Nursing Terminology Research Articles

Development of the nursing problem list subset of SNOMED CT®

ObjectiveTo create an interoperable set of nursing diagnoses for use in the patient problem list in the EHR to support interoperability. DesignQueries for nursing diagnostic concepts were executed against the UMLS Metathesaurus to retrieve all nursing diagnoses across four nursing terminologies where the concept was also represented in SNOMED CT. A candidate data set was retrieved and included the nursing diagnoses and corresponding SNOMED CT concepts from the UMLS Metathesaurus. The team members identified the concepts that met the semantic selection criteria for inclusion in the nursing problem list. Results1320 concepts were returned in the initial UMLS Metathesaurus query of nursing diagnostic concepts. Further analysis was conducted to identify those nursing diagnostic concepts mapped to SNOMED CT and duplicate concepts were removed resulting in 591 unique UMLS Metathesaurus concepts. The query extracted all concepts from two of the nursing terminologies that contained interventions and outcomes. After cleaning the dataset, the final count of SNOMED CT concepts in the nursing problem list subset is 369. ConclusionsThe problem list is a key component of the patient care and has been acknowledged as critical by the EHR Meaningful Use criteria. Nursing diagnoses on the problem list are foundational for constructing a nursing care plan. A multidisciplinary patient problem list will facilitate communication and evaluation of the contribution of nursing care to the patient’s clinical care experiences and outcomes.

NANDA International News

International Journal of Nursing Terminologies and ClassificationsVolume 22, Issue 2 p. i-i NANDA International News First published: 27 April 2011 https://doi.org/10.1111/j.1744-618X.2011.01189.xRead the full textAbout ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume22, Issue2April‐June 2011Pages i-i RelatedInformation

Content and Completeness of Care Plans After Implementation of Standardized Nursing Terminologies and Computerized Records

The nursing process and standardized nursing terminologies are essential elements to structure nursing documentation in daily nursing information management. The aim of this study was to describe sustainability and whether and how standardized nursing terminologies, in handwritten versus preprinted versus computerized nursing care plans, changed the content and completeness of documented nursing care. Three audits of patient records were performed: a pretest (n = 291) before a yearlong implementation of standardized nursing terminologies in nursing care plans followed by two posttests: (1) 3 weeks after implementation of nursing terminologies (n = 299) and (2) 22 months after implementation of nursing terminologies and 8 months after implementation of a computerized system (n = 281) in a university hospital. Content and completeness of documented nursing care improved after implementation of standardized nursing terminologies. Documentation of nursing care plans, signs and symptoms, related factors, and nursing interventions increased, whereas mean number of nursing diagnoses per patient did not change between audits. Computerized nursing care plans had the biggest impact, with more variety of nursing diagnoses and increased documentation of signs and symptoms, related factors, and nursing interventions. The use of standardized nursing terminologies improved nursing content in the nursing care plans. Moreover, computerized nursing care plans, in comparison with handwritten and preprinted care plans, increased documentation completeness.

Notification

International Journal of Nursing Terminologies and ClassificationsVolume 21, Issue 4 p. 187-187 Notification Jane Flanagan PhD, ANP-BC, Jane Flanagan PhD, ANP-BCSearch for more papers by this author Jane Flanagan PhD, ANP-BC, Jane Flanagan PhD, ANP-BCSearch for more papers by this author First published: 26 October 2010 https://doi.org/10.1111/j.1744-618X.2010.01168.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume21, Issue4October/December 2010Pages 187-187 RelatedInformation

Editorial: Change Is in the Air

International Journal of Nursing Terminologies and ClassificationsVolume 21, Issue 4 p. 143-143 Editorial: Change Is in the Air Jane Flanagan PhD, ANP-BC, Jane Flanagan PhD, ANP-BC flanagjg@bc.eduSearch for more papers by this author Jane Flanagan PhD, ANP-BC, Jane Flanagan PhD, ANP-BC flanagjg@bc.eduSearch for more papers by this author First published: 26 October 2010 https://doi.org/10.1111/j.1744-618X.2010.01167.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume21, Issue4October/December 2010Pages 143-143 RelatedInformation

Hoping to Hear From You

International Journal of Nursing Terminologies and ClassificationsVolume 21, Issue 3 p. 99-99 Hoping to Hear From You Jane Flanagan PhD, ANP-BC, Jane Flanagan PhD, ANP-BC flanagjg@bc.eduSearch for more papers by this author Jane Flanagan PhD, ANP-BC, Jane Flanagan PhD, ANP-BC flanagjg@bc.eduSearch for more papers by this author First published: 20 July 2010 https://doi.org/10.1111/j.1744-618X.2010.01154.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume21, Issue3July/September 2010Pages 99-99 RelatedInformation

The feasibility of integrating the Omaha system data across home care agencies and vendors.

Federal and state initiatives are aligning around the goal that by 2014 all Americans will have electronic health records to support access to their health information any time and anywhere. As a key healthcare provider, nursing data must be included to enhance patient safety, effectiveness, and efficiency of care that is patient-centric. The purpose of this study was to test the feasibility of abstracting, integrating, and comparing the effective use of a standardized terminology, the Omaha System, across software vendors and 15 home care agencies. Results showed that the 2900 patients in this study had an average of four problems on care plans, with interventions most frequently addressing surveillance (39%) and teaching (30%). Findings in this study support the feasibility of integrating data across software vendors and agencies as well as the usefulness for describing care provided in home care. However, before exchanging data across systems, data quality issues found in this study need attention. There were missing data for 10.8% of patients as well as concerns about the validity of using the problem rating scale for outcomes. Strategies for effective use of standardized nursing terminologies are recommended.

Editorial: Together, Sharing Knowledge

International Journal of Nursing Terminologies and ClassificationsVolume 21, Issue 2 p. 49-49 Editorial: Together, Sharing Knowledge Jane Flanagan PhD, ANP-BC, Jane Flanagan PhD, ANP-BC flanagjg@bc.eduSearch for more papers by this author Jane Flanagan PhD, ANP-BC, Jane Flanagan PhD, ANP-BC flanagjg@bc.eduSearch for more papers by this author First published: 14 April 2010 https://doi.org/10.1111/j.1744-618X.2010.01145.xCitations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume21, Issue2April/June 2010Pages 49-49 RelatedInformation

2010 NANDA—I and ATENDE Oral Presentations

International Journal of Nursing Terminologies and ClassificationsVolume 21, Issue 2 p. 89-92 2010 NANDA—I and ATENDE Oral Presentations First published: 14 April 2010 https://doi.org/10.1111/j.1744-618X.2010.01151.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume21, Issue2April/June 2010Pages 89-92 RelatedInformation

Acknowledgement: 2009 Reviewers and Call for Reviewers

International Journal of Nursing Terminologies and ClassificationsVolume 21, Issue 2 p. 96-96 Acknowledgement: 2009 Reviewers and Call for Reviewers First published: 14 April 2010 https://doi.org/10.1111/j.1744-618X.2010.01153.xRead the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume21, Issue2April/June 2010Pages 96-96 RelatedInformation

Education, Practice, and Research in Nursing Terminology: Gaps, Challenges, and Opportunities

To provide an overview of nursing terminology education, research, and clinical use, to identify and analyze any gaps therein, and to propose ways to close those gaps. We conducted an extensive Internet and literature search to establish the current status of nursing terminology education, research, and clinical use. We also surveyed 40 experts in nursing terminology from 15 countries to obtain more detailed information on nursing terminology education and clinical use. We found that there are gaps in nursing terminology education, research, and use, with the area of research being the most advanced. Nursing terminology is not taught widely in either informatics or nursing programs. Where it is taught, it constitutes only up to several hours of an informatics or nursing course. Research into nursing terminology has been very active, focusing mainly on the development and evaluation/validation of nursing terminology, using reference terminology models, and mapping between these and nursing terminologies. However, little research has been carried out on the use of nursing terminologies in clinical information systems. In addition, there are very few systems in which a standardized nursing terminology has been implemented. In order to close the gaps in nursing terminology education, research, and clinical use, qualified personnel are required to educate potential users as to the importance of terminology-based information systems for semantic interoperability. In addition, more research is required into the implementation of nursing terminologies in information systems, and we must demonstrate the usefulness and effectiveness of nursing terminology-based information systems.

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

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.

Standardizing Nursing Information in Canada for Inclusion in Electronic Health Records: C-HOBIC

The Canadian Health Outcomes for Better Information and Care (C-HOBIC) project introduced systematic use of standardized clinical nursing terminology for patient assessments. Implemented so far in three Canadian provinces, C-HOBIC comprises an innovative model for large-scale capture of standardized nursing-sensitive clinical outcomes data within electronic health records (EHRs). To support this activity, nursing assessment and outcomes concepts were mapped to the International Classification for Nursing Practice (ICNP®). By comparing serial data on a patient across multiple time points, the C-HOBIC model can generate nursing-sensitive patient outcome reports. A principle benefit of the C-HOBIC model is that it provides nurses with information critical to planning for and evaluating patient care. Inclusion of nursing information in either provincial databases or EHRs in three Canadian provinces promotes continuity of patient care across sectors of the healthcare systems in those provinces and also facilitates aggregation and analysis by administrators and policy makers. The C-HOBIC model provides standardized, consistent, interoperable clinical information that reflects nursing practice throughout the Canadian healthcare System.

Exploring the usability of the ISO reference terminology model for nursing actions in representing oriental nursing actions

Purpose This study examined the extent to which the ISO reference terminology model for nursing actions represents oriental nursing actions in a computerized nursing documentation system to share data and foster communication between oriental nursing care and conventional nursing care. Methods The narrative nursing notes of 545 patients retrieved from a nursing documentation system in an oriental medicine teaching hospital were analyzed. Among 49,118 entries, 933 were recorded as nursing actions. Each entry was decomposed in a set of single statements. A total of 1209 nursing action statements were derived and mapped to the components of the model. These processes were reviewed and validated by two domain experts and a nursing terminology expert. Results All of the oriental nursing actions documented contained a word or phrase that described the Action and Target in the model. The Recipient of Care was expressed explicitly in 1.2% of statements. The most frequently used Action terms were ‘administering’ (19.7%), ‘teaching’ (16.5%), and ‘explaining’ (13.6%). The Target terms that indicated unique oriental nursing concepts included ‘Sasang constitution differentiation’, ‘removal of acupuncture needles’, ‘herb moxibustion’, ‘oriental massage’, and ‘oriental medication’. Conclusion The findings demonstrate that oriental nursing actions can be represented using the ISO reference terminology model for nursing actions. Further specification of the components of the model will be useful to achieve consistent mapping across different settings. The addition of component qualifiers should also be taken into consideration to describe nursing actions at a more granular level.

Novel Nursing Terminologies for the Rapid Response System

Nursing terminology with implications for the rapid response system (RRS) is introduced and proposed: critical incident nursing diagnosis (CIND), defined as the recognition of an acute life-threatening event that occurs as a result of disease, surgery, treatment, or medication; critical incident nursing intervention, defined as any indirect or direct care registered nurse-initiated treatment, based upon clinical judgment and knowledge that a registered nurse performs in response to a CIND; and critical incident control, defined as a response that attempts to reverse a life-threatening condition. The current literature, research studies, meta-analyses from a variety of disciplines, and personal clinical experience serve as the data sources for this article. The current nursing diagnoses, nursing interventions, and nursing outcomes listed in the North American Nursing Diagnosis Association International Classification, Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC), respectively, are inaccurate or inadequate for describing nursing care during life-threatening situations. The lack of such standardized nursing terminology creates a barrier that may impede critical communication and patient care during life-threatening situations when activating the RRS. The North American Nursing Diagnosis Association International Classification, NIC, and NOC are urged to refine their classifications and include CIND, critical incident nursing intervention, and critical incident control. The RRS should incorporate standardized nursing terminology to describe patient care during life-threatening situations. Refining the diagnoses, interventions, and outcomes classifications will permit nursing researchers, among others, to conduct studies on the efficacy of the proposed novel nursing terminology when providing care to patients during life-threatening situations. In addition, including the proposed novel nursing terminology in the RRS offers a means of improving care in such situations.

Using Bibliometrics to Support Your Selection of a Nursing Terminology Set

Nurses are being pressured to integrate standardized nursing terminology into the electronic health record to enable the representation and evaluation of nursing practice. Five terminology sets are recognized by the American Nurses Association that contain terms to represent nursing diagnoses, outcomes, and intervention: CCC, ICNP, NANDA/NOC/NIC, Omaha System, and PNDS. Key criteria for choosing the most suitable include demonstrated use and testing under real-time clinical conditions, scope of terms, cost, and the administrative infrastructure to sustain and evolve the terminology. Likelihood of survival is also critical and was evaluated here by examining the diffusion pattern of each terminology set through bibliometric analysis. Each of the five sets had a unique diffusion pattern, with NANDA/NOC/NIC demonstrating the most extensive penetration and author network in the CINAHL literature examined from 1982 to 2006.

Evaluating nursing documentation – research designs and methods: systematic review

This paper is a report of a review conducted to assess the research methods applied in the evaluation of nursing documentation. The material was drawn from three databases: CINAHL, PubMed and Cochrane using the keywords nursing documentation, nursing care plan, nursing record system, evaluation and assessment. The search was confined to relevant electronically-retrievable studies published in the English language from 2000 to 2007. This yielded 41 studies, including two reviews. Content analysis produced a classification into three themes: nursing documentation, patient-centred documentation and standardized documentation. Each study was assessed according to its research design, methodology, sample size and focus of data collection. In addition, the studies categorized under the heading of standardized documentation were assessed in terms of their outcomes. Most of the studies (n = 19) focused on patient-centred documentation. Most (n = 20) were retrospective studies and used data collected from patient records (n = 35). An audit instrument was used to assess nursing documentation in almost all the studies. Studies classified under the heading of standardized documentation showed more positive than negative effects with respect to quality, the nursing process and terminology use, knowledge level and acceptance of computer use in documentation. The use of structured nursing terminology in electronic patient record systems will extend the scope of documentation research from assessing the quality of documentation to measuring patient outcomes. More data should also be collected from patients and family members when evaluating nursing documentation.

Coining and Defining Novel Nursing Terminology. Part 3: Critical Incident Control

In the third of a three-part series, a novel nursing terminology is introduced and proposed for inclusion in the Nursing Outcomes Classification (NOC)-Critical incident control (CIC)-defined as a response that attempts to reverse a life-threatening condition. Critical incident nursing diagnosis (CIND), defined as recognition of an acute life-threatening event that occurs as a result of disease, surgery, treatment, or medication, and critical incident nursing intervention, defined as any indirect or direct care registered nurse-initiated treatment, based upon clinical judgment and knowledge that a registered nurse performs in response to a CIND, were introduced in Parts 1 and 2 of this series, respectively. The current literature, research studies, meta-analyses from a variety of disciplines, and personal clinical experience serve as the data sources for this article. The current nursing outcomes in the NOC are inaccurate or inadequate for describing nursing care during life-threatening situations. The lack of standardized nursing terminology creates a barrier that may impede critical communication and patient care during life-threatening situations. Coining and defining novel nursing terminology, CIC, for patient care during life-threatening situations is important and fills the gap in the current standardized nursing terminology. Refining the NOC will permit nursing researchers, among others, to conduct studies on nursing diagnoses in conjunction with the proposed novel nursing terminology, CIC.

Development of a Nursing Care Decision Support SystemforHealth Problems of The Elementary and Secondary School Students

Objective: The aim of this study was to develop a decision support system that helps school nurses manage health problems they encounter while caring for the elementary and secondary school students, and evaluate usability of it. Methods: Knowledge was aquired by literatures review and interviews with senior school nurses and was validated by another group of school nurses. The Omaha System was used as a standardized nursing terminology to describe nursing diagnoses and interventions. The system was developed under the Windows environment. C++ was used as a program language and MS Structured Query Language as a database. To investigate usability of the system, 30 school nurses in elementary and secondary schools were recruited and asked to apply it to nursing problems they encountered in actual students care setting. Results: The decision support system with seven major signs and symptoms was developed. It automatically makes a nursing diagnosis based on the input data, and also provides nursing interventions with evidence. It was proven that the system was very useful for school nurses to manage students` health problems. Conclusion: The system will contribute to development of expert knowledge concerning student’s health problems and improve the quality of school nursing and professionalism.

Presidents’ Reports

International Journal of Nursing Terminologies and ClassificationsVolume 20, Issue 1 p. 40-44 Presidents’ Reports First published: 06 February 2009 https://doi.org/10.1111/j.1744-618X.2008.01112.x doi: 10.1111/j.1744-618X.2008.01112.x Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Volume20, Issue1January 2009Pages 40-44 RelatedInformation