Background: Antigua and Barbuda is a Caribbean nation consisting of two islands with a total of 94,298 inhabitants. It is a high-income country, yet healthcare is resource-limited. The nursing process is an evidence-based approach to systematically care for patients in a person-centered way. Having limited resources affects the application of the nursing process. The nursing process and the nursing role are understudied areas in Antigua and Barbuda. Aim: The aim was to describe nurses’ experiences of applying the nursing process in their daily work in Antigua and Barbuda. Method: A qualitative interview study was conducted by interviewing four nurses at a public hospital in Antigua. The data was analyzed using Braun and Clarke’s thematic analysis. Results: Three themes were identified: Empowering the patient, Applying the nursing competence, and Utilizing available resources. Conclusion: The nurses were highly competent and used the nursing process with emphasis on family involvement, however, the lack of staffing was evident. The result of staffing shortage created a stressful working environment. The nurse’s expertise was not always recognized in interprofessional collaboration. Therefore, the nursing role must be strengthened, and the number of nurses must increase to improve person-centered nursing care. / Bakgrund: Antigua och Barbuda är ett land i Karibien bestående av två öar med totalt 94 298 invånare. Det är ett höginkomstland, trots detta har sjukvården begränsat med resurser. Omvårdnadsprocessen är ett evidensbaserat arbetssätt för att systematiskt vårda patienter på ett personcentrerat sätt. Till följd av begränsade resurser påverkas tillämpningen av omvårdnadsprocessen. I Antigua och Barbuda är omvårdnadsprocessen och sjuksköterskerollen områden med begränsad forskning. Syfte: Syftet var att beskriva sjuksköterskors upplevelser av att tillämpa omvårdnadsprocessen i sitt dagliga arbete i Antigua och Barbuda. Metod: En kvalitativ intervjustudie genomfördes genom att intervjua fyra sjuksköterskor på ett offentligt sjukhus i Antigua. Data analyserades med Braun och Clarkes tematiska analys. Resultat: Tre teman identifierades: Stärkande av patienten, Tillämpande av sjuksköterskekompetensen och Utnyttjande av tillgängliga resurser. Slutsats: Sjuksköterskorna var högkompetenta och arbetade utifrån omvårdnadsprocessen, där stor vikt lades på att involvera familjen, trots tydlig brist på personal. Konsekvenserna av personalbristen skapade en stressframkallande arbetsmiljö. Inom det interprofessionella samarbetet beaktades inte alltid sjuksköterskors expertis. Sjuksköterskerollen måste därför stärkas och antalet sjuksköterskor bör öka för att förbättra personcentrerad omvårdnad.

Bakgrund: Bristfällig kommunikation är en ledande orsak till ogynnsamma händelser inom omvårdnaden. Kommunikationen påverkar både patientens tillfredsställelse och behandlingsresultatet. Brister i kommunikation kan leda till bristande information, förminskande attityder och bristande delaktighet vilket leder till felaktiga diagnoser och fördröjd eller ineffektiv medicinsk behandling. Syfte: Syftet var att belysa kommunikationens påverkan på omvårdnadsprocessen ur sjuksköterskors perspektiv. Metod: En allmän litteraturstudie med induktiv ansats där tio artiklar granskades och bearbetades. Resultat: Resultatet presenteras av två huvudkategorier: kommunikation under omvårdnaden och förbättringsmöjligheter inom kommunikation. Sjuksköterskorna betonade att effektiv kommunikation var avgörande för patientsäkerheten eftersom brister i kommunikationen kan innebära risker för patienterna. Sjuksköterskor strävade efter att etablera meningsfulla relationer med patienterna och betonade vikten av att använda strategier för att förbättra kommunikationen inom vården. Flera sjuksköterskor betonade behovet av regelbunden uppdatering av kommunikationsutbildning för att förbättra vårdkvaliteten och säkerheten. Konklusion: Sjuksköterskor avslöjar utmaningar inom kommunikation under omvårdnadsprocessen. Det framkom att det fanns tidsbrist och ett ökat behov av utbildning, vilket i sin tur påverkar omvårdnadsprocessen. Fortsatt forskning om både verbal och icke-verbal kommunikation och dess påverkan på omvårdnadsprocessen utifrån sjuksköterskors erfarenheter är väsentligt för att förbättra vårdkvaliteten. / Background: Deficient communication is a leading cause of adverse events in nursing. Communication influences both patient satisfaction and treatment outcomes. Communication gaps can result in inadequate information, belittling attitudes and lack of involvement, leading to incorrect diagnoses and delayed or ineffective medical treatment. Aim: The purpose was to highlight the impact of communication on the nursing process from nurses’perspective. Method: A general literature study employing an inductive approach where ten articles were reviewed and analysed. Results: The results are presented in two main categories: communication during nursing care and improvement opportunities within communication. Effective communication was identified fundamental by nurses, it is crucial for patient safety as deficiencies could mean risks to patients. Nurses aim to establish meaningful patient relationships with patients and emphasized the importance of employing strategies to enhance communication in healthcare Several nurses emphasized the need for regular updates in communication training to enhance both quality of care and safety. Conclusion: Nurses reveal communication challenges during the nursing process, influenced by time constraints and increased educational needs, impacting the nursing process. Further research on both verbal and non-verbal communication and its impact on the nursing process from nurses’ perspectives is essential to improve quality of care.

v AJ: This diploma thesis deals with the field of nursing diagnosis in internal intensive care units. The theoretical part describes the basics of the nursing process and mainly focuses on the nursing diagnosis. Subsequently, it informs the reader about history, development and structure of the NANDA Taxonomy II. The main part of the thesis consists of a quantitative survey which aims at general nurses' knowledge about the nursing diagnosis NANDA - International. It also comments on how nursing diagnoses are made and what opinion general nurses have about making nursing diagnosis and NANDA taxonomy II. Finally, it provides the reader with overview of nursing diagnoses that general nurses often come across in intensive care units. And these diagnoses create uniform file according to the NANDA Taxonomy I I. Klíčová slova v AJ: Nursing diagnosis, nursing process, nursing diagnoses, NANDA- International, intenzive care unit

A análise de pesquisas vinculadas aos Programas de Pós-Graduação em Enfermagem (PPGE) sobre o ensino do processo de enfermagem pode revelar a consonância com as diretrizes curriculares nacionais para o ensino superior de enfermagem e contribuir para o progresso da enfermagem enquanto profissão e ciência. A presente pesquisa documental foi conduzida por meio de revisão integrativa da literatura e teve como objetivo sintetizar a produção do conhecimento gerado pelos PPGE do Brasil sobre o ensino do processo de enfermagem em cursos de graduação, no período de 2004 a 2009. Por meio da leitura dos títulos das pesquisas, nos cadernos de indicadores disponíveis no sítio da Coordenação de Aperfeiçoamento de Pessoal de Ensino Superior (CAPES), foram selecionados 135 estudos. Com a leitura dos resumos, 99 foram excluídos e, após a leitura dos textos completos, restaram 18 estudos os quais foram organizados nas categorias analíticas: estratégias de ensino-aprendizagem utilizadas no ensino do processo de enfermagem (9); estrutura curricular e ensino do processo de enfermagem (2); e percepções de alunos e docentes frente ao ensino do processo de enfermagem (7). As estratégias de ensino- aprendizagem empregadas nos estudos analisados que enfocaram a aplicação do processo de enfermagem no ensino foram: estudo de caso, aplicação do processo de enfermagem na prática clínica, Instrução Assistida por Computador com uso de softwares de simulações em ambiente virtual de aprendizagem e no ensino clínico, e discussão de caso fundamentada na Aprendizagem Baseada em Problemas. Na categoria estrutura curricular e ensino do processo de enfermagem, apreendeu-se que as bases teórico- conceituais metodológicas estão concentradas em disciplinas específicas sobre o processo de enfermagem; que a teoria de Wanda Horta e a Taxonomia de Diagnósticos de Enfermagem da NANDA são as fundamentações teóricas mais presentes nos planos de curso, e que as etapas do processo de enfermagem são ministradas de acordo com a complexidade por meio de estratégias pedagógicas tradicionais. A categoria percepções de alunos e docentes frente ao ensino do processo de enfermagem abordou o significado do processo de enfermagem nos enfoques assistencial, gerencial e organizacional, associando aspectos positivos e negativos a essas definições. Os fatores que influenciam o ensino do processo de enfermagem foram relacionados ao currículo, aos docentes, aos estudantes e às instituições de saúde que servem de campo de estágio. Nos estudos analisados, os estudantes emitiram uma avaliação positiva sobre o aprendizado do processo de enfermagem e reconheceram a importância dessa temática para a formação do enfermeiro. Considerando-se as fontes analisadas e a evolução do processo de enfermagem divulgada no cenário internacional, o desenvolvimento do processo de enfermagem no Brasil requer maior avanço, observando-se a necessidade de fomentar pesquisas nessa temática. Recomenda-se o ensino do processo de enfermagem em todas as disciplinas profissionalizantes em cursos de graduação, com ênfase em estratégias de ensino- aprendizagem que estimulem o pensamento crítico do estudante, de modo a contribuir para a formação de enfermeiros críticos e reflexivos, conforme as diretrizes curriculares nacionais para o ensino superior de enfermagem / A review of researches related to Graduate Programs in Nursing (PPGE) on the teaching of the nursing process can reveal the consonance with national curriculum guidelines for higher education in nursing and contribute to the advancement of nursing as a profession and science. This documentary research was conducted by a integrative literature review and aimed to synthesize the production of knowledge generated by PPGE of Brazil on the nursing teaching undergraduate programs in the period from 2004 to 2009. By reading the titles of researches, in the notebooks of indicators of CAPES, we selected 135 studies. With the reading of the abstracts, 99 were excluded, and after reading the full text, remaining 18 studies which were organized into analytical categories: teaching and learning strategies used in teaching of nursing process (9); curriculum structure and teaching of nursing process (2), and perceptions of students and teachers against the teaching of the nursing process (7). The teaching-learning strategies applied in the analyzed studies that focused on the application of the nursing process in teaching were: case study, the application of the nursing process in clinical practice, Computer Aided Instruction using software simulations in virtual environment learning and in clinical teaching, and case discussion based on Problem Based Learning. In the category curriculum structure and teaching of the nursing process, it was learned that the theoretical - methodological concept are concentrated in specific disciplines on the nursing process, Wanda Horta\'s Theory and Taxonomy of Nursing Diagnoses, NANDA are the most present theoretical foundations in course plans, and the steps of the nursing process are taught according to complexity through traditional teaching strategies. The category perceptions of students and teachers against the teaching of nursing process addressed the meaning of the nursing process in the care, managerial and organizational focus, associating positive and negative aspects to these definitions. The factors that influence the teaching of nursing process were related to the curriculum, the teachers, the students and the institutions that serve the training field. Students issued a positive assessment on learning of the nursing process and recognized the importance of this theme for nursing education. Considering the sources reviewed and the evolution of the nursing process published internationally, the development of the nursing process in Brazil requires greater advancement, observing the need to foster researches on this topic. It is recommended the teaching of the nursing process in all the vocational subjects with emphasis on teaching-learning strategies that encourage the critical thinking of the student are emphasized, in order to contribute to the formation of critical and reflective nurses, according to the curriculum guidelines for higher education in nursing

Este estudo tem o objetivo de conhecer a prática dos enfermeiros que atuam diretamente em unidades de referência de hanseníase no município de São Paulo, através da apropriação da Sistematização da Assistência de Enfermagem (SAE), seus limites e possibilidades. Tendo como objetivos secundários, verificar se a capacitação sobre a SAE, realizada pelo Programa Municipal de Controle da Hanseníase (PMCH) de São Paulo nos anos de 2007/2008 foi incorporada pelos enfermeiros que participaram da mesma. Através de um questionário dirigido, trinta enfermeiros, que atuam diretamente com os pacientes de hanseníase nas unidades de referência do município de São Paulo, responderam a questões que mostram a caracterização profissional, do grupo e especificamente sobre a adoção da SAE e as contradições e dificuldades em suas diferentes fases de aplicação. O perfil desses profissionais é de 86,6% do gênero feminino, com prevalência de 40% na faixa etária entre 45 e 55 anos de idade, 43,3% formadas entre 1 e 10 anos e 60% atua de 1 a 4 anos nas respectivas unidades. O estudo mostrou que 100% dos enfermeiros envolvidos conhecem a referida sistematização, porem apenas 30% participou da capacitação de 2007/2008 e 83,4% a aplicam nos pacientes de hanseníase. Observamos as variáveis de importância, atributo, ação e decisão que os enfermeiros dão a esse modelo, bem como as dificuldades e limitações observadas nos resultados comparativos entre os enfermeiros que participaram da capacitação 2007/2008 e os que não participaram. Ambos os grupos apontam como maior dificuldade o diagnóstico de enfermagem, porem na sequência, o grupo que fez a capacitação (33,3%) aponta o exame físico o aspecto com maior dificuldade, enquanto que o grupo que não fez a referida capacitação aponta 31,3%, como sendo a prescrição de enfermagem a segunda maior dificuldade. 88,9% dos capacitados e 87,5% dos não capacitados pelo PMCH em 2007/2008, utilizam como guia de taxonomia o que a North American Nursing Diagnosis Association (NANDA) preconiza. Ambos os grupos também elegem como sendo o principal fator limitante na aplicação da SAE, o excesso de atividades e na sequência, a falta de espaço físico. Para o grupo que participou da capacitação, 88,9% aponta que a SAE auxilia no planejamento do cuidado e no acompanhamento da evolução, ainda elegendo como possibilidades 77,8% a contribuição na adesão ao tratamento e 66,7% na prevenção de incapacidades físicas. Igualmente eleito pelo grupo de enfermeiros que não participaram do treinamento, 81,3% refere que a SAE auxilia no planejamento do cuidado e no acompanhamento da evolução, elegendo como possibilidades a adesão ao tratamento (68,8%) e prevenção de incapacidades também 68,8%. Concluindo que esse modelo deva ser mais pesquisado mostrando as possibilidades de ser adequada a realidade na perspectiva da saúde coletiva, e que reuniões de atualização focadas, muito contribuiriam para o fortalecimento dessa prática, caminhando dessa maneira na construção do conhecimento da enfermagem, favorecendo a melhor qualidade na assistência prestada as pessoas atingidas pela hanseníase. / This study aims to understand the practice of nurses working directly in reference units of leprosy in São Paulo, through the appropriation of Systematization of Nursing (SAE), its limits and possibilities. Having as a secondary objective, verify that the training on the SAE held by the Municipal Leprosy Control (PMCH) in São Paulo in 2007/2008 was incorporated by the nurses who participated in it. Through a questionnaire, thirty nurses, who work directly with leprosy patients in the reference units in São Paulo, responded to questions that show featuring professional group and specifically on the adoption of SAE and the contradictions and difficulties in their different stages of implementation. The profile of these professionals is 86.6% female, with 40% prevalence in the age group between 45 and 55 years of age, 43.3% graduated from 1 to 10 years and operates 60% 1-4 years in respective units. The study showed that 100% of the nurses involved know that systematization, however only 30% participated in the training year 2007/2008 and 83.4% to apply in leprosy patients. Observed variables of importance, attribute, action and decision that nurses give this model as well as the difficulties and limitations noted on the comparative results between nurses who participated in the training 2007/2008 and those who did not participate. Both groups show greater difficulty as the nursing diagnosis, however as a result, the group that did the training (33.3%) suggests a physical examination looks more difficult, while the group that did such training 31 points 3%, as the path nursing prescription the second highest difficulty. 88.9% of skilled and unskilled 87.5% of the PMCH in 2007/2008, using as a guide the taxonomy of the North American Nursing Diagnosis Association (NANDA) calls. Both groups also elect to be the main limiting factor in the application of SAE, excessive activity and following, the lack of physical space. For the group that participated in the training, 88.9% indicates that the NCS assists in care planning and monitoring the progress, even as possibilities electing 77.8% contribution in treatment adherence and 66.7% in the prevention of disabilities physical. Also elected by the group of nurses who did not participate in training, 81.3% stated that the NCS assists in care planning and monitoring the progress, electing possibilities as treatment adherence (68.8%) and also POD 68 8%. Concluding that this model should be further researched the possibilities of showing the reality to be appropriate in view of public health, and update meetings focused much contribute to the strengthening of this practice, walking this way in the construction of nursing knowledge, favoring better quality in assisting people affected by leprosy.

Objetivos: Elaborar eletronicamente um banco de dados contendo Diagnósticos de enfermagem (DE), Intervenções de enfermagem (IE) e Resultados de Enfermagem (RE) de acordo com os referenciais das Classificações da North American Nursing Diagnosis Association (NANDA-I), Nursing Interventions Classification (NIC) e Nursing Outcomes Classification (NOC); inserir esse conteúdo no Sistema Gandhi para integrar as telas da SAE e verificar o tempo dispensado para o registro da SAE eletrônica. Material e método: Estudo descritivo e quantitativo desenvolvido na Unidade de Cuidados Semi-Intensivos, do Hospital de Reabilitação de Anomalias Craniofaciais, Universidade de São Paulo (HRAC-USP), Bauru. O banco de dados contém 13 DE, suas respectivas IE e atividades, RE e indicadores que foram inseridos no Sistema Gandhi, do Serviço de Informática da Instituição (SIH). A avaliação de enfermagem realizada pela pesquisadora antes de elaborar a SAE eletrônica contempla: exame físico, análise das anotações de enfermagem dos prontuários dos pacientes. Treze pacientes foram avaliados, sendo onze por 10 dias e dois por 9 dias consecutivos. Resultados: O conteúdo dos DE, das IE, e suas respectivas atividades, dos RE e seus indicadores foram identificados para cada paciente. Para os 13 pacientes avaliados obtivemos: média de 6,1(0,3) de DE e mediana 6; média de 15,5(1,4) de IE e mediana 14; média de 59,4(6,0) e mediana 53 de atividades de enfermagem; média de 64,6(7,2) e mediana 59 de RE e média de 92,2(11,0) e mediana 82 dos indicadores de enfermagem. A análise das variáveis tempo e dias de avaliação, a mediana geral foi de 704 segundos. O tempo com as variáveis DE, IE, atividade, RE e indicadores de resultados, a maior variável verificada foi para as IE e a menor para os indicadores, classificada como correlação substancial. Conclusão: A elaboração do banco dos dados constitui base fundamental para a SAE eletrônica. A utilização da Classificação de Enfermagem nas telas eletrônicas no Sistema Gandhi do SIH, fornece informações ao enfermeiro na prática clínica, agiliza o registro da SAE, e torna possível dedicar um tempo maior ao cuidado direto aos pacientes. / Objectives: Elaborate an electronic database containing Nursing diagnostics (ND), Nursing interventions (NI) and Nursing Results (NR) in accordance with the North American Nursing Diagnosis Association (NANDA-I) Classification, Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) references; enter this content in the Gandhi System for integration in the SAE screens and verify the time spent on electronic SAE registration. Material and Methods: Descriptive and quantitative study carried out at the Semi-Intensive Care Unit of the Hospital de Reabilitação de Anomalias Craniofaciais, University of São Paulo (HRAC-USP), Bauru. The database contains 13 ND, their respective NI and activities, NR and indicators that were entered in the \"Gandhi\" System at the Institution\'s Information Technology Service. The nursing evaluation conducted by the researcher before elaborating the electronic SAE considers: physical exam, analysis of nursing annotations for patient medical charts. Thirteen patients were evaluated, eleven for 10 days and two for 9 consecutive days. Results: The content of the ND, NI, and their respective activities, NR and their indicators were identified for each patient. For the 13 evaluated patients, we obtained: average of 6.1 (0.3) for ND, and median of 6; average of 15.5 (1.4) for NI, and median of 14; average of 59.4 (6.0), and median of 53 for nursing activities; average of 64.6 (7.2), and median of 59 for NR and average of 92.2 (11.0), and median of 82 for nursing indicators. The overall median for the variables in the analysis of time and days of evaluation was 704 seconds. The greatest variable verified for time with the ND, NI, activity, NR and result indicator variables was for the NI and the smallest was for the indicators, classified as a substantial correlation. Conclusion: The elaboration of the database is a fundamental aspect for the electronic SAE. Use of the Nursing Classification in the SIH Gandhi System electronic screens provides information for the nurse in clinical practice, speeds up SAE registration and makes it possible to dedicate more time to direct care of patients.

Objetivos: Elaborar eletronicamente um banco de dados contendo Diagnósticos de enfermagem (DE), Intervenções de enfermagem (IE) e Resultados de Enfermagem (RE) de acordo com os referenciais das Classificações da North American Nursing Diagnosis Association (NANDA-I), Nursing Interventions Classification (NIC) e Nursing Outcomes Classification (NOC); inserir esse conteúdo no Sistema Gandhi para integrar as telas da SAE e verificar o tempo dispensado para o registro da SAE eletrônica. Material e método: Estudo descritivo e quantitativo desenvolvido na Unidade de Cuidados Semi-Intensivos, do Hospital de Reabilitação de Anomalias Craniofaciais, Universidade de São Paulo (HRAC-USP), Bauru. O banco de dados contém 13 DE, suas respectivas IE e atividades, RE e indicadores que foram inseridos no Sistema Gandhi, do Serviço de Informática da Instituição (SIH). A avaliação de enfermagem realizada pela pesquisadora antes de elaborar a SAE eletrônica contempla: exame físico, análise das anotações de enfermagem dos prontuários dos pacientes. Treze pacientes foram avaliados, sendo onze por 10 dias e dois por 9 dias consecutivos. Resultados: O conteúdo dos DE, das IE, e suas respectivas atividades, dos RE e seus indicadores foram identificados para cada paciente. Para os 13 pacientes avaliados obtivemos: média de 6,1(0,3) de DE e mediana 6; média de 15,5(1,4) de IE e mediana 14; média de 59,4(6,0) e mediana 53 de atividades de enfermagem; média de 64,6(7,2) e mediana 59 de RE e média de 92,2(11,0) e mediana 82 dos indicadores de enfermagem. A análise das variáveis tempo e dias de avaliação, a mediana geral foi de 704 segundos. O tempo com as variáveis DE, IE, atividade, RE e indicadores de resultados, a maior variável verificada foi para as IE e a menor para os indicadores, classificada como correlação substancial. Conclusão: A elaboração do banco dos dados constitui base fundamental para a SAE eletrônica. A utilização da Classificação de Enfermagem nas telas eletrônicas no Sistema Gandhi do SIH, fornece informações ao enfermeiro na prática clínica, agiliza o registro da SAE, e torna possível dedicar um tempo maior ao cuidado direto aos pacientes. / Objectives: Elaborate an electronic database containing Nursing diagnostics (ND), Nursing interventions (NI) and Nursing Results (NR) in accordance with the North American Nursing Diagnosis Association (NANDA-I) Classification, Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) references; enter this content in the Gandhi System for integration in the SAE screens and verify the time spent on electronic SAE registration. Material and Methods: Descriptive and quantitative study carried out at the Semi-Intensive Care Unit of the Hospital de Reabilitação de Anomalias Craniofaciais, University of São Paulo (HRAC-USP), Bauru. The database contains 13 ND, their respective NI and activities, NR and indicators that were entered in the \"Gandhi\" System at the Institution\'s Information Technology Service. The nursing evaluation conducted by the researcher before elaborating the electronic SAE considers: physical exam, analysis of nursing annotations for patient medical charts. Thirteen patients were evaluated, eleven for 10 days and two for 9 consecutive days. Results: The content of the ND, NI, and their respective activities, NR and their indicators were identified for each patient. For the 13 evaluated patients, we obtained: average of 6.1 (0.3) for ND, and median of 6; average of 15.5 (1.4) for NI, and median of 14; average of 59.4 (6.0), and median of 53 for nursing activities; average of 64.6 (7.2), and median of 59 for NR and average of 92.2 (11.0), and median of 82 for nursing indicators. The overall median for the variables in the analysis of time and days of evaluation was 704 seconds. The greatest variable verified for time with the ND, NI, activity, NR and result indicator variables was for the NI and the smallest was for the indicators, classified as a substantial correlation. Conclusion: The elaboration of the database is a fundamental aspect for the electronic SAE. Use of the Nursing Classification in the SIH Gandhi System electronic screens provides information for the nurse in clinical practice, speeds up SAE registration and makes it possible to dedicate more time to direct care of patients.

<p><p><strong>SAMMANFATTNING</strong></p><p><strong>Syfte. </strong>Utvärdera omvårdnadsdokumentationens kvalité och omfattning i elektronisk patientjournal på kirurgisk vårdavdelning. <strong>Metod.</strong> De senaste 60 journalerna från två kirurgiska vårdavdelningar valdes ut genom bekvämt urval. Varje journal lästes och bedömdes av båda författarna. Varje steg i omvårdnadsprocessen utvärderades efter granskningsmall och bedömdes som fullständig, för omfattande eller ofullständig. <strong>Resultat.</strong> Standardvårdplan användes i alla granskade journaler. Antalet steg i omvårdnadsprocessen som fanns dokumenterade varierade mellan fem och nio. Anamnes, status och effekter av åtgärder fanns beskrivna i majoriteten av journalerna. I samtliga journaler fanns utförda åtgärder dokumenterade. Omvårdnadsepikris fanns i större delen av njurtransplantationsjournalerna, men inte alls i struma/hyperparatyroidism (HPT)-journalerna. Majoriteten av uppdaterade status bedömdes som ofullständiga.<strong> </strong>Sexton av struma/HPT-journalerna innehöll inte anteckningar i rapportbladet. Av dem som hade rapportbladsanteckningar bedömdes majoriteten vara för omfattande. Samtliga njurtransplantationsjournaler hade för omfattande anteckningar i rapportbladet. Ingen av journalerna hade en individuell vårdplan. <strong>Slutsats.</strong> Omvårdnadsdokumentationen i den elektroniska patientjournalen bedömdes som ofullständig då det inte gick att få en tydlig bild av patientens omvårdnadsproblem och omvårdnadsbehov. Kvalitén på dokumentationen behöver förbättras. Detta kan ske genom att minska dokumentationen i rapportbladet och istället använda standardvårdplan och uppdaterat status i större omfattning. Fortsatt utbildning och återkoppling krävs för att förbättra dokumentationen.</p></p> / <p><strong>ABSTRACT</strong></p><p><p><strong>Aim. </strong>To evaluate the quality and extent of the nursing documentation in electronic health record on surgical ward. <strong>Method. </strong>The latest 60 health records from two surgical wards were selected by convenience sample. Both authors read each health record. Every step of the nursing process was evaluated with a nursing documentation audit and was classified as complete, too extensive or incomplete. <strong>Results. </strong>Standardized care plan was used in all electronic health records. Numbers of steps documented in the nursing process were five to nine. Nursing history, status and outcome were documented in most health records. Done interventions were documented in all health records. Goiter/hyperparathyroidism (HPT)-records had no nursing discharge note, while the kidney transplantation-records had one in almost every health record. Majority of updated statuses were evaluated as incomplete. Sixteen of the goiter/HPT-records had no notes of occasional matters, all kidney transplantation-records had too extensive notes. No individualized care plan was found. <strong>Conclusion. </strong>The total nursing documentation in the electronic health records were evaluated as incomplete. The quality of documentation needs to be improved. This can be achieved by less documentation of occasional matters, using the standardized care plan, updating status more often and further education and feedback.</p></p>

Everyday life can be complex when next of kin of haemodialysis patients are preoccupied with taking care of the patient and his/her health, which implies the difficulties and requirements needed. The general aim of this thesis was to explore and describe everyday life among next of kin of haemodialysis patients with focus on the life situation, health, time and professional support. Two perspectives of the thesis was applied: a holistic perspective on the everyday life of next of haemodialysis patient and a social perspective with focus on human communication and understanding of next of kin’s experience of everyday life. A qualitative descriptive and explorative design, comprising a phenomenographic and content analysis was used in Studies I-IV. The data collected in the studies consisted of interviews with next of kin to haemodialysis patient and analysis of professional support for next of kin to chronic haemodialysis patients in nursing documentation from two hospitals in Sweden. The experience of time in everyday life among next of kin of haemodialysis patients demonstrated that time for them is minimised and life space contracted. Next of kin experienced ambivalence towards their own health, especially in cases of patients’ spouses When next of kin of haemodialysis patient’s became involved in the patients’ care, they experienced arduousness in relation to their own health as well as less uninterrupted time for themselves in everyday life, and their life situation was characterised by confinement and social isolation. They were aware of the prognosis of renal disease and the fact that haemodialysis is a life-sustaining treatment, which forced them to live for the moment. The everyday life among the next of kin changed when the family became involved in the care, which in turn lead to a changed life situation and restrictions in everyday life. Lack of knowledge in nursing documentation of professional support revealed necessity of the readiness of next of kin. It is therefore important to be familiar with this in the nursing process, especially when the patient and their next of kin need support and attention in everyday life. Original papers not included. / <p>Linköping University Medical Dissertation, 926, I. Ziegert K. &amp; Fridlund B. Conceptions of life situation among next of kin of haemodialysis patients. Journal of Nursing Management 2001; (9) 231-239. doi:10.1046/j.1365-2834.2001.00233.x, II. Ziegert K., Fridlund B. &amp; Lidell E. Health in everyday life among spouses of patients on haemodialysis; a content analysis. Scandinavian Journal of Caring Sciences, Volume 20, Number 2, June 2006, pp. 223-228(6). DOI: 10.1111/j.1471-6712.2006.00400.x, III. Ziegert K., Fridlund B. &amp; Lidell E. Time in everyday life as experienced by next of kin of haemodialysis patients (Submitted for publication)., IV. Ziegert K., Fridlund B. &amp; Lidell E. Professional support for next of kin of patients receiving chronic haemodialysis treatment. A content analysis study of nursing documentation. Journal of Clinical Nursing, Volume 16, Number 2, February 2007, pp. 353-361(9). DOI: 10.1111/j.1365-2702.2006.01597.x,</p>

SAMMANFATTNING Syfte. Utvärdera omvårdnadsdokumentationens kvalité och omfattning i elektronisk patientjournal på kirurgisk vårdavdelning. Metod. De senaste 60 journalerna från två kirurgiska vårdavdelningar valdes ut genom bekvämt urval. Varje journal lästes och bedömdes av båda författarna. Varje steg i omvårdnadsprocessen utvärderades efter granskningsmall och bedömdes som fullständig, för omfattande eller ofullständig. Resultat. Standardvårdplan användes i alla granskade journaler. Antalet steg i omvårdnadsprocessen som fanns dokumenterade varierade mellan fem och nio. Anamnes, status och effekter av åtgärder fanns beskrivna i majoriteten av journalerna. I samtliga journaler fanns utförda åtgärder dokumenterade. Omvårdnadsepikris fanns i större delen av njurtransplantationsjournalerna, men inte alls i struma/hyperparatyroidism (HPT)-journalerna. Majoriteten av uppdaterade status bedömdes som ofullständiga. Sexton av struma/HPT-journalerna innehöll inte anteckningar i rapportbladet. Av dem som hade rapportbladsanteckningar bedömdes majoriteten vara för omfattande. Samtliga njurtransplantationsjournaler hade för omfattande anteckningar i rapportbladet. Ingen av journalerna hade en individuell vårdplan. Slutsats. Omvårdnadsdokumentationen i den elektroniska patientjournalen bedömdes som ofullständig då det inte gick att få en tydlig bild av patientens omvårdnadsproblem och omvårdnadsbehov. Kvalitén på dokumentationen behöver förbättras. Detta kan ske genom att minska dokumentationen i rapportbladet och istället använda standardvårdplan och uppdaterat status i större omfattning. Fortsatt utbildning och återkoppling krävs för att förbättra dokumentationen. / ABSTRACT Aim. To evaluate the quality and extent of the nursing documentation in electronic health record on surgical ward. Method. The latest 60 health records from two surgical wards were selected by convenience sample. Both authors read each health record. Every step of the nursing process was evaluated with a nursing documentation audit and was classified as complete, too extensive or incomplete. Results. Standardized care plan was used in all electronic health records. Numbers of steps documented in the nursing process were five to nine. Nursing history, status and outcome were documented in most health records. Done interventions were documented in all health records. Goiter/hyperparathyroidism (HPT)-records had no nursing discharge note, while the kidney transplantation-records had one in almost every health record. Majority of updated statuses were evaluated as incomplete. Sixteen of the goiter/HPT-records had no notes of occasional matters, all kidney transplantation-records had too extensive notes. No individualized care plan was found. Conclusion. The total nursing documentation in the electronic health records were evaluated as incomplete. The quality of documentation needs to be improved. This can be achieved by less documentation of occasional matters, using the standardized care plan, updating status more often and further education and feedback.