Columbia University School of Nursing, 560 W 168th St, New York, NY 10032, USA.
Saint Camillus International University of Health Sciences, Via di Sant'Alessandro, 8 00131, Rome, Italy.
Int J Med Inform. 2024 Dec;192:105627. doi: 10.1016/j.ijmedinf.2024.105627. Epub 2024 Sep 19.
Standardized Nursing Languages (SNLs) have enabled nursing assessments and care to be better documented and visible in electronic health records (EHRs). However, its implementation is challenging and heterogeneous across clinical settings. This study aimed to demonstrate the challenges experienced by members of a European nursing organization, ACENDIO, in implementing SNLs in documentation systems across countries and offer recommendations about its use.
The study was executed in two phases. First, an online survey was distributed among ACENDIO members. Second, members participated in two expert panels. Discussions were recorded, and thematic analysis was performed to formulate challenges and recommendations on the use of SNLs.
The findings highlight that nurses across Europe are faced with several issues with current documentation systems in clinical settings, limited education on SNLs, and challenges in research on SNLs. Nurses, managers, vendors, educators and researchers should work closely together to face the challenges in the implementation of SNLs in electronic documentation systems.
To fully utilize the beneficial effects of the use of SNLs, the call to action is to develop comprehensive collaborations of nursing practice, education, and research.
标准化护理语言(SNLs)使护理评估和护理在电子健康记录(EHRs)中得到更好的记录和体现。然而,在不同的临床环境中,其实施具有挑战性且存在差异。本研究旨在展示欧洲护理组织 ACENDIO 的成员在跨国家的文档系统中实施 SNLs 时所遇到的挑战,并就其使用提供建议。
该研究分两个阶段进行。首先,向 ACENDIO 成员分发了在线调查。其次,成员参加了两个专家小组。记录了讨论内容,并进行了主题分析,以制定关于使用 SNLs 的挑战和建议。
研究结果表明,欧洲各地的护士在临床环境中面临着当前文档系统的多个问题,对 SNLs 的教育有限,以及 SNLs 研究方面的挑战。护士、管理人员、供应商、教育者和研究人员应密切合作,共同应对在电子文档系统中实施 SNLs 所面临的挑战。
为了充分利用使用 SNLs 的有益效果,需要采取行动,制定全面的护理实践、教育和研究合作。