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Bertocchi L, Chiappinotto S, Palese A. Exploring the nexus between the standardized nursing terminologies and the unfinished nursing care phenomenon: An empty systematic review. Int J Nurs Knowl 2024. [PMID: 38562121 DOI: 10.1111/2047-3095.12465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/19/2024] [Indexed: 04/04/2024]
Abstract
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.
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Affiliation(s)
- Luca Bertocchi
- Department of Hematology, Azienda Sanitaria Universitaria Giuliano Isontina, University Hospital, Trieste, Italy
- The Marjory Gordon Program for Clinical Reasoning and Knowledge Development at Boston College, William F. Connell School of Nursing, Chestnut Hill, Massachusetts, USA
| | | | - Alvisa Palese
- Department of Medicine, University of Udine, Udine, Italy
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ELEKE CHINEMEREM, NWANERI ADAC, SAMUEL JOYC, NGBALA-OKPABI SABINAH, AGU IFEYINWAS, AMACHREE DAMIETEM, DOKUBA TEXJACK. Configuring a computer-based nursing process form to support nursing diagnosis in rural healthcare clinics in Nigeria. J Public Health Afr 2023; 14:2359. [PMID: 38020264 PMCID: PMC10658472 DOI: 10.4081/jphia.2023.2359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 11/23/2023] [Indexed: 12/01/2023] Open
Abstract
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.
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Affiliation(s)
- CHINEMEREM ELEKE
- Department of Nursing Science, University of Port Harcourt
- Africa Center for Excellence in Public Health & Toxicological Research, University of Port Harcourt
| | - ADA C. NWANERI
- Department of Nursing Sciences, University of Nigeria Enugu Campus
| | - JOY C. SAMUEL
- Department of Nursing Science, University of Port Harcourt
| | - SABINAH NGBALA-OKPABI
- Department of Nursing Science, University of Port Harcourt
- Africa Center for Excellence in Public Health & Toxicological Research, University of Port Harcourt
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Fennelly O, Grogan L, Reed A, Hardiker NR. Use of standardized terminologies in clinical practice: A scoping review. Int J Med Inform 2021; 149:104431. [PMID: 33713915 DOI: 10.1016/j.ijmedinf.2021.104431] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/20/2021] [Accepted: 02/19/2021] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Orna Fennelly
- Insight Centre for Data Analytics, University College Dublin, Ireland; School of Public Health, Physiotherapy and Sports Science, University College Dublin, Ireland.
| | - Loretto Grogan
- Office of the Nursing and Midwifery Services Director, Health Service Executive (HSE), Ireland.
| | - Angela Reed
- Northern Ireland Practice & Education Council for Nursing and Midwifery, Northern Ireland.
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Macieira TGR, Chianca TCM, Smith MB, Yao Y, Bian J, Wilkie DJ, Dunn Lopez K, Keenan GM. Secondary use of standardized nursing care data for advancing nursing science and practice: a systematic review. J Am Med Inform Assoc 2021; 26:1401-1411. [PMID: 31188439 DOI: 10.1093/jamia/ocz086] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 05/04/2019] [Accepted: 05/09/2019] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
| | - Tania C M Chianca
- Department of Basic Nursing, School of Nursing, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Madison B Smith
- College of Nursing, University of Florida, Gainesville, Florida, USA
| | - Yingwei Yao
- Department of Biobehavioral Nursing Science, College of Nursing, University of Florida, Gainesville, Florida, USA
| | - Jiang Bian
- Department of Health Outcomes & Biomedical Informatics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Diana J Wilkie
- Department of Biobehavioral Nursing Science, College of Nursing, University of Florida, Gainesville, Florida, USA
| | - Karen Dunn Lopez
- Biomedical and Health Information Science, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Gail M Keenan
- Department of Family, Community and Health Systems Science, College of Nursing, University of Florida, Gainesville, Florida, USA
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Zamanzadeh V, Valizadeh L, Tabrizi FJ, Behshid M, Lotfi M. Challenges associated with the implementation of the nursing process: A systematic review. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2015; 20:411-9. [PMID: 26257793 PMCID: PMC4525336 DOI: 10.4103/1735-9066.161002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 01/17/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND 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. MATERIALS AND METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- Vahid Zamanzadeh
- Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Leila Valizadeh
- Department of Pediatric nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Faranak Jabbarzadeh Tabrizi
- Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mojghan Behshid
- Department of Medical Surgical Nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mojghan Lotfi
- Department of Pediatric nursing, Faculty of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
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Min YH, Park HA, Chung E, Lee H. Implementation of a next-generation electronic nursing records system based on detailed clinical models and integration of clinical practice guidelines. Healthc Inform Res 2014; 19:301-6. [PMID: 24523995 PMCID: PMC3920043 DOI: 10.4258/hir.2013.19.4.301] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 12/06/2013] [Accepted: 12/18/2013] [Indexed: 11/23/2022] Open
Abstract
Objectives 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. Methods 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. Results 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. Conclusions 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.
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Affiliation(s)
- Yul Ha Min
- College of Nursing, Seoul National University, Seoul, Korea. ; Research Institute of Nursing Science, Seoul National University, Seoul, Korea
| | - Hyeoun-Ae Park
- College of Nursing, Seoul National University, Seoul, Korea. ; Systems Biomedical Informatics Research Center, Seoul National University, Seoul, Korea
| | - Eunja Chung
- Department of Nursing, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyunsook Lee
- Department of Nursing, Seoul National University Bundang Hospital, Seongnam, Korea
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Zega M, D'Agostino F, Bowles KH, De Marinis MG, Rocco G, Vellone E, Alvaro R. Development and Validation of a Computerized Assessment Form to Support Nursing Diagnosis. Int J Nurs Knowl 2013; 25:22-9. [DOI: 10.1111/2047-3095.12008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Maurizio Zega
- School of Nursing; University Tor Vergata; Rome Italy
| | | | | | | | - Gennaro Rocco
- Center of Excellence for Nursing Scholarship; Rome Italy
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Validation of the Data Elements for the Health System Domain of the PNDS. AORN J 2013; 98:39-48. [DOI: 10.1016/j.aorn.2013.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Revised: 05/24/2012] [Accepted: 05/16/2013] [Indexed: 11/20/2022]
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Juvé-Udina ME. What patients' problems do nurses e-chart? Longitudinal study to evaluate the usability of an interface terminology. Int J Nurs Stud 2013; 50:1698-710. [PMID: 23684394 DOI: 10.1016/j.ijnurstu.2013.04.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2012] [Revised: 04/08/2013] [Accepted: 04/16/2013] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Maria Eulàlia Juvé-Udina
- Bellvitge Biomedical Research Institute (IDIBELL), Bellvitge University Hospital, Health Universitat de Barcelona Campus, School of Nursing, Barcelona, Spain.
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Rothman MJ, Solinger AB, Rothman SI, Finlay GD. Clinical implications and validity of nursing assessments: a longitudinal measure of patient condition from analysis of the Electronic Medical Record. BMJ Open 2012; 2:bmjopen-2012-000849. [PMID: 22874626 PMCID: PMC3425946 DOI: 10.1136/bmjopen-2012-000849] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES 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. DESIGN Cohort study of in-hospital and postdischarge mortality of patients over two 1-year periods. SETTING An 805-bed community hospital in Sarasota, Florida, USA. SUBJECTS 42 302 inpatients admitted for any reason, excluding obstetrics, paediatric and psychiatric patients. OUTCOME MEASURES All-cause mortalities and mortality OR. RESULTS 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. CONCLUSIONS 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.
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Furuya RK, Nakamura FRY, Gastaldi AB, Rossi LA. Sistemas de classificação de enfermagem e sua aplicação na assistência: revisão integrativa de literatura. Rev Gaucha Enferm 2011; 32:167-75. [DOI: 10.1590/s1983-14472011000100022] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
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