The Structuralization Analysis Of Hospital Nursing Records And Its Cross-mapping With ICNP

ObjectiveTo analyze nursing records and extract its main content, and to classify the content into categories according to nursing phenomenon, nursing action and nursing outcome. Also cross-mapping was conducted between the categories and ICNP, aimed to analyze domestic nursing terminoloy in clinical nursing practice, and reflect nursing contribution to patient outcome and significance of nursing profession as well. Finally, to discuss the possibility of nursing records structuralization and standardization with reference of ICNP.MethodsThis study used purposive sampling. Hospital nursing records and shift reports from nine departments in one general hospital were collected from the Record Room. The departments include Cardiology, Cardial Surgery, Gastrointestinal Surgery, Urology Surgery, Orthopedics, Respirology, Neurology, Obstetrics and Pediatric.Qualitative combined with quantitative design were used. Methods of content analysis were applied to analyze the nursing records and shift records within four specified periods of time. Narrative nursing notes were extracted and classified by nursing phenomenon, nursing action and nursing outcome. Descriptive statistic analysis was conducted to describe the basic information of nursing records, patients' demographic information and frequency of all the categories. Classification differences among the four groups were compared with Chi-square test (χ2).The whole study consists of the following four stages.1. Pilot study was conducted. Nursing records and shift reports in Department of Cardiology were analyzed. Preliminary codebook was formed by using content anlysis.2. Codebook test and verification. Based on the pilot study, nursing documents in the other eight departments were analyzed continuously to provide modifications for the preliminary codebook.3. Chi-square test andχ2 segmentation statistic methods were applied to find the difference among nursing notes in four periods of time. Moreover, associated changes after implementation of the High Quality Nursing Project were examined.4. Cross-mapping the categories in the codebook with ICNP terminology, to analyze the matching status between nursing descriptive terms and ICNP. Several techniques were adopted to establish the trustworthiness of content analysis, e.g. setting coding rules, inter-coder checking, debriefing, etc.ResultsTotally 715 patient records were searched,183 records containing general or critical nursing records were studied. The number of recording days is 1259 and the shift reports recorded 791 patients' health condition. The main research findings are as follows.1. All phrases in nursing notes can be classified into nursing phenomenon, nursing action and nursing outcome domains. The three domains include different categories, subcategories and detailed categories. There are 246 detailed categories in total. The inter-coder agreement is 95.12%.2. Since the document of strengthening basic nursing issued, overall frequency of nursing notes was decreased; differences of categories in nursing phenomenon and action domains were statistically significant while no obvious changes were found in nursing outcome domain. For example, in nursing action, proportion of records in both basic nursing and nursing technique increases while that of health education declines. Meanwhile, in nursing phenomenon, proportion of event rises while symptom and sign drops.3. Our domestic recording scope in nursing phenomenon, action and outcome differs from ICNP.459 terms from ICNP could be used to describe all the categories and subcategories of nursing notes. However, some terms can't be found in ICNP for representing some detailed categories and 40 terms should be added to reflect China nursing practice sufficiently. The inter-coder agreement of cross-mapping is 100%.ConclusionThe study analyzed hospital nursing records from the respective of clinical nursing practice and nursing language. It is conducive to inspect our nursing content and scope, and promote international development. The research findings indicate that nurses implement lots of behaviors during patient recovery; nursing outcome could also verify nursing contribution, but both lack of visualization and distinctiveness and need to strengthen standardization to better demonstrate unique efficacy of nursing. The vocabulary formed through cross-mapping will lay standardized language foundation to construct tabular nursing document. It also proves the feasibility of ICNP application in China, In addition, there is still a gap between our nursing practice and international nursing terminology. Great efforts are needed to improve nursing connotation.