Revising the Perioperative Nursing Data Set - Clinical Innovations

AORN Journal,  March, 2002  by Susan V.M. Kleinbeck

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The Perioperative Nursing Data Set (PNDS) defines the expected outcomes of perioperative patients, interventions and activities implemented by nurses to achieve those outcomes, and nursing diagnoses specific to patients scheduled for invasive or operative procedures. (1) It articulates the perioperative nursing process. To date, the PNDS is the only standardized vocabulary developed by a clinical specialty, recognized nationally by the American Nurses Association, and registered by a federal standards agency (ie, Health Level 7). During the past two years, AORN members, computerized patient record vendors, clinical practitioners, language experts, informatics specialists, and AORN staff consultants have recommended a variety of changes to the data set. Recommendations have been prompted by

* changes in patient needs;

* analysis of PNDS applications in the clinical setting;

* changes in the perioperative environment, technology, and surgical and other invasive procedures; and

* efforts to reflect RN first assistant (RNFA) contributions to patient care.

In an effort to include these recommendations, the PNDS has been reviewed, revised, and edited into a new format.

PNDS REVIEW

The original PNDS provided an essential foundation for the perioperative clinical specialty; however, the complex nature of vocabulary development and the diversity of clinical roles in the perioperative setting require periodic multilevel reviews of content and vocabulary. As the PNDS continues to be applied in perioperative settings, there will be continual growth and refinement in the vocabulary. Each new edition with changes, additions, and deletions will require repeated content validation from numerous experts in clinical practice, vocabulary development, and informatics. Final approval for all revisions comes from the AORN Board of Directors. Participants in the review process of this new edition included

* members of committees that developed the original PNDS,

* perioperative RNs and RNFAs with content expertise in a variety of specialties,

* nationally recognized vocabulary experts,

* nurse informaticians working with clinical applications,

* members of the AORN Nursing Practices Committee,

* staff members in the AORN Center for Nursing Practice and the Research Department, and

* doctorally prepared consultants.

GUIDELINES FOR THE REVISION

Underlying assumptions are prevailing, guiding principles. Assumptions are viewed as self-evident, unquestioned, and a starting point for reasoning. The assumptions that guided the systematic evaluation and change of the PNDS are

* the PNDS is a vocabulary, not a standard of care;

* the definition of perioperative goes beyond intraoperative practice;

* elements of the PNDS have a unique identifier, and no unique identifier may be used more than once;

* the attributes of consistency and standardization are desirable in a vocabulary;

* redundancy or duplication cannot be eliminated completely from the PNDS vocabulary; and

* consistent levels of abstraction facilitate application of the PNDS to the clinical setting.

Not a standard of care. The PNDS is a vocabulary that all perioperative nurses can use regardless of their role or clinical setting. No matter where a perioperative nurse delivers care, the PNDS should have the terms needed to describe the nurse's actions and the patient's responses. The PNDS is like an English dictionary. A dictionary lists all the words in the English language, but individuals do not have to use every word in the dictionary to speak English well. The PNDS is a dictionary of the terms used to describe the perioperative nursing process (eg, diagnoses, interventions, outcomes); however, a nurse does not have to use or perform all of the interventions or activities to deliver good perioperative care. When a perioperative nurse says "I never do that activity," it is acceptable. The appropriate question is "Does any perioperative nurse ever do that activity?" If the answer is yes, then it belongs in the PNDS vocabulary.

Beyond intraoperative practice. Although many perioperative nurses practice within the four walls of the OR, there are nurses who participate in preoperative preparation, postanesthesia care, and follow-up telephone calls. In some ambulatory settings, the same nurse admits, assesses, and prepares the patient before surgery; cares for that patient during surgery; and implements postoperative care after surgery. Although many PNDS terms reflect a unique language applicable to intraoperative care, preoperative, postoperative, and at-home care terms must be included for the vocabulary to be useful across settings.

Unique identifiers. The PNDS is a codified vocabulary, which means it is arranged in an orderly fashion that establishes a systematic pattern or outline that can be coded. Each element in the PNDS, including outcomes, interventions, and nursing diagnoses, has been assigned a unique identifier. For example, the nursing intervention "performs required counts" is defined as ensuring that the patient is free from injury related to retained sponges, instruments, and sharps, and it is coded I94. The intervention I94 always will address counts. Neither health care facilities nor nurses are permitted to change any coded element title or definition. Should technology ever make invasive procedures obsolete, the code I94 would be retired and never used again. Activities listed under I94 include