Defining the Contextual Differences of New Zealand Nursing in Preparation for the Implementation of Nursing Classification Schemes

• Abstract
• Introduction
• The Project
• Standardised Nursing Terminologies
• Processes
• Conclusion
• Acknowledgements
• References

Abstract
Technology New Zealand, supported by the Foundation of Research, Science and Technology, has recently approved a three-year PhD Technology in Industry Fellowship to PhD student Shona Wilson, iSOFT NZ Ltd and the Graduate School of Nursing, Midwifery and Health, Victoria University of Wellington to develop a model for the collection of nursing specific information to support nursing practice in New Zealand. The model will aim to determine the factors that need to be considered when implementing within New Zealand a standardised nursing classification scheme that has been developed in another country and to provide a way to inform future implementation that is contextualised to New Zealand’s nursing needs. The project involves the configuration of a nursing specific classification scheme into the iSOFT NZ Ltd existing clinical information system, the HealthViews Electronic Health Record solution. Once configured, the classification scheme/terminology will be implemented within a single service in a District Health Board, where nurses using the scheme to capture the nursing problems, activities and outcomes of daily care, will complete progressive surveys and focus group interviews to determine the professional nuances and colloquialisms of New Zealand nursing language that need to be considered at the user-interface level for nursing clinical information data collection. International strategies to maintain and sustain comparability of data will be considered within the development of the model along with ways to address infrastructural variances concerning nursing practice in New Zealand.

The major points that have emerged from the beginning of theoretical exploration and the intent of the project will be outlined in this paper. The case to support the need for the collection of nursing activities and outcomes in New Zealand in a manner that is comparable across providers and regions will also be presented.

Introduction
The Technology for Industry Fellowships (TIF) programme enables full-time students to complete research and development projects in collaboration with industry partners. According to the Foundation for Research, Science and Technology (FoRST; 2006)^[1] , TIF aims to:

• enhance scientific and technical skills and competencies in New Zealand businesses;
• expose undergraduates, masters and doctorate students and post-doctoral researchers to an industrial environment; 
• create research and technology of benefit for business; and
• foster links between universities, research institutes and businesses.

Technology New Zealand (TechNZ)supported by FoRST, has approved the three-year TIF to PhD in Nursing student Shona Wilson, iSOFT NZ Ltd, and the Graduate School of Nursing, Midwifery and Health (GSNMH), Victoria University of Wellington (VUW) to develop a model for the collection of nursing specific information to support nursing practice in New Zealand. The model will emerge from the introduction of a nursing specific tool for collection of data into the iSOFT NZ Ltd HealthViews EHR and so expand the potential for health information collection to include nursing data. The configuration of the expansion follows an in-depth exploration of the state of play in relation to the collection, storage and collation of nursing specific concepts within clinical information system (CIS) internationally. Testing of the new solution within a nursing service will provide ways to adjust international frameworks to the New Zealand context and so inform a way forward for using CIS for the benefit of nursing practice.

This paper outlines the project intent and the major points that have emerged from the beginning of theoretical exploration for the project. The case to support the need for the collection of nursing activities and outcomes in New Zealand in a manner that is comparable across providers and regions is also presented.

The Planned Project
This project aims to develop a theoretical model to guide the implementation of standardised nursing vocabularies in New Zealand within the local context of nursing practice. As a first step a nursing specific classification scheme/terminology that captures nursing practice will be configured into the existing CIS. Contemporary standardised terminologies centre on the activities of nursing care delivery in terms of nursing problems, interventions and the client outcomes that result. This will provide information about what nurses do, why they do it and what difference nursing makes to the health of New Zealanders.

The next step of the project will be to identify a classification scheme that is commensurate with the standards and information processes for collecting health related data in New Zealand and automate it within the iSOFT NZ Ltd HealthViews EHR to guide nursing documentation and manage nursing information. Such classification schemes exist overseas but are not in common usage within New Zealand CIS. The embedded terminology will be tested using Delphi techniques for completeness and congruency between the user interface language and the everyday vernacular that describes nursing practice in New Zealand. The cumulative results of the theoretical exploration, configuration of the terminology within the CIS and the study with nurses using the software in practice will inform the model’s development.

Outcomes from the project will be two-fold:

1. The iSOFT NZ Ltd Healthviews Electronic Health Record (EHR) CIS that will have the capacity to classify nursing activities and outcomes. It will be able to establish relationships between the data elements collected to provide discipline specific information that will be comparable nationally and internationally; and
2. A theoretical model for nursing practice which will define the major concepts to be considered for the implementation of nursing classification schemes/terminologies embedded within CIS in New Zealand. In particular it will posit ways to implement user interface terminologies that have originated outside New Zealand so that they are congruent with the common terms of practice nationally whilst maintaining potential for comparability of data. The model will also define any contextual issues that arise from the study that need to be addressed to maximise success of nursing specific data collection in New Zealand.

The project is congruent with the direction of the New Zealand Health Information Strategy (2005)^[2] for improving information flow in health care delivery. The strategy identifies the use of standardised terminologies within clinical practice domains as a fundamental prerequisite for the sharing of client record and care information between health care provider and service organisations that contribute to a client’s care.

Standardised Nursing Terminologies
As health care delivery becomes more complex the ability to use CIS to record, store and collate nursing documentation becomes increasingly important to support the delivery of nursing care and to measure its impact within the health services.^[3-6]  The use of databases within those CIS to make associations and relate to health outcomes for New Zealanders in a climate of emergent EHR repositories would enable the impact of nursing on health outcomes to be measured. It would enable nursing service delivery to be measured for contractual purposes and would allow the establishment of nursing knowledge repositories that cross map with multi-disciplinary health repositories.^[7-12] In particular, as mobile technologies are implemented in nursing, it would become increasingly important to capture nursing practice at the point of care (POC) delivery in a structured and standardised manner rather than as descriptive textual notes.

Nurses make up the largest group of health professionals in New Zealand and the cost of nursing is high. Nurses are required to document the care they deliver but have been left out of the information revolution; systems have not been developed which adequately record the activities of their day-to-day practice. As a consequence, nursing cannot be tracked or measured. Nurses’ current documentation processes are lengthy descriptive textual entries taking up large amounts of time and not contributing to analysis. What is needed is automation of nursing specific classification schemes within existing CIS.

Currently, various nursing specific terminologies are available – 13 are from within the US and one was initiated by the International Council of Nurses (ICN) and specifically designed to meet the need of practice internationally.^[7] It has been acknowledged that each country has its own nuances of language, cultural mores and differences of practice and that transposition of a language designed to meet the need in one country to another without consideration for those differences may not necessarily meet the need in the other. ^[13] Conversely, the longer the issue is not addressed and nursing practice remains without any means to classify the way it describes its intrinsic elements the more nursing will remain vulnerable to models driven by other professions, the less data will be able to be compared and the less capacity we will have to validate the discipline and measure the contribution it makes to the health status of New Zealanders.^[14]

This project commenced with a theoretical exploration which has considered the common practices and processes of nursing and situated them within the Nursing Council of New Zealand’s national definition of nursing.^[15] The emergent trend for nursing care to be documented using clinical pathways has been compared and contrasted with the activities and outcomes based model of the nursing process. This has then been located within the international literature that supports the need for nursing process based standardised terminologies to enable collection of nursing related data that meets the basic information needs of nursing practice.^[3]

An examination of current international trends for the uses of standardised nursing terminologies reveals that the academic community remains unsure as to whether it will be possible to have one terminology for all aspects of nursing.^[16] As nursing is so diverse, it is generally acknowledged that more than one terminology may be used as discipline specific while still maintaining comparability, or at least the potential for comparability, as long as what occurs at the user interface cross-maps satisfactorily with a recognised clinical reference terminology. What also emerges is the importance of using a vocabulary at the POC that nurses feel at ease using. Continued use of terms with which nurses have no or limited familiarity will only encourage rejection consistent with known technology adoption model findings. However success of the potential to compare the data depends upon widespread use by nurses.^[17]

For New Zealand nursing herein lies the dilemma. Do the decision-makers implement into existing CIS terminologies that have been developed in another country, suited to that context and which are known to be colloquial in nature for the nurses of that country? Terms that may be considered colloquial in one country may not be considered colloquial in another. Terms that have one meaning in one country may not have the same or even similar meaning in another. Both the terminologies and the meanings attached to them, along with the actual processes and practices of nursing, may differ quite widely country to country as each has its own nuances and contextual variances.

User interface terminologies may differ between services and also differ from a clinical reference tool in use such as SNOMED CT. Clinical reference tools contain the terms to refer to concepts and enable relationships to be drawn from amongst concepts from multiple services or between multiple disciplines. They are not commonly used at the user interface as a discipline specific terminology. To obtain comparable data for aggregation and analysis from the diversity of what constitutes nursing, the terms of the user interface need to be associated with the concepts within a clinical reference terminology. It is the reference terminology that traces and tracks identical concepts between user interface terminologies. It would appear that the potential for user interface terminologies to compare like data lies in their ability to cross-map with reference terminologies.^[17]

If the selection of the clinical reference tool has primacy in maintaining capability for comparability of data and can be mapped to from a variety of different terminologies, what user interface language should be used? Central to the argument is that the user interface terminology must contain the terms of everyday practice of the nurses who will be using it. In order to enable this to happen, it may be that what exists as a terminology overseas may require alteration in a country outside its country of origin to accommodate the everyday vernacular of the nursing group it serves. The dilemma is this: the more one deviates from the standardised terminology the greater potential for loss of comparability. On the other hand, the less familiar the terms, the higher the likelihood of non-use. Is there a compromise?

This project will go some way to suggesting a solution for these dilemmas. The study component is expected to be able to inform a theoretical model that will suggest a way to configure standardised terminologies into CIS so that user uptake is maximised and yet the potential to maintain comparability nationally and internationally can be retained.

Further complicating the issues for New Zealand nursing is the current lack of a clinical reference tool that includes nursing elements for use within the health care system to draw the relationships between data together. This means that any terminology that is implemented needs to be one that is recognised as cross-mapping with the clinical reference tools that have the market share internationally, with the expectation that one of these will eventually be implemented in New Zealand. However, the lack of reference terminology must not be permitted to impede the beginning of the journey towards nurses being able to use CIS in health to capture and so validate what they do.

As a means to address this tension, the model that emerges from this project will consider the unique features of health care delivery, the nuances and mores of nursing practice located within New Zealand, the international trends and movements in using CIS to capture nursing practice and the potentials for cross-mapping to multi-disciplinary clinical reference tools. It will define ways to preserve the unique factors associated with nursing practice in New Zealand and address such issues as computer uptake and nursing use of CIS to support practice. Significant benefits will result from this: the model will ensure that the principles of New Zealand that are reflected in nursing practice, such as partnership models for health care delivery, are valued as nursing related information becomes incorporated into health information collection strategies. It may offer some protection for nursing in New Zealand from the imposition, without consideration for contextual variances, of nursing classification schemes developed outside New Zealand.

The initial exploration, which has been undertaken by immersion in and synthesis of contemporary national and international literature using intuitive crystallisation methods, has served to determine some baseline criteria for the selection of an existing nursing specific standardised terminology to implement within HealthViews EHR. The terminology should be:

1. Structurally congruent with the existing CIS structure (eg, taxonomic);
2. Validated within the literature as able to cross-map with clinical reference terminologies;
3. Recognised by international nursing informatics organisations such as the ICN as valid and reliable in practice;
4. Readily available in the public domain as no resources are provided to purchase licenses;
5. Validated by contemporary research;
6. Congruent with national standards, protocols, policies and strategies such as those being developed by the Health Information Standards Organisation (HISO) and Health Information Service;^[2]
7. Cognisant of international movements such as the International Standards Organisation (ISO) vocabulary standards for health care;
8. In current use; and
9. Containing primarily concepts, terms and definitions that are in common usage in nursing in New Zealand. The next step will be to select a terminology that meets these criteria to write into the HealthViews EHR, followed by a small study of implementation in practice within a single service in a District Health Board (DHB). The study will use Delphi techniques with a small sample of Registered Nurses who will use the embedded terminology to capture the activities of their daily practice and provide insight into the usefulness of the user interface language and its congruency with nursing practice in New Zealand.

 

Processes
Three organisations have been brought together to collaboratively undertake this project:

1. The GSNMH, VUW, as New Zealand’s sole graduate school for nurses, midwives and other allied health professionals. It has an established reputation for sustaining practice based research and development with associated relationships within some DHBs. New Zealand’s nurses are key stakeholders and participants in the health care delivery process and nursing informatics education has become crucial for effective and efficient practice for nurses to achieve the information management and computing skills requirements of the Nursing Council of New Zealand (NCNZ). Historically medical and health informatics education in New Zealand has been offered from computer science and business schools with a focus on the technologies. The GSNMH recognises the primacy of nursing practice in the informatics equation and is developing graduate courses in this area for nurses with a nursing practice focus to address the gap in the educational market. Recognising the importance for standardised classification of nursing activities from POC and with a reputation for excellence in nursing practice development in New Zealand, the GSNMH has facilitated the relationship between iSOFT and a DHB. This research and development project will provide the foundation for research-based teaching and learning within the GSNMH.
2. iSOFT Health Systems New Zealand Ltd, as part of iSOFT Group Plc. iSOFT specialises exclusively in the development and delivery of IS solutions for health care markets. Its CIS development strategy is founded on clinical expertise, provided by clinical informaticians working within the company and upon partnership relationships with clinical experts in a wide variety of practice environments. iSOFT does not currently provide a nursing specific solution within their applications and has recognised the market gap. This project allows them to consolidate their working relationships and will address the market gap to provide a nursing specific solution within their existing CIS which is already widely used in New Zealand.
3. A DHB. Negotiations are currently taking place between GSNMH, VUW and a DHB that has an existing strong relationship with the university. The DHB uses iSOFT CIS and has a track record for innovation in health care technologies.

The relationship between these organisations functions at a high level of collaboration, indicative of the complexities that surround health care software development, implementation and evaluation to suit the local context. Each of the parties has a contractual relationship with TechNZ and each other that outlines their responsibilities within the project and protects intellectual property rights. This will ensure the successful development of this project as it unfolds over the next three years. The work up to this stage of the project has been lengthy in order to accommodate the successful merging of academia, commerce and nursing but nursing practice may now be able to move forward in New Zealand with a means to validate what it does and the contribution it makes to the health status of New Zealanders.

Conclusion
Although it is a significant step forwards, this project is very much a beginning only in standardised terminology implementation in New Zealand. It will provide a guideline for the validation of the nursing profession by being able to measure the contribution nursing and nurses make to health outcomes. The emerging model will draw on the opinions of nurses in the field while at the same time locating international movements within the context of New Zealand.

Acknowledgements
This work has been supported to date by several awards including:

1. New Zealand Health Information Service Working to Add Value through E-information (WAVE) Scholarship as a seeding grant which enabled proposal development and scoping of the project in 2005.
2. VUW Pro Vice-Chancellor Information Technology grant (2005) for initial PhD fee and time support that enabled relationships with systems developers and nursing practice to be established.
3. Education New Zealand Post Graduate Study Abroad Award, to enable presentation of the study in Korea in June 2006 and then Japan to further identify contextual differences when implementing a standardised terminology in nursing practice within a culture and/or country outside its country of origin. In particular, this will shape elements within the emergent model that are relevant to the transposition of existing terminologies.
4. TechNZ for a three-year fellowship to undertake the project.

References

1. Foundation for Research Science and Technology. Technology for industry fellowships (TIF). 2006. http://www.frst.govt.nz/business/fund_TIF.cfm. Accessed 4 July 2006.
2. Health Information Strategy Steering Committee. Health information strategy for New Zealand. Wellington, New Zealand: Ministry of Health; 2005.
3. Androwich IM, Bickford CJ. Button PS, Hunter KM, Murphy J, Sensmeier J. Clinical information systems: a framework for reaching the vision. Washington, DC American Nurses Publishing; 2003
4. Harris MR, Graves JR, Solbrig HR, Elkin PL, Chute GC. Embedded structures and representations of nursing knowledge. J Am Med Inform Assoc 7 November 7 2002; 7(6): 539-549
5. Ozbolt J, Abraham IL, Schultz S. Nursing information systems in nursing. In: Shortcliffe EH, Perreault L, Wiederhold GCM, Fagan LM (eds). Medical Informatics: Computer Applications in Health Care. Menlo Park, CA: Addison Wesley; 1990. pp244–72.
6. Zielstorff R, Hudgings C, Grobe S. Next-generation nursing information systems: essential characteristics for professional practice. Washington, DC: American Nurses Publishing; 1993.
7. Coenen A. The international classification for nursing practice (ICNP) programme: advancing a unifying framework for nursing. Online J Issues Nurs April 2003. http://www.nursingworld.org/ojin/tpc7_8.htm. Accessed 30 June 2004.
8. Conrick M, Hovenga E. A framework for nursing informatics in Australia: a strategic paper. 2004. http://www.hisa.org.au/PDF/Nursing%20Informatics%20in%20Australia_final%20Version1.pdf. Accessed 8 September 2005.
9. Englebart SP, Nelson R. Health care informatics: an interdisciplinary approach. Philadelphia: Mosby; 2002
10. Henry SB, Warren JJ, Lange L, Button P. A review of major nursing vocabularies and the extent to which they have the characteristics required for implementation in computer-base systems. J Am Med Inform 7 Nov 1998. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=61307. Accessed 5 July 2004.
11. Martin KS. The Omaha system: a key to practice, documentation and information management. 2nd ed. Missouri: Elsevier Inc; 2005. ^[12] Werley H, Lang N. The consensually driven nursing minimum data set: Elements and Definitions. In Identification of the Nursing Minimum Data Set. H Werley, N Lang (eds). New York: Springer; 1998.
12. Clark J. The international classification for nursing practice project. Online J Issues Nurs 1998. http://www.nursingworld.org/ojin/tpc7/tpc7_3.htm. Accessed 27 July 2004.
13. Saba V, Hovenga E,Coenen A, McCormick K, & Bakken S. Nursing language: terminology models for nurses. ISO Bulletin Sept 2003. http://www.iso.ch/iso/en/commcentre/isobulletin/articles/2003/pdf/terminology03-09.pdf. Accessed 20 August 2004.
14. Te Kaunihera Tapuhi o Aotearoa: Nursing Council of New Zealand. Scopes of practice. 2004. http://www.nursingcouncil.org.nz/scopes.html. Accessed 16 June 2005.
15. McCormick KA., Jones CB. Is one taxonomy needed for health care vocabularies and classifications? Online Journal of Issues in Nursing 30 September 1998. http://www.nursingworld.org/ojin/tpc7/tpc7_2.htm  
16. Ozbolt J. Terminology standards for nursing collaboration at the summit. J Am Med Inform 2000:7(6); 517–22.

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