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Questions | Responses (N=102) |
Never | Don't know | Sometimes | Usually | Always |
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Assessment and diagnosis | | | | | |
(1) Is an assessment made of new patients prior to planning | 2(2%) | 1(1%) | 12(11.8%) | 27(26.5%) | 60(58.5%) |
(2) Is written nursing history taken using a specific form | 7(6.9%) | 5(4.9%) | 16(15.7%) | 41(40.2%) | 33(32.4%) |
(3) Does the nursing assessment begins within 24 hours | 6(5.9%) | | 15(14.7%) | 30(29.4%) | 51(50%) |
(4) Does the assessment of the patient conclude with identification of problems | 8(7.8%) | 2(2%) | 19(18.6%) | 45(44.1%) | 28(27.5%) |
(5) Is an attempt made to find the cause of the problems | 8(7.8%) | 3(2.9%) | 25(24.5%) | 36(35.3%) | 30(29.4%) |
(6) Are problem statements arranges in order of priority | 3(2.9%) | 6(5.9%) | 27(26.5%) | 47(46.1%) | 19(18.6%) |
(7) Are patients'/or relatives opinions systematically takes in to account | 5(4.9%) | 7(6.9%) | 33(32.4%) | 42(41.2%) | 15(14.7%) |
Planning |
(1) Is a written care plan made before carrying out nursing interventions on the patient? | 6 (5.9%) | 7(6.9%) | 22(21.6%) | 36(35.3%) | 31(30.4%) |
(2) Does the nursing care plan incorporate the nursing problems identified? | 5(4.9%) | 2(2%) | 30(29.4%) | 36(35.3%) | 29(28.4%) |
(3) Are goals for the resolution of each one of the problems identified and documented in the care plan? | 4(3.9%) | 5(4.9%) | 26(25.5%) | 41(40.2%) | 26(25.5%) |
(4) Do the goals provide enough detail (i. e. time to be accomplished, who will accomplish what and how? | 4(3.9%) | 5(4.9%) | 33(32.4%) | 42(41.2%) | 18(17.6%) |
(5) Are nursing interventions identified and documented in the care plan? | 5(4.9%) | 5(4.9%) | 19(18.6%) | 41(40.2%) | 32(31.4%) |
(6) Are planned nursing interventions written with enough detail? | 6(5.9%) | 8(7.8%) | 23(22.5%) | 47(46.5%) | 18(17.6%) |
(7) Is there any systematization on the ward to take into account patient/relatives opinions regarding the goals and planned activities? | 10(9.8%) | 4(3.9%) | 32(31.4%) | 39(38.2%) | 17(16.7%) |
(8) Are nursing care planning discussions held on the ward? | 17(16.7%) | 6(5.9%) | 25(24.5%) | 34(33.3%) | 20(19.6%) |
(9) Do you periodically read professional journals or do you take part in research projects in order to update your practice accordingly? | 5(4.9%) | 8(7.8%) | 26(25.5%) | 46(45.1%) | 17(16.7%) |
Implementation |
(1) Is the patient's condition reassessed before implementing any planned nursing intervention in order to be sure of its appropriateness? | 9(8.8%) | 7(6.9%) | 26(25.5%) | 47(46.1%) | 13(12.7%) |
(2) Are nursing interventions explained to patients and/or relatives and their opinions taken into account? | 8(7.8%) | 8(7.8%) | 29(28.4%) | 42(41.2%) | 15(14.7%) |
(3) Is the way patient and /relatives should participate in their care systematized? | 3(2.9%) | 6(5.9%) | 39(38.2%) | 42(41.2%) | 12(11.8%) |
(4) Is patient allocation or primary nursing used throughout the ward all times? | 6(5.9%) | 6(5.9%) | 39(38.2%) | 38(37.3%) | 13(12.7%) |
(5) Are nurses allocated to the same patients for several days? | 13(12.7%) | 6(5.9%) | 38(37.3%) | 35(34.3%) | 10(9.8%) |
(6) Do nurses take part in medical round for their patients? | 3(2.9%) | 4(3.9%) | 24(23.5%) | 49(48%) | 22(21.6%) |
(7) Are nurses in this hospital responsible for the planning of patient care? That is, the nurse and not the supervisor. | 3(2.9%) | 4(3.9%) | 28(27.5%) | 48(47.1%) | 19(18.6%) |
(8) Is it compulsory on this ward to work with the nursing process approach? | 13(12.7%) | 4(3.9%) | 34(33.3%) | 34(33.3%) | 17(16.7%) |
(9) Is nursing documentation kept once the patient has been discharged? | 2(2%) | 4(3.9%) | 29(28.4%) | 38(37.3%) | 29(28.4%) |
(10) Are care plans used both day and night as a basis for giving care? | 3(2.9%) | 3(2.9%) | 35(34.3%) | 41(40.2%) | 20(19.6%) |
Evaluation |
(1) Is a systematic evaluation made of the effectiveness of care given to solve patient nursing problems?” | 3(2.9%) | 5(4.9%) | 37(36.3%) | 37(36.3%) | 20(19.6%) |
(2) Is the evaluation recorded in the care plans or progress notes? | 3(2.9%) | 6(5.9%) | 37(36.3%) | 41(40.2%) | 15(14.7%) |
(3) Are objective measures of patient progress towards the identified goals used on the ward?” | 3(2.9%) | 6(5.9%) | 35(34.3%) | 44(43.1%) | 14(13.7%) |
(4) Are care plans modified according to the results of evaluation? (example: to add new ones, stop others, ) | 5(4.9%) | 2(2%) | 43(42.2%) | 40(39.2%) | 12(11.8%) |
(5) Is there a systematic way in which patient/relatives participate in the evaluation of care on the ward? | 13(12.7%) | 6(5.9%) | 39(38.2%) | 35(34.3%) | 9(8.8%) |
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