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.

Development of an accurate nursing program based on function in chronic venous leg ulcers: protocol for matching function status with nursing interventions using the Delphi survey

Objective

Venous leg ulceration (VLU) is one of the complications of lower extremity venous reflux and reflux disorder of severe diseases, with many adverse effects on patient’s work and life. Nowadays, more and more patients with VLU accept wound care in community setting. Clinical nurses generally take care of the patients based on their own experiences. Healing in VLU is an incredibly complex process, which puzzles even experts. The majority of general nurses do not have this level of expertise, especially those nurses serving in community. Function is the basis of nursing activities. Patients always show different clinical manifestations and self-care abilities due to various function states, which cannot be reflected completely by the existing nursing practice. How to describe nursing practice standardized in order to demonstrate the effectiveness of interventions and facilitate interdisciplinary communication is another urgent problem. Therefore, the aim of this project is to develop an accurate nursing program based on function in chronic venous leg ulcers, which can both satisfy the needs of patients and promote nursing revolution.

Methods

This study will use International Classification of Functioning Disability and Health as a framework to choose suitable functions and to filter function classification standards of chronic venous leg ulcers through evidence-based systematic research. Nursing interventions related to VLU are selected based on Nursing Interventions Classification, adding other nursing activities by methods of evidence-based systematic review and clinical observation. Then, nursing interventions and function status are matched through steering committee. Finally, the Delphi survey method is adopted to make nursing program native and scientific.

Conclusions

This study is expected to be very significant and meaningful in using standardized nursing terminology. The nursing program established could better meet the needs of both patients with chronic venous leg ulcers and clinical nurses, promoting the development of wound specialist and standardized nursing language.

Prevalence of nursing diagnoses as a measure of nursing complexity in a hospital setting

AIMS

To describe the prevalence of nursing diagnoses on admission among inpatient units and medical diagnoses and to analyse the relationship of nursing diagnoses to patient characteristics and hospital outcomes.

BACKGROUND

Nursing diagnoses classify patients according to nursing dependency and can be a measure of nursing complexity. Knowledge regarding the prevalence of nursing diagnoses on admission and their relationship with hospital outcomes is lacking.

DESIGN

Prospective observational study.

METHODS

Data were collected for 6 months in 2014 in four inpatient units of an Italian hospital using a nursing information system and the hospital discharge register. Nursing diagnoses with prevalence higher or equal to 20% were considered as 'high frequency.' Nursing diagnoses with statistically significant relationships with either higher mortality or length of stay were considered as 'high risk.' The high-frequency/high-risk category of nursing diagnoses was identified.

RESULTS

The sample included 2283 patients. A mean of 4·5 nursing diagnoses per patient was identified; this number showed a statistically significant difference among inpatient units and medical diagnoses. Six nursing diagnoses were classified as high frequency/high risk. Nursing diagnoses were not correlated with patient gender and age. A statistically significant perfect linear association (Spearman's correlation coefficient) was observed between the number of nursing diagnoses and both the length of stay and the mortality rate.

CONCLUSION

Nursing complexity, as described by nursing diagnoses, was shown to be associated with length of stay and mortality. These results should be confirmed after considering other variables through multivariate analyses. The concept of high-frequency/high-risk nursing diagnoses should be expanded in further studies.

Advanced Nursing Process quality: Comparing the International Classification for Nursing Practice (ICNP) with the NANDA-International (NANDA-I) and Nursing Interventions Classification (NIC)

AIMS AND OBJECTIVES

To assess the quality of the advanced nursing process in nursing documentation in two hospitals.

BACKGROUND

Various standardised terminologies are employed by nurses worldwide, whether for teaching, research or patient care. These systems can improve the quality of nursing records, enable care continuity, consistency in written communication and enhance safety for patients and providers alike.

DESIGN

Cross-sectional study.

METHODS

A total of 138 records from two facilities (69 records from each facility) were analysed, one using the NANDA-International and Nursing Interventions Classification terminology (Centre 1) and one the International Classification for Nursing Practice (Centre 2), by means of the Quality of Diagnoses, Interventions, and Outcomes instrument. Quality of Diagnoses, Interventions, and Outcomes scores range from 0-58 points. Nursing records were dated 2012-2013 for Centre 1 and 2010-2011 for Centre 2.

RESULTS

Centre 1 had a Quality of Diagnoses, Interventions, and Outcomes score of 35·46 (±6·45), whereas Centre 2 had a Quality of Diagnoses, Interventions, and Outcomes score of 31·72 (±4·62) (p < 0·001). Centre 2 had higher scores in the 'Nursing Diagnoses as Process' dimension, whereas in the 'Nursing Diagnoses as Product', 'Nursing Interventions' and 'Nursing Outcomes' dimensions, Centre 1 exhibited superior performance; acceptable reliability values were obtained for both centres, except for the 'Nursing Interventions' domain in Centre 1 and the 'Nursing Diagnoses as Process' and 'Nursing Diagnoses as Product' domains in Centre 2.

CONCLUSION

The quality of nursing documentation was superior at Centre 1, although both facilities demonstrated moderate scores considering the maximum potential score of 58 points. Reliability analyses showed satisfactory results for both standardised terminologies.

RELEVANCE TO CLINICAL PRACTICE

Nursing leaders should use a validated instrument to investigate the quality of nursing records after implementation of standardised terminologies.

What patients' problems do nurses e-chart? Longitudinal study to evaluate the usability of an interface terminology

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.