Effects on the Quality of the Nursing Care Process Through an Educational Program and the Use of Electronic Nursing Documentation

PURPOSE: To evaluate the effect of the educational program "Guided Clinical Reasoning" (GCR) and the introduction of an intelligent electronic nursing documentation system (e-doc) on the quality of the nursing process. METHODS: Evaluation was conducted at three measurement points and rated with the instrument "Quality of Nursing Diagnoses, Interventions and Outcomes" (Q-DIO). FINDINGS: GCR showed the best Q-DIO-scores. No long-term effect was found after GCR cessation. The e-doc delivered the lowest scores, while showing adequate support in using nursing diagnoses. CONCLUSIONS: E-docs can support conducting the nursing process, but for meaningful e-doc use, clinical reasoning is essential. IMPLICATIONS: High-quality nursing documentation requires recognition of factors obstructing or supporting nurses in the use of e-docs while conducting the nursing process.