We conducted two national Internet surveys of nurses related to their use of standardized nursing terminologies recognized by the American Nurses Association (ANA). The results of Survey I were reported in a previous OJIN Informatics Column, The Standardized Nursing Terminologies: A National Survey of Nurses’ Experiences and Attitudes - Survey I (Schwirian & Thede, 2012). The results from Survey II are being distributed in several reports.  The first of these reports was published in OJIN as The Standardized Nursing Terminologies: A National Survey of Nurses’ Experience and Attitudes (Schwirian & Thede, 2012). In that column, we reported the demographics of our participants and compared the extent of their familiarity with each of the terminologies between Survey I and Survey II. We also examined sources of terminology information used by nurses and found that reading of current nursing literature was generally the most dominant source of information. Another area explored was the similarities in familiarity with the terminologies between those nurses engaged in direct care and those engaged in informatics. In this area with the exception of the Perioperative Nursing Data Set, we noted that informatics nurses were significantly more familiar with the ANA-recognized terminologies than their counterparts engaged in direct clinical care.

In this column, we will report on the Survey II participants’ opinions about the education they received for using a given terminology. There were 567 participants who started this survey. As we reported in the first Survey II column, 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). Participants were predominantly female and lived primarily in the United States (US) east of the Mississippi (Thede & Schwirian, 2012).

In Survey II, we used “required questions” and a technique called branching in which the questions that a respondent saw on the screen were based on their answers to prior questions. For required questions, if an answer was not provided the participant was unable to continue the survey. The branching technique allowed participants who answered a given question negatively to not waste time with questions that were not applicable to them. Thus a “no” answer to a question, such as “Have you ever used X terminology?” took the participant to the question asking about the next terminology. Unfortunately, skipping a question was treated by the program as if the participant had answered “yes.” We remedied this in our report by only providing responses from those who answered yes to the determinant question and were thus qualified to answer more questions about a topic. Given that we did not want to have too many required questions, which might force an untruthful answer not only to that question, but also to subsequent questions, the only questions that required answer were questions asking if the respondent was familiar with a given terminology.

The terminologies that were included in the survey are those that have been recognized by the ANA. Their acronyms and full names are listed in Figure 1 in the order that questions about a terminology were presented in the questionnaire. Of these terminologies, SNOMED, LOINC, and the ABC codes are interdisciplinary. LOINC is primarily concerned with lab results and assessment, and the ABC codes are a way for non-physicians to bill. The other terminologies are all nursing specific, that is, they were developed primarily for nursing.  With the exception of NANDA, NIC, and NOC, the nursing-specific terminologies and SNOMED include labels and coding for the nursing entities of: nursing problems (diagnoses), interventions, and outcomes. Thus they can capture all three of these nursing entities. NANDA, NIC, and NOC, however, each capture only one of these entities. Hence, to gain a full picture of a patient, NANDA, NIC, and NOC need to be used together.

Figure 1. Full Name of Terminologies

Familiarity and Use of the Terminologies

For each terminology, a series of identical questions were asked. However, because the ABC codes are intended for billing, and only apply to independent practitioners whose number among our participants was only 10, these questions were different in nature and are not included in the findings presented below. The first question for each terminology was the required question, “Are you familiar with X terminology?” A participant could select “Yes,” “No,” or “Don’t know.” Only those who answered “Yes” to that question saw additional questions about that particular terminology. If they answered “No” or “Don’t know” they were branched to the question of familiarity regarding the next terminology. When participants tried to proceed to the next question without answering the question about familiarity with a terminology, they received the message, ‘This question requires an answer,’ and they could not proceed in the survey until they provided an answer.

Table 1 shows the number of Survey II participants who stated that they were familiar with a given terminology. As expected, given that most participants were from the US, NANDA (87%) was the most widely recognized terminology, followed by NIC (60%) and NOC (57%). Although not indicated on Table 1, 271 of the 479 participants (57%) who indicated they were familiar with NANDA also indicated that they were familiar with NIC and NOC. As can be seen in Table 1, the numbers of participants for the questions about a terminology decreased with each terminology, due to participants’ refusal to answer the question about familiarity with a terminology thus being closed out of the rest of the survey. Because of the wide variation in the numbers of respondents who were familiar with a given terminology, percentages are also shown to provide a more meaningful comparison of users’ opinions.

Table 1. Familiarity With Terminologies

Table 2 and Figure 2 illustrate the number of participants who answered “yes” to the question about familiarity and the question “Have you ever used X terminology, such as in a paper, studying for a test, in a clinical lab, or in an actual patient care situation?” NANDA, NIC and NOC again had the highest number and percentage of actual use. One hundred and nine users who were familiar with all three of these terminologies had used all of them in some fashion. Although 50% of the 487 participants who had not stopped the survey before, indicated a familiarity with SNOMED; only 37% of this 50% had actually used the terminology in any way. After NANDA, the percentage of actual use drops to 50% for NIC. The lowest percentage of reported use was the CCC followed closely by the ICNP and LOINC. It should be noted that these responses reflect only the participants’ knowledge and opinions. The percentages do not always add up to 100% because some who answered “yes” to the question about use did not choose to answer the questions to which a yes answer led. It is also very possible that some of these terminologies (or parts of them) have been incorporated into existing electronic documentation records currently in use and the survey participants were unaware that they were using a given terminology.

Table 2. Actual Use of a Terminology By Those Familiar With the Terminology

Figure 2. Percentage of Those Familiar With and Having Used a Terminology

Education for Use of the Terminology

Table 3 describes the responses to three questions asked of those who were both familiar with a terminology and who answered “Yes” to the question about use. Those participants were asked three questions:

1. Do (did) you feel that the education you received about using X (terminology) was adequate?
2. Has there been (or was there) any follow-up education about how to use X?
3. Do you feel that follow up education was, or would have been helpful?

With the exception of the Omaha System (66.7%), and the CCC (57.5%), less than 55% of the users of all the other ANA recognized interface terminologies did not believe that their education for using the terminology was adequate (Table 3 and Figure 3).

Table 3. Adequacy of Education to Use a Terminology

Figure 3. Adequacy of Education to Use a Terminology

Only a fairly low percentage of users had any follow-up education in using the terminology (see Table 4 and Figure 4). Participants who used NANDA had the lowest percentage of follow-up education (16.3%). Except for the Omaha System (52.2%), less than 30% of the users of all the other terminologies had follow-up education.

Table 4. Users Who Had Follow-Up Education

Figure 4. Percentages of Users Who Had Follow-Up Education

For those who had follow-up education for all the terminologies, over 85% thought that it was helpful (Table 5). The percentages of participants finding it helpful ranged from 86.1% for the Omaha system to a high of 100% for both the ICNP and SNOMED.

Table 5. Helpfulness of Follow-Up Education

With the exception of user of LOINC (66.7%) over 75% of users of the other terminologies who did not have follow-up education felt that it would have been (Table 6). What is surprising is that for those who did not have follow-up education only between 14 and 30 percent did not feel that it would have been helpful.

Table 6. No Follow-Up Education: Perceptions of Helpfulness of Follow-Up Education

Discussion

With the exception of NANDA, only 50% or less of those who were familiar with a terminology have actually used it. This is not too surprising given that very few agencies are using any of the ANA-standardized terminologies. Those who perceived that their education to use a terminology was adequate was less than one would have hoped. The Omaha System users had the highest percentage of users who felt adequately prepared, yet only 66.7% of those felt prepared, while SNOMED (28.6% ) and LOINC (27.7%) users ranked their preparation the lowest. The lack of follow-up education coupled with the high percentage of users who thought that it would be helpful if provided, and who, when it was provided believed it was helpful, supported the finding that a low percentage of users felt their preparation for using a terminology was adequate. This causes one to question nurses’ accuracy in using the terminologies. The greatest amount of follow-up education was provided to the users of the Omaha System (52.2%) while users of the other terminologies were provided with follow-up less than 28% of the time. Looking at the perceptions of the helpfulness of follow-up education, one can understand the users’ desire for more education. Over 85% of the users of all the terminologies who had follow-up education, found it helpful. Although the percentages were not as high, 75% of those who did not have follow-up education thought that it would have been helpful.  These perceptions of inadequate preparation for use, plus a desire for more follow-up education, may explain Lunney’s (2008) finding of a low accuracy rate for nursing diagnosis. It would appear that if use of the standardized terminologies is to be improved, more preparation and educational follow up are needed. In the next column, we will look at the user’s perceptions of theirs and their colleagues’ comfort level in using a terminology.

Errata Notice: Linda Q. Thede, author of "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'" published March 25, 2013, recently advised us that she had inadvertently included an incorrect figure (Figure 3). This article was amended on November 26, 2013 to remove the incorrect figure and replace it with the correct Figure 3.

Linda Thede, PhD, RN-BC
E-mail: lqthede@roadrunner.com

Patricia M. Schwirian, PhD, RN
E-mail: schwirian.1@osu.edu