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?
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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.
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.
Sources available are below and attached, you can use your own as well just make sure it is legit
Recently a visit was made by the author to the labor and delivery unit of a local community hospital to observe the nurses’ recent implementation of the Nursing Intervention Classification (NIC) (McCloskey-Dochterman & Bulechek, 2004) and the Nursing Outcome Classification (NOC) (Moorehead, Johnson, & Maas, 2004) systems for nursing care documentation within their electronic health care records system.
it is impossible for medicine, nursing, or any health care-related discipline to implement the use of [electronic documentation] without having a standardized language or vocabulary to describe key components of the care process. During the conversation, one nurse made a statement that was somewhat alarming, saying, “We document our care using standardized nursing languages but we don’t fully understand why we do.” The statement led the author to wonder how many practicing nurses might benefit from an article explaining how standardized nursing languages will improve patient care and play an important role in building a body of evidence-based outcomes for nursing.
Most articles in the nursing literature that reference standardized nursing languages are related to research or are scholarly discussions addressing the fine points surrounding the development or evaluation of these languages. Although the value of a specific, standardized nursing language may be addressed, there often is limited, in-depth discussion about the application to nursing practice.
Practicing nurses need to know why it is important to document care using standardized nursing languages, especially as more and more organizations are moving to electronic documentation (ED) and the use of electronic health records. In fact, it is impossible for medicine, nursing, or any health care-related discipline to implement the use of ED without having a standardized language or vocabulary to describe key components of the care process. It is important to understand the many ways in which utilization of nursing languages will provide benefits to nursing practice and patient outcomes.
Norma Lang has stated, “If we cannot name it, we cannot control it, practice it, teach it, finance it, or put it into public policy” (Clark & Lang, 1992, p. 109). Although nursing care has historically been associated with medical diagnoses, today nursing needs a unique language to express what it does so that nurses can be compensated for the care provided. nurses need an explicit language to better establish their standards and influence the regulations that guide their practice.
A standardized nursing language should be defined so that nursing care can be communicated accurately among nurses and other health care providers. Once standardized, a term can be measured and coded. Measurement of the nursing care through a standardized vocabulary by way of an ED will lead to the development of large databases. From these databases, evidence-based standards can be developed to validate the contribution of nurses to patient outcomes.
The purpose of this article is to offer a definition of standardized language in nursing, to describe how standardized nursing languages are applied in the clinical arena, and to explain the benefits of standardizing nursing languages. These benefits include: better communication among nurses and other health care providers, increased visibility of nursing interventions, improved patient care, enhanced data collection to evaluate nursing care outcomes, greater adherence to standards of care, and facilitated assessment of nursing competency. Implications of standardized language for nursing education, research, and administration are also presented.
GCU Nursing Paper- Standardized Nursing Terminologies
Standardized Language Defined
Keenan (1999) observed that throughout history nurses have documented nursing care using individual and unit-specific methods; consequently, there is a wide range of terminology to describe the same care. Although there are other more complex explanations, Keenan supplies a straightforward definition of standardized nursing language as a “common language, readily understood by all nurses, to describe care” (Keenan, p. 12). The Association of Perioperative Registered Nurses (AORN) (n.d.) adds a dimension by explaining that a standardized language “provides nurses with a common means of communication.” Both convey the idea that nurses need to agree upon a common terminology to describe assessments, interventions, and outcomes related to the documentation of nursing care. In this way, nurses from different units, hospitals, geographic areas, or countries will be able to use commonly understood terminology to identify the specific problem or intervention implied and the outcome observed. Standardizing the language of care (developing a taxonomy) with commonly accepted definitions of terms allows a discipline to use an electronic documentation system.
Consider, for example, documentation related to vaginal bleeding for a postpartum, obstetrical patient. Most nurses document the amount as small, moderate, or large. But exactly how much is small, moderate, or large? Is small considered an area the size of a fifty-cent piece on the pad? Or is it an area the size of a grapefruit? Patients benefit when nurses are precise in the definition and communication of their assessments which dictate the type and amount of nursing care necessary to effectively treat the patient.
The Duke University School of Nursing website < www.nursing.duke.edu> has a list of guidelines for the nurse to use for evaluation of a standardized nursing language. The language should facilitate communication among nurses, be complete and concise, facilitate comparisons across settings and locales, support the visibility of nursing, and evaluate the effectiveness of nursing care through the measurement of nursing outcomes. In addition to these guidelines the language should describe nursing outcomes by use of a computer-compatible coding system so a comprehensive analysis of the data can be accomplished.
Current Standardized Nursing Languages and Their Applications
The Committee for Nursing Practice Information Infrastructure (CNPII of the American Nurses Association (ANA) has recognized thirteen standardized languages, one of which has been retired. Two are minimum data sets, seven are nursing specific, and two are interdisciplinary. The ANA (2006b) Recognized Terminologies and Data Element Sets outlines the components of each of these languages.
The submission of a language for recognition by CNPPII is a voluntary process for the developers. This terminology is evaluated by the committee to determine if it meets a set of criteria. “The criteria, which are updated periodically, state that the data set, classification, or nomenclature must provide a rationale for its development and support the nursing process by providing clinically useful terminology. The concepts must be clear and ambiguous, and there must be documentation of utility in practice, as well as validity, and reliability. Additionally, there must be a named group who will be responsible for maintaining and revising the system” (Thede & Sewell, 2010, p. 293).
Another ANA committee, the Nursing Information and Data Set Evaluation Center (NIDSEC), evaluates implementation of a terminology by a vendor. This approval is similar to obtaining the good seal of approval from Good Housekeeping or the United Laboratories (UL) seal on products. The approval signifies that the documentation in the standardized language supports the documentation of nursing practice and conforms to standards pertaining to computerized information systems. The language is evaluated against standards that follow the Joint Commission’s model for evaluation. The language must support documentation on a nursing information system (NIS) or computerized patient record system (CPR). The criteria used by the ANA to evaluate how the standardized language(s) are implemented, include how the terms can be connected, how easily the records can be stored and retrieved, and how well the security and confidentiality of the records are maintained. The recognition is valid for three years. A new application must be submitted at the end of the three years for further recognition. Some, but not all of the standardized languages are copyrighted. (The previous paragraphs were updated 2/23/09. See previous content.)
Vendors may also have their software packages evaluated by NIDSEC. The evaluation is a type of quality control on the vendor. An application packet must be purchased, priced at $100, then the fee for the evaluation is $20,000 (American Nurses Association, 2004). The only product currently recognized is Cerner Corporation CareNet Solutions (American Nurses Association, 2004). The recognition signifies that the software in the Cerner system has met the standards set by NIDSEC. The direct care/bedside nurse must understand the importance of the inclusion of standardized nursing languages in the software sold by vendors and demand the use of a standardized nursing language in these systems.
GCU Nursing Paper- Standardized Nursing Terminologies
Benefits of Standardized Languages
The use of standardized nursing languages has many advantages for the direct care/bedside nurse. These include: better communication among nurses and other health care providers, increased visibility of nursing interventions, improved patient care, enhanced data collection to evaluate nursing care outcomes, greater adherence to standards of care, and facilitated assessment of nursing competency. These advantages for the bedside/direct care nurse are discussed below.
Better Communication among Nurses and Other Health Care Providers
Improved communication with other nurses, health care professionals, and administrators of the institutions in which nurses work is a key benefit of using a standardized nursing language. Physicians realized the value of a standardized language in 1893 (The International Statistical Classification of Diseases and Related Health Problems, 2003) with the beginning of the standardization of medical diagnosis that has become the International Classification of Diseases (ICD-10) (Clark & Phil, 1999). A more recent language, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), provides a common language for mental disorders. When an obstetrician lists “failure to progress” on a patient’s chart or a psychiatrist names the diagnosis “paranoid schizophrenia, chronic,” other physicians, health care practitioners, and third-party payers understand the patient’s diagnosis.
Improved communication with other nurses, health care professionals, and administrators of the institutions in which nurses work is a key benefit of using a standardized nursing language. ICD-10 and DSM-IV are coded by a system of numbers for input into computers. The IDC-10 is a coding system used mainly for billing purposes by organizations and practitioners while the DSM-IV is a categorization system for psychiatric diagnoses. The DSM-IV categories have an ICD-10 counterpart code that is used for billing purposes.
Nurses lacked a standardized language to communicate their practice until the North American Nursing Diagnosis (NANDA), was introduced in 1973. Since then several more languages have been developed. The Nursing Minimum Data Set (NMDS) was developed in 1988 (Prophet & Delaney, 1998) followed by the Nursing Management Minimum Data Set (NMMDS) in 1989 (Huber, Schumacher, & Delaney, 1997). The Clinical Care Classification (CCC) was developed in 1991 for use in hospitals, ambulatory care clinics, and other settings (Saba, 2003). The standardized language developed for home, public health, and school health is the Omaha System (The Omaha System, 2004). The Nursing Intervention Classification (NIC) was published for the first time in 1992; it is currently in its fourth edition (McCloskey-Dochterman & Bulachek, 2004). The most current edition of the Nursing Outcomes Classification system (NOC), as of this writing, is the third edition published in 2004 (Moorhead, Johnson, & Maas, 2004). Both are used across a number of settings.
Use of standardized nursing languages promises to enhance communication of nursing care nationally and internationally. This is important because it will alert nurses to helpful interventions that may not be in current use in their areas. Two presentations at the NANDA, NIC, NOC 2004 Conference illustrated the use of a standardized nursing language in other countries (Baena de Morales Lopes, Jose dos Reis, & Higa, 2004; Lee, 2004). Lee (2004) used 360 nurse experts in quality assurance to identify five patient outcomes from the NOC (Johnson, Maas, & Moorhead, 2000) criteria to evaluate the quality of nursing care in Korean hospitals. The five NOC outcomes selected by the nurse experts as standards to evaluate the quality of care were vital signs status; knowledge: infection control; pain control behavior; safety behavior: fall prevention; and infection status.
Baena de Morales Lopes et al. (2004) identified the major nursing diagnoses and interventions in a protocol used for victims of sexual violence in Sao Paulo, Brazil. The major nursing diagnoses identified were: rape-trauma syndrome, acute pain, fear/anxiety, risk for infection, impaired skin integrity, and altered comfort. Through the use of these nursing diagnoses, specific interventions were identified, such as administration of appropriate medications with explanations of expected side effects, emotional support, helping the client to a shower and clean clothes, and referrals to needed agencies. The authors used these diagnoses in providing care for 748 clients and concluded that use of the nursing diagnoses contributed to the establishment of bonds with their clients. These are just two examples illustrating how a standardized language has been used across nursing specialties and around the world.
GCU Nursing Paper- Standardized Nursing Terminologies
Increased Visibility of Nursing Interventions
Nurses need to express exactly what it is that they do for patients. Nurses need to express exactly what it is that they do for patients. Pearson (2003) has stated, “Nursing has a long tradition of over-reliance on handing down both information and knowledge by word-of-mouth” (p. 271). Because nurses use informal notes to verbally report to one another, rather than patient records and care plans, their work remains invisible. Pearson states that at the present time the preponderance of care documentation focuses on protection from litigation rather than patient care provided. He anticipates that use of computerized nursing documentation systems, located close to the patient, will lead to more patient-centered and consistent documentation. Increased sensitivity to the nursing care activities provided by these computerized documentation systems will help highlight the contribution of nurses to patient outcomes, making nursing more visible.
Nursing practice, in addition to the interventions, treatments, and procedures, includes the use of observation skills and experience to make nursing judgments about patient care. Because nurses use informal notes to verbally report to one another, rather than patient records and care plans, their work remains invisible. Interventions that should be undertaken to in support nursing judgments and that demonstrate the depth of nursing judgment are built into the standardized nursing languages. For example, one activity listed under labor induction in the NIC language is that of re-evaluating cervical status and verifying presentation before initiating further induction measures (McCloskey-Dochterman & Bulechek, 2004). This activity guides the nurse to assess the dilatation and effacement of the cervix and presentation of the fetus, before making a judgment about continuing the induction procedure.
LaDuke (2000) provides an additional example of using the NIC to make nursing interventions visible. For example, LaDuke noted that the intervention of emotional support, described by McCloskey-Dochterman & Bulechek (2004) requires “interpersonal skills, critical thinking and time” (LaDuke, p. 43). NIC identifies emotional support as a specific intervention, provides a distinct definition for it, and lists specific activities to provide emotional support. Identification of emotional support as a specific intervention gives nurses a standardized nursing language to describe the specific activities necessary for the intervention of emotional support.
Improved Patient Care
The use of a standardized nursing language can improve patient care. Cavendish (2001) surveyed sixty-four members of the National Association of School Nurses to obtain their perceptions of the most frequent complaints for abdominal pain. They used the NIC and NOC to determine the interventions and outcomes of children after acute abdomen had been ruled out. Nurses identified the chief complaints of the children, the most frequent etiology, the most frequent pain management activities from the NIC, and the change in NOC outcomes after intervention.
The three chief complaints were nausea, headache, and vomiting; the character of the pain was described as crampy/mild or moderate; and the three most identified etiologies were psychosocial problems, viral syndromes, and relationship to menses. The psychosocial problems included test anxiety, separation anxiety, and interpersonal problems. Nutrition accounted for a large number of abdominal complaints, such as skipping meals, eating junk food, and food intolerances. Cultural backgrounds of the children, such as the practice of fasting during Ramadan, were identified as causes for abdominal complaints.
The three top pain management activities from NIC were: observe for nonverbal cues of discomfort, perform comprehensive assessment of pain (location, characteristics, duration, frequency, quality, severity, precipitating factors), and reduce or eliminate factors that precipitate/increase pain experience (e.g., fear, fatigue, and lack of knowledge) (Cavendish, 2001). Cavendish described a decrease in symptoms, based on the Nursing Outcomes Classification Symptom Severity Indicators, following the intervention. Symptom intensity decreased 6.25%, symptom persistence decreased 4.69%, symptom frequency decreased 6.25%, and associated discomfort decreased 41.06% (p. 272). Similar studies are needed to provide evidence that specific nursing interventions improve patient outcomes.
GCU Nursing Paper- Standardized Nursing Terminologies
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