Developing terminology for documenting perioperative nursing interventions

摘要

Objective: To develop terminology for documenting perioperative nursing interventions. Method: Nursing documentation of 250 patients was explored by content analysis. The study was conducted to validate further the Perioperative Nursing Data Set (PNDS) in Finland. The data included 3442 terms that were clustered into 104 nursing interventions. A Delphi-panel (N = 5) evaluated the relevance of each term on a scale from 1 to 4. The structure of each nursing intervention was checked to meet the minimum requirements of the ISO reference terminology model for nursing action concepts. Finally, the nursing interventions were compared with the original PNDS-interventions. Results: The Delphi-panel accepted 98 nursing interventions with Content Validity Index from 0.88 to 1.0. Of the 133 nursing interventions in the PNDS, 60% (n = 80) were covered by nursing interventions identified in this study. A notable portion of the nursing interventions related to preventive aspects of perioperative care and the patients' coping with perioperative experience. Conclusion: The findings supported the need for cross-cultural validation of a nursing language prior to clinical implementation. The ISO reference terminology model is recommended as framework in constructing concepts for nursing interventions in a regular form.