Background: Two significant challenges have always faced nursing: (a) how to differentiate nursing’s contributions to patient care from those of medicine; and (b) how to incorporate descriptions of nursing care into the health record in a manner that is commensurate with its importance to patients’ welfare. As the development of the Electronic Health Record (EHR), and the Nationwide Health Information Network, for which the EHR is foundational, proceed at an ever-increasing pace, these challenges become even more important. We need to identify nursing’s contribution to patient care and determine the best way to incorporate elements of nursing care into the EHR. Fortunately, the answer is already at hand; it lies in the use of standardized nursing terminologies (SNTs). Capturing nursing’s independent contributions requires the use of standardized terminologies that reflect the uniqueness of nursing care. A key element in differentiating between the purposes and practices of nursing and medicine lies in the professional languages that are used and understood within and between these disciplines.
The benefits of using standardized nursing terminologies include: (a) better communication among nurse and other healthcare providers, (b) increased visibility of nursing interventions, (c) improved patient care, (d) enhanced data collection to evaluate nursing care outcomes, (e) greater adherence to standards of care, and (f) facilitation of assessment of nursing competency.
Purpose: The purpose of this study was to determine registered nurses’ experiences with, and attitudes toward the standardized nursing terminologies that are recognized by the American Nurses Association.
Participants: Self-selected registered nurses who were using the Internet and who received information from selected electronic mailings. Eighteen selected nursing-related LISTSERVs were contacted and invited to introduce the study to their subscribers. Additionally, the request for participation was passed along to individuals who were not subscribers. For example, 105 respondents stated that they received the information about the survey from a professor or other school-connected person. Twelve more said their request to participate came from a work supervisor.
Method: The questionnaire was developed by the authors. The questionnaire and study received approval from the Ohio State University Office of Responsible Research Practices for Category 2 Exemption from review by the Institutional Review Board (Protocol Number: 2009E0612). We worked with Survey Monkey to develop and post both the invitations to participate and the survey itself. Following approval from each list owner, the survey was posted on October 1, 2009 and remained posted for seven weeks. Participation was anonymous.
Respondents: A total of 1,514 participants opened the survey and began completing the survey. Altogether 1,268 usable surveys were completed. Of these respondents, all answered the questions regarding their opinions; 1,147 answered the questions regarding their experiences in using a standardized nursing terminology (SNT) as reported in the table below.
Demographics: Ninety three percent of the 1,268 respondents who completed usable surveys were female. Respondents were also relatively mature, in that 68% became licensed prior to 1990 and 68% were 40-59 years of age. Students comprised 219 of the respondents. Of these 219 students, 39% were enrolled in Master’s degree programs. Geographically, over half (53%) were from the Eastern 1/3 of the United States (US). The largest single group (19%) was from Washington DC and environs. There were 60 International (non-U.S/Canada) respondents. In two successive questions respondents were asked to indicate if their principal job site was in a clinical agency or an educational institution. Of those who answered this demographic question (N=906), the main job site for 2/3s of the respondents was in clinical agencies (N=539). The remaining third identified with academic institutions. We refer to these as ‘clinical’ and ‘academic’ nurses’ respectively in the remainder of this report.
Respondents’ experience with SNTs: The primary question that fueled our interest in this project was: What experiences have registered nurses had with the Standardized Nursing Terminologies? Responses are presented as percentages of the total sample (not percentages of those who completed this section of the survey). Hence these percentages do not always add up to 100% (see Table below).
Table. Respondent Experience With SNTs
| Nursing Terminology/ Minimum Data Set | I have no knowledge or experience with it. (%) | I used it in nursing school or elsewhere, but I have no interest in using it again (%) | I used it in nursing school or elsewhere. I am neutral about using it again (%) | I would like to see it used in my clinical area (%) | I use it now in my clinical area to chart (%) | I can teach others to use it (%) |
| ABC Codes (Alternative Billing Codes) | 77.4 | 2.3 | 6.2 | 2.6 | .9 | 1.0 |
| CCC (Clinical Care Classifications) | 47.0 | 3.0 | 8.4 | 5.7 | 1.0 | 2.0 |
| NMDS (Nursing Minimum Data Set) | 55.3 | 5.4 | 15.6 | 8.6 | 2.3 | 3.3 |
| NMMDS (Nursing Management Minimum Data Set) | 63.7 | 4.3 | 11.9 | 6.5 | 1.4 | 2.5 |
| NANDA (North American Nursing Diagnosis Association) | 14.5 | 13.7 | 21.5 | 13.2 | 10.8 | 16.7 |
| NIC (Nursing Intervention Classification) | 33.0 | 8.3 | 15.6 | 14.7 | 7.5 | 11.4 |
| NOC (Nursing Outcomes Classification) | 33.0 | 8.5 | 16.0 | 15.0 | 6.9 | 11.0 |
| Omaha System | 60.5 | 4.2 | 11.5 | 4.6 | 5.0 | 4.7 |
| PNDS (Peri-operative Nursing Data Set) | 70.9 | 2.5 | 7.5 | 4.0 | 2.8 | 2.7 |
| ICNP (International Classification of Nursing Practice) | 68.8 | 4.3 | 8.8 | 5.3 | .9 | 2.3 |
| LOINC (Logical Observation Identifiers Names & Codes) | 73.3 | 2.8 | 7.3 | 4.3 | 1.3 | 1.4 |
| SNOMED (Systematized Nomenclature of Medicine) | 61.6 | 3.9 | 10.5 | 9.2 | 3.4 | 1.8 |
The most notable feature of the data is the large proportion of respondents in the general sample who reported that they had no experience with or knowledge of any SNT. For all but four of the twelve SNTs listed, well over half of the respondents reported that they had neither knowledge of, nor experience with the terminology. The North American Nursing Diagnosis Association (NANDA) framework was the most “recognizable” with over 1/3 of respondents reporting that they had used it in nursing school, but not since; about a quarter of the respondents reported the same thing for Nursing Intervention Classification (NIC) and Nursing Outcomes Classification (NOC).
These findings led us to raise questions regarding between-group differences. To answer those questions, we chose to examine responses related to the three SNTs that were the most familiar to these respondents: NANDA, NIC, and NOC.
Did clinical and academic nurses differ in terms of their experience with selected SNTs? Among the three most familiar SNTs (NANDA, NIC, and NOC), NANDA had the highest degree of recognition. Only 14% of clinical nurses and 15% of the academic nurses reported that they had no knowledge or experience with these three SNTs. This was true for slightly over a third of each group for both NIC and NOC. Response patterns were similar for both groups in the remainder of the ‘experience’ categories except for “I can teach others to use it.” Fifteen percent of the clinical nurses gave this response while 27% of the academic nurses did so. Overall, however, the differences between these two groups were not statistically significant.
Did informatics and non-informatics nurses differ in terms of their experience with selected SNTs? To answer this question, we separated the 511 clinical nurses into those who indicated that informatics was a significant part of their job, whom we called informatics nurses (N=125), from those who did not so indicate and whom we called non-informatics nurses (N=386). The patterns of familiarity did not differ between the informatics nurses and non-informatics nurses for NANDA. Informatics respondents reported more familiarity with NIC than did non-informatics nurses, but the numerical differences were not great enough to be considered statistically significant. For NOC, the informatics nurses also reported more familiarity than did non-informatics nurses; these differences were statistically significant (Chi square =12.88; p=.025).
Did nurses differ in terms of their experience with selected SNTs by time in nursing practice (as measured by year of first licensure)? Although the survey did ask the age of respondents, we determined that the year in which licensure was first obtained was a better indicator of how long the respondent had been in practice. Of most interest was the comparison between those who were first licensed before 1990 and those licensed from 1990 through 2008. This ‘cut date’ was seen as significant because Harriet Werley had convened the Minimum Data Set Conference in Milwaukee in 1985 (Werley & Lang, 1988)--a landmark event in the evolution of Nursing Informatics.
This proved to be a useful comparison. Cross-tabulations showed statistically significant differences between the groups. Among those whose licensure was pre-1990, almost 20% reported no knowledge of NANDA; for the post-1990 group, less that 10% did so. For those with pre-1990 licensure a third reported having used NANDA in nursing school but not since. However, almost half of the post-1990 licensure respondents indicated they had used NANDA in nursing school but not since. Response patterns were similar for NIC and NOC in that the more recently licensed respondents reported more familiarity; however the differences were not nearly as pronounced and were not statistically significant when considering NIC and NOC.
Strengths of the study: Given the open participation and anonymity of this study, nurses were free to report their range of experiences with, and express their true opinions about the SNTs without any adverse consequences to themselves or others.
Weaknesses of the study: Like all Web surveys, no one can be certain of the accuracy of the answers. Also, 95% of the respondents reported living in the US; thus, findings cannot be extrapolated to the international SNT experience.
The Future of the study: Like any interesting research project, our survey answered some questions, but it raised many more. We plan to follow up with these questions in another survey in the spring of 2011. We anticipate that the Nursing Informatics Landscape’ will have a dramatically different appearance by then. Stay Tuned!
*Note: On February 13, 2012 the title of this column was modified to include the words "SURVEY I" to differentiate this column from subsequent columns in the series.
Patricia M. Schwirian, PhD, RN
E-mail: schwirian.1@osu.edu
Linda Thede, PhD, RN-BC
E-mail: lqthede@roadrunner.com
