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The purpose of this study was to explore nurses' perceptions of the strengths and limitations of standardized nursing languages in the electronic health record to communicate a clinical event. Limited examples of research exist exploring the effectiveness of the electronic health record with embedded standardized nursing languages as a communication system. Therefore, their effect of standardized nursing languages on nurse-to-nurse communication remains largely unknown. Data from a larger study were analyzed using qualitative content analysis. Fifty-seven thematic units represented nurses' perceptions of the electronic health record with NANDA, NIC, and NOC for documenting and retrieving patient information associated with a clinical event. These thematic units were further analyzed, and three categories emerged: language comprehension, inexactness of the languages, and language usefulness. Standardized nursing languages were perceived to support planning care but also posed semantic challenges and fostered inaccuracies in patient information. Standardized nursing languages may constrain nurse-to-nurse communication related to a clinical event. For languages to support nurse-to-nurse communication and avoid potential safety issues, facilities must deal with inaccuracies and semantic misunderstandings to provide safe patient care.
The electronic health record (EHR) has been recommended by a variety of sources, for example, the Institute of Medicine, as a means to increase patient safety.1 Standardized nursing languages have also been suggested; however, their usefulness has not been assessed. The EHR with embedded standardized nursing languages (EHRSNL) potentially strengthens nursing documentation from paper-based systems in two very important ways. First, the EHR has been associated with more accurate and timely documentation. This documentation generally includes evaluating the effectiveness of care, describing patients' responses to interventions, communicating patient status, and meeting legal documentation requirements.2-4 Second, standardized nursing languages were created to enhance nursing documentation by increasing clarity and reducing ambiguity.5
Nurses are the primary users of the EHRSNL as they enter information each shift and when a clinical event or change in a patient's condition occurs. There are limited examples of research exploring nurse-to-nurse communication using standardized nursing languages. This article reports on research seeking to increase our understanding of nurses' perceptions of the strengths and limitations of standardized nursing languages as part of the EHR to communicate patient status associated with a clinical event.
Standardized nursing languages are used by nurses to describe their care.6 Examples of approved nursing languages include NANDA, NIC, and NOC.7,8 Research exploring the usefulness of standardized nursing languages has suggested that there are four ways languages can improve healthcare: (1) support nursing data comparisons for benchmarking at local, regional, national, and international levels; (2) provide valuable information to the healthcare organization regarding patient care for administrative decision making; (3) determine patient acuity by extracting data from a clinical database; and (4) improve communication among healthcare team members through the use of consistent terms for the description of assessments, interventions, and outcomes.5,9-13
Research applicable to both paper-based and electronic documentation systems has suggested that standardized nursing languages have limitations. Standardized nursing languages have been reported to be difficult to use because of the lack of complete alignment between terms nurses traditionally use in documentation and the terms used in standardized nursing language.9,11,14,15 Furthermore, it has been suggested that standardized nursing languages reduce the "individualized" focus of patient documentation.16 Standardized nursing languages therefore may not fully capture the subtle changes in patient status needed by nurses to accurately describe patient care and patient outcomes.
This study addresses standardized nursing languages as a vehicle for communication of a clinical event between members of the healthcare team, by examining nurse-to-nurse communication in terms of the perceived strengths and limitations of electronic documentation supported by standardized nursing language.
Effective communication between nurses during patient handoffs has the potential to decrease risks to patient safety. Failure to rescue, a risk to patient safety, is defined as patient deaths associated with a complication from treatment.17Antecedents to failure to rescue are high patient-to-nurse staffing ratios, chaotic work environment, nurse work dissatisfaction, and ineffective nurse-physician collaboration.18-20 Nurse-to-nurse communication as an antecedent to failure to rescue is not well understood. This study explored nurse-to-nurse communication by eliciting nurses' perceptions of standardized nursing languages as a communication system, when entering or retrieving patient information in an EHR associated with a clinical event. A clinical event is defined as an unexpected change in patient condition that does not result in a patient transfer and is not associated with a nursing protocol.21
Elements of Information Theory served as the conceptual framework for this study.22 These elements are information source, device, destination, redundancy, probability, and noise. The information source produces the message using a device consisting of a transmitter, channel, and receiver. The message is intended for the destination or receiver.
Redundant or repetitious messages are often sent using both verbal and written communication. Redundancy may prevent errors through duplication of the message.23,24 Nurse-to-nurse communication, nurse documentation, and change of shift report are inherently redundant. Content from patient assessments and progress notes are often repeated verbally during nurse change of shift report. Redundancy increases information. Probability, a measure of predictability, allows the receiver to act on the information received without presuming more than what is transmitted.25
Noise, on the other hand, may have occurred when nursing documentation and change of shift report do not contain useful or understandable information. Noise disrupts communication and is evident when the message either does not reach the intended destination (message may be lost) or reaches the destination and is not understandable.26 Noise decreases information.
For this research, the information source is the documenting nurse, and the device is the nursing languages embedded in the EHR. The message destination is the receiving nurse. Redundancy and noise were operationalized for this research as the nurses' perceptions of the strengths and limitations of the nursing languages, respectively.
This research is part of a study on nursing documentation and has been previously described in detail.21,27 In this study, documenting and receiving nurses were interviewed using a semistructured interview format. Thirty-seven nurses (20 documenting and 17 receiving nurses) from two sites were interviewed for the larger study. This report involves only the site using standardized nursing languages (EHRSNL), NANDA, NIC, and NOC. Text from 18 interviews (10 documenting and eight receiving nurses) was reviewed.
Qualitative content analysis was used to analyze the interview text. Nurses were interviewed from December 2007 to January 2008. Institutional review boards from the University of Arizona and the research sites granted permission to perform the study.
Nursing diagnosis (NANDA), nursing interventions (NIC), and nursing outcomes (NOC) were embedded in the EHR. The researchers approached the EHR at the conceptual level; therefore, the system name is intentionally not identified. Inclusion criteria for informants were RNs who (1) worked full time on the medical, surgical, or telemetry nursing unit; (2) had experience using the electronic nursing documentation system for at least 3 months; (3) understood and spoke English; and (4) cared for or assumed care for a patient who experienced a clinical event within the past 24 hours.
The researcher learned of a clinical event through communication with the charge nurses or other staff nurses on daily visits to the nursing units. When informed of a clinical event, the researcher approached the documenting nurse (RN caring for the patient who experienced the clinical event) and receiving nurse (RN receiving information to continue care) to participate in the study. Interviews were done within 8 to 12 hours after the clinical event. Documenting and receiving nurses were recruited as individuals, rather than dyads.
Interviews took place in an isolated area selected by the participant and required 20 to 30 minutes to complete. Each interview was digitally recorded, transcribed verbatim, and reviewed for accuracy prior to analysis. Data collection was discontinued when saturation was reached or no new themes emerged. Documenting nurses were asked how the nursing languages made it easy and/or difficult to document the clinical event and receiving nurses how easy and/or difficult to learn of the clinical event.
Eighteen nurses (10 documenting and eight receiving nurses) met the inclusion criteria and consented to participate in the study. Participants included six men and 12 women. Nurses had worked in a hospital for a mean of 10.33 +/- 9.5 years (range, 1-30 years). The participants had a mean of 3.04 +/- 2.37 years (range, 0.75-9.50 years) of experience working on the nursing unit. Nurses used the EHR for 5.94 +/- 4.45 years (range, 1.0-16.0 years). Nurses averaged more than 5 years (5.15 +/- 5.45 years) of experience using nursing languages (range, 0.75-20 years).
Eleven clinical events were captured for this study. The most frequent were changes in the level of mental status and drop in hemoglobin and hematocrit (two events each). Seven additional clinical events occurred once: fever, pain, fall, seizure activity, patient was emotional, low blood pressure, and intravenous catheter too small.
Qualitative content analysis was used to view data from its smallest unit or data bit, to the thematic unit or a data-organizing element. For this research, 99 pages of text data were analyzed. Fifty-seven thematic units specific to nursing languages emerged. The thematic units were then organized into categories and subcategories, and frequencies of thematic units and nursing citing themes were calculated.28,29 Categories and subcategories were reviewed by two experts, doctorally prepared informatics and nursing systems researchers with qualitative research experience, until 100% agreement was achieved.
Calculating the frequency of the number of thematic units (t) and number of nursing citing (n) the theme can provide some insight into the nurses' perceptions. Redundancy of data, or when themes are repeated by the same participant or many participants beyond saturation,30 made it difficult to determine the importance of the thematic units from the simple frequencies. Therefore, "degree of redundancy" (DOR) statistic was calculated based on the work of Miles and Huberman.31,32 The DOR, as previously described, was used to discuss proportional relationships among the number of emergent thematic units and the proportion of nurses who cited the theme.27 The DOR was calculated by (1) identifying the frequencies of the thematic unit (t) and the nurse citing each theme (n); (2) calculating the theme/sample ratio or (t/n), by dividing the frequency of thematic units (t) by the number of nurses citing (n) the thematic unit; and (3) proportioning the sample by dividing the number of nurses citing (n) the thematic unit by the total sample size (number of nurses interviewed) (N) or (n/N). The final values were multiplied to arrive at the DOR calculation (t/n x n/N). A DOR of 0.50 or greater was used to represent a strong category or subcategory. Three categories emerged from 57 thematic units: language comprehensiveness, inexactness of the languages, and language usefulness.
Thematic units were organized by similarities and then categorized. Both categories, language comprehensiveness and inexactness of the languages, were large and further organized into three subcategories: professional separation, care planning, and ease of use (language comprehensiveness) and lacks descriptiveness, fosters inaccuracies, and semantics (inexactness of the languages). The category language usefulness did not contain subcategories. Table 1 shows the thematic units that led to the organization of categories and subcategories.
Language comprehensiveness accounted for 23 thematic units or 40% of the total 57 thematic units. The strongest subcategory was care planning (DOR of 0.80) (Table 2). The category inexactness of the languages was the largest category, accounting for 29 thematic units or 50% of the total, and had two strong subcategories: fostering inaccuracies (DOR of 0.66) and semantics (DOR of 0.57). The category language usefulness contained thematic units describing potential solutions for improving functionality of the nursing languages. This was a weak category accounting for less than 1% of the thematic units (five of 57).
Within language comprehensiveness (Table 3), neither documenting nor receiving nurses perceived professional separation or ease of use as important (DOR <=0.50). Documenting nurses, however, perceived care planning as more important (DOR 0.99) than the receiving nurses (DOR 0.49). Within the category inexactness of the languages, documenting and receiving nurses differed. While neither documenting nor receiving nurses perceived lacks descriptiveness as important, documenting nurses perceived semantics (DOR 1.00) and receiving nurses perceived fosters inaccuracies (DOR 1.00) as issues with nursing languages. Semantics was a not identified as an issue for receiving nurses. Only documenting nurses identified potential solutions to improve nursing languages within the category language usefulness.
Based on this research, there are strengths and limitations to using standardized nursing languages. Participants generally perceived standardized nursing languages support planning care but pose semantic challenges and foster inaccuracies in patient information. When applied to Information Theory, the value of standardized nursing languages facilitating communication (redundancy) was planning care. The task of planning care is assisted by having a standard language to organize care. Standardized nursing languages, however, restricted communication (noise) through fostering inaccuracies and semantic challenges. This type of noise is not only a potential problem for communication of a clinical event, but is also directly related to patient safety. For example, if a nurse is unable to clearly receive communication related to an event, appropriate intervention may be affected, thereby delaying effective care.
When applied to the conceptual framework, documenting nurses perceived the standardized nursing languages (device) supporting communication through care planning while constraining communication through challenges with semantics. Receiving nurses did not perceive the standardized nursing languages as supporting communication; rather, the languages confounded communication through fostering inaccuracies of patient information. No receiving nurse identified the language as useful (DOR 0.0). The differences in perceptions between the documenting and receiving nurses may be accounted for when considering their roles with documentation and communication. Documenting nurses are primarily responsible for planning care to facilitate continuity of care. Receiving nurses, on the other hand, are responsible for taking and processing that information. If receiving nurses see inaccuracies in the documentation, this poses substantial risk to patient safety through misinterpretation of the significance of the information for timely intervention.
Research has suggested that standardized nursing languages do not capture patient care in an individualized manner.16 However, this was not supported by the findings since planning care emerged as a strong subcategory by documenting nurses. This may suggest that standardized nursing languages facilitated individualized care planning associated with a clinical event.
Consistent with the literature, both documenting and receiving nurses perceived the standardized nursing languages as not easy to use.9,11,14,15 Documenting nurses stated that the languages were not "regular English" and were based on the "legal language." One could not account for their dissatisfaction with the standardized nursing languages because of inexperience. For the most part, nurses in this study had considerable nursing experience as well as experience with the EHR.
From the receiving nurse's perspective, standardized nursing languages fostered inaccuracies in patient information. They stated the languages were difficult to "fit" to the clinical event and stated that nurses created workarounds by "making up" their own problems or interventions. This practice was done, as one nurse stated, "to fit a round peg into a square hole." This need to circumvent the standardized nursing languages is of concern and suggests the need to systematically reevaluate the benefit of the standardized nursing languages and its use by nurses.
Despite the adherence to elements of rigor, this study was limited in that the nurses were not asked how they used the nursing languages to communicate a clinical event. Nurses were asked to identify the strengths, limitations, and potential solutions to improving the nursing languages. Furthermore, nurses were not asked to what degree the EHR or nursing languages were used during nurse-to-nurse communication of a clinical event.
The implications of these findings are that standardized nursing languages may constrain nurse-to-nurse communication of a clinical event. Nurses reported the use of workarounds to cope with the barriers using the standardized nursing languages. The workarounds included using their own interventions or diagnoses. The use of workarounds calls into question the usefulness of databases constructed to facilitate decision making and benchmarking using standardized nursing languages. Therefore, for the EHRSNL to be entirely useful, these inadequacies must be dealt with, and the workarounds need to be evaluated.
Clinical events, as used and defined for this study, were deemed to be possible indicators of potential complications. Clinical events captured for this study align well with the work of Needleman and colleagues,33 who determined the common complications leading to failure to rescue events: pneumonia, shock or cardiac arrest, upper gastrointestinal tract bleeding, sepsis, or deep vein thrombosis. For example, a drop in hemoglobin and hematocrit and low blood pressure align with bleeding, while fever and pain align with pneumonia, deep vein thrombosis, or sepsis. This suggests that ineffective nurse-to-nurse communication of clinical events may be viewed as a precursor to failure to rescue incidents and patient complications.
If the communication device (nursing languages) is not understood by the sender and recipient, then communication is ineffective. Based on this study, albeit with a limited sample, we have some indication that while standardized nursing languages can facilitate planning care by the sender, they also interfere with communication because of inaccuracies of patient information and lack of semantic understanding. The data suggest that nurses perceived the inaccuracies in the patient information related to the lack of fit of the languages.
How the nursing languages affect the receiving nurses' ability to continue care remains unknown. Further research is needed to explore the relationship between nurse-to-nurse communication and failure-to-rescue events and how standardized nursing languages are used in such situations. The impact of nursing languages on nurse-to-nurse communication and the subsequent relationship to patient safety provide a fertile field for nursing research.
The author thanks Joyce Verran, PhD, RN, FAAN, and Suzanne Lareau, MS, RN, FAAN, for their thoughtful review and constructive feedback in preparation of this manuscript.
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