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Incorporating Standardized

Nursing Languages Into an Electronic Nursing Documentation

System in Korea : A Pilot Study

Grup 1

1. Inthoriqotul Khoiriah 152310101217

2. Larasati Setyo Pawestri 152310101218

3. Nunung Ratna Sari 152310101219

4. Efi Kusdian 152310101308

PROGRAM STUDI ILMU KEPERAWATAN

UNIVERSITAS JEMBER

2016


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Judul :

Incorporating Standardized Nursing Languages

Into an Electronic Nursing Documentation

System in Korea: A Pilot Study

Tahun Terbit :

2015Penulis :

Hyejin Park, PhD, RN, is an Assistant Professor,College of Nursing, Florida State University

Eunjoo Lee, PhD, RN is a Professor, College of

Nursing, Research Institute of Nursing Science

Tujuan :

1. Mengembangkan dan menerapkan standar berbasis bahasa keperawatan(SNLs) pada sistem dokumentasi keperawatan elektronik untuk

menyimpan, mengambil, dan menganalisis data keperawatan di Korea

untuk kualitas dan perawatan yang aman

2. Menggali pengalaman perawat dengan NANDA-I, NIC, dan NOC dengan

standarisasi bahasa keperawatan dalam kaitannya dengan alur kerja

keperawatan.


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Hasil :

Standar bahasa keperawatan yang paling sering digunakan

adalah NANDA-I, Nursing Interventions Classification(NIC) ,

dan Nursing Outcomes Classification (NOC)

Kesimpulan :

Memperoleh data yang valid melalui Standardized nursing

languages (SNLs) ini akan menjadi penting dalam

meningkatkan keselamatan pasien serta kualitas praktek

keperawatan.


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kungan

Dengan adanya Penggunaan

Standardized Nursing Languages

(SNLs) pada Electronic Nursing

Documentation System

Saat ini, Amerika Nurses Association (ANA) mengakui

12 SNLs dan elemen data setting untuk menggambarkan caring

keperawatan dan koleksi seragam informasi keperawatan itu

penting (ANA, 2006; Rutherford, 2008).

ANA mengakui bahwa

SNLs diperlukan untukmewakili pengetahuan

keperawatan dalam

mengembangkan

electronic health

records (EHRs )

SNLs digunakan

oleh perawat untuk menggambarkan

perawatan mereka (Keneen, 1999)

Sebuah contoh bahasa keperawatan

disetujui adalah NNN.

Dapat meningkatkan kesehatan yangmendukung data keperawatan, memberikan

informasi berharga untuk organisasi

kesehatan mengenai perawatan pasien, dan

meningkatkan komunikasi di antara penyedia

layanan kesehatan dengan menggambarkan

penilaian, intervensi, dan hasil perawatan.


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keunggulanPenggunaan Standardized Nursing

Languages (SNLs) NNN (NANDA, NIC,

NOC) dalam EHRs :

1. Data asuhan keperawatan dapat

ditangkap, disimpan, diambil, dan

ditransfer dengan mudah

2. Dapat memungkinkan pemutakhiran

dokumentasi keperawatan dengan

menambahkan, merevisi, atau melakukan

penghematan.

3. Sistem ini secara otomatis

menunjukkan kecocokan diagnosa

keperawatan, intervensi, dan hasil dari

NNN guna pembuatan keputusan klinis.

4. Bahasa berbasis NNN berguna untuk

mengekspresikan diagnosa, intervensi,

dan hasil keperawatan dengan cara yang

sesuai standar.

5. Perawat dapat memahami apa yang

perawat lain jelaskan dalam dokumentasi

mereka dengan segera karena SNLs

memiliki definisi yang jelas.


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keunggulanPenggunaan Standardized Nursing

Languages (SNLs) NNN (NANDA, NIC,

NOC) dalam EHRs :

6. Setiap perawat memiliki ID unik dan

password untuk akses sistem.

7. Bahasa SNLs dengan NNN dapat

meningkatkan komunikasi karena

setiap perawat menggunakan istilah

sama dalam dokumentasi.

8. Dapat lebih terorganisir dalam

melakukan rencana keperawatan dan

dapat memunculkan proses

keperawatan yang logis

10. Penggunaan SNLs NNN berguna

bagi perawat untuk berkomunikasi

tanpa kesalah pahaman, yang pada

gilirannya dapat meningkatkan

keselamatan pasien.

9. SNLs dikembangkan untuk

penyimpanan data yang efektif


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kelemahanPenggunaan Standardized Nursing Languages (SNLs)

NNN (NANDA, NIC, NOC) dalam EHRs :

• Kurangnya budaya kepekaan pada perawat.

• Perawat mengakui bahwa mereka memilih istilah-istilah yang samayang bisa menjadi hasil dari kurangnya individualisasi.

• Beberapa perawat mengungkapkan bahwa menggunakan SNLs itumerupakan suatu beban karena mereka tidak memiliki cukupwaktu, karena dianggap akan mengambil tambahan waktu untukmenulis dokumentasi jika mereka tidak memiliki pengetahuan yang

cukup tentang SNLs.• Jika perawat tidak sepenuhnya memahami konsep-konsep yang ada

pada NNN dan bagaimana menggunakannya, sistem ini akanmemiliki kegunaan terbatas. Perawat harus terbiasa dengan SNLs.


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Kemungkinan Pengaplikasian SNLs

berbasis NNN di Indonesia

Sangat memungkinkan untuk di aplikasikan di

Indonesia. Karena :

1. Penggunaannya yang cukup mudah.

2. Dinilai dari segi efektifitas dan ekonomi

sangat menunjang.

3. Keseragaman bahasa pendokumentasiansangat dibutuhkan bagi tenaga keperawatan

di Indonesia.


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TERIMA KASIH


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Incorporating Standardized Nursing Languages

Into an Electronic Nursing Documentation

System in Korea: A Pilot StudyHyejin Park, PhD, RN, and Eunjoo Lee, PhD, RN

Hyejin Park, PhD, RN, is an Assistant Professor, College of Nursing, Florida State University, Tallahassee, Florida, and

Eunjoo Lee, PhD, RN, is a Professor, College of Nursing, Research Institute of Nursing Science, Kyungpook National

University, Daegu, South Korea.

Search terms:

Electronic nursing documentationsystem, nursing informationsystem, nursing minimum data set,

standardized nursing language

Author contact:

[email protected], with a copy tothe Editor: [email protected]

PURPOSE: The purposes of this study were to (a) develop and implement astandardized nursing languages-based electronic nursing documentation systemin Korea, and (b) explore nurses’ experience with NANDA-I, Nursing InterventionsClassification, and Nursing Outcomes Classification languages in relation tonursing workflow.METHODS: The system was developed by the research team and implemented ina tertiary hospital in Korea. Ten nurses used the system and interviews wereconducted to explore nurses’ experiences with the standardized nursing lan-guages.FINDINGS: The most frequently used NANDA-I, Nursing Interventions Classifica-tion, and Nursing Outcomes Classification were identified. Nurses’ experienceswith standardized nursing languages and how they impact nursing workflow wereanalyzed.CONCLUSIONS AND IMPLICATIONS: Obtaining valid and comparable datafrom this system will be critical in improving patient safety, quality, and evidence-based practice.

The pressure to constrain costs while continuing toprovide a high quality of care has increased the need forreliable healthcare data. As a result, electronic healthrecords (EHRs) with standard terminologies have become arequirement for all healthcare providers and organizationsnationally and internationally. As with other health disci-plines, nurses have realized that standardized languages innursing information systems are required to systematicallycollect nursing data for evaluating quality assurance andcosting nursing service. The nursing minimum data set(NMDS) introduced by Werley and Lang (1998) makes animportant contribution to data management. The NMDSdefines data elements needed to capture the essence of

nursing in a care delivery context. It provides a core numberof essential standard data that are maximally useful fordifferent purposes. Standardized nursing languages (SNLs),such as the NANDA-I, Nursing Interventions Classification(NIC), and Nursing Outcomes Classification (NOC), repre-sent nursing diagnoses, nursing interventions, and nursingoutcomes, which are the critical components to describenursing practice.

Integrating these SNLs into EHRs is important because itensures that nursing care data can be captured, stored,retrieved, and transferred easily. In addition, it is an impor-

tant strategy for the effective management and measure-ment of the effects of nursing care by using a databasewithin the system because it is the most feasible method ofobtaining information necessary for clinical data collectionwhile reducing the cost, effort, and time required for datacollection (ANA, 2006; Cimino & Zhu, 2006; Lundberg et al.,2008; Sensmeier, 2010; Watkins et al., 2009; Westra,Delaney, Konicek, & Keenan, 2008). Other benefits includethe facilitation of documentation, communication amongnurses and other healthcare providers even when informa-tion is allocated at different sites or on different computersystems, the evaluation of nursing practice, and descrip-tions of nurses’ impact on patient outcomes (Carrington,

2012; Dontje & Coenen, 2011). Despite these benefits fromusing SNLs within EHRs, adoption of SNLs by nurses is slowwhen they are engaged in the development of EHRs inhealth care (Toroddsen, 2007).

The implementation of EHRs in hospitals or other com-munity settings has increased in Korea in recent years. Aresult of this trend is an increased interest in SNLs in Korea,but electronic nursing documentation systems in EHRs aredesigned with very limited use of SNLs to describe nursingpractice. In addition, SNLs in clinical practice are still newto many nurses, and the effective application of these

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35© 2014 NANDA International, Inc.

International Journal of Nursing Knowledge Volume 26, No. 1, January 2015

mailto:[email protected]:[email protected]:[email protected]:[email protected]


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languages in the healthcare setting is rare (Toroddsen,2007). This barrier makes it very difficult to collect data forbuilding nursing knowledge, measuring nursing outcomes,and establishing evidence-based nursing care.

The purposes of this study were to (a) develop andimplement a standardized nursing languages-based elec-

tronic nursing documentation system (SNLENDS) to store,retrieve, and analyze nursing data in Korea for qualityand safe care, and (b) explore nurses’ experience withNANDA-I, NIC, and NOC (NNN) languages in relation tonursing workflow.

Background

Currently, the American Nurses Association (ANA) rec-ognizes 12 SNLs and data set elements to describe nursingcare and the uniform collection of essential nursing infor-mation (ANA, 2006; Rutherford, 2008). Of the 12 SNLs,NANDA-I (NANDA-I, 2009), NIC (Bulechek, Butcher, &

Dochterman, 2008), and NOC (Moorhead, Johnson, Maas, &Swanson, 2008) were used for this study.

NNN

The ANA recognized that SNLs are necessary to repre-sent nursing knowledge in developing EHRs. SNLs are usedby nurses to describe their care (Keneen, 1999). An exampleof approved nursing languages is the NNN. The NNN is acomprehensive, research-based, standardized classificationof nursing diagnoses, nursing interventions, and nursing-sensitive patient outcomes. These classifications provide aset of terms to describe nursing judgments, treatments, and

nursing-sensitive patient outcomes. In addition, the NNN isused internationally by practicing nurses in acute care hos-pitals, outpatient and ambulatory settings, and rehabilita-tion and long-term care facilities (Herdman, 2008).

Using the NNN can improve health care by supportingnursing data comparisons for benchmarking at the nationaland international levels, providing valuable information tothe healthcare organizations regarding patient care, andimproving communication among healthcare providersby describing assessments, interventions, and outcomes(Clancy, Delaney, Morrison, & Gunn, 2006; Henry, Warren,Lange, & Button, 1998; Kim, Harris, Savova, & Chute, 2006;Lunney, 2006; Lunney, Delaney, Duffy, Moorhead, &Welton, 2005).

NMDS

“The purposes of the NMDS are to (a) establish compa-rability of nursing data across clinical populations, geo-graphic areas, and time, and (b) provide data about nursingcare to facilitate and influence clinical, administrative andhealth policy decision making” (Werley, Ryan, & Zorn, 1995,p. 21). Table 1 shows the 16 items that comprise the NMDS,categorized as nursing care items, patient demographic

items, and service items. In addition, the United States,Belgium, France, Australia, and some other countries aredeveloping international NMDS (Weaver, Delaney, Weber, &Carr, 2006). These are designed to provide information atthe international level and make it possible to benchmarkinternationally.

Method

Setting and Sample

A 250-bed Korean tertiary hospital with medical-surgical, orthopedics, and neurosurgical care units wasselected for this study. This facility has been used as

an electronic medical record (EMR) since 2006. In termsof nursing documentation, nurses described nursing careplans with narrative text formats (using either a word pro-cessor or writing personal digital assistants) without SNLs.The healthcare system in Korea is facing concerns aboutmaintaining a high quality of care at a reasonable cost. Dueto this issue, nursing executives in this hospital shouldprovide data regarding the effectiveness of care. UsingSNLs is required because they make nursing care and costvisible, tangible, and quantifiable in this facility.

For the pilot study, 10 nurses used the system for 180patients. This sample of patients consisted of adults over 18years old and included both genders.

Procedure

The SNLENDS was developed for effective storage andretrieval of data in a Korean tertiary hospital using an EMR.The project team consisted of two nursing professors, twoclinical nurses, and two information technology specialistsin the hospital. The SNLENDS was based on NMDS (seeTable 1). This system includes (a) nursing care items (nurseinformation, and nursing process such as diagnoses withdefining characteristics and related factors, interventions

Table 1. Nursing Minimum Data Set Elements

Nursing care items Nursing diagnosisNursing interventionNursing outcomeIntensity of nursing care

Patient demographic

items

Personal identification

Date of birthSexRace and ethnicityResidence

Service items Unique faci lity numberUnique patient health record numberUnique number of principal registered

nurse providerEpisode admission or encounter dateDischarge or termination dateDisposition of patientExpected payer for most of the bill

Incorporating Standardized Nursing Languages H. Park and E. Lee

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with activities, and outcomes with indicators and scalesrating from 1 to 5); (b) patient demographic items andmedical diagnoses (International Classification of Diseases[ICD]-9); and (c) service items (a unique patient healthrecord number, a unique number for the registered nurseprovider, admission date, discharge date, disposition of

patient, and billing information).Nursing diagnoses, interventions, and outcomes from

NNN were identified in order to integrate the nursingprocess with SNLs. All three SNLs have been translatedinto Korean. One hundred fifty-five NANDA-I in Korean,including defining characteristics and related factors, wereinstalled in the system for nursing diagnoses. Labels withactivities for 280 NIC interventions were used in thissystem, as well as the 87 NOC outcomes and correspondingindicators. The measurement scale of the NOC from 5 to 1was used, where 5 is always the desirable state. The link-ages among NANDA-I, NOC, and NIC are featured in thesystem to support decision making. NANDA-I nursing diag-

nosis is the entry point and suggests NOC outcomes withassociated NIC interventions. NANDA-I, NOC, and NIC link-ages by Johnson et al. (2006) were used to link the nursingcare components.

Ten nurses with more than 2 years of clinical experiencewere each trained by researchers biweekly for a monthabout NANDA-I, NOC, and NIC languages, as well as thesystem. The 10 nurses used the system for 180 patients for2 months across settings that included med-surgical, neu-rosurgical, and orthopedic in a tertiary hospital in SouthKorea. Each nurse selected NNN. The frequently used NNNwas determined. In addition, nurses’ experience with SNLsand how they impact nursing workflow were explored. Inter-views were conducted with 10 nurses to analyze their expe-

riences. Interview data were collected via tape recorder andtranscribed verbatim, then sent back to each intervieweefor review to ensure what they said in the interviews wasexactly what they had intended to say.

Data Analysis

The most frequently used three standardized nursingterminologies (NANDA-I, NIC, and NOC) variables were mea-sured. Data were analyzed using descriptive statisticsto describe the frequencies and percentages of NANDA-Inursing diagnoses, NIC interventions, NOC outcomes,NANDA-I–NOC linkages, and NANDA-I–NIC linkages. Inter-

view data were categorized using qualitative theme analy-sis to analyze nurses’ experience with SNLs and how theyimpact nursing workflow.

Results

SNLENDS

The items in this SNLENDS relate to nursing care, patientdemographics, and service (see Figure 1). The NNN lan-guages are integrated into EHRs to allow the updating of

nursing documentation by adding, revising, deleting, orsaving. In addition, this system automatically suggestssuitable nursing diagnoses, interventions, and outcomesfrom the NNN linkages database for clinical decisionmaking. Each nurse has a unique ID and password to accessthe system.

Nursing Care Items

Nursing diagnoses. Based on patients’ history taking,nurses select nursing diagnoses from existing NANDA-Inursing databases, which include 155 NANDA-I with definingcharacteristics and related factors. The labels of NANDA-Inursing diagnoses are placed within the nursing diagnosesscreen so nurses can easily see, search, and enter them.This is the entry point of the nursing process.

Nursing outcomes: Present state. After selectingnursing diagnoses, the nurses select outcomes to evaluate

present patients’ situations from the NOC outcome data-base. NOC outcomes include NOC labels and the nursingoutcomes indicators with measurement scales from 1 to 5,where 5 is the desirable status. Nurses select and rate oneor more than one of the indicators in the lists.

Nursing outcomes: Desired outcomes. Nurses selectNOC outcomes and indicators to set patients’ desired out-comes. After interventions, nurses determine whether ornot the desired outcomes are achieved. If they are not,the nurses return to the nursing process entry point. Thissystem allows nurses to do repeated assessments anddisplay all the results so they can document changes inpatients’ conditions.

Nursing interventions. After assessing the presentpatient state using NOC, nurses select interventions fromthe database. NIC interventions include NIC labels withnursing activities. Nurses then select appropriate activitiesfrom the lists on the screen. They can also enter nursingactivities if the database does not have appropriate nursingactivities.

Patient Demographic Items

Once nurses have entered the ID and password into thesystem, patients’ personal and medical diagnoses are dis-

played. Demographic items include the patient identifica-tion number, name, age, gender, history, type of healthinsurance, and medical diagnoses.

Service Items

Nurses can check general service items about the patientafter logging in using their ID and password. Service itemsinclude unit number, nurse information such as a nurse’sunique number, name, patient record number, admission ordischarge data, and billing information.

H. Park and E. Lee Incorporating Standardized Nursing Languages

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The SNLENDS is able to produce a large database fromaccumulated data, allowing identification of the most effec-tive nursing interventions as well as the most appropriateoutcome measurement indicators. These in turn helpnurses make optimal decisions about patient care.

Implementation of the System

General characteristics. Among the 180 patients, 48%(n = 86) were male, with the majority in their 30s (n = 28,15.5%) and 60s (n = 28, 15.5%). Medical-surgical consistedof 37.8% (n = 68), followed by orthopedics (n = 65, 36.1%)and neuro-surgical (n = 33, 18.3%) (see Table 2).

Top 10 NANDA-I nursing diagnoses. The top 10NANDA-I nursing diagnoses were identified. Acute pain(00132) (n = 45, 26.1%) was the most frequently used

Figure 1. Standardized Nursing Languages-Based Electronic Nursing Documentation System

Nursing Outcomes:

NOC code

NOC label

Definition

NOC indicators

NOC scores

(present: current, desired)

NOC measurement Scales

Sum of NOC Score

Date

Time

Patient Information Data

Unique identification number

Name

Age (date of birth)

Gender

Past history

Type of health insurance

Medical Diagnoses

ICD-9 code

Service Items

Unit number

Identification number

Unique patient record number

Unique number of nurse

provider

Admission or discharge date

Disposition of patient

Billing information

Nursing

Diagnosis

NANDA code

NANDA label

Definition

Sign/Symptom

Related factors

Date

Time

A) Nursing care item

B) Patient demographic items C) Service Items

Nursing

Interventions

NIC code

NIC label

Definitions

NIC activities

Date

Time

Table 2. General Characteristics (n = 180)

N %

Unit Med-surgical 82 45.6Orthopedics 65 36.1Neurosurgical 33 18.3

Gender Female 94 52.2Male 86 47.8

Age


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NANDA-I, followed by nausea (00134) (n = 12, 6.7%) andineffective breath pattern (00032) (n = 10, 5.5%) (seeTable 3).

Top two NIC interventions associated with top 10

NANDA-I. Pain management (1400) (n = 37, 32.2%) andanalgesic administration (2210) (n = 22, 19.1%) were themost frequently used NIC interventions for acute pain(00132) nursing diagnosis. For nausea, nausea management(1450) (n = 10, 31.1%) and fluid monitoring (4130) (n = 5,15.5%) were the most frequently used NIC interventions(see Table 4).

Top two NOC outcomes associated with top 10

NANDA-I. Pain level (2102) (n = 19, 39.4%) and paincontrol (1605) (n = 17, 36.1%) were the frequently usedNOCs for acute pain (see Table 5). Nutritional status: food

and fluid intake (0140) (n = 5, 41.6%) and comfort status(2008) (n = 3, 25%) were the most frequently used NOCsfor nausea nursing diagnosis (see Table 5).

Nurses’ Experiences With NNN Languages

Figure 2 shows the main positive and negative influences

of NNN languages on the nursing workflow. The positivethemes were logical nursing process, visibility of nursing,communication, and standardization. The negative themeswere cultural insensitivity, lack of individualization, andburden.

Interviewees were asked about their experiences withNNN languages, including whether they had any positive ornegative experiences. With regard to positive experiences,a nurse interviewee stated that “NNN languages are usefulway to express nursing diagnoses, interventions, and out-comes in a standardized way. . . . we can understand what

Table 3. The Selected Top 10 NANDA-I

Domain Class NANDA-I (code) N % Rank

Activity/rest Cardiovascular/pulmonary responses Ineffective breathing pattern (00032) 10 5.5 3Activity/exercise Impaired walking (00088) 10 5.5 4

Impaired transfer ability (00090) 8 4.4 7

Impaired physical mobility (00085) 7 3.9 8Comfort Physical comfort Acute pain (00132) 47 26 1

Nausea (00134) 12 6.7 2Chronic pain (00133) 7 3.9 9

Elimination and exchange Gastrointestinal function Perceived constipation (00012) 9 5 5Nutrition Ingestion Imbalanced nutrition: less than body

requirements (00001)9 5 6

Safety/protection Infection Risk for infection (00004) 6 3.3 10

Table 4. Top Two NICs Associated with Top 10 NANDA-I

NANDA-I NIC (code) N %

Acute pain Pain management (1400) 37 32.2Analgesic administration (2210) 22 19.1Nausea Nausea management (1450) 10 31.3

Fluid monitoring (4130) 5 15.5Ineffective breathing pattern Airway management (3140) 8 30.4

Respiratory monitoring (3350) 8 30.4Impaired walking Exercise promotion (0200) 5 25

Teaching: prescribed activity/exercise (5612) 3 15Perceived constipation Bowel management (0430) 7 31.3

Fluid management (4120) 4 18.1Imbalanced nutrition: less than body requirements Nutrition management (1100) 4 19.4

Fluid monitoring (4130) 4 19.4Impaired transfer ability Exercise therapy: balance (0222) 3 16.7

Exercise promotion: stretching (0201) 3 16.7Impaired physical mobility Fall prevention (6490) 3 20

Exercise therapy: balance (0222) 2 13.3Chronic pain Pain management (1400) 5 29.4

Medication management (2380) 2 11.8Risk for infection Infection protection (6550) 4 17.4

Wound care (3660) 4 17.4

NIC, Nursing Interventions Classification.


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other nurses described in their documentation right awaysince SNLs have clear definitions . . .” Other nurses alsoexpressed that the NNN languages improved communica-

tion since each nurse used the same terms in his/her docu-mentation. Another nurse stated: “. . . when I used NNNlanguages, I could be more organized with nursing careplans and it led to a logical nursing process . . . Well, It lookslike a roadmap so I know where I can go.”

While positive experiences were explored, negative expe-riences were also stated.

One of the negative experiences was a lack of culturalsensitivity. This experience was expressed as follows:

Emphasizing family values is one of the Korean subcul-tures. A nurse expressed: “. . . many family members stayed

with patients who are their loved ones . . . and many visitors,including relatives and friends, came to visit patientsaround-the-clock. . . . numbers of visitors were limited due

to the risk of infection or noise . . . I could not find anappropriate standard term from the system. . . . I only found‘visitation facilitation’ which was not appropriate.”

Nurses recognized that they selected the same termsregardless of patients’ comorbidity to describe patients’situations. This could be the result of a lack of individual-ization. Some nurses addressed that using SNLs was aburden since they do not have enough time. It will take extratime to write nursing documentation if they do not haveenough knowledge about SNLs. For example, there aremany SNLs in the system and nurses have to figure out

Table 5. Top Two NOCs Connected with Top 10 NANDA-I

NANDA-I NOC (code) N %

Acute pain Pain level (2102) 19 39.4Pain control (1605) 17 36.1

Nausea Nutritional status: food and fluid intake (1008) 5 41.6

Comfort status (2008) 3 25Ineffective breathing pattern Respiratory status: ventilation (0403) 5 50

Respiratory status: airway patency (0140) 5 50Impaired walking Ambulation (0200) 8 80

Mobility (0208) 1 10Perceived constipation Bowel elimination (0501) 7 77.8

Hydration (0602) 1 11.1Imbalanced nutrition: less than body requirements Nutritional status: food and fluid intake (1008) 8 62.5

Nutritional status (1004) 3 37.5Impaired transfer ability Mobility (0208) 5 62.5

Body position: self-initiated (0203) 3 37.5Impaired physical mobility Mobility (0208) 4 57.1

Ambulation (0200) 2 28.6Chronic pain Pain control (1605) 5 62.5

Discomfort level (2109) 2 25Risk for infection Risk control (1902) 4 66.7

Wound healing: secondary intention (1103) 1 16.7

NOC, Nursing Outcomes Classification.

Figure 2. Nurses’ Experience with NNN Languages


40


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which one is the most appropriate SNLs to describe patientcare. It could feel like extra work and a burden since nurseshave many other duties during their shifts.

Discussion

One of the major benefits of the system is its uniformcollection of data. Obtainingvalid andcomparabledata fromthis system is critical to improving patient safety, quality,and evidence-based practice. In addition, incorporatingSNLs into this system can expand the benefits of the data-base by more rapid and cost-effective data retrieval. Thisallows comparison of patient problems, nursing interven-tions, and nursing outcomes on a national and internationalbasis. Another benefit is that this system is user-friendly.For example, simply installing a list of NNN into the systemwould make it too time-consuming to choose each compo-nent of the nursing process, forcing nurses to spend timedocumenting instead of providing patient care. To avoid this

problem, the system has installed linkages of NNN intonursing process instead of a list of NNN. The predeterminedNNN linkages reduce documentation time by providing areasonably simple way fornurses to selectappropriate diag-noses, interventions, and outcomes.

In Korea, most EHRs have not included measurementsof nursing outcomes using a sensitive measurement toollike this system which includes NOC, allowing repeatedmeasures of nursing specific outcomes. For example,nurses measure patients’ situations at admission andtake repeated measures until discharge. NOC uses a Likert-type scale that generated interest because rating patientsinvolves more than just checking a number. For example,rating the indicators increases the nurses’ ability to identify

pain control issues and motivates them to change the paincare to achieve more positive outcomes.

In particular, this system enables the extraction of datarelated to patient characteristics or specific patient popu-lations. For example, the system allows for the systematicidentification of patterns in nursing care elements, such asnursing diagnoses, interventions, and outcomes, for a spe-cific patient population. It also enables clinical research onthe effectiveness of nursing care in responding to variouspatient characteristics. Nursing knowledge is expanded andevidence-based nursing practice supported when we candetermine patterns of nursing practice for specific popula-tions. In this study, patterns of NNN were identified. The

most frequently identified NANDA-I was acute pain. Painmanagement and analgesic administration were the top twoNIC interventions for acute pain. Pain level and pain controlwere the top two frequently used NOC outcomes for acutepain.

This system has incorporated SNLs into nursing docu-mentation records that describe nursing diagnoses, inter-ventions, and outcomes in order to produce systematic careplans and direct a continuation of health care. However, ifnurses do not fully understand the concepts of the NNNterminologies and how to use them, this system will have

limited usefulness. Nurses must be familiar with SNLs andhave a level of competency. To address this challenge,nursing staff needs the support of project managers andexpert nurses to ensure optimal utilization of SNLs.

Nurses in Korea recognized the main positive and nega-tive influences of NNN languages on workflow. They said

that NNN languages are useful for nurses to communicatewithout misunderstanding, which in turn can improvepatient safety. Rutherford (2008) also found that one of theadvantages of SNLs is enhancing communication. Nursesmentioned that having a standard way to communicatealso leads to the development of a logical nursing processand saves documentation time. Clancy et al. (2006) sup-ported this view that adopting SNLs reduces complexity andimproves completion time for documentation. The negativethemes that nurses identified were the lack of culture sen-sitivity and the lack of individualization. Several earlierstudies have supported these findings. One study foundthat SNLs are needed to accurately reflect the contents of

nursing practice in different cultures (Lee, Lee, & Jung,2006). Lee, Yeh, and Ho (2002) found that SNLs reduceindividualization in patient documentation.

The benefits and downfalls of using the SNLs in thesystem were identified. However, this is a pilot study so it isnecessary to use the system continuously in diverse unitsand populations to get more feedback from nurses indiverse settings. The system will be then modified based onthe feedback to become a more user-friendly system. Inaddition, nursing terms that represent Korean culture willbe captured and developed into standardized nursing ter-minologies. Updating and developing standardized nursingterminologies that reflect culture and subcultural differ-ences in nursing practice is critical to bringing nursing

together worldwide.

Limitations

This study was a pilot study in one hospital with a smallsample size so it limits the generalization of the findings.Second, this study identified the frequently used NNN,regardless of a specific population. It is necessary to iden-tify the pattern of nursing diagnoses, interventions, andoutcomes for a specific population to build knowledge thatsupports nurses’ decision making. Third, we only identifiednurses’ experience with NNN languages. Further research isnecessary to identify the effectiveness of the system and

nurses’ attitude or satisfaction regarding the system.

Implication and Conclusions

The better health care not only comes from the adoptionof technology and EHRs, but also by increasing the use ofSNLs. The use of SNLs with EHRs in health care in Korea isnecessary to improve the quality of care. The SNLENDS cancontribute to more effective nursing care practice bysaving, retrieving, and transforming nursing data, allowing


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for the evaluation of patient outcomes, the determinationof the cost of nursing care, and an assessment of the qualityof care.

Acknowledgment. This research was supported byKyungpook National University Research Fund, 2012 and

Research Institute of Nursing Science Fund, KyungpooKNational University in 2013.

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