Secondary use of standardized nursing care data for advancing nursing science and practice: a systematic review

Abstract

Objective The study sought to present the findings of a systematic review of studies involving secondary analyses of data coded with standardized nursing terminologies (SNTs) retrieved from electronic health records (EHRs). Materials and Methods We identified studies that performed secondary analysis of SNT-coded nursing EHR data from PubMed, CINAHL, and Google Scholar. We screened 2570 unique records and identified 44 articles of interest. We extracted research questions, nursing terminologies, sample characteristics, variables, and statistical techniques used from these articles. An adapted STROBE (Strengthening The Reporting of OBservational Studies in Epidemiology) Statement checklist for observational studies was used for reproducibility assessment. Results Forty-four articles were identified. Their study foci were grouped into 3 categories: (1) potential uses of SNT-coded nursing data or challenges associated with this type of data (feasibility of standardizing nursing data), (2) analysis of SNT-coded nursing data to describe the characteristics of nursing care (characterization of nursing care), and (3) analysis of SNT-coded nursing data to understand the impact or effectiveness of nursing care (impact of nursing care). The analytical techniques varied including bivariate analysis, data mining, and predictive modeling. Discussion SNT-coded nursing data extracted from EHRs is useful in characterizing nursing practice and offers the potential for demonstrating its impact on patient outcomes. Conclusions Our study provides evidence of the value of SNT-coded nursing data in EHRs. Future studies are needed to identify additional useful methods of analyzing SNT-coded nursing data and to combine nursing data with other data elements in EHRs to fully characterize the patient’s health care experience.

Development and Validation of Standardized Pain Management Documentation

“…These results are consistent with previous research, showing that patient education is inadequately documented, and nurses may not see the importance of documenting it [5,12]. In addition, the frequent use of free-text for documentation in lieu of the FinCC components and main and sub categories gives rise to terminology which is incompatible with good quality documentation [10,11].…”

“…There is also a category for 'Assessment of the effects of non-pharmacological management of pain', as well as 'Assessment of the intensity of pain at rest', and 'Assessment of the intensity of pain when mobile' [14]. The goal for these new terms in the revised terminology is to remedy nurses' skills deficit to record more than just 'painkillers given', and more completely document the content of the care provided to patients [2,9], as well as facilitate better quality data within nursing records [10,11]. The documentation of medication, prescribed by the physician and administered by the nurse, is an essential part of pain management and its documentation.…”

“…Thus, educational interventions and standardization of pain management and documentation are urgently needed [5,9]. There is evidence that if patient care can be documented structurally using standards and common terminology, that documentation can yield more complete and reliable data that better meet the requirements placed on patient records, including in secondary use [10,11].…”

Nursing Informatics Research Trends: Findings from an International Survey

“…Recently clinicians have raised concerns related to the development and implementation of AI and how innovations such as intelligent robots will impact practice and the nursing profession [9]. These findings reflect a shift in the current years regarding an increased demand for evaluating delivered care [10], an increase in the use of the large amount of data available for research [11], and an increase in discussions around the use of AI in health care [12]. Although, there has been a considerable amount of work on informatics education and competencies for nurses in different roles [13][14], educational programs still fail to adhere to standardized criteria for NI education and the need for educating NI educators [4].…”

The Essence and Role of Nurses in the Future of Biomedical and Health Informatics

“…It has been interpreted as "the degree to which individuals can obtain, process, and understand the basic health information and services they need to make appropriate health decisions [4]. This definition may also be extended to the context of technology through digital health literacy [5].…”