Togni Serena, Saracino Lucia, Cieri Mariangela, Bianco Rosita, Terzoni Stefano, Giulia Santini Magda, Zito Emanuela, Lusignani Maura, Silvia Pazzaglia Maria, Depalma Letizia
Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy.
Department of Biomedical Sciences for Health, University of Milan, Milan, Italy.
West J Nurs Res. 2025 Mar;47(3):159-168. doi: 10.1177/01939459241310402. Epub 2025 Jan 6.
Nursing care plans document the nursing process, displaying actions, and illustrating expected outcomes. Their integration into electronic health records (EHRs) is critical for accurate documentation, enhanced by standardized nursing terminologies that promote communication, critical reasoning, and patient safety through consistent language for information.
This study aimed to identify appropriate standardized nursing terminology tailored to the context of a Northern Italian Cancer Center and research facility for developing nursing care plans and starting their integration into institutional EHRs.
Participatory action research was conducted to select proper terminology respecting the oncological setting, develop nursing care plans, and start their implementation in EHRs. The nursing team of a pilot ward collaborated closely with the researchers as coresearchers. Care plan samples were presented using the North American Nursing Diagnosis Association-International Nursing Intervention Classification, Nursing Outcomes Classification, and International Classification for Nursing Practice (ICNP) in the test section of the EHRs to gather nurses' preferences. Quantitative data collection, focus groups, and survey analyses were conducted.
Nurses chose the ICNP for its flexibility but sought better methods to define patient severity in assessments and outcomes. They suggested incorporating the Common Terminology Criteria for Adverse Events to enable context-sensitive care plans.
End-user involvement is essential for developing EHRs, enhancing system usability, and reducing implementation resistance. Including nurses in management decisions empowers them, and improves care quality.
护理计划记录了护理过程，展示了护理措施，并说明了预期结果。将其整合到电子健康记录（EHR）中对于准确记录至关重要，标准化护理术语通过一致的信息语言促进沟通、批判性推理和患者安全，从而增强了这种记录。
本研究旨在确定适合意大利北部癌症中心和研究机构背景的标准化护理术语，以制定护理计划并开始将其整合到机构电子健康记录中。
开展参与式行动研究，以选择符合肿瘤学背景的合适术语，制定护理计划，并开始在电子健康记录中实施。一个试点病房的护理团队作为共同研究者与研究人员密切合作。在电子健康记录的测试部分使用北美护理诊断协会-国际护理干预分类、护理结果分类和国际护理实践分类（ICNP）展示护理计划样本，以收集护士的偏好。进行了定量数据收集、焦点小组讨论和调查分析。
护士们选择ICNP是因其灵活性，但寻求在评估和结果中更好地定义患者严重程度的方法。他们建议纳入不良事件通用术语标准，以制定情境敏感的护理计划。
最终用户的参与对于开发电子健康记录、提高系统可用性和减少实施阻力至关重要。让护士参与管理决策赋予了他们权力，并提高了护理质量。
