No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
The electronic use of the NANDA-, NOC- and NIC-classifications and implications for nursing practice
Abstract
The data model developed on behalf of the Nursing Service Commission of the Canton of Zurich (Pflegedienstkommission des Kantons Zürich) is based on the NANDA nursing diagnoses, the Nursing Outcome Classification, and the Nursing Intervention Classification (NNN Classifications). It also includes integrated functions for cost-centered accounting, service recording, and the Swiss Nursing Minimum Data Set. The data model uses the NNN classifications to map a possible form of the nursing process in the electronic patient health record, where the nurse can choose nursing diagnoses, outcomes, and interventions relevant to the patient situation. The nurses' choice is guided both by the different classifications and their linkages, and the use of specific text components pre-defined for each classification and accessible through the respective linkages. This article describes the developed data model and illustrates its clinical application in a specific patient's situation. Preparatory work required for the implementation of NNN classifications in practical nursing such as content filtering and the creation of linkages between the NNN classifications are described. Against the background of documentation of the nursing process based on the DAPEP(1) data model, possible changes and requirements are deduced. The article provides a contribution to the discussion of a change in documentation of the nursing process by implementing nursing classifications in electronic patient records.
... whether the NANDA_I nursing diagnoses properly address any nursing judgement on a patient's actual or potential health problem for which the nurse is accountable, within a general in-patient population (Gimé nez-Maroto and Serrano-Gallardo, 2009;Olaogun et al., 2011). The NANDA_I taxonomy has also been used, during the last decades, as an entry terminology in the electronic health records (Bernhart-Just et al., 2009;Klehr et al., 2009;Mü ller-Staub, 2009), because this classification system is the most known and researched nursing diagnoses vocabulary Mü ller-Staub et al., 2007). Fig. 1 contents a glossary of controlled vocabularies related terms. ...
... In the absence of published research on other nursing interface terminologies to compare, studies using NAN-DA_I nursing diagnoses have been addressed, because as previously explained, NANDA_I is a classification system but it has been used for long as an interface terminology (Bernhart-Just et al., 2009;Klehr et al., 2009;Mü ller-Staub, 2009). ...
BACKGROUND: The nurses' ability to document patient's status, problems and progress is an important issue in patients' safety. Nursing terminologies are intended to support nursing practice but as any other clinical tool, they should be evaluated to assure quality and warrant effective written communication among clinicians. OBJECTIVES: This study was aimed to evaluate the usability of the diagnosis axis of an interface terminology by assessing its completeness and the frequency of use of its concepts. DESIGN: Observational, longitudinal, multicentre study. SETTING: A total of 8 hospitals representing 162 acute medical-surgical, obstetric and mental health nursing wards, step-down units and home in-patient units were included. PARTICIPANTS: Overall, 246,400 electronic care plans were studied; 53.5% from male patients; 14.6% paediatrics and 33.7% from patients elder than 70 years old. Most were admitted due to cardiocirculatory, respiratory, digestive or musculoskeletal conditions (50.5%), other acute medical or surgical disorders (29.8%) and obstetrics (19.3%). METHODS: The main outcome measures were: the use of nursing diagnoses from the interface terminology evaluated and their accumulated frequency, analysed over a 3-year retrospective review of the electronic nursing care plans. The analysis of data included descriptive statistics with a confidence level of 95% for confidence intervals. RESULTS: Most of the diagnostic concepts from the interface terminology were used (92.3%) by nurses to illustrate patients' problems in the electronic care plans. Their frequency of use widely varied, from some very frequent diagnoses like Risk for haemorrhage (51.4%; CI 95%: 51.25-51.65) or Acute pain (49.6%; CI: 49.49-49.88) to others used only in exceptional cases like Faecal impaction or Extravasation. The first nursing diagnosis related to family or caregiver emerges in the 32nd place of the ranking. CONCLUSIONS: Results for outcome measures oriented that the diagnosis axis of this interface terminology meets the usability criterion of completeness when assessing for the use of its concepts in the acute care setting.
... The NNN system was also shown to best fulfill the essential features of nursing classification systems: standardized documentation of the nursing process, generation of a standard dataset, and practicability of data exchange between different electronic data systems (Just et al., 2005). Further, a conceptual data model for electronic nursing process documentation was developed that also defines nursing-related data for cost-centered accounting procedures as part of the Swiss Nursing Minimum Data Set (Bernhart-Just, Hillewerth, Holzer-Pruss, Paprotny, & Zimmermann Heinrich, 2009). Johnson et al. (2012) postulated that the NNN represents the domain of nursing in all settings and their subdomains. ...
Aims and objectives:
The study aimed to detect the prevalence of NANDA-I diagnoses and possible relationships between those and patient characteritics such as gender, age, medical diagnoses and psychiatric specialty/setting.
Background:
There is a lack on studies about psychiatric inpatient characteristics and possible relationships among these characteristics with nursing diagnoses.
Design:
A quantitative-descriptive, cross-sectional, completed data sampling study was performed.
Methods:
The data were collected from the electronic patient record system. Frequencies for the social demographic data, the prevalence of the NANDA-I diagnoses and the explanatory variables were calculated.
Results:
In total, 410 nursing phenomena were found representing 85 different NANDA-I diagnoses in 312 patients. The NANDA-I diagnosis "Ineffective Coping" was the most frequently stated diagnosis followed by "Ineffective Health Maintenance", "Hopelessness", and "Risk for other-directed violence". Men were more frequently affected by the diagnoses "Ineffective Coping", "Hopelessness", "Risk for Self-Directed Violence", "Defensive Coping" and "Risk for Suicide", whereas the diagnoses "Insomnia", "Chronic Confusion", "Chronic Low Self-Esteem", and "Anxiety" were more common in women. Patients under the age of 45 years were more frequently affected by "Chronic Low Self-Esteem" and "Anxiety" than older patients. "Ineffective Coping" was the most prevalent diagnosis by Patients with mental disorders due to psychoactive substance use. Patients with schizophrenia were primarily affected by the diagnoses "Ineffective Coping", "Impaired Social Interaction", and "Chronic Low Self-Esteem".
Conclusions:
This study demonstrates the complexity and diversity of nursing care in inpatient psychiatric settings. Patients' gender, age and psychiatric diagnoses and settings are a key factor for specific nursing diagnosis. This article is protected by copyright. All rights reserved.
... The NNN system was also shown to best fulfill the essential features of nursing classification systems: standardized documentation of the nursing process, generation of a standard dataset, and practicability of data exchange between different electronic data systems (Just et al., 2005). Further, a conceptual data model for electronic nursing process documentation was developed that also defines nursing-related data for cost-centered accounting procedures as part of the Swiss Nursing Minimum Data Set (Bernhart-Just, Hillewerth, Holzer-Pruss, Paprotny, & Zimmermann Heinrich, 2009). Johnson et al. (2012) postulated that the NNN represents the domain of nursing in all settings and their subdomains. ...
PurposeThis study explored how well NANDA-I covers the reality of adult inpatient psychiatric nursing care.Methods
Patient observations documented by registered nurses in records were analyzed using content analysis and mapped with the classification NANDA-I.FindingsA total of 1,818 notes were examined and contained 46 different patient responses. Twenty-nine patient responses were recognizable as NANDA-I diagnoses at the level of definitions, 15 as diagnoses-related factors, and 12 did not match with any NANDA-I diagnosis.Conclusions
This study demonstrates that NANDA-I describes the adult inpatient psychiatric nursing care to a large extent. Nevertheless, further development of the classification is important.Implications for Nursing PracticeThe results of this study will spur nursing research and further classification development.
Aim:
To describe the process of implementation of Individualized Care Plan in the Electronic Health Record and its impact on the University Hospital Alcorcón Foundation.
Methodology:
Working groups of staff nurses who analyzed activities usually performed to create a catalog of diagnoses, outcomes and interventions. A group of referents that refined the catalog to make it manageable was created. A training plan, nursing assessment forms and the Nursing Discharge Report were designed.
Results:
In February 2016 the new methodology was implemented in inpatient units of adults. Between 74.86 and 88.18% of the patients underwent a care plan with the new methodology. Between 69.41 and 76.25% of patients are discharged with a Nursing Discharge Report accordance with regulations. An increase of 24.1% of patients with Nursing Discharge Report after implantation is observed (P=.000; RR: 1.46; 95% CI 1.36-1.56). A total of 116 nurses has been trained.
Conclusions:
In the study conditions, the use of nursing taxonomies has generated thinking skills and allowed nurses to issue judgments, ensure quality of care, and implementing interventions with a planned results. The nursing taxonomy and care plan in the Electronic Health Record have increased interprofessional communication to improve continuity of care through improved Nursing Discharge Report.
Nursing informatics education is undergoing dramatic change as nursing informatics skills and knowledge expand and roles in practice proliferate. In the United States, Federal government initiatives and the activities of national nursing organizations are moving nursing informatics forward in preparation for the new millennium. This paper presents a history of nursing informatics education in the US, as it has emerged from a focus on computer literacy to a new model of information processing, cognitive science and computer science. The paper suggests specific computing skills and informatics concepts which should be integrated into nursing informatics courses or undergraduate nursing programs. Initiatives and goals of the National Agenda for Informatics in Nursing Education and Practice are presented.
It is often argued that Nursing Minimal Data Sets (NMDSs) have advantages for the nursing profession. The NMDSs that have been developed and applied in some countries have many features in common, but there are differences in purpose, content, sampling, collection approach, and developmental stage as well. This paper examines the advantages and disadvantages of data sets of nursing practice, and the differences and similarities of five national and international NMDS systems. The purpose is to apply this information toward an NMDS initiative in the Netherlands. Future initiatives in NMDS development should include international coordination.
First appeared as a paper in iSHIMR2004, Proceedings of the Ninth International Symposium on Health Information Management Research, 15-17 June 2004, Sheffield, UK. The aim of this paper is to examine the relationship between nursing practice and the recording of practice. Outlines the main findings of a Cochrane systematic review on nursing records, discussing the indications from the included studies that compared computerised nursing care planning with paper-based systems. Qualitative research on nursing records systems, and other survey evidence, is collated to answer questions on the format of the record (structured versus free text, for what type of practice), occasions when information exchange about nursing care may not, and should not be recorded formally, and the effective organisation of the nursing record. Concludes that more research is required to answer these questions, as it seems that computerisation does not always bring the expected benefits, and outcomes for patient care are not clear.
The purpose of the study is to explore the use of formal systems to model nursing terminology.
GRAIL is a formal, compositional terminologic language, closely related to frame-based systems and conceptual graphs, which allows concepts to be formed from atomic-level primitives and automatically classified in a multiple hierarchy. A formal model of the alpha version of the International Classification for Nursing Practice (ICNP) classification of nursing interventions was constructed in GRAIL.
The model was analyzed for completeness, coherence, clarity, expressiveness, usefulness, and maintainability.
GRAIL is capable of representing the complete set of atomic-level concepts within the ICNP as well as certain cross-mappings to other vocabularies. It also has the potential to represent many more concepts, to an arbitrary level of detail.
Formal systems such as GRAIL can overcome many of the difficulties associated with traditional nursing vocabularies without restricting the level of detail needed to describe nursing care.
The authors describe the online implementation of the standardized nursing language of the North American Nursing Diagnosis Association (NANDA) nursing diagnoses at one 250-bed community hospital located in Chicago. A brief description of NANDA nursing diagnoses is provided along with a discussion of issues regarding implementation of these nursing diagnoses in a clinical information system. This system did not support online documentation of patient problems, therefore the challenge was to add documentation of patient problems to the system's software. This article focuses on the design and implementation of the nursing diagnoses computer screens, rather than focusing on the two problems we encountered during implementation--appropriate use of nursing diagnoses and the fit of nursing diagnoses with nursing interventions. Yet, the lessons learned in designing and implementing NANDA nursing diagnoses online may help others.
The documentation of the nursing process is an important but often neglected part of clinical documentation. Paper-based systems have been introduced to support nursing process documentation. Frequently, however, problems such as low quality of documentation are reported. It is unclear whether computer-based documentation systems can reduce these problems and which factors influence their acceptance by users.
We introduced a computer-based nursing documentation system on four wards of the University Hospitals of Heidelberg and systematically evaluated its preconditions and its effects in a pretest-posttest intervention study. For the analysis of user acceptance, we concentrated on subjective data drawn from questionnaires and interviews.
A questionnaire was developed using items from published questionnaires and items that had to be developed for the special purpose of this study.
The quantitative results point to two factors influencing the acceptance of a new computer-based documentation system: the previous acceptance of the nursing process and the previous amount of self-confidence when using computers. On one ward, the diverse acceptance scores heavily declined after the introduction of the nursing documentation system. Explorative qualitative analysis on this ward points to further success factors of computer-based nursing documentation systems.
Our results can be used to assist the planning and introduction of computer-based nursing documentation systems. They demonstrate the importance of computer experience and acceptance of the nursing process on a ward but also point to other factors such as the fit between nursing workflow and the functionality of a nursing documentation system.
The ability to collect and store data has grown at a dramatic rate in all disciplines over the past two decades. Healthcare has been no exception. The shift toward evidence-based practice and outcomes research presents significant opportunities and challenges to extract meaningful information from massive amounts of clinical data to transform it into the best available knowledge to guide nursing practice. Data mining, a step in the process of Knowledge Discovery in Databases, is a method of unearthing information from large data sets. Built upon statistical analysis, artificial intelligence, and machine learning technologies, data mining can analyze massive amounts of data and provide useful and interesting information about patterns and relationships that exist within the data that might otherwise be missed. As domain experts, nurse researchers are in ideal positions to use this proven technology to transform the information that is available in existing data repositories into useful and understandable knowledge to guide nursing practice and for active interdisciplinary collaboration and research.
The electronic health record requires the use of standardized nursing languages such as NANDA International, the Nursing Outcomes Classification, and the Nursing Interventions Classification. Helping nurses use these languages for an electronic health record requires different educational strategies in 3 domains: intellectual, interpersonal, and technical. The author explains the rationale for changes in educational methods, expectations that educators and managers should set for students and nurses at various levels of expertise, and teaching strategies in each of the domains.
• Norway’s regional teaching hospitals are working together on a project to develop an interdisciplinary electronic patient record (EPR).
• This paper presents the results of a project to develop nursing documentation as part of an integrated EPR to improve the quality and continuity of patient care.
• The project used a consensus process as a working norm.
• The most important result is that the five hospitals have agreed on a framework for nursing documentation, and on the main components that need to be implemented in the electronic patient record.
With the increased interest in evidence-based medicine, Internet access and the growing emphasis on national standards, there is an increased challenge for teaching institutions and nursing services to teach and implement standards. At the same time, electronic clinical documentation tools have started to become a common format for recording nursing notes. The major aim of this paper is to ascertain and assess the availability of clinical nursing tools based on the NANDA, NOC and NIC standards. Faculty at 20 large nursing schools and directors of nursing at 20 hospitals were interviewed regarding the use of nursing standards in clinical documentation packages, not only for teaching purposes but also for use in hospital-based systems to ensure patient safety. A survey tool was utilized that covered questions regarding what nursing standards are being taught in the nursing schools, what standards are encouraged by the hospitals, and teaching initiatives that include clinical documentation tools. Information was collected on how utilizing these standards in a clinical or hospital setting can improve the overall quality of care. Analysis included univariate and bivariate analysis. The consensus between both groups was that the NANDA, NOC and NIC national standards are the most widely taught and utilized. In addition, a training initiative was identified within a large university where a clinical documentation system based on these standards was developed utilizing handheld devices.
The Nursing Interventions Classification (NIC) is the first comprehensive classification of treatments that nurses perform. It is a standardized language of both nurse-initiated and physician-initiated nursing treatments. An alphabetical listing of 336 interventions was published in a book in May 1992 [Iowa Intervention Project, McCloskey, J. C., & Bulechek, G. M. (eds). Nursing Interventions Classification (NIC). St. Louis: Mosby-Year Book]. Each NIC intervention is composed of a label, a definition, a set of activities that a nurse does to carry out the intervention, and a short list of background readings. NIC interventions include: the physiological (e.g., Acid-Base Management, Airway Suctioning, Pressure Ulcer Care) and the psychosocial (e.g., Anxiety Reduction, Preparatory Sensory Information, Home Maintenance Assistance); illness treatment (e.g., Hyperglycemia Management, Ostomy Care, Shock Management), illness prevention (e.g., Fall Prevention, Infection Protection, Immunization/Vaccination Administration), and health promotion (e.g., Exercise Promotion, Nutrition Management, Smoking Cessation Assistance); and those used for individuals and those for families (e.g., Family Integrity Promotion, Family Support). Most recently, indirect care interventions (e.g., Emergency Cart Checking, Supply Management) have been developed. Research methods used to develop the classification include content analysis, expert survey, focus group review, similarity analysis, and hierarchical cluster analysis. The research, conducted by a large team of investigators at the University of Iowa and supported by the National Institute of Nursing Research, is ongoing. Since the 1992 publication, approximately 50 additional interventions have been developed, a taxonomic structure has been constructed and validated, a feedback and review system has been established and implemented, NIC interventions have been linked to nursing diagnoses, and five clinical agencies are serving as field sites to study the implementation process of NIC in nursing information systems. A numerical coding system for the interventions will be available in 1995. A second edition of the NIC book is in early preparation and will be available from Mosby-Year Book in early 1996. NIC facilitates the implementation of a Nursing Minimum Data Set. The use of NIC to plan and document care will facilitate the collection of large databases that will allow us to study the effectiveness and cost of nursing treatments. The use of standardized language provides for the continuity of care and enhances communication between nurses and other providers. NIC provides nursing with the treatment language that is essential for the computerized health care record. The domains and classes provide a description of the essence of nursing. NIC is helpful in representing nursing to the public and in socializing students to the profession. The coded interventions can be used in documentation and in reimbursement. For the first time in the history of nursing, nurses have a language which can be used to describe their treatments. The language is comprehensive and can be used by nurses in all settings and in all specialties. poster, giving an overview of the development of NIC, will be accompanied by a display of books and publications about NIC and its use.
Redesigning health care environments has occurred in response to cost and quality pressures. Efforts to redesign the nursing practice environment have focused on the structure and process of nursing care delivery. When redesign efforts address the structure of nursing practice systems to facilitate one important process, nurses' participation in decision making, better patient and organizational outcomes are expected. The purpose of this study was to determine if two dimensions of structure: administrative (decentralization) and professional authority (expertise) influence the process of participation in decision making for two kinds of decisions (caregiving and condition-of-work) that nurses make. The stratified sample consisted of 300 registered nurses working on medical-surgical units. Administrative and professional authority accounted for a small but significant amount of variation in participation in decision making. Because the extent of explained variation was small, the findings may challenge the prevailing assumption that greater authority for decision making results in the exercise of that authority. Redesign of the practice environment therefore must incorporate multiple factors in achieving greater participation in decision making.
Are nursing's new languages merely cumbersome collections of code, or can they significantly alter nursing practice and the way it's viewed? Either way, NANDA, NIC, and NOC are probably here to stay. Here's help for making the transition.
To describe the importance of standardized nursing vocabularies as a foundation for quality in health care decision-making.
Literature, online sources, and committee documents.
Several standardized vocabularies are recognized by the American Nurses Association Committee for Nursing Practice Information Infrastructure. Vendors also have integrated the vocabularies into their information systems. Future efforts include developing an international nursing reference terminology.
Oncology nurses face quality of care issues that impact decision-making at the point of care. To describe their practice, oncology nurses must strive to use nursing data that are standardized, documented, and made visible by inclusion in computer-based systems.
To provide a synopsis of issues about clinical information systems for nurses not schooled in nursing informatics.
The past, present, and future of clinical computing, including major factors resulting in the early hospital information systems (HIS) and decision support systems (DSS) in the United States, current advances and issues in managing clinical information, and future trends and issues.
Literature review and analysis.
The first HIS and DSS were used in the late 1960s and were focused on applications for acute care. The change from fee-for-service to managed care required a change in the design of clinical information systems toward more patient-centered systems that span the care continuum, such as the computer-based patient record (CPR). Current difficulties with CPR systems include lack of systems integration, data standardization, and implementation. Increased advances in information and technology integration and increased use of the Internet for health information will shape the future of clinical information systems.
Organizations sometimes create online patient documentation systems that do not work very well for them. Reengineering, conducted by a consulting firm or key in-house staff, is a possible strategy to remedy the situation. This article is about one such revision, which resulted in increased end-user satisfaction in the medical/surgical unit of a 150-bed rural community hospital.
The American Nurses Association has long recognized the need for nursing to participate in the development of national healthcare data sets and standardized terminologies suitable for implementation in computer-based systems. In 1989, the American Nurses Association Steering Committee on Databases to Support Clinical Nursing Practice was established to make policy recommendations related to nursing data needs. A primary function of the committee was the development of criteria for "recognition" of nursing language systems toward the goal of a Unified Nursing Language System. The committee has evolved and, in 1998, was renamed the Committee on Nursing Practice Information Infrastructure. In this article the revisions in the American Nurses Association recognition criteria and the role of professional associations in standards development are discussed. Distinct criteria for nursing data sets, classification systems, and nomenclatures are reflective of the evolution in the healthcare environment toward concept-oriented terminologic systems that facilitate data re-use.
Today s rapidly changing health care environment creates pressure for the computerization of the patient record. Two requirements for inclusion of nursing activities into the computerized patient record (CPR) are a standardized nursing language of sufficient granularity and a database that allows for one time collection of data for multiple uses. Documentation systems raise issues of data completeness. Using a descriptive methodology, nursing documentation in one CPR was examined for prevalence and content of free text documentation in an otherwise structured nursing information system (NIS). Results demonstrate house wide use of free text (narrative note) fields. Variability in use unrelated to patient acuity suggests idiosyncratic individual or unit documentation practices. Findings support the use of quality management activities to improve documentation practices and point to areas of database enhancement and information system development.
PURPOSE AND AIMS: The purpose of this study was to analyse expressions or terms used by nurses in Iceland to describe patient problems. The classification of NANDA was used as reference. The research questions were: (a) Does NANDA terminology represent patient problems documented by Icelandic nurses? (b) If so, what kind of nursing diagnoses does it represent? (c) What kind of patient problems are not represented by NANDA terminology? (d) What are the most frequent nursing diagnoses used?
A retrospective chart review was conducted in a 400 bed acute care hospital in Iceland. The sample was defined as nursing diagnosis statements in charts of patients hospitalized in two 6-month periods in two separate years. The data were analysed according to a predefined grading system based on the PES format or Problem -- (A)aetiology -- Signs and symptoms.
A total of 1217 charts were used for the study, which yielded 2171 nursing diagnoses statements for analysis. Charts with at least one nursing diagnosis documented were 60.1% and the number of diagnoses per patient ranged from 0 to 10, with 65% of charts with three diagnoses or less. The number of diagnoses correlated with patients' length of stay, but not with increased age of the patients. The average number of statements per patient was 3.28. Almost 60% of the diagnoses were according to NANDA terminology, another 20% were stated as procedures, medical diagnoses or risks for complications. The 20 most frequently used nursing diagnoses accounted for 80% of all diagnoses documented. Discrepancy between nurses' documentation on emotional problems and availability of diagnosis in the NANDA taxonomy was evident.
It can be concluded that the NANDA taxonomy seems to be culturally relevant for nurses in different cultures.
Data from aggregate individual patient records can be gathered to answer many clinical and nursing research questions about quality assurance and resource allocation, assisting in the measurement and evaluation of patient care outcomes. The use of standardized nursing language, large integrated computer databases, and information management processes provide for the use of patient-specific data and information to facilitate patient care. The use of aggregated data can also facilitate the comparison of nursing practice across populations, demonstrate and project nursing care trends, serve as a financial and legal record, aid in clinical research, support decision analysis, and guide professional and organization performance improvement.
The consistent availability of a core set of clinical nursing data is essential to promote quality patient care. Although important work to improve terminology and enhance comparability of data is underway, the efforts do not address the immediate need for useful nursing data sets and valid methods of collection at the point of data entry. The Hands-on Automated Nursing Data System (HANDS) project is dedicated to refining a feasible methodology for gathering, storing, and retrieving a standardized nursing data set. To date the project team has developed and tested a prototype research tool that is automated and contains the structured terminologies (North American Nursing Diagnosis Association, Nursing Outcomes Classification, and Nursing Interventions Classification) to represent nursing diagnoses, outcomes, and interventions, respectively. The Phase I project development activities are reported in this article, along with Phase II and III plans for testing and refining the methodology under actual clinical conditions. Results and lessons learned during Phase I are reported.
This study examined and compared the processes of information collection and clinical judgement by nurses ( n =107) and physicians ( n =27) working with cancer patients. The data was collected in two university hospitals by means of a computer‐simulated case description and the thinking‐aloud method. Data interpretation was based on SPSS statistical software and the method of content analysis. Statistical differences between the two groups were tested with non‐parametric Kruskal–Wallis Anova or the Mann–Whitney U ‐test. The Wilcoxon test was applied in pairwise comparisons. Independent questions were analysed by cross‐tabulation and Pearson's χ ² .
According to the results nurses and physicians apply different approaches to clinical judgement and problem‐solving. On the basis of the status statement they received in the program both groups pointed to similar problems and sought a great deal of additional information. However the type of information required was different in the two groups. There were also significant differences in the knowledge base applied for purposes of clinical judgement: nurses tended to rely on personal knowledge, physicians on theory. Physicians were able to identify their patient's major clinical problems, but nurses had more difficulty doing this. On the other hand, nurses took a broader view on the general well‐being of patients than physicians did. Copyright © 2002 John Wiley & Sons, Ltd.
The purpose of this project was to develop a guide to support use of the Omaha System in primary care. The Omaha System is a community practice-based standardized nursing language developed by the Visiting Nurses Association (VNA) of Omaha, NE. Nurse practitioners at a primary care faculty practice clinic began using the Omaha System to describe more completely the advanced nursing care provided to clients, beyond ICD-9 and CPT codes. After 9 months of data collection, key faculty members convened to analyze the data and discuss issues in coding and interpretation. To simplify use of the system and facilitate orientation of new faculty, this group devised a Primary Care Guide for the Omaha System. High-frequency problems and interventions were identified. Definitions of the intervention categories were reviewed, and targets appropriate for the primary care environment were recorded. The result was a concise, user-friendly guide to assist the primary care nurse practitioner in the use of standardized nursing language.
A study was undertaken on the use of the Nursing Outcomes Classification (NOC) in different practice settings in Israel that included an analysis of problems that can arise in using NOC and a proposed solution. The results indicated four main problems with using the NOC in nursing practice: It is not possible to build from several indicators a weighted index for estimating patient outcomes; some of the indicators are not identical to the clinical guidelines; the grading scales depend largely on subjective judgment; and we question whether an evaluation scale of 5 grades is necessary for such numerical values as vital signs. We suggest dividing the NOC into three main categories (based on original values, objective values as suggested in the clinical guidelines, and values that require the development of quantitative indices) to enable better implementation.
Viable strategies are needed to move toward collection of a standardized nursing data set across settings for eventual use in examining nursing effectiveness. One strategy is to introduce potential nurse adopters to subsets of valid setting-specific standardized terms and measures to support adoption and initial implementation. The present study was designed to identify the "most clinically useful" NANDA (North American Nursing Diagnoses Association) diagnoses, NOC (Nursing Outcomes Classifications) outcomes, and NIC (Nursing Intervention Classifications) interventions pertinent to the adult care nurse practitioner setting. Ultimately, clinicians must recognize, however, that they will need to use additional terms and measures outside the subsets to more fully describe the nursing care provided.
Informatics knowledge and skills are essential if clinicians are to master the large volume of information generated in healthcare today. Thus, it is vital that informatics competencies be defined for nursing and incorporated into both curricula and practice. Staggers, Gassert, and Curran have defined informatics competencies for four general levels of nursing practice. However, informatics competencies by role (eg, those specific for advanced practice nursing) have not been defined and validated. This article presents an initial proposed list of informatics competencies essential for nurse practitioner education and practice. To this list, derived from the work of Staggers et al., 1 has been added informatics competencies related to evidence-based practice. Two nurse informaticists and six nurse practitioners, who are program directors, were involved in the development of the proposed competencies. The next step will be to validate these competencies via research.
Nursing informatics is a relatively new nursing specialty. Recognized by the American Nurses' Association in 1992, this field within nursing has grown exponentially. Once the purview of highly specialized individuals, nursing informatics has now crept into all dimensions of nursing, from domain of advanced nurse practitioners to prominence in critical care nursing. Nowhere is the management and processing of health-related information more important than in the care of the critically ill patient. Fast-paced environments, split-second decision making, wireless communications, monitoring systems run with computerized backbones, and computerized ordering and documentation, all things unimaginable just a decade ago, are now fundamental to nursing practice. Each requires a baseline understanding of informatics for true mastery. The domain of nursing informatics continues to grow as nursing incorporates expanded roles and new technology into practice. Education for nurse informaticians includes preparation from the baccalaureate level through the doctorate level and national board certification. Areas of practice are expansive, including hospitals, industry, education, policy-making, research, administration, and international settings. Although informaticians work with computers, computing technology is not the heart of the domain. Computers are simply tools that are used. Examples of informatics tools include handheld devices, point-of-care documentation, computerized provider order entry, and bar code medication administration. Nursing informatics plays an essential role in the future directions of healthcare by defining the relationship between nurses and information technology as well as the knowledge that can be gained when these domains work together.
The aim of this article is to explore the complex forms of knowledge involved in diagnostic and interventional decision making by comparing the processes in medicine and nursing, including nurse practitioners. Many authors assert that the practice of clinical decision making involves the application of theoretical knowledge (acquired in the classroom and textbooks) as well as research evidence, upon concrete particular cases. This approach draws on various universal principles and algorithms to facilitate the task. On the other hand, others argue that this involves an intuitive form of judgement that is difficult to teach, one that is acquired principally through experience. In an exploration of these issues, this article consists of three sections. A clarification of terms commonly used when discussing decision making is provided in the first section. In the second section, an epistemological analysis of decision making is presented by examining several perspectives and comparing them for their use in the nursing and medical literature. Bunge's epistemological framework for decision making (based on scientific realism) is explored for its fit with the aims of medicine and nursing. The final section presents a discussion of knowledge utilization and decision making as it relates to the implications for the education and ongoing development of nurse practitioners. It is concluded that Donald Schön's conception of reflective practice best characterizes the skillful conduct of clinical decision making.
This article discusses judgement and decision-making in nursing. It outlines an approach to analysing clinical problems known as decision analysis. It suggests decision analysis can be a useful technique for nurses to assist them with decision-making in practice.
The risk of errors in the planning and delivery of health care is an inescapable feature of clinical practice for which health providers have developed sophisticated defences. However, errors still occur. This paper, the final in a four-part series on nurses' decision-making and judgement, illustrates some common pitfalls facing clinicians who have to make complex decisions and judgements, and suggests simple techniques to help combat some of the systematic errors people make when exercising judgement and making choices.
The purpose of this study was to evaluate a 16-hour intervention designed to build clinician competency in the use of North American Nursing Diagnosis Association (NANDA), Nursing Outcome Classification (NOC), and Nursing Interventions Classification (NIC) (hereinafter: N3) among nurses with limited N3 knowledge. Each of 19 pairs of nurses independently selected N3 terms and rated the outcomes applicable to an actual patient for a specified time. A pair-through discussion then created a single consensus patient profile of the applicable terms. Before discussion, pairs agreed on 46% of the NANDA diagnoses, 30% of the NOC outcomes, and 20% of the NIC interventions selected. Eighty-nine percent of NOC label pair ratings were within 1 point. Building competency in N3 requires consistent use in written and oral communication with peers across time. Inter-rater reliabilities (IRRs) for NOC label ratings support previous findings.
Evidence-based practice is an important force in healthcare today. Its impact on the practice of the advanced practice nurse (APN) is becoming more apparent with the development of practice guidelines and protocols. The phrase, "That's the way I've always done it," is being replaced by, "This practice is evidence based." The philosophy of supporting practice with scientific evidence is not new but has been revitalized and emphasized as protocols have been developed to "mold" practice to achieve successful outcomes. This revolution is being applied to all areas of healthcare practice. Assessment of the patient is usually the first contact the APN has with the patient. It is an important time to gather information from the patient interview, physical examination, laboratory data, and test interpretation. Scientific evidence, properly interpreted, is applied in this step of assessment. The APN will then use clinical judgment and the knowledge gained from graduate education to assist with the formulation of a diagnosis. The APN has a unique opportunity to promote an evidence-based practice model at the grass roots level and persuade the bedside nurse to integrate this process into his or her practice. Ultimately, patients will receive better care and outcomes will be improved using evidence-based assessment.
This was a pilot study with a pretest and posttest design to test the feasibility of conducting large-scale studies of the effects of using computer-based terms from NANDA, NIC, and NOC on nurses' power to help children and children's health outcomes. Four hypotheses were tested with data from 12 public health nurses in school settings and 220 schoolchildren. Group A comprised six nurses who used SNAP Health Center (SNAP 98) software to record health visits with 117 children. Group B comprised six nurses who used the same software and NANDA, NIC, and NOC with 103 children. After use of the software, the power of the 12 nurses to help children significantly increased. For the 220 children, the number of coping strategies significantly increased but there were no changes in the other health outcomes. The hypotheses indicating that Group B nurses and children would have more positive changes than Group A were not supported. Positive and negative elements for large-scale studies were identified.
The aim of this paper is to introduce the theoretical framework that directs the project.
The Novice Computer Decision Support (N-CODES) Project is developing a point-of-care system to assist novice acute care nurses while making clinical judgements. Unlike prior approaches, N-CODES is guided by a theoretical understanding of nurses' decision-making processes, including the manner by which novices develop this skill.
Assumptions within information processing theory guided the clinical decision-making framework. The framework is composed of a clinical decision-making model and a second embedded model depicting the clinical reasoning development of novice nurses.
The model is developed within a pluralistic perspective synthesizing theoretical and empirical knowledge on clinical decision-making and the development of novice reasoning skills. A visual representation of experienced nurse decision-making is presented. A central element is the nurse's use of pre-encounter data and working knowledge. A second model integrates empirical data on the developing clinical reasoning of the novice. This knowledge is loosely scattered through 25 years of literature. The intersection of these models provides a novel perspective on the way novices begin to identify working knowledge patterns and develop a sense of saliency.
Previous attempts to build comprehensive clinical decision support systems have disregarded important theoretical considerations hindering the success of these projects. Grounding a Decision Support System in a theoretical model of novice nurse decision-making will strengthen the utility and acceptance of the Decision Support System. Additionally, a conceptualization of novice nurse development is an asset to nurse educators, managers and scientists interested in improving clinical decision-making.
The purpose of this study was to explore factors that may affect nurses' use of nursing diagnoses in charting standardized nursing care plans in their daily practice.
Care plans have been viewed as providing a structured approach to the assessment, planning and delivery of patient care. Nonetheless, the challenge for many institutions is to help professional nursing staff refine their understanding of nursing diagnoses and charting skills, to identify patient problems and propose appropriate care plans.
Twelve clinical nurses working at a medical center in Taiwan underwent one-on-one in-depth interviews from May to July 2000. Data analysis was based on Miles and Huberman's data reduction, data display, and a conclusion verification process to investigate the charting process.
Nurses tended to match patient conditions to the designated nursing diagnoses, be unfamiliar with statements of related factors, use objective data to describe patient conditions, ignore descriptions of nursing goals, dutifully check interventions without always executing them, and choose the same evaluation to meet hospital requirements.
These findings suggest that using educational programmes for enhancing nurses' ability to use nursing diagnoses and exploring the process of diagnostic reasoning would improve the quality of patient documentation.
The trend in health care is to focus on chart audit to reveal indicators of quality of care. Therefore, the experience of nurses in this study could be applied to in-service training programmes by institutions that are replacing traditional, manually written care plans with a standardized care planning system, thus helping other nurses through this transition process.
The aim of this survey was to test the applicability of the Nursing Interventions Classification (NIC) system for use in a future nursing information system for documenting nursing in an electronic patient record in Iceland. Also, the aim was to test the translation of NIC into Icelandic. In order to be applicable to nursing NIC needs to be sensitive enough to describe the work nurses do, differentiate between specialities in nursing, and be understandable to nurses. A sample of 198 nurses was asked to identify how often they used each of 433 NIC nursing interventions. Of the 36 most frequently used interventions half are within the physiological domain. Core nursing interventions were different between specialities, e.g. Analgesic Administration had a high mean score in surgical nursing, and Health Education in primary health care. anova for the 27 classes in NIC showed significant differences (p < 0.01) by all nursing specialities except one, Crisis Management. A Tukey post hoc test showed how nursing specialities were reflected differently in the NIC domains, e.g. medical/surgical nursing in the Physiological: Basic Domain, but psychiatric nursing in the Behavioural Domain. Factor analysis of classes in NIC show good resemblance with the domains in NIC and the structure of the classification is strongly supported, except the Safety Domain. The results from this study indicate that nurses in the sample consider NIC to be applicable to describe nursing. The language is a powerful tool and is central in reflecting nursing practice as well as supporting the construct of knowledge. The translation of NIC to Icelandic is one step in many in preparing nurses to use a standardized language which can also be used in an electronic patient record.
A computerized system for care planning and documentation of patient care was initiated at a western teaching hospital, using the framework of Nursing Interventions Classification and Nursing Outcomes Classification standardized languages. The software integrates care planning and documentation, and includes both order entry as well as a charting application. Prior to initiating the project, a study was conducted to evaluate staff attitude toward computerization, time needed for documentation, and comprehensiveness of charting entries. Data from staff surveys, observations, and chart audits conducted pre- and post-computer project implementation demonstrated that the staff attitudes toward computers were less positive, the time required for charting was unchanged, and there were improvements in how completely the nurses documented charting elements.
The rise of evidence-base practice (EBP) as a standard for care delivery is rapidly emerging as a global phenomenon that is transcending political, economic and geographic boundaries. Evidence-based nursing (EBN) addresses the growing body of nursing knowledge supported by different levels of evidence for best practices in nursing care. Across all health care, including nursing, we face the challenge of how to most effectively close the gap between what is known and what is practiced. There is extensive literature on the barriers and difficulties of translating research findings into practical application. While the literature refers to this challenge as the "Bench to Bedside" lag, this paper presents three collaborative strategies that aim to minimize this gap. The Bedside strategy proposes to use the data generated from care delivery and captured in the massive data repositories of electronic health record (EHR) systems as empirical evidence that can be analysed to discover and then inform best practice. In the Classroom strategy, we present a description for how evidence-based nursing knowledge is taught in a baccalaureate nursing program. And finally, the Bench strategy describes applied informatics in converting paper-based EBN protocols into the workflow of clinical information systems. Protocols are translated into reference and executable knowledge with the goal of placing the latest scientific knowledge at the fingertips of front line clinicians. In all three strategies, information technology (IT) is presented as the underlying tool that makes this rapid translation of nursing knowledge into practice and education feasible.
The new budget system for Dutch hospitals makes use of patient groups that are highly homogeneous in terms of diagnosis and treatment combinations (diagnose behandeling combinaties (DBC)). These DBCs are the Dutch DRG variants. The DBC mainly concerns medical care; nursing care is almost regarded as a constant factor. In this study the DBC is linked to the nursing minimum data set for The Netherlands (NMDSN), to explore the degree of homogeneity in terms of nursing care for patient groups that are homogeneous in terms of the DBC.
In nine Dutch hospitals, patient information was collected by means of the NMDSN. To answer the question, we performed a secondary data analysis on the NMDSN. First, groups were formed in terms of medical diagnoses as defined in the DBC. Next, explorative statistical analyses were used to form homogeneous groups in terms of nursing diagnoses. These groups were compared in terms of the nursing care interventions and in terms of medical diagnoses.
Some medical diagnoses seem to be homogeneous, others more heterogeneous in terms of nursing care.
Limitations in the study design hinder a firm conclusion. However, the results discourage the use of the medical DBC for nursing care.
To describe the methods used in design of a framework that (a) encompasses nursing knowledge, (b) functions as a cognitive map for clinicians, and (c) increases the efficiency of using the North American Nursing Diagnosis Association (NANDA), Nursing Intervention Classification (NIC), and Nursing Outcome Classification (NOC) terminologies together in the electronic patient record.
The taxonomies of the NANDA, NIC, and NOC terminologies were integrated to form a preliminary structure of domains and classes. New concepts and collocations of concepts were constructed using Walker and Avant's (1983, 1988) method for concept synthesis. The framework was validated using an expert group and clinical testing.
A framework organized as a taxonomy with eight domains (Physiological, Functional, Psychocognitive, Safety, Existential, Lifestyle, Family, and Environment) and 29 classes.
The framework has the potential to enhance the quality of nursing documentation, contribute to nursing research and education, and reduce job stress.
There are no nursing centric data in the hospital discharge abstract. This study investigates whether adding nursing data in the form of nursing diagnoses to medical diagnostic data in the discharge abstract can improve overall explanation of variance in commonly studied hospital outcomes.
A retrospective analyses of 123,241 sequential patient admissions to a university hospital in a Midwestern city was performed. Two data sets were combined: (1) a daily collection of patient assessments by nurses using nursing diagnosis terminology (NDX); and (2) the summary discharge information from the hospital discharge abstract including diagnosis-related group (DRG) and all payer refined DRG (APR-DRG). Each of 61 daily NDX observations were collapsed as frequency of occurrence for the hospital stay and inserted into the discharge abstract. NDX was then compared to both DRG and APR-DRG across 5 hospital outcome variables using multivariate regression or logistic regression.
In all statistical models, DRG, APR-DRG, and NDX were significantly associated with the 5 hospital outcome variables (P <.0001). When NDX was added to models containing either the DRG or the APR-DRG, explanatory power (R2) and model discrimination (c statistic) improved by 30% to 146% across the outcome variables of hospital length of stay, ICU length of stay, total charges, probably of death, and discharge to a nursing home (P <.0001). The findings support the contention that nursing care is an independent predictor of patient hospital outcomes. These nursing data are not redundant with the medical diagnosis, in particular, the DRG. The findings support the argument for including nursing care data in the hospital discharge abstract. Further study is needed to clarify which nursing data are the best fit for the current hospital discharge abstract data collection scheme.
The electronic health record (EHR) requires the use of standardized nursing languages such as NANDA, NOC, and NIC. Helping nurses use these languages for an EHR requires different educational strategies in 3 domains: intellectual, interpersonal, and technical. The author explains the rationale for changes in educational methods, expectations that educators and managers should set for students and nurses at various levels of expertise, and teaching strategies in each of the domains.
Paper-based medical record systems are becoming obsolete with the advent of electronic medical record (EMR) systems. With EMRs, patient data can be accessed instantly, patients can be tracked intelligently, and safeguards can help prevent medical errors. By integrating a universal nursing language, such as the Perioperative Nursing Data Set (PNDS), into EMR systems, nurses can document the nursing care they give to patients. This allows nurses to show the value of their role in the OR, promote nursing, and explain how their actions help meet National Patient Safety Goals. The transition to an EMR system for Jackson Health System, Miami, is discussed, including integration of the PNDS into the EMR system.
As new directions and priorities emerge in health care, nursing informatics leaders must prepare to guide the profession appropriately. To use an analogy, where a road bends or changes directions, guideposts indicate how drivers can stay on course. The AMIA Nursing Informatics Working Group (NIWG) produced this white paper as the product of a meeting convened: 1) to describe anticipated nationwide changes in demographics, health care quality, and health care informatics; 2) to assess the potential impact of genomic medicine and of new threats to society; 3) to align AMIA NIWG resources with emerging priorities; and 4) to identify guideposts in the form of an agenda to keep the NIWG on course in light of new opportunities. The anticipated societal changes provide opportunities for nursing informatics. Resources described below within the Department of Health and Human Services (HHS) and the National Committee for Health and Vital Statistics (NCVHS) can help to align AMIA NIWG with emerging priorities. The guideposts consist of priority areas for action in informatics, nursing education, and research. Nursing informatics professionals will collaborate as full participants in local, national, and international efforts related to the guideposts in order to make significant contributions that empower patients and providers for safer health care.
A complex set of needs--increased accessibility to and interest in health information, more respect for patients' rights, advanced information technologies, and pressure to seek cost-effective healthcare delivery--made the personal health record (PHR) necessary. Nursing, as essential to healthcare, must be represented in a PHR, but few studies have explored the nurse's role in the development and expansion of the PHR. The aim of this project was to design and develop an Internet-based PHR, IowaPHR, in order to demonstrate how nursing can be integrated into the PHR.
In addition to the common features of the PHR as detailed by previous studies, IowaPHR contains the following innovations: (1) the information embraces major community health concerns; (2) an interactive feature--the self-assessment and feedback field--was created by transforming a standardized nursing language into appropriate questions adjusted for consumer vocabulary level; and (3) a user-friendly interface was equipped with trends in health conditions and a diary function. This PHR was then evaluated by experts in terms of content, ease of navigation, time needed to complete tasks, ability to find desired information, and site presentation.
In the evaluation of this PHR, experts assigned high scores to four items. Completion of the tasks took an average of 16.25 min.
Allowing self- or caregivers to observe health conditions through completion of the questions on our PHR will precisely address clinic visitors' health problems, assist in planning interventions, and promote education of and empowerment for health care. This PHR will provide a new way for nursing informatics to enhance the capacity of nursing in consumer health and to make a difference in the larger context of health informatics.
This study investigated the development of a community-focused curriculum integrating primary, secondary, and tertiary prevention and nursing standardized terminologies as an organizing infrastructure. This is a case study of the curriculum redesign of the Marcella Niehoff School of Nursing, Loyola University Chicago. Faculty developed a conceptual framework integrating core concepts into curriculum design, course content, and clinical applications. A coherent curriculum was designed using a community-focused approach; primary, secondary, and tertiary prevention strategies; and standardized terminologies as the organizing infrastructure to teach and apply nursing practice. The curriculum provides a meaningful correlation between the classroom and clinical experience. Students journey with their patients throughout the health care experience, applying nursing concepts using standardized terminologies. Clinical experiences provide students with the opportunity to transfer knowledge to the health experiences of patients in their care. Patient encounters, whether at the primary, secondary, or tertiary level of prevention, are used to assist students in developing critical thinking skills through the use of standardized nursing terminologies.
To illustrate approaches for providing decision support for evidence-based nursing practice through integration of evidence into clinical information systems (CISs) with examples from our experience at Columbia University Medical Center.
Examples are organized according to three types of decision support functions: information management, focusing attention, and patient-specific consultation.
Three decision support tools that are integrated into three types of CISs are discussed: (1) infobuttons that provide context-specific access to digital sources of evidence; (2) automated Fall-Injury Risk Assessment; and (3) personal digital assistant-based screening reminders, screening assessments, and tailored documentation templates for the identification and management of obesity, depression, and tobacco cessation. The informatics infrastructure for implementing these decision support tools is described from the perspective of components identified in the published literature.
Efforts to facilitate application of evidence into nursing practice are unlikely to be successful unless the approaches used are integrated into the clinical workflow. Our approaches use a variety of informatics methods to integrate evidence into CISs as a mechanism for providing decision support for evidence-based practice in a manner consistent with nursing workflow.
This Conceptual Model for Nursing Information describes the core activities of nursing, the collection of information about these activities, and argues that these activities must be described using standardized nursing languages.
Relevant literature, both national and international, was reviewed and summarized.
A maximum data set for nursing was developed.
In the United Kingdom, a new and radical approach to the process of nursing is required; one that demonstrates that nursing is the decision-making that takes place in all core activities of nursing.
Unless nurses have a clear view of what the profession requires from technological solutions for the recording of nursing activities, less than optimal solutions will be forced upon the profession.