Informatics: the standardized nursing terminologies: a national survey of nurses' experiences and attitudes.

Citation: Thede, L. , Schwiran, P., (February 25, 2011) "Informatics: The Standardized Nursing Terminologies: A National Survey of Nurses' Experiences and Attitudes" OJIN: The Online Journal of Issues in Nursing Vol. 16 No. 2. DOI: 10.3912/OJIN.Vol16No02InfoCol01 Background : Two significant challenges have always faced nursing: (a) how to differentiate nursing's contributions to patient care from those of medicine; and (b) how to incorporate descriptions of nursing care into the health record in a manner that is commensurate with its importance to patients' welfare. As the development of the Electronic Health Record (EHR), and the Nationwide Health Information Network, for which the EHR is foundational, proceed at an ever-increasing pace, these challenges become even more important. We need to identify nursing's contribution to patient care and determine the best way to incorporate elements of nursing care into the EHR. Fortunately, the answer is already at hand; it lies in the use of standardized nursing terminologies (SNTs). Capturing nursing's independent contributions requires the use of standardized terminologies that reflect the uniqueness of nursing care. A key element in differentiating between the purposes and practices of nursing and medicine lies in the professional languages that are used and understood within and between these disciplines. The benefits of using standardized nursing terminologies include: (a) better communication among nurse and other healthcare providers, (b) increased visibility of nursing interventions, (c) improved patient care, (d) enhanced data collection to evaluate nursing care outcomes, (e) greater adherence to standards of care, and (f) facilitation of assessment of nursing competency. Purpose: The purpose of this study was to determine registered nurses' experiences with, and attitudes toward the standardized nursing terminologies that are recognized by the American Nurses Association. Participants: Self-selected registered nurses who were using the Internet and who received information from selected electronic mailings. Eighteen selected nursing-related LISTSERVs were contacted and invited to introduce the study to their subscribers. Additionally, the request for participation was passed along to individuals who were not subscribers. For example, 105 respondents stated that they received the information about the survey from a professor or other school-connected person. Twelve more said their request to participate came from a work supervisor. Method: The questionnaire was developed by the authors. The questionnaire and study received approval from the Ohio State University Office of Responsible Research Practices for Category 2 Exemption from review by the Institutional Review Board (Protocol Number: 2009E0612). We worked with Survey Monkey to develop and post both the invitations to participate and the survey itself. Following approval from each list owner, the survey was posted on October 1, 2009 and remained posted for seven weeks. Participation was anonymous. Respondents: A total of 1,514 participants opened the survey and began completing the survey. Altogether 1,268 usable surveys were completed. Of these respondents, all answered the questions regarding their opinions; 1,147 answered the questions regarding their experiences in using a standardized nursing terminology (SNT) as reported in the table below. Demographics: Ninety three percent of the 1,268 respondents who completed usable surveys were female. Respondents were also relatively mature, in that 68% became licensed prior to 1990 and 68% were 40-59 years of age. Students comprised 219 of the respondents. Of these 219 students, 39% were enrolled in Master's degree programs. Geographically, over half (53%) were from the Eastern 1/3 of the United States (US). The largest single group (19%) was from Washington DC and environs. There were 60 International (non-U. …