To Apply ICNP(?) To Nursing Records In NICU

Objective This research was to investigate nursing records in Neonatal Intensive Care Unit (NICU) about nursing phenomena, nursing action and nursing outcome, by referring to the hierarchical structure, composition function and terms in the International Classification for Nursing Practice (ICNP(?)), to propose appropriate terms and conceptual structure for the construction of nursing record sheets. This will benefit to the improvement of nursing documentation and the development nursing record sheets in NICU.Methods The research was a retrospective nursing documentation study. Purposive sampling was used to recruit three hospitals (named as A-, B-and C-hospital respectively) with NICUs meeting inclusion and exclusion criteria. Nursing records for newborn patients in NICUs who were discharged from1st to30th Nov.2012were collected from NICUs or Health Records Offices.The ICD-10in Chinese Mandarin, most recently disseminated by the Ministry of Health/China, was used to classify patient diseases diagnosed upon discharge. Content analysis was used to categorize meaningful units in NICU nursing records to nursing phenomena, nursing action and nursing outcomes, and SPSS18.0was used to conduct descriptive and frequency analysis for demographical or counts of categories and subcategories of meaningful units.The content analysis was a three-stage qualitative design as to be described below. Stage1is the preliminary study stage. NICU nursing records from the A-hospital was analyzed using the method of content analysis that the classification of meaningful units was tried and proposed leading to the generation of the codebook.Stage2is the stage for cross mapping to examine the comprehensiveness and exclusiveness of the classification as was specified in the codebook. The content analysis was performed with nursing records from B-and C-hospital and changes were made to the initial codebook for better classification strategies and outcomes.Stage3is carried out to optimize the codebook and to generate a guiding structure constituted by ICNP(?) terms and their inner relationships by referring to the hierarchical structure and its composing function of ICNP(?).The strategies of long engagement, member checking, debriefing and etc. were used to establish the trustworthiness for this qualitative study, especially those critical steps related to the generation of the codebook and the cross mapping of terms used in different NICU records.Results In total51NICU patients’records across742days in hospital were studied involving approximately150,000words on2,184pages. It was found that all meaningful units could be classified to three domains (i.e. nursing phenomena, nursing action, nursing outcomes) and then categories, subcategories as well as more descriptively concrete categories (n=98, recorded for43609times). The inter-coder agreement is92.9%(91/98) for all concrete categories.Two categories were identified for units in the domain of nursing phenomena, i.e.’individual processes, characteristics and outcomes’and’event/episodes’, and the most frequently recorded is the subcategory of’gastrointestinal system process’(33.6%,8617/25649),’nervous system process’(13.4%,3442/25649) and’other status (31.4%,8070/25649) such as body temperature, crying, sleeping and so forth. Three categories, labeled as’nursing technique’,’health service’and’safety measure’respectively, were identified for words classified to the domain of nursing action, while the most frequently recorded subcategories are ’positive temperature regulation promotion’(27.8%,4343/15597), medication technique/administration (24.8%,3866/15597) and feeding technique (18.5%,2893/15597).For nursing outcomes, three categories were identified, i.e.’improved/unimproved symptoms’,’effective/ineffective measures’ and ’adaptation to new status’.The above classification results were applied to the generation of the guiding framework constituted by NICU words and their relations in consistency with ICNP(?) terms and their hierarchical conceptual hierarchical relationships.Conclusion The research abides by stipulated standards and related procedures for a rigorous qualitative study focusing on the analysis of nursing records in NICUs from the perspective of nursing terminology for clinical nursing practice. Findings show that nurses play a crucial role in the healthcare for admitted newborns in danger in NICU by carrying out a number of nursing actions, but little evidence about the value of nursing work and the load was found from nursing records in this research. The proposed structural framework contributed by ICNP(?) terms and their relationships could be used to help improve the design of nursing record sheets in NICU to bridge the gap between nursing practice and terminologies in our country and those internationally appropriate.