The European Union (EU) comprises 28 member states and recognizes 24 official languages, highlighting the region's complexity.
The EU significantly influences healthcare policy and practice through its directives, aiming to enhance equality, quality, and safety in healthcare services across member states.
The EU supports research and development in education and health, with numerous formal and informal communities collaborating at the European level in nursing.
eHealth initiatives are a focal point, addressing patient safety, nursing language, education, management, and practice.
The Finnish national nursing documentation project exemplifies the implementation of standardized nursing terminology in electronic health record (EHR) systems.
Objectives
Describe elements of the European Union eHealth initiatives.
Describe nursing terminology work in Europe.
Give examples of nursing informatics education in Europe.
Give examples of nursing informatics cooperation in Europe.
Describe possibilities of meaningful use of structured data.
Describe a national model for documenting nursing and implementing an electronic nursing care plan.
Give examples of future developments.
Nursing Informatics as Part of the eHealth Strategies
In 2010, Europe had 738 million inhabitants, representing 10.7% of the world’s population.
The European Union includes most of Europe, with 28 member countries and a population exceeding half a billion, which is over 50% larger than the population of the United States, though the EU's geographic area is less than half.
Population density varies significantly across the European Union, impacting health service delivery.
For example, Malta has approximately 1300 inhabitants per square kilometer, while Finland has 15 inhabitants per square kilometer.
National health services differ across the European Union, leading to variations in the numbers of registered nurses (RNs) and physicians.
Aging populations across the European Union are leading to increased demand for health and social services coupled with a shortage of skilled nursing personnel.
By 2060, it's projected that almost one-third of the European Union’s population will be over 65 years old, a significant increase from 17.4% in 2010.
Higher income and education levels are also contributing to the increased demand for healthcare services, as are rising expectations among citizens for the best care available.
The increasing popularity of the Internet has changed the delivery of healthcare services, rendering the traditional office visit model insufficient to meet diverse patient needs; new methods for accessing health services and information are needed.
European countries must meet citizens’ needs while also reducing the increasing costs of healthcare services.
eHealth in European Union Policy Frameworks
Health informatics offers solutions to healthcare challenges.
The European Commission promotes the use of information and communication technology (ICT) through eHealth tools to improve healthcare services.
The eHealth Action Plan, published in 2004, defines eHealth as a tool for productivity gains and for restructuring healthcare systems to be more citizen-centered, while respecting Europe’s diverse healthcare traditions.
Successful eHealth developments include health information networks, electronic health records, telemedicine services, wearable and portable monitoring systems, and health portals.
eHealth is defined as health services and information delivered or enhanced through the Internet and related technologies (Eysenbach, 2001).
The European Commission introduced the eEurope initiative in 2000 to create an information society for all Europeans and ensure the European Union was ready for the development of the information society.
The eEurope 2002 Action Plan aimed to extend Internet connectivity and help member states adopt an existing legal framework; these aims were achieved by 2002.
The eEurope 2005 Action Plan focused on broadband technologies, electronic health services, and improving the quality and cost-effectiveness of public services.
The European Commission introduced an Action Plan for a European eHealth Area in 2004, alongside the eEurope strategy initiatives, with the central points of the first eHealth Action Plan being information transfer, health and patient information, patient identifiers, mobility of patients and health professionals, infrastructure and health information networks, as well as monitoring the effects of new interventions.
The eHealth Action Plan included recommendations for disseminating best practices and experiences regarding eHealth applications across the European Union.
Progress of eHealth application implementation was measured every two years from 2004 to 2010.
The Monitoring National eHealth Strategies study analyzed the results obtained by European Union member states through 2009, and the eHealth Benchmarking study, funded by the European commission, aimed to analyze existing benchmarking sources.
Based on the results of the benchmarking study, a European Union–level recommendation for eHealth benchmarking activities, including definition of indicators, data collection, and conclusions, was produced in 2009 (Meyer, Hüsing, Didero, & Korte, 2009).
In 2008, the European Commission published a recommendation on cross-border interoperability of EHR systems to support the goals of the eHealth Action Plan.
The recommendation stated that existing and future challenges of healthcare systems can be partly solved through the implementation of eHealth applications.
EHRs are a fundamental part of eHealth systems, thus interoperability between information systems needs to be achieved in order to fully utilize the benefits of EHRs; the guidelines set minimum requirements for member states to ensure that EHR systems can work together across the European Union.
The guidelines introduced issues of evaluation and monitoring, as well as education and awareness, presenting the following objectives:
Establish elements of EHRs that should be exchangeable between systems.
Enable health data to be shared among different healthcare systems.
Build appropriate networked systems and services covering all healthcare areas.
Work to achieve interoperability continued in 2012 when the European Commission aimed to develop an eHealth European Interoperability Framework (EIF), based on a generic European Interoperability Framework, meant to be an operational toolkit for stakeholders who participate in the deployment of eHealth systems.
Interoperability between information systems is not only a technical issue; health data are sensitive and trustworthy, thus, patient confidentiality and security are important as well as legal, ethical, economic, organizational, and cultural aspects.
The components of the eHealth EIF are as follows: governance, principles, agreements, the four levels of interoperability—legal, organizational, semantic, and technical—and the high-level use cases (European Commission, 2013).
Interoperability issues are one of the key aims of the eHealth network, established under the Directive on the application of patients’ rights in cross-border healthcare (Klazinga, Fischer, & ten Asbroek, 2011).
The eHealth network is a group of voluntary network of national authorities responsible for eHealth in European Union member states, purposing to make guidelines in the area of eHealth in order to enable continuity of care and to ensure access to safe and quality healthcare (European Commission, 2014a).
National Roadmaps for eHealth
The eHealth Action Plan required each member state to develop a national eHealth strategy to identify their current state and map a plan for future development (Commission of the European Communities, 2004).
National strategies focused on implementing eHealth systems, interoperability, utilizing EHRs, reimbursing eHealth services, and other related issues.
Evaluation of national strategies conducted in 2008 showed that 25 out of 27 member states had formulated a national eHealth strategy; many of these strategies had links to national information society programs as well as to eEurope and i2010 information society programs.
The Monitoring National eHealth Strategies study, published in 2010, showed that almost all European Union member states have detailed documents concerning eHealth goals, implementation, and achievements (Stroetmann, Artmann, & Stroetmann, 2011).
Finland introduced its eHealth strategy in 2007, based on the Finnish national information society strategy work started in the mid-1990s, with the following two main objectives:
Secure the access to information for those involved in care regardless of time or place.
Enable the involvement of citizens and patients, increasing the citizens’ access to information and offering a high-quality of health information.
The interoperability of information systems in healthcare is the starting point for information accessibility, and national-level legislation, recommendations, and specifications have been produced, with the first aim to attain interoperability between public and private service providers and then later between health and social welfare systems (Ministry of Social Affairs and Health, 2007).
Electronic patient records already have a nationally defined structure, and the specification has been implemented in the information systems.
Several classifications and codes, such as the Finnish Classification on Nursing Diagnosis and Interventions, have been agreed upon.
Finnish legislation supports availability of health information for citizens, and Finland has conducted implementation activities and plans, storing core patient data in the national electronic archive.
The e-archive enables citizens to access their health data and e-prescriptions online.
Some regional Internet-based health services were introduced in Finland; the Hyvis portal, for example, is a free service District that complements regional health services and promotes the welfare of inhabitants by offering reliable information about health and healthcare services; the portal also includes the ability to make appointments for some healthcare services and to communicate with healthcare professionals.
At the beginning of 2014, electronic services are under development, and more possibilities are coming in the near future (Hyvis, 2013).
In the United Kingdom, the role of health informatics, and certainly nursing informatics, became increasingly prominent over the course of 2010.
The U.K. Government is investing billions of pounds in developing information and communications technology (ICT) within the National Health Services to ensure that modernization and utilization of eHealth becomes a reality.
All four countries now have national programs for ICT:
England: NHS Connecting for Health.
Wales: Informing Healthcare.
Scotland: eHealth program.
Northern Ireland: HPSS ICT.
Toward eHealth Action Plan 2012–2020
In 2005, the European Union introduced a new strategic framework for the information society and media called i2010, where eHealth had an important role, focusing on accessible eHealth services and the participation and inclusion of Europe’s citizens in healthcare provision through electronic tools.
Concurrent with policy framework, a sub-group on eHealth was established (European Commission, 2014b), with the main objectives to improve quality and accessibility of healthcare services, while supporting the cost-effectiveness of eHealth systems and services; one of the main tasks of the sub-group was to facilitate and contribute the implementation of the previously mentioned eHealth Action Plan.
The i2010 framework was followed by a new policy framework, the Digital Agenda for Europe, which focused on the utilization of the economic and social potential of Internet technologies in all fields of society (European Commission, 2010).
In healthcare, the emphasis was on ambient assisted living (AAL) technologies, which makes ICT-based services accessible for all.
To support these strategic plans, the European Union launched the AAL Joint Program for conducting research on and development of eHealth applications, to enhance the quality of life of older people by extending the time people can live in their homes, supporting functional capability of the elderly, and increasing the efficiency and productivity of used resources (Ambient Assisted Living Joint Programme, 2012).
From the viewpoint of nursing informatics, AAL technologies offer the means to care for older patients who remain in their own homes and enables health information management at the point of care.
In addition to AAL activities, the following actions will be included in the Digital Agenda during the coming years:
Secure online access for Europeans to their medical health data.
Widespread deployment of telemedicine services.
Definition of a common minimum set of patient data for interoperability of electronic patient records (European Commission, 2010).
Despite successful implementation of eHealth initiatives in the region, many barriers still exist for the wider deployment of eHealth services; in order to find solutions to tackle existing barriers, the European Commission has launched a new eHealth Action Plan 2012–2020 (eHAP) aiming to innovative healthcare for the twenty-first century, addressing the barriers and aiming to fulfil the following objectives:
Achieving wider interoperability of eHealth services.
Supporting research, development, and innovation in eHealth and well-being to address the lack of availability of user-friendly tools and services.
Facilitating uptake and ensuring wider deployment.
Promoting policy dialog and international cooperation on eHealth at global level.
With these targets, the ultimate goal of the actions is to provide smarter, safer, and patient-centered health services in the European Union.
A recent directive on the application of patients’ rights in cross-border healthcare (Klazinga et al., 2011) enables citizens of European Union to seek health services from other EU country (Directives, 2011); to guarantee the continuity and safety of care, the cross-border exchange of health data is needed; the eHAP emphasizes the importance of data protection mentioning that it is a vital element of trust in eHealth, also notifying the technological development and thus one part of it focuses on mobile health (mHealth), meaning the utilization of mobile devices such as tablets and smartphones in health services (European Commission, 2012).
As stated in the eHAP, the European Commission will work together with member states to facilitate wider deployment of eHealth services; patient empowerment and skills to use eHealth services are essential for the uptake of eHealth; not only patients need more information, but also health professionals’ awareness of eHealth opportunities needs to be increased.
The European Commission will support the development of evidence-based clinical practice guidelines for telemedicine services especially in the field of nursing.
It is also important to measure the added value of eHealth services, for that purpose the Commission will launch sets of common indicators for the measurement of the added value and benefit of the eHealth; in addition Health Technology Assessment methodologies will be utilized in the evaluation of the costs and productivity of eHealth services in the period 2013–2016; in the near future research and innovation relating to eHealth tools and services will be supported under the Horizon 2020 program (European Commission, 2012).
Cross-Border Activities in eHealth
The Directive on the application of patients’ rights in cross-border healthcare (Klazinga et al., 2011) enables EU citizens cross-border access to healthcare services in the European Union member states (Directives, 2011).
The implementation of the directive has required the change of national legislation, and national authorities have created guidelines for the citizens; safe health information transfer is a basic principle of the cross-border healthcare.
The Smart Open Services for European Patients (epSOS) pilot (2008–2014) attempts to achieve cross-border interoperability between electronic health record systems in Europe (epSOS, 2014); the aim of this pilot is to enable seamless patient health information exchange and improve the quality and safety of healthcare when people move between European countries; totally 23 countries have participated on the pilot and are developing together a practical eHealth framework and infrastructure that makes possible to transfer patient health information between different healthcare systems in Europe.
In the first phase, the pilot focuses on two areas: access to important medical data for patient treatment (patient summary) and cross-border use of electronic prescriptions (e-Prescription).
Patient summary includes the most important clinical date required to ensure safe and secure healthcare, mainly intended to be used in emergency situations, but also in scheduled healthcare situations it is useful.
e-Prescription includes medication prescription and dispensing, where medication is prescribed in the patient’s home country with the patient’s consent; when traveling abroad, a patient has possibility to retrieve the prescribed medication.
At the moment information transfer in both cases is in use only in certain epSOS countries; the project extension started in 2011 and it analyzes and tests the following services: the patient access to their data, the Medication-Related Overview, the Healthcare Encounter Report, the integration of the 112 emergency services, and the integration of the European Health Insurance Card (EpSOS, 2014).
eHealth Applications
In 2008, the Finnish National Institute for Health and Welfare (previously referred to as STAKES) in cooperation with the eHealth ERA project evaluated the implementation of eHealth policies and the deployment of eHealth applications in the European Union.
According to the report (Hämäläinen et al., 2008), the main eHealth applications are EHRs, patient identifiers, health portals for informing patients and professionals on health issues and disease prevention, citizen card activities, and telemedicine.
The Monitoring National eHealth Strategies study provided an update on the progress of eHealth activities in Europe (Stroetmann et al., 2011).
The analysis of progress published in 2008 combined with the total number of reported activities in 2010 is presented in Table 52.2 (Hämäläinen et al., 2008; Stroetmann et al., 2011).
The table presents an overview of the situation, but is not conclusive due to differences in the features and functions of eHealth applications in different countries, and deployment can be present only in primary or secondary care.
In addition, deployment can be partly national, regional, or local (Hämäläinen et al., 2008).
The 2008 report shows that Finland was the only country to report activities in all 14 areas; additionally, 11 countries (Austria, Belgium, Denmark, Germany, Greece, Hungary, Italy, Poland, Slovakia, Sweden, and the United Kingdom) have reported activities in more than 10 areas.
All countries have reported activities on the EHR, but it is unknown whether these developments concern primary care, secondary, or both (Hämäläinen et al., 2008).
More specific activities regarding the development of the EHR in 2008 are not conducted often: patient summary (n = 10), data definition/coding (n = 15), standards (n = 20), semantic interoperability (n = 14).
In 2010, patient summary and EHR-like projects were in the routine use in 7 European countries, while in two countries piloting of the system was going and 5 countries were at implementation phase; surprisingly, 20 European countries were at the planning stage (Stroetmann et al., 2011).
EHR deployment in the European Union has mainly progressed well, but there are interesting differences in the deployment status of other eHealth applications.
In 2010, e-prescription activities (eCapture, eTransfer, eDispensation) were reported in 22 countries (21 countries in 2008), but eCapture was in use in 15 countries, eTransfer in 9 countries, and eDispensation in only 7 countries (Stroetmann et al., 2011).
In 2010, the citizen health card is used in almost all countries (n = 25), but activities regarding professional cards are reported by a smaller number of countries (n = 18); however, in 2008 only 7 countries reported professional card activities, so the progress has been good (Hämäläinen et al., 2008).
Different functions are included in citizens’ health cards in different countries; the most common were patient ID and national health insurance coverage; in many countries, health cards and identification issues are closely related to each other.
Almost all countries (n = 26) reported patient ID activities in 2010, while 22 countries reported professional ID activities; the type of identification method differs between countries; in general, there are two methods: healthcare-specific identifiers and national identification numbers.
Based on the 2008 report (Hämäläinen et al., 2008), health portals for citizens (23 countries) are introduced more often than health portals for professionals (16 countries); typically, citizens’ health portals include information about general health and service systems.
In accordance with the European Union’s strategic goals, telemedicine applications are reported in all countries.
The most common types of applications were teleconsultation and teleradiology including picture archiving communication systems (Hämäläinen et al., 2008).
Improvements in patient safety and quality of care are identified as a major benefit of eHealth, and the European Union has included them in the eHealth Action Plan as part of the i2010 strategic framework; in addition, the European Commission introduced in 2006 the eHealth for Safety study which aimed to identify key issues, topics, and challenges where ICT applications might improve patient safety and recommendation for future research topics (Empirica, 2007); these activities indicate the importance of patient safety issues in Europe, but surprisingly only 7 countries (Belgium, the Czech Republic, Finland, Greece, Slovakia, Sweden, and the United Kingdom) reported some activities in this field; Germany and Latvia reported no activities, and the data for the remaining 18 countries were missing (Hämäläinen et al., 2008).
The European Union has adopted patient safety as a key goal in the development of nursing informatics applications and healthcare systems.
At present, the EU-funded European Network for Patient Safety (EUNetPaS) project is coordinating national efforts, while WHO has launched programs on a global scale that include the inventories of ongoing researches; many European countries have executed studies to assess the magnitude of adverse events in their respective countries, mostly based on detailed audits of medical records or primarily involved in a running adverse event reporting programs (Klazinga et al., 2011).
A new EU-funded joint project concerning eHealth applications and activities was begun in the beginning of 2014; ENS4Care is a ematic Network involving 24 partners coordinated by European Federation of Nurses Associations (EFN) (ENS4Care, 2014); during the two-year period, the ENS4Care network aims to develop evidence-based ICT guidelines for the implementation of eHealth services in nursing and social care, based on best practices which have achieved major benefits in cost-effectiveness and better self-management of care.
The project is targeted on the following key areas of care: healthy lifestyle and prevention, early intervention and clinical practice in integrated care, skills development for advanced roles, and nurse e-Prescribing.
ENS4Care will collect existing guidelines and good practices from participating organizations and their networks; patient safety is one of the key drivers of the project and the project creates more understanding of how ICT tools might improve safety in healthcare (ENS4Care, 2014).
Nursing Terminology Development in Europe
In Europe, the first effort to have standardized nursing data took the form of a multi-national study from 1976 through 1985 called People’s Needs for Nursing Care, which included participation by 11 European countries and was sponsored by the World Health Organization (WHO, 1977); in this study, the nursing process model was used as a framework; since then the model has served as a standard for nursing documentation in many countries; nurses have mainly adopted four of its phases: assessment of nursing needs, planning of care, implementation of nursing actions, and assessment of nursing outcomes.
In the early 1980s, there was considerably discussion and debate about whether nurses should use the nursing diagnosis as the second phase of the process; however, in many European countries, nurses decided not to use the term nursing diagnosis and instead named the important conclusion after the assessment phase nursing needs or nursing problems.
Nowadays, the nursing process model with three or seven phases is used as the basis for structuring nursing documentation in various electronic nursing information systems in Europe (Saranto et al., 2013).
The European Union has played an important role in supporting research and development activities with various initiatives and programs since the 1980s; although these activities did not include nursing practice in the beginning, with the inception of the third framework program the European Union launched the Concerted Action on Nursing and delegates from member countries were invited to present proposals.
The Danish Institute for Health and Nursing Research was elected to coordinate the Concerted Action on Telematics for Nursing: European Classification on Nursing Practice with regard to patient’s problems, nursing interventions, and patient outcomes, including educational measures; the Concerted Action was later renamed the TELENURSING consortium and was funded by the European Union from 1991 through 1994, bringing together 15 member states.
At the same time, the International Council of Nursing (ICN) had started the development of the International Classification for Nursing Practice (ICNP), and since 1991 these two nursing classification projects worked together to support the development of the ICNP.
Following the TELENURSING project, the consortium was successful in gaining further European Union funding to start the TELENURSE project (1995 to 1998) and no European countries were involved in the three phases of the project in seven work packages; the central focus of the project was on clinical nursing’s aim to offer advanced ways of handling both nursing classifications of problems, interventions, and results as part of the registration of clinical data and collecting the information necessary to enhance the quality of clinical practice in nursing (Clark, 2003; Danish Institute for Health and Nursing Research, 1995).
The outcomes of these projects had a crucial impact on nursing terminology development; in 1999, the ICNP alpha version was launched by the ICN with joint international efforts; as is well known, the ICNP elements—nursing phenomena (nursing diagnoses), nursing actions, and nursing outcomes—have been published in the ICNP Version 2 launched in 2009; the latest ICNP version has been launched in 2013 (ICN, 2013; ICNP, 2013).
Use of Nursing Terminologies in Europe
Consisting of various countries with their own national languages, the use of nursing terminologies in Europe involves a considerable amount of translation and cultural validation, particularly regarding a terminology originally written in English.
Based on the results of a 2010–2011 survey, the use of nursing terminologies is not very common in European countries; however, the usage has extended since 2008 (oroddsen et al., 2009; oroddsen, Ehrenberg, Sermeus, & Saranto, 2012).
Also, the results of the survey should be interpreted conditionally; only 20 country members out of 30 European key informants replied to the electronic survey and countries like, e.g., Greece, the Netherlands, and Poland are not included in the results (oroddsen et al., 2012).
The NANDA International classification has been translated into many European languages, such as Dutch, French, German, Icelandic, Italian, Norwegian, Portuguese, and Spanish, but is still not in active use in nursing documentation (NANDA International, 2014); seemingly, the countries that adopted the NANDA-I Classification have also translated the Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC).
Some European countries have expressed a need to validate terminologies based on cultural differences in their healthcare service system.
Many European countries have followed the development work of the International Council of Nursing (ICN) and especially the terminology International Classification of Nursing Practice (ICNP); translations have been accomplished in Brazilian Portuguese, Chinese (Simple), Chinese (Traditional), English, Farsi (Persian), French, German, Icelandic, Indonesian, Italian, Japanese, Korean, Norwegian, Polish, Portuguese, Romanian, Slovak, Spanish.
The translation has often been supported by the national nursing organizations; ICNP offers also translation guidelines (ICNP, 2013); the active use of the ICNP in healthcare settings is still in its infancy in many European countries, mainly due to differences in nursing documentation legislation, policies, or electronic information systems; however, many nursing schools are using the terminology in teaching nursing documentation (oroddsen et al., 2012).
The VIPS model (acronym for the Swedish spelling well-being, integrity, prevention, and safety) developed in Sweden by Professor Margareta Ehnfors and her associates is widely used in the Nordic countries; the VIPS model conceptualizes the essential elements of nursing care, clarifying and facilitating systems thinking and nursing recording; the focus of the model is on patients’ functioning in daily-life activities rather than on pathophysiologic problems (Ehnfors, Ehrenberg, & orell-Ekstrand, 2002; Ehrenberg, Ehnfors, & orell-Ekstrand, 1996).
A significant amount of research on the VIPS model has been conducted, showing that the model has good content validity in different areas of nursing care; the model has proven useful in different nursing specialties and is fully computerized in information systems (Saranto et al., 2013; Saranto & Kinnunen, 2009; Ehnfors, Ehrenberg, & orell-Ekstrand, 2013).
Many European countries have also used the International Classification of Functioning, Disability and Health (ICF, formerly known as the ICIDH, International Classification of Impairments, Disabilities, and Handicaps) launched in 2001 by WHO (ICF, 2013); the ICF highlights the terms “health” and “disability,” meaning that every human being can experience a decrement in health and thereby experience some degree of disability; the ICF has been used in nursing as well as in rehabilitation context and several countries have started the process of streamlining ICF in their health and social information standards, e.g., Finland, Ireland, Italy, the Netherlands, and Sweden; translations have been conducted in Chinese, English, French, Russian, and Spanish; also a version for children and youth in English exists (ICF, 2013).
The National Health Service in England and other countries of the United Kingdom decided in the early 2000s to use a single, multi-disciplinary terminology across healthcare; this work evolved, combining with efforts in the United States and other countries, to become the Systematized Nomenclature of Medicine—Clinical Terms (SNOMED-CT).
The Systematized Nomenclature of Medicine—Clinical Terms terminology has maps to other classifications that have different but essential purposes; nurses have been involved in the crucial task of ensuring that nursing content is adequately represented in this large, multi-disciplinary terminology (Casey, 2003; Dykes et al., 2011; Imel & Campbell, 2003; Ingenerf & Pöppl, 2007); since this terminology is of English language origin, there is a major translation challenge for European countries adopting and implementing it into electronic information systems; at the moment, translations in European countries, such as Danish, Swedish, and Spanish, already exist. In 2013, translations for Lithuan and Slovak Republic were in process (e International Health Terminology Standards Development Organisation [IHTSDO], 2014).
Possibilities for Meaningful Use of Nursing Data
According to the study by oroddsen and colleagues (oroddsen et al., 2009; oroddsen et al., 2012), the use of standardized nursing terminologies in Europe is still quite rare which makes access to nursing data an obstacle; ough, as mentioned before, the usage has increased.
In more than 60% of the institutions in the countries that replied 2008 (oroddsen et al., 2009), nursing data were not stored and could, therefore, not be retrieved; in the study 2010–2011 in less than half of the institutions in the countries that replied, nursing data were not stored.
For the results, it is worrying that only 30 key informants out of 53 European countries could only be identified, and those who responded did not always have the knowledge or overview of the situation in their country in terms of nursing terminology and standardization work (oroddsen et al., 2012).
Clinical patient data can answer a variety of questions presented by managers, researchers, or policy-makers when it is collected and used appropriately.
Documentation developments, such as the increased standardization of patient records and the use of classifications, make healthcare data more reliable and useful for practice development, management, and research.
There are various local terminologies in nursing practice in addition to the international nursing classifications, which partly reflects the language differences, but also the differences in healthcare service systems; in many countries, nurses have devoted their activities to making nursing visible.
The nursing information reference model (NIRM) developed in the Netherlands by Goossen, Epping, and Dassen (1997) has also been used widely in other countries to accommodate both the information needs of nurses at the clinical level and for aggregating data at higher levels (Goossen et al., 1997); the model has also been exploited in Finland in the national nursing documentation project.
Along with the NIRM, nursing minimum data sets have been used to indicate nurses’ contribution in healthcare from administrative and economic perspectives the use of the Belgian nursing minimum data set (B-NMDS) was the first attempt among European nurses to show a nursing contribution since 1988.
The B-NMDS consists of 23 nursing interventions, medical diagnoses, patient demographics, nurse variables, and institutional characteristics; the data were collected four times per year (Sermeus, Delesie, Van Landuyt, Wuyts, Vandenboer, & Manna, 1994; Sermeus & Deleise, 1997).
The B-NMDS has been revised into B-NMDS-II based on the Nursing Intervention Classification (Sermeus et al., 2005; van den Heede, Michiels, onon, Sermeus, 2009).
In Ireland, the need to improve understanding of how to use nursing resources most effectively has also emerged (MacNeela, Scott, Treacy, Hyde, 2006); the development of the Irish Nursing Minimum Data Set (I-NMDS) for general nursing and the I-NMDS for mental health nursing has advanced data collection for multiple purposes.
There is a need to analyze and provide information on nursing trends; illustrate service provider trends and patterns in nursing and client care; inform hospital budgeting, nurse staffing levels, and consequently patient safety; as well as inform developments in nursing education.
Further, there is a need for integrating the data used to forecast the supply and demand of nurses and mid-wives with specific knowledge, skills, and competencies into the electronic patient record to facilitate access to nursing information and decision-making (National Council for the Professional Development of Nursing and Midwifery, 2006; Morris et al., 2010).
There have only been a few additional initiatives on NMDS in Europe, e.g., in Switzerland CH-NMDS (Berthou & Junger, 2003) and Finland.
In Finland, the nationally defined core nursing data (FiNMDS) includes nursing diagnoses, nursing interventions, nursing outcomes, patient care intensity, and nursing summary; the nursing summary consists of the four former items; at the national level, it has been decided that nursing summary will be among the first nursing representatives stored in the National Archive of Health Information in autumn 2014 (KanTa, 2013a).
Over the years, data collection and analysis has largely focused on indirect aspects of nursing service such as waiting times, length of stay, and operative procedures; addressing the international challenge of expanding the nursing workforce with qualified nurses is of crucial importance and requires cooperation to accomplish.
Researchers from 12 different European countries collaborated in one of the largest nursing workforce studies in Europe—the RN4CAST study (2009 to 2011); through nurse, patient, and organizational surveys and administrative data, the RN4CAST study aimed to provide innovative forecasting methods by addressing not only volume