assessment, planning, implementation and evaluation were included in all records after the intervention. The documentation of the nutrition problem-quality was improved. There were no substantial differences in the informal oral reports. The questionary showed that most of the nurses followed the steps of the nursing process and they found the nursing documentation easy to perform. This model improves the nursing documentation and is suitable at a pediatric ward.