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OR Nurse:
doi: 10.1097/01.ORN.0000388945.34674.98
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Charting the course with the PNDS

Bigony, Lorraine BSN, RN, CNOR, ONC

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Lorraine Bigony is the manager of Perioperative Services at Aria Health, Langhorne, Pa.

Perioperative nurses practice in a specialized setting that distinguishes it from other nursing disciplines. A specialized language developed by a professional perioperative nursing organization highlights the vast body of nursing knowledge and critical thinking skills necessary for the delivery of safe, quality surgical care. The Perioperative Nursing Data Set (PNDS) is a communication tool that defines and clarifies the day-to-day practice of perioperative nurses. Effective communication among providers via the patient record, whether paper or electronic, is crucial to patient safety. Yet, documentation omissions and misinterpretations are often the root cause of errors in patient care. The PNDS, validated in 1999 by the American Nurses Association (ANA) and one of only 13 recognized nursing languages, is distinguished by the fact that it was created by a nursing specialty organization, the Association of periOperative Registered Nurses (AORN).1

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An article published in International Nursing Review quoted author Norma Lang, PhD, RN, FAAN, FRCN, saying, "If we cannot name it, we cannot control it, practice it, teach it, finance it, or put it into public policy."2 This statement supports the fact that for nursing to better communicate its practice across the care continuum to all providers, there must be a uniformity and consensus in documentation that leaves no doubt as to its meaning. In addition, a standardized nursing language is a necessary component for the implementation of an electronic medical record (EMR), a national mandate. Therefore, the AORN has been a recognized leader for its creation of a common language that epitomizes the role perioperative nurses play in their specific clinical settings.

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Historical development

In the late 1980s, the AORN Board of Directors acknowledged the need for a national computerized database for its specialized field of nursing. Beginning in 1993, the commitment to develop a perioperative nursing language began with the establishment of the Task Force of Perioperative Data Elements in conjunction with the Data Elements Coordinating Committee (DECC). The DECC, comprising master's and doctoral prepared perioperative nurses, including those specialized in the areas of informatics, research, management, education, and clinical expertise, embarked on a 6-year project culminating in what is now known as the PNDS.3 Subcommittees developed each data element to ensure content validity and reliability as it relates to perioperative nursing with a review of current evidence-based practices, and a consideration toward future trends. In addition to literature and AORN document review, studies were conducted with experienced perioperative nurses, testing the validity and relevancy of the PNDS in various practice settings throughout the perioperative care experience.

After the ANA recognized it in 1999, PNDS was placed in a category with previously established nursing languages that includes the North American Nursing Diagnosis Association (NANDA) taxonomy, the Omaha System for community health, the Home Health Care Classification, the Nursing Intervention Classification, the Nursing Outcome Classification, and the Patient Care Data Set.4 Presently, no one common language embodies the essence of nursing practice. However, standardized nursing languages such as the PNDS will assist the profession with transition to an electronic health record in the not too distant future, ensuring acknowledgment of the vital contributions nursing makes to patient care.

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The language of nursing care

Language is essential to communication. Quite frequently in healthcare, communication gaps occur due to the complexity of terms (jargon) and the multiple meanings attached to terms (that is, start time, downtime, turnover time, and open time). Take for example the following scenario. Perioperative services at Hospital XYZ seek to better utilize its surgical block time allotment. The stakeholder group discovers that canceled cases are an impediment to the efficient use of available prime time. The group realizes that a canceled case has multiple meanings depending upon the reason for the cancellation. Through discussion, stakeholders identify cases that have been moved or reassigned to another day or at times have been classified as cancellations. However, is this truly a canceled or just a rescheduled case? Hence, the lack of standardized terminology is identified and consensus is reached with the definition of a canceled case approved by the group. Therefore, the agreement on a standardized term, in this instance what constitutes a case cancellation, clarifies the dialogue and results in an improvement in the scheduling process and use of prime operating time.

So too, standardized documentation of the nursing process clarifies the delivery of care, improves communication between providers, prevents the redundancy of care, highlights the value of nursing interventions, enhances data collection, promotes best practice standards, and assesses nursing competencies.5 Pearson stated, "Nursing has a long tradition of over-reliance on handing down information and knowledge by word of mouth." 6 In support of this statement, Rutherford contends that through documentation nurses express exactly what it is that they do for patients.5 Pearson expects that computerized documentation located near the patient bedside will result in more consistent, patient-focused nursing notes. Computerized documentation at the bedside can utilize nurses' time more efficiently, saving trips to the nursing station to access paper records, thereby leaving more time for the delivery of hands-on nursing care.6 Because a standardized language is integral to the advancement of electronic documenting, tools such as the PNDS should become the norm rather than the exception.

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Standardized language

Patient safety requires clinicians to quickly grasp the priority needs of patients. A language that uses a written narrative is often subject to individual interpretation. Four decades ago, pathologists identified this issue and began to research and develop a standardized language for pathology-centric terms.7 Further refinement and the need for a common taxonomy to describe patient conditions resulted in the Systematized Nomenclature of Medicine Clinical Terminology or SNOMED-CT. Introduced in 2002 and developed by the College of American Pathologists, SNOMED-CT standardizes terminology so that all caregivers have a basic understanding of the patient's problem.7 The most recent version of SNOMED-CT released in January 2007 is particularly suited to electronic documentation and is considered to be the most comprehensive international and multilingual clinical reference terminology in the world.7 SNOMED-CT links synonymous terms to a single concept. For example, appendicitis is linked to a disease of the appendix, inflammatory disorder of the intestine, inflammation, and appendix structures.

Much like SNOMED-CT, a standardized nursing language links terms to a single concept creating documentation that translates across the disciplines and contributes to the delivery of safe, quality care. For example, the NANDA-I taxonomy. NANDA-I assists nurses in developing the appropriate plan of care based on the nursing assessment.8 The nursing diagnosis drives interventions and outcomes enabling nurses to identify a comprehensive direction for patient care.8 For instance, the nursing assessment for a stroke patient could include the following nursing diagnoses: impaired verbal communication, risk of falls, or powerlessness. Again, this type of standardized classification makes documentation amenable to an electronic format, thus supporting the conversion to an electronic health record. When nursing interventions are captured electronically, a complete picture of what is happening to the patient becomes more accessible to all disciplines and highlights the important contribution nursing makes to quality patient care.

A lack of common definitions and defining characteristics in nursing language leads to miscommunication and potentially dangerous treatment errors. When everyone is speaking the same language, communication is seamless and effective. Standardized language ensures consistent communication and clarity. Heather Herdman, PhD, RN, is the Executive Director of NANDA International, the professional organization that develops, refines, and publishes the terminology that accurately reflects nurses' clinical judgments.9 She states that a standardized nursing language "provides clarity in communication among all professionals caring for that patient which, in turn, leads to a better level of care and improved patient safety." 9

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The PNDS defined

The PNDS is the only standardized nursing data set specifically tailored to the care of a patient undergoing a surgical or invasive procedure from preadmission to discharge. Lundberg explains that a data set is "used for consistent clinical documentation, communication between clinicians in various practice settings, benchmarking activities, evaluating patient outcomes, orientation programs and competency evaluation and effectiveness research."10 Kleinbeck defines a data set as "the smallest unit of information that has meaning and can be managed electronically." 3 Data elements not only assist in the standardization of language, but make that language amenable to electronic format. A data element is concise and exact as to the conceptual meaning it attempts to convey.

In the mid-1980s, Harriet Werley, PhD, RN, and colleagues identified the required elements of a nursing data set to include a nursing diagnosis, nursing interventions, patient outcomes, and the intensity of the required care.11 The PNDS is a nomenclature that describes perioperative nursing care through 74 nursing diagnoses, 133 nursing interventions, and 28 nurse-sensitive patient outcomes.11 The PNDS fulfills the intensity of care element through structural elements including the equipment, supplies, staffing, and physical structures necessary for a surgical procedure.3

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Basis for the PNDS

The PNDS has a conceptual framework based on the Perioperative Patient Focused Model.3 Kleinbeck described the model as representing "the universe of perioperative nursing. Patients and their family, at the core of the model, are surrounded by the concentric circles that symbolize the perioperative nursing process."12 The Perioperative Patient Focused Model includes four domains that support the context of the PNDS: patient safety, patient physiologic responses to surgery, patient/family behavioral response to the surgery, and the health system.12 Through research, each domain has been assigned specific nursing diagnoses, interventions, and outcomes. Kleinbeck proposed that the component parts of the model serve as the "building bricks of a midrange practice theory of perioperative nursing."3

For example, a perioperative nursing diagnosis within the realm of the safety domain is risk of infection. Appropriate interventions would be performance of proper skin preparation, implementation of sterile technique, and minimizing the length of invasive procedure by a preprocedure plan of care. Expected outcome would be the patient is free from signs and symptoms of infection. However, in contrast to patient-centered domains, a desired outcome for the health system domain would include benchmarking. Benchmarking could identify problems extracted from institutional report cards, with recognition of processes in need of revision to improve outcomes for patients or the organization.3 The PNDS provides validation for the care perioperative nurses routinely deliver with a formalized language based on evidence-based standards of care.

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The PNDS format

While the PNDS is divided into four domains with specific outcomes, diagnoses, and interventions assigned to each domain, to computerize the taxonomy each item has been labeled with a unique code number.3 Code numbers begin with a letter followed by a number. For example, O is assigned to outcomes, I to interventions, X to nursing diagnosis, followed by a number (that is, 1, 2, 3, 4). The four domains are signified as (D1) for safety, (D2) for psychological response, (D3) for behavioral response, and (D4) for health system.3 Coding permits the addition of new outcomes, interventions, diagnoses, or benchmarks without renumbering the entire tool.3 Using the previous example, the PNDS codification would adhere to the following format:

Outcome (O10)—The patient will be free from signs and symptoms of surgical site infection.

Intervention (I93)—Implements sterile technique.

Diagnosis (X29)—Risk of infection.

Domain (D1)—Safety.

Kleinbeck explains that coded elements are prohibited from being changed by clinicians or organizations. Once assigned, a code such as I93, the implementation of sterile technique, will always identify this intervention. In the event that such an element title or definition becomes obsolete, the code is withdrawn and never used again.13

Nursing data points, commonly documented on a perioperative record, link nursing activities with the codified elements of the PNDS. Utilizing the above Risk of Infection item, data fields pertinent to this diagnosis would include documentation of the appropriate wound class, skin prep solution, site of skin prep, staff performing skin prep, and sterile dressing applied postoperatively. While merely a small sample of the many nursing activities performed during a single surgical episode, these action elements are often standard on the average perioperative record. Nevertheless, Kleinbeck admits that a "nurse does not have to use or perform all the interventions or activities to deliver good perioperative care. The appropriate question is ‘Does any perioperative nurse ever do that activity?’ If the answer is yes, then it belongs in the PNDS vocabulary."13 However, clinicians should keep in mind that the PNDS is not a standard of care, but rather supplies the terms necessary to describe the nurse's action and the subsequent patient response.

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Stakeholder benefits with the PNDS

What advantages does the PNDS bring to clinical practice? The common language inherent within the tool promotes effective communication among caregivers throughout the surgical experience from the preoperative stage through the intraoperative and postoperative phases. Clinicians are "on the same page" as their uniform handoff communications support a safe patient environment. Additional benefits of a standardized language tool include increased visibility of nursing interventions, nurse autonomy, greater adherence to evidence-based care standards, enhanced nursing communication nationally as well as internationally, and the ability for data collection to compare quality of outcomes.5 Perioperative nurses in particular stand to gain from the implementation of the PNDS in terms of increased visibility for the specialized care they provide. This benefit alone has enormous implications for the validation of the perioperative RN and may be of particular importance for those clinicians practicing in regions of the country where the presence of the RN circulator isn't required by state law.14

Beyea extols the benefits of the PNDS for managers by stating "databases developed by structured term sets such as the PNDS allows managers to compare clinical data from a large number of patients. Such comparisons permit managers to measure, monitor and evaluate quality and the effectiveness of care."14 As a result, managers are better able to utilize the data to reconcile costs with quality, enhancing their ability to make informed decisions. In addition, a manager's use of the PNDS helps to develop nursing position descriptions, position responsibilities, evaluation forms, competency statements, a framework for policies and procedures, practice guidelines, critical pathways, and best practices.15

Since the PNDS is a specialty-based standardized vocabulary, perioperative educators can utilize this tool to augment content for educational and orientation programs for new perioperative students and personnel new to the organization, and for the continued instructional needs of experienced nurses as well.

For researchers, when fully implemented PNDS data supply clear-cut, unambiguous definitions with outcomes that are observable and measurable. Standardized documentation and a structured language provide nursing research with data sets in a useful format that can be aggregated and compared. AORN lists the following PNDS benefits for research: the identification of interventions that link to outcomes; improved data collection for benchmarking across clinical settings; the ability to support a data repository; and large patient populations from which to extract the data.16 When extracted from the EMR, data can be retrieved in real time, avoiding the painstaking process of sifting through stacks of charts for information. The PNDS offers a treasure trove of data from which to gather evidence-based results and draw conclusions applicable to the practice of perioperative nursing.

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The future of the PNDS

Since its inception and recognition by the ANA as the only taxonomy specific to perioperative nursing, the PNDS has been licensed by the following software vendors:

* Cerner Corporation

* iPath

* McKesson HBOC

* Medical Systems Management

* Mediware

* PerSe Technologoies

* Res-Q Healthcare Systems

* Surgical Information Systems

* Unibased Systems Architecture, Inc.17

However, there has been a lack of a perioperative documentation tool that can provide enough data for easy access to analysis, while effectively using the PNDS, and with integration of regulatory requirements. In addition, documentation has lacked the ability to cross over into each and every perioperative care phase and encompass all plan of care elements. Although the above vendors are licensed to use the PNDS into their documentation systems, there has been no uniformity in how it's reproduced.

Introducing Syntegrity, a standardized perioperative framework developed by the AORN in conjunction with Computer Sciences Corporation and currently available to the vendor market.18 The AORN recognized this lack of consistency with the use of the PNDS and therefore committed resources to the development of a standardized framework. Syntegrity builds upon the PNDS and, in addition to the standardized language, this tool will include data points necessary for reporting to regulatory and accrediting agencies, an all-important feature when considering pay-for-performance initiatives and Surgical Care Improvement Project measures.18 While clinicians can expect to see the coding of the PNDS change somewhat, the basic premise will remain the same. The revised PNDS Third Edition, has been updated to enhance functionality in an electronic format such as Syntegrity, and reflects regulatory changes and evidence based-practice innovations.19 Stanton reports, "Syntegrity breaks down the PNDS language to make clear connections between nursing diagnosis, care implementation and assessment and to get to a measurable outcome."20 The tool will also align outcomes with AORN standards of practice, as well as criteria set forth by the Joint Commission, the Centers for Medicare and Medicaid Services, and other regulatory and credentialing organizations. As an added component, Syntegrity employs an electronic companion guide, a quick search feature that provides users with a reference and the rationale for documenting elements.20 The provision of such rationale in real time helps to clarify and support necessary documentation points that previously may have been misunderstood or omitted by clinicians.

The PNDS is embedded within the Syntegrity framework. Although PNDS is the common language, Syntegrity is the vehicle that can deliver this language in an efficient, consistent, and reliable manner. Variability in language occurs across practice settings, often dictated by the facility or individual clinician. For example, under skin integrity, color may be signified as red, pink, or light pink, depending upon facility guidelines. Syntegrity will close the gap on such variability, reduce ambiguity, and enable busy clinicians to spend more time with patients and less time with documentation.

Syntegrity employs standardized data fields and values. It's designed to integrate consistent, reliable data across the total continuum of surgical care from the preadmission process through to the postoperative phase. Syntegrity's dynamic clinical support system incorporates national standards, regulatory and accreditation body criteria such as the Joint Commission's National Patient Safety Goals. Globally, the framework's ability to link with a national data repository will allow organizations to benchmark themselves against one another, identifying opportunities for patient and facility improvement.

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Conclusion

In 2004, former president George W. Bush called for the implementation of the EMR by 2014.21 President Barack Obama, in his February 2009 speech, posited that an EMR "will reduce error rates, reduce our long-term costs of health care and create jobs."22 The Obama administration in February 2010 announced $975 million in grants to help states, healthcare providers, and hospitals move from paper to computerized record keeping, thus supporting the rhetoric with the necessary financial incentives that will transform this mandate into reality.23

Meanwhile, nurses, the backbone of the healthcare system, have long depended upon their documentation for validation and visibility. Accurate documentation has never been more critical not only from a litigious standpoint, but also to ensure safe, quality patient outcomes. Pay-for-performance initiatives that threaten the fiscal health of healthcare organizations will be driven by measures extracted from patient records. The old adage "if it isn't documented, it isn't done" has taken on added significance. However, without a standardized language, documentation terms vary and are frequently clinician dependent. Standardized documentation clarifies critical communication and leaves little doubt as to its meaning or intent.

Therefore, the plan for health records to go electronic and the demand for effective communication to ensure patient safety have affirmed the need for a standardized nomenclature such as the PNDS. In fact, it would be virtually impossible to document electronically without such a tool. The PNDS supplies nurses with a common language, one easily understood by caregivers throughout all phases of the perioperative experience. As such, the PNDS developed for perioperative nurses by their own professional organization highlights the essential care RNs deliver to their patients on a regular basis. Through research, the PNDS has been proven to be clinically relevant and empirically validated.11

Syntegrity provides a standardized framework, taking the PNDS a step further placing perioperative language in a class by itself. While nursing in general has yet to introduce a universal language spanning all specialties, perioperative nurses using the PNDS continue to be poised to enter the age of electronic health records.

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© 2010 Lippincott Williams & Wilkins, Inc.

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