Measuring the domain completeness of the Nursing Interventions Classification in parish nurse documentation.
As the healthcare industry moves toward automating the patient record, care providers have been challenged to capture their domain of practice in a computerized format. Nurses have responded by developing a number of American Nurses Association (ANA) recognized nursing standardized terminologies. This study measured the domain completeness and uses of one such terminology, the Nursing Interventions Classification (NIC), within the specialty of parish nursing, a spiritually focused, community-based practice. Documentation samples from 170 health records submitted by 13 parish nurses in 7 sites across the country, stratified by urban, suburban, and rural sites were used. The nursing interventions that were documented in 1607 unique interactions in these charts were mapped into NIC using standardized mapping procedures. Intercoder reliability was assessed, with a final kappa of 0.92 (93% agreement) and code-recode reliability with a kappa of 0.72 (74% agreement). Overall, 93% of the 3059 interventions mapped into NIC. Recommended modifications in existing NIC labels and additional NIC labels are presented. The results suggest that NIC supports the documentation of parish nursing practice and has the capability of capturing the spiritual dimension of care.
Burkhart
Lisa
L
Marcella Niehoff School of Nursing, Loyola University Chicago, IL 60626, USA. eburkha@luc.edu
Androwich
Ida
I
D001291:Attitude of Health Personnel; D003152:Community Health Nursing / Q000458:organization & administration; D004282:Documentation / Q000592:standards; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000592:standards*; D033262:Narration; D020380:Needs Assessment; D024802:Nurse's Role; D015403:Nursing Evaluation Research; D009736:Nursing Process / Q000145:classification*; D009737:Nursing Records / Q000592:standards*; D009740:Nursing Staff / Q000523:psychology; D015588:Observer Variation; D010327:Pastoral Care; D012111:Residence Characteristics; D029181:Spirituality; D039061:Systematized Nomenclature of Medicine