Nurses record a lot of data and information as they provide client care. At the moment, permanent databases of health information do not include nursing care elements. These databases do not describe what nurses do, what difference nurses make to the health of their patients, families, and communities, or document the nursing care received.
In recent years, a movement to change the way we record client information has begun. For decades, all records were hand-written in the form of a client chart. The advent of computers has catalyzed a trend to move health care information to a computerized system. Currently, initiatives are underway to standardize computerized health data on a national and international level. Subjectively written data somehow has to fit into this standardized system. In order to facilitate this, common terms and language is necessary.
To articulate nursing and what nurses do, nurses themselves must agree on a common language. Efforts to make this a reality have begun. The most basic effort is the creation of common terms or Nursing Components, which will articulate what nurses actually do as they care for clients in a number of diverse settings.
The Canadian Institute for Health Information (CIHI) was organized to determine the information required to manage a national health information system. This organization continues to work to standardize health data (including nursing data) and to integrate information systems across the nation. The goal is to develop a comprehensive, standardized and integrated health information system for Canada. The Canadian Nurses Association (CNA) supports this initiative, reflected in their 1993 Policy Statement about Health Information: Nursing Components. Standardization is needed to reflect every aspect of nursing documentation, including client assessment, nursing interventions, care planning, nurse resource use and client outcomes. Nurses need to collaborate in choosing the most vital data elements and voicing the mutual decision. This nursing data must be standardized, clearly defined and consistent to facilitate data entry, easy data retrieval and accurate application.
As part of the formalized plan to develop a specific Minimum Nursing Data Set for Canada, the Canadian Nurses Association initiated a Health Information:Nursing Components Working Group in 1992. This group worked intensely to articulate data categories that uniquely identified the contribution of nursing to the health care system. This may seem simple enough, but to accurately reflect the complexities of what nurses do in concrete data form has been a challenge to this group, as well as the ICN. “In order to collect, store, retrieve, analyze and communicate information about their practice, nurses require classification systems” (Canadian Nurses Association, 2003, p. 1). The data had to be interconnecting so that all aspects of nursing could be reflected and supported, including practice, administration, education, and research aspects. In 1997, a national consensus about the basic key components that should be included in the Canadian nursing data set. Five essential classification elements were identified and agreed upon:
client status
nursing intervention
client outcome
nursing intensity
primary nurse identifier
This was an important but preliminary first step. Much more work has been done over the past decade and continues to this day. “To collect the nursing contribution data within the larger health information system, there is a need for consistent data collection using standardized languages to aggregate and compare data” (Canadian Nurses Association, 2000, p. 24). The next step was to choose a classification system that would serve the needs of Canadian nurses. Informatics experts agreed that the International Classification of Nursing Practice (ICNP®) would provide the best solution since it is the most “'universal, generic and comprehensive foundational classification system for nursing at this time” (p. 18). “With ICNP® nurses can begin to describe and compare nursing practice across settings, client populations, geographical areas and time. In turn, this data can be integrated into multidisciplinary health information systems” (p. 6).
It is important that nurses participate in decision making and planning so that nursing data is included in emerging Electronic Health Records. The Electronic Health Record (EHR) is a longitudinal electronic record of patient health information generated by one or more encounters in any care delivery setting. Included in this information are patient demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data and radiology reports. The EHR automates and streamlines the clinician's workflow. The EHR has the ability to generate a complete record of a clinical patient encounter, as well as supporting other care-related activities directly or indirectly via interface - including evidence-based decision support, quality management, and outcomes reporting.
“It has been widely accepted that the creation of a global EHR system may save more lives and have greater benefit to patients and our society at large than a cure to cancer. Four major reasons drive providers toward implementing an electronic health record system.” (Waegemann, 2002).
The first and most valuable is shareability. In real terms, this is a level of interoperability within an enterprise. The concept of sharing patient information among authorized professionals within an enterprise fits the vision of the electronic medical record (EMR). The benefits are for the provider organization. The provider organization has it in its power to select and implement systems that allow shareability or some lower level of interoperability.
The second reason is in regard to necessary accuracy and documentation in health care. The most prevalent information capture method is handwriting, which can lead to medical errors due to illegibility, non-standardized abbreviations, or other handwriting-caused misinformation. Therefore, electronic documentation brings the benefit of better accuracy.
The third benefit of electronic health records is in the field of work flow. The EHR is an important tool to achieve a more efficient way of delivering healthcare.
The fourth benefit is that the EHR is the necessary infrastructure for many of the necessary changes. For example, a good electronic order entry system is dependent on the patient information stored in the EHR. Similarly, many decision support systems depend on information stored in electronic format.
Ends in View
This learning activity is intended to give the learner the opportunity to:
1. Gain awareness of the need for standardized nursing data in the future Canadian
Health information system.
2. Examine nursing data and information and determine what is exclusive to nursing and
represents unique nursing care.
3. Recognize the need for nurses to be knowledgeable about the unique nursing components
of computerized health information.
4. Demonstrate beginning skill in distinguishing nursing data from the data collected by other
health care professionals.
5. Gain an understanding of the process and dynamics of establishing electronic health records at local, regional, national and global levels.
6. Recognize the complexity of an electronic health record and predict the implications for nursing.
1. If you were on a planning committee to determine the language to use to clearly articulate
nursing data (assessment, interventions, client perspectives/experiences, outcomes, etc.)
what important considerations would you keep in mind?
Would it be easy to reach consensus about this? Now, consider doing this on a national level.
What considerations would come into play?
2. Throughout your practice experience this semester, keep detailed notes (data) about the care
You give. Which tasks, data, responsibilities and actions performed were uniquely nursing?
3. Create a small database to reflect your list of unique nursing data, tasks, observations,
interventions, outcomes and so on. (See tutorials on Databases HERE). Save your work on disk and revise as needed.
In Reflection
1. How can nurses determine and articulate our unique role and territory within the evolving
health care system?
2. What societal factors and hegemony have promoted the devaluation of nursing data? How can
we change this?
3. What do you predict will happen to nursing if nurses do not clarify their unique contribution
and value to the changing health care system?
References
Canadian Nurses Association. (2001). What is nursing informatics and why is it important? Nursing Now: Issues and trends in Canadian nursing, Number 11. Ottawa: Author.
Canadian Nurses Association. (1995). Policy Statement on Health Information:
Nursing Components. Ottawa: Author.
Canadian Nurses Association and Office of Health and the Information Highway. (2000). Vision 2020 Workshop on information and communications technologies in health care from the perspective of the nursing profession. Ottawa: Authors.
Nursing Informatics Integration for the BSN and BSN-AE Nursing Programs at Kwantlen Polytechnic University
Design & Content by June Kaminski, RN MSN PhD(c) - 1999 - 2021
All rights reserved. No reproduction without written permission
Nurses record a lot of data and information as they provide client care. At the moment, permanent databases of health information do not include nursing care elements. These databases do not describe what nurses do, what difference nurses make to the health of their patients, families, and communities, or document the nursing care received.
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