Evidence for the existing American Nurses Association-recognized standardized nursing terminologies: a systematic...

Area of Science:

• Nursing Informatics
• Health Information Management
• Clinical Terminology Research

Background:

• Standardized nursing terminologies are crucial for consistent documentation and data analysis in healthcare.
• Understanding the current state of research, including evidence levels and focus areas, is essential for advancing their use.

Purpose of the Study:

• To systematically review the scientific literature on five standardized nursing terminology sets.
• To evaluate the level of evidence and primary focus of studies concerning these terminologies.

Main Methods:

• A systematic review of publications from 1960s to March 2012 was conducted using PubMed, CINAHL, and EMBASE.
• 1257 publications were screened, with 312 selected for full-text review and analysis by eight trained raters.
• Data extracted included terminology names, publication year, country, study focus, and level of evidence, with inter-rater reliability confirmed.

Main Results:

• Research publications on standardized nursing terminologies have significantly increased since 2000.
• The majority of studies (72.1%) focused on the North American Nursing Diagnosis-International, Nursing Interventions Classification, and Nursing Outcome Classification (NANDA-I, NIC, NOC) set.
• Most studies were descriptive (72.4%), with growing evidence for the integration of NANDA-I, NIC, NOC, and the Omaha System into electronic health records.

Conclusions:

• The body of research on standardized nursing terminologies has grown substantially, with a clear focus on NANDA-I, NIC, and NOC.
• Current evidence supports the successful implementation of NANDA-I, NIC, NOC, and the Omaha System in electronic health records.
• Further research employing stronger study designs is recommended to enhance the validity, reliability, and clinical application of these terminologies.