the need for and use of standardized nursing languages snls for the electronic health record
Download
Skip this Video
Download Presentation
The Need for and Use of Standardized Nursing Languages (SNLs) for the Electronic Health Record

Loading in 2 Seconds...

play fullscreen
1 / 26

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


  • 118 Views
  • Uploaded on

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. What are SNLs?. Names uniformly used with definitions & descriptions Language systems based on rules

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' The Need for and Use of Standardized Nursing Languages (SNLs) for the Electronic Health Record' - rendor


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
the need for and use of standardized nursing languages snls for the electronic health record

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

what are snls
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)
ana approved snls u s
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)
why snls
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
slide5
Why SNLs?Standardized names are needed for computer systems & EHR(U.S. National Committee for Vital & Health Statistics)
why snls1
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
why snls2
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
why select names for nursing phenomena
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

why snls3
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
effects on nursing care of using snls
Effects on Nursing Careof Using SNLs

Naming Thoughts Discernment

Communication + Cooperation + Action

Improved Access, Cost Effectiveness, & Quality

Lunney, 1999

nanda international i
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
nanda i examples
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
why ndx
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
why ndx1
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
nanda i
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)
nanda taxonomy ii
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)
nic nursing interventions classification nrxs
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
nic examples
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
slide19
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
nic 2008
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)

noc nursing sensitive patient outcomes nspos classification
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
noc examples
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
slide23
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
noc 2008
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)

noc principles
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
new directions
New Directions
  • Common structure for the 3 systems, partially funded by the NLM
  • Goal: Improve:

1) integration of three systems

2) ease of use

ad