Clinical Knowledge & Decision Making in Nursing Practice
Comprehensive educational resource for nursing students
Table of Contents
1. Introduction
In modern nursing practice, the effective management of knowledge forms the foundation of clinical excellence and policy development. This comprehensive resource explores how nursing professionals acquire, utilize, and transform knowledge to improve patient outcomes and healthcare systems.
The nursing profession continually evolves through the integration of evidence-based knowledge, clinical expertise, and patient preferences. Understanding how to navigate complex knowledge systems and standardized terminologies enhances communication, documentation, and ultimately, patient care.
Why Knowledge Management Matters in Nursing
- Supports evidence-based practice
- Enhances clinical decision-making
- Improves patient safety and outcomes
- Facilitates interprofessional communication
- Ensures regulatory compliance and quality improvement
2. Knowledge Management in Healthcare
Knowledge management (KM) refers to the systematic process of creating, sharing, using, and managing knowledge and information within an organization. In healthcare, effective knowledge management bridges the gap between what we know and what we practice.
The Knowledge Management Cycle
Healthcare knowledge consists of several distinct types, each playing a crucial role in nursing practice:
| Knowledge Type | Description | Application in Nursing |
|---|---|---|
| Explicit Knowledge | Formal, codified knowledge found in textbooks, journals, and guidelines | Evidence-based practice guidelines, clinical protocols, medication information |
| Tacit Knowledge | Personal, experience-based knowledge that is difficult to formalize | Clinical intuition, pattern recognition, situational awareness |
| Procedural Knowledge | Knowledge of how to perform specific tasks | Clinical skills, assessment techniques, equipment operation |
| Declarative Knowledge | Factual knowledge about concepts and principles | Anatomy, physiology, pathophysiology, pharmacology |
| Conditional Knowledge | Knowledge of when and why to apply procedures | Clinical judgment, prioritization of care, resource allocation |
3. Knowledge Management in Clinical Context
In the clinical setting, effective knowledge management directly impacts patient care quality and safety. Nurses must integrate various forms of knowledge to make sound clinical decisions under time pressure and with limited resources.
Mnemonic: “NURSE” for Clinical Knowledge Application
- N – Notice patterns and collect relevant data
- U – Understand the evidence and best practices
- R – Reason through options and alternatives
- S – Select appropriate interventions based on knowledge
- E – Evaluate outcomes and refine knowledge
Key Aspects of Clinical Knowledge Management
Evidence Integration
Combining the latest research findings with clinical expertise and patient preferences to inform care decisions. Nurses must be able to evaluate evidence quality and relevance.
Decision Support Systems
Electronic tools that provide patient-specific recommendations by integrating clinical knowledge with individual patient data, such as drug interaction alerts and care protocols.
Practice-Based Learning
Continuous refinement of clinical knowledge through reflection on practice experiences, peer discussion, and adaptation to new contexts.
Interprofessional Knowledge Sharing
Exchanging discipline-specific knowledge across healthcare teams to develop comprehensive care approaches and shared mental models.
Clinical Knowledge Management Benefits
- Reduced clinical variations and improved standardization of care
- Decreased medical errors and adverse events
- More efficient resource utilization
- Enhanced clinical reasoning and decision-making
- Improved patient outcomes and satisfaction
4. Knowledge Management in Policy Context
At the organizational and healthcare system levels, knowledge management supports policy development, quality improvement, and strategic planning. Nursing knowledge significantly contributes to policy frameworks that shape healthcare delivery.
The Knowledge-to-Policy Pathway
Generation of new knowledge through systematic inquiry
Transforming evidence into actionable guidance
Promoting evidence-informed policy changes
Enacting changes in practice guidelines and regulations
How Knowledge Management Influences Healthcare Policy
- Data-driven decision making: Using aggregated clinical data to identify trends, gaps, and opportunities for improvement in healthcare delivery systems.
- Best practice standardization: Developing evidence-based policies that promote consistency and quality across healthcare organizations.
- Resource allocation: Informing decisions about technology investments, staffing models, and program funding based on outcome data and knowledge of effective interventions.
- Regulatory compliance: Ensuring policies align with current scientific evidence and professional standards to meet regulatory requirements.
- Population health management: Applying knowledge about health determinants and effective interventions to develop policies addressing community health needs.
Mnemonic: “POLICY” for Knowledge-Based Policy Development
- P – Problem identification through data analysis
- O – Options for intervention based on current evidence
- L – Literature and research synthesis
- I – Implementation strategies with knowledge translation
- C – Collaboration with stakeholders and knowledge users
- Y – Yield measurement through evaluation frameworks
5. Standardized Healthcare Terminologies
Standardized terminologies create a common language for healthcare professionals, enabling precise communication, accurate documentation, and meaningful data exchange. These terminologies codify healthcare knowledge into structured, accessible formats.
Benefits of Standardized Terminologies
Clinical Benefits
- Improved clinical documentation
- Enhanced communication between providers
- Support for clinical decision-making
- Consistency in assessment and planning
System Benefits
- Facilitated data aggregation and analysis
- Enhanced interoperability between systems
- Support for research and quality improvement
- Optimized reimbursement processes
| Terminology System | Primary Focus | Use in Healthcare |
|---|---|---|
| SNOMED CT | Comprehensive clinical healthcare terminology | EHR documentation, clinical decision support, data analytics |
| ICD-10-CM | Disease classification and coding | Diagnosis coding, billing, epidemiological statistics |
| NANDA | Standardized nursing diagnoses | Nursing assessment, care planning, documentation |
| NOC | Standardized nursing outcomes | Measuring patient outcomes, evaluating nursing care effectiveness |
| NIC | Standardized nursing interventions | Planning and documenting nursing care activities |
| Omaha System | Problem-focused taxonomy for community care | Community health, home care, public health nursing |
6. SNOMED CT
The Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) is the most comprehensive, multilingual clinical healthcare terminology in the world. It provides a standardized way to represent clinical knowledge recorded in health records.
SNOMED CT Structure and Components
Concepts
Clinical meanings identified by unique numeric identifiers that never change. Each concept represents a distinct clinical idea.
Example: 22298006 (Myocardial infarction)
Descriptions
Terms or names assigned to a concept. Each concept may have multiple descriptions (synonyms).
Example: “Myocardial infarction,” “Cardiac infarction,” “Heart attack”
Relationships
Connections between concepts that provide logical definitions and show how concepts relate to each other.
Example: “Myocardial infarction” IS-A “Ischemic heart disease”
SNOMED CT Hierarchies
SNOMED CT organizes concepts into hierarchies, with each concept having at least one “is-a” relationship to a more general concept. The main hierarchies include:
- Clinical findings – Disorders and observations
- Procedures – Activities performed in healthcare
- Observable entities – Things that can be observed or measured
- Body structures – Anatomical structures
- Organisms – Bacteria, viruses, plants, animals
- Substances – Chemical constituents of the body
- Pharmaceutical/biologic products – Medications
- Situations – Contexts that influence health
Mnemonic: “SNOMED” for Understanding SNOMED CT Value
- S – Standardized terminology improves communication
- N – Nuanced clinical concepts capture specificity
- O – Organized hierarchies show relationships
- M – Multiple synonyms enhance retrievability
- E – Electronic health records integration
- D – Data analytics and research support
SNOMED CT in Nursing Practice
Nurses use SNOMED CT to document patient assessments, problems, interventions, and outcomes in structured, standardized formats. This facilitates:
- Precise documentation of nursing observations and actions
- Consistent communication with other healthcare providers
- Development of clinical decision support tools
- Data extraction for quality improvement and research
- Integration with other terminology systems
7. SNOMED CT to ICD-10-CM Mapping
Mapping between SNOMED CT and ICD-10-CM creates important connections between clinical knowledge (SNOMED CT) and administrative classification systems (ICD-10-CM), enabling both detailed clinical documentation and accurate coding for billing and reporting.
SNOMED CT vs. ICD-10-CM Comparison
SNOMED CT
- Clinical terminology system
- Over 350,000 unique concepts
- Designed for clinical documentation
- Hierarchical relationships between concepts
- Used primarily at point of care
- Supports detailed clinical descriptions
ICD-10-CM
- Classification system
- Approximately 70,000 codes
- Designed for statistical reporting and billing
- Organized by disease categories
- Used primarily for administrative purposes
- Limited to diagnoses and conditions
The Mapping Process
Mapping links SNOMED CT concepts to their corresponding ICD-10-CM codes. This process involves:
Source and Target Identification
Determining which SNOMED CT concepts need to be mapped to which ICD-10-CM codes.
Map Cardinality
Establishing whether the relationship is one-to-one, one-to-many, many-to-one, or many-to-many.
Map Rules and Advice
Creating rules that guide the selection of appropriate ICD-10-CM codes based on clinical context.
Validation and Quality Assurance
Reviewing mappings for accuracy, completeness, and clinical appropriateness.
Mapping Examples
| SNOMED CT Concept | SNOMED CT ID | ICD-10-CM Code | Mapping Type |
|---|---|---|---|
| Acute myocardial infarction | 57054005 | I21.9 (Acute myocardial infarction, unspecified) | Simple map |
| Essential hypertension | 59621000 | I10 (Essential (primary) hypertension) | Simple map |
| Fracture of neck of femur | 5913000 | S72.0- (requires additional specificity for laterality) | Complex map |
| Diabetes mellitus type 2 | 44054006 | E11.9 (Type 2 diabetes mellitus without complications) | Simple map with potential for complex mapping based on complications |
Benefits of SNOMED CT to ICD-10-CM Mapping for Nurses
- Allows nurses to document in detailed clinical terms while supporting billing requirements
- Reduces duplicate documentation efforts
- Improves data accuracy and completeness
- Enables better analysis of relationships between clinical observations and diagnoses
- Facilitates automatic generation of appropriate codes for reimbursement
8. Standardized Nursing Terminologies
Standardized nursing terminologies capture and organize nursing knowledge in structured formats, enabling consistent documentation, analysis, and communication of nursing practice across settings and specialties.
The Nursing Process and Terminology Systems
Assessment
Data collection and analysis
Diagnosis
Clinical judgment about responses
Planning
Setting goals and outcomes
Implementation
Performing interventions
Evaluation
Measuring progress toward goals
Nursing terminology systems organize nursing knowledge into standardized languages that support various aspects of nursing practice. The most prominent systems include:
- NANDA International (NANDA-I) – Standardized nursing diagnostic terminology
- Nursing Outcomes Classification (NOC) – Standardized outcomes for measuring patient progress
- Nursing Interventions Classification (NIC) – Standardized interventions performed by nurses
- The Omaha System – Problem-focused terminology for community and public health
- International Classification for Nursing Practice (ICNP) – Unified nursing language system
- Clinical Care Classification (CCC) – Standardized framework for documenting patient care
Integration of Nursing Terminologies in Healthcare Systems
- Electronic Health Records (EHRs) incorporate nursing terminologies to support nursing documentation
- Clinical decision support systems use standardized terminologies to provide guidance
- Quality improvement initiatives analyze nursing data using standardized terms
- Research studies utilize nursing terminologies to collect and analyze nursing-sensitive data
- Nursing education incorporates terminology systems to prepare students for practice
9. NANDA International
NANDA International (formerly North American Nursing Diagnosis Association) provides a standardized terminology of nursing diagnoses that represent clinical judgments about actual or potential health problems. NANDA diagnoses codify nursing knowledge about patient responses to health conditions.
NANDA Diagnostic Structure
NANDA nursing diagnoses follow a specific format to provide clarity and precision:
Anatomy of a NANDA Nursing Diagnosis
Problem (P)
The human response or clinical judgment about the health issue
Example: “Impaired Skin Integrity”
Etiology (E)
Related factors or causes contributing to the problem
Example: “related to prolonged immobility”
Signs/Symptoms (S)
Defining characteristics or evidence of the problem
Example: “as evidenced by pressure ulcer on sacrum”
NANDA Taxonomy Structure
NANDA diagnoses are organized into domains and classes that represent different aspects of human functioning:
| Domain | Description | Sample Diagnoses |
|---|---|---|
| Health Promotion | Awareness of well-being and normal function | Deficient Health Maintenance, Risk-Prone Health Behavior |
| Nutrition | Activities of taking in nutrients | Imbalanced Nutrition, Risk for Impaired Liver Function |
| Elimination and Exchange | Secretion and excretion of waste products | Impaired Urinary Elimination, Constipation |
| Activity/Rest | Production, conservation, expenditure of energy | Impaired Physical Mobility, Sleep Deprivation |
| Perception/Cognition | Human information processing system | Confusion, Impaired Memory, Deficient Knowledge |
| Self-Perception | Awareness about the self | Hopelessness, Disturbed Body Image |
| Role Relationships | Connections or associations between people | Impaired Parenting, Interrupted Family Processes |
Mnemonic: “DIAGNOSE” for NANDA Application
- D – Determine defining characteristics in assessment data
- I – Identify related factors or risk factors
- A – Analyze patterns in patient responses
- G – Generate potential nursing diagnoses
- N – Narrow to most appropriate diagnosis
- O – Outline diagnosis using PES format when applicable
- S – Select priority diagnoses for care planning
- E – Evaluate diagnosis through ongoing assessment
Types of NANDA Diagnoses
Actual Diagnoses
Present health problems validated by the presence of major defining characteristics
Example: “Acute Pain related to surgical incision as evidenced by verbal reports of pain intensity 7/10”
Risk Diagnoses
Vulnerabilities to develop a problem due to risk factors
Example: “Risk for Infection related to invasive procedures and compromised immune system”
Health Promotion Diagnoses
Motivation and desire to increase well-being and actualize health potential
Example: “Readiness for Enhanced Self-Health Management”
10. Nursing Outcomes Classification (NOC)
The Nursing Outcomes Classification (NOC) provides a comprehensive standardized language for describing patient outcomes that respond to nursing interventions. NOC organizes nursing knowledge about measurable patient states, behaviors, or perceptions.
NOC Structure and Components
Key Elements of NOC
Outcomes
Measurable patient/client states, behaviors, or perceptions responsive to nursing interventions
Example: “Pain Level”
Indicators
More specific states, behaviors, or perceptions that serve as cues for evaluating an outcome
Example: “Reported pain,” “Facial expressions of pain”
Measurement Scales
Five-point Likert scales that quantify patient status related to an outcome
Example: 1=severe, 2=substantial, 3=moderate, 4=mild, 5=none
Target Rating
The desired score on the measurement scale that represents achievement of the outcome
Example: Current: 2 → Target: 4
NOC Taxonomy Structure
NOC outcomes are organized into domains and classes:
| Domain | Classes (Examples) | Sample Outcomes |
|---|---|---|
| Functional Health | Energy Maintenance, Growth & Development, Mobility | Activity Tolerance, Endurance, Mobility Level |
| Physiologic Health | Cardiac, Elimination, Metabolic Regulation | Vital Signs, Wound Healing, Nutritional Status |
| Psychosocial Health | Psychological Well-Being, Social Interaction | Anxiety Level, Coping, Depression Level |
| Health Knowledge & Behavior | Health Behavior, Health Knowledge | Compliance Behavior, Knowledge: Disease Process |
| Perceived Health | Health & Life Quality, Symptom Status | Quality of Life, Comfort Status, Pain Level |
| Family Health | Family Caregiver Performance, Family Well-Being | Caregiver Performance, Family Functioning |
| Community Health | Community Well-Being, Community Health Protection | Community Disaster Readiness, Community Health Status |
NOC Application in Nursing Practice
Outcome Selection
Choosing appropriate outcomes for the patient based on nursing diagnoses and patient priorities.
Baseline Rating
Measuring the patient’s current status using the outcome’s indicators and measurement scales.
Target Setting
Determining realistic goals for improvement on the measurement scales.
Intervention Selection
Choosing appropriate nursing interventions designed to improve the selected outcomes.
Ongoing Evaluation
Periodically reassessing the patient using the same indicators and scales to measure progress.
Benefits of Using NOC in Nursing Practice
- Provides measurable targets for nursing care
- Facilitates tracking of patient progress over time
- Demonstrates nursing’s contribution to patient outcomes
- Enhances communication among healthcare providers about expected and actual patient results
- Supports nursing research through standardized outcome measures
- Guides quality improvement by identifying areas for care enhancement
Example: NOC in Practice – Pain Management
NANDA Diagnosis:
Acute Pain related to surgical procedure as evidenced by verbal reports of pain intensity 7/10 and guarding behavior
Selected NOC Outcome:
Pain Level – Severity of observed or reported pain
Selected Indicators:
- Reported pain
- Pain-related distress
- Protective body positioning
- Facial expressions of pain
Measurement Scale:
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None
Ratings:
Baseline: 2 (Substantial pain)
Target: 4 (Mild pain)
Timeframe: Within 24 hours
Evaluation Time Points:
Every 4 hours and as needed
11. The Omaha System
The Omaha System is a comprehensive standardized taxonomy designed to document and organize nursing knowledge and practice in community, home health, and public health settings. It provides a holistic framework that addresses the entire nursing process.
The Three Components of the Omaha System
Omaha System Framework
Problem Classification Scheme
A taxonomy of client problems organized into domains and specific problems.
Used for assessment and diagnosis
Intervention Scheme
A taxonomy of nursing actions organized into categories and specific interventions.
Used for planning and implementation
Problem Rating Scale for Outcomes
Three 5-point Likert-type scales measuring knowledge, behavior, and status.
Used for evaluation
Problem Classification Scheme
The Problem Classification Scheme organizes client problems into four domains:
| Domain | Description | Example Problems |
|---|---|---|
| Environmental | Material resources and physical surroundings | Income, Residence, Neighborhood/workplace safety |
| Psychosocial | Patterns of behavior, emotions, communications, relationships | Communication, Role change, Mental health |
| Physiological | Functions of body systems and structures | Circulation, Pain, Neuro-musculo-skeletal function |
| Health Related Behaviors | Activities related to health maintenance, promotion, and disease prevention | Nutrition, Physical activity, Substance use |
Intervention Scheme
The Intervention Scheme categorizes nursing actions into four categories:
Teaching, Guidance, and Counseling
Activities to provide information, anticipatory guidance, or counseling to enhance knowledge, behavior, or status regarding health issues.
Treatments and Procedures
Technical activities directed toward preventing signs/symptoms, identifying risk factors, or treating health problems.
Case Management
Activities to coordinate care, advocate for services, and refer to community resources.
Surveillance
Activities to detect risks, problems, or changes through observation and monitoring.
Problem Rating Scale for Outcomes
This component includes three 5-point Likert-type scales to measure client outcomes in three dimensions:
| Dimension | 1 | 2 | 3 | 4 | 5 |
|---|---|---|---|---|---|
| Knowledge | No knowledge | Minimal knowledge | Basic knowledge | Adequate knowledge | Superior knowledge |
| Behavior | Not appropriate | Rarely appropriate | Inconsistently appropriate | Usually appropriate | Consistently appropriate |
| Status | Extreme signs/symptoms | Severe signs/symptoms | Moderate signs/symptoms | Minimal signs/symptoms | No signs/symptoms |
Mnemonic: “OMAHA” for Applying the Omaha System
- O – Observe client holistically across all domains
- M – Map problems using the Problem Classification Scheme
- A – Assess initial ratings for knowledge, behavior, and status
- H – Harmonize interventions across the four categories
- A – Analyze progress using the Problem Rating Scale for Outcomes
Advantages of the Omaha System
- Comprehensive approach addressing the entire nursing process
- Holistic framework covering environmental, psychosocial, physiological, and behavioral domains
- Particularly suited for community and public health nursing settings
- Simple, practical structure that is easy to learn and apply
- Enables measurement of client outcomes over time
- Facilitates documentation of nursing contributions to client health
- Supports aggregate data analysis for program evaluation and research
12. Case Studies
The following case studies demonstrate how standardized terminologies and knowledge management are applied in nursing practice to enhance decision-making and patient care.
Case Study 1: Applying NANDA, NOC, and SNOMED CT in Acute Care
Patient Scenario
Mr. Johnson, a 68-year-old male, was admitted following coronary artery bypass surgery. He reports pain at the incision site rated 7/10. He is reluctant to move or cough due to pain. Vital signs show elevated heart rate and blood pressure when moving.
Documentation Using Standardized Terminologies
NANDA Diagnosis
Acute Pain related to surgical incision as evidenced by verbal reports of pain intensity 7/10 and guarding behavior during movement
NOC Outcomes
Pain Control – Baseline: 2 (Substantial constraint)
Pain Level – Baseline: 2 (Substantial)
Target for both: 4 (Mild) within 24 hours
SNOMED CT Concepts
22253000 | Pain associated with surgical wound |
225908003 | Pain management |
445528004 | Administration of analgesic |
Knowledge Management Application
The nurse accesses the hospital’s clinical decision support system, which integrates evidence-based guidelines for post-operative pain management. Using SNOMED CT codes, the system recommends appropriate pharmacological and non-pharmacological interventions based on patient-specific factors. By documenting with standardized terminologies, the nurse contributes to organizational knowledge about post-operative pain management effectiveness.
Outcome
By utilizing standardized terminologies, all members of the healthcare team understand the precise nature of Mr. Johnson’s pain and can evaluate the effectiveness of interventions using consistent measures. This facilitates continuity of care and enables the hospital to aggregate data on post-operative pain management strategies and their effectiveness.
Case Study 2: Using the Omaha System in Community Health
Client Scenario
Mrs. Garcia, a 72-year-old woman with Type 2 diabetes, lives alone in an apartment. A public health nurse is assigned to visit her following a recent hospitalization for hyperglycemia. During the assessment, the nurse identifies challenges with medication adherence, limited understanding of diabetic diet, and unsafe home conditions (scatter rugs, poor lighting).
Application of the Omaha System
| Omaha Problem | Domain | Initial Ratings (K/B/S)* | Interventions | Target Ratings |
|---|---|---|---|---|
| Medication regimen | Health Related Behaviors | 2/2/3 |
Teaching: Medication action, schedule Case Management: Medication assistance program Surveillance: Compliance behavior |
4/4/4 |
| Nutrition | Health Related Behaviors | 2/2/3 |
Teaching: Dietary management Surveillance: Blood glucose level |
4/4/4 |
| Residence | Environmental | 3/2/2 |
Teaching: Safety measures Case Management: Home modification program |
4/4/4 |
*K=Knowledge, B=Behavior, S=Status on a scale of 1 (worst) to 5 (best)
Knowledge Management Application
The nurse uses the public health department’s knowledge management system to access evidence-based interventions for older adults with diabetes. By documenting with the Omaha System, the nurse contributes to the organization’s aggregate data on diabetic client outcomes and intervention effectiveness in the community setting.
Outcome
After six weeks of home visits, Mrs. Garcia’s ratings improved to 4/3/4 for medication regimen, 4/3/3 for nutrition, and 4/4/3 for residence. These standardized measurements allow for precise evaluation of her progress and the effectiveness of nursing interventions. The public health department uses aggregate Omaha System data to identify common problems among elderly diabetic clients and develop targeted community programs.
13. Conclusion
Effective knowledge management and the application of standardized terminologies are fundamental to modern nursing practice. They enhance clinical decision-making, facilitate communication, support quality improvement, and advance the nursing profession.
By understanding and utilizing SNOMED CT, ICD-10-CM mapping, NANDA, NOC, and the Omaha System, nurses contribute to a standardized language of healthcare that transcends individual settings and specialties. This shared knowledge framework improves patient care and supports evidence-based practice.
Key Takeaways
Knowledge Management
- Bridges the gap between evidence and practice
- Supports both clinical and policy decision-making
- Facilitates continuous quality improvement
- Enhances organizational learning
- Promotes evidence-based practice
Standardized Terminologies
- Create a common language for healthcare
- Support precise documentation and communication
- Enable data aggregation and analysis
- Facilitate interoperability between systems
- Demonstrate nursing’s contribution to patient outcomes
As healthcare continues to evolve and become more complex, nurses who understand and effectively utilize knowledge management principles and standardized terminologies will be better equipped to provide high-quality care, advocate for patients, contribute to healthcare policy, and advance nursing practice.
The future of nursing practice lies in our ability to transform data into information, information into knowledge, and knowledge into wisdom that guides compassionate, evidence-based patient care.