Carrington Jane M
College of Nursing, University of Colorado Anschutz Medical Campus, Aurora, CO 80047, USA.
Comput Inform Nurs. 2012 Feb;30(2):82-8; quiz 89-90. doi: 10.1097/NCN.0b013e318224b338.
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.
本研究的目的是探讨护士对电子健康记录中标准化护理语言在传达临床事件方面的优势和局限性的看法。关于将嵌入标准化护理语言的电子健康记录作为一种通信系统的有效性的研究实例有限。因此,标准化护理语言对护士间沟通的影响在很大程度上仍不为人知。使用定性内容分析法对一项更大规模研究的数据进行了分析。57个主题单元代表了护士对使用北美护理诊断协会(NANDA)、护理干预分类(NIC)和护理结局分类(NOC)的电子健康记录在记录和检索与临床事件相关的患者信息方面的看法。对这些主题单元进行了进一步分析,出现了三个类别:语言理解、语言的不精确性和语言的有用性。标准化护理语言被认为有助于护理计划,但也带来了语义挑战,并导致患者信息出现不准确情况。标准化护理语言可能会限制与临床事件相关的护士间沟通。为了使语言支持护士间沟通并避免潜在的安全问题,医疗机构必须处理不准确情况和语义误解,以提供安全的患者护理。