It was 50 years ago when Harriet Werley prevailed upon the American Nurses Association (ANA) to recognize the value of data in improving health policy and health care for the patient (Ozbolt, 1997). She also spearheaded the development of the Nursing Minimum Data Set (NMDS), which consists of a minimum “set of items of information with uniform definitions and categories concerning the specific dimension of nursing which meets the information needs of multiple data users in the health care system” (Werley, Devine, Zom, Ryan, & Westra, 1991, p 422). Yet half a century later, we are still in the ‘early dawn’ of using data, especially nursing data, to improve patient care.
The Nursing Minimum Data Set includes nursing problems (diagnoses), nursing interventions, and nursing outcomes, along with a measure of nursing intensity and a unique number for the principal nursing care provider. Although the diagnoses, interventions, and outcomes have been operationalized by the ANA-recognized standardized nursing terminologies (SNTs), the use of these terms in actual patient care documentation is spotty at best. Currently, the ANA recognizes ten terminologies that are useful in various areas of nursing practice. Seven terminologies are nursing specific. The other three are multidisciplinary, with one designed for use by alternative health care providers during the billing process. A list of all the current recognized terminologies with links to additional information can be found at http://dlthede.net/Informatics/Chap16Documentation/anarecterm.html.
In 2009, we (the authors) completed an initial study (Survey I ) of nurses’ opinions of, and experience with, standardized terminologies (Schwirian & Thede, 2011). The findings from Survey I raised many questions in our minds. Because we wanted to learn more about the extent of, and opinions related to, the actual use of the terminologies, we conducted a second survey (Survey II) which was open in October and November of 2011. In this Informatics Column we will present the methodology we used in Survey II and compare, as much as possible, the Survey II participants and Survey II findings with those in Survey I. In future Informatics Columns, we will describe participants’ responses related to the educational and clinical aspects of nurses’ experiences with the SNT’s.
Survey II Methodology
Participants in this second survey were registered nurses recruited through the various LISTSERVS on which we had posted our call for participants. To better understand nurses’ familiarity with SNTs, we designed Survey II in such a way that only those participants who had actual knowledge of a specific terminology, or experience with it, answered the survey questions pertaining to that specific terminology. First, participants were asked if they were familiar with a terminology. If they answered ‘no,’ they were then asked the same question about the next terminology. If the answer was ‘yes,’ they were asked to describe their sources of knowledge of the terminology. Next, they were asked whether they had ever used the terminology, for example in writing a paper, studying for a test, working in a clinical lab, or participating in a patient care situation. A yes answer led them to questions regarding the manner in which they had learned about the terminology and their comfort level with using the terminology. Participants were also asked if they had had experience with the terminology as a student, and if they had used it in an actual patient care situation. A yes answer regarding actual patient care led to questions about documentation and the helpfulness of the terminology in patient care; whereas, a no answer skipped these questions. Participants who had used the terminology in any way were asked to evaluate the terminology on a scale of 1 to 5. In other words, those who were only familiar with, but had never used, the terminology did not evaluate it; all others did evaluate the terminology. A space for comments about many of the questions was provided.
Description of Respondents in Survey II
A total of 567 nurses responded to Survey II. This section will describe respondents (participants) in terms of their demographics, nursing education, certification, and employment.
Demographics
The number of participants responding to Survey II was about one third the number of those responding to Survey I. Ninety-three percent of the respondents were females. The largest age group was 50-59 years (47%), and the second largest was 40-49 (20%). In general, the year in which respondents were first licensed corresponded with their ages; 64% were first licensed before 1990. The gender and age distributions of these respondents were similar to those reported by the Survey I respondents, i.e., predominantly female and relatively mature in age. The Survey II participants were similar to Survey I respondents in that slightly over two thirds of Survey II respondents lived in the United States (US), east of the Mississippi.
Nursing Education
Survey II respondents were also asked to identify the various degrees they currently held. The percentage for each survey was similar. In the first Survey, 1,110 participants answered this question, while in Survey II, there were 405 responses. Figure 1 compares Survey I and Survey II participants in terms of the percentage of respondents’ highest degree and illustrates the similarity between the educational levels of the respondents in these two surveys.
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In the second survey, 54.6% of respondents held a Bachelor of Science in Nursing (BSN) degree compared with 55.7% in the first survey, while 31.6% in Survey I and 36.8% in Survey II held Master’s in Nursing degrees
A significant number (24%) responded affirmatively when asked, “Are you currently a student in any program either to prepare for a career in nursing or to further your nursing career?” Among the 114 nurses who responded affirmatively, the MSN was the most often cited program (26%), followed by RN-to-BSN programs and informatics programs (both 11%). Additionally, 23 respondents reported that they were currently enrolled in doctoral studies.
Certification
In comparing Surveys I and II, we noted an appreciable difference in the numbers of those who held nursing informatics certification from the American Nurses Credentialing Center (ANCC) and those who did not hold this certification. In Survey I, only 5.1% held this certification, while in Survey II, there were 16.7% who did so. The percentages for those holding other ANA certifications were 15.4% in Survey I and 18.4% in Survey II. What dropped dramatically in Survey II was the percentage of those who held other certifications. In Survey I, it was 42.1% and in Survey II 15.5%.
Employment
Our question about employment was much more specific in Survey II than in Survey I. In Survey I, 65.2% of the respondents stated that their principal job was in an educational agency, while in Survey II only 16.1% identified themselves as principally educators. Another large difference was in school nurses, in the first survey 17.2% were school nurses, while in this survey only 3.3% were school nurses. Unfortunately in the first survey, we did not ask participants to specify if their primary job was in informatics, an omission we rectified in this second survey in which 37.8% identified themselves as working primarily in informatics.
Findings Related to SNTs
This section will discuss nurses’ familiarity with SNTs and describe nurses’ sources of information about SNTs. It will also compare direct care nurses and informatics nurses.
Familiarity with SNTs
When analyzing Survey II data, we found it surprising to see that the level of familiarity had decreased for NIC, NOC, the CCC, and the ICNP (Table 1). However, it should be noted that in Survey II only 11% reported their principal job was in an educational institution versus 65% for Survey I. In Survey II, we asked more specifically about their employment, asking them to not only specify whether or not their primary job was in an educational agency, but also if their job was in a clinical setting, and if so to specify the nature of their clinical setting. In addition to the 11% working in an educational agency, 32.1% of the respondents were engaged in direct patient care and 37.0% in informatics.Thus we had a much higher participation rate among clinicians in Survey II. This could be construed as a positive sign demonstrating that information about standardized terminologies has reached the clinical area. However, it also may demonstrate that those in educational agencies are more familiar with standardized terminologies than clinicians, even those in informatics.
Although only two years had passed since the first survey, it was surprising to see that for NIC, NOC, the CCC, and the ICNP the level of unfamiliarity had increased. It was not surprising, however, to see that the level of unfamiliarity with both SNOMED and LOINC had decreased given the push by the U.S. Federal Government to make these national standards.
Sources of Information about SNT
In order to shed more light on how nurses became familiar with the SNTs, we asked Survey II respondents to describe their sources of information for each of the SNT’s. They could give as many answers as were appropriate. Responses are summarized in Table 2; additionally, Figure 2 provides a graphic representation of the importance of information sources for the ‘top 5’ SNT’s (i.e., the SNT’s that were familiar to the most respondents).
Table 2: Nurses Sources of Information Regarding ANA-Recognized SNTs
(view full size table [pdf])
With the exception of NANDA, for those familiar with a terminology, the predominant source of information about a terminology (among the five most recognized terminologies) was reading, followed by work (Figure 2). Even for those less familiar SNTs, with a few exceptions reading was the most prevalent source of information. For the 167 participants familiar with the PNDS terminology, work was the most important source (67.4%), although reading was a close second at 56.3%. For the 244 who were familiar with SNOMED, reading and work were equally important sources of information (63.1%).
| Figure 2. Graphic Representation of Information Sources of The Five Most Familiar SNT’s |
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Comparison of Direct Care Nurses and Informatics Nurses
In Survey I, we did not clearly identify the nurses whose professional responsibilities would classify them as ‘informatics nurses.’ In Survey II, we did identify informatics nurses. This is of considerable significance because the numbers of nurses who are classified as informatics nurses is growing rapidly; these nurses are playing an increasingly significant role in the evolution of the healthcare informatics systems in their institutions. Table 3 displays a comparison of direct care nurses and informatics nurses in terms of SNT familiarity.
Given the influence that nursing informatics nurses can have on nursing documentation, we find it encouraging that informatics nurses are beginning to become familiar with most of the terminologies. With the exception of the PNDS terminology, all of these differences are significant.
Summary
From this elementary data, it can be seen that in the US, NANDA has more familiarity to most nurses than any of the other terminologies although it has changed little between the surveys. More nurses are now familiar with SNOMED than in Survey I. Of the five most familiar terminologies, school was noted as the place where most nurses learned about NANDA, while reading was the best source of information for the others. In all cases the informatics nurses were more familiar with the terminologies than those whose primary job focus was clinical.
Patricia M. Schwirian, PhD, RN
E-mail: schwirian.1@osu.edu
Linda Thede, PhD, RN-BC
E-mail: lqthede@roadrunner.com
Article published May 21, 2012
