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Development of an instrument to measure the quality of documented nursing diagnoses, interventions and outcomes: the Q‐DIO
Author(s) -
MüllerStaub Maria,
Lunney Margaret,
Odenbreit Matthias,
Needham Ian,
Lavin Mary Ann,
Van Achterberg Theo
Publication year - 2009
Publication title -
journal of clinical nursing
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.94
H-Index - 102
eISSN - 1365-2702
pISSN - 0962-1067
DOI - 10.1111/j.1365-2702.2008.02603.x
Subject(s) - operationalization , documentation , audit , medical diagnosis , psychological intervention , medicine , nursing , nursing interventions classification , nursing outcomes classification , nursing minimum data set , nursing research , team nursing , computer science , philosophy , management , epistemology , pathology , economics , programming language
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 operationalised into items and eight experts assessed face and content validity of the Q‐DIO. Results. Criteria were developed and operationalised 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.