Sandra Boldreghini, MSN, RN, CS
Family Nurse Practitioner
Desoto Family Medical Practice, P.C
Olive Branch, MS

June H. Larrabee, PhD, RN
Research Scientist
Center for Nursing Research
Camcare Health Education & Research Institute

Relationship between Quality (NQUAL) and Beneficence (NGOAL)
Preimplementation and Postimplementation
The finding that there was no relationship between quality (NQUAL) and beneficence (NGOAL) before and after implementing an NIS was not entirely unanticipated. Although previous empirical evidence of relationship between patient-perceived quality and beneficence has been demonstrated (Hunter, 1994; Larrabee et al., 1995), the lack of relationship between NQUAL and NGOAL is consistent with a previous study using NQUAL and NGOAL (Larrabee et al.). In that study, the lack of relationship was thought to be due in part to NIS features. Opposite from NIS features at the present site, the former NIS had prompts for documenting nurse goal achievement but did not have prompts for all nursing interventions. The most plausible explanation for the failure to demonstrate a relationship postimplementation, then, is the disparity in NIS prompts for documenting interventions versus goal achievement. NIS programming revisions could eliminate this disparity.

However, NIS features are irrelevant to the failure to demonstrate a relationship in the preimplementation period. It is possible that the goal written in some care plans may have been quite broad and related to many other factors besides the accompanying interventions and, therefore, easily achieved whether or not those interventions were consistently done. If this is the explanation, the recommendation for reeducating nurses on care planning should eliminate this factor.

An implication of this study's findings is that agencies implementing an NIS need to conduct studies to evaluate the comprehensiveness of chart documentation periodically after implementation and to use the information obtained to make on-going improvements in their NIS or their nurses' use of the NIS. The findings also suggest caution with assuming that, in all settings with a computerized NIS, documentation of goal achievement and interventions is complete.

Further research with a larger sample is needed to ascertain whether or not the findings of this study are, in part, due to sampling error. Also, further investigation is needed to determine if internal quality improvement in response to the initial study improves documentation comprehensiveness. Research is also needed to compare care documented with care actually given, a study that would provide insight into the reliability and validity of chart data.

The growing interest in external benchmarking of care outcomes supports future investigations of this study's research questions in multiple sites with similar and dissimilar NIS features. To use NQUAL and NGOAL as the measures of nursing care quality and nurse goal achievement, respectively, such studies would require that the NIS's nursing diagnoses, outcomes, and interventions dictionaries consist of standardized nursing language. Such language would enable comparisons of care quality and outcomes across mutlitple sites. These studies could investigate the influence of dissimilar NIS features on the comprehensiveness of NQUAL and NGOAL documentation. Findings of such studies should provide further suggestions for improving nursing process documentation via NISs.

Strengths and Limitations
A strength of this study was use of the criterion-referenced NCP DCI for which acceptable interrater reliability was demonstrated. Strength of the study design was the timing of postimplementation data collection, allowing the nurses six months to master use of the system. As discussed, the validity of NQUAL and NGOAL as measures of quality and beneficence, respectively, is suspect and, therefore, a limitation. Generalizability is a limitation of the study, because the sample of charts was small and was from only one site with NIS characteristics that may be dissimilar to characteristics of other NISs.

In this pilot study, implementing computerized chart documentation did not improve either nurse-perceived quality (NQUAL) or nurse goal achievement (beneficence). Nor was there empirical support for the proposed relationship between quality and beneficence. Implications of the findings include revising the NIS to facilitate nurse goal achievement, reeducating nurses to generate appropriate individualized care plans using the NIS, and periodically assessing quality and improving documentation comprehensiveness. Other health care agencies using an NIS should consider these activities as a means to improve the reliability and validity of chart data, thereby enhancing the ability of using that data to investigate the influence of nursing care on desired patient outcomes.

The authors thank David L. Armbruster, PhD, Associate Professor, Scientific Publications, The University of Tennessee, Memphis, for editorial assistance, and Mary B. Oelman, RN, MSN, Administrator for Patient Services, UT Bowld Hospital, and Assistant Dean, College of Nursing, The University of Tennessee, Memphis, for support of the project.

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