Perspectives in nursing education: From paper standardized taxonomies to electronic records applied in nursing practice

Nursing process has a relevant impact on overall quality of healthcare services and patient outcomes, however nursing contribution appears to be almost ‘invisible’. Use of an international Standardized Nursing Language (SNL), as NANDA-I NOC NIC (NNN) taxonomy, allows making nursing visible in education, practice and research with final better outcomes on patients. Electronic Health Record (EHR) could facilitate learning of standardized languages in nursing undergraduate students, but only few studies analyzed it. This paper aims to report the experience of the ‘Caring project’ utilizing a SNL in an Italian healthcare setting and to discuss potentialities of EHR in improving nursing education and practice. ‘Caring project’ was an Italian pilot observational study, conducted on 231 patients of 8 Units retrospectively (January 2018–March 2019), using a ‘paper’ assessment form with Gordon’s Functional Health Patterns (FHPs) and an Individual Care Plan (ICP), an ‘Excel® based health record prototype’. In the study a total of 484 Nursing Diagnosis (NDs) has been identified, corresponding to a mean of 2.0 ± 1.5 NDs/patient. Integration of SNL with EHRs could help nurses to use a holistic approach and, in nursing education, it could improve undergraduate students clinical reasoning skills. Further researches are necessary in this subject, in particular regarding the nursing diagnostic accuracy.