Hidden outpatient oncology Clinical Nursing Minimum Data Set: Findings from an Italian multi-method study

Purpose: The main aim of this study was to present the hidden Clinical Nursing Minimum Data Set adopted by Italian nurses in outpatient oncology settings. Methods: A multi-method study design articulated in three phases was conducted from November 2009 to December 2010. A cross-sectional study design involving outpatient oncology centres located in the 20 Italian regions was undertaken in order to collect structured nursing records used by nurses in the documentation of daily nursing care. An evaluation of the items contained in each nursing record was performed in order to individuate homogeneities. A content analysis of the items was therefore undertaken in order to categorise them in assessment, problems, intervention, and outcomes. Results: A total of 1080 different items from the structured nursing records were counted, comprising on average 29 items (range 8-175; ±40.4) for each record. A total of 330 (30.6%) out of 1080 were categorised as assessment items, 146 (13.5%) as problems, 583 (54.0%) as interventions and 21 (1.9%) as outcomes items. Conclusion: Italian nurses have developed a micro-system Clinical Nursing Minimum Data Set capturing and documenting several types of clinical data, following their implicit representation of what it is important to document: much consideration is given to nursing surveillance/monitoring and to at-risk problems, indicating the importance of the nursing role in the prevention and early recognition of a patient's clinical deterioration. However, there is a need to develop a macro-system national NMDS which will be useful for evaluating nursing outcomes and making decisions on workforce resources. © 2012 Elsevier Ltd.