Nurses’ Use of Standard Terms In Nurses’ Use of Standard Terms In Electronic Records With and Electronic Records With and

Without NNNWithout NNN

Margaret Lunney, RN, PhD Margaret Lunney, RN, PhD Professor, College of Staten Island (CSI)Professor, College of Staten Island (CSI)

Linda Fiore, RN, MALinda Fiore, RN, MAAssistant Director of NursingAssistant Director of Nursing

New York City Dept of Health & Mental New York City Dept of Health & Mental HygieneHygiene

AcknowledgementsAcknowledgements

Main study (In review): Main study (In review): – Effects of Using Standard Terms in Electronic Records on Nurses’ Effects of Using Standard Terms in Electronic Records on Nurses’

Power and Children’s Health OutcomesPower and Children’s Health Outcomes

Main Study Co-Investigators:Main Study Co-Investigators:

– Laurence Parker, PhDLaurence Parker, PhD– Roberta Cavendish, RN, PhDRoberta Cavendish, RN, PhD– Joyce Pulcini, RN, PhDJoyce Pulcini, RN, PhD

Main study partially funded by:Main study partially funded by:– NINR, NIH, 1R15NR04870, $107, 700NINR, NIH, 1R15NR04870, $107, 700– CSI Foundation & President Marlene Springer, $15,000CSI Foundation & President Marlene Springer, $15,000– Professional Software for Nurses, $14,000 Professional Software for Nurses, $14,000

BackgroundBackground

CHANGE from paper to electronic health CHANGE from paper to electronic health records (EHR)records (EHR)

CHN specialty-nursing care in school CHN specialty-nursing care in school settingssettings

Decisions re: software to purchaseDecisions re: software to purchase

Many vendors, Medical model approachesMany vendors, Medical model approaches

Will EHR include sufficient nursing data?Will EHR include sufficient nursing data?– Driving ForcesDriving Forces– Restraining ForcesRestraining Forces

Driving Forces:Driving Forces: Use of NNN in School Settings Use of NNN in School Settings

1.1. Research-based standardized termsResearch-based standardized terms

2.2. Describes:Describes:Health promotionHealth promotion

Health protectionHealth protection

Management of problemsManagement of problems

3.3. Provides comprehensive nursing Provides comprehensive nursing process data; both decisions & actionsprocess data; both decisions & actions

Driving Forces:Driving Forces: Use of NNN in School Settings Use of NNN in School Settings

4.4. Measures broad range of child & family Measures broad range of child & family outcomes outcomes

5.5. Relates outcomes to interventionsRelates outcomes to interventions

6.6. Improves:Improves:CommunicationCommunication

Continuity of careContinuity of care

Restraining Forces: Restraining Forces: Use of NNN in School SettingsUse of NNN in School Settings

1.1. Historically:Historically:– Data organized by medical diagnoses (MDx) & tasksData organized by medical diagnoses (MDx) & tasks– Nursing model for care generally invisibleNursing model for care generally invisible– Low emphasis on documenting health promotion & health Low emphasis on documenting health promotion & health

protectionprotection

2.2. Resistance to change historical patternsResistance to change historical patterns

3.3. With familiarity of MDx, perception that With familiarity of MDx, perception that EHR based on MDx easier to implementEHR based on MDx easier to implement

Restraining Forces: Restraining Forces: Use of NNN in School SettingsUse of NNN in School Settings

4.4. Cost of purchasing licenses to use NNN Cost of purchasing licenses to use NNN

5.5. Paucity of research data to show the Paucity of research data to show the advantages of using NNNadvantages of using NNN

Research QuestionsResearch Questions

1.1. Are there patterns of documentation that Are there patterns of documentation that can be identified from health visit data?can be identified from health visit data?

2.2. Are there differences in documentation Are there differences in documentation patterns with and without use of NNN?patterns with and without use of NNN?

3.3. Does the data support the advantagesDoes the data support the advantages

of using NNN?of using NNN?

Study MethodsStudy MethodsQualitative & quantitative analyses of 12 Qualitative & quantitative analyses of 12 nurses’ documentationnurses’ documentation

Health visits with 220 children, ~1300 Health visits with 220 children, ~1300 contactscontacts

6 nurses used standard terms of vendor6 nurses used standard terms of vendor

6 nurses used NNN + vendor terms6 nurses used NNN + vendor terms

Investigators independently analyzed dataInvestigators independently analyzed data

Methods to support credibility, dependability, Methods to support credibility, dependability, confirmability, transferabilityconfirmability, transferability

FindingsFindings

Q 1: Documentation patterns evident: Q 1: Documentation patterns evident: – Type of care providedType of care provided

Primarily health promotion & health protection Primarily health promotion & health protection (~80%)(~80%)Management of therapeutic regimens (~10%)Management of therapeutic regimens (~10%)Management of health problemsManagement of health problems (~10%)(~10%)

– # of standard terms used per visit varied widely # of standard terms used per visit varied widely among nurses, e.g., 1 vs. 10 Rxs among nurses, e.g., 1 vs. 10 Rxs

– Poor documentation of outcomes, i.e., 9/12 Poor documentation of outcomes, i.e., 9/12 schools little to no outcome dataschools little to no outcome data

– Some errors implied in use of termsSome errors implied in use of terms

FindingsFindingsQ2 & 3: Comparison of two groups:Q2 & 3: Comparison of two groups:

Group that used NNN:Group that used NNN:– Data better illustrated a nursing model for careData better illustrated a nursing model for care– Data were more comprehensive, e.g.,Data were more comprehensive, e.g.,

Used 44 NDxs; 93 NIC Interventions, 33 NOC Used 44 NDxs; 93 NIC Interventions, 33 NOC Outcomes Outcomes Vendor termsVendor terms

– Data better reflected specialty emphasis on Data better reflected specialty emphasis on health promotion & health protectionhealth promotion & health protection

– Data showed diversity & complexity of practiceData showed diversity & complexity of practice

High Frequency NANDA DiagnosesHigh Frequency NANDA Diagnoses

Nursing diagnosisNursing diagnosis Freq.Freq. # Nurses# Nurses

Knowledge DeficitsKnowledge Deficits

Health Seeking BehaviorHealth Seeking Behavior

Risk of injury & other risk dxsRisk of injury & other risk dxs

PainPain

Self Concept, RFESelf Concept, RFE

Decisional ConflictDecisional Conflict

Self Esteem Disturbance Self Esteem Disturbance

Decision making, RFEDecision making, RFE

207207

7070

6262

8 8

3737

3535

3030

2222

5/65/6

5/65/6

5/65/6

5/65/6

3/63/6

3/63/6

3/63/6

3/63/6

High Frequency NIC InterventionsHigh Frequency NIC Interventions

InterventionIntervention Freq.Freq. # Nurses# Nurses

Active ListeningActive Listening

CounselingCounseling

Teaching: Group Teaching: Group

Health EducationHealth Education

Environmental Mgt: SafetyEnvironmental Mgt: Safety

Behavior ModificationBehavior Modification

Calming TechniqueCalming Technique

Anger Control AssistanceAnger Control Assistance

255255

134134

8686

7979

7676

6868

5050

4242

4/64/6

6/66/6

5/65/6

4/64/6

3/63/6

5/65/6

4/64/6

5/65/6

High Frequency NOC OutcomesHigh Frequency NOC Outcomes

OutcomesOutcomes Freq.Freq. # of Nurses# of Nurses

Safety Behavior: PersonalSafety Behavior: Personal

Knowledge: Health BehaviorsKnowledge: Health Behaviors

Play ParticipationPlay Participation

Role PerformanceRole Performance

Aggression ControlAggression Control

Information ProcessingInformation Processing

Knowledge: DietKnowledge: Diet

Knowledge: Health PromotionKnowledge: Health Promotion

8181

8181

4646

4444

3939

3939

3838

2929

3/63/6

2/62/6

3/63/6

3/63/6

2/62/6

2/62/6

2/62/6

4/64/6

Discussion:Discussion:Documentation PatternsDocumentation Patterns

Data (both groups) illustrated complexity & Data (both groups) illustrated complexity & diversity of school-based nursing diversity of school-based nursing

Wide variety of charting patterns r.t. “pilot” Wide variety of charting patterns r.t. “pilot” test, did not set specific expectationstest, did not set specific expectations

Inadequate use of outcomes r.t. new way Inadequate use of outcomes r.t. new way of thinking; additional education needed of thinking; additional education needed

Errors in use of terms-education neededErrors in use of terms-education needed

Discussion: Discussion: Use of NNN vs. Vendor TermsUse of NNN vs. Vendor Terms

Data better represented:Data better represented:– Nursing model for care (holism, health, caring)Nursing model for care (holism, health, caring)– Health PromotionHealth Promotion– Health ProtectionHealth Protection– Management of acute and chronic problemsManagement of acute and chronic problems

Use of NNN + vendor terms contributed to:Use of NNN + vendor terms contributed to:– Redundancy Redundancy – Inconsistent use of termsInconsistent use of terms

Implications/ConclusionsImplications/Conclusions

Computerized documentation can Computerized documentation can effectively represent school-based nursingeffectively represent school-based nursing

With use of NNN, omit vendor terms With use of NNN, omit vendor terms

With use of NNN, agencies need to plan: With use of NNN, agencies need to plan: Decision making re: preferred use of termsDecision making re: preferred use of terms

Ongoing data evaluation, e.g., monthlyOngoing data evaluation, e.g., monthly

Systematic feedback to nursesSystematic feedback to nurses

Ongoing education of nursesOngoing education of nurses

Implications/ConclusionsImplications/Conclusions

Facilitate driving forces for use of NNN: Facilitate driving forces for use of NNN: – Health-related perspectiveHealth-related perspective– Comprehensive terms needed to represent Comprehensive terms needed to represent

school-based nursingschool-based nursing– National and international recognition of terms National and international recognition of terms

Minimize the restraining forces, e.g., Minimize the restraining forces, e.g., – Research data neededResearch data needed

Promote purchase of software with NNNPromote purchase of software with NNN