Nursing Diagnoses, Interventions, and Activities as Described by a Nursing Minimum Data Set: A Prospective Study in an Oncology Hospital Setting

Background Oncological diseases affect the biopsychosocial aspects of a person's health, resulting in the need for complex multidisciplinary care. The quality and outcomes of healthcare cannot be adequately assessed without considering the contribution of nursing care, whose essential elements such as the nursing diagnoses (NDs), nursing interventions (NIs), and nursing activities (NAs) can be recorded in the Nursing Minimum Data Set (NMDS). There has been little research using the NMDS in oncology setting. Objective The aim of this study was to describe the prevalence and distribution of NDs, NIs, and NAs and their relationship across patient age and medical diagnoses. Methods This was a prospective observational study. Data were collected between July and December 2014 through an NMDS and the hospital discharge register in an Italian hospital oncology unit. Results On average, for each of 435 enrolled patients, 5.7 NDs were identified on admission; the most frequent ND was risk for infection. During the hospital stay, 16.2 NIs per patient were planned, from which 25.2 NAs per day per patient were delivered. Only a third of NAs were based on a medical order, being the highest percentage delivered on nursing prescriptions. The number of NDs, NIs, and NAs was not related to patient age, but differed significantly among medical diagnoses. Conclusions An NMDS can depict patient needs and nursing care delivered in oncology patients. Such data can effectively describe nursing contribution to patient care. Implications for Practice The use of an NMDS raises the visibility of nursing care in the clinical records. Such data enable comparison and benchmarking with other healthcare professions and international data.