Development of a Theory of Wisdom-in-Action for Clinical Nursing.

Nurses published dialogues on wisdom; yet, a conceptual model is unavailable. We present the development process for a theory of wisdom-in-action for clinical nursing developed in 3 phases: (1) a deductively derived model using derivation and synthesis; (2) inductively, a constructivist grounded theory captured the experience of wisdom in nursing practice; and (3) the 2 theories were synthesized into a nascent theory. The theory describes 2 antecedent dimensions, person-related and setting-related factors, and 2 types of wisdom, general and personal. The theory provides a framework for translating wisdom in nursing practice, depicting both the science and art of nursing.

Lessons Learned in Creating Interoperable Fast Healthcare Interoperability Resources Profiles for Large-Scale Public Health Programs.

OBJECTIVE: This article describes lessons learned from the collaborative creation of logical models and standard Health Level Seven (HL7) Fast Healthcare Interoperability Resources (FHIR) profiles for family planning and reproductive health. The National Health Service delivery program will use the FHIR profiles to improve federal reporting, program monitoring, and quality improvement efforts. MATERIALS AND METHODS: Organizational frameworks, work processes, and artifact testing to create FHIR profiles are described. RESULTS: Logical models and FHIR profiles for the Family Planning Annual Report 2.0 dataset have been created and validated. DISCUSSION: Using clinical element models and FHIR to meet the needs of a real-world use case has been accomplished but has also demonstrated the need for additional tooling, terminology services, and application sandbox development. CONCLUSION: FHIR profiles may reduce the administrative burden for the reporting of federally mandated program data.

Standardizing Physiologic Assessment Data to Enable Big Data Analytics.

Disparate data must be represented in a common format to enable comparison across multiple institutions and facilitate Big Data science. Nursing assessments represent a rich source of information. However, a lack of agreement regarding essential concepts and standardized terminology prevent their use for Big Data science in the current state. The purpose of this study was to align a minimum set of physiological nursing assessment data elements with national standardized coding systems. Six institutions shared their 100 most common electronic health record nursing assessment data elements. From these, a set of distinct elements was mapped to nationally recognized Logical Observations Identifiers Names and Codes (LOINC®) and Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT®) standards. We identified 137 observation names (55% new to LOINC), and 348 observation values (20% new to SNOMED CT) organized into 16 panels (72% new LOINC). This reference set can support the exchange of nursing information, facilitate multi-site research, and provide a framework for nursing data analysis.

Developing Standardized Physiologic Assessments.

A terminology for nursing assessments does not exist to support exchange of information and research. A team of nurse informaticts collaborated to create a standard for medical/surgical assessment terms coded in LOINC and SNOMED CT. Nursing assessments represented 106 observation (50% new LOINC), and 348 Values (20% New SNOMED CT) organized into fifteen panels (86% new LOINC).

Communicating Nursing Care Using the Health Level Seven Consolidated Clinical Document Architecture Release 2 Care Plan.

A care plan provides a patient, family, or community picture and outlines the care to be provided. The Health Level Seven Consolidated Clinical Document Architecture (C-CDA) Release 2 Care Plan Document is used to structure care plan data when sharing the care plan between systems and/or settings. The American Nurses Association has recommended the use of two terminologies, Logical Observation Identifiers Names and Codes (LOINC) for assessments and outcomes and Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) for problems, procedures (interventions), outcomes, and observation findings within the C-CDA. This article describes C-CDA, introduces LOINC and SNOMED CT, discusses how the C-CDA Care Plan aligns with the nursing process, and illustrates how nursing care data can be structured and encoded within a C-CDA Care Plan.

Nurses' Wisdom in Action in the Emergency Department.

Nurses seek to understand better what practicing with wisdom means and how to apply wisdom to practice; however, the experience of wisdom in nursing has not been well defined or researched. This study was designed to understand how emergency department (ED) nurses construct the meaning of wisdom within the culture of clinical nursing practice. Using Charmaz's constructivist grounded theory methodology, we developed a preliminary theory capturing the experience of wisdom in practice. The core theoretical model focuses on two juxtaposed processes, technical and affective, and is grounded in expertise. Significant findings were the recognition of affective categories, such as emotional intelligence, required to practice using wisdom. Results reinforce and extend the current wisdom literature and provide a new perspective on wisdom in practice in a nursing context.

Harmonizing and extending standards from a domain-specific and bottom-up approach: an example from development through use in clinical applications.

OBJECTIVE: Currently, the processes for harmonizing and extending standards by leveraging the knowledge within local documentation artifacts are not well described. We describe a collaborative project to develop common information models, terminology bindings, and term definitions based on nursing documentation systems, and carry the findings through to the adoption in standards development organizations (SDOs) and technical implementations in clinical applications. MATERIALS AND METHODS: Nursing flowsheet documents from six large organizations were analyzed to generate a common information model and terminologies that fully expressed documentation across all systems, and were sufficient for evidence-based decision support, reporting, and analysis. RESULTS: Significant gaps in existing standards were identified. The models and terminologies were submitted to and incorporated by SDOs, are published, implemented, and now serving as a foundation for an eMeasure. DISCUSSION: There are few examples in the literature of success working through the standards development process from a bottom-up perspective. Subsequently, standards do not yet fully address the need for detailed clinical data that enables, for example, decision support as well as a range of reporting and analytic requirements. Recommendations from this project include transparent processes within SDOs, registries that make models and associated terminologies freely available, and coordinated governance processes. CONCLUSION: We demonstrated the feasibility of using documentation artifacts in a bottom-up approach to develop common models and sets of terms that are complete from the perspective of clinical implementation. Importantly, we demonstrated a process by which a community of practice can contribute to closing gaps in existing standards using SDO processes.

A national action plan for sharable and comparable nursing data to support practice and translational research for transforming health care.

BACKGROUND: There is wide recognition that, with the rapid implementation of electronic health records (EHRs), large data sets are available for research. However, essential standardized nursing data are seldom integrated into EHRs and clinical data repositories. There are many diverse activities that exist to implement standardized nursing languages in EHRs; however, these activities are not coordinated, resulting in duplicate efforts rather than building a shared learning environment and resources. OBJECTIVE: The purpose of this paper is to describe the historical context of nursing terminologies, challenges to the use of nursing data for purposes other than documentation of care, and a national action plan for implementing and using sharable and comparable nursing data for quality reporting and translational research. METHODS: In 2013 and 2014, the University of Minnesota School of Nursing hosted a diverse group of nurses to participate in the Nursing Knowledge: Big Data and Science to Transform Health Care consensus conferences. This consensus conference was held to develop a national action plan and harmonize existing and new efforts of multiple individuals and organizations to expedite integration of standardized nursing data within EHRs and ensure their availability in clinical data repositories for secondary use. This harmonization will address the implementation of standardized nursing terminologies and subsequent access to and use of clinical nursing data. CONCLUSION: Foundational to integrating nursing data into clinical data repositories for big data and science, is the implementation of standardized nursing terminologies, common data models, and information structures within EHRs. The 2014 National Action Plan for Sharable and Comparable Nursing Data for Transforming Health and Healthcare builds on and leverages existing, but separate long standing efforts of many individuals and organizations. The plan is action focused, with accountability for coordinating and tracking progress designated.

Toward an Understanding of Wisdom in Nursing

As nurses, we seek to better understand how to gain nursing 'wisdom' and apply this wisdom in our daily practice. Yet the concept and experience of 'wisdom in nursing practice' has not been well defined. This article addresses wisdom-in-action for nursing practice. We briefly describe nursing theory, review the wisdom literature as presented in various disciplines, and identify characteristics of wisdom by analyzing four models of wisdom from other disciplines. We also present the ten antecedents of wisdom and the ten characteristics of wisdom identified in our analysis of the wisdom literature, discuss and summarize these antecedents, and conclude that understanding these ten antecedents and the ten characteristics of wisdom-in-action can both help nurses demonstrate wisdom as they provide nursing care and teach new nurses the process of becoming wise in nursing practice.

Nurses as knowledge workers: is there evidence of knowledge in patient handoffs?

Patient care handoffs are critical to ensuring continuity of care and patient safety. Current definitions of handoffs focus on information, but preventing errors and improving quality require knowledge. The objective of this study was to determine whether knowledge and wisdom were exchanged during medical and surgical patient care handoffs and to discover how these were expressed. The study was a directed content analysis of 93 handoffs using the data/information/knowledge/wisdom framework. Results indicated knowledge was present in all handoffs, comprising 41% of the phrases across the two types of units. No wisdom was coded. The percentage and types of knowledge phrases differed between medical and surgical units. Handoffs could be more knowledge based by linking handoff content to patient problems and goals. Future handoffs could be computationally derived, context-specific, and linked to problem-focused care plans and patient summaries. Improved data visualization and cognitive support are needed.

Standardized mapping of nursing assessments across 59 U.S. military treatment facilities.

OBJECTIVE: Create an interoperable set of nursing flowsheet assessment measures within military treatment facility electronic health records using the 3M Healthcare Data Dictionary (HDD). DESIGN: The project comprised three phases: 1) discovery included an in-depth analysis of the Essentris data to be mapped in the HDD; 2) mapping encompassed the creation of standard operating procedures, mapping heuristics, and the development of mapping tools; and 3) quality assurance incorporated validation of mappings using inter-rater agreement. RESULTS: Of 569,073 flowsheet concepts, 92% were mapped to the HDD. Of these, 31.5% represented LOINC concepts, 15% represented SNOMED CT and 1% represented both. 52.5% were mapped to HDD concepts with no standardized terminology representations. CONCLUSIONS: Nursing flowsheet data can be mapped to standard terminologies but there is not the breadth of coverage necessary to represent nursing assessments. Future work is necessary to develop a standard information model for the nursing process.

Development of the nursing problem list subset of SNOMED CT®.

OBJECTIVE: To create an interoperable set of nursing diagnoses for use in the patient problem list in the EHR to support interoperability. DESIGN: Queries for nursing diagnostic concepts were executed against the UMLS Metathesaurus to retrieve all nursing diagnoses across four nursing terminologies where the concept was also represented in SNOMED CT. A candidate data set was retrieved and included the nursing diagnoses and corresponding SNOMED CT concepts from the UMLS Metathesaurus. The team members identified the concepts that met the semantic selection criteria for inclusion in the nursing problem list. RESULTS: 1320 concepts were returned in the initial UMLS Metathesaurus query of nursing diagnostic concepts. Further analysis was conducted to identify those nursing diagnostic concepts mapped to SNOMED CT and duplicate concepts were removed resulting in 591 unique UMLS Metathesaurus concepts. The query extracted all concepts from two of the nursing terminologies that contained interventions and outcomes. After cleaning the dataset, the final count of SNOMED CT concepts in the nursing problem list subset is 369. CONCLUSIONS: The problem list is a key component of the patient care and has been acknowledged as critical by the EHR Meaningful Use criteria. Nursing diagnoses on the problem list are foundational for constructing a nursing care plan. A multidisciplinary patient problem list will facilitate communication and evaluation of the contribution of nursing care to the patient's clinical care experiences and outcomes.

Achieving "meaningful use" of electronic health records through the integration of the Nursing Management Minimum Data Set.

OBJECTIVE: To update the definitions and measures for the Nursing Management Minimum Data Set (NMMDS). BACKGROUND: Meaningful use of electronic health records includes reuse of the data for quality improvement. Nursing management data are essential to explain variances in outcomes. The NMMDS is a research-based minimum set of essential standardized management data useful to support nursing management and administrative decisions for quality improvement. METHODS: The NMMDS data elements, definitions, and measures were updated and normalized to current national standards and mapped to LOINC (Logical Observation Identifier Names and Codes), a federally recognized standardized data set for public dissemination. RESULTS: The first 3 NMMDS data elements were updated, mapped to LOINC, and publicly disseminated. CONCLUSIONS: Widespread use of the NMMDS could reduce administrative burden and enhance the meaningful use of healthcare data by ensuring that nursing relevant contextual data are available to improve outcomes and safety measurement for research and quality improvement in and across healthcare organizations.

Translation and integration of CCC nursing diagnoses into ICNP.

The purpose of this study was to translate and integrate nursing diagnosis concepts from the Clinical Care Classification (CCC) System Version 2.0 to DiagnosticPhenomenon or nursing diagnostic statements in the International Classification for Nursing Practice (ICNP) Version 1.0. Source concepts for CCC were mapped by the project team, where possible, to pre-coordinated ICNP terms. The manual decomposition of source concepts according to the ICNP 7-Axis Model served to validate the mappings. A total of 62% of the CCC Nursing Diagnoses were a pre-coordinated match to an ICNP concept, 35% were a post-coordinated match and only 3% had no match. During the mapping process, missing CCC concepts were submitted to the ICNP Programme, with a recommendation for inclusion in future releases.