An Internationally Consented Standard for Nursing Process-Clinical Decision Support Systems (NP-CDSS) in Electronic Health Records
Prof. Maria Müller-Staub (PhD, EdN, RN, FEANS, FNI) & Prof. Wolter Paans
(PhD, EdN, RN)
Future ‘Big Nursing Data’-Research depends on valid Electronic Nursing Documentation-Systems (NDS). Such systems guide clinical practice and therefore it’s essential to implement evidence-based nursing process concepts as Standardized Nursing Language (SNL) into NDS.
Nurses also require support by an SNL-based Nursing Process-Clinical Decision Support System (NP-CDSS) to effectively apply and document the Advanced Nursing Process.
To meet this research gap, Maria Müller Staub, Helen de Graaf-Waar and Wolter Paans developed the first, internationally ‘Consented Standard for Nursing Process-Clinical Decision Support Systems’ in Electronic Health Records.
The standards’ content validity was supported by the literature and internationally recognized experts representing Brazil (Graciele Linch), Canada (Noreen Frisch), Finland (Kaja Saranto), Spain (Carme Espinosa), Switzerland (Matthias Odenbreit), Sweden (Cathrin Björvell, Anna Ehrenberg), and the United States (Gail Keenan).
The authors specially thank these experts for their valuable contributions in the NP-CDSS Standards qualitative validation process. The Standard was recently published in Computers in Nursing (CIN), the abstract is reprinted in the next section.
Nurses are accountable to apply the nursing process, which is key for patient care: It is a problem-solving process providing the structure for care plans and documentation. The state-of-the art nursing process is based on classifications that contain standardized concepts, and therefore, it is named Advanced Nursing Process. It contains valid assessments, nursing diagnoses, interventions, and nursing-sensitive patient outcomes. Electronic decision support systems can assist nurses to apply the Advanced Nursing Process. However, nursing decision support systems are missing, and no “gold standard” is available. The study aim is to develop a valid Nursing Process-Clinical Decision Support System Standard to guide future developments of clinical decision support systems. In a multistep approach, a Nursing Process- Clinical Decision Support System Standard with 28 criteria was developed. After pilot testing (N = 29 nurses), the criteria were reduced to 25. The Nursing Process-Clinical Decision Support System Standard was then presented to eight internationally known experts, who performed qualitative interviews according to Mayring. Fourteen categories demonstrate expert consensus on the Nursing Process-Clinical Decision Support System Standard and its content validity. All experts agreed the Advanced Nursing Process should be the centerpiece for the Nursing Process-Clinical Decision Support System and should suggest research-based, predefined nursing diagnoses and correct linkages between diagnoses, evidence-based interventions, and patient outcomes.
KEY WORDS: Clinical decision support system, D-catch, Documentation, Electronic nursing record, Q-DIO, Standard validation
Access to the article: https://www.ncbi.nlm.nih.gov/pubmed/27414705