Nurses’ Use of Standard Terms In Electronic Records With and Without NNN Margaret Lunney, RN, PhD Professor, College of Staten Island (CSI) Linda Fiore, RN, MA Assistant Director of Nursing New York City Dept of Health & Mental Hygiene

Acknowledgements Main study (In review): –Effects of Using Standard Terms in Electronic Records on Nurses’ Power and Children’s Health Outcomes Main Study Co-Investigators: –Laurence Parker, PhD –Roberta Cavendish, RN, PhD –Joyce Pulcini, RN, PhD Main study partially funded by: –NINR, NIH, 1R15NR04870, $107, 700 –CSI Foundation & President Marlene Springer, $15,000 –Professional Software for Nurses, $14,000

Background CHANGE from paper to electronic health records (EHR) CHN specialty-nursing care in school settings Decisions re: software to purchase Many vendors, Medical model approaches Will EHR include sufficient nursing data? –Driving Forces –Restraining Forces

Driving Forces: Use of NNN in School Settings 1. Research-based standardized terms 2. Describes: Health promotion Health protection Management of problems 3. Provides comprehensive nursing process data; both decisions & actions

Driving Forces: Use of NNN in School Settings 4. Measures broad range of child & family outcomes 5. Relates outcomes to interventions 6. Improves: Communication Continuity of care

Restraining Forces: Use of NNN in School Settings 1. Historically: –Data organized by medical diagnoses (MDx) & tasks –Nursing model for care generally invisible –Low emphasis on documenting health promotion & health protection 2. Resistance to change historical patterns 3. With familiarity of MDx, perception that EHR based on MDx easier to implement

Restraining Forces: Use of NNN in School Settings 4. Cost of purchasing licenses to use NNN 5. Paucity of research data to show the advantages of using NNN

Research Questions 1. Are there patterns of documentation that can be identified from health visit data? 2. Are there differences in documentation patterns with and without use of NNN? 3. Does the data support the advantages of using NNN?

Study Methods Qualitative & quantitative analyses of 12 nurses’ documentation Health visits with 220 children, ~1300 contacts 6 nurses used standard terms of vendor 6 nurses used NNN + vendor terms Investigators independently analyzed data Methods to support credibility, dependability, confirmability, transferability

Findings Q 1: Documentation patterns evident: –Type of care provided Primarily health promotion & health protection (~80%) Management of therapeutic regimens (~10%) Management of health problems (~10%) –# of standard terms used per visit varied widely among nurses, e.g., 1 vs. 10 Rxs –Poor documentation of outcomes, i.e., 9/12 schools little to no outcome data –Some errors implied in use of terms

Findings Q2 & 3: Comparison of two groups: Group that used NNN: –Data better illustrated a nursing model for care –Data were more comprehensive, e.g., Used 44 NDxs; 93 NIC Interventions, 33 NOC Outcomes Vendor terms –Data better reflected specialty emphasis on health promotion & health protection –Data showed diversity & complexity of practice

High Frequency NANDA Diagnoses Nursing diagnosis Freq. # Nurses Knowledge Deficits Health Seeking Behavior Risk of injury & other risk dxs Pain Self Concept, RFE Decisional Conflict Self Esteem Disturbance Decision making, RFE /65/65/65/63/63/63/63/6

High Frequency NIC Interventions InterventionFreq. # Nurses Active Listening Counseling Teaching: Group Health Education Environmental Mgt: Safety Behavior Modification Calming Technique Anger Control Assistance /66/65/64/63/65/64/65/6

High Frequency NOC Outcomes OutcomesFreq. # of Nurses Safety Behavior: Personal Knowledge: Health Behaviors Play Participation Role Performance Aggression Control Information Processing Knowledge: Diet Knowledge: Health Promotion /62/63/63/62/62/62/64/6

Discussion: Documentation Patterns Data (both groups) illustrated complexity & diversity of school-based nursing Wide variety of charting patterns r.t. “pilot” test, did not set specific expectations Inadequate use of outcomes r.t. new way of thinking; additional education needed Errors in use of terms-education needed

Discussion: Use of NNN vs. Vendor Terms Data better represented: –Nursing model for care (holism, health, caring) –Health Promotion –Health Protection –Management of acute and chronic problems Use of NNN + vendor terms contributed to: –Redundancy –Inconsistent use of terms

Implications/Conclusions Computerized documentation can effectively represent school-based nursing With use of NNN, omit vendor terms With use of NNN, agencies need to plan: Decision making re: preferred use of terms Ongoing data evaluation, e.g., monthly Systematic feedback to nurses Ongoing education of nurses

Implications/Conclusions Facilitate driving forces for use of NNN: –Health-related perspective –Comprehensive terms needed to represent school-based nursing –National and international recognition of terms Minimize the restraining forces, e.g., –Research data needed Promote purchase of software with NNN