by Lynn M. Nagle, RN, PhD
Nagle, L. (2013). On Realizing Value and Visibility. Online Journal of Nursing Informatics (OJNI), 17 (2), Available at http://ojni.org/issues/?p= 2649
While the work of Canadian nurses parallels that of nurses in many other countries, the overall impact of their work on the health and well-being of citizens is unfortunately not reflected in national data sets and reports. Unlike the widespread adoption of other classification schemes such as the International Classification of Disease (ICD), there has been a degree of complacency in achieving coherence in the capture and reporting of nursing practice data. However, it is important to note that many countries, including Canada, have endorsed the International Classification of Nursing Practice (ICNP) (CNA, 2006), but the overall representation of same within electronic health records has been limited to date. Although there are efforts underway to achieve national consensus in the identification of key indicators of health (CNA, 2013), the consistent measurement and capture of nursing outcomes (Hannah et al, 2009), and the identification and reporting of national indicators for nurse administrators (Van deVelde-Coke, 2012), we have yet to achieve a unified approach to clinical documentation through the use of standardized tools and measures. Legislative and regulatory requirements aside, potentially one of our greatest attestations to the value of nursing is never surfaced or utilized to make incremental improvements in care. Alas, more often than not, this natural resource has been generally lost for all time, at least in the world of paper records.
To further demonstrate the point, the lack of consistency in capturing nursing practice is a pervasive problem that begins with basic nursing education. Notwithstanding the expectation to deliver on national entry level competencies, nursing school approaches to the teaching of clinical documentation methods are likely as varied as the curricula of each program. In clinical settings across the country, the degree of duplicative work associated with the design and redesign of clinical documentation tools is mind-boggling and has been only marginally improved with online approaches to documentation. Even in the world of electronic health records, a majority of organizations continue to design their own variations of proprietary documentation systems. Not surprisingly, nurses delivering care in an array of settings spend much of their time documenting clinical assessments, interventions and outcomes; by some estimates between 25-50% of nurses’ time goes into the completion of documentation activities (Gugerty et al, 2007). For all the time, effort and cost associated with the documentation of clinical care, one might expect to see a significant return for the profession and broader health care system. But sadly, most nursing documentation disappears into a black hole, never to be viewed again or serve any purpose unless summoned for legal review.
Imagine having nursing practice data and information viewed as a valued contribution to national data bases; on par, if not more important than other data to inform our understanding of clinical outcomes – what works, what doesn’t, in what setting, and for how long? This is not to suggest that no healthcare organizations have adopted standardized approaches to documentation. But therein lays a fundamental problem, the limitations of standardizing documentation approaches solely within single care settings or organizations – rather than across all care settings. The end result: a lack of longitudinally comparable data and metrics for improving our understanding of communities, populations, diagnoses or more importantly, one patient/client and family over the course of time. Furthermore, while analyses can be undertaken within a single care entity, how can we possibly generate regional, state or provincial or national repositories if there is no expectation for the use of standardized clinical documentation tools across the board? Standardized, codified, computerized nursing documentation offers the promise of a rich repository of comparable, analyzable data and information that could serve to advance clinical evidence and nursing knowledge. It is quite astounding that while budgets tighten, the opportunity to adopt consistency within sectors and across regions has not progressed as far as one might have anticipated. The time spent by nurses and others deliberating over the design, format, and elements of clinical documentation is a waste of precious resources whose time might be better utilized in understanding the impact of care activities. Having access to integrated repositories of nursing and other clinical data could conceivably outpace the rate of return garnered through traditional research. The advancement of electronic health records and the use of online documentation tools present the profession with untold possibilities for collecting and mining the data and information that historically has proven to be impractical to retrieve and analyse from voluminous paper records.
Although still a long way from having standardized clinical documentation, nation-wide progress is being made in the capture of consistent metrics to monitor health outcomes and reflect the contributions of nurses to the health status of Canadians. For every nurse in this country, the unfolding of initiatives such as the Canadian National Nursing Quality Report (NNQR-C), the Canadian Health Outcomes for Better Information and Care (C-HOBIC), and the database of Nursing Quality Indicators for Reporting and Evaluation (NQuIRE), signal a transformative shift in how nursing will be depicted, understood, referenced and supported. Each of these initiatives will significantly raise the bar on consistency and standardized approaches to the measurement and capture of nurses’ work in Canada. Collectively these efforts will likely bring about an unprecedented visibility and hopefully, value to the work of nurses in Canada and beyond. More details to follow in future columns – stay tuned. In the meantime, think about the possibilities for the adoption of national clinical documentation standards. Possible, yes…probable, it’s up to us.
Canadian Nurses Association. (2006). Position Statement: Nursing Information and Knowledge Management. Retrieved from http://www2.cna-aiic.ca/cna/documents/pdf/publications/ps87-nursing-info-knowledge-e.pdf
Canadian Nurses Association. (2013). Top 5 in 5. Retrieved from http://www.cna-aiic.ca/en/on-the-issues/national-expert-commission/top-5-in-5/
Gugerty, B., Maranda, M.J., Beachley, M., Navarro, V.B., Newbold, S., Hawk, W., Wilhelm, D. (2007). Challenges and opportunities in documentation of the nursing care of patients. Baltimore: Documentation Work Group, Maryland Nursing Workforce Commission. Retrieved from http://www.mbon.org/commission2/documentation_challenges.pdf
Hannah, K., White, P., Nagle, L.M., & Pringle, D. (2009). Standardizing nursing information for inclusion in electronic health records: C-HOBIC. Journal of the American Medical Informatics Association, 16, 524-530.
VanDeVelde-Coke, S., Doran, D. Grinspun, D., Hayes, L., Sutherland Boal, A., Velji , K.,…Hannah, K. (2012). Measuring outcomes of nursing care, improving the health of Canadians: NNQR (C), C-HOBIC and NQuiRE. Canadian Journal of Nursing Leadership 25(2), 26–37.