Perioperative Nursing Data Set Research Articles

Intervention-related demands: Criteria for an operating room-specific patient classification. A qualitative focus group study

Intervention-related demands: Criteria for an operating room-specific patient classification. A qualitative focus group study Abstract: Background: Optimal workforce deployment in the operating room-setting has gained high priority in the context of an economized health care system and the development of skill-grade mix. Therefore, mapping intervention-related demands on perioperative nurses as precisely as possible is a frequently discussed need. A surgery-specific patient classification might be helpful. Aim: This paper aims to present core elements of perioperative nursing care in the Swiss-German context and to establish a link to the Perioperative Nursing Data Set (PNDS). Methods: Three focus group interviews with perioperative nurses took place at a university hospital in the German-speaking part of Switzerland. Data analysis was performed in analogy to qualitative content analysis according to Mayring. The content structuring of the categories was based on the relevant PNDS taxonomies. Results: Intervention-related requirements can be divided into three areas: "patient safety", "nursing and caring", and "environmental factors". The conjunction with the PNDS taxonomy serves as a theoretical foundation. Conclusions: Elements of the PNDS taxonomies can describe the demands on perioperative nurses in the Swiss-German context. The identified definition of intervention-related demands can contribute to the visibility of perioperative nursing and promote professionalization as well as practice development in the operating room-setting.

AORN Position Statement on Perioperative Registered Nurse Circulator Dedicated to Every Patient Undergoing an Operative or Other Invasive Procedure

<scp>AORN</scp> Position Statement on Perioperative Registered Nurse Circulator Dedicated to Every Patient Undergoing an Operative or Other Invasive Procedure

Danish Perioperative Nurses’ Documentation: A Complex, Multifaceted Practice Connected With Unit Culture and Nursing Leadership

Researchers have described the documentation practices of perioperative nurses as flawed and characterized by subjectivity and poor quality, which is often related to both the documentation tool and the nurses’ level of commitment. Studies suggest that documentation of nursing care in the OR places special demands on electronic health records (EHRs). The purpose of this study was to explore how the use of an EHR tailored to perioperative practice affects Danish perioperative nurses’ documentation practices. This study was a follow-up to a baseline study from 2014. For three months in the winter of 2015 to 2016, six participants tested an EHR containing a Danish edition of a selected section of the Perioperative Nursing Data Set. This study relied on realistic evaluation and participant observations to generate data. We found that nursing leadership was essential for improving perioperative nurses’ documentation practices and that a tailored EHR may improve documentation practices.

Technology in the OR: AORN Members’ Perceptions of the Effects on Workflow Efficiency and Quality Patient Care

This collaborative study sought to describe technology used by AORN members at work, inclusive of radio-frequency identification or barcode scanning (RFID), data collection tools (DATA), workflow or dashboard management tools (DASHBOARD), and environmental services/room decontamination technologies (ENVIRON), and to identify the perceived effects of each technology on workflow efficiency (WFE) and quality patient care (QPC). The 462 respondents to the AORN Technology in the OR survey reported use of technology (USE) in all categories. Eleven of 17 RFID items had a strong positive correlation between the designated USE item and the perceived effect on WFE and QPC. Five of the most-used technology items were found in the DATA category. Two of the five related to Intraoperative Nursing Documentation and the use of the Perioperative Nursing Data Set. The other three related to Imaging Integration for Radiology Equipment, Video Camera Systems, and Fiber-optic Systems. All three elements explored in the DASHBOARD category (ie, Patient Update, OR Case, OR Efficiency) demonstrated approximately 50% or greater perceived effectiveness in WFE and QPC. There was a low reported use of ENVIRON technologies, resulting in limited WFE and QPC data for this category.

Evidence for the existing American Nurses Association-recognized standardized nursing terminologies: A systematic review

ObjectiveTo determine the state of the science for the five standardized nursing terminology sets in terms of level of evidence and study focus. DesignSystematic review. Data sourcesKeyword search of PubMed, CINAHL, and EMBASE databases from 1960s to March 19, 2012 revealed 1257 publications. Review methodsFrom abstract review we removed duplicate articles, those not in English or with no identifiable standardized nursing terminology, and those with a low-level of evidence. From full text review of the remaining 312 articles, eight trained raters used a coding system to record standardized nursing terminology names, publication year, country, and study focus. Inter-rater reliability confirmed the level of evidence. We analyzed coded results. ResultsOn average there were 4 studies per year between 1985 and 1995. The yearly number increased to 14 for the decade between 1996 and 2005, 21 between 2006 and 2010, and 25 in 2011. Investigators conducted the research in 27 countries. By evidence level for the 312 studies 72.4% were descriptive, 18.9% were observational, and 8.7% were intervention studies. Of the 312 reports, 72.1% focused on North American Nursing Diagnosis-International, Nursing Interventions Classification, Nursing Outcome Classification, or some combination of those three standardized nursing terminologies; 9.6% on Omaha System; 7.1% on International Classification for Nursing Practice; 1.6% on Clinical Care Classification/Home Health Care Classification; 1.6% on Perioperative Nursing Data Set; and 8.0% on two or more standardized nursing terminology sets. There were studies in all 10 foci categories including those focused on concept analysis/classification infrastructure (n=43), the identification of the standardized nursing terminology concepts applicable to a health setting from registered nurses’ documentation (n=54), mapping one terminology to another (n=58), implementation of standardized nursing terminologies into electronic health records (n=12), and secondary use of electronic health record data (n=19). ConclusionsFindings reveal that the number of standardized nursing terminology publications increased primarily since 2000 with most focusing on North American Nursing Diagnosis-International, Nursing Interventions Classification, and Nursing Outcome Classification. The majority of the studies were descriptive, qualitative, or correlational designs that provide a strong base for understanding the validity and reliability of the concepts underlying the standardized nursing terminologies. There is evidence supporting the successful integration and use in electronic health records for two standardized nursing terminology sets: (1) the North American Nursing Diagnosis-International, Nursing Interventions Classification, and Nursing Outcome Classification set; and (2) the Omaha System set. Researchers, however, should continue to strengthen standardized nursing terminology study designs to promote continuous improvement of the standardized nursing terminologies and use in clinical practice.

Standardizing Documentation for Postoperative Nausea and Vomiting in the Electronic Health Record

Postoperative nausea and vomiting (PONV) remains a common postoperative complication that causes patient discomfort and increases health care costs. Clinicians use the American Society of PeriAnesthesia Nurses (ASPAN) guideline to help prevent and treat PONV. However, the lack of standardized terminology in the electronic health record (EHR) and the lack of clinical decision support tools make it difficult for clinicians to document guideline implementation and to determine the effects of nursing care on PONV. To address this, we created a concept map of the Perioperative Nursing Data Set (PNDS) that illustrates the relationship between elements of this standardized nursing terminology and the ASPAN guideline, using the Systematized Nomenclature of Medicine—Clinical Terms multidisciplinary terminology to fill any gaps. This mapping results in a standardized dataset specific to PONV for use in an EHR, which links nursing care to nursing diagnoses, interventions, and outcomes. The mapping and documentation in the EHR also allows standardized data collection for research, evaluation, and benchmarking, which makes perioperative nursing care of patients who are at risk for or experiencing PONV measureable and visible. Distributing this information to perioperative and perianesthesia nursing personnel, in addition to implementing risk assessment tools for PONV and clinical support alerts in electronic documentation systems, will help support implementation of the PONV clinical practice guideline in the EHR.

Evaluating Perioperative Nursing in Finland: An Initial Validation of Perioperative Nursing Data Set Outcomes

The current Finnish version of AORN's Perioperative Nursing Data Set consists of nursing diagnoses and interventions but not outcomes. During the early Finnish validation phase, researchers determined that almost half of the outcomes listed in the AORN version were impossible to measure in Finland. We conducted this study to determine the applicability of the nursing outcomes identified in the Perioperative Nursing Data Set, 2nd ed Rev, and to test the use of the outcomes by exploring the relevance of the outcome indicators for eight selected outcomes. We collected the data by using two surveys with structured questionnaires that were provided to an expert panel of nurses and physicians. Panel members found that most of the outcomes were acceptable for use in Finnish perioperative care; however, further validation of the outcome indicators is needed to develop tools to support nurses in their attempts to reach desirable nursing-sensitive outcomes for patients.

Validation of the Data Elements for the Health System Domain of the PNDS

This research study established the data elements for the health system domain in the Perioperative Nursing Data Set. A sample of AORN members were asked to confirm the clarity, necessity, measurability, and accuracy of each proposed data element. As a result of this study, the health system domain contains 114 data elements with definitions. When integrated into an electronic health record, data elements can be used to identify, compare, and evaluate the context in which patient care is delivered across settings.

Informatics: The Standardized Nursing Terminologies: A National Survey of Nurses’ Experience and Attitudes—SURVEY II: Participants’ Education for the Use of Standardized Nursing Terminology “Labels”

We conducted two national Internet surveys of nurses related to their use of standardized nursing terminologies recognized by the American Nurses Association (ANA). The results of Survey I were reported in a previous OJIN Informatics Column, The Standardized Nursing Terminologies: A National Survey of Nurses' Experiences and Attitudes - Survey I (Schwirian & Thede. 2012J. The results from Survey II are being distributed in several reports. The first of these reports was published in OJIN as The Standardized Nursing Terminologies: A National Survey of Nurses' Experience and Attitudes (Schwirian & Thede. 20121. In that column, we reported the demographics of our participants and compared the extent of their familiarity with each of the terminologies between Survey I and Survey II. We also examined sources of terminology information used by nurses and found that reading of current nursing literature was generally the most dominant source of information. Another area explored was the similarities in familiarity with the terminologies between those nurses engaged in direct care and those engaged in informatics. In this area with the exception of the Perioperative Nursing Data Set, we noted that informatics nurses were significantly more familiar with the ANA-recognized terminologies than their counterparts engaged in direct clinical care.In this column, we will report on the Survey II participants' opinions about the education they received for using a given terminology. There were 567 participants who started this survey. As we reported in the first Survey II column, ninety-three percent of the respondents were females. The largest age group was 50-59 years (47%), and the second largest was 40-49 (20%). In general, the year in which respondents were first licensed corresponded with their ages (64% were first licensed before 1990). Participants were predominantly female and lived primarily in the United States (US) east of the Mississippi (Thede & Schwirian. 2012J.In Survey II, we used and a technique called branching in which the questions that a respondent saw on the screen were based on their answers to prior questions. For required questions, if an answer was not provided the participant was unable to continue the survey. The branching technique allowed participants who answered a given question negatively to not waste time with questions that were not applicable to them. Thus a no answer to a question, such as Have you ever used X terminology? took the participant to the question asking about the next terminology. Unfortunately, skipping a question was treated by the program as if the participant had answered yes. We remedied this in our report by only providing responses from those who answered yes to the determinant question and were thus qualified to answer more questions about a topic. Given that we did not want to have too many required questions, which might force an untruthful answer not only to that question, but also to subsequent questions, the only questions that required answer were questions asking if the respondent was familiar with a given terminology.The terminologies that were included in the survey are those that have been recognized by the ANA. Their acronyms and full names are listed in Figure 1 in the order that questions about a terminology were presented in the questionnaire. Of these terminologies, SNOMED, LOINC, and the ABC codes are interdisciplinary. LOINC is primarily concerned with lab results and assessment, and the ABC codes are a way for non-physicians to bill.The other terminologies are all nursing specific, that is, they were developed primarily for nursing. With the exception of NANDA, NIC, and NOC, the nursing-specific terminologies and SNOMED include labels and coding for the nursing entities of: nursing problems (diagnoses), interventions, and outcomes. Thus they can capture all three of these nursing entities. NANDA, NIC, and NOC, however, each capture only one of these entities. …

Clinical Issues—January 2013

This MonthPatient safety during the transition from paper to electronic health recordsKey words: electronic health record (EHR), documentation, paper documentation, electronic documentation, patient safety.Documentation needed for transitions from paper to electronic health recordsKey words: electronic health record (EHR), paper documentation, documentation.The meaning of electronic health record interoperabilityKey words: standardized nursing language, interoperability, Perioperative Nursing Data Set (PNDS).

Clinical Issues—December 2011

This MonthPre‐charting patient care informationKey words: documentation, pre‐charting, corrections, electronic health record.Using the most current edition of the Perioperative Nursing Data Set (PNDS)Key words: Perioperative Nursing Data Set, PNDS 3rd edition, PNDS 2nd edition, clinical terminology, versioning.Data quality and the electronic health record (EHR)Key words: data quality, electronic health record, retrospective data analysis, front‐end data acquisition.Assessing and improving the quality of health care dataKey words: data quality assurance, information quality, data quality control, subjective data metrics, objective data metrics.Electronic documentation and quality patient careKey words: nursing documentation, information system, designing an electronic documentation system.

Evolution and Revision of the Perioperative Nursing Data Set

The Perioperative Nursing Data Set (PNDS) is a nursing language that provides standardized terminology to support perioperative nursing practice. The PNDS represents perioperative nursing knowledge and comprises data elements and definitions that demonstrate the nurse's influence on patient outcomes. Emerging issues and changes in practice associated with the PNDS standardized terminology require ongoing maintenance and periodic in-depth review of its content. Like each new edition of the Perioperative Nursing Data Set, the third edition, published in 2010, underwent content validation by numerous experts in clinical practice, vocabulary development, and informatics. The goal of this most recent edition is to enable the perioperative nurse to use the PNDS in a meaningful manner, as well as to promote standardization of PNDS implementation in practice, both in written documentation and the electronic health record.

Implementing Health IT

The national dialogue surrounding health care information technology (IT) continues to expand. At the federal level, this dialogue has been fueled by the electronic health record (EHR) incentive programs introduced through the American Recovery and Reinvestment Act of 2009, and ongoing discussions defining the central concept of “meaningful use” of EHR technology which are being led by the Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health Information Technology. At the facility level, health care organizations are working with vendors to introduce and develop their use of electronic health documentation technology as they realize the benefits of standardized documentation. One significant benefit of using an EHR is the opportunity for comparative effectiveness research to drive evidence-based practice improvements. Three years ago, AORN projected the need for standardized electronic documentation specific to perioperative care. AORN SYNTEGRITYTM Standardized Perioperative Framework (SPF) was developed in response to this need. This technology uses AORN’s Perioperative Nursing Data Set (PNDS) language within an XML overlay that can be mapped into a software vendor’s electronic health record system, so facilities have a standardized language to record perioperative nursing care. Through a new collaboration announced in January 2010, Cerner Corporation became the first large-scale vendor to adopt the SYNTEGRITYTM Framework. The company collaborated with AORN and Computer Sciences Corporation (CSC) to map the SPF into its Cerner SurgiNet® surgery and anesthesia electronic management system, which includes scheduling, documentation, management, and reporting tools. Having and assimilating electronic patient care data lies at the heart of Cerner’s mission, according to Susan Stiles, MHA, BSN, RN senior strategist for Cerner Corporation. “Partnering with AORN enables us to even further improve the quality of perioperative care that is being delivered. Cerner recognizes AORN to be the leading nursing association that is driving standardized nursing practices and because the industry looks to AORN for their expertise in this area, it seemed like an ideal partnership.” This collaboration with Cerner is expected to be the first of many with most, if not all, of the leading perioperative vendors who also will make the decision to integrate the SPF into their applications, said David Hampshire, senior partner and managing director of Health Delivery at CSC, the company who has worked with AORN to develop the SYNTEGRITYTM Framework. “The key to standardizing data is wide spread adoption and uniformity in its use and AORN will play a vital leadership role in this regard.”

The Effects of Information Technology on Perioperative Nursing

Numerous advances in technology during the past decade require that nurses not only be knowledgeable in nursing science but that they also become educated in information technology (IT). Perioperative IT has the potential to improve the quality of health care, reduce costs, decrease medication administration errors, reduce time spent on paperwork, increase management efficacy, and allow affordable access to health care. Nursing knowledge is needed for designing, implementing, and updating software, including an electronic health record (EHR). With the support of EHR data, nurses will be able to develop best practices for patient care and support research for evidence-based practice. When a standardized terminology, such as the Perioperative Nursing Data Set, is incorporated into an EHR, consistent documentation can be shared among systems. With advances in technology, perioperative nursing roles are expanding in relation to IT requirements and nurses are pursuing additional education. In addition to traditional methods, e-learning is an effective way to provide ongoing technological education.

An Analysis of Nursing Diagnoses for Patients Undergoing Procedures in a Brazilian Interventional Radiology Suite

Innovations in minimally invasive surgery have led to more procedures being performed in the interventional radiology suite. It, therefore, is essential that nurses in radiology departments be competent to care for all types of patients. Use of nursing classification systems can improve care by providing standardized language for documentation. We conducted a project that involved 25 patients undergoing interventional radiology procedures between August and October 2006 in São Paulo, Brazil, to identify the most frequent North American Nursing Diagnosis Association (NANDA) nursing diagnoses used and then compared the NANDA diagnoses to Perioperative Nursing Data Set diagnoses. The most frequent nursing diagnoses in the participants were anxiety, chronic pain, inefficient tissue perfusion–peripheral, deficient knowledge, and risk for falls. These results are similar to diagnoses that have been reported in outpatient centers. The NANDA and Perioperative Nursing Data Set diagnoses were found to be similar.

The Use of Nursing Diagnoses in Perioperative Documentation

To clinically validate the nursing diagnoses of the first Finnish version of Perioperative Nursing Data Set (PNDS) by using them in perioperative documentation. Nursing diagnoses were used in documentation in four operating departments with 250 patients. In analysis, nonparametric tests were applied. While intraoperatively nursing diagnoses focused on physiological concerns, postoperatively the focus shifted to that of recovery. The findings revealed the importance of safety-related routines in perioperative care. Nursing diagnoses in the Finnish version of PNDS are sensitive in describing the rationales for perioperative care. Nursing classifications illustrate the nursing process in a structured form. Nursing diagnosis is an early step in the decision-making process that aims to achieve expected outcomes in nursing care.

The Perioperative Nursing Data Set

The Perioperative Nursing Data Set

Validation of Concept Mapping Between PNDS and SNOMED CT

The perioperative nursing data set (PNDS) is a structured vocabulary developed by AORN to help document perioperative nursing practices. The PNDS has been mapped to the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) reference terminology model to support the electronic exchange of nursing data. This study validates the concept mapping between the PNDS and SNOMED CT, supporting an equivalent meaning of concepts between the two terminology systems.

Utilizing the Perioperative Nursing Data Set in a Surgical Setting

The Perioperative Nursing Data Set (PNDS) is the standardized nursing language for documentation by perioperative nurses. The usage of this language is the essential framework for documentation standardization in the operating room. This article explores 2 specific patient outcomes and how the usage of the PNDS helps guide actions taken by registered nurses in the operating room. Furthermore, this article gives a brief overview of the history of the PNDS, and how this language helps improve nursing outcomes and promotes the profession of nursing.

The Perioperative Nursing Data Set in Korean: Translation, Validation, and Testing

Researchers in South Korea translated the Perioperative Nursing Data Set (PNDS) into Korean and tested its validity and usefulness in South Korean clinical settings. To evaluate the usefulness of the translated PNDS, 142 nurses were surveyed, and the narrative nursing notes of 20 surgical patients discharged from two tertiary hospitals in Seoul, South Korea, were analyzed and mapped using the PNDS. Although nurses found it to be useful, the researchers recommend certain additions to the PNDS, including the addition of action-related statements, to improve its usefulness in Korean perioperative settings.