Sammanfattning
Aim
The study aims to describe the impacts of different data structuring methods used in nursing records
or care plans. This systematic review examines what kinds of structuring methods have been
evaluated and the effects of data structures on healthcare input, processes and outcomes in previous
studies.
Materials and Methods
Retrieval from 15 databases yielded 143 papers. Based on Population (Participants), Intervention,
Comparators, Outcomes elements and exclusion and inclusion criteria, the search produced 61
studies. A data extraction tool and analysis for empirical articles were used to classify the data
referring to the study aim. Thirty-eight studies were included in the final analysis.
Findings
The study design most often used was a single measurement without any control. The studies were
conducted mostly in secondary or tertiary care in institutional care contexts. The standards used in
documentation were nursing classifications or the nursing process model in clinical use. The use of
standardised nursing language (SNL) increased descriptions of nursing interventions and outcomes
supporting daily care, and improving patient safety and information reuse.
Discussion
The nursing process model and classifications are used internationally as nursing data structures in
nursing records and care plans. The use of SNL revealed various positive impacts. Unexpected
outcomes were most often related to lack of resources.
Limitations
Indexing of SNL studies has not been consistent. That might cause bias in database retrieval, and
important articles may be lacking. The study design of the studies analysed varied widely. Further,
the time frame of papers was quite long, causing confusion in descriptions of nursing data structures.
Conclusion
The value of SNL is proven by its support of daily workflow, delivery of nursing care and data reuse.
This facilitates continuity of care, thus contributing to patient safety. Nurses need more education and
managerial support in order to be able to benefit from SNL.
Published by arrangement with John Wiley & Sons.