The Need for and Use of Standardized Nursing Languages (SNLs) for the Electronic Health Record

1. The Need for and Use of Standardized Nursing Languages (SNLs) for the Electronic Health Record Margaret Lunney, RN, PhD Professor, College of Staten Island/CUNY, New York

2. What are SNLs? • Names uniformly used with definitions & descriptions • Language systems based on rules of inclusion & organization. e.g., • ICD 9 (medical diagnoses) • CPT (medical interventions [U.S.]) • SNLs-3 elements of nursing care as defined by the Nursing Minimum Data Set (NMDS) • Diagnoses of human responses (NDxs) • Nursing interventions (NRxs) • Nursing-sensitive patient outcomes (NSPOs)

3. ANA Approved SNLs (U.S.) • NANDA (NDx) • NIC (NRx) • NOC (NSPOs) • Omaha System (NDx, NRx, POs) • Home Health Care Class. (NDx, NRx, POs) • Patient Care Data Set (NDx, NRx, POs) • Perioperative Data Set (NDx,NRx, POs)

4. Why SNLs? • Scientific names needed-word usage varies • Meanings of words-extensional & intensional • Scientific names provide extensional meanings • Prejudice (inaccurate interpretation of pt. data) occurs when only the intensional is used

5. Why SNLs?Standardized names are needed for computer systems & EHR(U.S. National Committee for Vital & Health Statistics)

6. Why SNLs? Communication through language is:* • Tool for communication (with self & others) • Source of cooperative actions • Tool to improve human experiences • Naming is great step forward-makes discussion possible • Fundamental to growth & survival (Nursing & HC) * Hayakawa’s Linguistics Theory

7. Why SNLs? • Words and phrases are maps to the territory • Many maps are needed to “know” a territory • No maps “fully” represent the territory • All maps together do not “equal” the territory • Goal is to make “good maps” of the territory • Example: Pluteus cervinus mushroom • fawn mushroom, deer mushroom, fawn pluteus, the deer mushroom, fawn shieldcap • North American Commission for Common Names for Mushrooms created in 2000

8. Why Select Names for Nursing Phenomena? • We experience only a small fraction of phenomena • We must abstract the objects of experiences • It makes no sense to distrust abstractions • We need to be aware of abstracting • Connect words with experiences; avoid this

9. Why SNLs? • SNLs represent pooled nursing knowledge • Use of pooled knowledge helps nurses to plan, interpret, intervene and evaluate • Sciences seek generally useful vocabularies, ones that produce results • Results = quality of care

10. Effects on Nursing Careof Using SNLs Naming Thoughts Discernment Communication + Cooperation + Action Improved Access, Cost Effectiveness, & Quality Lunney, 1999

11. NANDA International (I) • Nursing diagnoses are human responses (HRs) to health problems and life processes for which nurses provide interventions • Purposes: Name human responses of concern to nurses so accuracy can be addressed and the best NRxs can be selected for positive outcomes

12. Pain Death Anxiety Impaired Home Maintenance Readiness for Enhanced Community Coping Hopelessness Ineffective Breathing Pattern Risk for infection Relocation Stress Syndrome Decisional Conflict Acute Confusion Effective Breast Feeding NANDA I: Examples

13. Why NDx? • Human responses are complex • Research findings r.t. high risk of inaccuracy • 1966 series of studies • 1970’s series of studies • 1980-2001: Influencing factors • Clinician knowledge, abilities & other • Task difficulty level • Situational factors, e.g., agency policies

14. Why NDx? • Interpretations/diagnoses = foundation for NRxs & NSPOs • Low accuracy can lead to: • harm to patient/family • wasted time & energy • absence of positive outcomes • patient/family dissatisfaction • Basis for quality of nursing care • Accountability to HC consumers • Expand knowledge of health

15. NANDA I • History, 1973-present • Research-based submissions • Systematic approval process • International involvement • NDxs widely used • Publish every 2 years, latest 2009 • Recognized by significant organizations (ICD, HL7, ANA, ICN, ACENDIO, AENTDE, others)

16. NANDA: Taxonomy II • 7 axes (concept, time, unit of care, age, health status, descriptor, topology) • 206 diagnoses, definitions, descriptions • Problems • Risk states • Health promotion • Wellness/Strengths • 13 Domains, 2-6 classes in each domain • Coded for EHR; integrated with International Health Terminology Standards Development Organization (IHTSDO)

17. NIC (Nursing Interventions Classification [NRxs]) • NRxs are treatments performed by nurses based on clinical judgment & knowledge in order to achieve positive pt. outcomes • Purposes of naming: Consider appropriateness, communicate with others for continuity, relate to NDxs and NSPOs

18. Acid-Base Management Active Listening Community Disaster Preparedness Coping Enhancement Exercise Promotion Health Education Family Integrity Promotion Health Education Health Policy Monitoring Surveillance Presence Social Support Enhancement NIC: Examples

19. NIC • Hx: Interventions described in numerous literature sources • In 1987, NIC research group started to identify & standardize literature-based info • Funded by NIH, NINR for 7 yrs • 1st ed. 1992; 2nd ed. 1996; 3rd ed. 2000, 4th ed. 2004, 5th ed. 2008 • Coded for EHR; integrated with IHTSDO, formerly SNOMED CT

20. NIC (2008) • 542 interventions, definitions, descriptions • 7 Domains & 30 Classes 1. Physiologic: Basic (6 classes) 2. Physiologic: Complex (8 classes) 3. Behavioral (6 classes) 4. Safety(2 classes) 5. Family (3 classes) 6. Health System (3 classes) 7. Community (2 classes)

21. NOC (Nursing-Sensitive Patient Outcomes [NSPOs] Classification) • NSPOs define general pt. states, behaviors or perceptions that are influenced by & sensitive to NRxs and can be measured as variables • Purpose of Naming: Determine the quality and effectiveness of nursing care

22. Caregiver Homecare Readiness Knowledge: Illness Care Social Support Mobility level Risk Control: Drug Use Neglect Recovery Activity Tolerance Self Care: Hygiene Dialysis Access Integrity Wound Healing: Primary Intention Acceptance: Health Status Symptom Control NOC: Examples

23. NOC • Existing approaches: • Goal statements not quantifiable • Not comparable across localities • Not sensitive to changes in nursing care • 1991- NOC research group started • 7 yrs funding by NIH/NINR • 1st ed 1996, 2nd ed. 2000, 3rd ed. 2004, 4th ed. 2008 • Coded for EHR; integrated with IHTSDO

24. NOC (2008) • 385 outcomes, definitions, descriptions • 7 Domains, 29 Classes 1. Functional Health (4 classes) 2. Physiologic Health (10 Classes) 3. Psychosocial Health (4 Classes) 4. Health Knowledge & Behavior (4 Cl.) 5. Perceived Health (2 Classes) 6. Family Health (3 Classes) 7. Community Health (2 Classes)

25. NOC Principles • Neutral terms, variables • 17 five point scales 1 (least desirable) to 5 (most desirable) • Ex: Knowledge: Medication, None = 1, Limited = 2, Moderate = 3, Substantial = 4, Extensive = 5 • Other scales: • Very weak to very strong • None to Complete • Not At All to A Great Extent • Not Adequate to Totally Adequate • Extensive to None

26. New Directions • Common structure for the 3 systems, partially funded by the NLM • Goal: Improve: 1) integration of three systems 2) ease of use