Assignment: The Impact of Standardized Nursing Terminology
Assignment: The Impact of Standardized Nursing Terminology
Among the Resources in this module is the Rutherford (2008) article Standardized Nursing Language: What Does It Mean for Nursing Practice? In this article, the author recounts a visit to a local hospital to view the recent implementation of a new coding system.
During the visit, one of the nurses commented to her, “We document our care using standardized nursing languages but we don’t fully understand why we do” (Rutherford, 2008, para. 1).
How would you respond to a comment such as this one?
To Prepare:
- Review the concepts of informatics as presented in the Resources, particularly Rutherford, M. (2008) Standardized Nursing Language: What Does It Mean for Nursing Practice?
- Reflect on the role of a nurse leader as a knowledge worker.
- Consider how knowledge may be informed by data that is collected/accessed.
The Assignment:
In a 2- to 3-page paper, address the following:
- Explain how you would inform this nurse (and others) of the importance of standardized nursing terminologies.
- Describe the benefits and challenges of implementing standardized nursing terminologies in nursing practice. Be specific and provide examples.
- Be sure to support your paper with peer-reviewed research on standardized nursing terminologies that you consulted from the Walden Library.
Resources
McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones & Bartlett Learning.
- Chapter 25, “The Art of Caring in Technology-Laden Environments” (pp. 525–535)
- Chapter 26, “Nursing Informatics and the Foundation of Knowledge” (pp. 537–551)
American Nurses Association. (2018). Inclusion of recognized terminologies supporting nursing practice within electronic health records and other health information technology solutions. Retrieved from https://www.nursingworld.org/
Macieria, T. G. R., Smith, M. B., Davis, N., Yao, Y., Wilkie, D. J., Lopez, K. D., & Keenan, G. (2017). Evidence of progress in making nursing practice visible using standardized nursing data: A systematic review. AMIA Annual Symposium Proceedings, 2017, 1205–1214. Retrieved from https://www.ncbi.nlm.nih.gov/
Office of the National Coordinator for Health Information Technology. (2017). Standard nursing terminologies: A landscape analysis. Retrieved from https://www.healthit.gov/
Rutherford, M. A. (2008). Standardized nursing language: What does it mean for nursing practice? Online Journal of Issues in Nursing, 13(1), 1–12. doi:10.3912/OJIN.
Note: You will access this article from the Walden Library databases.
Thew, J. (2016, April 19). Big data means big potential, challenges for nurse execs. Retrieved from https://www.
Topaz, M. (2013). The hitchhiker’s guide to nursing theory: Using the Data-Knowledge-Information-
Note: You will access this article from the Walden Library databases.
Wang, Y. Kung, L., & Byrd, T. A. (2018). Big data analytics: Understanding its capabilities and potential benefits for healthcare organizations. Technological Forecasting and Social Change, 126(1), 3–13. doi:10.1016/j.techfore.2015.
Note: You will access this article from the Walden Library databases.
Answer and Expert Explanation
Benefits of Standardized Nursing Terminologies
The emphasis on delivery of the safe care is growing, and this warrants the need for the nursing practitioners to clearly, and accurately document clinical information including the details of the patient assessment and interventions. The accuracy and clarity with which these providers document the information is dependent on whether they use the Standardized Nursing Terminologies (SNTs).
The SNTs consist of the terminologies which users can use to share and document information. This prevents cases where the lack of the clarity of the information which stems from the provider deciding not to use the SNTs, affects its meaning (McGonigle & Mastrian, 2017). This study examines the approach of informing nursing practitioners the SNTs’ benefits, and the benefits and risks associated with the implementation of these terminologies.
Communication and Benefits
The idea of communicating the essence of the SNTs to the nurses is important because it helps them be aware of the availability and usability of these SNTs, and the person doing the communication can realize this objective by utilizing various methods. One of the most effective approach to communicating these benefits is organizing a conference meeting where nurses can meet, and directly informing them of the benefits they are likely to accrue if they use the SNTs.
The organizational memo can also be an effective way of delivering this information. When using it as a platform for communication, the individual delivering the message concerning the benefits of the SNTs may either post the memo on the strategic areas within the hospital premises, or send the memo to nurses’ emails addresses. However, they can also utilize the journals (Rutherford, 2008). The professional nursing journals can particularly be useful when it comes to communicating the value of the SNTs.
Benefits and Challenges
While the implementation of the SNTs can be important, it can present various challenges. A key benefit that an organization can derive from implementing the SNTs is effective communication. The SNTs present common terminologies which can be effective in relaying clinical information, and this ultimately makes it possible for the clinicians to effectively share information.
Sometimes, the need arises for the information to be in a form which only the providers can internalize. The use of the SNTs makes this possible in the sense that the codes or the taxonomies only make sense to clinicians, and people who do not know the meanings of these terminologies may not understand the conveyed message (Thew, 2016).
This ultimately helps secure the clinical data. The visibility of the nursing care, furthermore, becomes more noticeable with the use of the SNTs given that the conventional approach in which the nurse verbally communicate to colleagues presents visibility issues (Macieria et al., 2019). However, the SNTs do not have atomic level terminologies, and this can hamper the efforts aimed at developing the SNTs.
Conclusion
Reflecting on the discussion of the SNTs, it is clear that incorporating the SNTs into clinical practice can have significant benefits to the hospital, and it is therefore important that nurses understand the usefulness of the SNTs. Informing nurses about the merits of these terminologies may help them adopt a more positive attitudes towards the use of these terminologies. Consequently, they are likely to accommodate and encourage the use of these terminologies to document information. The security of the clinical information, and the improved visibility of the clinical intervention are some of the outcomes linked to the use of the SNTs.
References
Macieria, T. G. R., Smith, M. B., Davis, N., Yao, Y., Wilkie, D. J., Lopez, K. D., & Keenan, G. (2017). Evidence of progress in making nursing practice visible using standardized nursing data: A systematic review. AMIA Annual Symposium Proceedings, 2017, 1205–1214. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5977718/.
McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones & Bartlett Learning.
Rutherford, M. A. (2008). Standardized nursing language: What does it mean for nursing practice? Online Journal of Issues in Nursing, 13(1), 1–12. doi:10.3912/OJIN.Vol13No01PPT05.
Thew, J. (2016, April 19). Big data means big potential, challenges for nurse execs. Retrieved from https://www.healthleadersmedia.com/nursing/big-data-means-big-potential-challenges-nurse-execs.
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History of Standardized Nursing Languages
The history of standardized nursing languages dates back several decades and has evolved to meet the needs of the nursing profession and healthcare in general. Here is a brief overview of the history of standardized nursing languages:
- 1970s – Development of Early Nursing Languages:
- In the 1970s, the need for standardized nursing terminologies became evident as nursing documentation and communication lacked consistency and clarity. During this period, early efforts were made to develop nursing languages that could capture and convey essential nursing information.
- 1980s – NANDA and First Nursing Diagnosis Terminology:
- In 1982, NANDA (North American Nursing Diagnosis Association, now NANDA International) was founded. It played a pioneering role in the development of standardized nursing languages. NANDA developed the first nursing diagnosis terminology, providing a structured framework for identifying and describing patient health problems.
- 1990s – Growth of Nursing Languages:
- The 1990s saw significant growth in the development and adoption of standardized nursing languages. Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) were introduced to complement nursing diagnoses. These classifications aimed to standardize nursing interventions and outcomes.
- 2000s – SNOMED CT and Widespread Adoption:
- In the early 2000s, Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT) gained prominence as a comprehensive clinical terminology, not limited to nursing. SNOMED CT became widely adopted in electronic health records (EHRs) and health information systems, including nursing practice.
- Recent Years – Ongoing Development and Integration:
- Recent years have seen continued development and integration of standardized nursing languages into healthcare practice. Various nursing terminologies, including NANDA-I, NIC, NOC, and others, have been refined and expanded to better meet the needs of nursing care documentation and communication.
- International Collaboration:
- Standardized nursing languages have increasingly become the focus of international collaboration and standardization efforts. Organizations like NANDA International, the International Classification for Nursing Practice (ICNP), and others work to promote consistency in nursing documentation worldwide.
- Technological Advances:
- Advances in healthcare technology, including the widespread adoption of electronic health records, have further emphasized the importance of standardized nursing languages. These terminologies play a critical role in electronic documentation, data exchange, and interoperability.
- Research and Evidence-Based Practice:
- The use of standardized nursing languages has contributed to the growth of nursing research and evidence-based practice. Nurses and researchers use these terminologies to collect and analyze data, evaluate interventions, and improve patient care.
Standardized Language in Nursing Defined
Standardized language in nursing refers to the use of a universally accepted and consistent set of terms, classifications, and codes to describe, document, and communicate nursing care, assessments, interventions, and patient outcomes. It provides a common framework for healthcare professionals, including nurses, to convey essential information accurately and efficiently, ultimately enhancing patient care and safety.
Key features of standardized language in nursing include:
- Consistency: Standardized nursing terminologies ensure that healthcare professionals use the same terms and classifications consistently, reducing ambiguity and misinterpretation in documentation and communication.
- Interoperability: Standardized language allows for the seamless exchange of patient information across different healthcare settings, electronic health records, and systems, promoting continuity of care and patient safety.
- Coding and Classification: It involves the use of specific codes and classifications to represent nursing diagnoses, interventions, and outcomes, making it easier to track and analyze patient data for research and quality improvement.
- Evidence-Based Practice: Standardized language supports evidence-based practice by providing a structured framework for documenting and evaluating the effectiveness of nursing interventions, contributing to improved patient outcomes.
- Efficiency: Standardized terminology systems often include predefined terms and templates, streamlining the documentation process and allowing nurses to spend more time on patient care.
- Quality Improvement: Data collected using standardized language can be analyzed to identify best practices, areas for improvement, and trends, helping healthcare organizations enhance the quality and safety of care.
Examples of standardized nursing terminologies include the Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT), the Nursing Interventions Classification (NIC), and the Nursing Outcomes Classification (NOC). These systems provide a structured and common way to document nursing care, enabling healthcare professionals to communicate effectively and improve the overall quality of patient care.
What are the terminologies in nursing?
Nursing is a diverse field with many specialized areas, and it comes with a wide range of terminologies. Here are some common nursing terminologies:
- Nurse Practitioner (NP): A nurse with advanced education and training, authorized to diagnose and treat medical conditions, prescribe medications, and provide primary healthcare services.
- Registered Nurse (RN): A nurse who has completed a nursing program and passed the licensing exam, qualified to provide various patient care services.
- Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN): A nurse with a shorter training program than an RN, authorized to provide basic nursing care under the supervision of an RN or physician.
- Patient Assessment: The process of gathering and analyzing patient information, including medical history, vital signs, and physical examination findings.
- Nursing Diagnosis: A clinical judgment about a patient’s response to actual or potential health problems, used to guide nursing care.
- Care Plan: A written document that outlines a patient’s nursing care, including interventions, goals, and expected outcomes.
- Intravenous (IV) Therapy: Administration of fluids, medications, or blood products directly into the bloodstream using a needle or catheter.
- Medication Administration: The process of giving prescribed medications to patients, including dosage calculations, drug interactions, and monitoring for adverse effects.
- Wound Care: The management of wounds, including cleaning, dressing changes, and assessment of healing progress.
- Catheterization: The insertion of a catheter into a body cavity or vessel, such as a urinary catheter for draining the bladder.
- Disease Prevention: Strategies and interventions to promote health and prevent illness or injury, such as vaccinations and health education.
- Patient Education: Providing patients and their families with information about their conditions, treatment plans, and self-care techniques.
- Nursing Ethics: The principles and values that guide ethical decision-making in nursing practice, including patient confidentiality and informed consent.
- Evidence-Based Practice (EBP): The integration of clinical expertise, patient preferences, and the best available evidence to guide nursing care decisions.
- Nursing Informatics: The use of technology and information systems to manage and document patient care and improve healthcare outcomes.
- Cultural Competence: The ability to provide care that respects and considers the cultural beliefs and values of patients from diverse backgrounds.
- Hospice Care: End-of-life care provided to terminally ill patients to manage symptoms and provide comfort and emotional support.
- Critical Care Nursing: Specialized nursing care in intensive care units (ICUs) for critically ill patients.
- Geriatric Nursing: Nursing care for older adults, addressing age-related health concerns and promoting well-being.
- Pediatric Nursing: Nursing care for children and adolescents, addressing their unique healthcare needs.
- Obstetric and Gynecological Nursing: Nursing care for women during pregnancy, childbirth, and postpartum, as well as addressing women’s health issues.
- Psychiatric Nursing: Nursing care for patients with mental health and behavioral disorders.
Current Standardized Nursing Languages and Their Applications
There are several standardized nursing languages and classification systems that are widely used in healthcare settings to document and communicate nursing care. Here are some of the current standardized nursing languages and their applications:
- NANDA International (NANDA-I):
- Application: NANDA-I is a standardized nursing diagnosis terminology that provides a common language for nurses to identify and describe patient health problems. It is used for assessing, planning, and documenting patient care. Nursing diagnoses are typically structured as a problem, etiology, and signs and symptoms (PES) format.
- Nursing Interventions Classification (NIC):
- Application: NIC is a standardized terminology that defines and classifies nursing interventions. It helps nurses identify and describe the actions and activities they perform in patient care. NIC is often used to document nursing interventions in electronic health records (EHRs) and communicate nursing actions to the healthcare team.
- Nursing Outcomes Classification (NOC):
- Application: NOC is a standardized language that focuses on nursing-sensitive patient outcomes. It provides a framework for measuring and documenting patient responses to nursing interventions and helps nurses evaluate the effectiveness of their care.
- Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT):
- Application: SNOMED CT is a comprehensive standardized terminology that encompasses a wide range of clinical concepts, not limited to nursing. Nurses use SNOMED CT for precise and detailed documentation of patient information, including diagnoses, symptoms, procedures, and observations, in EHRs and health information systems.
- Clinical Care Classification (CCC):
- Application: CCC is a standardized nursing terminology that is designed to document the care provided by nurses. It includes concepts related to assessments, interventions, outcomes, and other aspects of nursing practice. CCC is used for nursing documentation and research.
- Omaha System:
- Application: The Omaha System is a standardized language for documenting community health nursing and home healthcare. It includes assessment, care planning, and documentation components that are used by community health nurses and other healthcare providers.
- Perioperative Nursing Data Set (PNDS):
- Application: PNDS is designed for perioperative nursing care. It helps perioperative nurses document patient assessments, interventions, and outcomes in surgical and perioperative settings.
- Clinical Reasoning and Decision-Making (CRDM):
- Application: CRDM is a standardized language used to document clinical reasoning and decision-making in nursing practice. It helps nurses describe their thought processes in assessing and planning patient care.
Benefits of standardized terminology in nursing
Standardized terminology in nursing refers to the use of consistent and universally accepted language and classification systems to describe and document nursing care, patient assessments, and outcomes. There are several significant benefits associated with using standardized nursing terminologies:
- Improved Communication: Standardized terminologies ensure that nurses and healthcare professionals share a common language. This facilitates clear and effective communication among healthcare team members, reducing the risk of misinterpretation and enhancing patient safety.
- Enhanced Data Sharing: When all healthcare providers use the same standardized terminology, it becomes easier to share patient data across different healthcare settings, electronic health records, and systems. This interoperability improves the continuity of care and patient outcomes.
- Quality and Safety: Standardized terminologies support evidence-based practice by enabling nurses to consistently document patient data and care interventions. This data can be analyzed to identify best practices and areas for improvement, ultimately enhancing the quality and safety of patient care.
- Streamlined Documentation: Nurses can document patient information more efficiently using standardized terminologies, as these systems often include predefined terms and templates. This reduces documentation time, allowing nurses to focus more on patient care.
- Outcome Measurement: Standardized terminologies provide a framework for measuring and comparing patient outcomes. This is essential for evaluating the effectiveness of nursing interventions and assessing the impact on patient health.
- Research and Evidence-Based Practice: Researchers can more easily analyze and aggregate data across multiple studies when standardized terminologies are used. This fosters nursing research and supports the development of evidence-based practice guidelines.
- Resource Allocation: Healthcare organizations can use standardized terminologies to analyze staffing needs and allocate resources more effectively based on patient acuity, care requirements, and workload.
- Nursing Education: Standardized terminologies are integrated into nursing education programs, ensuring that future nurses are well-prepared to use these systems in practice. This improves the consistency and quality of nursing care provided by new graduates.
- Accurate Billing and Reimbursement: Consistent terminology helps with accurate coding and billing for healthcare services. This is essential for healthcare organizations to receive appropriate reimbursement for the care they provide.
- Legal and Regulatory Compliance: Standardized terminology can help nurses and healthcare organizations comply with legal and regulatory requirements for documentation and reporting.
- Patient Involvement: When standardized terminologies are used, patients can better understand their care plans and participate in decision-making. It promotes transparency and patient engagement in their healthcare.
- Global Consistency: Standardized terminologies are often internationally recognized, making it easier for healthcare professionals to collaborate on a global scale and ensuring consistent care standards.
Challenges of implementing standardized nursing terminologies
While standardized nursing terminologies offer numerous benefits, their implementation in healthcare settings also comes with several challenges. Here are some of the key challenges associated with implementing standardized nursing terminologies:
- Resistance to Change: Healthcare professionals, including nurses, may resist adopting new terminology systems due to familiarity with existing practices and concerns about the learning curve.
- Training and Education: Implementing standardized terminologies requires comprehensive training and education for nurses and other healthcare staff. This can be time-consuming and costly.
- Time and Workload: Nurses may perceive the additional time required for documenting using standardized terminologies as a burden, potentially affecting their workflow and increasing workloads.
- Interoperability: Ensuring that different healthcare systems and electronic health records can communicate and share data effectively using standardized terminologies can be a significant technical challenge.
- Integration with Existing Systems: Many healthcare organizations already have established electronic health records and information systems that may not easily integrate with new terminology systems.
- Costs: The initial costs of implementing standardized terminologies, including software, training, and maintenance, can be a barrier for some healthcare institutions.
- Limited System Support: Some healthcare software and systems may not fully support or have limited support for standardized nursing terminologies, making it challenging to implement them effectively.
- Complexity: Standardized terminologies can be complex, with extensive coding and classification systems. Nurses and other healthcare professionals may find them difficult to navigate and use effectively.
- Sustainability: Maintaining the consistency and accuracy of standardized terminology data over time requires ongoing effort and resources.
- Lack of Standardization Among Systems: There are multiple standardized nursing terminologies available, and they are not always consistent with one another. This can lead to confusion and challenges in data exchange.
- Data Entry Errors: While standardized terminologies aim to reduce errors, data entry mistakes can still occur and have significant consequences for patient care and data accuracy.
- Documentation Burden: Nurses may feel overwhelmed by the extensive documentation requirements associated with standardized terminologies, leading to burnout and reduced job satisfaction.
- Limited Patient Understanding: Patients may have difficulty understanding the terminology used in their care plans, which can hinder their involvement in decision-making and self-care.
- Legal and Ethical Issues: The use of standardized terminologies can raise legal and ethical concerns, particularly regarding patient privacy and data security.
- Workflow Redesign: Implementing standardized nursing terminologies often requires a reevaluation and redesign of healthcare workflows, which can disrupt established routines.
- Socio-Cultural Factors: Differences in language, culture, and local practices can influence the adoption and interpretation of standardized terminologies.
