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Representing the Nursing Process With Nursing Terminologies in Electronic Medical Record Systems A Swiss Approach
Abstract
This article describes a framework model within a selected nursing classification system for the integration of nursing care processes into a clinical information system. The "Electronic Nursing Process Data Model," project was carried out from July 2004 to October 2006 in the Canton of Zurich in Switzerland. The Zurich Electronic Nursing Process Data Model integrates the nursing diagnosis, outcomes, and intervention terminologies in a standardized manner into the nursing care process within the electronic patient record. Findings of the pretest application in clinical nursing practices revealed that (1) functionalities are logically structured, (2) it is difficult to overview many details of the documentation, (3) a specific "to-do list" retrieved from the electronic system is needed, and (4) free-text entries are important to add description of the patient's situation. Furthermore, a consistent assessment terminology needs to be linked to the nursing diagnosis, outcomes, and intervention terminologies and the descriptions of nursing care process within the Electronic Nursing Process Data Model. As the project team, we recommend to implement the developed Electronic Nursing Process Data Model into professional software of clinical information systems and gradually into clinical practice. Therefore, an appropriate utilization strategy includes issues to improve nurses' understanding of the nursing care process and critical-thinking skills: not even the most comprehensive software program can substitute for facilitation.
... 5 The integration of nursing data into large datasets requires the frequent and rapid input of new valid information from EHRs. 6 These can be achieved through the use of controlled vocabularies in EHRs, which helps overcome the major challenges of aggregation, processing and analysis associated with unstructured text data. [7][8] In nursing, SNTs are controlled vocabularies that represent nursing care as nursing diagnoses, interventions and outcomes. 8 The SNT coded data retrieved from EHRs can be analyzed alone or merged with other EHRs data. ...
... [7][8] In nursing, SNTs are controlled vocabularies that represent nursing care as nursing diagnoses, interventions and outcomes. 8 The SNT coded data retrieved from EHRs can be analyzed alone or merged with other EHRs data. The use of SNTs to document nursing practice is a big step toward supporting the aggregation of nursing data to large datasets and big data science. ...
Nursing care documentation in electronic health records (EHRs) with standardized nursing terminologies (SNTs) can facilitate nursing's participation in big data science that involves combining and analyzing multiple sources of data. Before merging SNTs data with other sources, it is important to understand how such data are being used and analyzed to support nursing practice. The main purpose of this systematic review was to identify studies using SNTs data, their aims and analytical methods. A two-phase systematic process resulted in inclusion and review of 35 publications. Aims of the studies ranged from describing most popular nursing diagnoses, outcomes, and interventions on a unit to predicting outcomes using multi-site data. Analytical techniques varied as well and included descriptive statistics, correlations, data mining, and predictive modeling. The review underscored the value of developing a deep understanding of the meaning and potential impact of nursing variables before merging with other sources of data.
... To develop a nursing diagnosis, the nurse must possess intellectual, interpersonal, and technical abilities (Lunney, 2010). Several authors argue that the use of an assessment form with links to nursing diagnosis may facilitate diagnostic reasoning (Bernhart-Just, Lassen, & Schwendimann, 2010; Kurashima et al., 2008). The aim of this study was to develop a computerized nursing assessment form to facilitate the diagnostic reasoning of nurses to identify nursing diagnoses and then estimate its content validity. ...
... The criteria followed by the Nursing Research Group to specify the trigger answers to identify the nursing diagnoses are not shown in detail. @BULLET The Electronic Nursing Process Data Model (ENPDM) is an electronic nursing documentation system that uses a standardized nursing language, the NANDA, NIC, NOC (NNN) terminologies, for the integration of the nursing process into a clinical information system (Bernhart-Just et al., 2010). The ENPDM provides a focused assessment tool made of questions, specific instruments, or scales that allow collected data to be assigned to the appropriate item to formulate nursing diagnoses. ...
Describe the development and validation of the Nursing Assessment Form (NAF), within a clinical nursing information system, to support nurses in the identification of nursing diagnoses.
Content validity and consensus on NAF contents were established using a panel of experts in nursing diagnosis and Delphi rounds.
Expert consensus was achieved to validate an instrument to support nurses in the process of nursing diagnoses identification.
The use of the NAF can help nurses in diagnostic reasoning, facilitating the identification of the more suitable nursing diagnoses, and provide a basis for the best nursing interventions and outcomes.
The use of computerized decision support can improve the implementation of standardized terminology and the accuracy of nursing diagnosis.
Descrivere lo sviluppo e il processo di validazione della Scheda di Accertamento Infermieristico (SAI), contenuta all'interno di un sistema informativo infermieristico, ideata al fine di supportare gli infermieri nel processo di identificazione delle diagnosi infermieristiche.
La validità di contenuto e il consenso sui contenuti della SAI sono state stabilite tramite un panel di esperti sulla diagnosi infermieristica e Delphi rounds.
Un consenso di esperti è stato ottenuto al fine di validare uno strumento utile per supportare gli infermieri nel processo di identificazione delle diagnosi infermieristiche.
L'uso della SAI può aiutare gli infermieri nel ragionamento diagnostico, facilitando l'identificazione delle diagnosi infermieristiche più adatte e fornire una base per i migliori interventi e risultati infermieristici.
L'uso di sistemi di supporto decisionale computerizzati può favorire l'implementazione della terminologia standard e l'accuratezza della diagnosi infermieristica.
... 10,11 Nonostante i linguaggi standardizzati siano utili per uniformare la descrizione dei fenomeni di cui gli infermieri si occupano, migliorando la comunicazione di quanto viene fatto al paziente 12 e la raccolta di dati, [13][14][15] ci sono difficoltà determinate dalla scarsa familiarità con tali linguaggi e dalla convinzione che il supporto alla pratica sia limitato. 10 Inoltre, l'uso di linguaggi standardizzati non sempre favorisce la comunicazione interprofessionale 16,17 e non permette di catturare appieno la complessità dell'infermieristica. 18,19 Gli EHRs che non impiegano SNL sembrano più facili da usare rispetto a quelli che li includono, 12,14 tanto che in assenza di un consenso su quale terminologia utilizzare, diversi Paesi evitano di raccomandarne l'incorporazione nei propri EHRs. 20 In Italia sono in corso interessanti applicazioni, sperimentazioni e studi su questo ambito e un dibattito silente tra posizioni 'contro' e 'a favore'. ...
Unlabelled:
. The use of standardized nursing languages in electronic medical records: an exploratory study on opportunities, limitations, and strategies.
Introduction:
Standardized nursing languages (SNLs) have found increasing application in electronic medical records in recent years. In Italy their use is still uneven and accompanied by a silent debate between positions 'against' and 'for' their use.
Aim:
To render visible the debate regarding SNLs in Italy, and the strategies to consider when digitized records are based on a SNL.
Method:
Data has been collected through audio-recorded semi-structured interviews, selecting three Italian nursing professors, four managers representing Italian healthcare settings that used a SNT and a representative of the Central committee of the National federation of orders of nursing professions. The thematic approach was used to analyze the data.
Results:
Participants reported having introduced digitized records based on nursing diagnoses, integrated with the Nursing Interventions Classification System and Nursing Outcome Classification, Clinical Care Classification System, Nursing Sensitive Outcomes or mixed models. Divergent aspects emerge regarding: (1) using nursing languages vs a common language to other healthcare professions; (2) planning care vs enhancing clinical reasoning; (3) measuring nursing care vs accepting the variability of the practice, and (4) making documentation efficient vs dedicating more time. Some convergences have emerged and a set of indications for introducing electronic records when based on standardized languages.
Conclusions:
The introduction of electronic documentation requires the use of homogeneous languages. The debate on the potential and limits of SNL is still open and requires reflection among researchers, trainers, clinicians, and coordinators/managers of nursing care regarding the choices to be made which may have long-term effects on many nurses.
... Moreover, the SNTs have been proven to increase the accuracy of nursing documentation leading to better nursing-sensitive patient outcomes (Leoni-Scheiber et al., 2019;Müller-Staub et al., 2006) and interoperability across geographical boundaries (Fennelly et al., 2021). At the system level, SNTs have been considered as the minimum data set (Muntlin Athlin, 2018) to originate digitalized documentation, care plans, and decision support systems (Bernhart-Just et al., 2010;Flanagan, 2014;Hants et al., 2023). The increased digitalization of nursing documentation based on the SNTs has proven usable, interoperable, accessible, transparent, user-friendly, sharable, and comparable to the nursing care planned and provided (De Groot et al., 2020;Fennelly et al., 2020;Keenan et al., 2018). ...
Purpose
To identify and synthesize evidence regarding the documented relationship between the standardized nursing terminologies and the unfinished nursing care phenomenon.
Data sources
A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. PubMed, Scopus, and Cumulative Index to Nursing and Allied Health Literature Complete databases were last consulted on November 27, 2023. The review included primary quantitative studies that reported an association between recognized standardized nursing terminologies and unfinished nursing care. Two researchers completedtitle and abstract and full‐text screening.
Data synthesis
Our search identified 149 citations. A full‐text review of one paper was undertaken. No studies met our inclusion criteria. We report an empty review.
Conclusions
Standardized nursing terminologies and Unfinished Care are two sides of the same coin: despite their potential commonalities, no studies have documented their potential links. Digital systems, such as electronic health records and decision support systems, could foster this linkage.
Implications for nursing practice
This review suggests that linking the conceptual frameworks can promote the diffusion of standardized nursing terminologies in clinical practice and increase accuracy in the measurement of Unfinished Care. This synergy could promote the contribution of nursing knowledge to patient care, nursing visibility, and be beneficial to clinical nurses, managers, and healthcare systems to international level.
... The limitations of paper-based nursing process documentation have led nurse-researchers and software developers into designing nursing process tools. The previous computerized nursing assessment forms in existence are the Nursing Process Electronic Documentation System of the University of Sao Paulo (USP-PROCEnf), Electronic Nursing Process Data Model [ENPDM], Nursing Process Support System in Chinese (NPSSC), and Computer-Aided Nursing (CAN) diagnosis system (20)(21)(22)(23). However, the mentioned nursing process software tools have some strengths and weaknesses that limit their fit for purpose in rural African settings. ...
Poor internet infrastructure limits the use of computer‑based nursing process forms in rural areas. This study aimed to configure a computer‑based nursing process form to support nursing diagnosis and care evaluation in rural healthcare clinics in Africa. This study utilized a methodological design. The design process utilized a three‑stage procedure involving planning, configuration, and testing. Seven faculty members volunteered to participate in the laboratory verification process. Each simulation session lasted 45 min and span from patient admission to exit. The experts independently scored the software functionality dichotomously as Not Suitable (score 0) and Suitable (score 1) for nursing practice. The agreement between the faculty volunteers was 0.857. The configuration of a readily available Microsoft Access computer application to support nursing diagnosis without internet service is possible. Health facilities in rural areas without internet connectivity should resort to such local configurations to maximize the benefits of electronic‑based documentation.
... STs usually represent defined aspects of clinical practice [19][20][21] and facilitate semantic interoperability across geographical boundaries, irrespective of language [16,20,22,23]. Standardized nursing terminologies, which are often used interchangeably with standardized nursing languages, systematically group, J o u r n a l P r e -p r o o f define and encode nursing care as nursing diagnoses, interventions and/or outcomes [24][25][26][27], and link nursing diagnoses with evidenced-based interventions and outcomes [7]. No universal ST has been determined and several nursing-specific and multidisciplinary STs have been approved for clinical use by the American Nurses' Association [28,29]. ...
Aim
To explore the use and impact of standardized terminologies (STs) within nursing and midwifery practice.
Introduction
The standardization of clinical documentation creates a potential to optimize patient care and safety. Nurses and midwives, who represent the largest proportion of the healthcare workforce worldwide, have been using nursing-specific and multidisciplinary STs within electronic health records (EHRs) for decades. However, little is known regarding ST use and impact within clinical practice.
Methods
A scoping review of the literature was conducted (2019) across PubMed, CINAHL, Embase and CENTRAL in collaboration with the Five Country Nursing and Midwifery Digital Leadership Group (DLG). Identified studies (n = 3,547) were reviewed against a number of agreed criterion, and data were extracted from included studies. Studies were categorized and findings were reviewed by the DLG.
Results
One hundred and eighty three studies met the inclusion criteria. These were conducted across 26 different countries and in various healthcare settings, utilising mainly nursing-specific (most commonly NANDA-I, NIC, NOC and the Omaha System) and less frequently local, multidisciplinary or medical STs (e.g., ICD). Within the studies, STs were evaluated in terms of Measurement properties, Usability, Documentation quality, Patient care, Knowledge generation, and Education (pre and post registration). As well as the ST content, the impact of the ST on practice depended on thehealthcare setting, patient cohort, nursing experience, provision of education and support in using the ST, and usability of EHRs.
Conclusion
Employment of STs in clinical practice has the capability to improve communication, quality of care and interoperability, as well as facilitate value-based healthcare and knowledge generation. However, employment of several different STs and study heterogeneity renders it difficult to aggregate and generalize findings.
... In Switzerland, the Nursing Service Commission of Department of Health launched the Electronic Nursing Process Data Model (ENPDM) as a framework to design the ENRS. In this model, they developed the Swiss NMDS and integrated the NANDA, NIC and Nursing Outcomes Classification (NOC) terminologies into the electronic patient record (Bernhart-Just, Lassen, & Schwendimann, 2010). Similarly, Volrathongchai, Delaney, and Phuphaibul (2003) created the Thai NMDS that was considered more appropriate to the Thailand healthcare environment. ...
In Indonesian hospitals, particularly in South Sulawesi Province, one of the activities that needs improvement by design is that of nursing records. This vital task is not completed due mainly to the fact that, incredibly, no model has been implemented to date mainly because of financial constraints and the overall lack of nurses’ computer literacy within the health services area in Indonesia. Although copious nursing recordkeeping is standard practice abroad, this vital task is not the norm in our area. Thus, the aim of this integrative literature review was to investigate the development of the electronic nursing record system (ENRS) in hospital settings across different countries and its effects on the care process and care outcomes. The results of this review showed that ENRS has been used widely in other developed countries and has benefited nurses and other healthcare providers. Hence, the findings of this review can be used by hospital policymakers in other developing countries, where the ENRS have not been implemented yet, as the evidence to consider the use of the ENRS.
... Bryar 1987[71]Tanner 2000[29]Walters 1989[70]Hiraki 1997[73]Cuesta 1983[74]Henderson 1982[75]Hoeman 1996[76]Claflin 1992[77]Latimer 1995[78]Henderson 1987[79]Lauri 1982[80]Moraes 2010[15]Chenitz 1984[81]Woolley 1990[82]Carlson 1972[83]Castledine 2011[84]Moss 1988[85]Lambert 1987[86]Magnan 2009[87]Mason 1988[24]Pesut 2006[28]Goodwin 1975[88]Brennan 1972[89]Galante 1987Carthy 1981Dolan 1991[90]Shannon 1989[91]Macri 1986[92]Webb 1981[93]McHugh 1987[94]Rauen 1990[95]Persons 1987[96]Yu 2006[97]Bernhart 2012[98]Grennfild 1987[99]Tóthová[100]McGreevy 1980[101]Pompeo 2009[102]Rayfield 2013[103]Hao 2013[104]Akinsanya 1988[48]Lillesand 1983[105]Vogel 1988[106]Oreo 1994[107]Fox‑Ungar 1989[108]Lukes 2010[14]Cunning 1986[109]Kahouei 2008[18]Castledine 1981[110]Ungar 189[108]Mangare 2012[111]Medina 2011[33]Goldmann 1990[112]Rowden 1984[113]Crossetti 2003[25]Vaillancourt 1994[114]Evoy 2004[115]Bailey 1982[116]Vaillancourt 1994[114]Dayem 1990[117]Katherason 1998[118]Steck 1992[119]Steck 1990 Haas 1984[120]Knight 1974[121]Farkas 1990[122]Sperandio 2009[123]Bandell 2012[124]Henrikson 1998[125]Hollers 2004[126]Takahashi 2008[5]Yeh 2009 ...
Nursing process is a scientific approach in the provision of qualified nursing cares. However, in practice, the implementation of this process is faced with numerous challenges. With the knowledge of the challenges associated with the implementation of the nursing process, the nursing processes can be developed appropriately. Due to the lack of comprehensive information on this subject, the current study was carried out to assess the key challenges associated with the implementation of the nursing process.
To achieve and review related studies on this field, databases of Iran medix, SID, Magiran, PUBMED, Google scholar, and Proquest were assessed using the main keywords of nursing process and nursing process systematic review. The articles were retrieved in three steps including searching by keywords, review of the proceedings based on inclusion criteria, and final retrieval and assessment of available full texts.
Systematic assessment of the articles showed different challenges in implementation of the nursing process. Intangible understanding of the concept of nursing process, different views of the process, lack of knowledge and awareness among nurses related to the execution of process, supports of managing systems, and problems related to recording the nursing process were the main challenges that were extracted from review of literature.
On systematically reviewing the literature, intangible understanding of the concept of nursing process has been identified as the main challenge in nursing process. To achieve the best strategy to minimize the challenge, in addition to preparing facilitators for implementation of nursing process, intangible understanding of the concept of nursing process, different views of the process, and forming teams of experts in nursing education are recommended for internalizing the nursing process among nurses.
... Since the digitization of nursing records began in the late 1980s, a vast amount of data has been accumulated in electronic nursing records (ENR) systems, and there has been a heightened interest in collecting, sharing, and reusing patient information generated during nursing care [1][2][3]. To effectively share and reuse data of ENR systems, ensuring semantic interoperability [4] is a key factor. ...
The purpose of this paper is to describe the components of a next-generation electronic nursing records system ensuring full semantic interoperability and integrating evidence into the nursing records system.
A next-generation electronic nursing records system based on detailed clinical models and clinical practice guidelines was developed at Seoul National University Bundang Hospital in 2013. This system has two components, a terminology server and a nursing documentation system.
The terminology server manages nursing narratives generated from entity-attribute-value triplets of detailed clinical models using a natural language generation system. The nursing documentation system provides nurses with a set of nursing narratives arranged around the recommendations extracted from clinical practice guidelines.
An electronic nursing records system based on detailed clinical models and clinical practice guidelines was successfully implemented in a hospital in Korea. The next-generation electronic nursing records system can support nursing practice and nursing documentation, which in turn will improve data quality.
... Several authors have addressed the use of nursing diagnoses to represent patients' problems in charting the care planning in patient records, to reflect the nurses' judgements on patient' status (Bernhart-Just et al., 2010;Mü ller-Staub et al., 2006). Most of the nursing literature covering this issue focuses on the concept of nursing diagnosis as described by the North American Nursing Diagnosis Association (NANDA): A nursing diagnosis is a clinical judgement about individual, family or community responses to actual or potential health problems/life processes. ...
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.
... Nursing taxonomies and classifications are being used around the world as interface terminologies for healthcare computer-based systems [39][40][41]. Probably, the nursing community should rethink whether classifications and taxonomies are constructed to reach this or other goals, since "not all terminologies serve all purposes equally well" [5]. The degree of specificity of the concepts in an interface terminology may be more appropriate for direct patient care than that found in the classification systems. ...
A range of different language systems for nursing diagnosis, interventions and outcomes are currently available. Nursing terminologies are intended to support nursing practice but they have to be evaluated. This study aims to assess the results of an expert survey to establish the face validity of a nursing interface terminology. The study applied a descriptive design with a cross-sectional survey strategy using a written questionnaire administered to expert nurses working in hospitals. Sample size was estimated at 35 participants. The questionnaire included topics related to validity and reliability criteria for nursing controlled vocabularies described in the literature. Mean global score and criteria scoring at least 7 were considered main outcome measures. The analysis included descriptive statistics with a confidence level of 95%. The mean global score was 8.1. The mean score for the validity criteria was 8.4 and 7.8 for reliability and applicability criteria. Two of the criteria for reliability and applicability evaluation did not achieve minimum scores. According to the experts’ responses, this terminology meets face validity, but that improvements are required in some criteria and further research is needed to completely demonstrate its metric properties
... A associação entre os sistemas NANDA-I, NIC e NOC e o Nursing Diagnoses of the Center of Nursing Research and Development foi proposta e implementada em 14 hospitais na Suíça, com participação de enfermeiros pesquisadores, clínicos e especialistas em computação. As fases para implementação foram: integração dos passos do processo de cuidado de enfermagem no contexto clínico; ligação de cada fase do processo de cuidado em enfermagem; disponibilização como registro eletrônico para aplicação na prática clínica; teste e revisão do modelo aplicando diagnósticos da NANDA-I; adaptação do modelo conforme as avaliações dos enfermeiros e opiniões da equipe (19) . ...
This study sought for scientific evidences on the use of nursing classification systems in care through an integrative literature review. The following databases were used LILACS and PubMed. The keywords used were classification, nursing, standardized language, system. Thirty-eight articles were selected. Five major classification systems, implemented in the services, were found: nursing diagnosis (North American Nursing Diagnosis Association International), nursing interventions (Nursing Interventions Classification), nursing outcomes (Nursing Outcomes Classification), the International Classificationfor Nursing Practice and the International Classificationfor NursingPractice in Colletive Health. The articles covered aspects related to implementation, assessment continuing education and validation of terms related to classification systems. The use of nursing classification systems provides benefits for care, improving it, the quality of information and service organization.
Technological approaches are used to eliminate problems that prevent the nursing process to be used more effectively in healthcare areas. Preparing the nursing process on electronic media is among these technological approaches. This study aimed to provide a systematic review on studies that reveal the effect of the electronic nursing process on nursing care planning and contribute to the relevant literature. Studies conducted between 2005 and 2020 were reviewed using the following keywords and their combinations; “web-based nursing process,” “nursing process,” “electronic nursing process,” “nursing documentation system,” and “mobile application for nursing process.” The PubMed, Cochrane, Scopus and Ovid databases were used for the literature review. In four of eight studies included in this review, nursing students were asked to prepare the care plan in line with the electronic nursing process while nurses were asked to do the same thing in the remaining four studies. The results show that the electronic nursing process program may increase the students’ and nurses’ ability and competence to prepare the care plan and reduce their stress and anxiety levels in clinic work practices. It is seen that nurses mostly have positive feedbacks about the electronic nursing process program. The electronic nursing process program is effective both in improving the participants’ knowledge and skill performances and increasing their competence in planning nursing care. Additionally, the participants are highly satisfied with the system. An electronic nursing process program has positive contributions to the quality of nursing care. It was seen that students who used electronically supported practice had better NP preparation skills in comparison to those who used conventional practices.
Information plays a vital role in the nursing process. The information aggregated by registered nurses in a wide range of records across the breadth of practice underpins and can bring about services that will support global populations into the next decade and beyond. Nurse leaders need to be able to translate, synthesise, interpret and manage that information into measurable outcomes. The impact of knowledgeable and enthusiastic Executive Nurses who provide and develop informatics leadership is essential to build both the art and science of nursing into the next decade. In terms of how nursing data is captured and structured to effectively do that, no one type of clinical data will accommodate the spectrum of nursing and midwifery practice for every scenario but in determining the most appropriate type of data or combination of data types, the advantages and disadvantages of each should be considered, as well as the workflows and downstream effects of capturing data. Much work has been completed in the last 20 years to advance thinking around the use of nursing Standardised Terminologies. The findings from the identified studies cited demonstrate benefits of using Standardised Terminologies although it is difficult to determine whether STs impact directly on patient outcomes or the time efficiency of end-users. The careful implementation, education and support of nurses and midwives to utilise STs as well as a well-designed, user-friendly EHCR system contributes to its use and the benefits derived.
Objective:
The study sought to present the findings of a systematic review of studies involving secondary analyses of data coded with standardized nursing terminologies (SNTs) retrieved from electronic health records (EHRs).
Materials and methods:
We identified studies that performed secondary analysis of SNT-coded nursing EHR data from PubMed, CINAHL, and Google Scholar. We screened 2570 unique records and identified 44 articles of interest. We extracted research questions, nursing terminologies, sample characteristics, variables, and statistical techniques used from these articles. An adapted STROBE (Strengthening The Reporting of OBservational Studies in Epidemiology) Statement checklist for observational studies was used for reproducibility assessment.
Results:
Forty-four articles were identified. Their study foci were grouped into 3 categories: (1) potential uses of SNT-coded nursing data or challenges associated with this type of data (feasibility of standardizing nursing data), (2) analysis of SNT-coded nursing data to describe the characteristics of nursing care (characterization of nursing care), and (3) analysis of SNT-coded nursing data to understand the impact or effectiveness of nursing care (impact of nursing care). The analytical techniques varied including bivariate analysis, data mining, and predictive modeling.
Discussion:
SNT-coded nursing data extracted from EHRs is useful in characterizing nursing practice and offers the potential for demonstrating its impact on patient outcomes.
Conclusions:
Our study provides evidence of the value of SNT-coded nursing data in EHRs. Future studies are needed to identify additional useful methods of analyzing SNT-coded nursing data and to combine nursing data with other data elements in EHRs to fully characterize the patient's health care experience.
This research study established the data elements for the health system domain in the Perioperative Nursing Data Set. A sample of AORN members were asked to confirm the clarity, necessity, measurability, and accuracy of each proposed data element. As a result of this study, the health system domain contains 114 data elements with definitions. When integrated into an electronic health record, data elements can be used to identify, compare, and evaluate the context in which patient care is delivered across settings.
This study investigates risk of mortality associated with nurses' assessments of patients by physiological system. We hypothesise that nursing assessments of in-patients performed at entry correlate with in-hospital mortality, and those performed just before discharge correlate with postdischarge mortality.
Cohort study of in-hospital and postdischarge mortality of patients over two 1-year periods.
An 805-bed community hospital in Sarasota, Florida, USA.
42 302 inpatients admitted for any reason, excluding obstetrics, paediatric and psychiatric patients.
All-cause mortalities and mortality OR.
Patients whose entry nursing assessments, other than pain, did not meet minimum standards had significantly higher in-hospital mortality than patients meeting minimums; and final nursing assessments before discharge had large OR for postdischarge mortality. In-hospital mortality OR were found to be: food, 7.0; neurological, 9.4; musculoskeletal, 6.9; safety, 5.6; psychosocial, 6.7; respiratory, 8.1; skin, 5.2; genitourinary, 3.0; gastrointestinal, 2.3; peripheral-vascular, 3.9; cardiac, 2.8; and pain, 1.1. CI at 95% are within ±20% of these values, with p<0.001 (except for pain). Similar results applied to postdischarge mortality. All results were comparable across the two 1-year periods, with 0.85 intraclass correlation coefficient.
Nursing assessments are strongly correlated with in-hospital and postdischarge mortality. No multivariate analysis has yet been performed, and will be the subject of a future study, thus there may be confounding factors. Nonetheless, we conclude that these assessments are clinically meaningful and valid. Nursing assessment data, which are currently unused, may allow physicians to improve patient care. The mortality OR and the dynamic nature of nursing assessments suggest that nursing assessments are sensitive indicators of a patient's condition. While these conclusions must remain qualified, pending future multivariate analyses, nursing assessment data ought to be incorporated in risk-related health research, and changes in record-keeping software are needed to make this information more accessible.
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.
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.
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 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 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.
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.
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. © 1999 John Wiley & Sons, Inc. Res Nurs Health 22:388–398, 1999
Purpose: To provide a synopsis of issues about clinical information systems for nurses not schooled in nursing informatics.
Organizing construct: 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.
Methods: Literature review and analysis.
Findings and Conclusions: 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.
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 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.
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.
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.
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.
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.
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.
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.
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.
An expert system of diagnosis-based cardiac nursing care plans.
- Tsirintani
Helping nurses use NANDA, NOC, and NIC: novice to expert. reprint in J Nurs Adm. 2006;36(3):118-125; PMID: 16601513.
- Lunney