Nursing staff working in long-term institutional care attend to residents with an increasing number of severe physical and cognitive limitations. To exchange information about the health status of these residents, accurate nursing documentation is important to ensure the safety of residents. This study examined the accuracy of nursing documentation in 197 care plans of five long-term institutional care facilities. Based on the phases of the nursing process, the D-Catch instrument measures the accuracy of the content and coherence of documentation. Inadequacies were especially found in the description of residents' care needs and stated nursing diagnoses as well as in progress and outcome reports. In somatic and psycho-geriatric units, higher accuracy scores were determined compared with residential care units. Investments in resources (e.g., time), reasoning skills of nursing staff, and implementation of professional standards in accordance with legal requirements may be needed to enhance the quality of nursing documentation.
AIM: This paper is a report of a study conducted to describe the accuracy of nursing documentation in patient records in hospitals. Background. Accurate nursing documentation enables nurses to systematically review the nursing process and to evaluate the quality of care. Assessing nurses' reports in patient records can be helpful for improving the accuracy of nursing documentation.METHOD: In 2007-2008, we screened patient records (n = 341) from 35 wards in 10 hospitals in the Netherlands. The D-Catch instrument was used to quantify the accuracy of the (1) record structure, (2) admission data, (3) nursing diagnosis, (4) nursing interventions, (5) progress and outcome evaluations and (6) legibility of nursing reports. Items 2-5 were measured as a sum score of quantity criteria (1-4) and quality criteria (1-4), whereas Items 1 and 6 were measured on a 4-point Likert scale that addressed only quality criteria.FINDINGS: The domain 'accuracy of the interventions' had the lowest accuracy scores: 95% of the records revealed a scale score not higher than 5. However, the domain 'admission' had the highest scores: 80% of the records revealed a scale score over 5.CONCLUSION: Effective documentation systems that support nurses in linking diagnoses, interventions and progress and outcome evaluations could be helpful. To improve the accuracy of the documentation, further research is needed on what factors influence nursing documentation. Comparable outcomes from other studies indicate that applying our study findings to international contexts might support the development of universal criteria for accurate nursing documentation.
OBJECTIVES Previous studies regarding nursing documentation focused primarily on documentation quality, for instance, in terms of the accuracy of the documentation. The combination between accuracy measurements and the quality and frequencies of outcome variables such as the length of the hospital stay were only minimally addressed. METHOD An audit of 300 randomly selected digital nursing records of patients (age of >70 years) admitted between 2013-2014 for hip surgery in two orthopaedic wards of a general Dutch hospital was conducted. RESULTS Nursing diagnoses: Impaired tissue perfusion (wound), Pressure ulcer, and Deficient fluid volume had significant influence on the length of the hospital stay. CONCLUSION Nursing process documentation can be used for outcome calculations. Nevertheless, in the first generation of electronic health records, nursing diagnoses were not documented in a standardized manner (First generation 2010-2015; the first generation of electronic records implemented in clinical practice in the Netherlands).
KnowledgeFlows in Marine Spatial Planning - Sharing Innovation in Higher Education(KnowledgeFlows) aims at further enforcing the European higher education community to meet the growing demands for knowledge, skills and innovation within the still emerging field of marine or maritime spatial planning (MSP).Marine Spatial Planning (MSP) is an emerging governmental approach towards a more effective use of the sea. MSP is of great interest in Europe and can be considered a societal process to balance conflicting interests of maritime stakeholders and the marine environment. Many different activities take place at sea, ranging from shipping, fisheries, to offshore wind energy activities. Simultaneously, new and evolving policies focus on strategies to integrate different marine demands in space and resources. MSP is now legally binding in the EU and is much needed approach to manage and organize the use of the sea, while also protecting the environment.KnowledgeFlows will contribute to the development of new innovative approaches to higher education and training on MSP by means of problem-based learning schemes, transdisciplinary collaboration, and advanced e-learning concepts. KnowledgeFlows builds on results from former project outputs (Erasmus+ Strategic Partnership for Marine Spatial Planning SP-MSP), such as the online learning platform MSP Education Arena (https://www.sp-msp.uol.de).The strategic partnership consists of a transnational network of experts both in research and in practice based in the north Atlantic, Baltic Sea and North Sea Regions including Aalborg University (DK, lead partner), The University of Oldenburg (D), the University of Liverpool (U.K.), the University of Nantes (F), the Leibniz Institute for Baltic Sea Research (D), the Breda University of Applied Sciences (NL), University of Ulster (U.K.), and the Finnish Environment Institute (FI). Gothenburg University, also being a higher education organisation, will be associated partner.Furthermore, three international organisations, the Marine Spatial Planning Research Network, the Baltic inter-governmental VASAB and the pan-Nordic Nordregio will be involved in the partnership as associated organisations deeply rooted in the MSP community of practice.The further improvement of curricula, exchange of knowledge and experts, and transparency and recognition of learning outcomes to reach higher qualifications in MSP are key components of KnowledgeFlows. A mutual learning environment for MSP higher education will enable problem-driven innovation among students and their educators from research and governance also involving stakeholders. Related activities on intellectual outputs, multiplier events and lecturing will be carried out by all participating organisations.The intellectual outputs are related to three major contributions to the European higher education landscape:1) an advanced level international topical MSP course (Step-up MSP)2) digital learning facilities and tools (MSP Education Arena)3) designing problem-based learning in MSP (MSP directory)The advanced level inter-institutional topical MSP course will include different teaching and training activities within a problem-based learning environment. Digital learning facilities enabling communication and training will include a further enrichment of the MSP Education Arena platform for students, practitioners and lecturers for including modules forcollaborate learning activities, documentation and dissemination, mobilisation/recruitment, thesis opportunities, placements/internships. Designing problem-based learning in MSP will include topics as; the design of didactics and methods; guidance for lecturers, supervisors and students; evaluation and quality assurance; assessment.Five multiplier events back to back or as part of conferences within the MSP community will be organised to mainstream the outputs and innovative MSP didactics among other universities and institutions.Different teaching and training activities feeds into the intellectual output activities, which will include serious gaming sessions (MSP Challenge (http://www.mspchallenge.info/) and others), workshops, excursions, courses/classes as well as a conference with a specific focus on facilitating the exchange of innovative ideas and approaches among students at bachelor´s, master´s and doctoral level and the MSP community of practice.Project management meetings (twice a year) will assure coherence in project planning and implementation. As the core focus of the strategic partnership is on collaboration, mutual learning, and innovation among educators, students, and practitioners in order to meet actual and future needs regarding knowledge exchange and training within the MSP community, the project will be designed to have long lasting effects.Results
Quality criteria for patient documentation have to be developed based on research evidence. This project addresses the process of gathering patient information, processing information, and using information in the chain of care.
In summer 2020, part of a quay wall in Amsterdam collapsed, and in 2010, construction for a parking lot in Amsterdam was hindered by old sewage lines. New sustainable electric systems are being built on top of the foundations of old windmills, in places where industry thrived in the 19th century. All these examples have one point in common: They involve largely unknown and invisible historic underground structures in a densely built historic city. We argue that truly circular building practices in old cities require smart interfaces that allow the circular use of data from the past when planning the future. The continuous use and reuse of the same plots of land stands in stark contrast with the discontinuity and dispersed nature of project-oriented information. Construction and data technology improves, but information about the past is incomplete. We have to break through the lack of historic continuity of data to make building practices truly circular. Future-oriented construction in Amsterdam requires historic knowledge and continuous documentation of interventions and findings over time. A web portal will bring together a range of diverse public and private, professional and citizen stakeholders, each with their own interests and needs. Two creative industry stakeholders, Yume interactive (Yume) and publisher NAI010, come together to work with a major engineering office (Witteveen+Bos), the AMS Institute, the office of Engineering of the Municipality of Amsterdam, UNESCO NL and two faculties of Delft University of Technology (Architecture and Computer Science) to inventorize historic datasets on the Amsterdam underground. The team will connect all the relevant stakeholders to develop a pilot methodology and a web portal connecting historic data sets for use in contemporary and future design. A book publication will document the process and outcomes, highlighting the need for circular practices that tie past, present and future.
