Critical Path Network: Hands-on’ application tracks nursing care, results

Standardized nomenclatures aid benchmarking

A software application developed by the University of Michigan School of Nursing in Ann Arbor offers the promise of providing a means to collect comparable data for nursing care in the areas of diagnosis, intervention, and outcomes, resulting in far more accurate information both for self-evaluation and benchmarking across health care organizations.

Called HANDS (Hands-on Automated Nursing Data System), the application was developed over the past four years.

Currently, it is available in a CD-ROM version, but its developers hope to have it converted soon to a web-based format.

"The nursing profession had already developed standardized terminology to represent nursing care," explains Gail Keenan, PhD, RN, principal investigator for the HANDS project. "The reason we began our project was to enable them to pick up common information about patients across a continuum, within units, and across organizations."

Searching for a common language

Although a common language theoretically was available to all nurses, health care organizations still were measuring different things in different ways, she notes.

There were common terms for diagnosis (NANDA or North American Diagnoses Association, classifications), outcomes (NOC or Nursing Outcomes Classification) and interventions (NIC
or Nursing Interventions Classification).

However, "if that term is used differently in different organizations, or if you use some parts of the nomenclature and not others, depending on what the organization wants, that means you’re not going to have a standardized way of communicating your data," Keenan explains.

So, for example, two organizations may do the same things, but use different terms to describe them. "Some people may say abdomen, some tummy, and others, the lower quadrant," offers Marcy Treder, BSN, RN, HANDS project manager. "We’re all speaking about a particular location but capturing it in different terms."

"Take hyperglycemia management, which is an NIC term," Keenan says. "There is a set of terms called activities.’ So the term hyperglycemia management actually reflects not just monitoring blood glucose, but administering glucose, monitoring ketones in the urine, and so on."

On a larger scale, she says, there are some 470 NIC terms. "A given organization might limit the number of terms they would use to, say, 30," she posits.

"They might not include hyperglycemia management, while other organizations would have access to all the NIC terms to describe their care. If you had only 30, those areas not covered by NIC terms would have to be written up in narrative terms," Keenan adds.

HANDS across the borders

Although care differs across units, they should have access to the same set of terms all the time, the HANDS team argues. That’s the impetus for the project.

"HANDS is a standard interface through which everyone collects the data in the same way," Treder explains.

"Everybody’s got everything, and the search mechanisms to locate what they don’t know," Keenan adds. "If you don’t know the name of a term, you can search for it. In the glucose example we used earlier, you can search for interventions for high glucose levels or outcomes or problems that are related to glucose."

When using HANDS, nurses merely use a series of pull-down menus to access terms, and enter diagnoses, treatments, and outcomes for each patient. (See sample screen 1 and 2.) They can not only track current cases but study their progress over time.

"For example, NOC has a measurement scale rating from one to five," Keenan says. "So a nurse is actually giving a rating to the outcome. They can then see if the outcome gets better over time."

The HANDS team predicts its project also can lead to wide-scale benchmarking studies. "We’ve developed a methodology for the way information is displayed and captured," Keenan explains. "By so doing, the information available across organizations is comparable. There is a whole host of information, and you keep gathering data around the same variables."

HANDS is not a recipe for how to operate a unit or a hospital, she adds.

"However, since you use the same methodology, you can capture and compare differences," Keenan notes.

"One culture may be very different from the rest; there may be high staffing levels, good nurse satisfaction, and this may lead to different interventions and perhaps better outcomes. But by comparing the same information, you can benchmark against these other organizations," she says.

The HANDS project has completed Phase I and currently is seeking funding for Phase II (converting the tool to a web-based application and making it operational at several health care facilities). Phase I consisted of setting the nursing outcomes classifications.

"The data set [patient names, diagnoses, interventions, outcomes] — all the variables were entered into HANDS," Keenan says.

"We had nurse researchers shadow the nurses giving care. After talking with the nurses and observing what they did, they would record the information," she adds.

The nurses found the application very useful, Keenan reports. "It provided information nurses usually don’t capture; they got a clearer picture
of what care was provided to the patient — and they could see everything at a glance."

As for training, nurses are educated to use the language of the three nomenclatures. "Most nurses have not been educated around that, but the software makes it easy," Keenan says.

"We’ve got the HANDS application up in 17 schools of nursing in Michigan, and those schools are all using it now, so their nurses will know it when they graduate. Those clinicians who do not know it will have to learn it," she adds.

HANDS is a particularly important initiative, Keenan notes, because "What nurses do is not visible to anyone — not even to the nurses."

Most people describe nursing as a caring profession whose members advocate for patients and carry out physicians’ orders. "In reality, nurses carry out 80% of the hands-on patient care that is provided," she notes. "What they do has a tremendous impact on outcomes."

[For more information, contact:

Gail Keenan, PhD, RN, Principal Investigator, The HANDS Project, University of Michigan School of Nursing, 400 North Ingalls Building, Ann Arbor, MI 48109-3705. Telephone: (734) 763-3705. E-mail:

Marcy Treder, BSN, RN HANDS Project Manager. Telephone: (734) 615-1457. Fax: (734) 647-2416. E-mail: HANDS web site:]