Use of Theory in Quality Innovations: Shift Change Protocol in the Emergency Department.

BACKGROUND: Inconsistent and nonstandardized patient handoffs can increase the risk of adverse events. Using change theory may promote adoption of effective handoff processes. LOCAL PROBLEM: A Midwest emergency department (ED) had no standardized practice for shift change handoffs. Previous handoff quality improvement efforts had been unsuccessful. METHODS: A pre/postintervention pilot project design was used. Nurses' compliance with the new handoff protocol was evaluated. INTERVENTIONS: Using Diffusion of Innovation (DOI) theory, an evidence-based shift change protocol was designed and implemented, which included a comprehensive handoff tool specific to the ED. RESULTS: Four elements in the new shift change process saw statistically significant improvements after implementation, including discussion of the patient's illness severity ( P = .001), synthesis of the patient's care ( P < .001), completing a bedside safety checklist ( P < .001), and providing a formal transition-of-care process ( P < .001). CONCLUSIONS: Using DOI theory may improve the adoption of new shift change practices.

Harmonising Nursing Terminologies Using a Conceptual Framework.

The International Classification for Nursing Practice (ICNP®) and the Clinical Care Classification (CCC) System are standardised nursing terminologies that identify discrete elements of nursing practice, including nursing diagnoses, interventions, and outcomes. While CCC uses a conceptual framework or model with 21 Care Components to classify these elements, ICNP, built on a formal Web Ontology Language (OWL) description logic foundation, uses a logical hierarchical framework that is useful for computing and maintenance of ICNP. Since the logical framework of ICNP may not always align with the needs of nursing practice, an informal framework may be a more useful organisational tool to represent nursing content. The purpose of this study was to classify ICNP nursing diagnoses using the 21 Care Components of the CCC as a conceptual framework to facilitate usability and inter-operability of nursing diagnoses in electronic health records. Findings resulted in all 521 ICNP diagnoses being assigned to one of the 21 CCC Care Components. Further research is needed to validate the resulting product of this study with practitioners and develop recommendations for improvement of both terminologies.

Harmonizing Nursing Terminologies.

In this paper, the authors report on a study aimed at harmonising two nursing terminologies, the Clinical Care Classification (CCC) and the International Classification for Nursing Practice (ICNP®). As the electronic health record evolves and the need for interoperability extends beyond local and national borders, a degree of standardisation across healthcare terminologies become essential. Harmonising across terminologies results in a) increased consensus relating to domain content and b) improvements in the terminologies involved. Findings from this study suggest that there is much overlap of content in nursing terminologies. The continued harmonisation between nursing terminologies and other healthcare terminologies are recommended to achieve international interoperability.

Modeling a Nursing Guideline with Standard Terminology and Unified Modeling Language for a Nursing Decision Support System: A Case Study.

In recent years, Decision Support Systems (DSSs) have been developed and used to achieve "meaningful use". One approach to developing DSSs is to translate clinical guidelines into a computer-interpretable format. However, there is no specific guideline modeling approach to translate nursing guidelines to computer-interpretable guidelines. This results in limited use of DSSs in nursing. Unified modeling language (UML) is a software writing language known to accurately represent the end-users' perspective, due to its expressive characteristics. Furthermore, standard terminology enabled DSSs have been shown to smoothly integrate into existing health information systems. In order to facilitate development of nursing DSSs, the UML was used to represent a guideline for medication management for older adults encode with the International Classification for Nursing Practice (ICNP®). The UML was found to be a useful and sufficient tool to model a nursing guideline for a DSS.

Challenges associated with the secondary use of nursing data.

There is a prevailing 'collect once, use many times' view of clinical data and its secondary use. This study challenges this view through an assessment of the degree to which the International Classification for Nursing Practice (ICNP) might be used to provide raw data for the Belgian Nursing Minimum Data Set (B-NMDS). A mapping exercise identified exact matches between ICNP and B-NMDS for just 8% of B-NMDS care descriptions; no matches at all for 23%; possible broader matches in ICNP for 55%; possible narrower matches for 8%; and a possible broader and narrower match for 1%. Refining ICNP content and developing and implementing purposive data sets or catalogues that accommodate both ICNP concepts and B-NMDS care descriptions would lay the foundations for the potential re-use of primary ICNP-encoded data in populating the B-NMDS. One unexpected result of the study was to re-affirm the utility of ICNP as a reference terminology.

Collaborative development and maintenance of health terminologies.

The quest for a standardized terminology that can meet the varying needs of healthcare practice, and requirements for secondary use, is ongoing. The number of potential users and the number of potential uses for standardized terminologies make collaborative development, rather than the traditional de jure approach, an imperative, and there appears to be significant worldwide interest in this area. In this article we describe an initiative of the International Council of Nurses (ICN), ICNP C-Space (Collaborative Space), which utilized a social media platform to encourage and facilitate global collaborative development of its terminology, the International Classification for Nursing Practice (ICNP(®)). We report on several years of experience of managing the platform and provide valuable lessons on collaborative terminology development. Our experience suggests that web-based platforms such as ICNP C-Space certainly offer the promise of a broader, wider-reaching, and more inclusive community of contributors to the terminology development process. However, there are also potential limitations for which we provide practical recommendations.

ICNP Catalogues for supporting nursing content in electronic health records.

The purpose of this study was to describe sets of nursing concepts including, for example, nursing diagnoses and interventions, which are knowledge-based and clinically relevant to support nursing practice. Health information systems using the International Classification for Nursing Practice (ICNP®) provide a platform for standardized nursing documentation for patients' health care, clinical decision support, and repositories for re-use of clinical data for quality evaluation, research, management decisions and policy development. Clinically relevant sets of ICNP concepts can facilitate implementation of health information systems for nursing. Descriptive analysis was used to examine the types of, and relationships among, existing nursing content sets. Findings included the need for various types of content sets, as represented in ICNP catalogues, for nursing documentation. Five types of ICNP Catalogues included Care Plans, Order Sets, Clinical Templates, Nursing Minimum Data Sets, and Terminology Subsets.

NI2012 Classification of Reasons for Hospital Readmission.

Hospital readmission is a focus of efforts to improve quality and reduce cost in our healthcare system. Use of a standard readmission classification in a clinical information system would facilitate examination and analysis of reasons for hospital readmission and provide direction for targeting interventions. The purpose of this quality improvement project was to examine coverage of reasons for readmission in three existing classification schemes compared with a "gold standard" conceptual framework. Data were obtained from five data sources about reasons for readmission for a select group of patients using a modified Institute for Healthcare Improvement (IHI) tool. Both the structure and the level of granularity of the three classifications had an impact on the classification of reasons. Between 53% and 65% of the reasons for readmission could be coded in the three readmission classifications, leaving 35% to 47% of the reasons uncoded, when compared with the conceptual framework.

A dynamic classification approach for nursing.

Nursing has a long tradition of classification, stretching back at least 150 years. The introduction of computers into health care towards the end of the 20(th) Century helped to focus efforts, culminating in the development of a range of standardized classifications. Many of these classifications are still in use today and, while content is periodically updated, the underlying classification structures remain relatively static. In this paper an approach to classification that is relatively new to nursing is presented; an approach that uses formal Web Ontology Language definitions for classes, and computer-based reasoning on those classes, to determine automatically classification structures that more flexibly meet the needs of users. A new proposed classification structure for the International Classification for Nursing Practice is derived under the new approach to provide a new view on the next release of the classification and to contribute to broader quality improvement processes.

Mapping nursing concepts to ontologies for evidence-based nursing.

In this paper we describe a project to map natural language expressions of nursing-related concepts to standard ontologies in support of an evidence-based nursing initiative. Natural language concept expressions are identified from syntheses of nursing knowledge and mapped to ICNP and SNOMED-CT.