The results of a pilot study

Building nursing’s minimum data set: the results of a pilot study

Cecelia Gatson Grindel

Nursing’s viability in health care databases is nonexistent. If nursing is to receive acknowledgment and reimbursement for the services provided to patients, nursing data elements must be visible in national health care databases. To identify nursing data elements, this pilot project tested three instruments that could be used to identify nursing diagnoses commonly used in the pert-operative and periprocedural care of patients. The results of the pilot project survey, the instrument of choice, and nursing diagnoses used during the pre, intra, and postoperative/procedural experience are described

Changes in the health care environment have highlighted the need for nurses to document that what they do makes a difference in patient outcomes. Existing computerized databases of health care facts are resources for much valuable information about patient care, as they provide data from which the effectiveness of health care interventions can be analyzed; they speak to quality of care issues, regional health care needs, the distribution of health care providers, and the cost of heath care. However, these databases have not included data elements that report nursing care.

The American Nurses Association (ANA) and other nursing specialty organizations have responded to the need to document that nursing care does make a difference in patient outcomes by supporting efforts to create Nursing’s Minimum Data Set (NMDS) (American Nurses Association, 1994a, 1994b; Kleinbeck, 1996). In Spring 1995, the Association of Operating Room Nurses (AORN) invited nursing specialty organizations to a meeting to discuss collaborative efforts to contribute to the NMDS by describing nursing care (diagnoses, interventions, patient outcomes) of patients during the pert-operative experience. As a result of this meeting, the Academy of Medical-Surgical Nurses (AMSN) and the National Association of Orthopaedic Nurses (NAON) decided to collaborate to identify nursing problems most commonly used in the pert-operative and pert-procedural care of patients. Dr. Dennis Ross, then NAON’s Project Director for Research, and Dr. Cece Grindel, past-president of AMSN, have directed efforts to examine nursing problems associated with the perioperative experience.

Background

The ANA has taken the lead in establishing a nursing minimum data set (ANA, 1986). As defined by the Unites States Health Information Policy Council (1983), a uniform minimum data set is “a minimum set of items of information with uniform definitions and categories, concerning a specific aspect or dimension of the health care system which meets the essential needs of multiple data users.” Similarly the NMDS is a minimum set of items of information with uniform definitions and categories concerning the specific dimension of nursing (ANA, 1994a). The purposes of the NMDS are to: (a) establish comparability of nursing data across clinical populations, settings, geographic areas, and time; (b) describe the nursing care of patients/clients and their families in a variety of settings, both institutional and noninstitutional; (c) demonstrate or project trends regarding nursing care provided and the allocation of nursing resources to patients/clients according to their health problems or nursing diagnoses; (d) stimulate nursing research through links to the detailed data existing in nursing information systems and other health care information systems; and (e) provide data about nursing care to influence clinical, administrative, and health policy decision-making (ANA, 1994a).

The NMDS includes three broad categories of elements: (a) nursing care; (b) patient/client demographics, and (c) service elements (ANA, 1994a). See Figure 1 for the elements included under each category. As can be seen, some of the elements are not unique to nursing; those highlighted by an asterisk (*) are already being collected and are available via the Uniform Hospital Discharge Data Set. The nursing care elements are not currently being collected as part of a data set; thus, nursing care is not visible as health care is being evaluated by health policymakers and third-party payers. To correct this omission, nursing specialty organizations are accepting the task of identifying specific nursing data (nursing diagnoses, nursing interventions, nursing outcomes, and the intensity of nursing care) that will be included as nursing care elements.

Three key nursing care elements in NMDS are nursing diagnoses, interventions, and outcomes (see Figure 1). These key elements are basic to describing nursing care of all patients and served as the foundation of this project. In deciding how to tackle this research initiative, several factors were considered. It became evident that there was a lack of a common language to communicate patient problems across nursing specialty groups and across disciplines. Until nursing began using a common language (nursing diagnoses) to describe a patient problem, communication across nursing specialties was difficult at best. From a theoretical perspective, nursing diagnoses result from a nursing assessment and give justification to the interventions that are implemented. The effectiveness of the interventions is determined by the patient outcomes. Given the fact that nurses are familiar with nursing diagnoses and that nursing diagnoses serve as the anchor for intervention implementation, it was decided that nursing diagnoses would be the initial focus in determining nursing care elements used during the operative experience. Thus, the ultimate goal was to identify nursing diagnoses used by nurses in caring for the patient during pert-operative and pert-procedural experiences. This report presents the results of the pilot study that was implemented to assess the usefulness of three research survey instruments proposed for use in the major project. These results are based on the data received from medical-surgical nurses responding to the pilot survey.

Method

The pilot project was designed to determine which of three research survey instruments would be most effective in collecting data. A randomly selected sample of 300 members from each organization (AMSN and NAON) was identified and 100 subjects from each organization were asked to complete one of three and a stamped self-addressed envelope was included for return of the surveys. Completion of the survey served as consent to participate.

Tool development As there were no tested tools available, three instruments were developed by the investigators: an open response form, a closed response form, and a combined response form. On the open response form, nurses were asked to identify associated nursing diagnoses used in caring for patients prior to, during, and after an operation or invasive procedure (cardiac catheterization, placement of arterial line, biopsy, etc.). On the closed response form, nurses were asked to record up to 20 invasive procedures or operations common in their practice and identify nursing diagnoses that were used prior to, during, and after the procedure or operation; the subjects were asked to refer to the list of diagnoses formally approved by the North American Nursing Diagnosis Association (NANDA) in selecting the nursing diagnoses. On the form that was both closed and open-ended, nurses were requested to list up to 10 common procedures and surgeries. Keeping these in mind, the nurses were asked to rate how frequently they would use each of the nursing diagnoses from the NANDA list. These responses were entered on a Scantron sheet which was returned to the association’s national office for analysis. All forms included demographic and workplace questions. Three content experts reviewed each survey for face validity. Revisions were made based on suggestions received from the content experts.

Sample. The sample for the pilot included a purposive sample of AMSN members who identified their practice area as surgical or medical-surgical nursing. The subjects were randomly selected from the membership list and stratified based on geographic location. A total sample of 300 members was used, 100 subjects for each instrument.

Procedure. The survey methodology for the pilot consisted of one mailing of the instrument, with reminder letters sent 3 weeks later to request completion of the survey if the subject had not done so. Mailings were sent in Spring 1996, by Anthony J. Jannetti, Inc., AMSN’s management firm. Returns from the survey were collected at the national office. Demographic and workplace data were scanned via Scantron and coalesced as descriptive data. All surveys were then forwarded to the investigator who entered the written responses into word processing files (WordPerfect 6.0) for content analysis.

Results. The subjects for this pilot project were fairly similar in composition, with most of the respondents of each group working in urban areas, in inpatient (hospital) facilities, and in institutions of 300400 beds. The diagnoses identified from the various instruments were comparable, demonstrating a wide range of nursing diagnoses used, with a concentrated number of them being used more consistently. Common surgeries identified were gastrointestinal, gynecologic, and orthopedic cases, while procedures that were frequently listed included insertion of central lines, angiogram, thoracentesis, and cardiac catheterization.

Summary results of the survey data are presented in the following tables. Table 1 displays the results of Response Form A (closed response form) and identifies the common invasive procedures and nursing diagnoses used during the operative experience. Thirty-two nurses responding to this survey identified 58 surgeries and 18 procedures, demonstrating the wide range of nursing care that the medical-surgical nurse participates in. The most common surgeries included cholecystectomy, bowel resections, mastectomy, and total hip replacement; the most common procedures included angiogram/arteriogram and central line placement.

Table 1.

Results of Tool A (Closed Response Form)

Common Invasive Procedures and Nursing Diagnoses Used During the Operative

Experience

Response Rate: 32%

Surgery or Procedure(*)

Surgeries:

Cholecystectomy (laser

or abdominal) (12)

Bowel resections with

or without colostomy, colectomy (11)

Mastectomy (modified or radical) (10)

Total hip replacement (9)

TURP (8)

Hysterectomy (8)

Revascularization surgery (fem-pop,

pop-tib) (7)

AAA (6)

Laminectomy (6)

Total knee replacement (5)

Coronary artery bypass (5)

Thoracotomies with or

without lobectomy (5)

Procedures:

Angiogram, arteriogram (7)

Central line placement

(Hickman cash, triple

lumen cash) (6)

Endoscopy (4)

Colonoscopy (4)

J-, PEG, or G-tube

placement (3)

Lumbar puncture (3)

Pre-procedure Diagnoses(**)

Knowledge deficit (146)

Anxiety (116)

Fear (35)

Pain (19)

Altered peripheral

tissue perfusion (14)

Activity intolerance (12)

Potential for infection (11)

Impaired physical

mobility (11)

Ineffective individual

coping (9)

Altered cardiopulmonary

tissue perfusion (8)

Fatigue (7)

Anticipatory grieving (7)

Potential activity intolerance (6)

Altered nutrition: less than

body requirements (6)

Decreased cardiac output (5)

Impaired tissue integrity (5)

Impaired home maintenance management (5)

Intra-procedure Diagnoses(***)

Potential for infection (27)

Hypothermia (12)

Decreased cardiac output (12)

Pain (8)

Postprocedure Diagnoses(****)

Potential for infection (159)

Pain (141)

Knowledge deficit (115)

Impaired gas exchange (46)

Ineffective airway clearance (46)

Impaired skin integrity (43)

Potential for altered body temperature (42)

Impaired physical mobility (42)

Potential fluid volume deficit (41)

Potential impaired skin integrity (41)

Potential for suffocation (41)

Impaired tissue integrity (40)

Urinary retention (40)

Anxiety (38)

Constipation (37)

Altered urinary elimination (28)

Altered peripheral tissue perfusion (26)

Potential for injury (22)

Altered nutrition: less than body requirements (20)

Activity intolerance (20)

Potential activity intolerance (20)

Ineffective individual coping (18)

Fear (16)

Fatigue (14)

Sleep pattern disturbance (14)

Impaired home maintenance management (14)

Sexual dysfunction (12)

Fluid volume deficit (11)

Altered role performance (10)

Altered parenting (10)

(*) A total of 58 surgeries were identified by respondents; only those listed 5 or more times are presented; a total of 18 procedures were identified, only those listed 3 or more times are presented.

(**) Only those nursing diagnoses listed 5 times or more are presented.

(***) Only 1 nurse identified nursing diagnoses during the intra-procedure period for surgeries, while 3 nurses identified intra-procedure diagnoses during the intra-procedure period for invasive procedures.

(****) Only those nursing diagnoses listed 10 times or more are presented.

Overwhelmingly these nurses recognized that, prior to the operative experience, patients had knowledge deficits about the surgical or invasive procedure and that they were anxious. Intra-procedure diagnoses were identified by four nurses who indicated that the potential for infection was a major concern. Postoperatively, the diagnoses of potential for infection, pain, and knowledge deficit were consistently identified as pertinent.

Table 2 presents nursing diagnoses used for the top four surgical procedures identified from Response Form A. These data provide the reader with a general perspective of the distribution of nursing diagnoses by surgery type and throughout the operative experience. For example, 12 nurses listed cholecystectomy as a common surgical procedure. Of these 12, seven of them identified that anxiety and knowledge deficit were relevant pre-operative diagnoses; a total of 12 pre-operative diagnoses were listed for a cholecystectomy. Postoperatively 25 diagnoses were listed by the 12 nurses. Eleven of them agreed that the potential for infection and pain were key nursing diagnoses for this postoperative experience. Similar patterns prevailed when examining the data for bowel resection (n= 11), mastectomy (n=10), and total hip replacement (n=9).

[TABULAR DATA 2 NOT REPRODUCIBLE IN ASCII]

Table 3 lists common invasive procedures, surgical procedures, and nursing diagnoses derived from Response Form B (combined form). Thirty-five nurses completed this survey. A total of 60 surgeries were listed. Similar to the results noted in Form A, cholecystectomy, lower bowel resection, mastectomy, and total hip replacement were identified as common surgical procedures. Thirty-seven invasive procedures were listed, with central line placement and angiogram/arteriograms again topping the list of procedures. Pain, potential for infection, and knowledge deficit were the nursing diagnoses most often related to the operative experience; however, anxiety, potential for injury, impaired skin integrity, and the potential for impaired skin integrity were also frequently reported.

Table 3.

Results of Tool B

(Open and Closed-Ended Form)

Common Surgeries, Invasive Procedures, and Nursing Diagnoses

Response Rate: 35%

Common Operative Procedures(*)

Cholecystectomy (17)

Lower bowel resections (14)

Mastectomy with or without

TRAM flap (13)

TURP (11)

Total knee replacement (11)

Total hip replacement (11)

Colectomy (11)

Common Invasive Procedures(**)

Central line placement

(Hickman, triple lumen cash, Swan Ganz, PORTs) (23)

Angiogram, arteriogram (19)

Thoracentesis with or without

chest tube placement (14)

Cardiac catheterization (12)

Colonoscopy with or without biopsy (12)

Endoscopy/gastroscopy (11)

GI studies (UGI, BE, IVP, etc.) (9)

Drainage catheter placement (9)

Biopsy (renal, breast, liver, bone marrow, etc.) (8)

J-, PEG, or G-tube placement (7)

ERCP (7)

Myelogram (5)

I&D, debridement (5)

Common Diagnoses.(***)

Pain (91.43%)

Potential for infection (74.29%)

Knowledge deficit (61.76%)

Anxiety (54.29%)

Potential for injury (48.57%)

Impaired skin integrity (42.86%)

Potential for impaired skin

integrity (40%)

(*)Only those surgeries listed 10 or more times are presented. A total of 60 surgeries were listed.

(**)Only those procedures listed 5 or more times are presented. A total of 37 invasive procedures were listed.

(***)These diagnoses were used “frequently” or “always” by 40% or more of the respondents.

The total number of nursing diagnoses identified on Response Form C (open-ended form) is presented in Table 4. Twenty-one nurses returned this survey, in which the nurses were asked to think about common surgeries and invasive procedures in their area of practice and then identify nursing diagnoses used throughout the operative experience. Knowledge deficit and anxiety were frequently associated with the pre-operative and pre-procedure experience. More nursing diagnoses were listed for surgical procedures during the intra-operative period; however, there were five nursing diagnoses that were common to both (impaired gas exchange, fluid volume deficit, impaired tissue integrity, risk for injury, decreased cardiac output). With the exception of “activity intolerance,” all of the diagnoses listed for postprocedure care were found in the list of postoperative diagnoses. The rank ordering of the diagnoses identified by these nurses, however, is different for postprocedure and postoperative care. For example, pain ranks first on the postoperative list, while it places second on the postprocedure list.

Table 4.

Response for Tool C

(Open-Ended Form)

Nursing Diagnoses Used During Pre, Intra, and Postoperative

Care of the Patient

Response Rate: 21%

Most Commonly Used Nursing

Phase of Care Diagnoses for Procedures.

Pre-operatively [Total diagnoses listed=28]

Knowledge deficit (11)

Anxiety (7)

Alteration in tissue perfusion (5)

Pain (4)

Alteration in comfort (4)

Intra-operatively [Total diagnoses listed=21]

Impaired gas exchange (4)

Fluid volume deficit (4)

Impaired tissue integrity (3)

Risk for injury (3)

Decreased cardiac output (3)

Postoperatively [Total diagnoses listed=29]

Alteration in tissue perfusion (8)

Pain (5)

Potential for infection (4)

Knowledge deficit (4)

Risk for injury (3)

Impaired physical mobility (3)

Alteration in comfort (3)

Anxiety (3)

Impaired gas exchange (3)

Activity intolerance (3)

Self-care deficit (3)

Most Commonly Used Nursing

Diagnoses for Surgeries.(*)

Pre-operatively [Total diagnoses listed=22]

Knowledge deficit (14)

Anxiety (9)

Pain (3)

[Total diagnoses listed=241

Impaired tissue integrity (5)

Potential for altered body

temperature (5)

Impaired gas exchange (4)

Decreased cardiac output (4)

Risk for injury (4)

Fluid volume deficit (3)

Alteration in skin integrity (3)

Potential for aspiration (3)

Postoperatively [Total diagnoses listed =51]

Pain (11)

Impaired physical mobility (11)

Alteration in fluid and electrolyte

balance (10)

Impaired skin integrity (9)

Altered nutrition (8)

Altered tissue perfusion (8)

Alteration in elimination (8)

Infection (7)

Knowledge deficit (7)

Alteration in comfort (6)

Risk for injury (6)

Self-care deficit (6)

Ineffective airway clearance (5)

Fluid volume deficit (6)

Anxiety (4)

Impaired gas exchange (4)

Impaired tissue integrity (4)

Ineffective breathing patterns (3)

(*) Only those diagnoses listed 3 or more times are presented.

Respondents pointed out the strengths and weaknesses of the particular survey they completed and addressed the clarity of the survey and ease in completing it. A few suggestions were offered for clarifying two of the demographic questions. Additional comments were made regarding the use of nursing diagnoses in their hospital. Some nurses reported that due to the use of critical pathways/ caremaps, nursing diagnoses are no longer used. One nurse noted that their computer-based documentation system limited the amount of detail in nursing diagnoses that could be charted. Another respondent noted the difficulty in using nursing diagnoses on a Kardex[TM] that is structured around body systems and corresponding clinical problems. A couple of nurses indicated that they were not sure that their units represented the “typical” medical-surgical unit.

Discussion

Criteria for selecting the tool for the major study included the following factors: response rate, comments of respondents about the tools, data collected by the tools, staff time to input/collate data, and ease in completing the forms by respondents and analysis of results by investigators. Based on these criteria, a modified version of Response Form B (a combination of closed and open-ended questions) was selected for the major study. Respondents reported that the tool was clear, concise, and easy to complete. Tool B was revised to reflect comments offered by the subjects and to enhance data collection. To assure differentiation between diagnoses used during the invasive procedure experience and the operative experience, the revised form requests that the respondent use the NANDA list of nursing diagnoses to identify diagnoses related to invasive procedures and then use the same list to report diagnoses used during the operative experience. Although the length of the tool increased with this approach, experience specific data will be assured. To facilitate ease in data management and analysis, the open-ended section (respondents were asked to list common surgeries and invasive procedures) was replaced with a list of common surgical and invasive procedures identified in the pilot surveys.

This revised survey was distributed to all AMSN members in September 1996. Each member was requested to complete the survey and return the Scantron sheet to the AMSN national office. Reminder postcards were sent to all members 3 weeks after the initial mailing. Data analysis is underway. The results of the major study will be published in MEDSURG Nursing.

Comments

The purpose of this pilot study was to identify a research tool that could be used in the major study, thus, the correct use of nursing diagnoses was not examined. However, it was observed that in some cases, respondents were not familiar with the defining characteristics of individual nursing diagnoses, as was evident by the use of potential for alteration of skin integrity and altered skin integrity following a surgical procedure. Another example was the use of impaired gas exchange and ineffective airway clearance following a surgical procedure; these nursing diagnoses seemed to be used interchangeably.

The wide range of practice by medical-surgical nurses was supported by the pilot study. The variety in the number of identified surgical and invasive procedures demonstrated that medical-surgical nurses cared for a broad spectrum of patients. Such observations suggest that there may not be a “typical” medical-surgical unit. Changes in the health care environment support this suggestion as restructuring in acute care agencies has resulted in merging patient populations within units, diversifying the types of clinical problems that are managed within a unit.

A few respondents reported that their facility did not use nursing diagnoses as critical pathways or caremaps had replaced the nursing care plan. Nursing diagnoses should be implicit within a caremap/critical pathway, as they give justification for the interventions implemented. A major concern in areas where nursing care plans are extinct due to the use of critical pathways/caremaps is that patient needs and nursing interventions that do not fall within the parameters of the critical pathway are not documented. Nurses do identify such patient needs and implement interventions to meet those needs. If, however, no system exists for documenting nursing diagnoses and interventions related to these needs, nursing’s contributions to patient outcomes will not be adequately recognized. Lack of documentation of nursing’s contributions to patient outcomes continues to support the current reality of reimbursement for nursing services as a component of room and board.

In some facilities, respondents reported that computerized charting systems were used to document multidisciplinary interventions. Although health care is an interdisciplinary field of practice, it is important to identify and document nursing’s contributions in health care databases. A major concern is that these documentation systems do not adequately identify nursing’s role or allow later analysis of nursing’s unique contributions to patient outcomes (ANA, 1994a). If nursing’s contributions are not visible, reimbursement specifically for nursing services will not be forthcoming.

The purpose of this pilot project was to identify an instrument to survey nurses about nursing diagnoses used throughout the operative experience. This was accomplished and the major study was implemented in September 1996. For the major study, nurses using critical path ways/caremaps and/or computerized charting systems were encouraged to complete the study by reflecting on nursing diagnoses that would be used to support the interventions that they implement via the critical pathway/caremap. It is hoped that this information can be used to influence future critical pathways/caremaps and computerized charting systems to insure that nursing’s contributions to patient outcomes are identifiable.

Note: For additional information regarding this project, please contact Cecelia Gatson Grindel, PhD, RN, 213 Willowgate Rise, Holliston, MA 01746; e-mail: mikgrin@aol.com

A good reference for an overview of the state of the art of NMDS follows:

Ryan, P., & Delaney C. (1995). Nursing minimum data set. In J.J. Fitzpatrick & J.S. Stevenson (Eds.), Annual review of nursing research (Vol. 13) (pp. 169195). New York: Springer Publishing Company.

References

American Nurses Association. (1986). Development of computerized nursing information systems in nursing services. (Resolution No. 24). Kansas City, MO: Author.

American Nurses Association. (1994a). Brief synopsis of the nursing minimum data set (NMDS) meeting. Washington, DC: Author.

American Nurses Association, Steering Committee on Databases, Congress on Nursing Practice. (1994b). Position statement on: A national nursing database to support clinical nursing practice. Washington, DC: Author.

Health Information Policy Council. (1983). Background paper. Uniform minimum health data sets. Unpublished manuscript.

Kleinbeck, S.V.M. (1996). In search of perioperative minimum data elements. AORN journal, 63(5), 926-931.

Ross, D. Pilot study report. NAON News. In press.

Cecelia Gatson Grindel, PhD, RN, is Assistant Professor, College of Nursing, Northeastern University, Boston, MA.

Acknowledgment: AMSN would like to acknowledge the contributions of those members who assisted with the pilot project and Dr. Dennis Ross for his assistance in moving this project forward.

COPYRIGHT 1996 Jannetti Publications, Inc.

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