Aim

To explore the use and impact of standardized terminologies (STs) within nursing and midwifery practice.

Introduction

The standardization of clinical documentation creates a potential to optimize patient care and safety. Nurses and midwives, who represent the largest proportion of the healthcare workforce worldwide, have been using nursing-specific and multidisciplinary STs within electronic health records (EHRs) for decades. However, little is known regarding ST use and impact within clinical practice.

Methods

A scoping review of the literature was conducted (2019) across PubMed, CINAHL, Embase and CENTRAL in collaboration with the Five Country Nursing and Midwifery Digital Leadership Group (DLG). Identified studies (n = 3547) were reviewed against a number of agreed criterion, and data were extracted from included studies. Studies were categorized and findings were reviewed by the DLG.

Results

One hundred and eighty three studies met the inclusion criteria. These were conducted across 25 different countries and in various healthcare settings, utilising mainly nursing-specific (most commonly NANDA-I, NIC, NOC and the Omaha System) and less frequently local, multidisciplinary or medical STs (e.g., ICD). Within the studies, STs were evaluated in terms of Measurement properties, Usability, Documentation quality, Patient care, Knowledge generation, and Education (pre and post registration). As well as the ST content, the impact of the ST on practice depended on the healthcare setting, patient cohort, nursing experience, provision of education and support in using the ST, and usability of EHRs.

Conclusion

Employment of STs in clinical practice has the capability to improve communication, quality of care and interoperability, as well as facilitate value-based healthcare and knowledge generation. However, employment of several different STs and study heterogeneity renders it difficult to aggregate and generalize findings.

中文翻译：

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在临床实践中使用标准化术语：范围界定审查

目的

探索护理和助产士实践中标准化术语（ST）的使用和影响。

介绍

临床文献的标准化创造了优化患者护理和安全性的潜力。在全球医疗保健工作人员中占最大比例的护士和助产士数十年来一直在电子健康记录（EHR）中使用特定于护理和多学科ST的ST。但是，关于ST的使用及其在临床实践中的影响知之甚少。

方法

与五国护理和助产士数字领导小组（DLG）合作，在PubMed，CINAHL，Embase和CENTRAL之间对文献进行了范围界定性审查（2019年）。已对确定的研究（n = 3547）进行了对照一致同意的标准的审查，并从纳入的研究中提取了数据。DLG对研究进行了分类，并对发现进行了审查。

结果

一百八十三项研究符合纳入标准。这些活动是在25个不同的国家和不同的医疗机构中进行的，主要利用特定于护理的（最常见的是NANDA-I，NIC，NOC和奥马哈系统），而较少使用本地，多学科或医疗性ST（例如ICD）。在研究中，对ST进行了评估，包括测量属性，可用性，文档质量，患者护理，知识生成和教育（注册前和注册后）。除了ST内容之外，ST对实践的影响还取决于医疗机构，患者队列，护理经验，在使用ST中提供的教育和支持以及EHR的可用性。

结论

在临床实践中使用ST可以改善沟通，护理质量和互操作性，并促进基于价值的医疗保健和知识创造。但是，使用几种不同的ST和研究异质性使得难以汇总和归纳研究结果。