Implementation of the Austrian Nursing Minimum Data Set (NMDS-AT): A Feasibility Study

BMC Medical Informatics and Decision Making

Research Article

Renate Ranegger¹  Werner O. Hackl²  Elske Ammenwerth² 

[1] Steiermärkische Krankenanstaltengesellschaft m.b.H., Management/Pflege, Stiftingtalstraße 4-6, 8010, Graz, Austria;UMIT - University for Health Sciences, Medical Informatics and Technology, Institute of Biomedical Informatics, Eduard Wallnöfer-Zentrum I, 6060, Hall in Tirol, Austria;

关键词: Nursing care;    Nursing process;    Nursing informatics;    Nursing records;    Nursing classification;    Decision making;    Data collection;    Healthcare data;    Nursing data;    Austria;   

DOI  :  10.1186/s12911-015-0198-7

 received in 2015-05-22, accepted in 2015-09-08,  发布年份 2015

来源: Springer

【 摘 要 】

BackgroundAn Austrian Nursing Minimum Data Set (NMDS-AT) has been developed to describe the diversity of patient populations and variability of nursing care based on nursing diagnoses, nursing interventions, and nursing outcomes. The aim of this study is to test the feasibility of using this NMDS-AT by assessing the availability of data needed for the NMDS-AT in routine nursing documentation, and to assess its reliability and usefulness.MethodsData were collected in a general hospital from patient records of 20 patients representing 457 patient days. Availability of needed data was assessed by two raters in a chart review based on an NMDS-AT form. The interrater reliability (n = 20) and intrarater reliability (n = 5) was assessed using Cohen’s kappa coefficient and intraclass correlation coefficient (ICC). Usefulness was assessed by verifying whether typical analysis questions can be answered by the documented NMDS-AT data.ResultsIn the 20 patient records, thirteen nursing diagnoses, 50 nursing interventions, and five nursing outcomes occurred, representing 68 (58.6 %) of the overall 116 data elements of the NMDS-AT. The data were found at different data sources (e.g., electronic nursing record or paper-based fever chart) and in various forms (e.g., standardized or free text).The interrater reliability of the thirteen nursing diagnoses showed kappa values (percentage of agreement) ranging from 0.35 (85 %) to 1.00 (100 %). The 50 nursing interventions showed ICCs ranging from 0.03 to 1.00. All nursing outcomes showed an ICC of 1.00. The intrarater reliability showed 100 % agreement. Performing typical analysis questions showed that the extracted NMDS-AT data are able to answer questions of clinical management, of policy makers, and of nursing science.ConclusionsThe NMDS-AT was found to be feasible: needed data was available in the analysed patient records, data extraction showed good reliability, and typical analysis could be performed and showed interesting results. Before the NMDS-AT can be introduced in healthcare institutions, the following challenges need to be addressed: 1. improve the quality of nursing documentation; 2. reduce fragmentation of documentation; 3. use a standardized nursing classification system; and 4. establish mappings between nursing classification systems and the NMDS-AT.

【 授权许可】

CC BY   
© Ranegger et al. 2015

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