This is the third column in the series reporting on the second online survey that we have done to examine nurses’ perceptions of the American Nurses Association’s recognized, standardized terminologies. In the first column we compared the respondents between Survey I and II and reported the demographics of our respondents who were mostly female. We also found that more nurses who are engaged in informatics are familiar with the terminologies than those nurses in a non-informatics specialty. In our previous (second) column, we looked at the percentage of those who were familiar with a terminology and who had actually used it, and found, not surprisingly, that the North American Nursing Diagnosis Association (NANDA), Nursing Intervention Classification (NIC), and Nursing Outcomes Classification (NOC) were the most recognized and most used terminologies among our respondents. However, NANDA was the only terminology reported as being used by more than 50% of participants who were familiar with a terminology. In the second column (March 25, 2013), we reported that participants described their educational preparation for using a terminology to be less than satisfactory. With the exception of the Clinical Care Classifications and the Nursing Intervention Classification, less than half of the users of the other terminologies believed their educational preparation to use a terminology to be adequate. We also looked at how many users had any follow-up education for using a terminology, finding that with the exception of the Omaha System, less than 30% of users of the other terminologies had received any follow-up education. However, over 85% of those who did have this follow-up found it to be helpful. In this present column, we report our respondents’ perception of their comfort in using a terminology as well as their opinions about their colleagues’ comfort.

Comfort in Using the Terminology

The same branching techniques reported in the previous column were used in this survey. Thus, in this column we report only data from respondents who answered that they were familiar with a terminology and had actually used it. Participants who indicated that they had experience in using the terminology were asked to describe their own perceptions and their perceptions of their colleagues’ comfort in using the terminologies. Specifically participants were asked:

1. Do (did) you feel comfortable applying the labels using X (terminology)?
2. In your opinion, are (were) your colleagues comfortable applying the labels using X (terminology)?

Table 1 shows the number and percentage of users of each terminology who either did or did not feel comfortable in the application of the labels themselves, and users’ opinions as to whether their colleagues either did or did not feel comfortable with this task. Figure 1 shows the perceptions of the respondents’ comfort and perceptions of their colleagues’ comfort in using the labels of a terminology. The participants’ highest level of comfort in using the labels was indicated by those who had used the Omaha System (71%) followed by those using the CCC (65%). Only between 48% and 58 % of participants who used the other terminologies were comfortable in their use of the labels.

When one looks at participants’ perception of colleagues’ comfort in using a terminology, however, less than 45% of users of all the terminologies felt that their colleagues were comfortable using the labels (Table 1 and Figure 1). Users of the CCC (42.5%), PNDS (40.6%) and Omaha System (40.6%) perceived the highest level of colleague comfort in using the labels. Users of NOC (19%) and the ICNP (18.5%) reported the lowest incidence of colleague comfort in using the ICNP (18.5%).

Table 1. Comfort Level in Applying Labels

Figure 1. Percentage of Participants’ Own (Self) Comfort and Perception of Colleague Comfort in Applying Various Terminology Label

When users had follow-up education, however, their comfort level for using a terminology improved (Table 2).  The highest percentage of users who were comfortable applying the labels for a terminology even though they did not have follow-up education was 55.2% for CCC. When, however, they did have follow-up education, this comfort level increased to 100%. The overall comfort level for all users of the CCC (both with and without follow up) was 65%. The lowest level of comfort with applying the labels after follow-up education was with NANDA (76.3% ).  Although only 55.6% of all NANDA users reported comfort with applying the labels, 51.9% of NANDA users who had no follow-up education reported that they were comfortable with applying the labels.

Table 2. Self Comfort Level in Applying Terminology Labels With and Without Follow-Up Education

Figure 2. Comparisons of Those Who Were Comfortable Applying All Terminology Labels With and Without Follow-Up (FU) Education

Discussion

NANDA had the highest number of users of all the terminologies as well as the highest percentage of those who were familiar with a terminology and actually used it. Except for NANDA (70%), all the other terminologies had 50% or fewer participants who said they were both familiar with the terminology and actually used the terminology in any way.

Data reported in the previous column addressing participants’ education regarding the use of Standardized Nursing Terminology ‘Labels’ (Thede & Schwirian, 2013)  showed that few participants felt their education for using a nursing terminology was adequate. The highest percentage of users who felt that their education for using a terminology was adequate were those using Omaha (66.7%); only CCC (57.5%) and NANDA (53.1%) had more than 50% of their users feeling that their education was adequate. This user perception of a lack of adequacy in their education is reflected by the low percentage of users who were comfortable using a terminology.  The highest overall level of comfort in using the labels was reported by users of the Omaha System (71%). When users were asked their opinion of their colleagues’ level of comfort in using a terminology, the picture is even more dismal; the highest percentage of users who felt their colleagues were comfortable using a terminology was only 42.5% for CCC, followed at 40.6% for Omaha and the PNDS. When, however, follow-up education was provided for users, the percentage of users with comfort in their abilities increases to more than 75% for all the terminologies (Table 2).

It would appear that if the terminologies are to be successful in increasing the knowledge base for nursing, better education in their use is needed. Lunney (2006) has urged the ‘rethinking’ of how we educate students and nurses regarding nursing terminology concepts. Although her research looked at only NANDA, NIC and NOC, it is likely that these principles would be useful for all the terminologies. She proposed that education for using NANDA, NIC, and NOC encompass three domains: intellectual, interpersonal, and technical, with the biggest change needed in the intellectual domain. This would include an increased focus on developing nurses’ diagnostic skills so nurses both increase their knowledge of the meanings of the various labels for diagnoses, interventions, and outcomes, and also strengthen their thinking abilities. Lunney (2006) added that additional attention to interpersonal skills is needed to develop nurses’ ability to collect reliable and valid data and to work in partnership with clients. She further stated that the technical domain encompass not only collecting data, but also developing reasoning and documenting abilities related to the use of a standardized terminology. Lunney’s rationale for suggesting these changes was that using standardized terminologies differs from using the traditional nursing process in that it increases the awareness “…of the extensive number of data interpretations, outcomes, and interventions to consider for individual patient situations”  (p. 40).

In our surveys, both participants’ self-reports of comfort using the terminologies, and especially their doubts about their colleagues’ comfort in using the terminologies are areas of concern. Our findings lend support to Lunney’s (2008) examination of studies of nurses’ interpretations of data from 1966 to 2006 in which she found wide variations in interpretations, thus creating a low accuracy rate for nursing diagnoses. Interventions based on data interpretations that may be inaccurate is another cause for concern.

Conclusion

It is important to recognize that just ‘using a terminology’ is insufficient. Terminologies must be used correctly. It is quite possible that more emphasis on how to use a standardized terminology, giving appropriate attention to Lunney’s (2008) three domains, would result in better identification of nursing problems as well as greater provision of appropriate interventions and improved outcomes. Our data would also suggest that education for using a terminology must be ongoing and not confined to one or two in-service sessions. Instead, discussions and educational updates regarding the use of nursing terminologies should be continuously provided.

Readers are free to take away any conclusion they might develop based on these reports. However, two things seem fairly obvious to us. The comfort level of respondents in using the terminologies is low, and their opinions regarding their colleagues’ comfort in using a terminology is even lower. The vast majority of users who responded that they did not have follow-up education but would have liked it, along with the increase in comfort level noted when follow-up education was provided, supports the need for follow-up education if these terminologies are to be used with any confidence in either their reliability or validity.

Note: The next column will report findings from nurses who have used a standardized nursing terminology in a clinical setting.

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

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