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.

Quality of nursing documentation and approaches to its evaluation: a mixed-method systematic review

AIMS

This paper reports a review that identified and synthesized nursing documentation audit studies, with a focus on exploring audit approaches, identifying audit instruments and describing the quality status of nursing documentation.

INTRODUCTION

Quality nursing documentation promotes effective communication between caregivers, which facilitates continuity and individuality of care. The quality of nursing documentation has been measured by using various audit instruments, which reflected variations in the perception of documentation quality among researchers across countries and settings.

DATA SOURCES

Searches were made of seven electronic databases. The keywords 'nursing documentation', 'audit', 'evaluation', 'quality', both singly and in combination, were used to identify articles published in English between 2000 and 2010.

REVIEW METHODS

A mixed-method systematic review of quantitative and qualitative studies concerning nursing documentation audit and reports of audit instrument development was undertaken. Relevant data were extracted and a narrative synthesis was conducted.

RESULTS

Seventy-seven publications were included. Audit approaches focused on three natural dimensions of nursing documentation: structure or format, process and content. Numerous audit instruments were identified and their psychometric properties were described. Flaws of nursing documentation were identified and the effects of study interventions on its quality.

CONCLUSION

Research should pay more attention to the accuracy of nursing documentation, factors leading to variation in practice and flaws in documentation quality and the effects of these on nursing practice and patient outcomes, and the evaluation of quality measurement.

Sistemas de classificação de enfermagem e sua aplicação na assistência: revisão integrativa de literatura

O objetivo deste estudo foi buscar evidências sobre o uso de sistemas de classificação de enfermagem na assistência, por meio de revisão integrativa da literatura. Com a busca nas bases LILACS e PubMed, com as palavras-chave classificação, enfermagem, padronizado, sistema, linguagem, selecionaram-se 38 artigos. Encontraram-se cinco sistemas de classificação principais implementados nos serviços: de diagnósticos de enfermagem (da North American Nursing Diagnosis Association International), intervenções de enfermagem (Nursing Interventions Classification), resultados de enfermagem (Nursing Outcomes Classification), a Classificação Internacional para a Prática de Enfermagem e a Classificação Internacional das Práticas de Enfermagem em Saúde Coletiva. Os artigos abordaram aspectos relacionados à implementação, avaliação, educação continuada e validação de termos relacionados aos sistemas de classificação. Há benefícios para a assistência com a implementação desses sistemas, com melhora da assistência, da qualidade das informações e da organização do serviço.

Identification and comparison of interventions performed by Korean school nurses and U.S. school nurses using the Nursing Interventions Classification (NIC)

The purpose of the study was to identify Nursing Interventions Classification (NIC) interventions performed by Korean school nurses. The Korean data were then compared to U.S. data from other studies in order to identify differences and similarities between Korean and U.S. school nurse practice. Of the 542 available NIC interventions, 180 were selected as the basis of a questionnaire designed to quantify key aspects of school nursing practice. The data were collected from 131 school nurses working in Korea. The results indicated that Korean school nurses focused on classifications from the Physiological Basic domain. Comparisons to previously reported U.S. data reflect that U.S. school nurses focus primarily on the Behavioral domain. The data reflect important differences between the practice characteristics of Korean and U.S. school nurses. Further, the data support the utility of NICs in quantifying the practice characteristics of school nurses in Korea.

[Knowledge production about nursing outcomes]

This literature review aimed at identifying and analysing the knowledge production regarding nursing outcomes in a worldwide context. A systematized review was carried out using LILACS and MEDLINE databases. The following key words were used: outcomes, nursing and classification. No national production was identified. The main issues raised were: the use of the standardized outcomes classifications to measure changes in the patient's health condition; the use of the Nursing Outcomes Classifications (NOC) as the chosen terminology for nursing practice; the need to rank effectivity of nursing interventions by identifying the nursing-sensitive patient outcomes, as well as to make the nursing practice a profitable one to the institutions. It is important to develop and Brazilian studies addressing the issue.

Elementary School Nurse Interventions: Attendance and Health Outcomes

Regular school attendance is a necessary part of the learning process; student absenteeism has a direct association with poor academic performance. School nurses can influence student attendance. This study describes the impact of school nurse interventions on student absenteeism and student health. A retrospective review of 240 randomly selected elementary student health folders and attendance records was conducted. School nurses were involved with 75% of high-absence students as compared to 66% of low-absence students; they were also more involved with students who had previously identified health conditions. There were no referrals to the school nurse for absenteeism and school nurse interventions were not targeted to attendance, despite 17% of students missing 11 or more school days. Nursing documentation was sparse and primarily task related. Few records contained entries of nursing diagnoses, interventions, or outcomes. Of the 134 interventions provided, only 56 (41.2%) had some information about the condition outcome, but it was insufficient to determine the effectiveness of nursing interventions. Furthermore, the record system did not support the collection of standard information for interventions or outcomes from which effectiveness could be determined. Recommendations include establishment of an attendance referral policy and improved documentation systems, including the use of standardized nursing language to demonstrate student outcomes.