NURSE EDUCATOR Volume 31, Number 1, pp 40–46 * 2006 Lippincott Williams & Wilkins, Inc. Helping Nurses Use NANDA, NOC, and NIC Novice to Expert In the United States, implementation of an electronic health record (EHR) is imminent; by 2010, all healthcare Margaret Lunney, PhD, RN events will be electronically recorded and healthcare agencies will be required to submit data elements to regional and national data banks.1,2 The electronic health record (EHR) requires the use of standardized With an EHR, nursing data elements nursing languages such as NANDA, NOC, and NIC. Helping nurses use will be documented through the use these languages for an EHR requires different educational strategies in 3 of standardized nursing languages such as those published by NANDA domains: intellectual, interpersonal, and technical. The author explains the rationale for changes in educational methods, expectations that International and the project teams of educators and managers should set for students and nurses at various the Nursing Outcomes Classification levels of expertise, and teaching strategies in each of the domains. (NOC) and the Nursing Interventions Classification (NIC).3-5 These and other standardized languages that were approved by the American Nurses Association for use in elec- of standardized nursing languages ages of cues with diagnoses, and tronic records provide a broad base of requires increased attention to devel- diagnoses with outcomes and inter- nursing knowledge at the point of opment of intellectual, interpersonal, ventions. Without the use of NNN in care and enable the documentation and technical competencies; and an EHR, nurses are often encouraged of nursing care elements in formats 6 (c) accurate diagnosing is the basis to collect large amounts of data with- that support the aggregation of data. for appropriate selection of patient out naming data interpretations. With Aggregation of nursing data enables outcomes and nursing interventions. the use of NNN in an EHR, decisions the development of knowledge These reasons are explained as the about data collection are based on related to the quality and cost of care basis for helping nurses to implement initial cues to diagnoses and diagnos- in agency units and comparison of NANDA, NOC, and NIC (herein tic hypotheses being considered for quality and cost across localities and referred to as NNN) and other nursing individual patients. time periods. languages. The systems of NNN are Without the use of NNN in an EHR, addressed in this article but a majority nurses describe patient outcomes and Rationale for Educational of these teaching methods also apply interventions in a narrative format with Changes to other languages. little consistency among nurses. With the use of NNN in an EHR, the names Three major reasons for changes in used for patient outcomes and nursing educational methods are: (a) use of Differences in the Nursing interventions are easily available to all standardized nursing languages in Process With Use of NNN nurses so consistency and continuity the nursing process differs from the will be expected. traditional nursing process; (b) use When nurses have opportunities to Without the use of NNN in an EHR, use standardized languages such as nurses may not be held accountable NNN, significant differences exist from for the accuracy of their data interpre- Author Affiliation: Professor and Grad- use of the traditional nursing process. tations. With the use of NNN in an EHR, uate Programs Coordinator, Department of Without use of NNN, nurses are prob- nurses’ diagnoses are easily noted and Nursing, College of Staten Island, The City ably not aware of the extensive num- addressed, so accountability for accu- University of New York, Staten Island, NY. ber of data interpretations, outcomes, racy will be critically important to save Correspondence: Department of Nurs- and interventions to consider for indi- the time and money involved when ing, College of Staten Island, 2800 vidual patient situations. With use of Victory Boulevard, Staten Island, NY 10314 many nurses provide care for inaccu- ([email protected]). NNN in an EHR, knowledge of 172 rate diagnoses. For example, if one diagnoses, 330 patient outcomes, and This article was adapted from a Key- nurse selects the diagnosis of Deficient 514 nursing interventions can be Knowledge when a patient has note Address given at the 2005 Institute on 3-5 Nursing Informatics and Classification, easily available. adequate knowledge and then many hosted by the University of Iowa College Decision support systems can nurses waste time in teaching, there of Nursing, Center for Nursing Classifica- also be included in an EHR that will be excessive costs without posi- tions and Clinical Effectiveness. prompt nurses to consider the link- tive outcomes. 40 NURSE EDUCATOR Volume 31, Number 1 January/February 2006 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Development of Competencies potential for inaccuracy in nurses’ ical Mobility is only appropriate if identification of diagnoses and contrib- nurses currently plan to help this Intellectual, interpersonal, and techni- uting factors.8 In every study of patient to improve mobility. The pur- cal competencies support the account- nurses’ interpretations of the same pose of nurses’ diagnoses should be ability that is needed for collection data elements, there were wide varia- to guide nursing interventions, not to and interpretation of patient data, as tions in interpretations of data, even label patients with nursing diagnoses. well as appropriate selection of with strong data support for the most New users often do not realize that patient outcomes and nursing inter- accurate diagnoses. These variations the neutral outcome labels (eg, Weight ventions. Based on the improved in interpretations are influenced by 3 Control) and the associated overall organization of an EHR over paper major factors: the diagnostic task (eg, score on specific scales (eg, 3 = records, the choices of individual complexity and amounts of data), the sometimes demonstrated), are the out- nurses’ diagnoses, outcomes, and situational context (eg, organizational come, not the indicators, and the interventions will be addressed by all policies, nurses’ roles), and nurses’ abil- intervention labels (eg, Presence) are nurses involved in care of the same ities as diagnosticians (eg, thinking the interventions, not the activities.4,5 patients. Thus, nurses’ choices will abilities, experience with similar For the outcomes in NOC, the indica- have broader, more profound effects cases).8-10 Studies have shown that tors serve as evidence to help patients on nursing care in general, not just the high accuracy is associated with nurses and providers to identify overall care provided by themselves. In being educated as diagnosticians.8 scores prior to and after nursing theory, continuity of care was sup- interventions. For the NIC interven- posed to occur with use of paper tions, the activities represent how to records, but, with the inability to do the intervention and are individu- effectively track data, continuity of Set Expectations: Novice 2 ally applied according to patients’ care was not realized. to Expert needs. In setting expectations for students Students and nurses should be Accurate Interpretations of Data and nurses, it is important that educa- expected to correctly use the concepts are Foundational tors and managers do not underesti- in each system in accordance with the mate nurses’ abilities to effectively use concept definitions, descriptions, and In a classic study, it was established standardized nursing languages and the context of each clinical situation. that short-term memory only holds 7 T incorporate them with other knowl- For example, the NANDA Interna- 2 bits of data,7 so nurses, as all human edge bases. Based on the author’s tional diagnosis of Social Isolation is beings, continuously convert bits of experience teaching NNN to nurses not used unless the patient is being data or cues to interpretations. For at all levels of expertise, novices and rejected by others, not if he or she example, the interpretation that a advanced beginners learn to use NNN chooses to be alone.3 The NOC out- person is a male or female is based as well, if not better and easier than, come of Knowledge: Diet should not on the cues of hairstyle, facial struc- experienced nurses. This is because be used if the person already has ture, body type, body language, they have not had enough experience extensive information about the rec- clothes, name, and others. It is com- in nursing to know other ways of ommended diet. There are many rea- mon to think of such interpretations as doing things. The languages of NNN sons why people do not follow ‘‘fact’’ because these interpretations can be used throughout basic nursing recommended diets besides Deficient are relatively valid and reliable. Other programs, from the first week, as Knowledge. interpretations, however, such as the part of a framework for practice The NIC intervention of Coping patient is happy, sad, or anxious, are along with theories and models of Enhancement should not be used if not likely to be valid and reliable nursing.11 In contrast, nurses at com- the patient problem to be treated is unless nurses attend to the accuracy petent, proficient, and expert stages Stress Overload rather than Ineffective of interpretations. need to be ‘‘sold’’ on new ways to Coping. With stress overload, a better