CHAPTER 17 THEORIES, MODELS, and FRAMEWORKS
Objectives • Discuss the relationship between healthcare informatics and nursing informatics. • Discuss different definitions and models of nursing and healthcare informatics. • Discuss core concepts and the scope of practice of nursing informatics. • Describe nursing informatics as a distinct specialty. • Discuss key aspects of the electronic health record(EHR). • Discuss terminologies for nursing. • Identify available organizational resources.
Foundational Documents Guide Nursing Informatics Practice • In 2001, the American Nurses Association(ANA) published the Code of Ethics for Nurses with Interpretative Statements, a complete revision of previous ethics provisions and interpretive statements that guide all nurses in practice, be it in the domains of direct patient care, education, administration, or research. • Terms – such as decision-making, comprehension, information, knowledge, shared goals, disclosure, policies, protocols, evaluation, judgment, standards, and factual documentation abound throughout the explanatory language of the interpretive statements.
In 2003, a second foundational professional document, Nursing’s Social Policy Statement, Second Edition, provided a new definition of nursing. Nursing- is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations. Early 2004- further reinforces the recognition of nursing as a cognitive profession.
1st Assessment- data collection begins the nursing process. 2nd step diagnosis/ Problem Definiton- reflects the interpretation of the data and information gathered during assessment. 3rd step- Outcomes identification 4th step- Planning 5th step- Implementation Nursing Process – literature, includes numerous feedback loops, and incorporates evaluation activities throughout the sequencing.
Informatics and Healthcare Informatics • Informatics- is a science that combines a domain science, computer science, information science, and cognitive science. • Healthcare Informatics -may be defined as the integration of healthcare sciences, computer science, information science, and cognitive science to assist in the management of healthcare information. -a subdiscipline of informatics.
Cont… • Healthcare Informatics : -is a relatively young addition to the informatics umbrella, you may see other terms that seem to be synonyms for this same area, such as health informatics or medical informaticss. Medical Informatics : -historically has been used in Europe. -is now more clearly a subdomain of healthcare informatics and health informatics may mean informatics used in educating healthcare clients and/or the general public.
Nursing Informatics • Is a unique areas that address the special information needs for the discipline of nursing. In 1985, Kathryn Hannah proposed a definition that nursing informatics is the use of information technologies in relation to any nursing functions and actions of nurses. Graves & Corcoran definition with the development of the first scope of practice for nursing informatics, presented a more complex definitions of nursing informatics.
ANA defined nursing informatics as the specialty that integrates nursing science, computer science, and information science in identifying, collecting, processing, and managing data and information to support nursing practice, administration, education, research, and the expansion of nursing knowledge. In 2000, the ANA convened an expert panel to review and revise the scope and standards of nursing informatics practice.
Models for Nursing Informatics • Models are representations of some aspect of the real world. - Models show particular perspectives of a selected aspect and may illustrate relationships. Models evolve as knowledge about the selected aspect changes and are dependent on the “world view” of those developing the model. It is important to remember that different models reflect different viewpoints and are not necessarily competitive; that is, there is no one “right” model. - is a direct depiction of their definition of nursing informatics. - provides a framework for identifying significant information needs, which in turn can foster research.
4 ELEMENTS : 1.Raw Material (nursing related information) 2.Technology (a computing system) 3. Users (nurses, students and context) 4. Goal or Object toward which the preceding elements are directed. • Bidirectional arrows connect the three base components of raw material, user, and computer system to form the pyramid’s triangular base. • In 1996, proposed another model in which the core components of informatics (cognitive science, information science, and computer science) are depicted as intersecting circles. • Nursing science- a larger circle that completely encompasses the intersecting circles.
Data, Information, and Knowledge • Identified as current met structures or overarching concepts for nursing informatics with specific definitions in the Scope and Standards of Nursing Informatics Practice. • Data are “discrete entities that are described objectively without interpretation” and would include some value assigned to a variable. • Information reflects interpretation, organization, or structuring of data. • Knowledge emerges from the transformation of information. “Knowledge is information that is synthesized so that relationships are identified and formalized”.
> Registered Nurses as Knowledge Workers • Knowledge work is the exercise of specialist knowledge and competencies (Blackleaf, 1995). • Registered nurses are consummate twenty-first century knowledge workers. Their skills in assessment, planning, critical thinking, and evaluation are transferable to many different settings but are most exquisitely employed in nursing practice. • Competencies Every Nurses must continually exhibit the capability to acquire and then demonstrate specific skills beginning with the very first student experience.
ANCC content expert panel has oversight responsibility for the content of this examination and considers the current informatics environment and research when defining the test content outline. • The topics addressed include human factors, -system life cycle (system planning, analysis, design, implementation and testing, evaluation, maintenance, and support), -information technology (hardware, software, communications, data representation, and security), -information management and knowledge generation (data, information, knowledge), -professional practice, trends, and issues (roles, trends and issues, ethics), and models and theories (foundations of nursing informatics, nursing and healthcare data sets , classification systems and nomenclatures, related theories and sciences).
Electronic Health Record (EHR) • Healthcare environment is characterized by significant emphasis on establishing the EHR in all settings. • Data sets are comprised of data elements brought together for a specific reason. • Modern databases are used for storing data in a way that maintains the logical relationships among data elements, and are stored in a computer. • The focus in this chapter is on the client health record as a database. • Simple perspective is that the EHR is a client health record database supported by computer, electronic, and communications technologies. • American Society for Testing and Materials(ASTM) Standard E 1384-02a defines the EHR as “any information realated to the past, present or future physical/mental health, or condition of an individual.
Terminologies • to convey important data and information to others, the communication must be understood by the listener and be interpreted as having meaning. • this is the best accomplished by using standard communication formats and terminologies. • Concept representation involves the set of terms and relationships. • Data Elements are terms for which data are collected and for which values are assigned. • Purposeful group of data elements, representing a subset of concepts within a discipline is a data set.
Cont… The nursing minimum data set (NMDS) developed through Dr. Harriet Werley’s research is considered the foundational work for nursing languages and represents the first attempt to standardize the collection of essential nursing data. This data set contains 16 data elements divided into patient, service, and nursing care elements, and fosters the comparison of nursing data across time, settings, and populations (Werley and Lang, 1988).
Four Nursing Care Elements include; • Nursing Diagnosis • Nursing Intervention • Nursing Outcome • Intensity of Nursing care • Patient/Client Demographic • Elements address personal identification • Date of birth • Gender • Race • Residence
Seven Service Elements include; • Unique facility or service agency number • Unique health record number of patient or client • Unique number of principal registered nurse provider • Episode admission or encounter data • Discharge or termination date • Disposition of patient or client • Expected payer • There are other data sets that contain nursing data elements such as the minimum data set (MDS) developed for long term care facilities (http:// www.cms.hhs.gov/medicaid/mds20/default.asp?) and outcome and assessment information set (OASIS) • the home health data set that is used by home health agencies (http:// www.cms.hhs.gov/oasis/).
Nursing terminologies offer systematic, standardized ways of describing nursing practice and include data sets, taxonomies, nomenclatures, and classification systems. Nomenclatures are terms or labels for describing concepts in nursing such as diagnoses, interventions, and outcomes. Classifications are the ordering entities, Taxonomy is the study of classification Often used interchangeably with classification, classification is an ordering of entities into groups according to a set of criteria as well as the end result of the ordering.
Cont… • A nomenclature or vocabulary is a set of word labels for naming concepts. • Nursing terminologies focus on the patient and care process, not reimbursement or mortality, and are increasingly important as EHRs. • Terminologies are used to capture, store, and manipulate data in EHRs. • This Diversity offers practitioners choices in how to best describe their patient population and practice. • Interested readers are referred to the terminology developers or custodian. • What is Important to remember is that each of the ANA-recognized terminologies was developed for specific purposes and does not yet provide the language to describe every segment of the nursing process.
NANDA - Nanda-I has evolved from an alphabetical listing in the mid-1980’s to a conceptual system that guides the classification of nursing diagnoses in a taxonomy and includes definitions and defining characteristics. • Nursing Interventions Classificiation (NIC) - the fourth edition of NIC contains 514 nursing interventions that describe the treatments nurses perform, updated linkages with NANDA diagnoses, and core interventions identified for 44 specialty practice areas (including three new specialties). • Nursing Outcomes Classification (NOC) - the latest edition of NOC has 330 research-based outcomes to provide standardization of expected patient, caregiver, family, and community outcomes for measuring the effect of nursing interventions.
Clinical Care Classification (CCC) [Formerly Home Health Care Classification (HHCC) - the CCC system is research-based nomenclature designed to standardize the terminologies for documenting nursing care in all clinical care settings. 2 Interrelated terminologies; - CCC of Nursing Diagnoses and Outcomes - CCC of Nursing Interventions and Actions • Omaha System - the ohama system is used in all clinical settings. It includes an assessment component (Problem Classification Scheme), an intervention component (Intervention Scheme), and an outcomes component (Problem Rating Scale for Outcomes).
Perioperative Nursing Data Set (PNDS) - the PNDS provides a universal language for perioperative nursing practice and education and a framework to standardize documentation. • SNOMED CT - the SNOMED CT is a core clinical terminology containing over 357,000 healthcare concepts organized into multiple hierarches. • ABC Codes - the ABC codes provide a mechanism for coding integrative health interventions by clinician by state location for administrative billing and insurance claims.
Patient Care Data Set (PCDS) - the PCDS includes terms and codes for patient problems, therapeutic goals, and patient care orders. This data set was developed by Dr. Judith Ozbolt from research data from nine acute care hospitals throughout the United States. • Logical Observation Identifiers Names and Codes (LOINC) - the LOINC originated as a database of standardized laboratory terms for results reporting for chemistry, hematology, serology, microbiology, and toxicology. > International Classification for Nursing Practice ( ICNP) - is a combinatorial terminology for nursing practice developed by the international nursing community under sponsorship of the International Council of Nurses(ICN).
Nursing Management Minimum Data Set (NMMDS) - the NMMDS includes terms to describe the context and environment of nursing practice, and includes terms for nursing delivery unit/service, patient/client population, care delivery method, personnel characteristics, and financial resources. • Organizations as Resources - Many organizations have emerged to provide information resources and value-added membership benefits that support those individuals interested in healthcare and nursing informatics. • American Medical Informatics Association - the AMIA is an individual membership organization dedicated to the development and application of Medical informatics in the support of patient care, teaching, research, and healthcare administration.
Healthcare Information and Management Systems Society - the HIMSS represents a membership of over 14,000 individuals and 200 corporations interested in healthcare informatics, clinical systems, information systems, management engineering, and telecommunications. • National League for Nursing - the mission of NLN is to advance quality nursing education that prepares the nursing education that prepares the nursing workforce to meet the needs of divers populations in an ever-changing healthcare environment. • Society for Health Systems - the Society for Health Systems (SHS) is a society of the Institute of Industrial Engineers.
Association for Computing Machinery - the ACM was founded in 1947 and has become a major force in advancing the skills of information technology professionals and students worldwide. • ARMA International - ARMA International (ARMA) is a non-for-profit association serving more than 10,000 information management professionals in the United States, Canada, and over 30 other nations. • American Society for Information Science and Technology - the ASSIS&T established in 1937, describes itself as the society for information professionals leading the search for new and better theories, techniques, and technologies to improve access to information. The explosion of the WORLD WIDE WEB now makes those diverse resources continously available from any world location.
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