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).

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]

Conclusion

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
Email: lqthede@roadrunner.com

Patricia M. Schwirian, PhD, RN
Email: schwirian.1@osu.edu

© 2013 OJIN: The Online Journal of Issues in Nursing
Article published December 16, 2013