The development of a nursing subset of patient problems to support interoperability

Since the emergence of electronic health records, nursing information is increasingly being recorded and stored digitally. Several studies have shown that a wide range of nursing information is not interoperable and cannot be re-used in different health contexts. Difficulties arise when nurses share information with others involved in the delivery of nursing care. The aim of this study is to develop a nursing subset of patient problems that are prevalent in nursing practice, based on the SNOMED CT terminology to assist in the exchange and comparability of nursing information. Explorative qualitative focus groups were used to collect data. Mixed focus groups were defined. Additionally, a nursing researcher and a nursing expert with knowledge of terminologies and a terminologist participated in each focus group. The participants, who work in a range of practical contexts, discussed and reviewed patient problems from various perspectives. Sixty-seven participants divided over seven focus groups selected and defined 119 patient problems. Each patient problem could be documented and coded with a current status or an at-risk status. Sixty-six percent of the patient problems included are covered by the definitions established by the International Classification of Nursing Practice, the reference terminology for nursing practice. For the remainder, definitions from either an official national guideline or a classification were used. Each of the 119 patient problems has a unique SNOMED CT identifier. To support the interoperability of nursing information, a national nursing subset of patient problems based on a terminology (SNOMED CT) has been developed. Using unambiguously defined patient problems is beneficial for clinical nursing practice, because nurses can then compare and exchange information from different settings. A key strength of this study is that nurses were extensively involved in the development process. Further research is required to link or associate nursing patient problems to concepts from a nursing classification with the same meaning

Applicability of the nursing interventions classification in the psychiatric outpatient care setting

Standardized nursing terminologies (SNT) have been developed to describe the nursing process systematically. The aim of this research was to study the applicability of the Nursing Interventions Classification (NIC) in the psychiatric outpatient care setting in Finland. The research includes three phases. In the first phase using an integrative literature review we identified nursing interventions in research publications (n=60) and used the NIC to analyze the identified interventions. In the second phase, we used an ethnographically oriented work-place study to identify interventions in the clinical setting. This included observations and interviews and the findings were analyzed together with nurses (n=17). The core interventions were identified using the Delphi method. The panelists consisted of nurses and nurse managers (round one n=54, round two n=26). In the third phase we identified nursing interventions in nursing progress notes (n=1150) and in nursing care summaries (n=17) and mapped these into the NIC. In all we identified 105 different nursing interventions, of which 95% could be mapped into the NIC. The emphasis was in interventions aiming at behavioral change and more specifically interventions that support coping by building on patients’ strengths. In nursing documentation, the most frequent interventions were Surveillance and Care Coordination. The group delivery method was common in all phases. The findings of this study emphasize the need for a systematic terminology to describe nursing interventions for nurses to conceptualize their work, to make the work visible and to ensure the quality of nursing documentation. The broad coverage, descriptiveness of the interventions and the taxonomical structure of the NIC support its applicability. However, the interventions in the classification were found to be overlapping which limits the systematic transfer of information and the possibilities for secondary use of data. Additional limitations are the lack of semantic coherence with the concepts used in research and the difficulty of describing interventions delivered using the group method. This research generated recommendations for the development of the classification. The most central ones include the need to include multiple methods in the research and development and the integration of concepts used in research literature.Hoitotyön interventioiden luokituksen soveltuvuus aikuispsykiatrian avohoitoon Hoitotyön systemaattinen kuvaaminen edellyttää yhteisen kielen ja käsitteistöjen käyttöä. Tässä tutkimuksessa selvitetään hoitotyön interventioiden luokituksen (Nursing Interventions Classification, NIC) soveltuvuutta aikuispsykiatrian avohoitoon. Tutkimus koostuu kolmesta osavaiheesta. Ensimmäisessä vaiheessa integratiivisen kirjallisuuskatsauksen avulla tutkimuksista (n=60) tunnistettiin hoitotyön interventioita ja nämä analysoitiin NIC-luokituksen avulla. Toisessa vaiheessa hyödynnettiin etnografista työntutkimusta. Hoitotyön interventioita tunnistettiin hoitajien työtä havainnoimalla ja hoitajia haastattelemalla. Analysointi tapahtui yhdessä hoitajien (n=17) kanssa. Ydininterventioiden tutkimus tapahtui sähköistä Delfoi-menetelmää hyödyntäen. Panelisteina toimivat sairaanhoitajat ja hoitotyön lähijohtajat (ensimmäisellä kierroksella n=54, toisella kierroksella n=26). Kolmannessa vaiheessa tutkittiin hoitotyön päivittäiskirjauksia (n=1150) ja hoitotyön yhteenvetoja (n=17), joista tunnistetut interventiot yhdistettiin NICluokitukseen. Tutkimuksessa tunnistettiin yhteensä 105 interventioita, joista 95 %:lle löytyi vastine luokituksesta. Keskeisiä interventioita kirjallisuuskatsauksessa, etnografisessa työntutkimuksessa ja ydininterventioiden tutkimuksessa olivat käyttäytymisen muutokseen tähtäävät psykososiaaliset interventiot ja erityisesti voimavaralähtöinen selviytymiskyvyn tukeminen. Hoitotyön kirjauksissa korostuivat seuranta ja hoidon koordinointi. Interventioiden ryhmämuotoinen toteutustapa oli yleinen kaikissa tutkimusvaiheissa. Tutkimuksen tulokset korostavat yhteisten käsitteiden tarvetta hoitotyön interventioille työn käsitteellistämisen, näkyväksi tekemisen ja kirjaamisen laadun näkökulmista. Tutkitun luokituksen soveltuvuutta tukevat sen kattavuus, käsitteiden hyvä tunnistettavuus ja hierarkkinen rakenne. Luokituksen interventiokäsitteet ovat osittain päällekkäisiä heikentäen sen systemaattista käytettävyyttä ja tiedon toisiokäytön mahdollisuuksia. Soveltuvuutta rajoittavat myös luokituksen vähäinen yhteys tutkimuskirjallisuudessa käytettyihin käsitteisiin ja vaikeus kuvata ryhmämuotoisia interventioita. Tutkimus antaa suosituksia luokituksen jatkokehittämiselle. Keskeisimpänä ovat monimenetelmäisyys tutkimuksessa ja kehittämisessä sekä tutkimuskirjallisuuden käsitteistöjen vahvempi integroiminen luokitukseen

The development of a nursing subset of patient problems to support interoperability.

Background: Since the emergence of electronic health records, nursing information is increasingly being recorded and stored digitally. Several studies have shown that a wide range of nursing information is not interoperable and cannot be re-used in different health contexts. Difficulties arise when nurses share information with others involved in the delivery of nursing care. The aim of this study is to develop a nursing subset of patient problems that are prevalent in nursing practice, based on the SNOMED CT terminology to assist in the exchange and comparability of nursing information. Methods: Explorative qualitative focus groups were used to collect data. Mixed focus groups were defined. Additionally, a nursing researcher and a nursing expert with knowledge of terminologies and a terminologist participated in each focus group. The participants, who work in a range of practical contexts, discussed and reviewed patient problems from various perspectives. Results: Sixty-seven participants divided over seven focus groups selected and defined 119 patient problems. Each patient problem could be documented and coded with a current status or an at-risk status. Sixty-six percent of the patient problems included are covered by the definitions established by the International Classification of Nursing Practice, the reference terminology for nursing practice. For the remainder, definitions from either an official national guideline or a classification were used. Each of the 119 patient problems has a unique SNOMED CT identifier. Conclusions: To support the interoperability of nursing information, a national nursing subset of patient problems based on a terminology (SNOMED CT) has been developed. Using unambiguously defined patient problems is beneficial for clinical nursing practice, because nurses can then compare and exchange information from different settings. A key strength of this study is that nurses were extensively involved in the development process. Further research is required to link or associate nursing patient problems to concepts from a nursing classification with the same meaning. (aut. ref.

Additional file 1: of The development of a nursing subset of patient problems to support interoperability

Overview of patient problems (level of occurrence compared to level of reported influence). (DOCX 17 kb