Electronic nursing care plans through the use of NANDA, NOC, and NIC taxonomies in community setting: A descriptive study in northern Italy

PURPOSE: To carry on a descriptive analysis of nursing standardized language through the use of a software within outpatient facilities in northern Italy, organized according to the Chronic Care Model (CCM) and called Community Health Centers (CHC). METHODS: A descriptive design was adopted for the study. NANDA‐I, NOC, and NIC taxonomies have been used to analyze care plans pulled from the software. Both qualitative and quantitative data were analyzed. FINDINGS: The average of nursing diagnosis correctly identified with respect to the nursing assessment is 83.7% (SD 29.9%). Class 4 diagnoses from Domains 4 have been identified as the most prevalent (22.4%), followed by risk for unstable blood glucose level 00179 (16.4%) and risk for overweight 00234 (13%). The main nursing outcomes were vital signs 0802 (22.5%), blood glucose level 2300 (16%), and weight loss behavior 1627 (11%). The most prevalent nursing interventions are wound care 3660 (27%), medication administration: intramuscular 2313 (19%), and health education 5510 (14%). The analysis shows ability in identifying nursing diagnoses, but a larger variability with outcomes and interventions. The study highlights the nursing role within CHC and identifies the main areas of expertise in chronic disease management: prevention and health education. CONCLUSIONS: Nurses’ role is fundamental for chronic disease management within CHC; NANDA‐I taxonomy helps to analyze care plans. IMPLICATIONS FOR NURSING PRACTICE: ‐ A taxonomy such as NANDA‐I represents a valid opportunity to make more visible how much nursing skills affect the achievement of a higher level of health in chronic patients. ‐ This study is useful in the further training of outpatient nurses who works in CHC. ‐ The study represents the starting point for future research to deepen the development of a standardized nursing language in outpatient facilities.