1. 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

2. 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)

3. ANA Approved SNLs (U.S.) NANDA (NDx) NIC (NRx) NOC (NSPO s) 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)

4. 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

5. Why SNLs? Standardized names are needed for computer systems & EHR (U.S. National Committee for Vital & Health Statistics)

6. 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

7. 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

8. 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

9. 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

10. Effects on Nursing Care of Using SNLs Naming Thoughts Discernment Communication + Cooperation + Action Improved Access, Cost Effectiveness, & Quality Lunney, 1999

11. 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

12. 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

13. 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

14. 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

15. 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)

16. 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)

17. 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

18. 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

19. 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 1 st ed. 1992; 2 nd ed. 1996; 3 rd ed. 2000, 4 th ed. 2004, 5 th ed. 2008 Coded for EHR; integrated with IHTSDO, formerly SNOMED CT

20. 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)

21. 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

22. 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

23. 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 1 st ed 1996, 2 nd ed. 2000, 3 rd ed. 2004, 4 th ed. 2008 Coded for EHR; integrated with IHTSDO

24. 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)

25. 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

26. New Directions Common structure for the 3 systems, partially funded by the NLM Goal: Improve: 1) integration of three systems 2) ease of use