Nursing Records With Standardized Nursing Language in Prehospital Emergency Care: From Utopia to Reality

Abstract

PURPOSETo design a record containing “traditional” and nursing process–related data, adapted to prehospital emergency care.METHODSIn the course of conducting a research project about nursing process implementation strategies in prehospital emergency care, a pilot electronic patient record was designed by expert critical care nurses. A prehospital emergency service of a leading city in the Andalusian region in Spain was chosen to test the initial implementation of the record using a qualitative approach that included semistructured interviews and record evaluation, plus a 1‐week education program about clinical use of nursing process. The record included assessment parameters, NANDA, NIC, and NOC standardized nursing terminologies as the main focus of clinical reasoning, care planning, and delineating outcomes and interventions.FINDINGSTwelve prehospital emergency care nurses were trained with a specific nursing process program. They all applied the electronic record during their clinical perfomance and related high satisfaction with it in their interviews, although they reported some initial difficulties with terminology. After this pilot phase, the record was extended to the other seven leading cities in the region following a presentation by two expert nurses. The record has been included as a formal component of the hospital information system and the NOC labels will be used as criteria when evaluating the prehospital emergency nurses. A copy of each record is deposited at the admission hospital.DISCUSSIONThe enrichment of an information system with nurse‐sensitive data is crucial for emergency services where the nurse offers complex but often neverdocumented services. The difficulties of combining easily recordable forms and exhaustive data gathering can be overcome with qualitative techniques and education activities that highlight the benefits of standardized nursing language and critical paths prior to implementation.CONCLUSIONSThe aim of developing a nursing recording system based on standardized nursing language must be balanced against a lack of a nurse‐oriented conceptual framework among emergency nurses and their unfamiliarity with nurse terminology.