Linda Q. Thede, PhD, RN-BC
Patricia M. Schwirian, PhD, RN
Citation: Thede, L., Schwirian, P., (December 16, 2013) "Informatics: The Standardized Nursing Terminologies: A National Survey of Nurses’ Experience and Attitudes—SURVEY II: Participants’ Documentation Use of Standardized Nursing Terminologies" OJIN: The Online Journal of Issues in Nursing Vol. 19 No. 1.
This is the fourth column reporting on our survey assessing nurses’ experiences with and attitudes towards the American Nurses Association (ANA) standardized nursing terminologies. In the first column , we reported the demographics of our participants and compared the extent of their familiarity with each of the terminologies between our first and second surveys (Survey I and Survey II) and also their source of information about a terminology (Schwirian & Thede, 2012). The number and percentage of those who were familiar with a terminology and who had actually used the terminology were reported in this first column. In the second column, we reported nurses’ perceptions of their educational preparation for using the terminology (Thede & Schwirian, 2013a). The third column looked at terminology users’ comfort level in actually applying the terms to clinical situations and also their perceptions of their colleagues’ comfort level (Thede & Schwirian, 2013b).
NANDA (North American Nursing Diagnosis Association)
NIC (Nursing Intervention Classification)
NOC (Nursing Outcomes Classification)
CCC (Clinical Care Classifications)
PNDS (Perioperative Nursing Data Set)
ICNP (International Class-ification of Nursing Practice)
SNOMED (Systematized Nomenclature of Medicine)
LOINC (Logical Observation Identifiers Names & Codes)
In this column, we will examine reports from those nurses who actually used a terminology in documenting clinical (patient-care) situations. See Box for a list of the terminologies.
Clinical Use of Terminologies
Using the ‘branching’ research technique that we described in our second column on this topic (Thede & Schwirian, 2013b), only those participants who indicated a ‘familiarity’ with a terminology were asked questions regarding their documentation related to nursing terminologies in this study. These who did indicate a familiarity were then asked if they had used a terminology in any capacity, such as in a school paper, in a clinical lab, or in actual patient care, as was reported in Table 2, Column 2 (Thede & Schwirian, 2013b). These who indicated a familiarity were then asked if they had used the terminology in actual patient care.
Figure 1 reports the percentage of users who answered yes to the question about use in patient care. As expected, the largest number, as well as highest percentage of those who had used a terminology in clinical settings, had used NANDA (67.8%), followed by users of the Omaha System (66.7%), and the PNDS (62.3%). The percentages for those who did or did not use the terminology are based on the total number of users of a terminology who answered ‘yes’ to using the terminology in patient care.
Figure 1. Percentage of Terminology Users Who Used (Did Not Use) a Terminology Clinically [full size figure]
Clinical Documentation with a Terminology
Respondents who answered yes to the question about clinical use for a terminology were asked the following questions:
- Did you document using X (name of terminology participants indicated they had used)?
- Do you feel that using X made your documentation more understandable to others?
- Did the documentation system in place assist you in documenting with X?
- Did using X for documentation make the documentation easier?
- Did you document electronically using X
Their responses are described below.
Documenting with a Terminology
The percentage of users who both used a terminology in clinical care and also documented with it exceeded 75% for all the terminologies (Figure 2). The greatest percentage of users of a terminology who actually documented with the terminology were users of the ICNP (100%), CCC (94.4%), PNDS (93.0%) and Omaha System (91.3%). The ICNP had a very small number of users who responded to the questions about use, thus this percentage is probably not representative beyond those who answered the question.
Figure 2. Percentage of Clinical Users Who Documented (Did Not Document) with a Terminology [full size figure]
The respondents’ opinions about the other four questions asked of clinical users who documented using a terminology are presented in the Table and discussed below. Because these responses represent all those who answered affirmatively that they used a terminology both clinically and to document, leaving a question with no response causes the percentages to not equal 100%. For example, 10 LOINC users left the question about whether the documentation system assisted them in using the terminology blank thus generating a 0% for “No.”
Table. Numbers and Percentages of Opinions about Documentation [full size table]
Documentation More Understandable to Others
Over 55% of all clinical terminology users who documented with the given terminology believed that documenting with the terminology made their documentation more understandable to others (Figure 3). The highest number of users who documented using the terminology and who believed that using the terminology made their documentation more understandable to others were users of the CCC (82.4%) and Omaha System (78.6%). NANDA (56.3%) users had the least confidence that using the terminology to document made it more understandable to others followed by NOC users (61.5%) and NIC users (66.2%) (Figure 3).
Figure 3. Percentage of Users Who Believed That Documenting with a Terminology Made It More Understandable (Not More Understandable) To Others [full size figure]
System Assisted Using the Terminology to Document
More than 50% of clinical users who documented with a terminology reported that the documentation system assisted them in documenting with the terminology (Figure 4). Clinical users who documented with a terminology using CCC (94.1%), LOINC (93%) and PNDS (92.5%) reported the highest level of system assistance while NANDA (55.8%) users reported the least system assistance (Figure 4).
Figure 4. Percentage of Users Whose Documentation System Assisted (Did Not Assist) Documentation with the Terminology [full size figure]
Documentation Easier Using a Terminology
At least 50% of clinical users of all the terminologies reported that the documentation was easier with the terminology. Users of the CCC (82.4%), Omaha System (78.6%), and NIC (72.3%) who documented clinically using a standardized terminology believed that their documentation was easier (Figure 5). NANDA (52.1%) had the least number of users who found that their documentation was easier using a terminology.
Figure 5. Documentation Easier (Not Easier) with the Terminology [full size figure]
Documenting Electronically with a Terminology
Surprisingly NANDA clinical users (40.0%) reported the lowest percentage of documenting electronically with the terminology whereas CCC, ICNP, and LOINC users all reported 100% electronic documentation when using the terminology. Again, note that these percentages reflect only those who answered this question, although they are based on the total number of clinical users of a terminology. Figure 6 illustrates these percentages.
Figure 6. Percentage of Those Who Documented Electronically (Not Electronically) Using a Terminology [full size figure]
Those users of a terminology who documented using the terminology were generally positive about their documentation being more understandable to others and easier to do when using a standardized terminology. Additionally more than 50% of the respondents who used a terminology clinically reported that the documentation systems that were in use made documentation easier. With only one exception, over 60% of those who documented with a terminology documented electronically. The next column will explore clinical users’ perception of usefulness of the standardized terminologies in actual clinical care.
Linda Thede, PhD, RN-BC
Linda Thede is currently the editor of CIN Plus, a 12 page insert in CIN: Computers, Informatics, Nursing. She has served as course mentor for informatics for St. Joseph’s College, Excelsior College, and Thomas Edison College. Prior to this she was an Assistant Professor in the School of Nursing at Kent State University where she participated in numerous University Committees studying and implementing computer uses and distance education. At Kent she taught nursing informatics and assisted the faculty in the use of technology for many uses including databases and is a Professor Emeritus. She was a cofounder of the Informatics Nurses of Ohio, and served as its first president. She is certified in Informatics and has published a book, Informatics and Nursing, which is in its fourth edition. She founded the second listserv used in nursing, Gradnrse, which she merged with NurseRes, a listserv that she started with the support of the Midwest Nursing Research Society.
Patricia M. Schwirian, PhD, RN
Dr. Pat Schwirian is Professor Emeritus of Nursing at The Ohio State University (OSU), Columbus, Ohio, and an Adjunct Professor in the College of Information Science and Technology at Drexel University (Philadelphia, PA) where she teaches a graduate course in Nursing Informatics. Patricia became one of the initial adopters of online instruction while teaching in The OSU College of Nursing; she currently teaches an online course in Gerontology for The OSU College of Medicine. Dr. Schwirian was very actively involved in the ‘early days’ of Nursing Informatics, serving as the first Research Editor of the journal, Computers in Nursing (now CIN: Computers, Informatics, Nursing), and has been named as a Pioneer in Nursing Informatics by the National Library of Medicine & American Medical Informatics Association. She earned her BS in Science/Math Education at Illinois State University, Normal, IL; her BS in Nursing at Capital University in Columbus, OH; her MS in Science Education at the University of Iowa in Iowa City, and her PhD in Science Education at The Ohio State University. In addition she has completed a post-doctoral fellowship in Medical Sociology at The Ohio State University.
Schwirian, P., & Thede, L. (2012). Informatics: The standardized nursing terminologies: A national survey of nurses’ experience and attitudes—SURVEY II: Participants, familiarity and information sources. The Online Journal of Issues in Nursing, 17(2). doi: 10.3912/OJIN.Vol17No2InfoCol01
Thede, L. Q., & Schwirian, P. (2013a). Informatics: The standardized nursing terminologies: A national survey of nurses’ experience and attitudes —SURVEY II: Participants’ education for the use of standardized nursing terminology “labels.” The Online Journal of Issues in Nursing, 18(2). doi: 10.3912/OJIN.Vol18No02InfoCol01
Thede, L. Q., & Schwirian, P. (2013b). Informatics: The standardized nursing terminologies: A national survey of nurses’ experience and attitudes —SURVEY II: Participants’ perception of comfort in the use of standardized nursing terminology "labels." The Online Journal of Issues in Nursing, 18(2). doi: 10.3912/OJIN.Vol18No02InfoCol02
© 2013 OJIN: The Online Journal of Issues in Nursing
Article published December 16, 2013