Standardized Documentation for the Nursing Profession Allison Corbin, RN, BSN Chamberlain College of Nursing NR660: Capstone DATE Standardized Documentation for the Nursing Profession Many healthcare clinicians couldn’t
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Standardized Documentation for the Nursing Profession Allison Corbin, RN, BSN Chamberlain College of Nursing NR660: Capstone DATE Standardized Documentation for the Nursing Profession Many healthcare clinicians couldn’t wait until the health record was available electronically, which would provide patient information at their fingertips. Now that the record is available electronically, those same clinicians are faced with a number of challenges. One of those challenges is the lack of standardized nursing terminology in documentation as evidenced by nurses voicing their dissatisfaction with the electronic health record design and cumbersome documentation processes. Most professions, such as medicine and law, have a specialized vocabulary that is used and understood by its own members. The nursing profession’s challenge is that it does not have that same standardized language to differentiate nursing’s contributions to patient care from those of medicine, especially in hospital settings. Standardized nursing terminologies provide a consistent basis for communicating the unique contributions of nursing to direct patient care and research (Schwirian, 2013). Identification of Problem Lack of standardized documentation can cause poor system usability, non-integrated systems; poor interoperability and failure of systems to meet nursing clinical needs, as well as disruption to productivity and negative impacts on nurse-patient communication (Topaz, 2016). Up until the development of standardized nursing languages beginning in the 1970s, nurses lacked that standardized language to communicate their practice. The North American Nursing Diagnosis classification (NANDA) was the first SNL to be developed and development of SNLs continues to be an ongoing process (Adubi, Olaogun & Adejumo, 2018). Nursing has seven recognized SNLs, which serve multiple purposes, but ultimately undermines the goal of consistency, global recognition, and acceptance by nursing. In my organization we have adopted several of these term sets. The problem with having multiple SNL sets is the conflict it can cause in documentation and lack of consistency for the nurses to follow when documenting in the EHR. Using multiple SNLs has caused confusion and mismatch in documentation at times for our nurses. Electronic health records need to be both usable and relevant for nurses in their practice and standardization is part of the usability. There are impacts from suboptimal technology and those can include error generation, decreased productivity, user frustration, and in extreme measures system de-installation (Rojas and Seckman, 2014). This issue leads to my PICOT question: Among staff nurses using a newly implemented EHR, will standardizing nursing terminology, compared to current EHR documents, increase nurse satisfaction with the EHR from 79% to 84% within a 6-month time period? The elements of the PICOT are as follows: • P-(Population)=Among staff nurses using a newly implemented HER • I-(Intervention)=Standardized nursing terminology • C-(Comparison)=Compared to current EHR documents • O-(Outcomes)=Increase nurse satisfaction with the EHR from 79% to 84% • T-(Time)=6-month time period Proposed Change According to Tastan et al., (2014), studies are showing that the number of standardized nursing terminology publications has increased since 2000, but there is some evidence supporting the successful integration and use in EHRs for two standardized nursing terminology sets; 1.) North American Nursing Diagnosis-International, Nursing Interventions Classification, and Nursing Outcome Classification set; and 2.) Omaha System set. The proposal for my organization is that we reduce the number of term sets we are currently using and focus on these two standardized terminology sets. Using our informatics nurse specialists to help identify and evaluate the importance of nursing data to improve practice, facilitate nursing involvement in re-design of the EHR, and help to coordinate the impact the change in SNLs will have on the nurses (Darvish, Bahramnezhad, Keyhanian, & Naavidhamidi, 2014). The INSs are essential in bridging the gap of information technology and nursing practice to improve quality of care. Benefits to Nursing Profession Using standardized nursing language has several important benefits to the nursing profession. They include better communication among nurses and other healthcare providers; increased visibility of nursing interventions and patient outcomes; improved patient care; greater adherence to standards of care; and will further nursing research agendas by generating consistent patient care data (Schwirian, 2013). Since not having standardized nursing language is a usability issue for nurses and since not all nurses have the skills or knowledge to recognize standardized documentation or perform usability testing, the informatics nurse specialists plays a vital role. Informatics nurse specialists in their role can help with the integration of clinical, informatics, and technology together in the process of usability that will help nursing in our organizations. The INSs will help to facilitate the development, evaluation and implementation of the EHR for nurses, which includes efforts to standardize language for nursing documentation. This will help in the improvement of content and process of clinical practice; provide new paradigms for care delivery models; and increase nursing efficiency with better outcomes for our patients and our practice. Working with the informatics nurse specialists to identify SNLs will help to improve documentation, improve patient care and patient safety, and increase productivity for nursing. Conclusion Mapping of standardized terminologies in the EHR is important for clinical decision support, quality measures, research, and data exchange across healthcare systems. Standardized nursing language models are important as they support evidence-based practice in order to generate data through clinical care. Having standardized terminology means consistency, which is important in usability in the electronic health record. Informatics nurse specialists are in a unique position to help organizations understand and integrate standardization of clinical documentation to ensure accurate data exchange, effective documentation and regulatory compliance. The increase in communication between nurses and healthcare providers, increased efficiency and improved patient outcomes and nursing satisfaction with the EHR are just a few of the benefits the nursing profession will see by standardization of nursing languages. References Adubi, I., Olaogun, A., & Adejumo, P. (2018). Effect of standardization nursing language continuing education programme on nurses’ documentation of care at University College Hospital, Ibadan. Nursing Open, 5(1), 37-44. doi:10.1002/nop2.108 Darvish, A., Bahramnezhad, F., Keyhanian, S., & Naavidhamidi, M. (2014). The role of nursing informatics on promoting quality of health care and the need for appropriate education. Global Journal of Health Science, 6(6), 11-18. doi:10.5539/gjhs.v6n6p11 Rojas, C. & Seckman, C. (2014). The informatics nurse specialist role in electronic health record usability evaluation. CIN: Computers, Informatics, Nursing, 32(5), 214-220. Retrieved Schwirian, P. (2013). Informatics and the future of nursing: Harnessing the power of standardized nursing terminology. Bulletin of the American Society for Information Science and Technology banner, 39(5), 20-24. doi:10.1002/bult.2013.5 Tastan, S. et al., (2013). Evidence for the existing American Nurses Association-recognized standardized nursing terminologies: A systematic review. International Journal of Nursing Studies, 51(8), 1160-1170. doi:10.1016/stu.2013.12.004 Topaz, M., (2017). Nurse informaticians report low satisfaction and multi-level concerns electronic health records: Results from an international survey. AMIA Annual Symposium Proceedings. AMIA Symposium 2016. 2016-2025. Retrieved
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