Models, standards and structures of nursing documentation in European countries.

Abstract

The use of standardized nursing languages varies between and even within different European countries. Standardization of a nursing language is a demanding process which requires substantial methodological and technological knowledge as well as cultural experience in terminology development work. A survey was carried out to describe the current state of art of the use of models, standards and structures in nursing documentation. A web-based questionnaire was targeted to members of the Association for Common European Nursing Diagnoses, Interventions and Outcomes (ACENDIO). Replies were received from 17 countries in Europe. Results show that the nursing process is the model most often used to structure nursing documentation in Europe. Many standardized nursing terminologies are used in Europe but general use in nursing is still lacking which makes access to nursing data an obstacle. In more than 60% of the institutions in the countries that replied were nursing data not stored and could therefore not be retrieved. These results should be a major concern to nurses in Europe. This relates to the lack of use of standards in use of nursing terminologies and information systems. Standardization activities in existing and evolving networks in Europe, as well as in other parts of the world, need to be enhanced. As a European platform, ACENDIO can play a role in these standardization activities and should develop its role accordingly.