Standardized Nursing Language Research Articles

A two-arm cluster randomized control trial to determine the effectiveness of a pressure ulcer prevention bundle for critically ill patients.

This study tested the effectiveness of a pressure ulcer (PU) prevention bundle in reducing the incidence of PUs in critically ill patients in two Saudi intensive care units (ICUs). A two-arm cluster randomized experimental control trial. Participants in the intervention group received the PU prevention bundle, while the control group received standard skin care as per the local ICU policies. Data collected included demographic variables (age, diagnosis, comorbidities, admission trajectory, length of stay) and clinical variables (Braden Scale score, severity of organ function score, mechanical ventilation, PU presence, and staging). All patients were followed every two days from admission through to discharge, death, or up to a maximum of 28 days. Data were analyzed with descriptive correlation statistics, Kaplan-Meier survival analysis, and Poisson regression. The total number of participants recruited was 140: 70 control participants (with a total of 728 days of observation) and 70 intervention participants (784 days of observation). PU cumulative incidence was significantly lower in the intervention group (7.14%) compared to the control group (32.86%). Poisson regression revealed the likelihood of PU development was 70% lower in the intervention group. The intervention group had significantly less Stage I (p = .002) and Stage II PU development (p = .026). Significant improvements were observed in PU-related outcomes with the implementation of the PU prevention bundle in the ICU; PU incidence, severity, and total number of PUs per patient were reduced. Utilizing a bundle approach and standardized nursing language through skin assessment and translation of the knowledge to practice has the potential to impact positively on the quality of care and patient outcome.

Nutrition as a Vital Sign: Progress Since the 1990 Multidisciplinary Nutrition Screening Initiative and Opportunities for Nursing

Vital signs provide critical information about health and help form the baseline for clinical care. Twenty years ago, the Nutrition Screening Initiative posed nutrition screening as a vital sign for older Americans but this has still not occurred. Nursing is on the frontline for monitoring as well as working to improve nutrition intake in collaboration with dietitians and other healthcare professionals. This article describes the importance of malnutrition screening, key indicators of elder well-being, and how the older American population has changed in the last few decades. The article also chronicles the multidisciplinary Nutrition Screening Initiative, its accomplishments, challenges, and new developments including new screening data collection instruments and the frailty index. Other developments described are the Alliance to Advance Patient Nutrition's intervention framework and documentation of the economic value of nutrition intervention. Opportunities and next steps for nurses to help malnutrition screening become a vital sign are identified. These include the need to make malnutrition screening and intervention part of the core training for nurses. In the hospital setting, the Joint Commission requires that all patients be screened for malnutrition within 24 hours, however malnutrition interventions are often lacking. Thus another opportunity is for malnutrition measurement and documentation to be developed as a summative measure and included as part of the standardized nursing language, with a specific section in the Electronic Health Record. Becoming part of national health goals, such as the Healthy People 2020 objectives, is an additional important step for the evolution of malnutrition screening as a vital sign as is integrating malnutrition screening and intervention into healthcare incentives, including the Patient Protection and Affordable Care Act, transitions of care, and community intervention. Finally, committing funding for malnutrition screening, such as through reauthorization of the Older Americans Act, and gaining key learning from international experiences are important.

Incorporating standardized nursing languages into an electronic nursing documentation system in Korea: a pilot study.

The purposes of this study were to (a) develop and implement a standardized nursing languages-based electronic nursing documentation system in Korea, and (b) explore nurses' experience with NANDA-I, Nursing Interventions Classification, and Nursing Outcomes Classification languages in relation to nursing workflow. The system was developed by the research team and implemented in a tertiary hospital in Korea. Ten nurses used the system and interviews were conducted to explore nurses' experiences with the standardized nursing languages. The most frequently used NANDA-I, Nursing Interventions Classification, and Nursing Outcomes Classification were identified. Nurses' experiences with standardized nursing languages and how they impact nursing workflow were analyzed. Obtaining valid and comparable data from this system will be critical in improving patient safety, quality, and evidence-based practice.

Using the Omaha System to Describe Health Problems, Interventions, and Outcomes in Home Care in Istanbul, Turkey

Preparing nursing students to achieve informatics competencies is essential in today's information-intensive healthcare delivery systems. This study aimed to provide hands-on informatics experience to nursing students and to identify the frequency and type of home care clients' health problems, nursing interventions, and outcomes using a standardized nursing terminology, the Omaha System. Data were collected by 159 nursing students on home visits to 598 clients, who received 8657 interventions from students and faculty for 2267 problems, in addition to the services provided by the home care centers. Skin, neuromusculoskelatal function, personal care, nutrition, and urinary function were the most common problems. The most common intervention category was teaching, guidance, and counseling (47%), followed by treatments and procedures (22%), surveillance (22%), and case management (9%). Outcomes evaluation showed significant improvement in 97.5% of the identified problems. Students gained informatics experience in the use of a standardized nursing language in electronic health records, data management, and use of nursing data at the basic practice level. This study demonstrated that the Omaha System was a useful data collection tool for evaluating problems, interventions, and outcomes in home care and a positive teaching and learning tool for baccalaureate nursing education.

Impact of an Educational Program on the Use of Standardized Nursing Languages for Nursing Documentation Among Public Health Nurses in Nigeria

To measure the effect of an educational package on documentation of care among public health nurses (PHNs). A quasi-experimental design was adopted. Forty PHNs working in primary healthcare settings were selected. Education was given through a 5-day workshop. Documentation of care was assessed using a modified "Muller-Staub Q-DIO instrument." Data were analyzed using t test third and twelfth months postintervention. There was a significant improvement on documentation of care at p = .0001. Educating PHNs and providing them with standardized nursing care plans enhance documentation of care. IMPLICATION TO PRACTICE: A combination of education on the use of standardized nursing languages and standardized nursing care plans can enhance documentation of care. There is a need for more research on the use of standardized nursing languages in developing nations.

Study on the effect of standard nursing language to reduce nurse-patient conflicts in transfusion observation room

Objective To formulate the specification nursing language in nurse-patient conflict situation so as to make up the deficiencies of the existing nursing language.Methods Collected the causes of 46 conflicts of nurse-patient,developed standardized nursing language,and 80 nurses were randomly divided into intervention group and control group,the intervention group received the training.After six months,the communication skills of two groups of nurses were compared.Results In the nurse-patient conflict situation,causes including the unreasonable process by patients,hospital facilities,the issue of fees,nursing errors in the work and other factors,the intervention group nursing language score respectively were (62.81 ± 2.79,35),(76 ± 2.92),(18.41 ± 2.35),(21.06 ± 2.32),and that in the control group were (48.87 ± 3.63),(26.31 ±5.75),(14.02 ± 2.68),(15.26 ± 3.14),respecctively,and the difference between the two groups was statistically significant (t =13.251,14.260,9.252,11.902,respectively;P ＜ 0.01).Conclusions The standardized nursing language training to broaden the resolving ideas of nurse-patient conflict,improve communication skills and flexibilities of nurses,so as to achieve the purpose of harmonious nurse-patient relationship. Key words: Nurse; Nurse-patient conflict; Nurse-patient communication; Nursing language; Transfusion observation room

Participant Action Research With Staff Nurses in End-of-Life Care

Standardized nursing languages should be used in end-of-life care for ease of transition to the electronic health record and to be able to benchmark best practices through aggregation of nursing care elements such as human response diagnoses, patient outcomes, and nursing interventions. The most comprehensive of the languages approved by the American Nurses Association are the research-based classifications of NANDA-International (NANDA-I), the Nursing Outcomes Classification (NOC) and the Nursing Interventions Classification (NIC). This was a qualitative study using participant action research methods to identify the NANDA-I diagnoses, NOC outcomes, and NIC interventions that staff nurses identified as relevant for end-of-life care in a hospital unit that is totally devoted to end-of-life care in collaboration with patients and families. The results are that 24 NANDA-I diagnoses were selected as relevant for typical patients, each with one or more outcomes and two to 12 interventions. A majority of diagnoses were in the coping/stress tolerance domain (n = 6) and in the safety/protection domain (n = 5). The intervention of feeding was identified as mainly used for comfort with spiritual and cultural aspects. In contrast to other types of care, feeding is not related to maintenance or improvement of nutrition. The selected standardized nursing language terms will be used for nursing care plans and in the front screens of this hospital’s electronic health record.

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).

Health Technology Assessment in nursing: a literature review

The Health Technology Assessment (HTA) approach, which provides scientific support for the decisions taken within the health field, is of increasing importance worldwide. In a context of limited resources, HTA has the potential of being an efficient tool for addressing the sustainability problems and the allocation choices arising from the constant increase in demand. This study aims to investigate HTA use in nursing, both in terms of quantifying HTA evaluations of nursing phenomena which have been conducted and in terms of the extent to which nursing has used the HTA approach. The Italian context has been analysed because of the growing diffusion of the HTA in Italy along with the recent developments in the nursing profession. A narrative review of international literature was undertaken using the following databases: HTA, PubMed, CINAHL, ILISI. Seventy evaluation studies on nursing were identified from the HTA database (1.12% of all studies in the database). The areas of nursing intervention and the country of origin of the studies were identified. Two nursing studies on the HTA approach were found in the PubMed, CINAHL and HTA databases. The first focused on the evaluation of nursing technology process and analysed 126 studies in six main thematic areas; the second was a systematic review on HTA in nursing and analysed 192 studies (46 meta-analyses, 31 Finnish primary studies, 117 international primary studies). Three Italian studies were identified from the ILISI database and Italian grey literature. In the international literature, although analyses regarding the efficacy of nursing interventions have been conducted, there are to date very few research projects that focus exclusively on the HTA process as applied to nursing. The recent development of a standardized nursing language coupled with the open debate as to which research method (qualitative vs. quantitative) best serves to 'read' nursing phenomena may explain the scarce diffusion of HTA in the field of nursing.

Identifying the barriers to use of standardized nursing language in the electronic health record by the ambulatory care nurse practitioner

This study identified the perceived user barriers to documentation of nursing practice utilizing standardized nursing language (SNL) in the electronic health record (EHR) by ambulatory care nurse practitioners (NPs). A researcher-developed survey was sent to a randomized sample of ambulatory care NPs in the United States who belonged to the American Academy of Nurse Practitioners (n= 1997). Surveyed ambulatory care NPs placed a higher value on documenting medical care versus nursing care. Only 17% of respondents currently use SNL and 30% believe that SNL is not important or appropriate to document NP practice. Barriers to using SNL in EHRs included lack of reimbursement for nursing documentation, lack of time to document, and lack of availability of SNL in electronic records. Respondents identified NP practice as a blend of medical as well as nursing care but NPs have not embraced the current SNLs as a vehicle to document the nursing component of their care, particularly in EHRs. Until these barriers are addressed and discreet data in the form of SNL are available and utilized in the EHR, the impact of the NPs care will be unidentifiable for outcomes reporting.

Harnessing the Power of Student Health Data

School nurses manage an immense amount of student health information, making electronic documentation systems essential to provide effective care for students. This article describes the elements of and rationale for using an electronic documentation system, the use of standardized nursing languages, and strategies for successfully implementing an electronic documentation system.

Enhancing the Visibility of NP Practice in Electronic Health Records

Electronic health records (EHRs) are being rapidly adopted as a tool for nurse practitioners (NPs) to organize, document, and report data for health outcomes. The development of EHRs has focused on documenting medical information, making the nursing portion of NP practice invisible in the electronic record. Standardized nursing language (SNL) is the vehicle to capture discrete nursing data. Until SNL is widely available and used, the impact of the nursing portion of NP practice will be unidentifiable for outcomes reporting. Opportunities to promote NP practice through SNL in EHRs are available at the national, state, and practice levels.

Definições para o resultado de enfermagem comportamento de prevenção de quedas: uma revisão integrativa

Devido à necessidade de mensurar o risco de quedas em concordância à linguagem padronizada de enfermagem, foi selecionado o resultado de enfermagem Comportamento para Prevenção de Quedas da Nursing Outcomes Classification (NOC), com objetivo de identificar evidências sobre seus elementos, mensuração, comparação com indicadores existentes e construir definições constitutivas. Foi efetuada revisão integrativa entre abril e novembro de 2009, mediante identificação da questão, estabelecimento de critérios de inclusão/exclusão, extração das informações, avaliação, interpretação e síntese. Destacaram-se pesquisas transversais e perspectivas de especialistas. Os indicadores Uso de recursos de correção da visão e Uso de sapatos amarrados e do tamanho adequado foram considerados insuficientes para avaliar fatores de risco como déficits sensoriais e roupas/calçados inadequados. Percebe-se que algumas definições precisam ser melhor desenvolvidas e que esse resultado de enfermagem merece refinamento sobretudo referente aos indicadores. Foram identificados 22 indicadores e definições foram propostas baseadas nas evidências da literatura. Descritores: Enfermagem; Processo de Enfermagem; Avaliação em Enfermagem; Acidentes por quedas; Prevenção.

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.

Supporting Breast-feeding When a Woman Is Homeless

This case study demonstrates use of standardized nursing languages in the care of new mothers in community settings. The author collected data from clinical practice as an instructor in a baccalaureate nursing program and from the research literature. The appropriate nursing diagnoses, outcomes, and interventions were identified in partnership with the new mother. This case shows that NANDA International (NANDA-I), the Nursing Outcomes Classification (NOC), and the Nursing Interventions Classification (NIC) are useful to direct nursing care in community settings. When teaching nursing students in a baccalaureate program, nurse faculty can use NANDA-I, NOC, and NIC classifications to guide the growing practice of nursing students in community settings.

A Case Study of Teen Parenting

The purpose of this case study is to demonstrate how the use of the standard nursing languages of NANDA International (NANDA-I), the Nursing Interventions Classification (NIC), and the Nursing Outcomes Classification (NOC) help a teen mother provide safe care for her newborn. In addition, this study aims to demonstrate how important standardized nursing languages are in documenting the care provided. The data sources for this article are clinical nursing practice, research evidence in the form of care directives from the American Academy of Pediatrics regarding newborn safety and feeding, and the books that provide directions for the use of NANDA-I, NIC, and NOC. This case demonstrates the use of the nursing process in providing care for a teen mother and a newborn. Many new mothers, especially teens, are poorly informed regarding normal newborn care and safety upon hospital discharge. For this reason, teen mothers should be referred for nursing assessments in the home environment after discharge. This case demonstrates the need for education of all parents prior to hospital discharge and supports the need for home-based evaluations to ensure the safety of the infant. This case also supports the use of standardized nursing language to document the care provided.

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 today's 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 nursing's 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 nurse-patient 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 nursing's 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.

A Documentation Approach for Faith Community Nursing

Faith Community Nursing: Scope and Standards of Practice (American Nurses Association and Health Ministries Association, 2005) establishes the professional responsibility for documenting relevant data in a retrievable format that is both confidential and secure. Documentation systems used by faith community nurses (FCNs) need to be accurate, yet simple and concise. This article presents an approach to documenting FCN activities, the provided care, and outcomes of that care, while emphasizing the use of standardized nursing language.

Nursing Specialty Knowledge as Expressed by Standardized Nursing Languages

To describe how nursing specialty knowledge is demonstrated in nursing records by use of standardized nursing languages. A cross-sectional review of nursing records (N = 265) in four specialties. The most common nursing diagnoses represented basic human needs of patients across specialties. The nursing diagnoses and related interventions represented specific knowledge in each specialty. Sixty-three nursing diagnoses (nine appeared in four specialties) and 168 nursing interventions were used (24 appeared in four specialties). Findings suggest that standardized nursing languages are capable of distinguishing between specialties. Further studies with large data sets are needed to explore the relationships between nursing diagnoses and nursing interventions in order to make explicit the knowledge that nurses use in their nursing practice. Nursing data in clinical practice must be stored and retrievable to support clinical decision making, advance nursing knowledge, and the unique perspective of nursing.

NNN Language and Evidence-Based Practice Guidelines for Acute Cardiac Care

Multidisciplinary management of the acute cardiac patient, for decades, has been driven by best practices, treatment algorithms, and research-based protocols. As nurses continue to develop and implement evidence-based care, they must ensure that the essence of nursing is not lost in the process. In this article, strategies for the development of evidence-based practice guidelines for acute cardiac patients using standardized nursing language are provided.