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

Margaret Lunney, RN, PhDProfessor, College of Staten Island/CUNY, New York

What are SNLs? Names uniformly used with definitions & descriptionsLanguage systems based on rulesof 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.)

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?

Scientific names needed-word usage varies Meanings of words-extensional & intensionalScientific names provide extensional meaningsPrejudice (inaccurate interpretation of pt. data) occurs when only the intensional is used

Why SNLs?Standardized names are

needed for computer systems & EHR

(U.S. National Committee for Vital & Health Statistics)

Why SNLs?

Communication through language is:*Tool for communication (with self & others)Source of cooperative actionsTool to improve human experiencesNaming is great step forward-makes discussion possibleFundamental to growth & survival (Nursing & HC) * Hayakawa’s Linguistics Theory

Why SNLs?

Words and phrases are maps to the territoryMany maps are needed to “know” a territoryNo maps “fully” represent the territoryAll maps together do not “equal” the territory Goal is to make “good maps” of the territoryExample: Pluteus cervinus mushroom

fawn mushroom, deer mushroom, fawn pluteus, the deer mushroom, fawn shieldcapNorth American Commission for Common Names for Mushrooms created in 2000

Why Select Names for Nursing Phenomena?

We experience only a small fraction of phenomenaWe must abstract the objects of experiences It makes no sense to distrust abstractionsWe need to be aware of abstractingConnect words with

experiences; avoid this

Why SNLs?

SNLs represent pooled nursing knowledgeUse of pooled knowledge helps nurses to plan, interpret, intervene and evaluateSciences seek generally useful vocabularies, ones that produce resultsResults = quality of care

Effects on Nursing Careof Using SNLs

Naming Thoughts Discernment

Communication + Cooperation + Action

Improved Access, Cost Effectiveness, & QualityLunney, 1999

NANDA International (I)

Nursing diagnoses are human responses (HRs) to health problems and life processes for which nurses provide interventionsPurposes: Name human responses of concern to nurses so accuracy can be addressed and the best NRxs can be selected for positive outcomes

NANDA I: ExamplesPainDeath AnxietyImpaired Home MaintenanceReadiness for Enhanced Community CopingHopelessnessIneffective Breathing Pattern

Risk for infectionRelocation Stress SyndromeDecisional ConflictAcute ConfusionEffective Breast Feeding

Why NDx?Human responses are complex Research findings r.t. high risk of inaccuracy

1966 series of studies1970’s series of studies1980-2001: Influencing factors• Clinician knowledge, abilities & other • Task difficulty level• Situational factors, e.g., agency policies

Why NDx?Interpretations/diagnoses =foundation for NRxs & NSPOsLow accuracy can lead to:

harm to patient/familywasted time & energyabsence of positive outcomespatient/family dissatisfaction

Basis for quality of nursing careAccountability to HC consumersExpand knowledge of health

NANDA IHistory, 1973-presentResearch-based submissionsSystematic approval process International involvementNDxs widely usedPublish every 2 years, latest 2009Recognized by significant organizations (ICD, HL7, ANA, ICN, ACENDIO, AENTDE, others)

NANDA: Taxonomy II7 axes (concept, time, unit of care, age, health status, descriptor, topology) 206 diagnoses, definitions, descriptions

ProblemsRisk statesHealth promotionWellness/Strengths

13 Domains, 2-6 classes in each domainCoded for EHR; integrated with International Health Terminology Standards Development Organization (IHTSDO)

NIC (Nursing Interventions Classification [NRxs])

NRxs are treatments performed by nurses based on clinical judgment & knowledge in order to achieve positive pt. outcomesPurposes of naming: Consider appropriateness, communicate with others for continuity, relate to NDxs and NSPOs

NIC: ExamplesAcid-Base ManagementActive ListeningCommunity Disaster PreparednessCoping EnhancementExercise PromotionHealth Education

Family Integrity PromotionHealth EducationHealth Policy MonitoringSurveillancePresenceSocial Support Enhancement

NICHx: Interventions described in numerous literature sourcesIn 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. 2008Coded for EHR; integrated with IHTSDO, formerly SNOMED CT

NIC (2008)

542 interventions, definitions, descriptions7 Domains & 30 Classes1. 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)

NSPOs define general pt. states, behaviors or perceptions that are influenced by & sensitive to NRxs and can be measured as variablesPurpose of Naming: Determine the quality and effectiveness of nursing care

NOC: ExamplesCaregiver Homecare ReadinessKnowledge: Illness CareSocial SupportMobility levelRisk Control: Drug UseNeglect Recovery

Activity ToleranceSelf Care: HygieneDialysis Access IntegrityWound Healing: Primary IntentionAcceptance: Health StatusSymptom Control

NOCExisting approaches:

Goal statements not quantifiableNot comparable across localitiesNot 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. 2008Coded for EHR; integrated with IHTSDO

NOC (2008)

385 outcomes, definitions, descriptions7 Domains, 29 Classes1. 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 PrinciplesNeutral terms, variables17 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 strongNone to CompleteNot At All to A Great ExtentNot Adequate to Totally AdequateExtensive to None

New Directions

Common structure for the 3 systems, partially funded by the NLMGoal: Improve:1) integration of three systems2) ease of use