Describing Intraoperative Nursing Practice Using Clinical Data

The focus of the study was nursing interventions and the language used to describe interventions nurses take to prevent or resolve patients\u27 problems. A standardized language of nursing interventions is necessary to describe nursing care across settings and sites. The purpose of this study was to describe intraoperative nursing practice. Nursing interventions documented during the intraoperative period on the operating room nursing notes were used to describe intraoperative nursing practice. The documented nursing interventions were then mapped to two standardized nursing languages to facilitate this description of practice. The standardized nursing languages used in this study were the Nursing Interventions Classification (NIC) (Me Closkey and Bulechek 1996) and the Association of Operating Room Nurses Perioperative Nursing Data Elements (PNDS) (AORN, 1998a). Mapping is a process of classifying, matching, or nearly matching actual clinical terms used to document nursing interventions with terms or categories in the two standardized nursing languages. The medical records of 55 patients with total hip replacement were reviewed. and nursing interventions were abstracted from the operating room nursing notes. A total of 61 unique interventions were identified in the records. The identified nursing interventions were mapped into NIC at 95.00% and PNDS at 100.00%. The intervention mapping had inter-rater reliability of 96.66%. This study indicates that standardized nursing languages do facilitate the description of intraoperative nursing care of the total hip patient. Implications for nursing administration, practice, education, and further research are discussed