Exploring the usability of the ISO reference terminology model for nursing actions in representing oriental nursing actions

Abstract 

Purpose

This study examined the extent to which the ISO reference terminology model for nursing actions represents oriental nursing actions in a computerized nursing documentation system to share data and foster communication between oriental nursing care and conventional nursing care.

Methods

The narrative nursing notes of 545 patients retrieved from a nursing documentation system in an oriental medicine teaching hospital were analyzed. Among 49,118 entries, 933 were recorded as nursing actions. Each entry was decomposed in a set of single statements. A total of 1209 nursing action statements were derived and mapped to the components of the model. These processes were reviewed and validated by two domain experts and a nursing terminology expert.

Results

All of the oriental nursing actions documented contained a word or phrase that described the Action and Target in the model. The Recipient of Care was expressed explicitly in 1.2% of statements. The most frequently used Action terms were ‘administering’ (19.7%), ‘teaching’ (16.5%), and ‘explaining’ (13.6%). The Target terms that indicated unique oriental nursing concepts included ‘Sasang constitution differentiation’, ‘removal of acupuncture needles’, ‘herb moxibustion’, ‘oriental massage’, and ‘oriental medication’.

Conclusion

The findings demonstrate that oriental nursing actions can be represented using the ISO reference terminology model for nursing actions. Further specification of the components of the model will be useful to achieve consistent mapping across different settings. The addition of component qualifiers should also be taken into consideration to describe nursing actions at a more granular level.

Keywords: Nursing care, Nursing records, Terminology, Standards, Oriental medicine