This study was to construct a useful nursing language system on military nursing field.
Method
Military hospital nursing records were analyzed using NANDA(North American Nursing Diagnosis Association), NIC(Nursing Interventions Classification), and NOC(Nursing Outcomes Classification) systems. All kinds of nursing statements from 80 sets of orthopedics inpatient's records were deduced. All nursing statements were mapped to 167 NANDA diagnoses, 433 NIC interventions, and 260 NOC outcomes.
Result
14,744 nursing statements were extracted. Among the extracted nursing statements, 11.75% were linked with NANDA diagnosis, 83.62% were connected with NIC intervention, and 0.96% was tied to NOC outcome. 3.66% of nursing statements were not linked with NANDA-NIC-NOC system. In the nursing statements, 18 diagnoses of NANDA, 63 interventions of NIC, 8 outcomes of NOC were used.
Conclusions
The majority of those nursing statements focused on nursing intervention of the nursing process; few nursing plans or goals were found in nursing records. Therefore, it's difficult to make the nursing process network with the nursing statements. Documenting nursing records using a nursing process will contribute to strengthen nursing practice in patient care and to develop nursing as science. Continuous further researches related to nursing records are needed to provide basic data for developing nursing language system and nursing record system.
1. Cheon HS, Moon SN, Kim EJ. Development and evaluation of nursing process program in DEMIS. Presented at 17th Military Nurse Conference. 2005, September.
2. Chi SA, Choi KS, Park KS, Jung YK. A basic study on improvement and computerization of nursing record. J Korean Acad Nurs. 1999;29(1):21-33.
3. Choi JY, Kim HS, Park MS. A correlation study of perceived importance of nursing interventions with performance frequency in psychiatric nursing units using the 3th NIC. J Korean Acad Nurs. 2003;33(1):95-103.
4. Choi JY, Park MS, Kim HS. A survey on nursing interventions of psychiatric nursing unit using the 3th NIC. J Korean Acad Psychiatr Ment Health Nurs. 2002;11(2):125-136.
5. Choi SH, Cho BH, Ji HR, Lee EJ, Kim HS, Park MJ. Standardized linkage between nursing diagnosis and intervention. 2004;Seoul, Hyunmoon publlishung co..
6. Kang HS. Nursing interventions for the patient with liver cirrhosis under the patient classification. 2003;Seoul, Seoul National University. Unpublished master's thesis.
7. Kim HS. Development and application of a computerized nursing process program for orthopedic surgery inpatients - NANDA, NOC, and NIC Linkages. J Korean Acad Nurs. 2005;35(6):979-990.
8. Kim KMJ, Kim KJ, Cha YN, Jang JS, Yoon J, Gong ES, Jung YS, Hwang SJ, Yang BS. NANDA nursing diagnosis and intervention guide. 2006;Seoul, Hyunmoon publlishung co.
9. Kim MS. Use of the nursing intervention classification by the coronary care nurses in Korea. 1997;Seoul, Seoul National University. Unpublished master's thesis.
10. Kim SY, Chin YR, Oh VC, Park EJ, Yun SN, Lee IS. Analysis of the nursing interventions performed by public health nurses in health centers using the NIC. J Korean Acad Nurs. 2006;36(2):217-226.
11. Kim YJ. Analysis of nursing records of cardiac surgery patients based on nursing process focusing on nursing outcome. 2004;Seoul, Seoul National University. Unpublished master's thesis.
12. Kwon MS. Analysis of nursing intervention using NIC. 2002;Seoul, Chung-Ang University. Unpublished master's thesis.
13. Lee E. International comparison of nursing interventions performed by neurologic and orthopaedic nurses. J Korean Acad Adult Nurs. 2001;13(4):517-528.
14. Lee EJ, Choi IH. Comparison on nursing importance and performance of nursing interventions linked to nursing diagnoses-focused on 5 NANDA nursing diagnoses. J Korean Acad Nurs. 2003;33(2):210-219.
15. Lee MS. Analysis of nursing records of cancer patients using standardized nursing language. 2003;Daegu, Keimyung Universty. Unpublished master's thesis.
16. Lee MS, Lee BS. Analysis of nursing records of cancer patients with standardized nursing language systems. J Korean Acad Nurs Adm. 2004;10(2):243-254.
17. Lee YY, Chi SA. Analysis of core intervention using NIC. Chung-Ang J Nurs. 2001;5(2):33-44.
18. McCloskey JC, Buleckek GM.
Yom YH
Kim MS
Park SA
Park JH
. NIC. 1998;Seoul, Hyunmoon publlishung co.. Original work published 1996.
19. Oh WO, Suk MH, Yoon YM. A survey of the nursing interventions performed by neonatal nursing unit nurses using the NIC. Korean J Child Health Nurs. 2001;7(2):161-178.
20. Park HA, Kim JE, Cho ES. Taxonomy of nursing diagnosis, intervention, and outcome. 2000;Seoul, Seoul National University publishing department.
21. Park OY. Analysis of the nursing intervention performed in the medical & surgical units and the health insurance cost items based on the NIC. 2006;Jinju, Kyungsang National University. Unpublished master's thesis.
22. Park SA. Nursing management. 2005;Seoul, Parkmoongak.
23. Park SH. Linkages of nursing diagnoses and nursing interventions for nursing clinical decision support system. 2006;Seoul, Seoul National University. Unpublished doctoral dissertation.
24. Ryu DH. Analysis of nursing records of cardiac internal medicine unit using ICNP classification. 2001;Seoul, Seoul National University. Unpublished master's thesis.
25. Ryu EJ, Choi KS, Kwon YM, Joo SN, Yun SR, Choi HS, Kwon SB, Lee JH, Kim BJ, Kim HY, Ahn OH, Rho ES, Park KS. Analysis of the nursing interventions done by MICU and SICU nurses using NIC. J Korean Acad Nurs. 1998;28(2):457-467.
27. Yom YH, Kim SS, Kim IS, Park WS, Kim EJ. Nursing Interventions Classification (NIC) use in Korea: Oriental medicine hospitals and general hospitals. J Korean Acad Nurs. 1999;29(4):802-816.
28. Yom YH, Lee KE, Chang HK, Kim EJ, Li CY, Kim KY, Huang ZY, Yuk MA. Analysis of nursing interventions performed by Chosunjok nurses in Yanbian using NIC. J Korean Acad Nurs. 2001;31(5):793-807.
29. Yu HS. Database construct of nursing diagnosis, intervention and outcome for laparotomy patient. 2001;Seoul, Chung-Ang University. Unpublished doctoral dissertation.
Figure 1
Process of nursing records analysis (Cluster N. / Total N.)
Table 1
Cluster and number of statement per record
Table 2
Statement analysis in nursing taxonomy per record
Table 3
Nursing taxonomy analysis per record
Table 4
No link nursing statement
Figure & Data
References
Citations
Citations to this article as recorded by
Implementation of an Electronic Nursing Record for Nursing Documentation and Communication of Patient Care Information in a Tertiary Teaching Hospital Myeong-Seon Lee, Seonah Lee CIN: Computers, Informatics, Nursing.2021; 39(3): 136. CrossRef
Identification of Nursing Diagnosis–Outcome–Intervention Linkages for Inpatients in the Obstetrics Department Nursing Unit in South Korea Min Ji Yang, Hye Young Kim, Eun Ko, Hyun Kyung Kim International Journal of Nursing Knowledge.2019; 30(1): 12. CrossRef
Identification of Nursing Diagnosis-Outcome-Intervention Linkages for Inpatients in Gynecology Department Nursing Units Min Ji Yang, Hye Young Kim Korean Journal of Women Health Nursing.2016; 22(3): 170. CrossRef
Modeling job effectiveness in the context of coming out as a sexual minority: a socio-cognitive model Yuan-Hui Tsai, Sheng-Wuu Joe, Wei-Te Liu, Chieh-Peng Lin, Chou-Kang Chiu, Chiao-Chih Tang Review of Managerial Science.2015; 9(1): 197. CrossRef
Construction and Application of Nursing Information System Using NANDA-NOC-NIC Linkage in Medical-Surgical Nursing Units Eun Ko, Hyang-Sook So Korean Journal of Adult Nursing.2013; 25(4): 365. CrossRef
Factors Influencing the Drinking Behavior in Female University Students Hyun-Sook Ryu, Min-Ja Baek Journal of Korean Academy of Community Health Nursing.2012; 23(3): 307. CrossRef
Korean and United States: Comparison of Costs of Nursing Interventions Sung-Jung Hong, Eun-Joo Lee Korean Journal of Adult Nursing.2012; 24(4): 358. CrossRef
Analysis of Nursing Interventions Performed by Gynecological Nursing Unit Nurses Using the Nursing Interventions Classification Sung-Jung Hong, Sung Hee Lee, Hwa Sun Kim Korean Journal of Women Health Nursing.2011; 17(3): 275. CrossRef
