Preliminary Evidence for the Usefulness of Standardized Nursing Terminologies in Different Fields of Application: A Literature Review

Törnvall, Eva; Jansson, Inger

doi:10.1111/2047-3095.12123

Cited by 38 publications

(44 citation statements)

References 38 publications

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“…Our results suggest SNTs are more widely implemented to code point-of-care nursing documentation in EHRs within clinical settings than previously thought. 74,75 The vast majority of studies conducted association analyses, employing methods such as multiple regression analysis, data clustering, and association mining techniques to select clinically important features and reduce dimensions of the dataset. Some also used decision trees, k-nearest neighbors, and support vector machines to identify hidden patterns in nursing data or to construct predictive models for patient outcomes.…”

Section: Discussionmentioning

confidence: 99%

Secondary use of standardized nursing care data for advancing nursing science and practice: a systematic review

Macieira

Chianca

Smith

et al. 2019

Journal of the American Medical Informatics Association

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Objective The study sought to present the findings of a systematic review of studies involving secondary analyses of data coded with standardized nursing terminologies (SNTs) retrieved from electronic health records (EHRs). Materials and Methods We identified studies that performed secondary analysis of SNT-coded nursing EHR data from PubMed, CINAHL, and Google Scholar. We screened 2570 unique records and identified 44 articles of interest. We extracted research questions, nursing terminologies, sample characteristics, variables, and statistical techniques used from these articles. An adapted STROBE (Strengthening The Reporting of OBservational Studies in Epidemiology) Statement checklist for observational studies was used for reproducibility assessment. Results Forty-four articles were identified. Their study foci were grouped into 3 categories: (1) potential uses of SNT-coded nursing data or challenges associated with this type of data (feasibility of standardizing nursing data), (2) analysis of SNT-coded nursing data to describe the characteristics of nursing care (characterization of nursing care), and (3) analysis of SNT-coded nursing data to understand the impact or effectiveness of nursing care (impact of nursing care). The analytical techniques varied including bivariate analysis, data mining, and predictive modeling. Discussion SNT-coded nursing data extracted from EHRs is useful in characterizing nursing practice and offers the potential for demonstrating its impact on patient outcomes. Conclusions Our study provides evidence of the value of SNT-coded nursing data in EHRs. Future studies are needed to identify additional useful methods of analyzing SNT-coded nursing data and to combine nursing data with other data elements in EHRs to fully characterize the patient’s health care experience.

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Section: Discussionmentioning

confidence: 99%

Secondary use of standardized nursing care data for advancing nursing science and practice: a systematic review

Macieira

Chianca

Smith

et al. 2019

Journal of the American Medical Informatics Association

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“…However, the availability of different standardized nursing terminologies and the incipient use of electronic records by nurses may contribute to the invisibility of some classification systems (Tastan et al, 2014). In European countries, for example, several rating systems are available for use, which is a limiting factor for the consensus, recommendation, and use of a single system (Törnvall & Jansson, 2017). Additionally, these limitations make it difficult to conduct multicenter studies in this scenario.…”

Section: Introductionmentioning

confidence: 99%

International Collaboration and New Research Evidence on Nanda International Terminology

Rabelo‐Silva

Mantovani

Pedraza

et al. 2020

Int J of Nursing Knowl

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To discuss priorities and possibilities for promoting international collaboration and new research evidence on NANDA International, Inc. (NANDA-I). METHODS: Theoretical reflection article based on the literature and the authors' opinions on the subject matter, carried out by six research nurses. CONCLUSIONS: International research collaboration for NANDA-I allows the improvement of research production in an actual clinical setting, especially with multicenter and validation studies, conducted by researchers from different countries. This provides for improved understanding of patients' experiences and may help to produce robust scientific evidence. IMPLICATIONS FOR NURSING KNOWLEDGE:The generation of new evidence may lead to an increase in NANDA-I visibility and in nurses' understanding of its meaning for clinical practice and for the formulation of diagnostic hypotheses.

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“…This can be a risk when words can have different meanings, but in different contexts different degrees of precision are required to convey the concepts. An extensive review 25 showed that standardized nursing terminology was found to be essential for measuring, clarifying, and understanding nursing care. These same reasons apply for other professions to use standardized terminologies.…”

Section: Discussionmentioning

confidence: 99%

Double documentation in electronic health records

Törnqvist

Törnvall

Jansson

2016

Nordic Journal of Nursing Research

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Documentation in the patient record must be systematic and rigorous. However, each health care profession documents parts of the electronic health record (EHR) separately. This system can lead to double documentation. The aim of the study was to describe the amount of double documentation in health records for in-patients. A retrospective descriptive review of 30 records for in-patients diagnosed with hip fracture was conducted. Double documentation occurred on all records reviewed during the stay in hospital and in or between all professions reviewed. In total, 822 instances of double documentation were found. The EHRs available today are not designed to monitor processes. Instead, they follow each health profession, which can lead to double documentation. It would be desirable to develop an EHR from a process perspective and not a record per profession.

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Preliminary Evidence for the Usefulness of Standardized Nursing Terminologies in Different Fields of Application: A Literature Review

Abstract: The use of standardized terminologies could be advantageous. However, there are shortcomings in nursing documentation and the use of standardized nursing terminologies that obstruct evaluation of nursing care.

Cited by 38 publications

References 38 publications

Secondary use of standardized nursing care data for advancing nursing science and practice: a systematic review

Secondary use of standardized nursing care data for advancing nursing science and practice: a systematic review

International Collaboration and New Research Evidence on Nanda International Terminology

Double documentation in electronic health records

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