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The Impact of Standardized Nursing Terminology

The Impact of Standardized Nursing Terminology

Sample Answer 

The Impact of Standardized Nursing Terminology

Importance of Standardized Nursing Terminologies

The use of standardized nursing terminologies is important in maintaining interprofessional collaboration in patient care. These terminologies foster effective and optimum communication among nurses and between nurses and other members of the healthcare team. Effective interprofessional communication and the exchange of health information in the healthcare setting are crucial in the achievement of collaborative and coordinated patient care (Huard & Monsen, 2017). In clinical information systems, the use of standardized terminologies is specifically important in making health information interoperable by promoting a shared understanding of data (Strudwick & Hardiker, 2016). As a result, standardized terminology ultimately contributes to high-quality care by supporting interprofessional cooperation in care.

Similarly, standardized terminologies facilitate quality evaluation and improvement. These terminologies provide common phrases and references for healthcare information. The use of standardized terminologies in describing and documenting components of the nursing process, such as specific nursing interventions and outcomes, is important in ensuring that patient care quality can be accurately determined based on similar metrics (Huard & Monsen, 2017). Nursing data, such as the number of patient falls, are important indicators of healthcare quality. Standardized terminologies facilitate quality determination by enabling comparable data collected from different patients and clinical settings to be aggregated (Strudwick & Hardiker, 2016). Quality indicators are important for care quality improvement efforts.

Benefits of Standardized Nursing Terminologies

Standardized terminologies increase the visibility of nursing care (Rutherford, 2008). Indeed, the caregiver role of the nurse includes multiple clinical and non-clinical roles that may easily be effaced in the clinical setting when compared to other clinical disciplines. For example, nursing interventions such as helping debilitated patients to perform activities of daily living such as toileting may remain unrecognized. Standardized terminologies facilitate the measurement of nursing care by allowing the specific information describing nursing care actions to be recorded and aggregated into databases (Rutherford, 2008). This will highlight the contributions of nursing practice in patient care.

Additionally, the use of standardized terminologies will also encourage accurate nursing assessment. These terminologies provide meaningful references for patient health information that may be important in accurately describing assessment findings (Rutherford, 2008). For example, when describing the amount of blood loss following an injury, the use of non-standard terminology such as ‘significant’ or ‘major’ does not provide information on the patient’s clinical status. On the other hand, standardized terminology in which the term ‘significant’ describes severe hemorrhage associated with specific features such as syncope and tachycardia provides a more accurate description of the patient’s clinical status.

Standardized terminology will also enhance adherence to standards of care. Some nursing terminologies describe a range of nursing actions that are typically performed consecutively and in entirety (Rutherford, 2008). For example, bowel preparation for a patient who is supposed to undergo colonoscopy implies that the nurse obtained informed consent, a brief medical history, administered a laxative agent, and monitored the patient to establish compliance with the procedure. Standardized terminologies may, therefore, be important in enhancing guideline adherence.

Challenges in Implementing Standardized Nursing Terminologies

An important challenge in the implementation of standardized nursing terminologies is the poor emphasis on the practice by the government. For example, legislation that could have supported the practice, such as the Meaningful Use federal legislation, did not include any provisions regarding standardized terminologies metrics (Huard & Monsen, 2017). The absence of compelling legislation to encourage the uptake of standardized terminologies reduces the implementation rate.

Additionally, the majority of clinical information systems do not include capabilities for implementing standardized nursing terminologies in these systems. Many clinical information systems use proprietary software that lacks robust, standardized language features (Huard & Monsen, 2017). This limits the ability to adapt these systems to existing standardized nursing languages.

Finally, standardized nursing terminologies also introduce nursing care challenges by limiting the ability to effectively characterize some clinical situations (Törnvall & Jansson, 2017). An excellent example of this challenge is the ambiguity in some of the NANDA nursing diagnoses. Diagnoses such as impaired gaseous exchange and ineffective breathing patterns may present diagnostic challenges in certain patients due to extensive similarities in their clinical manifestations. This may present documentation challenges.

References

Huard, R. J., & Monsen, K. A. (2017). Standardized Nursing Terminology Use in Electronic Health Records in Minnesota.

Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice OJIN: The Online Journal of Issues in Nursing13(1), 243-50.

Strudwick, G., & Hardiker, N. R. (2016). Understanding the use of standardized nursing terminology and classification systems in published research: A case study using the International Classification for Nursing Practice®. International journal of medical informatics94, 215-221.

Törnvall, E., & Jansson, I. (2017). Preliminary evidence for the usefulness of standardized nursing terminologies in different fields of application: a literature review. International journal of nursing knowledge28(2), 109-119.

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Question 


The Impact of Standardized Nursing Terminology

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.

The Impact of Standardized Nursing Terminology

The Impact of Standardized Nursing Terminology

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

Accessible player

Vinay Shanthagiri. (2014). Big Data in Health Informatics [Video file]. Retrieved from https://www.youtube.com/watch?v=4W6zGmH_pOw.

 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.

Grading Rubric

The responses accurately and thoroughly explain in detail how to inform the nurse in the scenario, as well as others, on the importance of standardized nursing terminologies.

The responses accurately and thoroughly describe in detail the benefits and challenges of implementing standardized nursing terminologies in nursing practice, with sufficient supporting evidence and detailed examples.

Responses are fully supported as evidenced by 3 or more accurate, peer-reviewed research sources on standardized nursing terminologies.

Paragraphs and sentences follow writing standards for flow, continuity, and clarity.

Uses correct grammar, spelling, and punctuation with no errors.

Uses the correct APA format with no errors.

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