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.

Accuracy of Defining Characteristics for Nursing Diagnoses Related to Patients with Respiratory Deterioration

PURPOSE

To evaluate accuracy of defining characteristics (DCs) for impaired gas exchange (IGE), impaired spontaneous ventilation (ISV), and ineffective breathing pattern (IBP) in respiratory deterioration.

METHODS

This study is a retrospective analysis of medical records. The accuracy and predictive ability of DC or of clusters are calculated.

FINDINGS

In this study, 391 records were evaluated. For IGE, DCs or clusters with higher efficiency were "hypercapnia" (78%), "somnolence" (74.4%), and "hypercapnia + tachycardia" (88%); for ISV, the cluster with higher efficiency was "increased heart rate ± decrease in cooperation" (70.1%); and for IBP, no DC or cluster exceeded 70% efficiency. These were confirmed by logistic regression.

CONCLUSION

Few DCs had adequate efficiency for respiratory nursing diagnoses, while in some cases clusters accounted for higher efficiency.

IMPLICATIONS FOR NURSING PRACTICE

Clusters of DC may be relevant for respiratory diagnoses.

Clinical Differentiation of Respiratory Nursing Diagnoses among Children with Acute Respiratory Infection

The aim of this study was to identify the defining characteristics that allow clinical differentiation of the nursing diagnoses, ineffective breathing pattern (IBP), ineffective airway clearance (IAC), and impaired gas exchange (IGE). A secondary analysis with a cohort design was developed from 1128 records obtained during the hospital stay of 136 children with acute respiratory infection. Groups of defining characteristics with greater differentiation capacity were identified by multiple correspondence analyses. The results showed that the defining characteristics that better differentiate the studied diagnoses are agitation, irritability and diaphoresis for IGE; dyspnea, use of accessory muscles to breathe, orthopnea, and abnormal breathing pattern for IBP and excessive sputum, absence of cough, difficulty verbalizing, nasal flaring, and adventitious breath sounds for IAC. Twelve defining characteristics that can assist clinicians to differentiate the three main respiratory nursing diagnoses among children with acute respiratory infection were identified in this study.