摘要
目的分析临床护理分类系统(CCC)应用现状,为CCC在我国的应用推广提供依据。方法计算机检索PubMed、CINAHL、Wed of Science、万方、知网、维普等22个数据库中关于CCC的文献,对符合纳入标准的实证研究型文献进行分析。结果共纳入15篇文献,关于CCC的文献研究主要围绕CCC与其他标准化护理术语体系的兼容性、CCC在临床护理中的应用、在护理管理中的应用、在护理教育中的应用4个主题展开。结论基于已发表文献,CCC在不同人群、不同环境中的适用性已经得到验证,并能与其他标准化术语相协调,在计算护理服务成本、帮助护生提高临床决策能力方面,也有显著作用。但目前的研究均围绕CCC本身展开,未见利用CCC产生临床证据、支持临床实践的研究。国内学者应当验证CCC在国内的适用性,并利用CCC收集临床数据,产生临床证据,推动护理质量的持续改进和我国护理信息化进程。
Objective To explore the status of the clinical care classification(CCC) system and provide the basis for the promotion of the CCC application in China. Methods The literatures of CCC system were retrieved from PubMed,CINAHL,the Cochrane library,WangFang database, CBM,CNKI and other databases. The research literature conformed to the requirements were analyzed. Results A total of 507 records were identified and 38 full‐texts assessed. Fifteen studies were reviewed. The literature research on CCC mainly focused on the compatibility between CCC and other standardized nursing terminology systems, the application of CCC in clinical nursing, the application of CCC in nursing management and the application of CCC in nursing education. Conclusion Based on the published literatures, the CCC system appears to be well developed for various populations, settings. It harmonizes with other nursing terminology systems. But no studies used the system to generate information about the outcomes of nursing practice. We should verify the applicability of CCC in China,use CCC to collect clinical data and produce clinical evidence. It can promote the continuous improvement of nursing quality and the process of nursing informatization in China
引文
[1]Whittaker AA,Aufdenkamp M,Tinley S.Barriers and facilitators to electronic documentation in a rural hospital[J].J Nurs Scholarsh,2009,41(3):293-300.
[2]Keenan GM.Use of standardized nursing language will make nursing visible[J].Mich Nurse,1999,72(2):12-3.
[3]刘霖,Amy Coenen,陶红,等.国际护理术语分类体系发展概况及其对我国护理的启示[J].中华护理杂志,2015,50(5):593-7.
[4]Saba V.Clinical care classification(CCC)system,version2.5 user's guide[M].New York:Springer Publishing Company,2012:35-6.
[5]Matney SA,Dadamio R,Couderc C,et al.Translation and integration of CCC nursing diagnoses into ICNP[J].J Am Med Informat Assoc,2008,15(6):791-3.
[6]Dykes PC,Dadamio RR,Kim HE.A framework for harmonizing terminologies to support representation of nursing practice in electronic records[J].NI,2012,(12):103-12.
[7]Jansen K,Kim TY,Coenen A,et al.Harmonising nursing terminologies using a conceptual framework[J].Studies Health Technol Informat,2015,165(14):471-80.
[8]Varzeshnezhad M,Rassouli M,Tafreshi MZ,et al.Transcultural mapping and usability testing of the clinical care classification system for an iranian neonatal ICU population[J].Comput Inform Nurs,2014,32(4):182-8.
[9]Heidarizadeh K,Rassouli M,Manoochehri H,et al.Effect of electronic report writing on the quality of nursing report recording[J].Electronic Physician,2017,9(10):5439-45.
[10]Gülbahar KA.Oya nuran E L evaluation of the applicability of the clinical care classification system to the care of elderly nursing home residents[J].Comput Inform Nurs,2013,31(4):178-88.
[11]Whittenburg L,Meetim A.Electronic nursing documentation:patient care continuity using the clinical care classification system(CCC)[J].Studies Health Technol Informat,2016,166(1):13-24.
[12]Feng RC,Tseng KJ,Yan HF,et al.A preliminary study on the use of clinical care classification in nursing documentation data sets[J].Comput Methods Programs Biomed,2013,112(3):713-9.
[13]Kaija S,Jacqueline M,Virpi J.Medication counseling:analysis of electronic documentation using the clinical care classification system[J].Studies Health Technol Informat,2010,160(Pt 1):284-93.
[14]Feng RC,Chang PL.Usability of the clinical care classification system for representing nursing practice according to specialty[J].Comput Inform Nurs,2015,33(10):448-55.
[15]Moss J,Saba V.Costing nursing care using the clinical care classification system to value nursing intervention in an Acute-Care setting[J].Comput Inform Nurs,2011,29(8):455-60.
[16]Dykes PC,Wantland D,Whittenburg L,et al.A pilot study to explore the feasibility of using the Clinical Care Classification System for developing a reliable costing method for nursing services[J].AMIA Annu Symp Proc,2013,(2013):364-71.
[17]Saba VK,Feeg VD.A bedside PC charting system for nursing students using Clinical Care Classification(CCC)System[J].AMIAAnnu Symp Proc,2005,62(13):1101-15.
[18]Feeg VD,Saba VK,Feeg AN.Testing a bedside personal computer clinical care classification system for nursing students using microsoft access[J].CIN-Comput Informat Nurs,2008,26(6):339-49.
[19]Mannino JE,Feeg VD.Field-Testing a PC electronic documentation system using the clinical care classification(c)system with nursing students[J].J Healthc Eng,2011,2(2):223-40.
[20]Sally R,Margaret AK.Innovation in transformative nursing leadership:nursing informatics competencies and roles[J].Nurs Leadersh,2012,25(4):14-26.