developing clinical terms for health visiting in the united kingdom

PURPOSE. To establish professional nursing practicestandards for perioperative documentation in order toprovide clinicians and software developers with a na-tional model for perioperative documentation.

METHODS. The sample consisted of paper and com-puterized records representing clinical practice settingsfrom for-profit, nonprofit, and government agencies. Fa-cilities ranged in size from 45�>900 beds and performed,on average, 500 surgeries each month. Intraoperativerecords ranged from 1�7 pages.

A national sample of more than 150 perioperativerecords representing both inpatient and ambulatory settingswere collected and analyzed to identify common data ele-ments. Data elements that represented the intraoperativeperiod were noted, using a structured format. Two expertnurses conducted the analysis and achieved a high level ofinterrater reliability when coding the clinical records.

FINDINGS. This analysis uncovered a disappointingreality about the current status of intraoperative nursingdocumentation. One major finding included themarginal consistency in the collection of structural dataelements (e.g., start time, stop time, anesthesia type,wound classification). Also, nursing diagnoses, interven-tions, and patient outcomes were documented in fewerthan 22% of the records.

CONCLUSIONS. In surgical settings, the professional

International Journal of Nursing Terminologies and Classifications Volume 14, No. 4 Supplement, October-December, 2003 23

aspects of intraoperative nursing care are embedded inthe care delivered and not accurately or fully representedin clinical documentation. To understand the contribu-tions of perioperative nurses to surgical outcomes, theframework for documentation must be structured in amanner that includes nursing diagnoses, interventions,and outcomes. The benefits of structured vocabulary canonly be fully realized when national documentationstandards are established and implemented within andacross settings. This effort resulted in the development ofa best practice model for a nursing preoperative assess-ment and intraoperative documentation that has beenadopted by clinicians and software developers.

Professional nurses must document the care they pro-vide in a manner that represents the professional aspectof their care. Nursing contributions cannot be fully eval-uated unless they are represented and documented inclinical records. The use of structured vocabulary may as-sist nurses to accept and utilize standardized terms, butthe most important factor is a nursing record that fullyrepresents and describes professional nursing practice.The ability to computerize clinical records will not help inevaluating the effectiveness of nursing practice unless as-sessments, identified problems, interventions, and out-comes are consistently and appropriately documented.

Author contact: [email protected]

Presented Papers: Support of Nursing Effort

Presented Papers: Standardized Language and Nursing Information Systems

Describing Professional Nursing Through a Universal Record in Perioperative Settings

Suzanne C. Beyea

Developing Clinical Terms for Health Visiting in the United Kingdom

June Clark and Jean Christensen

BACKGROUND. The UK health visiting service pro-vides a universalist preventive health service that focusesmainly on families with young children and the elderlyor vulnerable, but anyone who wishes can access the ser-vices. The principles of health visiting have been formally

defined as the search for health needs, the stimulation ofawareness of health needs, influencing policies that affecthealth, and the facilitation of health-enhancing activities.

The project is currently in its fourth phase. In phase 1,17 health visitors recorded their encounters with families

BACKGROUND. The Internet is an economical globalcommunication strategy that can be used to sustain andpromote development and refinement of nursing lan-guages, including global participation and input. Globalparticipation is required to represent the cultural rele-vance and cultural specificity of diverse populations. AnInternet site can link nurses and consultants from globalsettings and eventually provide support for the develop-ment and submission of diagnoses, interventions, andoutcomes to language developers.

MAIN CONTENT POINTS. The Concept Analysis Cen-ter for the NLINKS Project will be an Internet site topromote the development and refinement of nursinglanguage. It will reflect a worldview of nursing lan-guage, including nursing diagnoses, nursing outcomes,

24 International Journal of Nursing Terminologies and Classifications Volume 14, No. 4 Supplement, October-December, 2003

and nursing interventions. Literature resources will beprovided for nurses worldwide, as well as methods forsubmission of concept analysis products to the devel-opers of nursing languages. The development of theConcept Analysis Center will be conducted in threephases.

Phase 1 will be the development of a prototype site forall participating languages to (a) hire and train staff toexpand a prototype site developed for the existingNLINKS site; (b) add protocols, training, resources, con-sultants, and linkages for all participating standardizedlanguages; (c) train language coordinators and researchassistants; (d) develop and pilot test the Concept Analy-sis Center in English and in two other languages; (e) ad-vertise through state, national, international leaders; and


with new babies over a period of 3 months; in phase 2,27 health visitors recorded their encounters with a widerrange of clients (769 encounters with 205 families) over aperiod of 9 months; in phase 3, the system is being usedby a variety of healthcare professionals in a specialistprogram that provides intensive parenting support;phase 4 is developing a prototype of an automated ver-sion for point-of-contact recording.

UK nursing has no tradition of standardized languageand the concept of nursing diagnosis is almost un-known. Over the past decade, however, the governmenthas initiated the development of a standardized termi-nology (Read codes) to cover all disciplines and all as-pects of health care, and it is likely that the emergingSNOMED-CT terminology (a merger of the Read codeswith the SNOMED terminology) will be mandated foruse throughout the National Health Service (NHS).

MAIN CONTENT POINTS. The structure and key ele-ments of the Omaha System were retained but the termi-nology was modified to take account of the particularfield of practice and emerging UK needs. Modificationsmade were carefully tracked. The Problem ClassificationScheme was modified as follows:■ All terms were anglicized.■ Some areas � notably relating to antepartum/post-

partum, neonatal care, child protection, and growthand development�were expanded.

■ The qualifiers �actual,� �potential,� and �health pro-motion� were changed to �problem,� �risk,� and �noproblem.�

■ Risk factors were included as modifiers of �risk�alongside the �signs and symptoms� that qualifyproblems.The Intervention Classification was modified by

substituting synonymous terms for �case manage-ment� and �surveillance� and dividing �health teach-ing, guidance, and counseling� into two categories.The Omaha System �targets� were renamed �focus�and a new axis of �recipient� was introduced in linewith SNOMED-CT.

The revised terminologies were tested in use and alsosent for review to 3 nursing language experts and 12practitioners, who were asked to review them for do-main completeness, appropriate granularity, parsimony,synonymy, nonambiguity, nonredundancy, context inde-pendence, and compatibility with emerging multiaxialand combinatorial nomenclatures. Review commentswere generally very favourable and modifications sug-gested are being incorporated.

CONCLUSIONS. The newly published governmentstrategy for information management and technology inthe NHS in Wales requires the rapid development of anelectronic patient record, for which the two prerequisitesare structured documentation and the use of standard-ized language. The terminology developed in this projectwill enable nursing concepts to be incorporated into thenew systems. The experiences of the project team alsooffer many lessons that will be useful for developing thenecessary educational infrastructure.

Author contact [Clark]: [email protected]

A Concept Analysis Center for the NLINKS Project

Martha Craft-Rosenberg

BACKGROUND. Renal dialysis at our institution is aunique specialty area that provides both nursing care fora stable chronic outpatient population and treatment forhospitalized patients with acute episodes of renal failure.The ability to respond to these patients� special needs isinherent in delivering nursing care and must be compre-hensively and consistently documented. The purchasedcomputerized documentation system did not have anyexperience with online renal dialysis documentation.Since the institution was using an electronic patientrecord, we decided to blend the move to electronic docu-mentation with the use of standardized languages to de-scribe dialysis care.

MAIN CONTENT POINTS. A review of existing stan-dardized nursing language materials revealed that thenecessary interventions and outcomes were not avail-able, so leadership and staff collaborated to produce newinterventions and outcomes specific to the dialysis popu-lation. These interventions and outcomes were submit-ted to NIC and NOC for approval. The existing careplans were converted to standardized nursing languageand the implementation process begun. All existing dial-ysis documentation and data collection forms were ex-amined, grouped, and converted to NANDA, NIC, andNOC terminologies. Standardized languages were incre-mentally introduced as the electronic record was put intouse. First the basic patient information and medicationlist were used in the �live� setting, while documentationwas still done on paper.

The care plan, which incorporated standardized lan-guage, was introduced next. The standard dialysis careplan included 8 nursing diagnoses, 14 outcomes, and 26interventions. Finally, the interventions and outcomeswere used in the actual documentation of treatment pa-


rameters and patient data. Also available are all the out-comes in the inpatient dictionary, which can be used toindividualize the care plan as needed. Use of the com-puter allayed staff fears of having to �memorize thebooks� to learn all the components of the standardizednursing language.

Interdisciplinary aspects of care were addressed by as-sisting nutrition services, social work, and the chaplaincyto find appropriate interventions and outcomes in thestandardized language. Documentation screens then de-veloped for each discipline contributed to the overall in-tegrity of the record. Regardless of discipline, documen-tation occurs in a standardized, logical, and retrievableway. Measurement of outcomes makes tracking thecourse of each patient, as well as the cohort, possible.Pertinent documentation elements are displayed on a pa-tient profile to provide individual treatment records.

CONCLUSIONS. NANDA, NIC, and NOC are ex-tremely useful in the care of the dialysis patient. Becauseparticular interventions are used repeatedly, the elec-tronic format and standard responses give a consistencyto patient evaluation not present previously. Use of elec-tronic documentation eased the transition to the use ofstandardized nursing language by presenting standard-ized documentation responses for each intervention.Outcomes documentation was enhanced by clear defini-tion and quick access to ranking criteria.

Outcomes of this project include (a) enhanced commu-nication between inpatient and outpatient dialysis ser-vices, (b) ability to immediately access information aboutpatients treated at satellite dialysis units, (c) ability tomeasure outcomes over time for the aggregate and for in-dividuals, and (d) staff satisfaction with documentation.



(f) seek feedback from users for needed modificationsthrough questions placed on the Web site.

Phase 2 will include expansion of advertising by lead-ers in standardized language and advertising throughWeb sites, listserves, and nursing organizations for allparticipating countries. Up to four languages in additionto English will be added if justified by pilot study andavailability of translators. Standardized language devel-opment and refinement will continue.

Phase 3 evaluation will be based on several criteria: acomparison of the number and quality of concept analy-

sis submissions to developers of standardized languagebefore and following Internet site development; thenumber of NLINKS Concept Analysis site users; and usersatisfaction with concept analysis content and with staff re-sponsiveness and helpfulness. These data will be collectedusing an online questionnaire.

CONCLUSIONS. As this project evolves, a global net-work of experts in nursing language will be establishedand provide the support to continue the work of defin-ing nursing using standardized language.


Use of Standardized Nursing Languages in the Documentation of Renal Dialysis Services

Mary Date

BACKGROUND. Professional nurses worldwide areconcerned as we struggle to communicate and documentwhat a nurse actually does, and how nursing decisionsand actions contribute to the care component of healthcare. Nurses are confident that their actions affect patientcare quality through improved patient outcomes, butdata collection is the only way to defend this position. Toenable nurses to contribute to these data, we need to ex-pose them to the new languages in a pragmatic ratherthan theoretical format. Nurse-friendly documents mustbe made available to assist the practitioner to assimilatethe new languages into the daily practice of nurses whowork with and care for real clients.


MAIN CONTENT POINTS. This tool, organized accord-ing to the NIC taxonomy, begins appropriately with pa-tient assessment and guides the nurse to courses of ac-tion that increase the probability of producing effectiveoutcomes. As suggested interventions reflect currentnursing practice gathered from expert clinicians in mostspecialties, the learning curve is not overwhelming.

CONCLUSIONS. While this document focused on theelderly, the format can be adapted for any patient popu-lation by a facility�s expert clinicians, who would choosethe most appropriate interventions and outcomes for thepopulation served.



Integrating Nursing Acuity, NANDA, NIC, and NOC Into an Automated Nursing Documentation System

Julie Frederick and Mary Watters

BACKGROUND. The goal of this project was to havenursing documentation drive acuity in a seamless fash-ion. The success we have encountered was building ourframework with standardized nursing language, inte-grating our stable patient classification system into theframework, and enclosing them online in the computerdocumentation system.

MAIN CONTENT POINTS. Nursing documentationwith NIC and NOC drives the acuity system. Acuitymapping is integrated into the automated nursing docu-mentation system.

CONCLUSIONS. Our success in integrating nursing acu-

ity, NANDA, NIC, and NOC into an online nursing docu-mentation system has been monumental. The healthcareteam�s documentation can truly identify the patient�s needsand provide the necessary acuity to make appropriate as-signments, staff according to skill level requirements, andcharge patients accurately. The journey from online docu-mentation to integrating NANDA, NIC, and NOC into anonline acuity system is just a start in identifying nursingbest practices and efficient and effective patient outcomes.Continued research will prove exciting and lead the institu-tion into the next step of patient outcome successes.

Author contact [Frederick]: [email protected]

Nursing Care Documentation Using NANDA, NIC, and NOC

Carole Johnson

NIC Use by Urologic Nurses in Iceland

Anna Jonsdottir and Asta Thoroddsen

PURPOSE. To investigate which NIC interventions areused by nurses in the urologic unit in order to establish anursing documentation system for an electronic patientrecord.

METHODS. The NIC Use Survey questionnaire, devel-oped by the Iowa Intervention Project Team, had beentranslated into Icelandic by a group of nurses within theDirectorate of Health. Some changes were made to thequestionnaire in concordance with the up-to-date ver-

sion of NIC; it included 450 intervention labels and theirdefinitions grouped into 27 classes of interventions ac-cording to the NIC class structure. Respondents (a con-venience sample of 19 nurses who worked in the urolog-ical units) were asked to rate how often they performedeach intervention. Six responses are possible: never,rarely, about once a month, about once a week, aboutonce a day, or several times a day.

FINDINGS. The respondents were 15 nurses (response

BACKGROUND. A uniform system of representingand describing nursing practice is essential and shouldbe constructed in such a way as to allow integration ofimprovements and refinements. After 2 years of theoreti-cal developments, the framework for a national nursinginformation system, called NURSING data, became a re-ality. NURSING data is a national nursing project de-signed to shape nursing information systems to improveclinical information systems (records), improve manage-ment systems (cost and quality), provide a complementto the healthcare medical statistics, and give reliable in-formation on the cost of nursing care.

MAIN CONTENT POINTS. As a starting point, theNURSING data project worked on two preconditions:(a) the information system must be unified at the Swisslevel and compatible at an international level, and (b) itmust, as far as possible, be built from what exists and isused. The overall objective was to provide a representa-tion of nursing practice through the use of statistical in-dicators, providing a helpful tool for decision makingin the fields of health policy and health economics. Inorder to ensure the validity of results, the modelneeded to reflect practice. The construction of themodel was achieved by moving between nursing prac-tice itself and the highest level of abstraction possiblefrom available statistical data. Additionally, the modelneeded to be compatible with current internationalwork in the same field.

Numerous nursing professionals in many differentareas of practice were called to participate in order to


guarantee the feasibility of the proposed solutions and toensure the diffusion of information. A mixed group con-sisting of different partners in the healthcare field andprofessional nurses with expertise in information sys-tems chooses and defines variables, while at the sametime ensuring compatibility and conformity with preex-isting federal health statistics. While waiting for the gen-eralization of an internationally recognized terminology,it would appear necessary to formalize, in the Swiss con-text, the characteristics of each of these variables in theform of two standardized, accepted reference classifica-tions for nursing phenomena and interventions. Withthis aim in mind, three working groups have been setup, one for each of the linguistic regions �French, Ger-man, Italian � to put forward two lists of terms (phe-nomena and interventions), which are at present under-going assessment by a Delphi panel of volunteer nurses(about 50 from each linguistic region).

CONCLUSIONS. While some of this work is still in adevelopmental stage, the current NURSING Data projectaims to produce a list of appropriate variables that de-scribe the how and why of nursing in Switzerland (theSwiss Nursing Minimum Data Set) that takes into ac-count the needs of the various partners; an acceptednursing classification for phenomena and interventions,adapted to the different areas of clinical practice for sta-tistical use; and a validated system of data analysis, al-lowing different types of feedback according to specificneeds (e.g., clinical, research, finance).



rate 79%). Most of the subjects had >5 years of experi-ence in nursing (93%) and most had >5 years of experi-ence in urologic nursing (73%).

On the urologic unit, 299 (66%) of the 450 interven-tions were used rarely or more often by >50% of thenurses. Of those 299 interventions, 153 (34%) were usedmonthly or more often by more than 50% of the nurses;151 interventions (34%) were never used by more than70% of the nurses, and of these interventions 71 (15%)were never used by 100% of the urologic nurses.

CONCLUSIONS. The NIC Use Survey was a useful toolto determine which interventions should be included inthe computer software of specialities. However, the inter-ventions that are most frequently used by urologic nursescannot be called core interventions because they include alot of common nursing interventions and therefore do notdefine the nature of the speciality.

Author contact [Jonsdottir]: [email protected]

A Bridge Between Data and Language: The Swiss Nursing Information System Project

Alain Junger



HANDS: Refining Methods to Generate Comparable Nursing Data

Gail M. Keenan, Crystal Heath, Marcy Treder, Julia Stocker, and Beth Yakel

PURPOSE. To create a feasible method for collecting,storing, and retrieving a standardized clinical nursingdata set across the continuum of care: the Hands-on Au-tomated Nursing Data System (HANDS).

METHODS. In phase 1 of a three-phase approach, amultidisciplinary team of clinicians, researchers, andtechnical experts at the University of Michigan devel-oped a data model for capturing a standardized nursingdata set and from this a prototype automated system.The single-user application provided a consistent formatfor recording, updating, and retrieving care plans en-tered across settings and time with terms and measuresfrom NANDA, NOC, and NIC. The application is incompliance with the American Nurses Association Nurs-ing Information and Data Set Evaluation Center stan-dards and HL7 standards.

It is intended that the prototype application evolve togenerate comparable information that is useful and easyfor clinicians to capture in daily practice and can be ag-gregated for use in examining nursing effectiveness. Tar-get users were asked to operate the system under arange of laboratory conditions and to note strengths,weaknesses, and suggestions for enhancing use underactual clinical conditions. Three research assistants testedthe application while gathering data for the Michigancomponent of a regional study designed to examine thereliability and validity of NOC measures across the con-tinuum of care. The assistants collected a baseline ofHANDS data from approximately 250 patient subjects.Another 100 students and faculty from schools of nurs-ing have also tested the application in the HANDS labo-ratory and provided input to the team.

FINDINGS. In general, the feedback from testers indi-cated that the application is an efficient means for help-ing potential users understand at a glance why nursingstandardized languages are important, and the intendeduse. Nurse, student, and faculty evaluators were posi-tively impressed with the ease and simplicity of the ap-

plication. Users noted that the time needed to create andenter care plans with standardized terminologies wassignificantly less when compared to noncomputerizedapproaches. In addition, the software was found to pro-mote efficient learning of the standardized languages.The search functions, linkage of terms, and measures fordiagnoses, outcomes, and interventions were describedas major facilitators for identifying appropriate standard-ized terms. The online help feature was also rated verypositively because it provided immediate access to com-plete information on any NANDA, NOC, or NIC term.

A number of suggestions were also noted to improvefunctionality. For example, many found it cumbersometo select terms one at a time for a diagnosis, outcome, orintervention and recommended that a multiple-term se-lection feature be made available. Another suggestionwas to allow the user the option to enter NANDA, NOC,and NIC terms in any sequence versus the current linearpath that requires selection of diagnoses first and thenoutcomes followed by interventions.

DISCUSSION AND CONCLUSIONS. The favorable re-sponses of the test audience indicate the value ofHANDS in speeding the integration of nursing lan-guages into practice. Well-designed automated systemscan be used to enhance understanding and motivationfor learning and incorporating standardized terminolo-gies into documentation. In addition, the application canbe used to dramatically decrease the training time andcosts associated with educating nurses to use standard-ized terminologies competently. Phase 2 involves thetranslation and upgrade of the software into a Web-based format. In phase 3 the application will be thor-oughly tested and refined across settings under actualconditions of use. With adequate resources a standardfor collecting and retrieving a standardized nursing dataset will be available for use in practice within the nextfew years.

Author contact [Keenan]: [email protected]



Describing Nursing Effectiveness Through Standardized Nursing Languages and Computerized Clinical Data

Cindy A. Scherb

PURPOSE. To analyze actual patient data recorded bynurses within a computerized documentation systemusing standardized NANDA, NIC, and NOC nursinglanguage in order to validate the linkages of diagnoses,interventions, and outcomes; identify the important vari-ables for risk adjustment; and verify which nursing inter-ventions assist patients to achieve their desired outcomesfor patients with pneumonia, congestive heart failure(CHF), and total joint replacement (TJR).

METHODS. This was a descriptive exploratory study.The study sample consisted of all records of patients ad-mitted with pneumonia, CHF, or TJR. A total of 566 pa-tient records were collected for analysis. The most fre-quent nursing diagnoses, interventions, and outcomeswere identified for each of the populations. Linkagesamong nursing diagnoses, interventions, and outcomesfrom the study data were compared with published link-age work.

FINDINGS. The average number of nursing diagnosesfor patients admitted with pneumonia was 9.5 (SD ± 3.0),patients with CHF averaged 10.1 (SD ± 2.70), and pa-tients with TJR averaged 10.4 (SD ± 2.07). Nursing diag-noses common across all three populations were knowl-edge deficit, ineffective airway clearance, decreased cardiacoutput, pain, impaired physical mobility, altered urinary elimi-nation, risk for impaired or impaired skin integrity, and alterednutrition: less than body requirements. The average numberof interventions for each patient population was pneu-monia 18.3 (SD ± 7.74), CHF 19.3 (SD ± 7.02), and TJR20.5 (SD ± 4.28). Interventions common across all threepopulations were �teaching: individual,� �dischargeplanning,� �family involvement,� �respiratory monitor-ing,� �ventilation assistance,� �cardiac care,� �self-careassistance,� �urinary elimination management,� and�gastrointestinal surveillance.� The number of outcomesfor patients with pneumonia, CHF, and TJR, respectively,averaged 9.01 (SD ± 3.58), 9.71 (SD ± 3.0), and 9.58 (SD ±1.80). Outcomes common across the three populationswere Knowledge: Illness Care, Respiratory Status: Venti-lation, Cardiac Pump Effectiveness, Mobility Level, Uri-nary Elimination, and Nutritional Status. Results of thecomparisons among nursing diagnoses, outcomes, andinterventions from the study data and previously pub-

lished works indicated that, for the three populationscombined, 71%�85% of the interventions were classifiedas major, suggested, or optional.

The effect of nursing interventions on patient outcomeswas evaluated using repeated measures MANCOVA con-trolling for the variables of age, gender, acuity, and comor-bid conditions. The five most frequent outcomes for eachpatient population were studied. Nursing interventionsthat were statistically significant or indicated a positive ef-fect for patients in the pneumonia population were �oxy-gen therapy� and �family involvement.� Statistically sig-nificant nursing interventions for patients with CHF were�oxygen therapy,� �anxiety reduction,� and �gastrointesti-nal surveillance.� The interventions of �multidisciplinarycare conference,� �orthopedic appliance,� and �tube care:urinary� were the interventions shown to have a statisti-cally significant effect for TJR patients.

DISCUSSION. This is one of the first studies completedusing computerized standardized nursing languages todetermine the most effective interventions to achieve thebest outcomes. The results suggest that not all the neces-sary variables have been identified to explain thechanges in outcome rating from admission to dischargeassociated with nursing interventions. Future studiesneed to use larger samples and should include interven-tions from other disciplines.

CONCLUSIONS. It is crucial that national data sets rep-resent nursing, so nursing does not remain unrecognizedas an essential healthcare provider. Considerations forfuture studies should include issues related to study de-sign, system concerns, inadequate specification of vari-ables, and documentation issues. Other research implica-tions include the need to make data retrieval fromcomputerized systems easier, and the need for increasedcollaboration between academic centers and practice tofurther these research efforts. The practice arena needs toevaluate the expectations of the documentation systemand how the use of the study results will change prac-tice. With development of clinical nursing databases andthe ability to build relational databases with other largedata sets, nursing research will be able to include all rele-vant variables in the analysis of nursing effectiveness.




Program, Practice, and Vision: Standardized Nursing Language and the Computerized Patient Record

Marita Schifalacqua, Mary Hook, and Janet Lotegeluaki

BACKGROUND. In 1997, the community-based NurseCase Management program of Aurora Health Care inMilwaukee, WI, was created to coordinate care for high-risk clients. Advanced practice nurse case managerspartner with clients, families, and providers to establishgoals and support efficient and effective use of health-care resources. Clients referred to the program have evi-dence of suboptimal self-management, complex healthconditions, multiple specialty providers, or a history ofhigh or inappropriate service utilization. Clients are typi-cally seen in their homes, medical clinics, outpatient orother community sites.

MAIN CONTENT POINTS. From the start, the programwas designed to provide coordinated care across the en-tire care continuum. Access to patient encounters, clini-cal, and financial data was identified as an essential com-ponent to providing and evaluating individual andprogram outcomes. The staff also needed a way to inputdata into the system. The program director was able tojustify educational and information system support forthe creation of a program-specific documentation pro-gram. She valued the use of standardized nursing lan-guage as a way to capture and retrieve data about thediscipline-specific aspects of care. The NANDA, NIC,and NOC taxonomies were selected as the cornerstonefor the nursing department of the largest Aurora hospitaland the nurse case manager program. Administrationfurther provided support for the department to partnerwith the established information system vendor in thecreation of new software specifically designed to func-tion within the integrated healthcare delivery system.

The program was established based on the AmericanNurses Association standards for advanced practice andliterature-based best practice guidelines for patient care.Prior to implementation, the staff had basic computer ac-cess and limited standardized nursing language experi-ence with NANDA diagnoses. The group set out to learnmore about the NANDA/NIC/NOC taxonomies by at-tending a conference, using self-study techniques from

texts, and applying the concepts in their clinical practice.Several common patient problems and nursing interven-tions were recognized immediately. Sample plans withsuggested NANDA/NIC/NOC linkages were devel-oped for staff to use as a framework to tailor to theunique needs of their patients. Networking with col-leagues provided an avenue to build confidence andconsensus regarding taxonomy application.

The documentation system was designed on paperand evolved into the program-specific component of thesystemwide computerized patient record. In addition toeducation, the staff invested much time in designing anddeveloping expertise in computer use. Care Manager, theprogram-specific software, went live in January 2000 andprovided the case managers with a vehicle to accessdata, enter clinical notes and care plans, share data be-tween providers, and track patient outcomes over time.

CONCLUSIONS. It is important for users to have a clearvision of the functionality needed for practice. Significanteducational and information system resources are needed.�Superusers� and focused education can increase the speedand efficiency of design and implementation processes.

Because standardized nursing language is used to de-scribe practice, staff members must develop expertise inusing this terminology language to describe assessments,diagnoses, outcomes, and interventions in their dailypractice. The next steps involve increasing system func-tionality to allow for more efficient documentation of as-sessments and interventions on the care plan and im-prove the ability to prescribe specific interventionswithin a NIC label. In regard to research, standardizednursing language provides a framework for descriptiveand correlational studies that identify those interventionsmost effective in achieving best practice outcomes. Casemanagers need to use change theory to identify stage ofreadiness, appropriate NOCs to describe incrementalchange, and most effective NICs to promote patientmovement toward action.Author contact [Schifalacqua]: [email protected]



Interdisciplinary Care Planning: Building for the Future

Christine Szabo and Terry Lockhart

BACKGROUND. Computerized physician order entry,test results retrieval, medication administration, nursingcare planning, and other functions have been in place atVirginia Commonwealth University Health System(VCUHS) for more than 20 years. Today there are multi-ple ways for communicating the patient plan of care inthe computerized information system (CIS). Methodsvary depending on the clinician�s role and the settingand focus of the communication, but all are essentiallyvariations in a basic pattern. Ultimately, all physician or-ders � but only some of the interventions, orders, andnotes by other clinical disciplines � are printed togetheron the nursing Kardex, the working document for orga-nizing inpatient care on a shift-by-shift basis.

No similar computer-generated document exists foroutpatients or emergency department patients, and noneis available to disciplines other than nursing. This ap-proach fragments communication and creates a sensethat the patient care plan designed by each discipline isisolated from all others. We are currently building a re-placement CIS using Cerner Millennium software. Webelieve the first step to improve these system-drivenproblems is to design the new system so that all patientcare problems, interventions, and orders are entered inthe same way.

MAIN CONTENT POINTS. Product functionality can re-place traditional nursing care planning. Plans initiatedby nonphysician clinicians tend to risk isolation. Soft-ware limitations (e.g., field lengths) and features such asduplicate order alerts must be taken into considerationwhen planning an overall redesign. To take advantage ofthe benefits offered by our new CIS, all licensed clini-cians must have the ability to independently place ordersand document problems that fall within their scope ofpractice.

Our plan for identifying diagnoses/problems is to usethe �Problem List� feature. A variety of nomenclaturessuch as CPT, ICD-9, and SNOMED are available withinthe software. With the development of NIC and NOCnomenclatures, it is now possible to expand the use ofstandardized language to capture and track new aspectsof patient care delivery.

The Virginia Board of Nursing does not permit or re-

strict the procedures a nurse is licensed to perform. Twoimportant factors that influence scope of practice are re-imbursement and organizational culture. The more im-portant concept within scope of practice is validation ofcompetency. The culture at VCUHS centers on the con-cept that the physician initiates all patient care orders.While the new system must allow nurses and other dis-ciplines to enter orders as an agent for the physician,there are orders for activities that fall within each disci-pline�s scope of practice that will not require order entryas an agent for the physician.

The VCUHS design will be implemented in phases.The use of NIC within the backend programming struc-ture is in phase 1. For phase 2 and beyond, the priorityfor system development should focus on the clinician�sability to complete the loop of the care process to includemore assessment data, outcome identification, and mea-surement of progress toward outcomes.

CONCLUSIONS. To accomplish the goal of interdisci-plinary care planning and to raise the standard of profes-sional responsibility and accountability, the followingmust be present:■ Administrative support with effective change man-

agement process■ Organizational policies/procedures congruent with

the approach■ Scopes of practice defined with validation and docu-

mentation for individuals and groups within disci-plines

■ Inclusion of appropriate clinicians in the design andimplementation process.A well-designed CIS can provide the foundation for

capturing the contributions of each discipline to the pa-tient�s plan of care, promote professional practice, andprovide information for administrative decision making.In addition, it should continue to support administrativeand research information needs such as resource utiliza-tion, workload, and patient acuity measurement. TheVCUHS design will provide a framework for studyingrelationships between patient problems/diagnoses, in-terventions, outcomes and the structures of the health-care organization.

Author contact [Szabo]: [email protected]

developing clinical terms for health visiting in the united kingdom

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