Effectiveness of a Standardized Nursing Process Using NANDA International, Nursing Interventions Classification and Nursing Outcome Classification Terminologies: A Systematic Review

Abstract

The decision-making in clinical nursing, regarding diagnoses, interventions and outcomes, can be assessed using standardized language systems such as NANDA International, the Nursing Interventions Classification and the Nursing Outcome Classification; these taxonomies are the most commonly used by nurses in informatized clinical records. The purpose of this review is to synthesize the evidence on the effectiveness of the nursing process with standardized terminology using the NANDA International, the Nursing Interventions Classification and the Nursing Outcome Classification in care practice to assess the association between the presence of the related/risk factors and the clinical decision-making about nursing diagnosis, assessing the effectiveness of nursing interventions and health outcomes, and increasing people’s satisfaction. A systematic review was carried out in Medline and PreMedline (OvidSP), Embase (Embase-Elsevier), The Cochrane Library (Wiley), CINAHL (EbscoHOST), SCI-EXPANDED, SSCI and Scielo (WOS), LILACS (Health Virtual Library) and SCOPUS (SCOPUS-Elsevier) and included randomized clinical trials as well as quasi-experimental, cohort and case-control studies. Selection and critical appraisal were conducted by two independent reviewers. The certainty of the evidence was assessed with the Grading of Recommendations Assessment, Development and Evaluation Methodology. A total of 17 studies were included with variability in the level and certainty of evidence. According to the outcomes, 6 studies assessed diagnostic decision-making and 11 assessed improvements in individual health outcomes. No studies assessed improvements in intervention effectiveness or population satisfaction. There is a need to increase studies with rigorous methodologies that address clinical decision-making about nursing diagnoses using NANDA International and individuals’ health outcomes using the Nursing Interventions Classification and the Nursing Outcome Classification as well as implementing studies that assess the use of these terminologies for improvements in the effectiveness of nurses’ interventions and population satisfaction with the nursing process.

Using interoperable nursing care data to improve outcomes for multiple traumas patients with Impaired Physical Mobility

“…With the ongoing digital transformation in nursing and the recognition of the importance of data-driven health care, integrating interoperable nursing data with standardized nursing terminologies has become increasingly crucial to delivering high-quality, patientcentred care (Fennelly et al, 2021;Rodríguez-Suárez et al, 2023).…”

“…Effective nurse care for multiple trauma patients requires comprehensive and integrated approaches aimed at reducing risks of complications (Rodríguez‐Suárez et al., 2023). Traumatic events primarily affect the musculoskeletal, integumentary and nervous systems, often leading to changes in mobility.…”

“…In this context, optimizing nursing care plans and using standardized nursing terminologies (SNTs) provides a common language and structure to organize and represent nursing data. In addition, nursing care plans for multiple trauma patients, using health data facilitate communication and interpretation of information and make its use relevant for multiple trauma patients, who may have severe complications due to changes in mobility and the severity of their clinical condition (Fennelly et al., 2021; Rodríguez‐Suárez et al., 2023).…”

“…Accurate documentation facilitates a seamless flow of information across nursing shifts, enhances interdisciplinary collaboration and supports evidence‐based decision‐making (Keenan et al., 2018). With the ongoing digital transformation in nursing and the recognition of the importance of data‐driven health care, integrating interoperable nursing data with standardized nursing terminologies has become increasingly crucial to delivering high‐quality, patient‐centred care (Fennelly et al., 2021; Rodríguez‐Suárez et al., 2023). However, the lack of standardized terminology in nursing can pose challenges, particularly the ability to analyse and compare nursing data in different contexts (Morais et al., 2018).…”