Standardized Nursing Terminologies
Standardized Nursing Terminologies
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.
- Be sure to support your paper with peer-reviewed research on standardized nursing terminologies that you consulted from the Walden Library.
Learning Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Required Readings
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/practice-policy/nursing-excellence/official-position-statements/id/Inclusion-of-Recognized-Terminologies-Supporting-Nursing-Practice-within-Electronic-Health-Records/
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/
Office of the National Coordinator for Health Information Technology. (2017). Standard nursing terminologies: A landscape analysis. Retrieved from https://www.healthit.gov/sites/default/files/snt_final_05302017.pdf
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.
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.healthleadersmedia.com/nursing/big-data-means-big-potential-challenges-nurse-execs
Topaz, M. (2013). The hitchhiker’s guide to nursing theory: Using the Data-Knowledge-Information-Wisdom framework to guide informatics research. Online Journal of Nursing Informatics, 17(3).
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.2015.12.019.
Note: You will access this article from the Walden Library databases.
Required Media
Laureate Education (Executive Producer). (2012). Data, information, knowledge and wisdom continuum [Multimedia file]. Baltimore, MD: Author. Retrieved from http://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6051/03/mm/continuum/index.html
Laureate Education (Producer). (2018). Health Informatics and Population Health: Analyzing Data for Clinical Success [Video file]. Baltimore, MD: Author.
SAMPLE ANSWER
Standardized Nursing Terminologies
Introduction
Standardized nursing terminologies refer to a wide range of vocabularies that are used by nurses to describe standard care. The common language is understood by all nurses from different geographical areas and various health institutions. Nurses agree on a common form of communication to ensure that there is no confusion on patient health history even when given care by different nurses of health professionals in various hospitals, units, and countries. For instance, nurses document postpartum vaginal bleeding as large, moderate, or small. The terms small, large, and moderate describe a standard amount that is known by the nurse (Topaz, 2013). Thus, if a patient is treated in a different hospital by different nurses, their health information would remain clear without causing any confusion or inconveniences. This paper aims to review the concepts of informatics as described by Rutherford (2008), in “Standardized Nursing Language; What Does It Mean for Nursing Practice?”. The paper also describes the importance of standardized nursing terminologies.
In the “Standardized Nursing Language: What Does It Mean for Nursing Practice?”, the author describes how he visited a delivery and labor unit in a local community hospital with the aim of observing the implementation of the recent Nursing Outcome Classification and the Nursing Intervention Classification. One of the nurses commented that they document their care through the use of standardized nursing terminologies, but they do not understand why they do so. Therefore, Rutherford (2008) thought of writing an article describing the importance of Standardized Nursing Terminologies in improving patient care and evidence-based patient outcome for the nurses. Besides, based on various studies, there is a wide range of benefits of using the terminologies to both nursing practice and patient outcome.
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Benefits of Standardized Nursing Terminologies
Nurses should understand why they use standardized terminologies in documenting their care and their importance to nursing practice as well as patient outcome. Some of the benefits are outlined below:
- Improved Patient Care
The use of Standardized Nursing Terminologies helps in reducing misunderstandings and medical errors. The use of unstandardized data may cause a lot of challenges when it comes to data analysis and processing. When data is unstandardized, similar terminologies may have different meanings depending on the institutions since cultures and standards of care can considerably vary (Wang, Kung & Byrd, 2018). Medical errors and misunderstandings may lead to poor treatment of a patient which may lead to health emergencies such as the death of worsening of a patient’s health condition (Macieria, et al.2017). Therefore, nurses should be informed that its is highly beneficial to quality patient outcome.
- Improved communication among nurses and other health practitioners
The use of Standardized Nursing Terminologies enhances clear communication among health practitioners, such as administrators of health institutions and other health practitioners. For instance, through the use of the International Classification of Diseases, physicians can have a standard understating of various health conditions (Rutherford, 2008). The Diagnostic and Statistical Manual Disorders gives a common language for psychological disorders (Macieria, et al.2017). When a psychologist indicates the status of a patient on the patient chart using SNTs, other health practitioners, physicians, and nurses understand the diagnosis of the patient.
- Enable Data Collection to Evaluate Nursing Care Outcomes
Application of Standardized Nursing Terminologies to document nursing care may provide the necessary consistencies when comparing care quality for different interventions. Many health organizations are adopting the use of electronic health records (Rutherford, 2008). When nursing care is documented electronically in a common language, data from large state, local and national institutions can be used for benchmarking with other institutions that give nursing care.
- Easy assessment of competencies in nursing
The use of Standardized Nursing Terminologies can be used in examining the competencies of nurses in the field. It is a requirement for the healthcare institutions by the joint commission to demonstrate the competency of the nursing staff (Macieria, et al.2017). The interventions which are described in the terminologies can be used to evaluate the competencies of nurses in performing those interventions (Rutherford, 2008). Besides, the documentation of care done by different nurses using the standardized language can be used to tell whether a nurse is giving the right care to a patient.
- Enhances the visibility of nursing interventions
Most nurses use non-formal notes or verbal communication when communicating with each other about patient care. Therefore, their interventions main remain invisible. Nurses need to understand that the use of Standardized Nursing Terminologies to document their care helps in making their interventions visible. Besides, the documentation of nursing interventions in computers helps describe their contributions to patient outcome, thereby making them more visible.
Challenges in implementation of Standardized Nursing Terminologies
- Lack of professional practice understanding
One of the challenges in the implementation of Standardized Nursing Terminologies is that in most of the health institutions, nursing care is fails to be represented the documentation value of Standardized Nursing Languages (Topaz, 2013). Thus, there is no familiarity of nursing practice with Nursing Standardized Terminologies represented.
- Lack of proficiency with electronic health records and computers
Most nurses fail to understand the Standardized Nursing Terminologies. Besides, some nurses do not understand the application of Electronic health documentation and the use of computers (Topaz, 2013). Therefore, the implementation of the terminologies becomes a great challenge.
- Technology and Information System barriers
Information System and technology barriers may include such factors as insufficient ability to retrieve or document nursing practice in form of Standardized Nursing Terminologies. Also, its unavailability in the Electronic Health Records poses great challenges during the implementation of SNTs. In addition, the Standardized Nursing Terminologies acts as one of the major challenges in the implementation of SNTs.
Conclusion
In conclusion, the nurses who commented that they do not understand why they document their care through Standardized Nursing Terminologies should first learn the importance of the common terminologies. They enhance easy communication between nurses, other health practitioners, and administrators in health institutions. The languages also reduce the instances of misunderstandings and medical errors when patients are treated by different health practitioners in different geographical areas and various health institutions. Besides, it is easy to assess the competencies of nursing interventions through the use of Standardized Nursing Terminologies. Data collection and benchmarking are also quickly done when Standardized Nursing Terminologies are used in healthcare.
References
Macieira, T. G., 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. In AMIA Annual Symposium Proceedings (Vol. 2017, p. 1205). American Medical Informatics Association.
Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice. OJIN: The Online Journal of Issues in Nursing, 13(1), 243-50.
Topaz, M. (2013). Invited Editorial: The Hitchhiker’s Guide to nursing informatics theory: using the Data-Knowledge-Information-Wisdom framework to guide informatics research. Online Journal of Nursing Informatics (OJNI), 17(3).
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, 3-13.
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