Diagnóstico de enfermagem síndrome de terminalidade em idosos com demência avançada: mapeamento cruzado / Nursing diagnosis of terminal syndrome in elderly with advanced dementia: cross mapping / Diagnóstico de enfermería del síndrome terminal en ancianos con demencia avanzada: mapeo cruzado

Objetivo: identificar elementos da Síndrome de terminalidade a partir do cruzamento de termos registrados pelos enfermeiros no cuidado ao fim de vida em idosos com demência avançada. Método: estudo observacional, retrospectivo, da ferramenta metodológica mapeamento cruzado. Foram coletados registros dos últimos 10 dias de vida de 38 prontuários de pessoas com demência avançada. Resultados: foram identificados 97 termos de respostas humanas, e através do mapeamento cruzado, foram elencados 22 diagnósticos de enfermagem, desses 11 diagnósticos de enfermagem apresentaram relevância estatística em 50% ou mais dos pacientes e oito diagnósticos de enfermagem apresentaram-se relevantes estatisticamente quando avaliados de acordo com a prevalência nas 380 observações. A Síndrome de terminalidade foi verificada em todas 380 avaliações, em média 7,5 diagnósticos da síndrome foram observados. Conclusão: a alta prevalência da Síndrome de terminalidade sustenta a inclusão do diagnóstico de enfermagem na Taxonomia II da NANDA-I, dado que os enfermeiros já a observam e a registram em sua prática(AU)

Objective: to identify elements of Terminal Syndrome by cross-referencing terms recorded by nurses providing end-of-life care for elderly people with advanced dementia. Method: in this retrospective, observational study, using a cross-mapping methodological tool, records of the last 10 days of life were collected from 38 medical records of people with advanced dementia. Results: 97 human-response terms were identified, and by cross-mapping, 22 nursing diagnoses were listed; of these, 11 nursing diagnoses displayed statistical importance in 50% or more of the patients, while eight nursing diagnoses were statistically important when assessed by prevalence in the 380 observations. Terminal Syndrome was found in all 380 evaluations, averaging 7.5 diagnoses of the syndrome. Cases were observed Conclusion: the high prevalence of Terminal Syndrome supports the inclusion of this nursing diagnosis in the NANDA-I Taxonomy II, as nurses already observe and record in practice(AU)

Objetivo: identificar elementos del síndrome terminal mediante términos de referencia cruzada registrados por enfermeras que brindan atención al final de la vida a personas mayores con demencia avanzada. Método: en este estudio observacional retrospectivo, utilizando una herramienta metodológica de mapeo cruzado, se recolectaron registros de los últimos 10 días de vida de 38 historias clínicas de personas con demencia avanzada. Resultados: Se identificaron 97 términos de respuesta humana y, mediante mapeo cruzado, se enumeraron 22 diagnósticos de enfermería; de estos, 11 diagnósticos de enfermería mostraron importancia estadística en el 50% o más de los pacientes, mientras que ocho diagnósticos de enfermería fueron estadísticamente importantes cuando se evaluaron por prevalencia en las 380 observaciones. El síndrome terminal se encontró en las 380 evaluaciones, con un promedio de 7,5 diagnósticos del síndrome. Se observaron casos Conclusión: la alta prevalencia de Síndrome Terminal apoya la inclusión de este diagnóstico de enfermería en la Taxonomía II de NANDA-I, ya que las enfermeras ya observan y registran en la práctica(AU)

Satisfacción de las enfermeras de Osakidetza con las aplicaciones móviles para el cuidado enfermero / Satisfaction among Osakidetza nurses with mobile applications for nursing care

OBJETIVO: explorar la satisfacción de las enfermeras de Osakidetza con las aplicaciones informáticas móviles para el cuidado enfermero, así como su valoración sobre la formación recibida para su utilización, la facilidad de su uso, las características de la información gestionada y el impacto sobre el cuidado del paciente. MÉTODO: estudio descriptivo transversal. Población objeto de estudio: enfermeras de Osakidetza que trabajaban con aplicaciones informáticas móviles. VARIABLES: sociodemográficas y laborales, de usabilidad, formación y soporte recibidos, impacto, satisfacción con las aplicaciones móviles incluidas. Fueron recogidas mediante cuestionario diseñado adhoc. Se realizó un análisis estadístico descriptivo y un análisis bivariantes, mediante el test Chi cuadrado. RESULTADOS: se recibieron 518 cuestionarios (33,5%). El 37,8% refirió satisfacción a nivel general con las aplicaciones utilizadas, el 27,2% mayor agilidad al efectuar el trabajo con tableta y el 36,1% una mejor realización del trabajo. La aplicación con mayor satisfacción fue la que facilita el registro de constantes (61,8%). Un 74,8% refirió impacto positivo sobre la seguridad del paciente. Se encontraron diferencias estadísticamente significativas según la función desempeñada (mayor satisfacción en las enfermeras gestoras; p= 0,023), según nivel de utilización en la vida diaria (mayor satisfacción en utilización media y alta; p= 0,036), y en función del turno de trabajo (mayor satisfacción en turno fijo; p= 0,021). CONCLUSIONES: el nivel de satisfacción con las aplicaciones móviles para el cuidado es discreto. Para conocer el impacto de estas herramientas y la satisfacción general con ellas, se recomienda ser valoradas cuando el despliegue realizado en las organizaciones esté consolidado

OBJECTIVE: to explore the satisfaction among Osakidetza nurses with the mobile applications for nursing care, as well as their evaluation of the training received for their use, ease of use, characteristics of the information managed, and impact on patient care. METHOD: a descriptive cross-sectional study. Population object of the study: Osakidetza nurses working with mobile applications. VARIABLES: sociodemographical and occupational, usability, training and support received, impact, satisfaction with the mobile applications included; these were collected through a questionnaire designed ad hoc. Descriptive statistical analysis was conducted, as well as bivariate analysis, through Chi Square Test. RESULTS: in total, 518 questionnaires (33.5%) were received; 37.8% reported overall satisfaction with the applications used, 27.2% reported that working with the tablet was faster, and 36.1% stated that their work was better conducted. The application with the highest satisfaction level was the one that provides vital sign records (61.8%); 74.8% of participants reported a positive impact on patient safety. Statistically significant differences were found depending on the role played (higher satisfaction among nurse managers; p= 0.023), according to the level of use in daily life (higher satisfaction in medium and high use; p= 0.036), and based on the working shift (higher satisfaction in regular shifts: p= 0.021). CONCLUSIONS: there is a moderate level of satisfaction with mobile applications for patient care. In order to understand the impact of these tools and the overall satisfaction with them, it is recommended to assess them once the display conducted in agencies has been firmly established

Documented Nursing Interventions in Inpatient Psychiatry.

PURPOSE: This study explored how well the Nursing Interventions Classification (NIC) covers adult inpatient psychiatric care. METHODS: By systematic analyses and a mapping approach, documented nursing interventions were assessed on concurrencies with the NIC. FINDINGS: From 2,153 intervention descriptions in nursing notes, 1,924 were recognizable as NIC interventions, and 229 did not match the NIC. 89.4% of all identified descriptions of interventions were recognizable as NIC interventions on the level of definition. CONCLUSIONS: This study demonstrates that the NIC describes adult inpatient psychiatric care to a large extent. Nevertheless, further development of the classification is important. PRACTICE IMPLICATIONS: The study results provide a basis for further developing the NIC and to reinforce its use in inpatient psychiatric settings.

El desarrollo del lenguaje enfermero produce avances / Nursing language development achieves breakthroughs

La importancia de los lenguajes enfermeros estandarizados (LEE) ya no se pone en duda en nuestro país. Utilizar un lenguaje normalizado para documentar la práctica permite comparar y evaluar la efectividad de los cuidados suministrados en múltiples situaciones y por distintos profesionales de la enfermería. Además, en el ámbito educativo en España, los currículos recogen la necesidad de que las enfermeras tengan competencias específicas respecto a los LEE y el proceso enfermero. En este sentido, habría que destacar el papel de la NANDA- I, que comenzó a codificar, agrupar y dar nombre a los diagnósticos de enfermería dentro de una taxonomía lógica. El lenguaje del cuidado, del aprendizaje del autocuidado, de la autonomía del otro, supuso un cambio también en la percepción que tenían de la enfermería otros profesionales de la salud y la población en general. En los últimos veinticinco años, se ha tratado el desarrollo teórico y práctico de los cuidados de enfermería y de su lenguaje preciso y unificado. En España, en estas aportaciones, destacaron especialmente numerosas profesoras de las escuelas de enfermería que han abierto las puertas a conocimientos nuevos e impulsado la renovación de la enfermería, y también un gran número de enfermeras clínicas de centros conosanitarios que, en los distintos niveles de atención, han tenido el empeño de trabajar con procesos de enfermería, con diagnósticos enfermeros y, ahora, con las nuevas taxonomías enfermeras (NOC, NIC). Juntas, han hecho un buen trabajo para estimular la utilización de un lenguaje común y para impulsar el despliegue práctico de las nuevas aportaciones teóricas para mejorar los cuidados de enfermería. El empleo de terminologías estandarizadas se considera un requisito previo imprescindible para la historia clínica electrónica (HCE), de la cual forma parte el plan de cuidados de enfermería. El progreso de la profesión enfermera pasa necesariamente por la insistencia en la formación y el trabajo moderno de la enfermería, y la investigación con los LEE (AU)

The importance of standardised nursing languages (SNLs) is no longer questioned in our country. Using a standardised language to document practice enables comparison and assessment of the effectiveness of care provided in multiple situations and by different nursing professionals. In addition, curriculums in the Spanish educational field pick up on the need for nurses to possess specific competence with regard to SNLs and the nursing process. Accordingly, it is necessary to highlight the role of NANDA-I, which is starting to codify, group and give a name to nursing diagnoses within a logical taxonomy. The language used in care, in the learning process of self-care, and for the autonomy of the other, represents a change too in how nursing is perceived by other health professionals and the population. In the past 25 years, the theoretical and practical development of nursing care and its precise, unified language have been addressed. In Spain, this input particularly comes from numerous teachers in nursing schools that have opened the doors to new knowledge and fostered the renewal of nursing. It also includes a large number of clinical nurses from health centres who, in the different levels of care, are committed to working with the nursing process, nursing diagnoses and now with the new nursing taxonomies (NOC, NIC). Together, they have done a good job in stimulating the use of a common language and fostering the practical deployment of the new theoretical contributions for the improvement of nursing care. The use of standardised terminology is considered an absolute prerequisite for the electronic medical record (EMR) of which the nursing care plan forms part of. Nursing profession’s progress necessarily involves persisting with training, modern nursing work and research on SNLs (AU)

Rationale for Quantification in Nursing Services Using the International Council of Nurses Nurse-Patient Summary.

This review provides evidence that new data from nurses meets criteria that explains variation in hospital charges, length of hospital stay and end results of hospital care compared with ICD data; that nurses' data can be used to evaluate assignments of nurses to patients; that new data properly distinguishes patients' human needs within ICD categories. These new data are derived from the professional literature indexed and synthesized by Henderson. It is proposed to adopt the ICN-NPSum to standardize quantification in nursing services.

Information Content Across Types of Nurse Cognitive Artifacts.

Acute care nurses commonly use personalized cognitive artifacts to organize information during a shift. The purpose of this content analysis is to compare information content across three formats of cognitive artifacts used by acute care nurses in a medical oncology unit: hand-made free-form, preprinted skeleton, and EHR-generated. Information contained in free-form and skeleton artifacts is more tailored to specific patient context than the NSR. Free-form and skeleton artifacts provide a space for synthesizing information to construct a "story of the patient" that is missing in the NSR. Future design of standardized handoff tools will need to take these differences into account for successful adoption by acute care nurses, including tailoring of information by patient, not just unit type, and allowing a space for nurses to construct a narrative describing the patients "story."

Using a Text-Mining Approach to Evaluate the Quality of Nursing Records.

Nursing records in Taiwan have been computerized, but their quality has rarely been discussed. Therefore, this study employed a text-mining approach and a cross-sectional retrospective research design to evaluate the quality of electronic nursing records at a medical center in Northern Taiwan. SAS Text Miner software Version 13.2 was employed to analyze unstructured nursing event records. The results show that SAS Text Miner is suitable for developing a textmining model for validating nursing records. The sensitivity of SAS Text Miner was approximately 0.94, and the specificity and accuracy were 0.99. Thus, SAS Text Miner software is an effective tool for auditing unstructured electronic nursing records.

Adequação da linguagem de enfermagem a prática com idosos residentes em uma instituiçãopsiquiátrica de longa permanência: mapeamento cruzado / Adecuación del lenguaje de enfermería a la práctica con los ancianos residentes en una instituciónpsiquiátrica de largo plazo: mapeo cruzado / Adequacy of nursing language to the practice with elderly residents in a long term psychiatric institution: cross mapping

Objective: to map the free terms of nursing records and compare with the Nursing Diagnosis classification. Method: quantitative, documentary and retrospective approach, cross mapping type. There were 30 medical records analyzed of elderly women with psychiatric disorders living in two long-term institutions. The data collection took place in from August 2013 to March 2013 in two stages. Results: diagnostics more occurring were: ineffective health self-control; Impaired swallowing; Self-care deficit for intimate and bath hygiene; Impaired physical mobility; Decreased cardiac output; Ineffective peripheral tissue perfusion; Chronic confusion; Dysfunctional family processes; Teething impaired and falls risk. They are related to the physiological and biopsychosocial aspects. Conclusion: this findings point to the complexity and comprehensiveness of care provided in the context of mental health, using classification systems in this context to contribute to the advancement of knowledge and to compare them.

Objetivo: mapear os termos livres dos registros de enfermagem e comparar com a classificação de Diagnósticos de Enfermagem. Método: abordagem quantitativa, documental e retrospectiva, do tipo mapeamento cruzado. Foram analisados 30 prontuários de idosas com doenças psiquiátricas, residentes em duas casas de longa duração. A coleta e análise dos dados ocorreu em agosto de 2013 a março de 2014 em quatro etapas. Resultados: os diagnósticos com maior ocorrência foram: Autocontrole ineficaz de saúde; Deglutição prejudicada; Déficit no autocuidado para higiene íntima e banho; Mobilidade física prejudicada; Débito cardíaco diminuído; Perfusão tissular periférica ineficaz; Confusão crônica; Processos familiares disfuncionais; Dentição prejudicada; e Risco de quedas, os quais estão relacionados tanto aos aspectos fisiológicos quanto biopsicossociais. Conclusão: tais achados apontam para a complexidade e a integralidade do cuidado prestado no contexto da saúde mental, o uso de sistemas de classificação nesse contexto contribuirá para o avanço do conhecimento e a comparação destes.

Objetivo: mapear los términos libres de los registros de enfermería y comparar con la clasificación de Diagnósticos de Enfermería. Método: enfoque cuantitativo, documentario y retrospectivo, del tipo mapeado cruzado. Fueron analizados 30 registros de ancianos con enfermedades psiquiátricas, residentes en dos casas de larga duración. La recolección y análisis de los datos fueron en agosto de 2013 a marzo de 2014 en cuatro etapas. Resultados: los diagnósticos con mayor ocurrencia fueron: Autocontrol ineficaz de salud; Deglución perjudicada; Déficit en el autocuidado para higiene íntima y baño; Movilidad física perjudicada; Débito cardíaco disminuido; Perfusión tisular periférica ineficaz; Confusión crónica; Procesos familiares disfuncionales; Dentición perjudicada; y Riesgo de caídas, los cuales están relacionados tanto a los aspectos fisiológicos como a los biopsicosociales. Conclusión: tales hallados apuntan para la complexidad y la integralidad del cuidado prestado en el contexto de la salud mental, el uso de sistemas de clasificación en ese contexto contribuirá para el avance del conocimiento y la comparación de estos.

Usability of the Clinical Care Classification System for Representing Nursing Practice According to Specialty.

This study examined the ability of the Clinical Care Classification system to represent nursing record data across various nursing specialties. The data comprised nursing care plan records from December 1998 to October 2008 in a medical center. The total number of care plan documentation we analyzed was 2 060 178, and we used a process of knowledge discovery in datasets for data analysis. The results showed that 75.42% of the documented diagnosis terms could be mapped using the Clinical Care Classification system. However, a difference in nursing terminology emerged among various nursing specialties, ranging from 0.1% for otorhinolaryngology to 100% for colorectal surgery and plastic surgery. The top five nursing diagnoses were identified as knowledge deficit, acute pain, infection risk, falling risk, and bleeding risk, which were the most common health problems in an acute care setting but not in non-acute care settings. Overall, we identified a total of 21 established nursing diagnoses, which we recommend adding to the Clinical Care Classification system, most of which are applicable to emergency and intensive care specialties. Our results show that Clinical Care Classification is useful for documenting patient's problems in an acute setting, but we suggest adding new diagnoses to identify health problems in specialty settings.

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.

Are we talking about the same patient?

The objective of this study is to determine the degree of similarities between the clinical terms used by physicians and nurses in their documentation.

Valoración enfermera de las Urgencias Pediátricas en Atención Primaria. Calidad del registro y satisfacción de usuarios y profesionales con el sistema VEUPAP / Nurse pediatric emergency valuation in primary care: quality record and patients and nurses satisfaction with tool VEUPAP

Objetivo. Valorar el grado de cumplimentación del registro VEUPAP y el nivel de satisfacción de los acompañantes de los niños y de las enfermeras con este sistema. Diseño. Estudio transversal descriptivo. Se valoró la cumplimentación del registro de forma global y específica por la enfermera según criterios de calidad definidos. La satisfacción de los acompañantes se valoró con el cuestionario AMABLE, la de las enfermeras con el CSLPS-EAP y la realización personal en el trabajo con el Maslach Bornout Inventory (MBI) en su versión validada en castellano. Resultados. Se evaluaron 266 casos registrados con VEUPAP. El cumplimiento general de los ítems supera el 95 % (92-98%), excepto en dificultad respiratoria, gastrointestinal y dolor abdominal, con 93 % (90-96 %), 90 % (86-94 %) y 67 % (61-73 %), respectivamente. Supera el 95 % (93-97 %) los usuarios que refieren estar satisfechos con la atención enfermera. El cien por cien de las enfermeras están muy satisfechas con sus tareas y actividades y la realización personal que consiguen; el 88 % (84-92 %) con la calidad de atención a los pacientes y logro de objetivos. Todas se sienten bastantes satisfechas con su grado de autonomía. La inestabilidad laboral supone un 50 % (44-56 %) de insatisfacción. El agotamiento emocional (AE) es bajo para el 94 % de las enfermeras y medio para el 6 %, la despersonalización (DP) alta para 17 % y baja para el 13 %, y la realización personal (RP) baja para el 53 % y media para el 47 %. Conclusiones. Calidad de registro, satisfacción del usuario y de la enfermera son tres piedras angulares de la atención pediátrica de Urgencias. VEUPAP incide de manera positiva sobre estos tres aspectos (AU)

Objective. To value the degree of completion of VEUPAP record, the level of satisfaction of the accompanists of children with nursing care and nurse satisfaction. Design. Descriptive study. There was valued the cumplimentation of record of global and specific form by nurse according to defined quality criteria. The satisfaction of the accompanists was valued by the AMABLE questionnaire, the nurses satisfaction with the use of VEUPAP by the CSLPS-EAP and the personal accomplishment in the work by the MBI in his validated spanish version. Results. 266 VEUPAP cases were evaluated. The general compliance of the items exceeds 95(92-98) %, except for three items. Completion of protocols fever, respiratory distress, gastrointestinal, and abdominal pain is 95(92-98) %, 93(90-96) %, 90(86-94) % and 67(61-73) % respectively. More than 95(93-97) % users referring to be satisfied with the nurses attention. The 100(100-100) % of the nurses are very satisfied with their tasks and activities and personal accomplishment they get, 88(84-92) % with the quality of patient care and achievement of objectives. All feel quite satisfied with their degree of autonomy. Job instability represents 50(44-56) % of dissatisfaction. The EE is low for 94% of nurses and a medium for 6 %, the DP high for 17 % and low for 13 % and the PA low for 53 % and medium for 47 %. Conclusions. Quality of registration, user satisfaction and the nurse who provides care satisfaction are three cornerstones of pediatric emergency care. VEUPAP impacts positively on these three aspects (AU)

Registros enfermeros. Contribución a la seguridad del paciente y a la visualización de la disciplina enfermera / Nursing records. Contribution to the security of patient and visualizing of the discipline of nursing

Los registros enfermeros conforman la historia de enfermería de un paciente con el objetivo de dejar constancia de la atención prestada y de la evolución de la persona desde la mirada holística que identifica la profesión. Estos registros tienen un contexto legal, profesional y de seguridad que deben cumplir. También a través de la escritura se puede inferir la visión que de la profesión tiene el profesional/escritor. En este artículo se analizan algunas expresiones extraídas de registros enfermeros de unidades de cuidados paliativos tomando como referencia los elementos contextuales nombrados. Se concluye que se debería prestar más atención a esta actividad, que es una obligación profesional y un derecho del paciente, para dotar a los registros enfermeros de información objetiva, clara, sin ambigüedades ni interpretaciones erróneas, y que refleje la aportación específica de la enfermería a la sociedad (AU)

The nursing records conform the clinical history of a patient with the aim to bring evidence of care provided by professional as well as to bring evidence of evolution of a person from a holistic point of view that identifies the profession. These records have a legal, professional and security contexts that ought to be fulfilled. In addition, with help of record keeping it is possible to infer a vision of the profession that was transmitted by the author. This article discusses the qualitative data based on various expressions extracted from the nursing records of palliative care units, taking as a reference the contextual elements that were named above. It concludes that it’s important to give more attention to this activity as it presents a professional obligation and belongs to patient’s rights. The current research stresses the importance to have the nursing records updated with the objective information, clear, without ambiguities or misinterpretations, and which can evidence the specific contribution of nursing to the society (AU)

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.

Discovering health knowledge in the BC nurse practitioners encounter codes.

Integrating the Nurse Practitioner (NP) role into clinical practice settings is new in British Columbia (BC), Canada. Encounter codes are unique numeric codes assigned to specific types of patient care services performed by NPs. In this study we apply knowledge discovery techniques to analyze the encounter codes extracted from the BC Ministry of Health database to understand the most common practice activities carried out by NPs and what diseases patients sought care for from NPs. The analysis produced important information about NPs' practice patterns. This work leads to a better understanding of NP practice patterns in BC.

Korean hospice nursing interventions using the Nursing Interventions Classification system: a comparison with the USA.

In this study, nursing interventions used by hospice nurses in Korea were identified and compared with core interventions selected by US end-of-life care nurses in order to determine similarities and differences between the two nations regarding such care. Data were collected from the electronic medical records of 353 hospice patients admitted to a tertiary hospital in Korea over a period of two years. First, extracted narrative interventions were mapped onto the Nursing Interventions Classification for comparison with interventions selected by nurses in the USA. A total of 56,712 intervention statements were mapped onto 147 Nursing Interventions Classification interventions. Hospice nurses in Korea performed more nursing interventions in the physiological basic domain, compared to nurses in the USA. The most frequently-used interventions in Korea were related to patient pain management. Among 47 core Nursing Interventions Classification interventions used in the USA, only 18 were used by Korean nurses in this study. This study highlights cultural differences in hospice care nursing interventions between the two countries.

DPC in acute-phase inpatient hospital care. Visualization of amount of nursing care provided and accessibility to nursing care.

OBJECTIVE: The purpose of this study was to improve accessibility to nursing care by clarifying the relationship between patient characteristics and the amount of nursing care for the Diagnosis Procedure Combination system (DPC). METHOD: The subjects included 528 lung cancer patients; 170 gastric cancer patients; and 91 colon cancer patients, who were hospitalized from July 1, 2008, to March 31, 2010, at a university hospital. The patients were categorized into groups according to factors that could affect the amount of nursing care. Next, the relationship between the patient characteristics and the amount of nursing care was analyzed. Then the results from this study were used to classify patient characteristics according to the patient type and the amount nursing care required. RESULTS: The patient characteristics, which affected the amount of nursing care, varied according to each DPC code. The major factors affecting the amount of nursing care were whether the patient had received a surgical (under general anesthetics) treatment or a non-surgical treatment and the level of activities of daily living (ADL) of the hospitalized patients. For those who had received a surgical operation for colon cancer, the patient's age also affected the amount of nursing care. CONCLUSIONS: The findings show that the method for the visualization of the amount of nursing care based on the classification of patient characteristics can be implemented into the electronic health record system. This method can then be used as a management tool to assure appropriate distribution of nursing resources.

A pilot study to explore the feasibility of using theClinical Care Classification System for developing a reliable costing method for nursing services.

While nursing activities represent a significant proportion of inpatient care, there are no reliable methods for determining nursing costs based on the actual services provided by the nursing staff. Capture of data to support accurate measurement and reporting on the cost of nursing services is fundamental to effective resource utilization. Adopting standard terminologies that support tracking both the quality and the cost of care could reduce the data entry burden on direct care providers. This pilot study evaluated the feasibility of using a standardized nursing terminology, the Clinical Care Classification System (CCC), for developing a reliable costing method for nursing services. Two different approaches are explored; the Relative Value Unit RVU and the simple cost-to-time methods. We found that the simple cost-to-time method was more accurate and more transparent in its derivation than the RVU method and may support a more consistent and reliable approach for costing nursing services.