Research for Evidence Based Practice

International Journal of Nursing Studies 104 (2020) 103523

Contents lists available at ScienceDirect

International Journal of Nursing Studies

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / i j n s

Use of electronic health records and standardized terminologies: A

nationwide survey of nursing staff experiences

Kim De Groot a , b , ∗, Anke J.E. De Veer a , Wolter Paans c , Anneke L. Francke

a , d

a Netherlands Institute for Health Services Research (Nivel), PO Box 1568, 3513 CR Utrecht, The Netherlands b Thebe Wijkverpleging [Home care organisation], Lage Witsiebaan 2a, 5042 DA Tilburg, The Netherlands c Research Group Nursing Diagnostics, School of Nursing, Hanze University of Applied Sciences, Petrus Driessenstraat 3, 9714 CA Groningen, The Netherlands d Department of Public and Occupational Health, Amsterdam Public Health Research Institute (APH), Amsterdam UMC, Vrije Universiteit Amsterdam, Van

der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands

a r t i c l e i n f o

Article history:

Received 1 May 2019

Received in revised form 31 December 2019

Accepted 31 December 2019

Keywords:

Electronic health records

Nurses

Nursing documentation

Standardized nursing terminology

a b s t r a c t

Background: Nursing documentation could improve the quality of nursing care by being an important

source of information about patients’ needs and nursing interventions. Standardized terminologies (e.g.

NANDA International and the Omaha System) are expected to enhance the accuracy of nursing documen-

tation. However, it remains unclear whether nursing staff actually feel supported in providing nursing

care by the use of electronic health records that include standardized terminologies.

Objectives: a. To explore which standardized terminologies are being used by nursing staff in electronic

health records. b. To explore to what extent they feel supported by the use of electronic health records. c.

To examine whether the extent to which nursing staff feel supported is associated with the standardized

terminologies that they use in electronic health records.

Design: Cross-sectional survey design.

Setting and participants: A representative sample of 667 Dutch registered nurses and certified nursing

assistants working with electronic health records. The respondents were working in hospitals, mental

health care, home care or nursing homes.

Methods: A web-based questionnaire was used. Descriptive statistics were performed to explore which

standardized terminologies were used by nursing staff, and to explore the extent to which nursing staff

felt supported by the use of electronic health records. Multiple linear regression analyses examined the

association between the extent of the perceived support provided by electronic health records and the

use of specific standardized terminologies.

Results: Only half of the respondents used standardized terminologies in their electronic health records.

In general, nursing staff felt most supported by the use of electronic health records in their nursing ac-

tivities during the provision of care. Nursing staff were often not positive about whether the nursing

information in the electronic health records was complete, relevant and accurate, and whether the elec-

tronic health records were user-friendly. No association was found between the extent to which nursing

staff felt supported by the electronic health records and the use of specific standardized terminologies.

Conclusions: More user-friendly designs for electronic health records should be developed. The poor user-

friendliness of electronic health records and the variety of ways in which software developers have inte-

grated standardized terminologies might explain why these terminologies had less of an impact on the

extent to which nursing staff felt supported by the use of electronic health records.

© 2020 Elsevier Ltd. All rights reserved.

W

(

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hat is already known about the topic?

• Nursing documentation could help improve the quality of

nursing care by being an important source of information

about patients’ needs and nursing interventions.

∗ Corresponding author at: Netherlands Institute for Health Services Research

Nivel), PO Box 1568, 3513 CR Utrecht, The Netherlands.

E-mail address: [email protected] (K. De Groot).

ttps://doi.org/10.1016/j.ijnurstu.2020.103523

020-7489/© 2020 Elsevier Ltd. All rights reserved.

• Standardized terminologies are expected to be helpful in

achieving more accurate nursing documentation.

• In the last few years, various software developers have in-

tegrated standardized terminologies in the electronic health

records, using different methods.

2 K. De Groot, A.J.E. De Veer and W. Paans et al. / International Journal of Nursing Studies 104 (2020) 103523

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What this paper adds

• Nursing staff feel only moderately supported by the use of elec-

tronic health records.

• Nursing staff are often not positive about whether the nursing

information in the electronic health records was complete, rel-

evant and accurate, and whether the electronic health records

were user-friendly.

• This study demonstrates that the extent to which nursing staff

felt supported by the use of electronic health records was not

associated with the use of a standardized terminology.

1. Introduction

Accurate nursing documentation is not only important for com-

munication between nursing staff, but also has the potential to

improve nursing care and patient outcomes by being an important

source of information about patients’ needs and nursing inter-

ventions ( Jefferies et al., 2010 ; Urquhart et al., 2009 ; Wang et al.,

2011 ). Various definitions of nursing documentation exist in the

professional and research literature. Taking inspiration from Blair

and Smith (2012) and Jefferies et al. (2010) , we define nursing

documentation as the process of documenting nursing information

about nursing care in health records. Nursing documentation in

health records is internationally understood to reflect the phases of

the nursing process ( Blair and Smith, 2012 ; De Groot et al., 2019 ;

Flemming and Hübner, 2013 ; Paans et al., 2011 ; Wang et al., 2011 ).

Also in the Netherlands it is a standard practice to document

nurses’ assessment information, as well as nursing diagnoses, and

planning, implementation and evaluation of nursing interventions

( VandVN and NU’91, 2011 ). Nursing documentation helps nursing

staff to continuously reflect on the impact of interventions on

their patients, and is therefore vital for the quality and continuity

of care ( Björvell et al., 2003 ; Needleman and Buerhaus, 2003 ;

Paans et al., 2011 ). Standardized terminologies are expected to be

helpful in achieving more accurate nursing documentation ( De

Groot et al., 2019 ; Müller-Staub et al., 2007 ; Tastan et al., 2014 ;

Törnvall and Jansson, 2017 ).

Standardized terminologies can guide nursing staff through

the phases of the nursing process, and can improve the accurate

formulation of patients’ care needs and the planning of concrete

interventions ( The Office of the National Coordinator for Health

Information Technology, 2017 ; Wang et al., 2011 ). Furthermore,

the use of standardized terminologies could improve communi-

cation among nursing staff themselves and communication with

other healthcare professionals, because recognizable words and

distinguishable terms are used ( Rutherford, 2008 ; Thede and

Schwirian, 2011 ). Another benefit of standardized terminologies is

that these terminologies provide a certain structure in electronic

health records that could facilitate the reuse of documented data,

for instance as information sources for scientific research or for

quality assurance ( Monsen et al., 2010 ). Besides, standardized

terminologies could facilitate the comparison within and between

care organizations of the effect of nursing interventions on pa-

tient outcomes ( Rutherford, 2008 ; The Office of the National

Coordinator for Health Information Technology, 2017 ).

Thus standardized terminologies have potential advantages, but

they do not automatically lead to one common nursing language.

Nowadays, nursing staff use various standardized terminologies.

The frequency of use of standardized terminologies can be in-

fluenced by several factors, including governmental policies. For

example, the Dutch government decided in 2015 that it would be

mandatory by 2017 for home care providers to implement stan-

dardized terminologies in their health records ( Ministry of Health

Welfare and Sports, 2015 ). This obligation only applies to the home

are setting; nursing staff working in the other Dutch healthcare

ettings are not obligated to use standardized terminologies in

heir nursing documentation ( Ministry of Health Welfare and

ports, 2015 ). Nursing staff use standardized terminologies in

articular in electronic health records. Various software developers

ave incorporated standardized terminologies in the electronic

ealth records. According to an international expert panel, clear

inkages between the phases of the nursing process are mostly

acking in the current electronic health records ( Müller-Staub

t al., 2016 ). This results in differences even between electronic

ealth records using the same standardized terminology. Moreover,

hese experts estimate that the frequency of use of standardized

erminologies would increase if improvements were to be made to

he user interfaces of the electronic health records ( Müller-Staub

t al., 2016 ).

Standardized terminologies that include a theoretical frame-

ork or concept specific to nursing care are often referred to

s standardized nursing terminologies or classification systems.

he American Nursing Association (ANA) has recognized twelve

tandardized nursing terminologies, see Table 1 ( The Office of the

ational Coordinator for Health Information Technology, 2017 ).

lthough the ANA is based in the USA, it is also referred to across

urope and can be seen as a worldwide reference. Within the

welve standardized nursing terminologies, the ANA distinguishes

etween interface terminologies, reference terminologies and min-

mum data sets. Interface terminologies include actual words and

erms used by nursing staff in their documentation ( The Office of

he National Coordinator for Health Information Technology, 2017 ).

eference terminologies can facilitate the electronic exchange of

nformation from various electronic health records ( The Office

f the National Coordinator for Health Information Technology,

017 ). Even though the reference terminologies are not based

n concepts specific to nursing care, they are still recognized

s standardized nursing terminologies. Minimum data sets are

ets of data elements intended for the collection of essential

ursing care data ( Westra et al., 2008 ). The theoretical frameworks

f these twelve standardized nursing terminologies differ. For

nstance, the Omaha System contains components for all steps

f the nursing process, whereas NANDA-I is used only for the

rst steps of the nursing process ( Topaz et al., 2014 ; Warren and

oskins, 1990 ).

In addition to the twelve standardized nursing terminologies,

ursing staff also use standardized terminologies which are not

ecognized by the ANA, see Table 1 . These terminologies are not

ecognized by the ANA because either they are not based on a

heoretical framework or they are not specific to nursing care.

In spite of the available research on the benefits of standard-

zed terminologies (e.g. Törnvall and Jansson, 2017 ), there have

een fewer studies of how nursing staff experience the use of

lectronic health records that include standardized terminologies

nd their perceptions of the accuracy of nursing documentation in

uch electronic health records ( Park and Cho, 2009 ). Therefore, it

emains unclear whether nursing staff actually feel supported in

roviding good-quality nursing care by the different aspects of the

lectronic health records. For instance, it is unknown whether the

ursing information within electronic health records is sufficient

or nursing staff to evaluate their interventions and to contribute

o care decision-making. Given the wide diversity in standardized

erminologies it can also be questioned whether the support

hat nursing staff feel they get from electronic health records

s associated with the standardized terminologies used in these

ecords. However, to our knowledge no research is available that

ompares the experiences of nursing staff with electronic health

ecords that include different standardized terminologies. For this

easons, this study explored the experiences of Dutch nursing

taff working with different electronic health records that include

K. De Groot, A.J.E. De Veer and W. Paans et al. / International Journal of Nursing Studies 104 (2020) 103523 3

Table 1

Standardized terminologies used in electronic health records.

Standardized terminology Description Recognized by the ANA

NANDA International (NANDA-I) a A classification of nursing diagnoses, used to form a clinical judgment about the actual

or potential reactions of an individual, (family) system or society to health problems

or life processes ( Warren and Hoskins, 1990 ).

Yes

Nursing Interventions Classification (NIC) a A classification of nursing interventions, used to formulate any intervention performed

by nurses based on their expert judgment and clinical knowledge ( McCloskey and

Bulechek, 2000 ).

Yes

Nursing Outcomes Classification (NOC) a A classification of nursing care outcomes, used to assess the situation and monitor the

progress of patients, informal caregivers, families or communities ( Johnson et al.,

2000 ).

Yes

Omaha System

a A standardized healthcare terminology that consists of a patients’ needs component, an

intervention component, and an evaluation component. This terminology is used by

nursing staff and other professionals such as physical therapists ( Topaz et al., 2014 ).

Yes

Clinical Care Classification (CCC) System

a A nursing terminology that provides a standard framework for assessing, documenting

and evaluating nursing care ( Saba, 2012 ).

Yes

International Classification for Nursing

Practice (ICNP) a A nursing terminology that includes nursing diagnoses, nursing-sensitive patient

outcomes and nursing interventions ( International Council of Nurses, 2001 ).

Yes

Perioperative Nursing Data Set (PNDS) a A standardized language for documenting perioperative patient care that describes the

nursing diagnoses, interventions and patient outcomes ( Taulman and Latz, 2011 ).

Yes

Alternative Billing Concepts (ABC) Codes a Codes that were designed for documentation and measurement of non-physician and

alternative medicine health services ( The Office of the National Coordinator for

Health Information Technology, 2017 ).

Yes

Nursing Minimum Data Set (NMDS) b A set of items with uniform definitions for nursing care, patient demographics and

service elements ( The Office of the National Coordinator for Health Information

Technology, 2017 ).

Yes

Nursing Management Minimum Data Set

(NMMDS) b A set of items that identify variables relevant to nursing administrators for

decision-making about nursing care effectiveness ( Gardner-Huber et al., 1992 ).

Yes

International Classification of Functioning,

Disability and Health (ICF)

A classification of the health components of functioning and disability. This terminology

is of interdisciplinary origin ( World Health Organization, 2001 ).

No

Gordon’s Functional Health Patterns

(Gordon)

A method used by nursing staff to provide a comprehensive nursing assessment of the

patient ( Gordon, 1987 )

No

Resident Assessment Instrument (RAI) An instrument for needs assessment and care screening for nursing-home residents. This

terminology is of interdisciplinary origin ( Hawes et al., 1997 ).

No

SNOMED Clinical Terms (SNOMED CT) c A comprehensive, multilingual clinical healthcare terminology that enables exchange of

data. This terminology is of interdisciplinary origin ( SNOMED International, 2019 ).

Yes

Logical Observation Identifiers Names and

Codes (LOINC) c A comprehensive clinical terminology that includes terms for laboratory tests, clinical

measurements and patient observations. This terminology is of interdisciplinary

origin ( Forrey et al., 1996 ).

Yes

a Interface terminology = actual words and terms used by nursing staff in their documentation. b Minimum data set = a set of data elements with standardized definitions and codes. c Reference terminology = a terminology that can be linked to multiple interface terminologies.

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tandardized terminologies. The following research questions were

ddressed:

1. Which standardized terminologies do nursing staff use in the

electronic health records?

2. To what extent do nursing staff feel supported in their docu-

mentation by the use of electronic health records, and in which

aspects?

3. Is there an association between the extent to which nursing

staff feel supported by the use of electronic health records and

the specific standardized terminologies that they use in these

records?

. Method

.1. Design

A cross-sectional survey design was used.

.2. Setting and participants

An online survey was conducted with data collection in De-

ember 2016 and January 2017 among nursing staff who were

embers of a pre-existing research panel known as the Nursing

taff Panel. The Nursing Staff Panel is a nationwide, representative

roup of nursing staff who deliver direct nursing care to patients

n various healthcare settings. Certified nursing assistants as well

s registered nurses participate in the Nursing Staff Panel.

In the Netherlands, certified nursing assistants receive three

ears of vocational education and training. Dutch registered nurses

re educated to two different levels, namely to the secondary vo-

ational level (a nursing qualification after completing senior sec-

ndary vocational education) and to the bachelor’s level (a degree

n nursing after education at a university of applied sciences).

Members of the Nursing Staff Panel are recruited through a ran-

om sample of Dutch healthcare employees, provided by two pen-

ion funds. Together, these pension funds register all employees in

he Dutch healthcare sector. The employees in the random sam-

le were asked to participate in healthcare research for various

urposes. Nursing staff who agreed to this request and who de-

iver direct nursing care to patients were asked to join the Nursing

taff Panel. This recruitment method ensures the representative-

ess of the panel for the general population of Dutch nursing staff

n terms of age, gender, region and healthcare settings ( Maurits

t al., 2015 ).

.3. Data sources

A web-based questionnaire was used. The questionnaire was

ent by email to 1609 panel members (all registered nurses or cer-

ified nursing assistants) who worked in one of the main health-

are settings, i.e. hospitals, mental health care, home care and

ursing homes. To increase the response rate, electronic reminders

ere sent after one week and after three weeks to nursing staff

ho had not yet responded.

4 K. De Groot, A.J.E. De Veer and W. Paans et al. / International Journal of Nursing Studies 104 (2020) 103523

Table 2

Respondents’ characteristics.

Characteristics Total ( n = 667)

Age (mean (standard deviation), [range]) 49 (10.6) [22–67]

Gender ( n , %)

Female 592 88.8

Male 75 11.2

Level of education ( n , %)

Certified nursing assistant 187 28.0

Registered nurse secondary vocational qualification 233 34.9

Registered nurse bachelor’s degree 247 37.0

Healthcare setting ( n , %)

Hospitals 156 23.4

Mental health care 83 12.4

Home care 305 45.7

Nursing homes 123 18.4

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2.3.1. Questionnaire

In the questionnaire it was explained that questions were

focused on the process of documenting nursing information about

nursing care in health records. Moreover, we explained that

nursing documentation is related to the nursing process, and we

explained the phases of the nursing process. Documentation by

and relating to other professionals or lab results was not covered

by the questionnaire. Besides questions relevant to this paper,

the questionnaire also included questions related to other aspects

of nursing documentation (e.g. patients’ involvement in nursing

documentation). In total, the questionnaire contained 35 self-

developed questions, of which seven questions were relevant for

this paper. Most questions had pre-structured response options.

After establishing a first draft, the questionnaire was tested for

comprehensibility and completeness by nine registered nurses and

three certified nursing assistants. Based on their comments, the

questionnaire was modified where necessary to produce the final

version.

The part of the questionnaire with questions rele-

vant for this paper can be found at: https://nivel.nl/nl/pdf/

nursing- documentation- questionnaire.pdf .

2.3.2. Variables

Data were collected on the following characteristics of nurs-

ing staff: age (continuous), gender (male or female), level of ed-

ucation (certified nursing assistant, registered nurse at secondary

vocational level or registered nurse with bachelor’s degree) and

healthcare setting (hospital, mental health care, home care or

nursing home).

We asked for the standardized terminologies that nursing staff

used in their electronic health records. The fixed response op-

tions were the Omaha System, Gordon, ICF, RAI, the combination

of NANDA-I, NIC and NOC, and a Dutch terminology called ‘Four

Domains’. Besides these predefined options, respondents could also

fill in their own answer.

The extent to which nursing staff felt supported by different

aspects of the electronic health records was measured by their

agreement with a set of eight statements on a five-point scale

(1 = completely disagree to 5 = completely agree). The statements

were based on relevant international and Dutch literature about

nursing documentation (e.g. research on aligning documentation

with the nursing process ( Blair and Smith, 2012 ; Flemming and

Hübner, 2013 ; Paans et al., 2011 ; Wang et al., 2011 ), and research

on handovers ( De Blok et al., 2012 ) and consultation with six

experts on nursing documentation and/or nursing care. The in-

ternal consistency of the eight statements was high (Cronbach’s

alpha 0.92), indicating that these statements reflected one concept,

namely the extent to which nursing staff felt supported by the

use of electronic health records. A mean score over the eight

statements was calculated, ranging from 1 (completely disagree) to

5 (completely agree), whereby higher scores indicated that nursing

staff felt more supported by the use of electronic health records.

2.4. Statistical methods

Descriptive statistics were performed to describe the charac-

teristics of the respondents and to answer the first and second

research questions. Furthermore, the potential relationships be-

tween the use of standardized terminologies and the respondent’s

healthcare setting were examined using Pearson’s chi-square test.

A one-way ANOVA test was also used to examine the potential

differences between the respondents’ healthcare settings in the ex-

tent to which respondents felt supported by the use of electronic

health records.

To answer the third research question, first a multiple linear

regression analysis was conducted in which the experienced

upport provided by electronic health records was the depen-

ent variable, and the use of a standardized terminology (0 = no,

= yes) and the socio-demographic characteristics (gender, age,

ducational level, healthcare setting) were the independent vari-

bles. Next, a multiple linear regression analysis was conducted

o determine whether there was a difference between different

tandardized terminologies. In this analysis, we included the

xperienced support provided by electronic health records as the

ependent variable, and the specific standardized terminologies

nd socio-demographic characteristics as independent variables.

The level for determining statistical significance was 0.05. All

nalyses were conducted using STATA, version 15.0.

.5. Ethical considerations

The study was conducted in accordance with the Dutch Per-

onal Data Protection Act, by strictly safeguarding the anonymity of

he participants ( Sauerwein and Linnemann, 2001 ). All participants

ere competent individuals, were not subjected to procedures and

ere not required to follow rules of behavior. For these reasons,

urther ethical approval of this study was not required under the

pplicable Dutch legislation.

. Results

.1. Participants

A total of 745 nursing staff working in one of the main health-

are settings completed the questionnaire (response 46.3%). This

tudy focussed on the use of various standardized terminologies in

lectronic health records . Therefore, we excluded from the analysis

ursing staff working exclusively with paper-based health records

n = 78), leaving 667 respondents who worked with electronic

ealth records.

As seen in Table 2 , the mean age of these respondents was 49

ears. This mean age was higher than the mean age of employ-

es working in hospitals, mental health care, home care or nurs-

ng homes in the Netherlands, which varied per sector from 41 to

5 years ( AZW, 2017 ). In our sample 88.8% was female, which is

imilar to the Dutch nursing staff population ( AZW, 2017 ).

In our study, the three groups of nursing staff with different

ducational levels were approximately equal in size. The largest

roup in the sample in terms of the healthcare setting was the

roup of respondents working in home care (45.7%). This means

here was an overrepresentation of home care nursing staff, since

nly 13.5% of the overall Dutch nursing staff population work in

he home care setting ( AZW, 2017 ). Nursing staff working in nurs-

ng homes are underrepresented in our study, with a share of 18.4%

ompared to 46.3% in the overall population.

K. De Groot, A.J.E. De Veer and W. Paans et al. / International Journal of Nursing Studies 104 (2020) 103523 5

Table 3

Use of standardized terminologies in electronic health records as reported by nursing staff ( n = 667).

Standardized terminologies (in %) Hospitals

( n = 156)

Mental health care

( n = 83)

Home care

( n = 305)

Nursing homes

( n = 123)

Total

( n = 667)

Gordon (%) 39.1 26.5 3.0 7.3 15.1

NANDA-I, NIC and NOC (%) 10.3 10.8 9.8 4.9 9.2

Omaha System (%) 0.6 0 65.3 8.1 31.5

ICF (%) 1.3 0 0 0.8 0.5

RAI (%) 0 1.2 0 0 0.2

I do not know (%) 22.4 21.7 8.5 35.8 18.4

No standardized terminology (%) 17.3 24.1 2.0 22.0 12.0

No standardized terminology mentioned by respondent a (%) 9.0 15.7 11.5 21.1 13.2

Total (%) 100 100 100 100 100

a = we were not able to determine from the open-ended answers of these respondents whether they used a standardized terminology.

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Given that the content and structure of electronic health

ecords might vary across the four healthcare settings, we present

urther findings for each of the healthcare settings separately.

.2. Standardized terminologies

Only half of the respondents (56.4%) used a standardized termi-

ology in the electronic health records. The most frequently used

erminologies were the Omaha System (31.5%) and Gordon (15.1%),

ee Table 3 . The Omaha System was mostly used by respondents

orking in home care, and Gordon mostly within hospitals and

ental health care. In addition, nursing staff also used ICF, RAI,

nd the combination of NANDA-I, NIC and NOC. Respondents did

ot mention other standardized terminologies that are recognized

y the ANA. How often a specific kind of standardized termi-

ology was used was associated with the healthcare setting in

hich respondents were working; see Table 3 . Other respondents

id not recognize the use of a standardized terminology. They

ither answered that they did not know whether they used a

tandardized terminology (18.4%), or they answered that they used

structure in the electronic health records that was not a stan-

ardized terminology (12.0%). It is notable that most respondents

n nursing homes answered that they did not know if they used

tandardized terminologies. Furthermore, one group of nursing

taff (13.2%) gave open-ended answers that pointed to the name

r software developer of the electronic health records. Some of

hese electronic health records might also include standardized

erminologies. However, it was not possible to work out which

pecific standardized terminology was used from the answers

iven by this group of respondents.

.3. Experienced support from electronic health records

The extent to which nursing staff felt supported in their doc-

mentation by the use of electronic health records varied across

ealthcare settings. Mental health care nurses felt significantly less

upported compared to home care nursing staff (mean score 3.54,

D 0.61 vs mean score 3.87, SD 0.65; p < 0.00). Nursing staff

orking in hospitals and nursing homes felt moderately supported,

ith a mean score of 3.73 (SD 0.58) for hospitals and 3.73 (SD

.61) for nursing homes. The scores of respondents working in hos-

itals or nursing homes did not differ significantly from those of

ursing staff working in the other two healthcare settings.

Overall nursing staff gave the most positive scores for the state-

ent that the information from the health records supported their

ctivities during the provision of care (mean 3.98). Respondents

ave the lowest scores for the statement that the information

n the health records was complete, relevant and accurate (mean

.47), and the statement about the user-friendliness of the health

ecords (mean 3.63), see Table 4 .

.4. Association between perceived support and use of standardized

erminologies

To estimate differences in the perceived support from electronic

ealth records between nursing staff who did use a standardized

erminology and nursing staff who did not, respondents were di-

ided into two groups. First, all respondents who used one of

he standardized terminologies were merged to form one group

n = 376, 64.9%). Next, respondents who did not recognize the

se of a standardized terminology ( n = 123) and respondents who

id not use a standardized terminology ( n = 80) were merged,

esulting in a group of 203 respondents (35.1%). The use of stan-

ardized terminologies was unclear when respondents only men-

ioned the name or software developer of the electronic health

ecords, so these respondents ( n = 88) were excluded from this

nalysis.

The first multiple linear regression analysis showed no signif-

cant differences in the perceived support provided by electronic

ealth records between respondents who did use a standardized

erminology and respondents who did not ( p = 0.48). Also gender,

ge and educational level had no significant effect on the support

hat respondents experienced. However, we did find that nursing

taff working in home care felt significantly more supported by

heir electronic health records than nursing staff working in hospi-

als (mean 3.87 (SD 0.65) vs mean 3.73 (SD 0.59); p < 0.05).

To examine whether there was an association between the ex-

ent to which nursing staff felt supported by the use of electronic

ealth records and the use of specific standardized terminologies, a

econd multiple linear regression analysis was conducted. Respon-

ents using ICF and RAI were excluded due to their small numbers,

esulting in a further analysis of the data of 574 respondents.

No statistically significant differences were found in the ex-

ent to which nursing staff felt supported by the use of electronic

ealth records, see Table 5 . Only weak differences were found at

he 10% significance level. Nursing staff using the Omaha System

ended to feel somewhat more supported by the electronic health

ecords than nursing staff using Gordon ( p = 0.067) and nursing

taff not using a standardized terminology ( p = 0.074). The vari-

bles ‘healthcare setting’ and ‘level of education’ were not associ-

ted with the extent to which nursing staff felt supported by the

se of electronic health records. The explained variance was low as

ell, namely 2.5%.

. Discussion

This study sought to gain insight into the frequency of use of

tandardized terminologies in the electronic health records, the ex-

ent to which nursing staff feel supported by the use of electronic

ealth records, and whether this perceived support is associated

ith the use of specific standardized terminologies.

6 K. De Groot, A.J.E. De Veer and W. Paans et al. / International Journal of Nursing Studies 104 (2020) 103523

Table 4

Statements about the extent to which nursing staff felt supported by the use of electronic health records ( n = 666, range 1–5).

Statements Mean SD 95% CI

The health record that I am working with is user-friendly 3.62 0.95 3.54 to 3.69

The information in the health records gives me sufficient insight into the actual and potential

problems/diagnoses/needs of the patient

3.86 0.78 3.80 to 3.92

The information in the health records supports my activities during the provision of care 3.98 0.68 3.93 to 4.04

The information in the health records gives me sufficient information for the evaluation of care 3.87 0.73 3.81 to 3.92

I can easily use the information in the health records to make an adequate handover 3.89 0.73 3.83 to 3.94

The information in the health records is complete, relevant and accurate 3.47 0.84 3.40 to 3.53

The health record that I am working with supports me in adequate documentation of the choices I make during the

provision of care

3.73 0.78 3.67 to 3.79

The health record that I am working with supports me in adequate documentation of the nursing process 3.74 0.80 3.68 to 3.80

Mean score (Cronbach’s alpha = 0.92) 3.76 a 0.63 3.72 to 3.82

a = mean scores varied across respondents working in different healthcare settings.

Table 5

Regression model to examine the association between perceived support from elec-

tronic health records and use of standardized terminologies ( n = 574).

Self-reported experienced support (range 1–5,

higher scores indicate more support was

experienced)

Coef. Std. err. P -value

Gender (0 = male; 1 = female) 0.081 0.091 0.378

Age (continuous) −0.001 0.003 0.819

Level of education

Certified nursing assistant Ref Ref Ref

Registered nurse secondary vocational level 0.011 0.078 0.891

Registered nurse bachelor’s degree 0.041 0.080 0.604

Healthcare setting

Hospitals Ref Ref Ref

Mental health care −0.161 0.097 0.097

Home care 0.032 0.100 0.748

Nursing homes −0.000 0.100 0.999

Standardized terminology

Omaha System Ref Ref Ref

Gordon −0.197 0.107 0.067

NANDA-I, NIC and NOC −0.137 0.100 0.169

No standardized terminology −0.162 0.090 0.074

Constant 3.826 0.205 0.000

Adjusted R -square 0.025

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The first main finding from this study was that only half of

nursing staff (56%) were actually using a standardized terminology

in their electronic health records. The most frequently used termi-

nologies were the Omaha System and Gordon. These findings differ

from other research, which showed that nurses in the USA were

most familiar with NANDA-I ( Thede and Schwirian, 2011 ). How-

ever, it should be noted that most nurses in the USA reported using

NANDA-I during nursing school, but not since.

The use of a specific kind of standardized terminology was

related to the healthcare setting in which nursing staff were

working. This association is understandable given the variation

in nursing care itself between healthcare settings. Furthermore,

governmental policies may also influence the frequency of use of

standardized terminologies within specific healthcare settings. For

instance, the relatively high frequency of the use of a standardized

terminology (mostly Omaha System) in the home care setting

might partly be explained by the obligation imposed by the Dutch

government specifically on home care providers to implement

a standardized terminology in their health records ( Ministry of

Health Welfare and Sports, 2015 ).

Besides, in our study there was a large group of nursing staff

(30%) who did not recognize the use of standardized terminolo-

gies. This finding is in line with results from a survey in the USA,

in which a large proportion of respondents also had no knowl-

edge of or experience with standardized terminologies ( Thede and

Schwirian, 2011 ). Literature research also showed gaps in both the

knowledge of standardized terminologies and their use ( Park and

Cho, 2009 ).

A second main finding of this study was that nursing staff felt

oderately supported by the use of electronic health records. They

xperienced most support from the use of electronic health records

n their nursing activities during the provision of care. However,

ur study also showed points for concern.

First, nursing staff were often not positive about the user-

riendliness of the electronic health records. This finding is in

ine with other research, which indicated that the poor user-

riendliness of electronic health records seemed to be a prominent

ource of time pressure and psychological distress among regis-

ered nurses ( Vehko et al., 2019 ). Likewise, other studies reported

hat nursing staff commented that the electronic health records

ere too long, lacked links between the different phases of the

ursing process and increased their workload ( De Groot et al.,

017 ; Drummond and Simpson, 2017 ; Müller-Staub et al., 2016 ).

he current structure of the electronic health records may not

lways match the routines of nurses in their daily practice ( Wisner

t al., 2019 ). A review of systematic reviews also showed that

ser-friendly health records are an important precondition for

igh-quality electronic nursing documentation ( De Groot et al.,

019 ). Therefore, user-friendly electronic health records are much

eeded in healthcare. To improve this user-friendliness, nursing

taff should be more involved in the further development of elec-

ronic health records ( De Groot et al., 2019 ; Urquhart et al., 2009 ).

Second, nursing staff were least positive about the complete-

ess, relevance and accuracy of the nursing information in the

lectronic health records. This is a notable finding. Evidence for

he effect of using standardized terminologies on the quality

f nursing documentation is limited to date, but several recent

tudies do show a positive association between the accuracy of

ocumentation and the use of standardized terminologies ( Adubi

t al., 2017 ; Aling et al., 2018 ; Gencbas et al., 2018 ; Goncalves

t al., 2019 ; Kerr et al., 2019 ). Even though using standardized

erminologies is just one criteria for accurate nursing documenta-

ion, it can be assumed as an important criteria ( De Groot et al.,

019 ; Tastan et al., 2014 ; Törnvall and Jansson, 2017 ). In conse-

uence, the misuse of a standardized terminology could result in

naccurate nursing documentation. Research did show that nursing

taff need to understand a standardized terminology for it to be

sed correctly ( Park and Cho, 2009 ). For instance, nursing staff

hould know how to apply standardized terminologies within the

ursing process and how to fit the standardized words and terms

o a specific patient situation. Our study showed a large group

f nursing staff who did not recognize the use of standardized

erminologies. Given that nursing care is mostly performed by

eams, if one person within a team is using the standardized

erminology incorrectly, this could result in the experience for

ther team members that nursing information in electronic health

ecords is incomplete, irrelevant and inaccurate.

The third main finding from our study was that there was

o association between the extent to which nursing staff felt

K. De Groot, A.J.E. De Veer and W. Paans et al. / International Journal of Nursing Studies 104 (2020) 103523 7

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upported by the use of electronic health records and the use

f specific standardized terminologies. This is a remarkable find-

ng since standardized terminologies are expected to help nurs-

ng staff achieve accurate documentation ( De Groot et al., 2019 ;

astan et al., 2014 ; Törnvall and Jansson, 2017 ). However, it should

e noted that the explained variance in the regression model was

ow, namely 2.5%. This low percentage suggests that factors other

han the variables included in our study explain the extent to

hich nursing staff feel supported by the use of electronic health

ecords.

A factor that could be related to the perceived support from

lectronic health records is that nursing staff in the Netherlands

re currently in a transition from paper-based records to electronic

ealth records ( Wouters et al., 2018 ). Therefore, nursing staff are

till adjusting their own routines so that they can work with

lectronic health records. For instance, a previous survey among

utch nursing staff indicated some negative attitudes among

ursing staff to working with electronic health records ( De Veer

nd Francke, 2010 ).

Another factor that could be associated with the extent to

hich nursing staff felt supported by the use of electronic health

ecords is the variety in health records that have been developed

y software developers. For instance, the health records lack links

etween the different phases of the nursing process ( Müller-Staub

t al., 2016 ). In addition, research showed that nursing diagnoses

re not documented in a standardized manner in the present

utch electronic health records ( Paans et al., 2016 ). This suggests

hat current generation of electronic health records might not

rovide a structure that meets the expectations and needs of

ursing staff ( Wisner et al., 2019 ).

What is more, in our study some respondents answered with

he name of an electronic health record or software developer in-

tead of the standardized terminology they used. These answers

uggest that nursing staff find it difficult to distinguish between

tandardized terminologies (e.g. words and terms) and applications

rom software developers.

Furthermore, it should be noted that the standardized termi-

ologies used by nursing staff within our study were difficult to

ompare with one another, given that their theoretical frameworks

iffer. For instance, Gordon is used only for the first step of the

ursing process, namely the assessment of patients’ needs. In con-

rast, the Omaha System and the combination of NANDA-I, NIC

nd NOC contain components for all steps of the nursing process.

his difference in theoretical frameworks could be a possible ex-

lanation for the slightly greater support that nursing staff using

he Omaha System experienced from the use of electronic health

ecords compared with nursing staff using Gordon.

.1. Limitations and strengths

Some limitations to this study need to be acknowledged. First,

non-validated questionnaire was used since no validated ques-

ionnaire exists for the support nursing staff experience from the

se of electronic health records. However, questions were devel-

ped based on the relevant literature and in consultation with ex-

erts on this topic. Moreover, nursing staff pilot-tested the ques-

ionnaire for comprehensibility. For this reason, the questionnaire

s expected to have content validity.

Second, the average age of our respondents (49 years) was

omewhat higher than the national mean age of Dutch nursing

taff working in hospitals, mental health care, home care and

ursing homes, which varied from 41 to 45 years ( AZW, 2017 ).

evertheless, the variable ‘age’ was included in the multiple linear

egression analysis and was found not to be associated with

he extent to which nursing staff felt supported by the use of

lectronic health records.

Third, there was an overrepresentation of home care nursing

taff in the sample (45.7%), since only 13.5% of the overall Dutch

ursing staff population work in the home care setting ( AZW,

017 ). This overrepresentation might be explained by the present

omposition of the Nursing Staff Panel, in which home care nurs-

ng staff are also slightly overrepresented. However, we presented

he findings for each of the sub-samples working in different

ealthcare settings separately. Moreover, in the multiple linear re-

ression analysis the variable ‘healthcare setting’ was included, but

as found not to be associated with the extent to which nursing

taff felt supported by the use of electronic health records.

Notwithstanding these limitations, our research adds some in-

eresting knowledge to an area of research and nursing practice

hat is relatively new and unfamiliar. A strength of this study is

hat it was the first study to compare the experiences of nurs-

ng staff who were all working directly with patients, and who

orked in the four main healthcare settings. Another strength is

hat our study compared the use of various standardized termi-

ologies with each other, instead of focusing on the use of one

tandardized terminology.

.2. Conclusion

Only half of Dutch nursing staff used a standardized termi-

ology in electronic health records. That standardized terminol-

gy was generally either Gordon’s Functional Health Patterns, the

ombination of NANDA-I, NIC and NOC, or the Omaha System.

he specific kind of standardized terminology used by nursing

taff was associated with the healthcare setting. In general, nurs-

ng staff only felt moderately supported by the use of electronic

ealth records. They experienced most support from the use of

lectronic health records in their nursing activities during the pro-

ision of care. However, nursing staff were often not positive about

hether the nursing information in the electronic health records

as complete, relevant and accurate, and whether the electronic

ealth records were user-friendly. No association was found be-

ween the extent to which nursing staff felt supported by the use

f electronic health records and the use of particular standard-

zed terminologies. In the Netherlands, standardized terminologies

re integrated in electronic health records by various software de-

elopers in various ways, resulting in considerable diversity be-

ween electronic health records. Clear linkages between phases of

he nursing process are mostly lacking in current electronic health

ecords, according to an international expert panel ( Müller-Staub

t al., 2016 ). Therefore, the variety of ways in which software de-

elopers have integrated standardized terminologies might explain

hy these terminologies had less of an impact on the extent to

hich nursing staff felt supported by the use of electronic health

ecords.

.3. Implications for research

Further research is needed into whether nursing documentation

n general and the use of standardized terminologies in particular

re associated with the perceived quality of care for patients.

urthermore, our study showed that nursing staff were often

ot positive about the user-friendliness of their electronic health

ecords. Comparable findings have been mentioned in a Finnish

urvey study, which also showed that poor user-friendliness of

lectronic health records is a prominent source of time pressure

mong registered nurses ( Vehko et al., 2019 ). However, in-depth

nowledge about the relation between the user-friendliness of

lectronic health records and the time pressure experienced in

elation to nursing documentation is lacking. Further research is

ecommended on this topic. In addition, our study shows that half

f nursing staff used standardized terminologies in the electronic

8 K. De Groot, A.J.E. De Veer and W. Paans et al. / International Journal of Nursing Studies 104 (2020) 103523

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D

D

F

F

G

G

G

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I

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M

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P

P

P

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S

S

health records. There could be tension between documenting in-

formation in standardized terminologies, which include words and

terms familiar to nursing staff, and documenting information in a

way that is understandable for patients. For instance, it is known

that information at hospital discharge is often not comprehensible

for patients ( Newnham et al., 2017 ). Patients’ involvement in

nursing documentation therefore requires further investigation.

4.4. Implications for practice

The results of our study show that nursing staff were often

not positive about the user-friendliness of their electronic health

records. To increase the extent to which nursing staff feel sup-

ported by their electronic health records, user-friendly designs

for these health records should be developed. Therefore, nursing

staff, nursing associations, healthcare organisations, government

and software developers need to work together. For instance, they

should work towards electronic health records that include links

between the different phases of the nursing process.

CRediT authorship contribution statement

Kim De Groot: Conceptualization, Formal analysis, Investiga-

tion, Writing - original draft. Anke J.E. De Veer: Conceptualization,

Formal analysis, Writing - review & editing. Wolter Paans: Con-

ceptualization, Funding acquisition, Investigation, Writing - review

& editing. Anneke L. Francke: Conceptualization, Funding acquisi-

tion, Investigation, Supervision, Writing - review & editing.

Acknowledgments

We would like to thank all the participants of the Dutch Nurs-

ing Staff Panel who participated in this study. Furthermore, we

thank Clare Wilkinson for the language editing.

Supplementary material

Supplementary material associated with this article can be

found, in the online version, at doi: 10.1016/j.ijnurstu.2020.103523 .

Conflict of interest

The authors declare that they have no conflict of interest.

Funding

This research was funded by ZonMw (Grant no. 5160 040 07 ),

the Netherlands organisation for Health Research and Development

(Quality Standards program). The funder had no role in conducting

this research.

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