Phase 1: Literature Review
Searching the online databases resulted in 3520 articles from PubMed, Embase, Scopus, Science Direct, and Cochrane after removing duplicates. Initial screening of titles and abstracts resulted in 145 articles, of which 113 articles were excluded because they did not address reporting template items in relation to nursing practices. Three further articles were identified through checking the bibliographies, leading to a total of 35 articles for full-text review (Figure 2).
Phase2: Delphi stage
In this study, after searching in scientific databases and according to the processes provided by NANDA, CCC, ICNP nursing calcifications, we extracted a set of data elements and validated via a two-round Delphi survey for inclusion in the final MDS of nursing documentation. We divided this dataset into three general categories, including administrative, nursing assessment, and nursing diagnoses. The number of participants in the Delphi stage was 80 people, including 74 individuals with nursing Ph.D. degrees, and six persons with MSC nursing degrees. About 43% of the participants were female, 88% of them had more than 10 years of clinical experience, and all participants had an RN degree. (Table 1)
Administrative information
This section has 19 items in our study. The items were delivered by the Delphi survey for nursing professionals. In the first round of Delphi, all items of this section were confirmed (Table 2).
Nursing assessment information:
This section has a total of 875 items that are divided into 9 categories. These categories are including (Table 2):
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Cardiovascular system:
The cardiovascular system had 140 items. Items 1 to 60 (95.63% agreement), items 61 to 100 (89.87% agreement), items 101 to 130 (88.6% agreement) are accepted in the first stage of Delphi, and items 131 to 140 (85.46% agreement) are accepted in the second stage of Delphi and finally, all 140 cardiovascular items were accepted. Each item had a percentage of acceptance that those items whose acceptance percentage was close to each other are listed in a column.
- Muscle and Skeletal system
The Muscle and Skeletal system had 80 items. Items 1 to 40 (98.32% agreement), items 41 to 68 (92.87% agreement), items 69 to 78 (90.56% agreement) are accepted in the first stage of Delphi. Items 79 to 80 (65.36% agreement) are removed in the second stage of Delphi and finally, 77 Muscle and Skeletal items were accepted. Each item had a percentage of acceptance that those items whose acceptance percentage was close to each other are listed in a column.
- GU system
The GU system had 85 items. Items 1 to 30 (98.1% agreement), items 31 to 56 (96.23% agreement), items 57 to 82 (97% agreement) are accepted in the first stage of Delphi. Items 83 to 85 (65.66% agreement) are removed in the second stage of Delphi and finally, 82 GU items were accepted. Each item had a percentage of acceptance that those items whose acceptance percentage was close to each other are listed in a column.
- Renal system
The renal system had 50 items. Items 1 to 36 (89.1% agreement), items 37 to 45 (90.39% agreement), items 46 to 50 (98.85% agreement) are accepted in the first stage of Delphi and finally, all 50 renal items were accepted. Each item had a percentage of acceptance that those items whose acceptance percentage was close to each other are listed in a column.
- Neurological system
The Neurological system had 110 items. Items 1 to 48 (99% agreement), items 49 to 88 (91.41% agreement), items 89 to 100 (95% agreement), items 101 to 108 (88.64% agreement), are accepted in the first stage of Delphi. Items 109 to 110 (69.75% agreement) are removed in the second stage of Delphi and finally, 108 Neurological items were accepted. Each item had a percentage of acceptance that those items whose acceptance percentage was close to each other are listed in a column.
- Psychological and social
The Psychological and social had 65 items. Items 1 to 42 (98.12% agreement), items 43 to 58 (96.55% agreement), items 59 to 65 (100% agreement) are accepted in the first stage of Delphi and finally, all 65 Psychological and social were accepted. Each item had a percentage of acceptance that those items whose acceptance percentage was close to each other are listed in a column.
- Skin system
The skin system had 55 items. Items 1 to 49 (100% agreement), items 50 to 55 (96% agreement are accepted in the first stage of Delphi and finally all 55 skin items were accepted. Each item had a percentage of acceptance that those items whose acceptance percentage was close to each other are listed in a column.
- General appearance
The General appearance had 150 items. Items 1 to 36 (100% agreement), items 37 to 88 (94.96% agreement), items 89 to 95 (98% agreement), items 96 to 106 (96% agreement), items 107 to 120 (86.76% agreement), items 121 to 134 (79.23% agreement), items 135 to 145 (89% agreement), items 146 to 150 (88% agreement), are accepted in the first stage of Delphi and finally all 150 General appearance items were accepted. Each item had a percentage of acceptance that those items whose acceptance percentage was close to each other are listed in a column.
- Respiratory system
The respiratory system had 140 items. Items 1 to 55 (89.51% agreement), items 56 to 78 (98.23% agreement), items 79 to 100 (96.37% agreement), items 101 to 125 (95% agreement) are accepted in the first stage of Delphi, and items 126 to 140 (79.80% agreement) are accepted in the second stage of Delphi and finally, all 140 respiratory items were accepted. Each item had a percentage of acceptance that those items whose acceptance percentage was close to each other are listed in a column.
Due to a large amount of information, we had to provide, for example, only Table 3, which is an example of a platform developed for cardiovascular nursing assessment.
Source of nursing diagnoses:
In this study, we conducted a Delphi survey to determine the source for writing nursing diagnoses. For this purpose, the main sources for NANDA, ANA, ICNP, CCC, and CINA nursing diagnoses were selected and sent to the participants. 100% of the survey returned, the NANDA classification was accepted with 98% approval, and based on NANDA, nursing diagnoses were written and included in the final MDS of the nursing reporting system (Table 4).
Nursing documentation software development tools are shown in Figures 3 and 4.
System evaluation:
After developing the system, it was used experimentally by the users and a pilot study was performed on user satisfaction. This study was performed on 150 participating clinical nurses. 74.66% of the participants were female and their average age was 36.4 (SD±6.4). 45.33% of them were employed in the internal medicine-surgical wards, 35.33% works in critical wards, 12.66% in emergency wards, and 6.68% in other medical wards. The average work experience was 15.66 years (SD±4.5) (Table 5).
The extracted data are classified into three categories. Figure5 and 6 identifies the positive and negative impact of developed Electronic Nursing Report by nurses after it using at the Abadan Hospitals respectively.
ENR system can improves the communication between departments (89% of the nurse who answered the question on communication agreed that the system functioned well and nurses were satisfied with the ENR system; it can also improves the quality of care of the patient (92%); by using it the retrieval and entry of patient information is an accurate and easy way (80%); access to the system is an easy and available(91%); the system can be used for in nurses in different wards (89%); reduces documentation errors (85%); legal system (65%); it’s used bedside (93%), exchange information from shift to shift (79%) and enhances the productivity (87%).
The second section of the survey is shown in Figure 6 describing the negative impact of the ENR system: such as loss of confidentiality (35% of the nurses answering the question on the confidentiality issue agreed the ENR system require increased confidentiality); the ENR system is under utilities (35% of nurse agree); the hospital is still using a paper system in some departments (89%); the ENR system is time consuming (28% agree), and speed of the system is too slow (60%) and 17% of participants disagreed with the appropriateness of coding the nursing diagnosis and 15% of them disagreed with the appropriateness of the coding of the nursing assessment.