Standardized Nursing Language Research Articles

The use of standardized nursing languages in electronic medical records: an exploratory study on opportunities, limitations, and strategies

Standardized nursing languages (SNLs) have found increasing application in electronic medical records in recent years. In Italy their use is still uneven and accompanied by a silent debate between positions 'against' and 'for' their use. To render visible the debate regarding SNLs in Italy, and the strategies to consider when digitized records are based on a SNL. Data has been collected through audio-recorded semi-structured interviews, selecting three Italian nursing professors, four managers representing Italian healthcare settings that used a SNT and a representative of the Central committee of the National federation of orders of nursing professions. The thematic approach was used to analyze the data. Participants reported having introduced digitized records based on nursing diagnoses, integrated with the Nursing Interventions Classification System and Nursing Outcome Classification, Clinical Care Classification System, Nursing Sensitive Outcomes or mixed models. Divergent aspects emerge regarding: (1) using nursing languages vs a common language to other healthcare professions; (2) planning care vs enhancing clinical reasoning; (3) measuring nursing care vs accepting the variability of the practice, and (4) making documentation efficient vs dedicating more time. Some convergences have emerged and a set of indications for introducing electronic records when based on standardized languages. The introduction of electronic documentation requires the use of homogeneous languages. The debate on the potential and limits of SNL is still open and requires reflection among researchers, trainers, clinicians, and coordinators/managers of nursing care regarding the choices to be made which may have long-term effects on many nurses.

Prevalence and clustering of NANDA-I nursing diagnoses in the pre-hospital emergency care setting: A retrospective records review study.

To determine the prevalence and clustering of NANDA-International nursing diagnoses in patients assisted by pre-hospital emergency teams. Retrospective descriptive study of electronic record review. Episodes recorded during 2019, including at least a nursing diagnosis, were recovered from the electronic health records of a Spanish public emergency agency (N = 28,847). Descriptive statistics were used to characterize the sample and determine prevalence. A two-step cluster analysis was used to group nursing diagnoses. A comparison between clusters in sociodemographic and medical problems was performed. Data were accessed in November 2020. Risk for falls (00155) (27.3%), Anxiety (00146) (23.2%), Acute pain (00132), Fear (00148) and Ineffective breathing pattern (00032) represented 96.1% of all recorded diagnoses. A six-cluster solution (n = 26.788) was found. Five clusters had a single high-prevalence diagnosis predominance: Risk for falls (00155) in cluster 1, Anxiety (00146) in cluster 2, Fear (00148) in cluster 3, Acute pain (00132) in cluster 4 and Ineffective breathing pattern (00032) in cluster 6. Cluster 5 had several high prevalence diagnoses which co-occurred: Risk for unstable blood glucose level (00179), Ineffective coping (00069), Ineffective health management (00078), Impaired comfort (00214) and Impaired verbal communication (00051). Five nursing diagnoses accounted for almost the entire prevalence. The identified clusters showed that pre-hospital patients present six patterns of nursing diagnoses. Five clusters were predominated by a predominant nursing diagnosis related to patient safety, coping, comfort, and activity/rest, respectively. The sixth cluster grouped several nursing diagnoses applicable to exacerbations of chronic diseases. Knowing the prevalence and clustering of nursing diagnoses allows a better understanding of the human responses of patients attended by pre-hospital emergency teams and increases the evidence of individualized/standardized care plans in the pre-hospital clinical setting. What problem did the study address? There are different models of pre-hospital emergency care services. The use of standardized nursing languages in the pre-hospital setting is not homogeneous. Studies on NANDA-I nursing diagnoses in the pre-hospital context are scarce, and those available are conducted on small samples. What were the main findings? This paper reports the study with the largest sample among the few published on NANDA-I nursing diagnoses in the pre-hospital care setting. Five nursing diagnoses represented 96.1% of all recorded. These diagnoses were related to patients' safety/protection and coping/stress tolerance. Patients attended by pre-hospital care teams are grouped into six clusters based on the nursing diagnoses, and this classification is independent of the medical conditions the patient suffers. Where and on whom will the research have an impact? Knowing the prevalence of nursing diagnoses allows a better understanding of the human responses of patients treated in the pre-hospital setting, increasing the evidence of individualized and standardized care plans for pre-hospital care. STROBE checklist has been used as a reporting method. Only patients' records were reviewed without further involvement.

Standardized Nursing Language (SNL) Application in Diverse Nursing Practice and Documentation Settings

Background: Effective communication in healthcare is crucial, and Standardized Nursing Language (SNL) has emerged as a powerful tool to enhance nursing practice and documentation. However, disparities in SNL awareness and knowledge pose challenges to its effective implementation. This systematic review aims to synthesize research on SNL application in nursing practice across diverse settings, utilizing a comprehensive database search and predefined criteria for study selection. Methods: Comprehensive searches were conducted across databases like PubMed, Scopus, ProQuest, and Web of Science. This systematic review adhered to the updated guidelines provided by PRISMA 2020. Three independent reviewers assessed study eligibility based on predefined criteria, resolving discrepancies through discussion. A narrative synthesis approach categorized and thematically analyzed the data, focusing on SNL's impact in diverse healthcare settings. Data was retrieved after the studies were subjected to quality assessment and risk of biases. Results: The review included twelve studies spanning various healthcare systems and regions. While SNL demonstrated potential benefits, disparities in awareness, knowledge, and utilization were evident among participants. Challenges such as complex documentation processes and feasibility concerns were raised. Conclusion: SNL plays a pivotal role in enhancing nursing practice, improving documentation, and facilitating effective communication. Addressing education gaps and providing ongoing training opportunities are essential to overcome implementation challenges. Collaboration among healthcare institutions, educators, and regulatory bodies is crucial to fully leveraging SNL's benefits for better patient care and healthcare outcomes.

The Effect Of Mentoring Programs On Improving Critical Thinking Ability Using Standardized Nursing Language As A Learning Method In Students

Nursing mentoring is method appropriate in increase culture safety patient . Culture safety patient need developed more Formerly For can overcome concern. Describe the influence of mentoring programs on enhancement ability think critical use standardized nursing language as a learning method for students . In this study the researchers used the Quasi Experimental method with the One Group Pretest-posttest design approach , the population in this study were students of the Faathir Husada Tangerang College of Health Sciences semesters 4, 6, 8 with a total of 34 respondents. characteristics respondent based on type sex from 34 respondent type sex Woman the most with frequency 21 respondent . In research This analysis univariate used For know percentage from each variable research . Namely Program mentoring And Think Critical to student in STIKes Fathir Husada Tangerang. From the results research that has done exists influence positive and significant before and after given a mentoring program ability think critical use standardized nursing language .

The quality of nursing diagnoses, interventions, and outcomes in Romanian nursing documentation measured with the Q-DIO: A cross-sectional study.

To assess the quality of the nursing process in Romania by evaluating nursing documentations with the quality of diagnoses, interventions and outcomes (Q-DIO) measurement instrument. A quantitative cross-sectional research design was employed using probabilistic sampling to select nursing documentations from a Romanian university hospital. The data were analyzed using the Q-DIO measurement instrument. Low quality levels of nursing process documentation were found. The Q-DIO subscale "Nursing diagnoses as process" (assessment) revealed a mean=1.36 (SD 0.52) of maximum 2. Nurses collected lots of data but did not use these to state nursing diagnoses. "Nursing diagnoses as product" showed inaccurate diagnoses; mean=1.24 (SD 0.48) of maximum 4. Nursing interventions were planned and documented, but their impact on the etiology of nursing diagnoses was low; mean=0.76 (SD 0.18). The quality of nursing outcomes mean was 0.57 (SD 0.29). Nurses failed making connections between nursing assessment, diagnoses, interventions, and outcomes, and standardized nursing languages (SNLs) were not used. Statistically significant differences were found among all Q-DIO sub-concepts except for "Nursing diagnoses as process." The documentation was structured but did not support the nursing process and its documentation, and SNLs were not implemented. There was an underutilization of data to state nursing diagnoses, and nursing interventions were mostly ineffective, leading to low nursing outcomes. This study provides new insights on the nursing process and its documentation in Romania and a baseline for future research. Policymakers, administrators, and educators should consider educating nurses to use standardized nursing languages and apply the Advanced Nursing Process.

How Nurses Develop Standardized Care Plans Under a Clinical Decision Support System: A Mixed-Methods Study.

Standardized care plans are being increasingly introduced to health facilities; however, their level of adoption remains unsatisfactory. Little is known about nurses' use of standardized care plans in China. This study aims to investigate acute care nurses' practices and experiences of care planning within a clinical decision support system embedded with standardized nursing languages. We explored the importance and performance of nursing interventions by retrospective analysis of 400 standardized care plans (performance) and a survey among nurses (importance). Semistructured interviews were conducted to supplement quantitative findings and delve deeper into nurses' experience with standardized care plans. A total of six core nursing diagnoses were determined, each corresponding to seven to 15 nursing interventions. The correlations between nurses' perceived importance and actual performance of nursing interventions in the care plan were weak. Qualitative interviews identified three themes: negative attitudes toward the care plan, uncertainty regarding care planning, and new routines with the care plan. Our findings indicate that nurses' care planning may not reflect their professional judgments. Effective leadership from nurse administrators is warranted to engage nurses with standardized care plan implementation. The content of the standardized nursing language embedded-knowledge base should be continuously adapted to clinical needs to facilitate nurses' care planning practices.

Using Nursing Interventions Classifications to Document Faith Community Nursing Transitional Care.

One out of five Medicare beneficiaries is readmitted within 30 days after hospital discharge, and as many as three in four readmissions are preventable. This study describes transitional care interventions (TCIs) delivered by one faith community nurse (FCN) to at-risk seniors living in a certain ZIP code. Two years of nursing documentation (2,280 interventions) were translated into Nursing Interventions Classification standardized nursing language. Results indicate the FCN provided priority TCIs including spiritual care. In fully describing TCIs using a nursing language, results support that the FCN transitional care model is a method worth exploring to provide wholistic transitional care.

Situation-Specific Theory for Health Management in Heart Failure.

This situation-specific theory was developed by linking concepts from Orem's Self-Care Deficit Nursing Theory and standardized nursing languages with the purpose of explaining and describing the health management of outpatients with heart failure. This theory suggests that the health management of these patients is influenced by basic conditioning factors, which may affect individuals' health management capability and may interfere with the ability to present health management behaviors. Knowing the ability of these patients to manage their health will allow nurses to plan their interventions, which will reflect directly on a patient's quality of life, and reduce the chances of hospitalization and health costs.

Nurses' preferences for the format of care planning clinical decision support coded with standardized nursing languages.

Current electronic health records (EHRs) are often ineffective in identifying patient priorities and care needs requiring nurses to search a large volume of text to find clinically meaningful information. Our study, part of a larger randomized controlled trial testing nursing care planning clinical decision support coded in standardized nursing languages, focuses on identifying format preferences after random assignment and interaction to 1 of 3 formats (text only, text+table, text+graph). Being assigned to the text+graph significantly increased the preference for graph (P = .02) relative to other groups. Being assigned to the text only (P = .06) and text+table (P = .35) was not significantly associated with preference for their assigned formats. Additionally, the preference for graphs was not significantly associated with understanding graph content (P = .19). Further studies are needed to enhance our understanding of how format preferences influence the use and processing of displayed information.

Implementing a Care Plan System in a Community Hospital Electronic Health Record.

Nursing care plans, the result of the nursing process, are important because they guide quality patient care, define the nurse's role in patient treatment, and support patient specific nursing interventions. Nurse leaders at a community hospital identified that 70% of hospitalized patients shared the same three nursing problems and three-day resolution target dates. This quality improvement project involved the implementation of a nursing care plan system within the organization's existing electronic health record platform that supported the development of individualized plans. The implementation included a) integration of care plan activities into the nursing workflow, b) adoption of a standardized nursing language to provide structure nursing care plan data capture and reporting, c) configuration of the electronic health record to recommend patient data-driven care plan problems based on nursing assessment documentation; and d) trended care plan data to identify problem patterns within the patient population. A postimplementation audit indicated a 130% improvement in achieving individualized care plans within 24 hours of admission.

Heuristic smartphone usability evaluations of the mobile application NANDA, nursing interventions classification, and nursing outcomes classification customized for nursing home registered nurses.

We aimed to evaluate the usability of a smartphone application consisting of standardized nursing language (SNL) using NANDA, Nursing Intervention Classification, and Nursing Outcome Classification for nursing home nurses. Applying convenience sampling, a total of 14 experts and 15 real users were invited to test and evaluate the smartphone application independently. For the usability evaluation of the developed application, the Korean version of the Mobile Application Rating Scale for experts and Mobile Application Rating Scale: User Version developed by Stoyanov etal. were used. Both groups determined that the SNL application was quite informative about SNL and efficient function; however, the engagement was quite lower than other categories. Although SNLs were scientifically developed for several decades, the widely available technological application for registered nurses in different languages is urgently needed to improve quality of nursing care. The identified problems and recommendations by users and experts using heuristic evaluation will be reflected in the application's final version to be used for research.

Transition to a new nursing information system embedded with clinical decision support: a mixed-method study using the HOT-fit framework

BackgroundNursing information systems embedded with standardized nursing language and clinical decision support have been increasingly introduced in health care settings. User experience is key to the adoption of health information technologies. Despite extensive research into the user experience with nursing information systems, few studies have focused on the interaction between user, technology and organizational attributes during its implementation. Guided by the human, organization and technology-fit framework, this study aimed to investigate nurses’ perceptions and experiences with transition to a new nursing information system (Care Direct) 2 years after its first introduction.MethodsThis is a mixed-method study using an embedded design. An online survey was launched to collect nurses’ self-reported use of the new system, perceived system effectiveness and experience of participation in system optimization. Twenty-two semi structured interviews were conducted with twenty nurses with clinical or administrative roles. The quantitative and qualitative data were merged using the Pillar Integration Process.ResultsThe average score of system use behavior was 3.76 ± 0.79. Regarding perceived system effectiveness, the score of each dimension ranged 3.07–3.34 out of 5. Despite large variations in approaches to participating in system optimization, nurses had generally positive experiences with management and technical support. Eight main categories emerged from the integrated findings, which were further condensed into three themes: perceptions on system content, structure, and functionality; perceptions on interdisciplinary and cross-level cooperation; and embracing and accepting the change.ConclusionsEffective collaboration between clinicians, administrators and technical staff is required during system promotion to enhance system usability and user experience. Clear communication of organizational missions to staff and support from top management is needed to smooth the system implementation process and achieve broader system adoption.

Nurses' lived experiences in the utilization of standardized nursing languages in documentation of nursing care, in Cross River State, Nigeria.

The concept of standardized nursing languages (SNLs) was introduced to solve the problem created by the use of different terminologies to document care by nurses working in diversified contexts. This study explored professional nurses' experiences in the utilization of SNL in documenting patients' care. A qualitative descriptive design was adopted for this study, and a purposive sampling technique was used to select eight nurses for the study from a tertiary health facility. Data were collected using an in-depth interview guide. Rigour and trustworthiness were ensured using the techniques of credibility, dependability, transferability, and confirmability. Data were analyzed according to Braun and Clarke's six-step thematic analyses. The key finding indicates that nurses appreciate the advantages of utilizing SNLs; however, they encounter some problems in formulating correct nursing diagnoses and several challenges in using SNLs, such as manpower shortage, lack of time, inappropriate materials, inadequate knowledge of NOC and NIC. These challenges have caused the utilization of SNLs among nurses to be poor. SNLs have been recognized as the gold standard for nursing practice; however, their usage is poor. To ensure the adequate use of SNLs, it is the responsibility of the nurse and the institution to resolve the barriers to the use of SNLs. The study recommends that the utilization of SNLS could be improved with the provision of more seminars, the creation of a policy on SNLs use, and the use of electronic documentation IMPLICATION TO NURSING: This study contributes by providing a picture of nurses' experiences in utilizing SNLs in Nigeria, identifying challenges experienced and recommending ways to tackle these challenges.

Challenges to sustainability of standardized nursing care plan in selected tertiary health institutions in Nigeria.

The purpose of this study was to assess the challenges to sustainability of standardized nursing care plan in selected tertiary health institutions in Nigeria. Using convergent mixed method design, the qualitative and quantitative data were collected from 427 nurses and nine stakeholders. This was done in one phase with the use of validated questionnaires and in-depth interview guide/key informant interview guide. Data were collected for 5 months and analyzed with SPSS version 25. Qualitative data were analyzed using themes. The explored significant challenges by stakeholders and nurses to sustainability of standardized nursing care plan (SNCP) in all the selected hospitals were inadequate knowledge of standardized nursing languages (SNLs), inadequate staffing, lack of motivation, lack of mandate to use SNLs by the educational system, lack of computers on the wards, weakness of previous training on SNL/SNCP, lack of interest, and high patient load. The study concludes that inadequate knowledge of SNLs and inadequate staff could contribute to non sustainability of SNCP. Nurses should be continuously trained on standardized nursing languages. Staff motivation and increasing the number of staff on the wards would increase the interest of the nursing staff. This will in turn improve the quality of documentation and patient care.

Nursing knowledge captured in electronic health records.

The purpose of this study was to describe the extent to which nursing assessment data was present in the electronic health record and linked to NANDA-I, NIC, and NOC. This retrospective review used a descriptive approach to examine documentation in the electronic health records (EHR) of 10 hospitalized patients requiring cardiac surgery. A team of experts applied a Delphi consensus-building process to identify the supports and barriers for nursing documentation. Collection of the health history was organized using Gordon's Functional Health Pattern (FHP) Framework. Seventy-five fields were noted for the entry of nursing assessment data of which 65 focused on health history data and 30 documented physical findings and observations. There were no references to the defining characteristics or etiologies with any of the diagnostic labels used. Care plans included the nursing diagnoses, goals of care, and interventions, although there was a lack of clear alignment between the assessment, NANDA-I, NIC, and NOC and the care plan. Progress note documentation addressed significant events in the patient's clinical course; however, these were not nursing problem or diagnosis focused. Four expert reviewers arrived at consensus regarding the supports and challenges impacting nurses' ability to document data depicting nursing's contribution to care using a FHP and standardized nursing language in the EHR. The EHR provides an opportunity to reflect nursing clinical judgment and make nursing care visible. These findings suggest there are challenges to capturing nurse focused data elements in the EHR. This work has important implications for clinicians, educators, and administrators alike. EHR systems must accurately capture nurses' contribution to patient care to plan for resource allocation and quality care delivery. Ultimately, the development of standardized data sources reflecting the outcomes of nursing care will expand the opportunities to advance nursing knowledge.

Case study: School-based care for a girl and her primary caregiver experiencing difficulties in managing diabetes treatment.

To describe the use of the nursing process and standardized nursing language by the school nurse to facilitate the monitoring of the therapeutic regimen of a girl with type 1 diabetes mellitus and her caregiver. Data were collected through clinical reports, observation, and physical examination of the girl and through interviews with her and her caregiver in accordance with Virginia Henderson's conceptual model. Clinical reasoning informed the selection of NANDA-I nursing diagnoses. NIC nursing interventions were selected taking into consideration the available scientific evidence related to the care of children with type 1 diabetes mellitus. The school nurse is a key figure in improving and supporting the monitoring of the prescribed therapeutic regimen for children with chronic disease. This case demonstrates the importance of adopting a conceptual model to guide the nursing process, as well as showing that standardized nursing languages are suitable for school nursing practice.

Cross-mapping medical records to NANDA-I to identify nursing diagnoses in a vulnerable population.

To assess the association between vulnerable populations and nursing care needs, using NANDA-I diagnostics, in the population of the Canary Islands, Spain. Nursing social epidemiology study. Cross Mapping of Medical Records to NANDA-I to Identify Nursing Diagnoses in a Population usinga medical, epidemiological follow-up study of a cohort of 7,190 people. The level of vulnerability of the participants was assigned, among those who were also assigned nursing diagnoses, using the "ICE index" to calculate the expected associations. The most prevalent nursing diagnosis in our sample was Sedentary lifestyle (60.5%), followed by Ineffective health self-management (33.8%) and Risk-prone health behaviour (28.7%). Significant differences were found by sex, age group and social class, with the nursing diagnoses included in the study being more prevalent among the most socio-economically disadvantaged social class. The cross-mapping method is useful to generate diagnostic information in terms of care needs, using the NANDA-I classification. The expected associations between high social vulnerability and care needs have been verified in a comprehensive and representative sample of the Canarian population (Spain). From an epidemiological perspective, identifying nursing diagnoses at the population level allows us to find the most prevalent needs in the different community groups and to focus appropriate nursing interventions for their implementation and impact assessment.

Development of a Clinical Data Model Addressing the Nursing Focus "Anxiety": A Consensus Development Study.

Anxiety disorders are among the most prevalent mental disorders worldwide. However, anxiety is not exclusive to anxiety disorders. In fact, the nursing discipline approaches anxiety as a human response to health conditions/life processes. Health information systems should primarily contribute to improving the quality of care, patient safety, and the effectiveness of care delivery. Nevertheless, nursing information systems still fail to incorporate evidence-based clinical data models addressing the nursing focus "anxiety." Thus, this study aimed to obtain consensus on the data to be included in a clinical data model addressing the nursing focus "anxiety," its organization, and its interrelationships by using a brainstorming session and a modified e-Delphi technique with a panel of nurse experts from across Portugal. Eight experts participated in the brainstorming session. A total of 59 and 54 participants completed the survey in e-Delphi rounds 1 and 2, respectively. Consensus was achieved to all data presented to the participants, and these data were later included in the clinical data model. This evidence-based clinical data model, grounded on a nursing theory and with standardized nursing language, will substantially contribute to nursing documentation and, consequently, to nursing care targeted at patients with anxiety.

Electronic nursing care plans through the use of NANDA, NOC, and NIC taxonomies in community setting: A descriptive study in northern Italy.

PurposeTo carry on a descriptive analysis of nursing standardized language through the use of a software within outpatient facilities in northern Italy, organized according to the Chronic Care Model (CCM) and called Community Health Centers (CHC).MethodsA descriptive design was adopted for the study. NANDA‐I, NOC, and NIC taxonomies have been used to analyze care plans pulled from the software. Both qualitative and quantitative data were analyzed.FindingsThe average of nursing diagnosis correctly identified with respect to the nursing assessment is 83.7% (SD 29.9%). Class 4 diagnoses from Domains 4 have been identified as the most prevalent (22.4%), followed by risk for unstable blood glucose level 00179 (16.4%) and risk for overweight 00234 (13%). The main nursing outcomes were vital signs 0802 (22.5%), blood glucose level 2300 (16%), and weight loss behavior 1627 (11%). The most prevalent nursing interventions are wound care 3660 (27%), medication administration: intramuscular 2313 (19%), and health education 5510 (14%). The analysis shows ability in identifying nursing diagnoses, but a larger variability with outcomes and interventions. The study highlights the nursing role within CHC and identifies the main areas of expertise in chronic disease management: prevention and health education.ConclusionsNurses’ role is fundamental for chronic disease management within CHC; NANDA‐I taxonomy helps to analyze care plans.Implications for nursing practice‐ A taxonomy such as NANDA‐I represents a valid opportunity to make more visible how much nursing skills affect the achievement of a higher level of health in chronic patients.‐ This study is useful in the further training of outpatient nurses who works in CHC.‐ The study represents the starting point for future research to deepen the development of a standardized nursing language in outpatient facilities.

Factors associated with nursing diagnoses in chronic kidney patients: a cross-sectional study

Introduction: To the care plan, the nurses must use the nursing process and adopt their perspectives, cognitive and documentary, considering the human responses of each chronic kidney disease patient, to define the nursing diagnoses, results, and interventions. This study is aimed to analyze the nursing diagnoses of NANDA-I in chronic renal patients and its association with clinical and sociodemographic variables. Materials and Methods: Analytical cross-sectional study, performed with chronic renal patients undergoing hemodialysis. The study population consisted of 177 medical records of chronic kidney disease patients. They were selected in the pre-established period of six months: July to December 2018. It was used the Google Forms® platform to import the data directly to Microsoft Excel® Program by generating an electronic spreadsheet that allowed organizing the data, this was then transcribed to the Stata 14.0 software to perform the statistical analyses. Results: The risk for bleeding diagnosis showed a significant difference with the variable access route (p = 0.02); risk for falls was associated with the variables age, occupation, education (p <0.01) and excessive fluid volume with the variable duration of treatment (p = 0.01). Discussion: In the case of nursing diagnoses, these must be planned and documented based on a standardized nursing language, with NANDA-I. Conclusion: The findings of this study showed the main nursing diagnoses and its association with clinical and sociodemographic variables in chronic renal patients in a Brazilian context. Future research may lead to implement care plans for the most prevalent nursing diagnoses in this type of population.