Relationship beetween Knowledge and Suitability of Nursing Notes : a disconnect between knowledge and practice

Objective: to analyze the relationship between knowledge and the adequacy of nursing annotations and their determinants. Method: An exploratory, descriptive and quantitative approach, carried out in the Medical Clinic and in the Adult Intensive Care Unit of a Brazilian university hospital. A total of 114 professionals and 41 medical records were included. Results: The professionals had a high mean score of knowledge and a low mean score of adequacy and there was no correlation between them (rs = -0,122; p > 0.05). The knowledge score was higher for professionals graduated in Nursing. The mean score of adequacy was higher for the professional category nurse if packed in Medical Clinic and with the professional that was dissatisfied with the training. Conclusion: there is no relationship between the professional's knowledge about nursing notes and the adequacy of the notes, which leads to serious ethical, legal and patient safety issues. Descriptors: Medical record; Continuing education; Legislation; Nursing team; Patient safety. RESUMO Objetivo: analisar a relação entre o conhecimento e a adequação das anotações de enfermagem e seus determinantes. Método: Estudo exploratório, descritivo e de abordagem quantitativa, realizado no setor de Clínica Médica e na Unidade de Terapia Intensiva Adulto de um hospital universitário brasileiro. Foram incluídos 114 profissionais e 41 prontuários. Resultados: Os profissionais apresentaram um alto escore médio de conhecimento e um baixo escore médio de adequação e não houve correlação entre eles (rs = -0,122; p > 0,05). O escore de conhecimento foi maior para os profissionais graduados em Enfermagem. Já o escore médio de adequação foi maior para a categoria profissional enfermeiro, se lotado na Clínica Médica e se o profissional estava insatisfeito com as capacitações. Conclusão: não existe relação entre o conhecimento do profissional sobre anotações de enfermagem e a adequação das anotações realizadas, fato que leva a serias questões éticas, legais e de segurança do paciente. Descritores: Prontuário; Educação continuada; Legislação; Equipe de enfermagem; Segurança do Paciente. RESUMÉN Objetivo: analizar la relación entre el conocimiento y la adecuación de las anotaciones de enfermería y sus determinantes. Método: Estudio exploratorio, descriptivo y de abordaje cuantitativo, realizado en el sector de Clínica Médica y en la Unidad de Terapia Intensiva Adulto de un hospital universitario brasileño. Se incluyeron 114 profesionales y 41 prontuarios. Resultados: Los profesionales presentaron una alta puntuación promedio de conocimiento y un bajo puntaje promedio de adecuación y no hubo correlación entre ellos (rs = -0,122; p > 0,05). La puntuación de conocimiento fue mayor para los profesionales graduados en Enfermería. La puntuación promedio de adecuación fue mayor para la categoría profesional enfermero, abarrotados en la Clínica Médica y profesionales insatisfechos con las capacitaciones. Conclusión: no existe relación entre el conocimiento del profesional sobre anotaciones de enfermería y la adecuación de las anotaciones realizadas, hecho que lleva a serias cuestiones éticas, legales y de seguridad del paciente. Descriptores: Prontuario; Educación contínua; Legislación; Equipo de enfermería; Seguridad del paciente. How to cite: Souza RC, Jesus NM, Antunes AV, Mendes-Rodrigues C. Relationship beetween Knowledge and Suitability of Nursing Notes: a disconnect between knowledge and practice. Rev Pre Infec e Saúde[Internet]. 2019;5:8274. Available from: http://www.ojs.ufpi.br/index.php/nupcis/article/view/8274 DOI: https://doi.org/10.26694/repis.v5i0.8274 Original Souza RC, et al Evaluation of the nursing notes Rev Pre Infec e Saúde.2019;5:8274 2 INTRODUCTION Annotation or nursing record consists of the transcriptions made by Nursing professional in the patient's chart in an orderly and systematic way of the assistance provided by the nursing team to the patient during the period in which he or she is under their care. In this sense, registration is seen as a fundamental means of communication for health teams, since in addition to expressing the actions carried out, it allows continuity of care and legitimates the professional's work through support in ethics and legislation. The registration is the representation of a fact or an act, relative to the patient's conditions, provided they are expressed in an organized, clear, objective and concise manner, being considered a way of proving and guaranteeing the effectiveness of care and quality of the assistance provided. For the correct accomplishment of nursing notes, it is necessary to know what to note, when, where, how, why, and who should be annotated. The record must be written legibly and must have no erasures; must include the identification of the author, the registration number in the Regional Nursing Council and the stamp. Must be duly identified with patient data, plus date and time, and written pen as established by institution. Under the legislation, art. 1 of Resolution no. 429 of May 30, 2012, of the Federal Nursing Council says that "it is the responsibility and duty of nursing professionals to record in the patient's medical records and in other documents of the area, the information inherent in the care process". Article 4 of Deliberation no. 135 of October 10, 2000, of the Regional Council of Nursing of the state of Minas Gerais, states that "the registry must contain subsidies to allow the continuity of nursing care planning". 5 Decree of no. 94,406 of June 8, 1987 and Law no. 7,498 of June 25, 1986, which regulate the exercise of nursing, it is incumbent upon the nursing staff, the responsibility for recording in the patient's chart the activities of nursing care. Even though Brazilian legislation indicates that nursing records are mandatory and important in order to legally support professionals, even those who are aware still carry out the annotations without considering their legal value and the quality of their notes, not considering them as a tool for work, devaluing its functionality. It is noteworthy that the Brazilian literature has an extensive number of publications that evaluate and analyze nursing notes in patients' charts, in which the common denominator is the absence of complete and consistent records. In this context, another topic that is much discussed concerns the professional's perception of their notes, in this sense, professionals recognize the importance of noting all the data, but often do not make the necessary notes. This situation can generate ethical, legal problems and even risk the patient's safety by not continuing care. Thus, this research aimed to analyze the relationship between knowledge and adequacy of nursing notes. And as specific objectives: to evaluate some determinants of this relation as degree of complexity of the unit, time of performance of the professional, professional category of the performer, professional training and if participated in continuing education. Souza RC, et al Evaluation of the nursing notes Rev Pre Infec e Saúde.2019;5:8274 3 METHODS An exploratory, descriptive, analytic and quantitative approach, at the Hospital de Clínicas de Uberlândia, a university hospital in the state of Minas Gerais, Brazil. Two hospitalization units were evaluated: the Medical Clinic (MC) and the Intensive Care Unit for Adults (ICUA). The research was submitted to the Human Research Ethics Committee of the Federal University of Uberlândia, approved under opinion number 1823972, and followed Resolution 466 of 2012 of the National Health Council. Nursing professionals with active professional ties in the hospital were included in the study period, who accepted to participate in the study and signed the Free and Informed Consent Term. The charts consulted were those of patients who received care from a professional included in the study, were older than 18 years and patients whose legal representatives authorized access to the medical record, both through the signature of the term. All the professionals of the units were invited to participate in the study. The data collection was carried out from January to June 2017. For the evaluation of the professionals' level of knowledge, the sample consisted of 114 participants. Of these, 45 were professionals of the Medical Clinic and 69 professionals of the ICUA. As for the professional category, for which they were hired at the institution, 22 nursing assistants, 74 nursing technicians and 18 nurses were included. In order to evaluate the profile of the professionals, data were collected on: age, sex, time of professional work, professional category for which was hired in the institution, if you have a degree in Nursing, if you had any type of training on nursing notes, whether or not satisfied with the training they received and how satisfied they were with the training (assessed by a Likert numerical scale from 0 to 10). In order to evaluate whether the professionals' knowledge contemplated the legal aspects and the main characteristics for the accomplishment of a nursing note, a questionnaire with 24 questions with dichotomous answers was used, true or false, adapted from Antunes et al. The questions evaluated mandatory criteria and techniques covered in a short course offered by the hospital and given by a representative of the Regional Nursing Council of the State of Minas Gerais. Details of the course can be found in MendesRodrigues et al. In this questionnaire the participants were identified with a code so that their identity was not known. The codes were randomly distributed at the time of returning the questionnaire. This was necessary so that the data about their knowledge about the nursing notes were paired and compared with the scores of appropriateness of the notes that they made. An adapted form of Antunes et al. was used to assess the adequacy of nursing notes. The same was used to record the appropriate characteristi


INTRODUCTION
Annotation or nursing record consists of the transcriptions made by Nursing professional in the patient's chart in an orderly and systematic way of the assistance provided by the nursing team to the patient during the period in which he or she is under their care. 1 In this sense, registration is seen as a fundamental means of communication for health teams, since in addition to expressing the actions carried out, it allows continuity of care and legitimates the professional's work through support in ethics and legislation. 2e registration is the representation of a fact or an act, relative to the patient's conditions, provided they are expressed in an organized, clear, objective and concise manner, 3 being considered a way of proving and guaranteeing the effectiveness of care and quality of the assistance provided. 4For the correct accomplishment of nursing notes, it is necessary to know what to note, when, where, how, why, and who should be annotated.The record must be written legibly and must have no erasures; must include the identification of the author, the registration number in the Regional Nursing Council and the stamp. 5Must be duly identified with patient data, plus date and time, and written pen as established by institution. 1 Under the legislation, art. 1 of Resolution no.429 of May 30, 2012, of the Federal Nursing Council says that "it is the responsibility and duty of nursing professionals to record in the patient's medical records and in other documents of the area, the information inherent in the care process". 6Article 4 of Deliberation no.135 of October 10, 2000, of the Regional Council of Nursing of the state of Minas Gerais, states that "the registry must contain subsidies to allow the continuity of nursing care planning". 5Decree of no.94,406 of June 8, 1987 and Law no.7,498 of June 25, 1986, which regulate the exercise of nursing, it is incumbent upon the nursing staff, the responsibility for recording in the patient's chart the activities of nursing care. 7en though Brazilian legislation indicates that nursing records are mandatory and important in order to legally support professionals, even those who are aware still carry out the annotations without considering their legal value and the quality of their notes, not considering them as a tool for work, devaluing its functionality. 8[3][4]8 This situation can generate ethical, legal problems and even risk the patient's safety by not continuing care.All the professionals of the units were invited to participate in the study.Details of the course can be found in Mendes-Rodrigues et al. 10 In this questionnaire the participants were identified with a code so that their identity was not known.The codes were randomly distributed at the time of returning the questionnaire.This was necessary so that the data about their knowledge about the nursing notes were paired and compared with the scores of appropriateness of the notes that they made.
An adapted form of Antunes et al. 9 was used to assess the adequacy of nursing notes.3).being daily activity in the nursing professional practice.These constitute an evaluation tool to measure the quality of service provided by the nursing team. 12e median of correct answers for knowledge test conducted in ICUA sector did not differ in Medical Clinic.We believed that the complexity of the sector would be a determining factor in the professionals' knowledge and that, therefore, the ICUA professionals would present a better knowledge than those of the Medical Clinic, which did not occur.A study that compares the knowledge of nursing professionals regarding the knowledge acquired by different professional categories in patient safety courses in the same institution showed nurses obtaining higher scores than the other categories, 13 but when the subject matter was related to hand hygiene there were no differences between the categories regarding acquired knowledge. 14As pointed out by Antunes et al., 9 several studies have detected a low representation of nurses, which in some institutions may even be non-existent, 9 a fact that hinders a better evaluation of the records of these professionals.

In
When comparing the knowledge of the participants, it was verified that those who had graduation in Nursing had scores of knowledge greater than those who did not have.Thus, higher formal education seems to have been the only relevant factor for the increase of knowledge, since the baccalaureate must work the skills and abilities of the nurse. 15It is important to point out that there is a trend towards a higher academic level than that required for the position of the professional.
This can be seen both at national level, 16 and at local institutions.A study in Porto Alegre Clinical Hospital found that 41% of the studied nursing professionals attended or had graduation, highlighting qualifications required above the position for which the professional was hired. 17though there are studies that demonstrate that in to 100% of the records made by nurses regarding the collection of tracheal secretion there are short records, without details and without the description of post-collection results. 18These results and the low frequency of registrations performed by Nurses, raises the need for studies that understand this behavior.
In the Medical Clinic sector the mean adequacy score for nursing notes was higher than that presented in the ICUA.1] The process of systematizing nursing care enables the elaboration of individual care through the construction of nursing prescription, being an instrument that tends to make possible the improvement of records for the care provided to the patient. 22 In the nursing annotations knowledge test, applied to the participating professionals, the highest percentage of errors was observed in the issue related to the accomplishment of the ink registration and in the color standardized by the institution.Regarding this, it is important to emphasize that the color of the paint to be used is an institutional standardization and not a rule of records, and a differentiation can be observed from one institution to another, as observed in other studies. 232 Sometimes professionals forget that for a document to be considered a legal instrument it must be signed and dated, otherwise it may not be accepted as evidence or be indicative of poor quality of care. 12For the question regarding the identification of the date in the registry, a high percentage of errors was observed, since it demonstrates the lack of concern pointed out by the studies mentioned above.There are records of 12-17% of nursing notes with no date and time record, and that approximately 98% of the notes do not contain the responses to patient care. 19n addition, recording analyzed data instead of raw data was another issue with a high percentage of errors.This fact can be a reflection of the difficulty of the professionals in differentiating annotation of nursing evolution. 8 is also believed that this characteristic has a relationship with the formation of professionals above that required for the position held.
Another item that had a high percentage of errors in the questionnaires evaluated was the use of terms with a connotation of value rather than measurement, which should not be used according to the Federal Nursing Council. 24A study carried out in an intensive care unit reinforces the importance of correctly and accurately specifying the drained and eliminated volumes for the performance and evaluation of the water balance and also for the correlation with the results of the exams, 25 highlighting how important it is the nursing annotation for the continuity of health care. 2 There is a disregard of the professional with the recipient of documents and/or records, using ambiguous terms that seriously compromise information and pose legal risks to all involved. 25 a study evaluating nursing notes, it was observed that the content of the records is deficient, does not portray the reality of the patient nor does the nursing care provided do not contribute to the development of the nursing process of these patients. 19

CONCLUSION
The study allowed to conclude that there is no relationship between the knowledge of the These results demonstrate the need to know the reasons why professionals do not make the notes as they should, despite knowing how to do them ignoring ethical, legal and patient safety issues.
Thus, this research aimed to analyze the relationship between knowledge and adequacy of nursing notes.And as specific objectives: to evaluate some determinants of this relation as degree of complexity of the unit, time of performance of the professional, professional category of the performer, professional training and if participated in continuing education.METHODS An exploratory, descriptive, analytic and quantitative approach, at the Hospital de Clínicas de Uberlândia, a university hospital in the state of Minas Gerais, Brazil.Two hospitalization units were evaluated: the Medical Clinic (MC) and the Intensive Care Unit for Adults (ICUA).The research was submitted to the Human Research Ethics Committee of the Federal University of Uberlândia, approved under opinion number 1823972, and followed Resolution 466 of 2012 of the National Health Council.Nursing professionals with active professional ties in the hospital were included in the study period, who accepted to participate in the study and signed the Free and Informed Consent Term.The charts consulted were those of patients who received care from a professional included in the study, were older than 18 years and patients whose legal representatives authorized access to the medical record, both through the signature of the term.

The same was used
to record the appropriate characteristics or not of the notes made by the professional in the patient's chart.The instrument is a cheklist composed of 21 evaluation items, all of which are dichotomous (yes -appropriate or not -not suitable).The data collection in the nursing annotations occurred in notes that had already been made by some cases in the ICU, the collection was done in notes made after the response to the evaluation questionnaire because there was a delay in the questionnaire response and it was not possible to obtain authorization from patients who had already left hospital or died.One hundred and four nursing notes made by 99 of the 114 professionals participating in the study were evaluated for the adequacy of nursing notes, totaling 349 annotations from 41 patients' charts, from 1 to 17 annotations per patient record.Only the nursing notes from the "Nursing Notes" form standardized at the institution were evaluated, and all the annotations were considered in a period of 6 hours for the morning and afternoon shifts or 12 hours for the night shift.In this form, no nursing evolutions are recorded, and the annotation of care provided by the nursing team during hospitalization is restricted.For each employee, the mean of the nursing scores adequacy scores was calculated, and this mean was considered the mean adequacy score.The data were tabulated in spreadsheets, processed and analyzed using the IBM SPSS software (version 20.0 for Windows).The level of significance was set at 5% for all analyzes.The data mostly did not follow Gaussian distribution, being tested with the Kolmogorv Smirnov Lilliefors test.Quantitative data were described with mean, median, standard error, minimum and maximum; and qualitative data with absolute and relative frequencies.In order to evaluate the relationship between knowledge scores and mean adequacy score with quantitative variables, a Spearman correlation analysis was performed and the significance of the correlation was tested with Student's t-test.The values of the knowledge scores and the adequacy of the records were compared between the variables of the socio-professionaldemographic profile with the Mann-Whitney test or Kruskal-Wallis test and for multiple comparisons the Dunn test.The relationship between the mean adequacy score (dependent variable) and the knowledge score (independent variable) was tested with simple linear regression and its significance was tested with F statistic from ANOVA.
When comparing the medians between the strata of the variables of the profile, we observed that the median of the percentage of correct answers for the Medical Clinic sector was not different from that obtained in the ICUA (Z = -0.484,p = 0.628), as we did not observe difference for sex (Z = -0.761,p = 0.447), for the professional category (X 2 = 3.246, p = 0.197), and for the participation being or not satisfied with the training on the subject (Z = -0.771,p = 0.441).When comparing whether the participant has undergraduate or not, those who are graduated in Nursing have the highest knowledge score (median 91.67, mean 89.20, standard error = 0.88, variation = 62.50-100, n = 54) than those without undergraduate nursing (median = 87.50,mean 84.10, standard error = 1.34, variation = 45.83-100,n = 60) (Z = -3.113,p = 0.002).In the Medical Clinic, the nursing score adequacy score was higher (median = 16.75, n = 45, mean ± standard error = 16.58 ± 0.27, variation = 13.50 -20.0) when compared with the UTIA (median = 15.25, n = 69; mean ± standard error = 14.89 ± 0.40, range = 5.00 to 21.0) (Z = -3.021;p = 0.003).The nurses have the most adequate records (median = 18.62, n = 18, mean ± standard error = 18.29 ± 0.69, variation = 13.25 to 21.00) when compared to the values obtained by technicians (median = 15.25, n = 74, mean ± standard error = 15.32 ± 0.32, range = 5 to 20) and nursing assistants (median = 16.00,n = 22, mean ± standard error = 15.02 ± 0.60, range = 5.33 to 18.50) (X 2 = 12.590, p = 0.002).The comparison between auxiliaries and nursing technicians showed no differences in the mean adequacy score (p > 0.05).Participants who selfreported dissatisfaction with training received a median of the highest mean adequacy score (median 17.62, n = 13, mean ± standard error = 17.19 ± 0.77, variation = 10.75 to 20.0) than those who self-reported satisfaction (median = 15.25, n = 72, mean ± standard error = 15.23 ± 0.33, range = 5 to 20.0) (Z = -2.686;p = 0.007).There were no differences for the variables gender (Z = -0.048,p = 0.962), graduation in Nursing (Z = -1.904,p = 0.057), and participation in training on the subject (Z = -0.189;p = 0.850).There was no significant linear relationship between the knowledge score and the nursing score adequacy score (p = 0.5227; Figure1), showing a disconnect between theory and care practice.This lack of relationship shows that there is no relationship between knowledge about nursing notes and the application of this knowledge (evaluated by the mean adequacy score) in the execution of nursing notes.The highest percentage of errors identified in the questionnaire assessing knowledge about nursing annotations was in the issues related to ink registration and color standardization according to schedule (44.74%), followed by date report (39.47%), raw data recording without analysis, interpretation or evolution of the data (35.96%), and the use of terms with a connotation of value instead of the measurement (35.09%).

Figure 1 :F
Figure1: Linear regression model between the knowledge score (x = independent variable) and the mean adequacy score (y = dependent variable) for nursing records in two units of a Brazilian university hospital, 2017.Caption: y = linear regression model y as a function of x, R 2 = coefficient of determination, F: ANOVA F statistic, d.f.= degrees of freedom, p = probability.
Further studies are needed to assess in depth the effect of the degree of assistance complexity on the level of knowledge of professionals in each unit.One factor that may explain this is the possible standardization of the level of knowledge among the professionals of the two units through selfreferenced participation in training on the subject, since the units present good indicators of participation in continuing education courses. 10In the evaluation of a hospital training cycle in which Nursing Notes was addressed, the Medical Clinic reached an mean of 37.50 hours of training per professional and the UTIA reached 28.92 hours per professional, and this indicator oscillated between the hospital unit from 14.93 to 48.25 hours per professional. 10 professional about nursing notes and the adequacy of the annotations he makes in the patient's chart, that the nursing professionals present a high mean score of knowledge about nursing notes and a low score mean of adequacy of such annotations.It was also concluded that nursing professionals, regardless of their position, present better scores of knowledge than those who are not graduates, nurses make more adequate records than technicians and nursing assistants and in the Medical Clinic the records were better than in the Intensive Care Unit.

Table 1 :
). Profile of nursing professionals evaluated regarding the relation of knowledge and adequacy of nursing notes in two units of a Brazilian university hospital.2017.

Table 2 :
Spearman correlation between the quantitative variables related to knowledge and performance on nursing notes in two units of a Brazilian university hospital, 2017.

Table 3 :
Frequency of correct answers and errors in the knowledge test about the adequacy in nursing notes in two units of a Brazilian university hospital.2017.