Standardizing Terminologies in Nursing
Nursing care planning is one of the most impacted areas by standardized nursing terminologies. The standardizing language in nursing here denotes the use of a common language that all nurses can understand in describing care (Rutherford, 2008). A survey conducted on nursing practitioners revealed a myriad of nursing functions including organizing care, interventions generation, and information retrieval on the same terms for many patients, planning care and generating appropriate outcomes as areas highly impacted on by standardized nursing terminologies (Walker, Cleondon & Nelson, 2015). However, as Rutherford (2008) reveals, some nurses are not aware of the need for these terminologies and exhibit ignorance on the critical roles that standardized nursing terminologies play in their practice. This paper delves into the importance of these terminologies as well as the benefits and challenges of implementing them in nursing practice.
Essence of standardizing language in nursing
Rutherford (2008) explores why the standardization of nursing language for documentation is crucial in healthcare and most significantly to the direct care nurses dealing with patients. By documenting planning of care and clinical outcomes in a nursing language that is standardized, nurses benefit the entire profession by contributing immensely towards the improving patient care and also contribute to the evidence-based outcomes that can be shared by all nurses (Rutherford, 2008).
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In the era of electronic documentation of health records, peer sharing of information is critical in achieving the highest standards of care. Moreover, details about information across organizations that deal with patient care has been necessitated by the law (Balestra, 2017). The implementation of electronic documentation by any healthcare cannot happen without adopting standardized nursing care as EHR incorporate templates that describe the key components of nursing care. These records ought to be shared and read across all healthcare organizations making it a must for healthcare providers to adopt them (Rutherford, 2008).
Standardized nursing terminology use in nursing care is also crucial in aiding accurate communication of care among nurses and other healthcare providers. Nursing outcomes generated by one nursing practitioner adds to the evidence-based care that helps in easier diagnosis of issues and provision of care. As such, it is important that it is documented in such a manner that they are easy to understand and interpret by other nurses. Also, HIPAA mandates healthcare providers to share patients’ healthcare data needed in the provision of services by other players in the health sector (Olatubi et al., 2018). The use of standard nursing language, in such a case, makes it easier for the sharing of such information as the law dictates.
Benefits and challenges of Standardizing Terminologies in Nursing
First, standardizing terminologies in nursing improves patient care. For a population of surveyed members of the National Association of School Nurses, there was evidence of improved nursing outcomes and interventions for the nurses that adhered to NOC and NIC standards (Rutherford, 2008).
Standardized nursing terminologies also facilitates in collection of data that is used in evaluating the quality of care outcomes. Standardizing language in nursing offers a consistent means of comparing the quality of care used under the various nursing interventions. Data repositories can also be established when data is stored in the EHR under the standardized nursing language to serve as a benchmarking tool for the profession of nursing (Rutherford, 2008).
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It also through the contribution of standardizing language in nursing that has developed better improved engagement among nurses and with other professional in healthcare provision. The sharing of information to improve nursing outcomes as well as document evidence-based practice outcomes has become a vital part of nursing practice today. This is being aided by adopting a standardized nursing language that can be used by nursing from all over the world.
There is also an improved adherence to the standards of care. For instance, the use of NOC and NIC standardized nursing languages that are based on the inputs of the nurses and the standards of care from other professions in health care is reinforced by nurses that have adopted these languages (Rutherford, 2008).
It provides a framework to facilitate assessment of practitioners on account of their competency. Nursing interventions obtained from the standardized languages in nursing may equally be employed as the standard for assessing nurses’ competence in performing the given interventions
As revealed in Rutherford (2008), the ignorance among the nurses on the role that standardizing terminologies in nursing play while attending to patients is the main challenge. The lack of understanding and knowledge on how standard nursing language affects the outcomes in healthcare provision limits the level of exploitation of the benefits conferred by the system. Nurses that are not aware of the capabilities of standardizing terminologies in nursing in the documentation of nursing outcomes are less likely to adopt the use of systems that store health records electronically, which contribute to the overall slow intake of technology in healthcare (Shwiran & Thede, 2011).
In conclusion, standardized nursing technologies play a critical role in the documenting of nursing outcomes. This system is important in the implementation of EHR systems as well as in aiding communication in the nursing profession and with healthcare providers. Benefits of standardizing language in nursing include; the facilitating of assessment of nurses based on competency, ensuring that nursing standards have been adhered to, enhancing data collection that is used in assessing nursing care outcomes and helps in improving patient care. The main challenge to this is the lack of knowledge and understanding of the role that standardized nursing terminologies play in the provision of nursing care.
- Balestra, M. L. (2017). Electronic Health Records: Patient Care and Ethical and Legal Implications for Nurse Practitioners. The Journal of Nursing Practioners, 105-111. doi:doi.org/10.1016/j.nurpra.2016.09.010
- Olatubi, M. I., Oyediran, O. O., Faremi, F. A., & Salau, O. R. (2018). Knowledge, Perception, and Utilization of Standardized Nursing Language (SNL) (NNN) among Nurses in Three Selected Hospitals in Ondo State, Nigeria. International Journal of Nursing Knowledge. doi:https://doi.org/10.1111/2047-3095.12197
- Rutherford, M. (2008, January 31). Standardized Nursing Language: What Does It Mean for Nursing Practice? The Online Journal of Issues in Nursing, 13(1). doi:10.3912/OJIN.Vol13No01PPT05
- Schwiran, P. M., & Thede, L. Q. (2011). Informatics: The Standardized Nursing Terminologies: A National Survey of Nurses’ Experiences and Attitudes – Survey I. The Online Journal of Issues in Nursing, 48-60. doi:10.3912/OJIN.Vol16No02InfoCol01
- Walker, L., Clendon, J., & Nelson, K. (2015). Nursing roles and responsibilities in general practice: Three case studies. Journal of Primary Health Care, 236-243.
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