Preliminary Evidence for the Usefulness of Standardized Nursing Terminologies in Different Fields of Application: A Literature Review

Implementing Oncologic Nursing Care Plans in Electronic Health Records With Two Taxonomies: A Pilot Study

BACKGROUND

Nursing care plans document the nursing process, displaying actions, and illustrating expected outcomes. Their integration into electronic health records (EHRs) is critical for accurate documentation, enhanced by standardized nursing terminologies that promote communication, critical reasoning, and patient safety through consistent language for information.

OBJECTIVE

This study aimed to identify appropriate standardized nursing terminology tailored to the context of a Northern Italian Cancer Center and research facility for developing nursing care plans and starting their integration into institutional EHRs.

METHODS

Participatory action research was conducted to select proper terminology respecting the oncological setting, develop nursing care plans, and start their implementation in EHRs. The nursing team of a pilot ward collaborated closely with the researchers as coresearchers. Care plan samples were presented using the North American Nursing Diagnosis Association-International Nursing Intervention Classification, Nursing Outcomes Classification, and International Classification for Nursing Practice (ICNP) in the test section of the EHRs to gather nurses' preferences. Quantitative data collection, focus groups, and survey analyses were conducted.

RESULTS

Nurses chose the ICNP for its flexibility but sought better methods to define patient severity in assessments and outcomes. They suggested incorporating the Common Terminology Criteria for Adverse Events to enable context-sensitive care plans.

CONCLUSIONS

End-user involvement is essential for developing EHRs, enhancing system usability, and reducing implementation resistance. Including nurses in management decisions empowers them, and improves care quality.

An Evaluation of the NANDA International, Inc., Diagnostic Classification Among Spanish Nurses: A Cross-Sectional Study

Background/Objectives: The NANDA International, Inc., (NANDA-I) diagnostic classification is the most widely used standardized nursing language internationally. The EVALUAN-I tool was developed to evaluate the NANDA-I diagnostic classification. The aim was to analyze the use of the NANDA-I diagnostic classification among Spanish nurses and assess its correlation with sociodemographic characteristics. Methods: A cross-sectional study was conducted on a non-probabilistic sample of Spanish nurses working in clinical, management, and academic settings using the EVALUAN-I tool (September 2019-December 2020). The analysis was conducted using R® (version 3.6.3, Lavaan package; R Core Team, 2020), with statistical significance set at p < 0.05. This study was approved by the Research Ethics Committee (2019-190-1). Results: A total of 483 responses were obtained. There was a correlation between the intensity of use of NANDA-I and its application in practice (polychoric correlation = 0.50; p < 0.001). Nurses with a PhD degree considered nursing diagnoses to be less evidence-based (p = 0.037) but more useful (p = 0.035). Academic and research nurses stated that NANDA-I was more useful (p = 0.007), even for exclusive responsibilities (p = 0.034), and that it provided greater significance to diagnoses (p = 0.0012). Conclusions: NANDA-I is the most widely used standardized nursing language in Spain. Nurses' academic qualifications and work environment significantly influence their perceptions and use of NANDA-I. Advanced education fosters a critical yet positive perspective, highlighting a relationship between the intensity of its use, its application in clinical practice, and the nurse's educational background. Tools such as EVALUAN-I promote its integration and evidence-based practice, but challenges remain in improving perceptions, scientific evidence, and visibility in electronic health records to enhance its clinical impact and nursing recognition.

Nursing diagnoses for people hospitalized with heart failure: an integrative review

OBJECTIVES

to identify in the literature the main nursing diagnoses according to the NANDA-I diagnostic classification for people hospitalized with heart failure.

METHODS

an integrative literature review, carried out in February 2019 and updated in July 2023, in the MEDLINE via PubMed, LILACS, SciELO and CINAHL databases. Given the use of acronym PEO, studies without a time cut in Portuguese, English and Spanish were included. Descriptive analysis was carried out to present the identified information.

RESULTS

analysis of 27 articles identified 24 nursing diagnoses, with emphasis on Decreased Cardiac Output, Excessive Fluid Volume, Decreased Activity Tolerance and Fatigue.

FINAL CONSIDERATIONS

evidence can contribute to better diagnostic decisions centered on people with heart failure in search of more assertive health results and have the potential to support future studies on a possible syndromic pattern in this population.

The Nurse-Patient Relationship in Nursing Documentation: The Scope and Quality of Interactions and Prevalent Interventions in Inpatient Mental Health Units

Aims

(i) To evaluate the scope and quality of nurse-patient interactions recorded in the clinical notes of inpatient mental health units and (ii) to identify nursing interventions recorded in the context of the nurse-patient relationship in the clinical notes of inpatient mental health units.

Design

A multimethod approach was use.

Methods

Employing a quantitative cross-sectional design for the first aim, and a qualitative content analysis design of secondary data for the second aim. In total, 1,714 clinical notes were examined from 44 randomly selected patients who were hospitalized in five mental health units over the years 2022-2023.

Results

The patient's experience of the interaction was present in 69.9% (n = 1,198) of the notes. However, only 12.0% (n = 205) of the notes reached a sufficient standard of quality in terms of describing the nurse-patient interactions. Specifically, more than half of the notes did not reflect any type of nursing intervention (n = 723; 60.4%). Thirty interventions compatible with the nursing intervention classification were identified, of which more than 70% corresponded to domains in the physiological area.

Conclusion

This study shows that the quantity and scope of patients' clinical notes in mental health units do not sufficiently reflect the interventions performed by nurses, nor the quality or impact of these interventions in the context of the nurse-patient therapeutic relationship. Implications for the Profession and/or Patient Care. Improving the quality of clinical notes by integrating interventions and their impact can increase the quality of nursing care. Impact. The use of standardized nursing terminologies would contribute to the understanding of the extent and quality of nurse-patient interactions recorded in clinical notes. Thus, standardized documentation would also help to improve these interactions and their recording, which will facilitate decision-making. Reporting Method. Findings were reported using COREQ and STROBE guidelines. Patient or Public Contributions. There were no patient or public contributions.

Are We Speaking the Same Language? Terminology Consistency in EBD

OBJECTIVE

The aim of this study is to analyze the consistency, variability, and potential standardization of terminology used to describe architectural variables (AVs) and health outcomes in evidence-based design (EBD) studies.

BACKGROUND

In EBD research, consistent terminology is crucial for studying the effects of AVs on health outcomes. However, there is a possibility that diverse terms have been used by researchers, which could lead to potential confusion and inconsistencies.

METHODS

Three recent large systematic reviews were used as a source of publications, and 105 were extracted. The analysis aimed to extract a list of the terms used to refer to the unique concepts of AVs and health outcomes, with a specific focus on people with dementia. Each term's frequency was calculated, and statistical tests, including the χ2 and the post hoc test, were employed to compare their distributions.

RESULTS

The study identified representative terms for AVs and health outcomes, revealing the variability in terminology usage within EBD field for dementia-friendly design. The comparative analysis of the identified terms highlighted patterns of frequency and distribution, shedding light on potential areas for standardization.

CONCLUSIONS

The findings emphasize the need for standardized terminologies in EBD to improve communication, collaboration, and knowledge synthesis. Standardization of terminology can facilitate research comparability, enhance the generalizability of findings by creating a common language across studies and practitioners, and support the development of EBD guidelines. The study contributes to the ongoing discourse on standardizing terminologies in the field and provides insights into strategies for achieving consensus among researchers, practitioners, and stakeholders in health environmental research.

Creating Subsets of International Classification for Nursing Practice Precoordinated Concepts: Diagnoses/Outcomes and Interventions Categorized Into Areas of Nursing Practice

The International Classification for Nursing Practice is a comprehensive terminology representing the domain of nursing practice. A categorization of the diagnoses/outcomes and interventions may further increase the usefulness of the terminology in clinical practice. The aim of this study was to categorize the precoordinated concepts of the International Classification for Nursing Practice into subsets for nursing diagnoses/outcomes and interventions using the structure of an established documentation model. The aim was also to investigate the distribution of the precoordinated concepts of the International Classification for Nursing Practice across the different areas of nursing practice. The method was a descriptive content analysis using a deductive approach. The VIPS model was used as a theoretical framework for categorization. The results showed that all the precoordinated concepts of the International Classification for Nursing Practice could be categorized according to the keywords in the VIPS model. It also revealed the parts of nursing practice covered by the concepts of the International Classification for Nursing Practice as well as the parts that needed to be added to the International Classification for Nursing Practice. This has not been identified in earlier subsets as they covered only one specific area of nursing.

Removing the roadblocks to promoting health equity: finding the social determinants of health addressed in standardized nursing classifications

Providing 80% of healthcare worldwide, nurses focus on physiologic and psychosocial aspects of health, which incorporate social determinants of health (SDOH). Recognizing their important role in SDOH, nurse informatics scholars included standardized measurable terms that identify and treat issues with SDOH in their classification systems, which have been readily available for over 5 decades. In this Perspective, we assert these currently underutilized nursing classifications would add value to health outcomes and healthcare, and to the goal of decreasing disparities. To illustrate this, we mapped 3 rigorously developed and linked classifications: NANDA International (NANDA-I), Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC) called NNN (NANDA-I, NIC, NOC), to 5 Healthy People 2030 SDOH domains/objectives, revealing the comprehensiveness, usefulness, and value of these classifications. We found that all domains/objectives were addressed and NNN terms often mapped to multiple domains/objectives. Since SDOH, corresponding interventions and measurable outcomes are easily found in standardized nursing classifications (SNCs), more incorporation of SNCs into electronic health records should be occurring, and projects addressing SDOHs should integrate SNCs like NNN into their ongoing work.

Utilizing standardized nursing terminologies in implementing an AI-powered fall-prevention tool to improve patient outcomes: a multihospital study

OBJECTIVES

Standardized nursing terminologies (SNTs) are necessary to ensure consistent knowledge expression and compare the effectiveness of nursing practice across settings. This study investigated whether SNTs can support semantic interoperability and outcoming tracking over time by implementing an AI-powered CDS tool for fall prevention across multiple EMR systems.

MATERIALS AND METHODS

The study involved 3 tertiary academic hospitals and 1 public hospital with different EMR systems and nursing terms, and employed an AI-powered CDS tool that determines the fall risk within the next hour (prediction model) and recommends tailored care plans (CDS functions; represented by SNTs). The prediction model was mapped to local data elements and optimized using local data sets. The local nursing statements in CDS functions were mapped using an ICNP-based inpatient fall-prevention catalog. Four implementation models were compared, and patient outcomes and nursing activities were observed longitudinally at one site.

RESULTS

The postimplementation approach was practical for disseminating the AI-powered CDS tool for nursing. The 4 hospitals successfully implemented prediction models with little performance variation; the AUROCs were 0.8051-0.9581. The nursing process data contributed markedly to fall-risk predictions. The local nursing statements on preventing falls covered 48.0%-86.7% of statements. There was no significant longitudinal decrease in the fall rate (P = .160, 95% CI = -1.21 to 0.21 per 1000 hospital days), but rates of interventions provided by nurses were notably increased.

CONCLUSION

SNTs contributed to achieving semantic interoperability among multiple EMR systems to disseminate AI-powered CDS tools and automatically track nursing and patient outcomes.

Implementing a Care Plan System in a Community Hospital Electronic Health Record

Nursing care plans, the result of the nursing process, are important because they guide quality patient care, define the nurse's role in patient treatment, and support patient specific nursing interventions. Nurse leaders at a community hospital identified that 70% of hospitalized patients shared the same three nursing problems and three-day resolution target dates. This quality improvement project involved the implementation of a nursing care plan system within the organization's existing electronic health record platform that supported the development of individualized plans. The implementation included a) integration of care plan activities into the nursing workflow, b) adoption of a standardized nursing language to provide structure nursing care plan data capture and reporting, c) configuration of the electronic health record to recommend patient data-driven care plan problems based on nursing assessment documentation; and d) trended care plan data to identify problem patterns within the patient population. A postimplementation audit indicated a 130% improvement in achieving individualized care plans within 24 hours of admission.

Use of the clinical care classification in South Korean nursing practice: Challenges and opportunities

BACKGROUND AND OBJECTIVES

A government-driven standardization of nursing terminology including the Clinical Care Classification (CCC) was endorsed in South Korea in 2015, but the number of hospitals who have adopted this standard terminology remains unknown. This study aimed to determine the CCC awareness, adoption, and utilization statuses and its association with patient experience in South Korea.

DESIGN, SETTING, AND PARTICIPANTS

A nationwide telephone survey was conducted from January 13 to February 12, 2022 among 217 tertiary and secondary hospitals participating in the health information exchange network. The survey questionnaire included 22 items in 3 categories: current status of electronic nursing records, awareness and adoption of standard terminology, and open-ended questions regarding standard usage and dissemination. General characteristics and experience scores of the patients of the surveyed hospitals were collected from the publicly available data sources. Data analysis was performed using descriptive statistics, t-test, and generalized linear regression.

MAIN OUTCOMES AND MEASURES

The rates of awareness and adoption in hospitals to the nursing terminology standard of the CCC were calculated, and the current status of electronic nursing records used in practice was examined. The relationships between CCC awareness and the characteristics of hospitals in their patient experiences of health services were also identified.

RESULTS

The survey response rate was 24.9 % (54/217). Two out of three hospitals (68.5 %) were aware of the CCC. These hospitals had 800 beds or more, and higher scores for patient experience. CCC awareness was significantly related to increases in the overall scores for patient experiences (t = 2.70, p =.0103), but no significance with sub-score for nursing service (t = 1.23, p =.1594).

CONCLUSIONS

With a high adoption rate of electronic medical record systems, two-third hospitals acknowledged their CCC awareness, but were still lagged in adoption and usage of it in practice with operational challenges. The CCC awareness has potential relationships with positive patient experience.

Effectiveness of educational video on standardized nursing language for nursing home nurses

OBJECTIVES

Developing nursing plans using standardized taxonomy offers for a better understanding of how nursing abilities affect the achievement of better levels of outcomes for NH residents. This study aimed to investigate the effectiveness of an educational video on standardized nursing languages (SNLs) developed for nursing home nurses.

METHODS

We used a single group pre-post study design. We collected presurvey data from April 25 to June 22, 2022 and postsurvey data from May 23 to July 18, 2022. Sixteen nursing homes (NHs) participated in this study. We collected data on nurses' knowledge, perceptions, and attitudes towards SNLs and the evidence-based nursing practice self-efficacy. Analysis was conducted utilizing the McNemar test.

RESULTS

The educational video about standardized nursing languages were provided to 31 registered nurses (RNs) from 16 NHs in Korea. Knowledge about the definition of SNLs and the benefits of their utilization improved after watching educational video.

CONCLUSIONS

Study findings support the effectiveness of educational videos on SNLs in increasing knowledge of SNLs, as well as confidence in the profession. To support NH nurses' professional development, ongoing SNL-focused education and research on innovative training methods like videos are recommended.

IMPLICATION FOR AN INTERNATIONAL AUDIENCE

Developing nursing plans using a common, standardized taxonomy offers a good chance to more clearly observe how nursing abilities affect the achievement of better levels of health and wellbeing. Education using audiovisual materials may help NH RNs learn how to utilize SNLs and may further enhance the development of SNL through periodic, long-term education and SNL-based nursing practice.

Identifying Frequently Used NANDA-I Nursing Diagnoses, NOC Outcomes, NIC Interventions, and NNN Linkages for Nursing Home Residents in Korea

This study aimed to identify the terminologies of NANDA-I, NOC, NIC, and NNN linkages that have been used for nursing home (NH) residents. This study used a retrospective descriptive design. Data accrued from 57 registered nurses (RNs) in 25 Korean NHs. The RNs randomly selected one resident and assessed for applied NANDA-I, NOC, and NIC from the previous 7 days by reviewing nursing charts and records. Finally, the data of 57 residents in 25 NHs were collected. Results: We identified seven NNN linkages: risk for falls-fall prevention behavior-fall prevention; self-care deficit: bathing/hygiene-self-care: activities of daily living (ADL)-self-care assistance: bathing/hygiene; impaired memory-memory-cognitive stimulation; chronic confusion-neurological status: consciousness-medication management; chronic confusion-memory-medication management; impaired walking-mobility-exercise promotion: strength training; and impaired walking-ambulation-exercise promotion: strength training. The identified core NANDA-I, NOC, NIC, and NNN linkages for NH residents from this study provide a scope of practice of RNs working in NHs.

Evaluation of wound healing in patients with hip prosthesis according to nursing outcome classification

PURPOSE

The purpose of this study is to perform Turkish adaptation and validation of NOC (1102) Wound Healing: Primary Intent and examine wound healing in patients with hip prosthesis diagnosed with impaired tissue integrity.

METHOD

The study was carried out in methodological and descriptive design, and the sample of the study consisted of 55 patients. Introductory Characteristics Form and Wound Healing: Primary Intention NOC Form were used for data collection. Ethical consent was obtained before initiating the study.

FINDINGS

In the study, content validity index value of the NOC scale was calculated was 95.71%. Looking at NOC scale indicators for postoperative day 1, 2, and 7 and the distribution of the total mean scores, it was determined that there was a statistically significant difference between the mean scores over time (p = 0.000). It was found that patients with chronic disease had lower NOC scale scores and wound healing was slower on the postoperative first day compared to the patients with no chronic diseases (p < 0.05).

CONCLUSIONS

As a result of the study, it was concluded that the Turkish version of the Wound Healing: Primary Intention NOC (1102) scale was a valid tool for evaluating the location of the wound in patients with hip prosthesis, the presence of chronic diseases affected wound healing, and mean scores obtained by the patients in NOC scale increased over time with a good progress in terms of wound healing.

IMPLICATIONS OF NURSING PRACTICE

With the use of Wound Healing: Primary Intention NOC (1102) scale, a common language will be formed in the evaluation of the wound site of patients undergoing hip prosthesis.

Effectiveness of Standardized Nursing Terminologies for Nursing Practice and Healthcare Outcomes: A Systematic Review

PURPOSE

This review evaluates the effectiveness of using standardized terminologies in nursing.

METHODS

A systematic literature review was performed via PubMed, Web of Science, CINAHL, and OVID databases for articles published between January 1973 and September 2020. The Effective Public Health Practice Project's Quality Assessment Tool for Quantitative Studies was used to assess the quality of all included studies.

RESULTS

Fourteen studies were selected for data extraction and analysis, which included a total of 24,243 patients and 99 nurses. Of the studies that met the inclusion criteria, the quality of five were of high quality, one was of moderate quality, and eight was of weak quality. All articles were summarized according to two themes: the identification of common outcomes or interventions, and the validation or evaluation of the effectiveness of standard nursing terminology sets.

CONCLUSION

Standardized terminologies in nursing help nurses to implement care plans according to nursing procedures, supervise changes in patients' sensitive indicators, improve patients' health outcomes, and contribute to evidence-based nursing practices and global data resource sharing.

IMPLICATIONS FOR NURSING PRACTICE

Standardized nursing terminologies have positive effects on clinical practice, are essential for enriching nurses' knowledge, and alter nurses' attitudes regarding education and guidance, which promotes the clinical application of these terminologies.

Facilitating the Implementation of Standardized Care Plans in Municipal Healthcare

Standardized care plans have the potential to enhance the quality of nursing records in terms of content and completeness, thereby better supporting workflow, easing the documentation process, facilitating continuity of care, and permitting systematic data gathering to build evidence from practice. Despite these potential benefits, there may be challenges associated with the successful adoption and use of standardized care plans in municipal healthcare information practices. Using a participatory approach, two workshops were conducted with nurses and nursing leaders (n = 11) in two Norwegian municipalities, with the objective of identifying success criteria for the adoption and integration of standardized care plans into practice. Three themes were found to describe the identified success criteria: (1) "facilitating system level support for nurses' workflow"; (2) "engaged individuals creating a culture for using standardized care plans"; and (3) "developing system level safety nets." The findings suggest success criteria that could be useful to address to facilitate the integration of standardized care plans in municipal healthcare information practice and provide useful knowledge for those working with implementation and further development of standardized care plans.

Patient Safety Through Nursing Documentation: Barriers Identified by Healthcare Professionals and Students

Background: Although access to accurate patient documentation is recognized as a prerequisite for delivering of safe and continuous municipal elderly care, healthcare professionals often fail to provide comprehensive clinical information in an accurate and timely manner. The aim of this study was to understand the perceptions of healthcare professionals and healthcare students regarding existing barriers to patient safety through the performance of documentation practices.

Methods: Using a qualitative, exploratory design, this study conducted six focus group interviews with nurses and social educators (n = 12) involved in primary care practice and nursing and social educator bachelor’s degree students from a University College (n = 11). Data were analyzed using qualitative content analysis.

Results: Four themes emerged from the analysis, which described barriers to patient safety and quality in documentation practices: “Individual factors,” “Social factors,” “Organizational factors,” and “Technological factors.” Each theme also included several sub-themes.

Conclusion: According to the findings, several barriers negatively influenced documentation practices and information exchange, which may place primary care patients in a vulnerable and exposed situation. To achieve successful documentation, increased awareness and efforts by the individual professional are necessary. However, primary care services must facilitate the achievement of these goals by providing adequate resources, clear mission statements, and understandable policies.

Electronic nursing care plans through the use of NANDA, NOC, and NIC taxonomies in community setting: A descriptive study in northern Italy

Purpose

To carry on a descriptive analysis of nursing standardized language through the use of a software within outpatient facilities in northern Italy, organized according to the Chronic Care Model (CCM) and called Community Health Centers (CHC).

Methods

A descriptive design was adopted for the study. NANDA‐I, NOC, and NIC taxonomies have been used to analyze care plans pulled from the software. Both qualitative and quantitative data were analyzed.

Findings

The average of nursing diagnosis correctly identified with respect to the nursing assessment is 83.7% (SD 29.9%). Class 4 diagnoses from Domains 4 have been identified as the most prevalent (22.4%), followed by risk for unstable blood glucose level 00179 (16.4%) and risk for overweight 00234 (13%). The main nursing outcomes were vital signs 0802 (22.5%), blood glucose level 2300 (16%), and weight loss behavior 1627 (11%). The most prevalent nursing interventions are wound care 3660 (27%), medication administration: intramuscular 2313 (19%), and health education 5510 (14%). The analysis shows ability in identifying nursing diagnoses, but a larger variability with outcomes and interventions. The study highlights the nursing role within CHC and identifies the main areas of expertise in chronic disease management: prevention and health education.

Conclusions

Nurses’ role is fundamental for chronic disease management within CHC; NANDA‐I taxonomy helps to analyze care plans.

Implications for nursing practice

‐ A taxonomy such as NANDA‐I represents a valid opportunity to make more visible how much nursing skills affect the achievement of a higher level of health in chronic patients.

‐ This study is useful in the further training of outpatient nurses who works in CHC.

‐ The study represents the starting point for future research to deepen the development of a standardized nursing language in outpatient facilities.

Use of standardized terminologies in clinical practice: A scoping review

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 = 3547) 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 25 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 the healthcare 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.

Secondary use of standardized nursing care data for advancing nursing science and practice: a systematic review

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.

The Core Nursing Interventions in Adult Psychiatric Outpatient Care Identified by Nurses, a Delphi Study

PURPOSE

To define the core nursing interventions identified by nurses in the adult psychiatric outpatient care setting.

METHODS

A two-round Delphi study. The panel consisted of nurses and nurse managers.

FINDINGS

Nurses identified 53 core interventions, 50 of which are described in the Nursing Interventions Classification (NIC). Altogether, two thirds of these interventions were in the NIC domain 'Behavioral' and the emphasis was on NIC classes 'Coping Assistance' and 'Behavior Therapy,' suggesting that nurses define providing psychosocial support as the core in their work.

CONCLUSIONS

The findings indicate that the main role of nurses in the psychiatric outpatient care is to deliver psychosocial care for their patients. The lack of family interventions among the core interventions and the need to add the missing three interventions into the classification need more research in the future.

IMPLICATIONS FOR NURSING PRACTICE

This study helps to define nurses' role in the psychiatric outpatient care. The findings can be used in developing nursing education programs.

International Collaboration and New Research Evidence on Nanda International Terminology

OBJECTIVES

To discuss priorities and possibilities for promoting international collaboration and new research evidence on NANDA International, Inc. (NANDA-I).

METHODS

Theoretical reflection article based on the literature and the authors' opinions on the subject matter, carried out by six research nurses.

CONCLUSIONS

International research collaboration for NANDA-I allows the improvement of research production in an actual clinical setting, especially with multicenter and validation studies, conducted by researchers from different countries. This provides for improved understanding of patients' experiences and may help to produce robust scientific evidence.

IMPLICATIONS FOR NURSING KNOWLEDGE

The generation of new evidence may lead to an increase in NANDA-I visibility and in nurses' understanding of its meaning for clinical practice and for the formulation of diagnostic hypotheses.

Use of electronic health records and standardized terminologies: A nationwide survey of nursing staff experiences

BACKGROUND

Nursing documentation could improve the quality of nursing care by being an important source of information about patients' needs and nursing interventions. Standardized terminologies (e.g. NANDA International and the Omaha System) are expected to enhance the accuracy of nursing documentation. However, it remains unclear whether nursing staff actually feel supported in providing nursing care by the use of electronic health records that include standardized terminologies.

OBJECTIVES

a. To explore which standardized terminologies are being used by nursing staff in electronic health records. b. To explore to what extent they feel supported by the use of electronic health records. c. To examine whether the extent to which nursing staff feel supported is associated with the standardized terminologies that they use in electronic health records.

DESIGN

Cross-sectional survey design.

SETTING AND PARTICIPANTS

A representative sample of 667 Dutch registered nurses and certified nursing assistants working with electronic health records. The respondents were working in hospitals, mental health care, home care or nursing homes.

METHODS

A web-based questionnaire was used. Descriptive statistics were performed to explore which standardized terminologies were used by nursing staff, and to explore the extent to which nursing staff felt supported by the use of electronic health records. Multiple linear regression analyses examined the association between the extent of the perceived support provided by electronic health records and the use of specific standardized terminologies.

RESULTS

Only half of the respondents used standardized terminologies in their electronic health records. In general, nursing staff felt most supported by the use of electronic health records in their nursing activities during the provision of care. Nursing staff were often not positive about whether the nursing information in the electronic health records was complete, relevant and accurate, and whether the electronic health records were user-friendly. No association was found between the extent to which nursing staff felt supported by the electronic health records and the use of specific standardized terminologies.

CONCLUSIONS

More user-friendly designs for electronic health records should be developed. The poor user-friendliness of electronic health records and the variety of ways in which software developers have integrated standardized terminologies might explain why these terminologies had less of an impact on the extent to which nursing staff felt supported by the use of electronic health records.

Nurses' Experiences of Documenting the Mental Health of Older Patients in Long-Term Care

Nursing documentation is repeatedly reported to be insufficient and unsatisfactory. Although nurses should apply a holistic approach, they tend to document physical needs more often than other caring dimensions. This study aimed to describe nurses' experiences documenting mental health in older patients receiving long-term care. Individual interviews were conducted with nine nurses and were analyzed by content analysis. One main theme, two categories and seven sub-categories emerged. The findings showed that the nurses perceived mental health as an ambiguous phenomenon that could be difficult to observe, interpret, and agree upon. Thus, the nurses were uncertain about what concepts and words corresponded to their observations. They also struggled with finding the right words to create accurate and complete documentation without breaking confidentiality or diminishing the dignity of the patient. The findings are relevant for nurses in different types of healthcare services and in the educational context to ensure comprehensive nursing documentation.

Validation and applicability of instrument for documenting the nursing process in intensive care

OBJECTIVE

to validate the content of an instrument for documenting the steps of the Nursing Process, using the standardized languages NANDA-I, NOC, and NIC (NNN), aiming at hospitalized patients in an Intensive Care Unit (ICU).

METHOD

A methodological research performed in three steps: design of the existing instrument from the systems NANDA-I, NOC and NIC; content validation by 13 judges, from a four-point Likert-type scale - items were evaluated as to their clarity and pertinence; applicability: judgement of the content regarding clarity, reading ease, and presentation for 40 critical-care nurses. The Content Validity Index (CVI) and the Kappa coefficient (k) was calculated to measure the proportion of relevance and clarity, was well as to verify the level of agreement between the experts in each item.

RESULTS

The instrument was considered clear and pertinent, with CVI above 0.8 in most items and overall Concordance Index (CI) of 0.90, showing a satisfactory level of agreement between judges. Regarding applicability, the instrument was deliberated clear, of easy reading, and with proper presentation by most critical-care nurses, being validated through 11 diagnoses with their respective results and nursing interventions.

CONCLUSION

The instrument showed to be valid and applicable for the group studied. It is expected that this study is able to contribute to the improvement of the Nursing Process in intensive care.

Assessing the relation of the coded nursing care and nursing intensity data: Towards the exploitation of clinical data for administrative use and the design of nursing workload

Patient-care data from the electronic health record systems are increasingly in demand for re-use in administration and resource planning. Nursing documentation with coded concepts is expected to produce more reliable data, fulfilling better requirements for re-use. The aim was to ascertain what kind of relation exist between coded nursing diagnoses, nursing interventions, and nursing intensity and to discuss the possibilities for re-using nursing data for workload design. We analysed the retrospective nursing records of 794 patients documented by the Finnish Care Classification and nursing intensity data assessed by the Oulu Patient Classification over a 15-day period in nine inpatient units at a university hospital. Using the generalised linear mixed model, the clear relationship between the number of coded nursing notes and nursing intensity levels were ascertained. The number of coded nursing notes increases when the nursing intensity increases. The outcomes construct a good basis for continuing elaboration of electronic health record data re-use.