An Internationally Consented Standard for Nursing Process-Clinical Decision Support Systems in Electronic Health Records

Abstract

Nurses are accountable to apply the nursing process, which is key for patient care: It is a problem-solving process providing the structure for care plans and documentation. The state-of-the art nursing process is based on classifications that contain standardized concepts, and therefore, it is named Advanced Nursing Process. It contains valid assessments, nursing diagnoses, interventions, and nursing-sensitive patient outcomes. Electronic decision support systems can assist nurses to apply the Advanced Nursing Process. However, nursing decision support systems are missing, and no "gold standard" is available. The study aim is to develop a valid Nursing Process-Clinical Decision Support System Standard to guide future developments of clinical decision support systems. In a multistep approach, a Nursing Process-Clinical Decision Support System Standard with 28 criteria was developed. After pilot testing (N = 29 nurses), the criteria were reduced to 25. The Nursing Process-Clinical Decision Support System Standard was then presented to eight internationally known experts, who performed qualitative interviews according to Mayring. Fourteen categories demonstrate expert consensus on the Nursing Process-Clinical Decision Support System Standard and its content validity. All experts agreed the Advanced Nursing Process should be the centerpiece for the Nursing Process-Clinical Decision Support System and should suggest research-based, predefined nursing diagnoses and correct linkages between diagnoses, evidence-based interventions, and patient outcomes.

Quality of nursing documentation: Paper‐based health records versus electronic‐based health records

“…Much more attention needs to be paid to the education of nursing documentation based on the nursing process. Education and organisational support for documentation of the nursing process helped nurses understand nursing process theory and improve clinical reasoning skills in the application of the nursing process (Müller‐Staub, de Graaf‐Waar, & Paans, ; Zamanzadeh et al., ). Informatics courses and capacity building programmes for effective use of technology in nursing practice are lacking in some undergraduate nursing programmes as in Jordan.…”

Healthcare professionals´ experiences of assessing, treating and preventing constipation among older patients during hospitalization: An interview study

“…The importance of clinical reasoning is emphasized by Woolley (39), who considered that healthcare professionals need to develop speci c skills in order to be able to provide an accurate diagnosis. Muller-Staub, de Graaf-Waar (40) described the usefulness of the nursing process as a systematic approach to the organization of nursing knowledge and clinical decision-making through assessing, diagnosing and identifying appropriate interventions, as well as following up and evaluating the effects of these interventions.…”

Cross-mapping of results and Nursing Interventions: contribution to the practice

“…Using the mapping as a source of void identification of nurses' knowledge has shown to be a viable strategy to be incorporated into the nurses training and improvement process, as it allows for a review of clinical reasoning, an accurate clinical practice and on the registration of the stages of the nursing process through a uniform language. To document nursing care through a standardized language system is to ensure uniform communication, a description of the uniqueness of nursing, and the storage of data for educational purposes in decision making and/or statistical data (5,7,(15)(16)(17)(18) .…”

“…The registry of clinical decisions includes the set of data that result in diagnoses, interventions and nursing outcomes achieved. This formal registration is a fundamental requirement for the health information system and, when supported in a standardized language system (SLS), enables interdisciplinary communication, facilitates quality assessment of care, promotes patient and professional safety, provides institutional information about the patient and provides the development of science, the production of knowledge and the contribution of nursing in the different care settings (4)(5)(6)(7)(8)(9) .…”