Transcript The Need for and Use of Standardized Nursing Languages

The Need for and Use of
Standardized Nursing
Languages (SNLs) for the
Electronic Health Record
Margaret Lunney, RN, PhD
Professor, College of Staten Island/CUNY,
New York
What are SNLs?
Names uniformly used with definitions &
descriptions
Language systems based on rules
of inclusion & organization. e.g.,
ICD 9 (medical diagnoses)
CPT (medical interventions [U.S.])
SNLs-3 elements of nursing care as defined by
the Nursing Minimum Data Set (NMDS)
Diagnoses of human responses (NDxs)
Nursing interventions (NRxs)
Nursing-sensitive patient outcomes (NSPOs)
ANA Approved SNLs (U.S.)
NANDA (NDx)
NIC (NRx)
NOC (NSPOs)
Omaha System (NDx, NRx, POs)
Home Health Care Class. (NDx, NRx, POs)
Patient Care Data Set (NDx, NRx, POs)
Perioperative Data Set (NDx, NRx, POs)
Why SNLs?
Scientific names needed-word usage varies
Meanings of words-extensional & intensional
Scientific names provide extensional meanings
Prejudice (inaccurate interpretation of pt.
data) occurs when only the intensional is used
Why SNLs?
Standardized names are needed for
computer systems & EHR
(U.S. National Committee for Vital & Health Statistics)
Why SNLs?
Communication through language is:*
Tool for communication (with self & others)
Source of cooperative actions
Tool to improve human experiences
Naming is great step forward-makes discussion
possible
Fundamental to growth & survival (Nursing & HC)
* Hayakawa’s Linguistics Theory
Why SNLs?
Words and phrases are maps to the territory
Many maps are needed to “know” a territory
No maps “fully” represent the territory
All maps together do not “equal” the territory
Goal is to make “good maps” of the territory
Example: Pluteus cervinus mushroom
fawn mushroom, deer mushroom, fawn pluteus, the
deer mushroom, fawn shieldcap
North American Commission for Common Names for
Mushrooms created in 2000
Why Select Names for Nursing
Phenomena?
We experience only a small fraction of
phenomena
We must abstract the objects of experiences
It makes no sense to distrust abstractions
We need to be aware of abstracting
Connect words with
experiences;
avoid this
Why SNLs?
SNLs represent pooled nursing
knowledge
Use of pooled knowledge helps nurses
to plan, interpret, intervene and
evaluate
Sciences seek generally useful
vocabularies, ones that produce results
Results = quality of care
Effects on Nursing Care
of Using SNLs
Naming
Thoughts
Discernment
Communication + Cooperation + Action
Improved Access, Cost Effectiveness, & Quality
Lunney, 1999
NANDA International (I)
Nursing diagnoses are human
responses (HRs) to health problems and
life processes for which nurses provide
interventions
Purposes: Name human responses of
concern to nurses so accuracy can be
addressed and the best NRxs can be
selected for positive outcomes
NANDA I: Examples
Pain
Death Anxiety
Impaired Home
Maintenance
Readiness for
Enhanced
Community Coping
Hopelessness
Ineffective Breathing
Pattern
Risk for infection
Relocation Stress
Syndrome
Decisional Conflict
Acute Confusion
Effective Breast
Feeding
Why NDx?
Human responses are complex
Research findings r.t. high risk of
inaccuracy
1966 series of studies
1970’s series of studies
1980-2001: Influencing factors
• Clinician knowledge, abilities & other
• Task difficulty level
• Situational factors, e.g., agency policies
Why NDx?
Interpretations/diagnoses =
foundation for NRxs & NSPOs
Low accuracy can lead to:
harm to patient/family
wasted time & energy
absence of positive outcomes
patient/family dissatisfaction
Basis for quality of nursing care
Accountability to HC consumers
Expand knowledge of health
NANDA I
History, 1973-present
Research-based submissions
Systematic approval process
International involvement
NDxs widely used
Publish every 2 years, latest 2009
Recognized by significant organizations
(ICD, HL7, ANA, ICN, ACENDIO, AENTDE,
others)
NANDA: Taxonomy II
7 axes (concept, time, unit of care, age,
health status, descriptor, topology)
206 diagnoses, definitions, descriptions
Problems
Risk states
Health promotion
Wellness/Strengths
13 Domains, 2-6 classes in each domain
Coded for EHR; integrated with International
Health Terminology Standards Development
Organization (IHTSDO)
NIC (Nursing Interventions
Classification [NRxs])
NRxs are treatments performed by
nurses based on clinical judgment &
knowledge in order to achieve positive
pt. outcomes
Purposes of naming: Consider
appropriateness, communicate with
others for continuity, relate to NDxs and
NSPOs
NIC: Examples
Acid-Base
Management
Active Listening
Community Disaster
Preparedness
Coping
Enhancement
Exercise Promotion
Health Education
Family Integrity
Promotion
Health Education
Health Policy
Monitoring
Surveillance
Presence
Social Support
Enhancement
NIC
Hx: Interventions described in numerous
literature sources
In 1987, NIC research group started to
identify & standardize literature-based info
Funded by NIH, NINR for 7 yrs
1st ed. 1992; 2nd ed. 1996;
3rd ed. 2000, 4th ed. 2004, 5th ed. 2008
Coded for EHR; integrated with IHTSDO,
formerly SNOMED CT
NIC (2008)
542 interventions, definitions, descriptions
7 Domains & 30 Classes
1. Physiologic: Basic (6 classes)
2. Physiologic: Complex (8 classes)
3. Behavioral (6 classes)
4. Safety(2 classes)
5. Family (3 classes)
6. Health System (3 classes)
7. Community (2 classes)
NOC (Nursing-Sensitive Patient
Outcomes [NSPOs] Classification)
NSPOs define general pt. states,
behaviors or perceptions that are
influenced by & sensitive to NRxs and
can be measured as variables
Purpose of Naming: Determine the
quality and effectiveness of nursing care
NOC: Examples
Caregiver Homecare
Readiness
Knowledge: Illness
Care
Social Support
Mobility level
Risk Control: Drug
Use
Neglect Recovery
Activity Tolerance
Self Care: Hygiene
Dialysis Access
Integrity
Wound Healing:
Primary Intention
Acceptance: Health
Status
Symptom Control
NOC
Existing approaches:
Goal statements not quantifiable
Not comparable across localities
Not sensitive to changes in nursing care
1991- NOC research group started
7 yrs funding by NIH/NINR
1st ed 1996, 2nd ed. 2000, 3rd ed. 2004,
4th ed. 2008
Coded for EHR; integrated with IHTSDO
NOC (2008)
385 outcomes, definitions, descriptions
7 Domains, 29 Classes
1. Functional Health (4 classes)
2. Physiologic Health (10 Classes)
3. Psychosocial Health (4 Classes)
4. Health Knowledge & Behavior (4 Cl.)
5. Perceived Health (2 Classes)
6. Family Health (3 Classes)
7. Community Health (2 Classes)
NOC Principles
Neutral terms, variables
17 five point scales
1 (least desirable) to 5 (most desirable)
Ex: Knowledge: Medication,
None = 1, Limited = 2, Moderate = 3, Substantial = 4,
Extensive = 5
Other scales:
Very weak to very strong
None to Complete
Not At All to A Great Extent
Not Adequate to Totally Adequate
Extensive to None
New Directions
Common structure for the 3 systems,
partially funded by the NLM
Goal: Improve:
1) integration of three systems
2) ease of use