12 Nursing Data Standards Nursing Values Related to Health Information The initial systems for gathering minimum uniform health data can be traced back to systems devised by Florence Nightingale over a century ago (Verney 1970). Nightingale (1859) asserted the need for nurses to use their powers of memory and nonsubjective observation to track the condition of those in their care. Subsequently (Nightingale 1863), she provided forms and def- initions for the collection of uniform hospital statistics. In conclusion, she wrote (Nightingale 1863): I am fain to sum up with an urgent appeal for adopting this or some uniform system of publishing the statistical records of hospitals. There is a growing conviction that in all hospitals, even in those which are best conducted, there is a great and unnecessary waste of life;...Itis imperative that this impression should be either dissipated or confirmed. In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison...ifwisely used, these improved statistics would tell us more of the relative value of particular operations and modes of treatment than we have any means of obtaining at present. They would enable us, besides, to ascertain the influence of the hospital...upon the general course of operations and diseases pass- ing through its wards; and the truth thus ascertained would enable us to save life and suffering, and to improve the treatment and management of the sick and maimed poor. The needs have not changed. Nurses must be able to manage and process nursing data, information, and knowledge to support patient care delivery in diverse care delivery settings (Graves and Corcoran, 1989). Ozbolt, (1999) maintained that: Standard terms and codes are needed to record as structured data the problems and issues that nurses and other caregivers address; the actions they take to prevent, 171 172 Infrastructure Elements of the Informatics Environment ameliorate, or resolve the problems; and the results of their care. Such data could be used to increase the effectiveness of care and control costs. There is an essential linkage among access to information, client outcomes and patient safety. “As Lang has succinctly and aptly described the present situation: If we cannot name it, we cannot control it, finance it, teach it, research it or put it into public policy” (Clark and Lang, 1992). Access to information about their practice arms nurses with evidence to support the contribution of nursing to patient outcomes. Outcomes research is an essen- tial foundation for evidence-based nursing practice. Evidence-based practice is a means of promoting and enhancing patient safety. Evolution of Nursing Information and Nursing Data Elements There are a variety of concepts that interlink when considering the capture of nursing practice data. Figure 12.1 illustrates the derivation, from nursing practice, of nursing classification, nursing terminology, min- imum data sets, reference terminology models, and the resulting feedback loop. FIGURE 12.1. Relationships between nursing practice and classification, terminology, minimum data sets, and reference terminology model. Nursing Data Standards 173 United States Uniform Hospital Discharge Data Set In the United States, the Uniform Hospital Discharge Data Set (UHDDS) was developed over a 5-year period during the early 1970s. It identified the minimum basic set of data elements to be collected from all hospital records at the point of patient discharge from hospitals. In 1974, the UHDDS was adopted and mandated by the Secretary of the Department of Health and Human Services for collection by the U.S. National Committee on Vital and Health Statistics (Abdellah, 1988; Pearce, 1988). The UHDDS provided the model for the hospital discharge abstract that was subsequently developed in Canada and ultimately evolved into the Discharge Abstract Database (DAD), now maintained by the Canadian Institute for Health Information (CIHI). The care items included in the UHDDS focused on physician-derived clinical data (specifically,medical diagnosis and procedures based on medical treatments). There were absolutely no nursing clinical data included in this data set. Patient care is not exclusively physician-directed; therefore, a data set of this nature falls short of providing a complete, accurate representation of information related to the operation of hospitals. Nursing Minimum Data Set In response to recognition of the information gap created by the exclusion of nursing data elements from the Uniform Hospital Discharge Data Set, Werley and colleagues developed the Nursing Minimum Data Set (NMDS) through a consensus conference at the University of WisconsinMilwaukee School of Nursing in 1985 (Werley and Lang 1988). The NMDS was defined as “a minimum set of items of information with uniform definitions and categories concerning the specific dimension of professional nursing, which meets the information needs of multiple data users in the healthcare system” (Werley and Lang 1988). There were five purposes of the NMDS. r Establish comparability of nursing data across practice settings and geo- graphic boundaries r Capture descriptors reflecting the nursing care of clients and their families in a variety of settings r Project trends in nursing care needs and resource use according to health problems r Provide a database for nursing research r Provide data about nursing care for consideration by individuals involved in health policy decision-making The NMDS consisted of nursing care elements, patient demographic ele- ments, and service elements. The nursing care elements of nursing diagnosis, nursing intervention, nursing outcome, and intensity of nursing care drew 174 Infrastructure Elements of the Informatics Environment on the nursing process used by nurses to plan and provide patient care in any setting. The patient demographic and service elements, except health record number and the unique number of the nurse provider, are data elements con- tained in the UHDDS and could be accessed through linkage with this data set (Werley and Lang, 1988). Once the NMDS was agreed upon, uniform definitions for each of the data elements and standard classification systems were necessary for collection of uniform, accurate data to be feasible. Classification Systems for NMDS Data Elements The North American Nursing Diagnosis Association (NANDA) initiated the development of labels for the clinical phenomena for which nurses provide care (i.e. nursing diagnosis) in 1973. NANDA has defined nursing diagnosis as “a clinical judgment about individual, family, or community responses to actual and potential health problems and life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes of which the nurse is accountable” (Carpenito, 1989). The Visiting Nurses Association (VNA) of Omaha developed the problem classification scheme, intervention scheme, and problem rating scale for out- comes related to community health client problems and nursing problems used for documenting community health nursing services. The Omaha classi- fication system defined a problem as “a clinical judgment about environmen- tal, psychosocial, physiologic and health related behavior data that is [sic]of interest or concern to the client” (Martin, 1988; Martin and Scheet 1992). The Home Healthcare Classification (HHCC) was developed at the Georgetown University School of Nursing from 1988 to 1991 to assess and classify home health Medicare clients for predicting their need for nursing and other home care services as well as for measuring outcomes and data on the resources employed (Saba, 1992). Nursing interventions were defined in the HHCC: Nursing Interventions as a nursing service, with significant treat- ment, intervention, or activity identified to carry out the medical or nursing order (Saba, 1992). Nursing interventions were considered critical measures of the resources used. The Nursing Interventions Classification (NIC) and Nursing Outcomes Classification System (NOC) were developed by a large research team (the Iowa Intervention Project) led by McCloskey and Bulechek at the University of Iowa. This team defined nursing interventions as “any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance pa- tient/client outcomes. Nursing interventions include both direct and indirect care; both nurse-initiated, physician-initiated and other-provider-initiated treatments”(McCloskey and Bulechek, 1996). NIC was coded to be consis- tent with the Current Procedural Terminology, American Medical Associ- ation, and the Healthcare Financing Administration’s Common Procedure Coding System and was included in the Library of Medicine’s Metathesaurus for a Unified Medical Language. Additionally, it has been endorsed by the Nursing Data Standards 175 American Nurses Association (ANA) for inclusion in the proposed Unified Nursing Language System (McCloskey and Bulechek, 1996; McCormick et al., 1994). NIC provides a standardized language that can be used across settings and across healthcare disciplines (McCloskey and Bulechek, 1996). Independent and collaborative interventions as well as basic and complex interventions were included. A nursing outcomes classification (NOC) sys- tem has also been developed in conjunction with the NIC through the Iowa Intervention Project Johnson et al., 2000). The Unified Medical Language System (UMLS) includes NANDA, the