Gail M. Keenan

Nursing standards to support the electronic health record

Quality and low cost health care that is free of medical mistakes requires continuity of person-centric healthcare information across the life span and healthcare settings. Interoperable clinical information systems that rely on the use of multiple standards to support health information exchange and, in particular, nurse sensitive data, information, and knowledge are key components to support high quality, safe care. A 2004 Executive Order called for a National Health Information Network and the widespread adoption of electronic health records (EHRs) by 2014. While there are numerous standards influencing the exchange of health data, the primary focus of this article is to synthesize the state-of-the-art in nursing standardized terminologies to support the development, exchange, and communication of nursing data. Research exemplars are described for information systems to support nursing practice using standardized terminologies and secondary use of standardized nursing data from EHRs for knowledge development.

Challenges to nurses' efforts of retrieving, documenting, and communicating patient care information

OBJECTIVE To examine information flow, a vital component of a patients care and outcomes, in a sample of multiple hospital nursing units to uncover potential sources of error and opportunities for systematic improvement. DESIGN This was a qualitative study of a sample of eight medical-surgical nursing units from four diverse hospitals in one US state. We conducted direct work observations of nursing staffs communication patterns for entire shifts (8 or 12 h) for a total of 200 h and gathered related documentation artifacts for analyses. Data were coded using qualitative content analysis procedures and then synthesized and organized thematically to characterize current practices. RESULTS Three major themes emerged from the analyses, which represent serious vulnerabilities in the flow of patient care information during nurse hand-offs and to the entire interdisciplinary team across time and settings. The three themes are: (1) variation in nurse documentation and communication; (2) the absence of a centralized care overview in the patients electronic health record, ie, easily accessible by the entire care team; and (3) rarity of interdisciplinary communication. CONCLUSION The care information flow vulnerabilities are a catalyst for multiple types of serious and undetectable clinical errors. We have two major recommendations to address the gaps: (1) to standardize the format, content, and words used to document core information, such as the plan of care, and make this easily accessible to all team members; (2) to conduct extensive usability testing to ensure that tools in the electronic health record help the disconnected interdisciplinary team members to maintain a shared understanding of the patients plan.

Health data use, stewardship, and governance: ongoing gaps and challenges: a report from AMIA's 2012 Health Policy Meeting

Large amounts of personal health data are being collected and made available through existing and emerging technological media and tools. While use of these data has significant potential to facilitate research, improve quality of care for individuals and populations, and reduce healthcare costs, many policy-related issues must be addressed before their full value can be realized. These include the need for widely agreed-on data stewardship principles and effective approaches to reduce or eliminate data silos and protect patient privacy. AMIAs 2012 Health Policy Meeting brought together healthcare academics, policy makers, and system stakeholders (including representatives of patient groups) to consider these topics and formulate recommendations. A review of a set of Proposed Principles of Health Data Use led to a set of findings and recommendations, including the assertions that the use of health data should be viewed as a public good and that achieving the broad benefits of this use will require understanding and support from patients.

Standardized nursing terminologies can transform practice

This department, sponsored by the American Organization of Nurse Executives, presents information to assist nurse leaders in shaping the future of healthcare through creative and innovative leadership. The strategic priorities of the American Organization of Nurse Executives anchor the editorial content. They reflect contemporary healthcare and nursing practice issues that challenge nurse executives as they strive to meet the needs of patients.

The HANDS project: Studying and refining the automated collection of a cross-setting clinical data set

The consistent availability of a core set of clinical nursing data is essential to promote quality patient care. Although important work to improve terminology and enhance comparability of data is underway, the efforts do not address the immediate need for useful nursing data sets and valid methods of collection at the point of data entry. The Hands-on Automated Nursing Data System (HANDS) project is dedicated to refining a feasible methodology for gathering, storing, and retrieving a standardized nursing data set. To date the project team has developed and tested a prototype research tool that is automated and contains the structured terminologies (North American Nursing Diagnosis Association, Nursing Outcomes Classification, and Nursing Interventions Classification) to represent nursing diagnoses, outcomes, and interventions, respectively. The Phase I project development activities are reported in this article, along with Phase II and III plans for testing and refining the methodology under actual clinical conditions. Results and lessons learned during Phase I are reported.

Data Mining Nursing Care Plans of End-of-Life Patients: A Study to Improve Healthcare Decision Making

PURPOSE To reveal hidden patterns and knowledge present in nursing care information documented with standardized nursing terminologies on end-of-life (EOL) hospitalized patients. METHOD 596 episodes of care that included pain as a problem on a patients care plan were examined using statistical and data mining tools. The data were extracted from the Hands-On Automated Nursing Data System database of nursing care plan episodes (n = 40,747) coded with NANDA-I, Nursing Outcomes Classification, and Nursing Intervention Classification (NNN) terminologies. System episode data (episode = care plans updated at every hand-off on a patient while staying on a hospital unit) had been previously gathered in eight units located in four different healthcare facilities (total episodes = 40,747; EOL episodes = 1,425) over 2 years and anonymized prior to this analyses. RESULTS Results show multiple discoveries, including EOL patients with hospital stays (<72 hr) are less likely (p < .005) to meet the pain relief goals compared with EOL patients with longer hospital stays. CONCLUSIONS   The study demonstrates some major benefits of systematically integrating NNN into electronic health records.

Evaluating Home Health Care Nursing Outcomes With OASIS and NOC

PURPOSE To determine the sensitivity and responsiveness of the Outcome and Assessment Information Set (OASIS) and the Nursing Outcomes Classification (NOC) to the effects of home healthcare nursing interventions. METHODS A quasi-experimental before-after study was conducted using a sample of 106 home healthcare participants referred to one of seven participating Midwest home healthcare agencies for treatment of a cardiac condition. Patient outcomes data were collected at home healthcare admission and discharge using OASIS and NOC. Nursing intervention data were collected at each visit using the Nursing Interventions Classification (NIC). Intervention intensity was calculated by totaling the number of NIC interventions provided over the episode of care. FINDINGS Neither OASIS nor NOC were sensitive to the effects of home healthcare nursing as measured by intervention intensity. The OASIS was not responsive to clinically discernable changes in patient outcomes; while the NOC was responsive to patient status change in the outcome categories including activities of daily living, cardiopulmonary status, coping, and illness management behavior. CONCLUSIONS Outcome measures that are more condition-specific and discipline-specific are more responsive to the effects of home healthcare nursing. Further research is needed to identify and refine outcome measures that are sensitive and responsive to the effects of nursing care in home health and other nursing settings. CLINICAL RELEVANCE The use of outcome measures that are more sensitive and responsive to nursing are more effective in guiding nursing practice.

Current state of pain care for hospitalized patients at end of life.

We report findings on the current state of pain care in hospitals for end-of-life (EOL) patients using longitudinal data from 8 diverse medical–surgical units located in 4 different Midwestern hospitals over 24 months. We identified 1425 EOL care episodes, 596 (41.3%) of which had a pain diagnosis. The percentage of EOL patients with pain varied significantly across units (P < .001) and was even lower (27.7%) for those with “acute confusion.” Additionally, 30% of EOL patients had severe or significant pain at death or discharge to hospice and only 42.7% actually met the expected pain-related outcome ratings. Pain often improved within 48 hours of admission (P < .005), the improvement, however, stagnated following this initial time period (P = .92). A sizable gap between pain science and clinical practice continues.

Conducting research with end-of-life populations: Overcoming recruitment challenges when working with clinical agencies

Conducting end-of-life (EOL) research can present numerous challenges associated with recruitment and retention of research subjects. Such issues may result from working with a variety of clinical settings or the uniqueness of the patient population. The purposes of this article were to describe recruitment challenges in EOL research when collaborating with different types of clinical agencies and to discuss strategies that are being used to overcome these recruitment issues.

Standardized nursing languages: essential for the nursing workforce

The evolution of standardized nursing languages (SNLs) has been occurring for more than four decades. The importance of this work continues to be acknowledged as an effective strategy to delineate professional nursing practice. In todays health care environment, the demand to deliver cost-effective, safe, quality patient care is an essential mandate embedded in all health reform policies. Communicating the contributions of professional nursing practice to other nurses, health providers, and other members of the health care team requires the articulation of nursings focus of concern and responses to these concerns to improve patient outcomes. The visibility of the electronic health record (EHR) in practice settings has accelerated the need for nursing to communicate its practice within the structure of the electronic format. The integration of SNLs into the patient record offers nurses an opportunity to describe the focus of their practice through the identification of nursing diagnosis, interventions and outcomes (IOM, 2010). Continued development, testing, and refinement of SNLs offers nursing an accurate and reliable way to use data elements across populations and settings to communicate nursing practice, enable nursing administrators and leaders in health care to delineate needed resources, cost out nursing care with greater precision, and design new models of care that reflect nursepatient ratios and patient acuity that are data driven (Pesut & Herman, 1998). The continued use of nursing languages and acceleration of nursing research using this data can provide the needed evidence to help link nursing knowledge to evidence-driven, cost-effective, quality outcomes that more accurately reflect nursings impact on patient care as well as the health care system of which they are a part. The evaluation of research to support the development, use, and continued refinement of nursing language is critical to research and the transformation of patient care by nurses on a global level.