Changing the way nurses document care: Implementing the Omaha System in a New Zealand Community Nursing Organisation

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dc.contributor.advisor Honey, M en
dc.contributor.advisor Rowe, D en East, Sheree en 2015-02-26T04:53:39Z en 2014 en
dc.identifier.citation 2014 en
dc.identifier.uri en
dc.description Full text is available to authenticated members of The University of Auckland only. en
dc.description.abstract Electronic information systems incorporating nursing terminology are limited in community clinical practice in New Zealand and none are currently in use in District Nursing services. The strategy for the development of a universal personal electronic health record in New Zealand provides an opportunity for nursing to contribute their patient data so that a complete record is available, promoting safe and effective care. For nursing data to be available to the EHR a planned approach and nursing leadership is required to enable changes to the way care is documented and recorded. While system capability is being developed, nursing needs to ensure that structured data that captures the inputs and outcomes of nursing care is readily available. Nursing data will then be available to be collected, transmitted, and identified within the record, enabling recognition of the contribution of nursing to patient care outcomes. One community nursing organisation has undertaken a developmental journey towards enabling nursing data to be included in the electronic health record by implementing a standardised nursing language - the Omaha System - in its clinical documentation. This portfolio outlines the organisation’s journey towards developing an electronic clinical record and describes research projects undertaken to specify Omaha System terminology and the development of Omaha System based pathways for the organisation’s District Nursing service. The Omaha System Problem Classification Scheme had been initially used in a pilot electronic health record by the organisation. A research project was undertaken to define the problem list and care pathways for District Nursing. Data from a pilot electronic health record was compared with problem lists from literature that described the use of the Omaha System in similar service contexts. A problem list of 36 of the Omaha system problem classification scheme terms was developed and tested with focus groups of nurses. Proof of concept care pathways were developed using the problem list and associated interventions from the Omaha System Intervention Scheme. The proof of concept pathways were then tested using a mapping exercise with existing client records and the pathways were then validated by a nursing focus group. The Omaha System was demonstrated to be a standardised nursing language that was, with some interpretation for a small number of terms, well understood and acceptable to New Zealand based District Nurses. The system captured the work of District Nursing in a structured format that could be used to enable data capture in an electronic format. Enabling the capture of nursing data in an electronic system using a standardised nursing language enables nursing to measure the outcomes of care and make nursing visible within the health care environment. This research study demonstrates that an internationally developed standardised nursing language was able to be applied in the District Nursing context, challenging the theory that New Zealand nursing needs to undertake the significant levels of research, investment, and development required to create its own national standardised nursing language. The validity and reliability of the foremost international standardised nursing languages is well established and ongoing work being undertaken by nursing researchers and informaticians promises to provide increasing levels of interoperability and specificity into the future. en
dc.publisher ResearchSpace@Auckland en
dc.relation.ispartof Masters Thesis - University of Auckland en
dc.rights Items in ResearchSpace are protected by copyright, with all rights reserved, unless otherwise indicated. Previously published items are made available in accordance with the copyright policy of the publisher. en
dc.rights Restricted Item. Available to authenticated members of The University of Auckland. en
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dc.rights.uri en
dc.title Changing the way nurses document care: Implementing the Omaha System in a New Zealand Community Nursing Organisation en
dc.type Thesis en The University of Auckland en Masters en
dc.rights.holder Copyright: The Author en
pubs.elements-id 476945 en
pubs.record-created-at-source-date 2015-02-26 en

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