D-Catch instrument: development and psychometric testing of a measurement instrument for nursing documentation in hospitals.

AIM This paper is a report of the development and testing of the psychometric properties of an instrument to measure the accuracy of nursing documentation in general hospitals. BACKGROUND Little information is available about the accuracy of nursing documentation. None of the existing instruments that quantify accuracy of nursing diagnoses, interventions, and progress and outcome evaluations are suitable to measure documentation in general hospital environments, nor were they intended for this purpose. METHOD The D-Catch instrument, based on the Cat-ch-Ing instrument and the Scale for Degrees of Accuracy in Nursing Diagnoses, was developed in 2007-2008. Content validity of the D-Catch instrument was assessed by two Delphi panels, in which pairs of independent reviewers assessed 245 patient records in seven hospitals in the Netherlands. Construct validity was assessed by explorative factor analysis with principal components and varimax rotation. Internal consistency was measured by Cronbach's alpha. The inter-rater reliability of the D-Catch instrument was tested by calculating Cohen's weighted kappa (K(w)) for each pair of reviewers. Results. Quantity and quality variables were used to assess the accuracy of nursing documentation. Three constructs were identified in the factor analysis. 'Accuracy of the nursing diagnosis' was the only variable with substantial loading on component two (0.907) and a modest loading on component one (0.230). Internal consistency (Cronbach's alpha) was 0.722. The inter-rater reliability (K(w)) varied between 0.742 and 0.896. CONCLUSION The D-Catch instrument is a valid and reliable measurement instrument to assess nursing documentation in general hospital settings.

[1]  Kaija Saranto,et al.  Evaluating nursing documentation - research designs and methods: systematic review. , 2009, Journal of advanced nursing.

[2]  U B Nilsson,et al.  Evaluation of nursing documentation. A comparative study using the instruments NoGA and Cat-ch-ing after an educational intervention. , 2000, Scandinavian journal of caring sciences.

[3]  C. Dulberg,et al.  Factors associated with nursing diagnosis utilization in Canada. , 1999, Nursing diagnosis : ND : the official journal of the North American Nursing Diagnosis Association.

[4]  B. Davis,et al.  Case management for young children with special health care needs. , 1991, Pediatric nursing.

[5]  M. Muller-Staub Evaluation of the implementation of nursing diagnostics. A study of the use of nursing diagnoses, interventions and outcomes in nursing documentation. , 2007 .

[6]  Christine Koczmara,et al.  Communication of medication orders by telephone--"writing it right". , 2006, Dynamics.

[7]  G. Nordström,et al.  Nursing documentation in patient records. , 1996, Scandinavian journal of caring sciences.

[8]  T. Dassen,et al.  Criteria for Nursing Information Systems as a Component of the Electronic Patient Record An International Delphi Study , 1997, Computers in nursing.

[9]  Cheryl Tatano Beck,et al.  Resource Manual for Nursing Research: Generating and Assessing Evidence for Nursing Practice , 2011 .

[10]  Anna Ehrenberg,et al.  Improved quality and comprehensiveness in nursing documentation of pressure ulcers after implementing an electronic health record in hospital care. , 2009, Journal of clinical nursing.

[11]  Maria Müller-Staub,et al.  Development of an instrument to measure the quality of documented nursing diagnoses, interventions and outcomes: the Q-DIO. , 2009, Journal of clinical nursing.

[12]  Evaluation of nursing documentation. A comparative study using the instruments NoGA and Cat-ch-ing after an educational intervention. , 2000 .

[13]  M. Whyte,et al.  Computerised versus handwritten records. , 2005, Paediatric nursing.

[14]  K. Curtis Nurses' experiences of working with trauma patients. , 2001, Nursing standard (Royal College of Nursing (Great Britain) : 1987).

[15]  C. Delaney,et al.  Standardized nursing language for healthcare information systems , 1992, Journal of Medical Systems.

[16]  J. Fleiss Statistical methods for rates and proportions , 1974 .

[17]  Jan Florin,et al.  Quality of nursing diagnoses: evaluation of an educational intervention. , 2005, International journal of nursing terminologies and classifications : the official journal of NANDA International.

[18]  M. Moorhouse,et al.  Application of Nursing Process and Nursing Diagnosis: An Interactive Text for Diagnostic Reasoning , 1992 .

[19]  C. Björvell Nursing documentation in clinical practice : Instrument development and evaluation of a comprehensive intervention programme , 2002 .

[20]  Bryan R. Cole,et al.  Stability of response characteristics of a Delphi panel: application of bootstrap data expansion , 2005, BMC medical research methodology.

[21]  I. Thorell-Ekstrand,et al.  Development of an audit instrument for nursing care plans in the patient record , 2000, Quality in health care : QHC.

[22]  Marion Johnson Nursing Diagnoses, Outcomes, and Interventions: NANDA, NOC and NIC Linkages , 2001 .