Sue Moorhead

Advocating for standardized nursing languages in electronic health records

“For 40 years, people have been waiting for the breakthrough of EHR, Electronic Health Record, systems. The current combination of driving forces, standards developments, and technological progress has finally brought us to a point where substantial progress can be made on this road.”1 Recent reports from the Institute of Medicine (IOM) demand that electronic records support patient care that is timely, efficient, equitable, and free of mistakes.2-4 Nurse executives, as central coordinators of patient care, have the capacity to meet this imperative through advocacy of, and contribution to, the use of stan-

Most frequent nursing diagnoses, nursing interventions, and nursing-sensitive patient outcomes of hospitalized older adults with heart failure: part 1

PURPOSE Rank and compare the 10 most frequently documented nursing diagnoses, interventions, and patient outcomes using NANDA International, Nursing Interventions Classification, and Nursing Outcomes Classification for care of patients with heart failure (HF). METHODS A descriptive comparative multisite study of documented care for 302 older adults with HF. FINDINGS There were four common nursing diagnoses, two interventions, and only three common outcomes across three sites. CONCLUSIONS This and similar analyses of clinical nursing data can be used by nursing administrators and clinicians to monitor the quality and effectiveness of nursing care. IMPLICATIONS Similar analyses may be used for continuing education, quality improvement, and documentation system refinement. Part 2 will discuss data retrieval and implications for building a multiorganizational data warehouse.

The nursing minimum data set, standardized language, and health care quality

Providers and consumers of health care have been attempting to define quality for the past several decades. The article describes one of nursings contributions to the multidisciplinary health care quality revolution: its ability to provide a more complete and holistic picture of the consumer (patients/clients). Nursings focus on responses to health care problems, not just illness events in isolation, provides insight into causes and effective management strategies for health problems. The Nursing Minimum Data Set (NMDS) documents patient/client responses, interventions, patient-sensitive outcomes, and resource consumption. By implementing the NMDS, nursing collaborates with other health care professionals to identify the needs of patient populations as well as the needs of individual patients. The article examines the relationship of the NMDS to other health care databases used in quality measurement, describes the integral role of standardized language in implementing the NMDS, provides examples of NMDS data analyses to address specific aspects of quality measurement, and outlines a methodology for using nonstandardized data.

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.

Mapping parish nurse documentation into the nursing interventions classification: a research method

Mapping, or linking like terms that represent the same concept, is a research method increasingly used for testing the reliability and validity of standardized taxonomies. For mapping to be useful, it is critical that the procedure is reliable. One way to maximize reliability is to develop standardized mapping procedures, or rules to follow when linking the terms. This article will present a standardized mapping procedure method in a study that mapped narrative parish nurse documentation (170 health records, 1607 interactions) into the Nursing Interventions Classification (NIC), yielding an intercoder reliability kappa of 0.92. The mapping process identified conceptual issues in the NIC, which also are presented. Because the NIC is included in the Systematic Nomenclature of Medicine of Clinical Terms® (SNOMED CT®), these conceptual issues raised data aggregation issues in SNOMED CT. Those issues are also presented.

Excessive bleeding predictors after cardiac surgery in adults: integrative review.

AIMS AND OBJECTIVES To integrate literature data on the predictors of excessive bleeding after cardiac surgery in adults. BACKGROUND Perioperative nursing care requires awareness of the risk factors for excessive bleeding after cardiac surgery to assure vigilance prioritising and early correction of those that are modifiable. DESIGN Integrative literature review. METHODS Articles were searched in seven databases. Seventeen studies investigating predictive factors for excessive bleeding after open-heart surgery from 2004-2014 were included. RESULTS Predictors of excessive bleeding after cardiac surgery were: Patient-related: male gender, higher preoperative haemoglobin levels, lower body mass index, diabetes mellitus, impaired left ventricular function, lower amount of prebypass thrombin generation, lower preoperative platelet counts, decreased preoperative platelet aggregation, preoperative platelet inhibition level >20%, preoperative thrombocytopenia and lower preoperative fibrinogen concentration. Procedure-related: the operating surgeon, coronary artery bypass surgery with three or more bypasses, use of the internal mammary artery, duration of surgery, increased cross-clamp time, increased cardiopulmonary bypass time, lower intraoperative core body temperature and bypass-induced haemostatic disorders. Postoperative: fibrinogen levels and metabolic acidosis. CONCLUSIONS Patient-related, procedure-related and postoperative predictors of excessive bleeding after cardiac surgery were identified. RELEVANCE TO CLINICAL PRACTICE The predictors summarised in this review can be used for risk stratification of excessive bleeding after cardiac surgery. Assessment, documentation and case reporting can be guided by awareness of these factors, so that postoperative vigilance can be prioritised. Timely identification and correction of the modifiable factors can be facilitated.

Nursing Interventions Classification: A Comparison with the Omaha System and the Home Healthcare Classification

Standardized languages for nursing practice are required to meet the needs of the profession and the patients we serve. The authors review and compare three classifications of nursing interventions: Nursing Interventions Classification (NIC), the Omaha System, and the Home Healthcare Classification (HHC). The information will help users make the best selection for their agency and client population.

Evaluation of the reliability and validity of nursing outcomes classification patient outcomes and measures

One hundred sixty-nine of the Nursing Outcomes Classification (NOC) patient outcomes were tested for interrater reliability, criterion validity, and sensitivity. In 10 field sites, ranging from hospitals to home care, pairs of nurses rated the outcome measures for 5 to 130 patients. Inter-class correlations were greater than or equal to 0.70 for 63 outcomes. Pearson’s correlations with criterion measures were greater than or equal to 0.60 for 40 outcomes and from 0.39 to 0.60 for 43 additional ones. Change scores for 99 outcomes ranged from 0 to 2.0 from first to second and second to third rating. Most NOC measures demonstrated good inter-rater reliability, substantial criterion validity, and sensitivity to change. More testing and thorough training of nurses using NOC outcomes are needed.

Nursing Diagnoses, Interventions, and Patient Outcomes for Hospitalized Older Adults with Pneumonia

A study was conducted by academic and community hospital partners with clinical information systems that included the standardized nursing language classifications of the North American Nursing Diagnosis Association International (NANDA-I), Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC). The aim of the study was to determine the frequency of NANDA-I, NIC, and NOC (NNN) terms documented for older adults with pneumonia who were discharged from three hospitals during a 1-year period. NNN terms were ranked according to frequency for each hospital, and then the rankings were compared with previous studies. Similarity was greater across hospitals in rankings of NANDA-I and NOC terms than in rankings of NIC terms. NANDA-I and NIC terms are influenced by reimbursement and regulatory factors as well as patient condition. The 10 most frequent NNN terms for each hospital accounted only for a small to moderate percentage of the terms selected.

Nursing Outcomes Classification implementation projects across the care continuum

The health care environment in which nurses deliver care is experiencing constant change characterized by decreased lengths of stay in acute care settings, increased use of technology, increasing emphasis on computerized patient records and care planning options, increasing markets dominated by managed care, and an emphasis on outcomes rather than process. These changes dictate that nursing as a profession ensures that the work of nursing is visible in this health care environment and included in the data used to make health policy decisions. This article describes the rich history of a Midwestern hospitals use of standardized nursing languages for the last 25 years. Currently this facility is in the process of implementing the Nursing Outcomes Classification (NOC). Four projects are described that illustrate the ways nurses can use this language with diagnoses from the North American Nursing Diagnoses Association (NANDA) and interventions from the Nursing Interventions Classification (NIC).