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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

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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? (SNLs) for the Electronic Health Record

  • 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.) (SNLs) for the Electronic Health Record

  • 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? (SNLs) for the Electronic Health Record

  • 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


The need for and use of standardized nursing languages snls for the electronic health record
Why SNLs? (SNLs) for the Electronic Health RecordStandardized names are needed for computer systems & EHR(U.S. National Committee for Vital & Health Statistics)


Why snls1
Why SNLs? (SNLs) for the Electronic Health Record

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? (SNLs) for the Electronic Health Record

  • 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? (SNLs) for the Electronic Health Record

  • 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) for the Electronic Health Record

  • 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 Care (SNLs) for the Electronic Health Recordof Using SNLs

Naming Thoughts Discernment

Communication + Cooperation + Action

Improved Access, Cost Effectiveness, & Quality

Lunney, 1999


Nanda international i
NANDA International (I) (SNLs) for the Electronic Health Record

  • 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 (SNLs) for the Electronic Health Record

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? (SNLs) for the Electronic Health Record

  • 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? (SNLs) for the Electronic Health Record

  • 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 (SNLs) for the Electronic Health Record

  • 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 (SNLs) for the Electronic Health Record

  • 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]) (SNLs) for the Electronic Health Record

  • 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 (SNLs) for the Electronic Health Record

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


The need for and use of standardized nursing languages snls for the electronic health record
NIC (SNLs) for the Electronic Health Record

  • 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) (SNLs) for the Electronic Health Record

  • 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 Classification)

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


The need for and use of standardized nursing languages snls for the electronic health record
NOC Classification)

  • 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) Classification)

  • 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 Classification)

  • 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 Classification)

  • Common structure for the 3 systems, partially funded by the NLM

  • Goal: Improve:

    1) integration of three systems

    2) ease of use