Structural Data Elements — Standardized Terms and Definitions

AORN Journal, March, 2000 by Suzanne C. Beyea

Editor's note: This is the fourth of a series of articles planned to help perioperative nurses understand the AORN Perioperative Nursing Data Set, This clinically validated standardized language and the Perioperative Patient Focused Model are a beginning point to help RNs document and describe perioperative patient core,

Imagine being a foreign-speaking individual coming to an English-speaking country for the first time. You struggle to decipher meanings of words from a pocket dictionary. Reading the definition of "branch," for example, you discover it has multiple meanings. You wonder if the correct meaning is a tree branch, the branch of a stream, a unit of a business, or separating or diverging. Imagine your confusion as you struggle to :interpret what branch means.

Generally speaking, language provides our primary method of communication. When language is precise and clearly defined, it contributes to our understanding. In health care, two major challenges surround language and effective communication. One issue is the use of a complex technical language replete with jargon (eg, NPO, up ad lib). The second communication problem in health care is the lack of standardized definitions for many terms we commonly use to describe our work and measure our contributions. In the perioperative arena, terms such as star, time, turnover time, and open time may have as many meanings as the number of facilities using the terms.

This issue is important because this lack of standardization leads to confusion and miscommunication. For example, a surgeon may discuss reducing turnover time with a nurse manager who believes the department is run at top efficiency. Imagine the confusion until they discover they use different definitions for the same concept. Establishing one mutually held concept of turnover time is critical for these professionals to work together and address their shared concerns.

This lack of precise definitions can lead to problems in an institution, but it has larger implications as well. Perhaps a surgical department is interested in comparing its outcomes with other health care facilities. An agreement is reached to compare turnover time, average procedure length, open time, room cleanup time, and total hours. Moreover, the institutions have computerized documentation and databases that include the same data fields. Unless each institution has precisely and identically defined each term and collected data accurately, data comparisons cannot be made. Standardized language provides mechanisms for effective and meaningful communication between and among health care professionals and institutions.

Worldwide, a number of initiatives are underway to develop standardized vocabularies and minimize health care terminology confusion. Health care organizations and associations, researchers, medical and nursing informatics specialists, vocabulary authors, software developers, clinicians, and others are spearheading and supporting these efforts. Quality health care data are crucial to understanding contributions of health care providers, but they must be linked to standardized languages, definitions, and valid and reliable measurements.

Identifying and defining structural elements allows nurses and other clinicians to use specific terms with clear and precise definitions. For example, 5tart time is a commonly used term in the perioperative setting; however, it is impossible to compare start times between institutions because definitions and documentation often vary. Some facilities have perioperative records that require documentation about aspects of care that are not addressed in other institutions. Without a perioperative minimum nursing data set there is no standardization between settings.

EFFORTS AT AORN

Since 1993, members of AORN have been involved in activities to describe, define, and establish a data set that represents perioperative nursing practice. The organization's initial goal was to develop a unified language so that nursing care could be systematically quantified, coded, and easily captured in a computerized format in the perioperative setting. The ultimate goal was to help perioperative nurses achieve recognition and reimbursement for their unique knowledge, skills, and contributions to perioperative patient outcomes.

This project was originally organized and directed by the AORN Task Force on Perioperative Data Elements (1993-1995). The original charge of the Task Force was to describe, define, and develop the data elements of perioperative nursing practice that describe nursing practice. From 1995 to 1908, that work was continued by the Data Elements Coordinating Committee (DECC). The cumulative result of these efforts was the Perioperative Nursing Data Set (PNDS).

Background. A growing awareness of the need to establish a database describing perioperative nursing began in 1988 with the AORN Critical Issues Committee. The organization's Project 2000 evaluation initiative and the Project Team on the Effectiveness Initiatives supported this same premise. A four-year organizational evaluation clearly demonstrated the need to identify the relationship of nursing interventions to patient outcomes and the need for a database capable of providing evidence of the value of the perioperative nurse during a patient's surgical experience.