Evidence of Progress in Making Nursing Practice Visible Using Standardized Nursing Data: a Systematic Review
Tamara G. R. Macieira, BSN, PhD student1, Madison B. Smith, BSN, RN, PhD student1 Nicolle Davis, BSN, RN, SCRN, PhD student1, Yingwei Yao, PhD1, Diana J. Wilkie, PhD,
RN, FAAN1, Karen Dunn Lopez, PhD, MPH2, Gail Keenan, PhD, RN, FAAN1 1University of Florida, Florida; 2University of Illinois at Chicago, Illinois
Abstract
Nursing care documentation in electronic health records (EHRs) with standardized nursing terminologies (SNTs) can facilitate nursing’s participation in big data science that involves combining and analyzing multiple sources of data. Before merging SNTs data with other sources, it is important to understand how such data are being used and analyzed to support nursing practice. The main purpose of this systematic review was to identify studies using SNTs data, their aims and analytical methods. A two-phase systematic process resulted in inclusion and review of 35 publications. Aims of the studies ranged from describing most popular nursing diagnoses, outcomes, and interventions on a unit to predicting outcomes using multi-site data. Analytical techniques varied as well and included descriptive statistics, correlations, data mining, and predictive modeling. The review underscored the value of developing a deep understanding of the meaning and potential impact of nursing variables before merging with other sources of data.
Introduction
The main frontline providers of care are nurses who also represent the largest category of health workers in the hospital setting. Among the 2.8 million registered nurses currently working in the United States (U.S.), 61% work in hospitals1 whereas 19% of 297,1002 pharmacists and 41.9% of 854,698 physicians in practice work in hospitals.3,4
Nurses are responsible 24 hours each day for continuously identifying care issues, implementing and adjusting care prescribed by themselves and other providers to achieve desired patient outcomes. To date, however, it has been difficult to effectively evaluate the impact of nursing on patient outcomes. The growing use of electronic health records (EHRs) to document care now offers the opportunity to use the data captured in practice for discovering knowledge to transform health care. Thus, the documentation entered by nurses into EHRs, for the first time ever, is a potential source for discovering the impact of nursing care on patient outcomes and using the knowledge to
improve care. In this article, we report our systematic review of studies that utilized nursing EHRs data to answer a variety of research questions from describing nursing care for a specific population to predicting patient outcomes. The publications reviewed provide a foundation for identifying future paths of inquiry involving nursing and other data retrievable from EHRs.
The use of standardized nursing terminologies (SNTs) to document nursing care enables the easy retrieval and analysis of nursing data while also representing the nurse’s clinical reasoning.5 The integration of nursing data into large datasets requires the frequent and rapid input of new valid information from EHRs.6 These can be achieved through the use of controlled vocabularies in EHRs, which helps overcome the major challenges of aggregation, processing and analysis associated with unstructured text data.7-8 In nursing, SNTs are controlled vocabularies that represent nursing care as nursing diagnoses, interventions and outcomes.8 The SNT coded data retrieved from EHRs can be analyzed alone or merged with other EHRs data. The use of SNTs to document nursing practice is a big step toward supporting the aggregation of nursing data to large datasets and big data science.
Different sets of SNTs are used to document nursing care. The American Nurses Association (ANA) recognizes and supports the use of certain nursing terminologies to guide and document care if those have clear and unambiguous concepts, are coded with a unique identifier per concept, and if those terminologies were tested for reliability, clinical usefulness and validity.9 The following nursing terminologies are recognized by ANA: NANDA-International (NANDA-I)10; Nursing Interventions Classification (NIC)11; Nursing Outcomes Classification (NOC)12; International Classification for Nursing Practice (ICNP)13; Omaha System14; Clinical Care Classification (CCC)15; and the Perioperative Nursing Data Set (PNDS).16 While ICNP, Omaha System, CCC and PNDS sets contain diagnoses, interventions and outcomes terms; NANDA-I (diagnoses), NIC (interventions) and NOC (outcomes) are three separate terminologies. Since NANDA-I, NIC and NOC are very often used together, we will refer to them as a terminology set (NNN).
Systematically reporting and analyzing studies that used SNTs nursing data retrieved from EHRs is important to understand the analytic issues related to the complexity and richness of data generated from the use of these
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