This paper includes a description of what databases

currently exist and provides examples showing the use of

those databases for documenting nursing effectiveness.

An apparent finding from a review of the literature, is the

absence of nursing research descriptions of the use of

databases for effectiveness research. This paper then,

describes the possibilities instead of the actualities. Unfortunately, data on the current state of practice are often

unavailable; however, it may be possible to use data gathered for other purposes. Finally, this paper highlights the

potential role of the clinical practice guidelines developed

by expert panels facilitated by the Agency for Health Care

Policy and Research for improving nursing research effectiveness through interpolation with current databases

and recommends further research.

Databases For Outcomes Research

In a recent paper summarizing health services research

in nursing, Ingersoll et al defined only 113 studies published between 1980 and 1989 (Ingersoll, et al, 1990).

The article summed the areas of research in health services and outcomes research, and identified the gaps in

research. The gaps included comprehensive cost-benefit

and cost-effectiveness analyses, effects of technology on

patient care, evaluations of information systems, evaluations of innovative care delivery approaches, and studies

of ethical issues related to the use of scarce resources.

The article stresses the need for nurses to access databases for health services research.

Databases that may be used for synthesis of research

results, combined analysis, or meta-analysis are available

but have infrequently been described in annual reviews

of nursing research. Databases that may be used for health

policy components of nursing effectiveness research include:

Medicare and private sector claims data, collected

by Medicare peer review organizations, the National Disease and Therapeutic Index, and the

National Ambulatory Medical Care Survey.

A number of other data bases that have age specific data are also proposed for consideration, including

the following:

1. The SEER (Surveillance, Epidemiology, and End

Results) program (in the United States) and its

international equivalents

2. Hospital and physician use and expenditure data

from the Health Care Financing Administration,

possibly linked with other data sets

3. The Global Epidemiological Surveillance Program of WHO, which may have useful information for cause-of-death validation studies based

on consistency checks, time and age trend checks

Nursing Effectiveness Research

Using Existing Databases

Kathleen A. McCormick, Ph.D., R.N., F.A.A.N.
4 Existing data bases from international studies such

as MONICA, which have the advantage of highly

standardized methods and good quality control.

It is believed that researchers could have access

to these data

5 The Intersalt Study (sodium and blood pressure);

however, the numbers in the data base are quite

small for the elderly population

6 ARIC (Atherosclerosis Risk Communities)

7 The CARDIA (Coronary Artery Risk Factors

Development in Young Adults) Study, which is

limited by small numbers

8 Other international community-registries, although they often have a low age limit. (Vital

and Health Statistics (Proceedings of 1988 International Symposium on Data on Aging) Series

5: Comparative International Vital and Health

Statistics Report, No. 6.

A new database for nursing effectiveness research

is an existing network. It is published by the Library of

Medicine and is called “E.T. Net.” Susan Sparks has been

working on the development of this (NLM, Fact Sheet,

“E.T. Net”, March 1991). Many nurses may not even be

familiar with this, or have even thought of looking at a

currently available network already available through the

National Library of Medicine. The only costs associated

with its use are for the linkages that have to be purchased

for the system. Consider the use of that network in establishing a system to monitor and exchange information

about outcomes research in this country; an “effectiveness network”. This network should be explored as a

prime opportunity to make accessible the clinical practice guidelines. Feedback could be obtained from nursing professionals or professional associations about the

use of that database in their current practices. The practitioners involved in practice, the researchers involved in

clinical trials, and the academicians involved in theoretical research outcomes, could participate in that database

and provide a rich resource for effectiveness research.

Databases that may be used in clinics practice for

monitoring complex observations over time, measuring

contributions of nursing practice to outcomes, and/or

manipulating of data that require multiple transformations,

are database management systems that have been described by McCormick on numerous occasions over the

past 6 years (McCormick, 1985, 1988a, 1988b; Saba and

McCormick, 1986). Currently, natural language query

systems have been developed for use with database management systems now, and programming is not necessary to use these systems to monitor outcomes of care.

Much has been published about the database of the

future in which the contents are developed using the Nursing Minimum Data Set (Werley and Lang, 1988).

Through this database, it is anticipated that nursing research outcomes could be linked with various nursing

databases for the purpose of possibly performing metaanalysis to test specific nursing theories related to

nursing’s clinical outcomes.

Examples of using databases for effectiveness research

come from the Inpatient Clinical Geriatric Continence

Project supported by the National Institute on Aging and

the Health Care Financing Administration. The database

was described in a paper by McCormick and McQueen

in 1986. Examples included the use of nursing documentation to support the clinical trial of changing patient’s

wetness to dryness status in nursing homes. In addition,

the costs of care were also collected. A separate publication describes the potential cost savings when nursing

monitors their outcomes and documents the cost impact

(McCormick et al, 1990). The uniqueness of this type of

database format is that:
1) it structures the input of nursing documentation,

2) it cues the nursing personnel about what aspect of care to documentation that are clinically

useful and relevant to outcomes,

3) it provides graphics and feedback about the

care being delivered in a timely manner so that

the plan can be changed, and/or interventions can

be changed,

4) it monitors both positive, negative and the absence of trends, so that patients care can be prioritized,

5) it produces tables of results that can be used to

summarize treatment effects,

6) it provides statistical analysis so that trends can

be compared and significance applied to findings

as they happen,

7) it includes word processing capabilities so that

results can be summed and sent for publication

so that others can utilize the research outcomes

in dissemination.

Clinical Practice Guidelines

How will clinical practice guidelines facilitate nursing effectiveness research utilizing existing databases?

The clinical practice guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical

conditions.” (Program Note, August, 1990) The guidelines, developedby panels of experts composed of multidisciplinary groups, synthesize the existing research and

indicate what the appropriate obtainable outcomes have

been. In addition, they describe the diagnosis and treatment options that exist for clinicians. The AHCPR facilitated guidelines will also have algorithms/flowcharts

available that map the appropriate course of action for a

health professional to take. Thus, the guidelines provide

the potential uniform content for database systems that

can be used to document nursing practice, report the outcomes achieved, and monitor the use of diagnostic and

treatment options that effect positive outcomes most frequently. While the guidelines provide this structure, they

also remain flexible enough to include diagnostic and treatment options may be used.

Through its grant mechanisms, the AHCPR welcomes

applications from nurse researchers who are interested in

incorporating clinical practice guidelines into current databases to determine their usefulness for the nursing profession.

Future Research Needs

What are potential directions for future research?

Some research areas of the future are those in which nursing outcomes can be generated from computer databases

that are structured around repetitive tasks, interpolations,

and integration as follows:

Repetitive tasks:

1) Identify more costly tasks that can be automated

2) Evaluate whether automation of new repetitive

tasks reduces times, costs, and personnel needs;

Interpolation:

1) The use of patient care documentation to determine patient care needs, outcomes, and costs,

2) The use of patient care documentation to automate quality assurance monitoring

3) The use of patient care documentation to define

further research needs

4) The use of patient care documentation to define

continuing education needs

5) The use of previously collected databases for secondary analysis of nursing care, patient care

needs, outcomes, and costs
Integration:

1) The use of computes in practice for decision-support

2) The use of decision-support to influence patient

outcomes

3) The use of decision-support to influence costs

4) The use of decision-support to influence delivery

of care services

5) The use of bibliographic retrieval in determine

appropriate assessments and actions related to patient care.

In summary, the outcomes research recommendations

should be to encourage the use of clinical guidelines in

current databases, to compare the content in clinical practice guidelines to content currently in existing databases,

to design new database systems that are most useful to

nursing for nursing information and patient outcomes

achieved by nursing, to support nursing research into different types of claims data in order to define what is useful to nursing and what is not, to support the use of further meta-analysis reviews of current nursing research

outcomes literature, to further define the Nursing Minimum Data Set and test its usefulness in defining nursing

effectiveness, and to support more research on clinical

conditions where nursing makes the difference in outcomes of care.

References

AHCPR Program Note. Clinical Guideline Development.

AHCPR, Rockville, MD 20857, August, 1990.

Ingersoll, G.L., Hoffart, N., and Schultz, A Health services research in nursing: Current status and future directions. Nursing Economics, Vol. 8, No. 4, July-August, 1990, pp. 317-326.

McCormick, K. Computers in nursing research: Clinical, laboratory, statistical, in Nursing Uses of Computer

and Information Science.

K. Hannah and E. Guillemin, and D. Conklin (eds).

Elsevier Science Publishers, B.V. (North-Holland), 1985,

pp 269-277.

McCormick, K., and McQueen, L. The development and

use of a database management system for clinical geriatric research in MEDINFO 86. R. Salamon, B. Blum, M.

Jorgensen (eds).

Elsevie Science Publishers B.V. (North-Holland), 1986,

pp 527-531.

McCormick, K. Accessing clinical data. In information

Sources for Nursing: A Guide. Judith Schokley (ed).

New York, NY: National League for Nursing, 1988a, pp

87-102.

McCormick, K Conceptual considerations, decision criteria, and guidelines for development of the Nursing Minimum Data Set from a research perspective. In Identification of the Nursing Minimum Data Set, H. Werley and N.

Lang (eds), New York, NY: Springer Publishing Co., Inc.,

198b, pp 34-47.

McCormick, K. Future data needs for quality of care

monitoring, DGR considerations, reimbursement and

outcome measurement. Image: Journal of Nursing Scholarship. Vol. 23, No. 1, Spring, 1991, pp 29-32.
National Library of Medicine, Fact Sheet on E.T. Net,

March 1991.

Vital and Health Statistics, Proceedings of 1988 International Symposium on Data Aging; Series 5: Comparative International Vital and Health Statistics Report, No.

5; Manning Feinleib, M.D., Dr. P.H., Editor, U. S. Department of Health and Human Services, DHHS Publication No. (PHS)91-1482, p. 248.