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Nursing Excellence

The Online Newsletter for Children's Nurses
e-Edition, Issue 6 


Diana Tubera Informatics: The Language of Nursing

By Diana Tubera, MS, BSN, R-BC - Nursing Informatics Specialist

Background

Historically, even before the time of Florence Nightingale, it is believed that nursing dates back to motherhood. Its origins are of caring for mother and child; hence, nursing has been described as a calling or a vocation. Because nursing has been so closely intertwined with the medical profession, unfavorable stereotypes have negatively affected the view of nursing as an independent entity. Nursing has struggled to establish itself as a profession in the realm of healthcare. This resulted in nursing not seeking or having the means to control its own practice. In discussing the nature of nursing in 1859, Florence Nightingale observed that, “nursing has been limited to signify little more than the administration of medicines and the application of poultices.”1

The nursing profession has continued to evolve defining nursing as a unique body of professional knowledge. Early works in 1986 focused on standardization of nursing educational programs and laws governing nursing practice. Levels of competency and creating descriptive terminology reflecting specific nursing functions were created.2   Erickson, Tomlin, and Swain believe, “nursing will thrive as a unique and valued profession when nurses present a theory and rationalistic model for their practice, correct misleading stereotypes, locate control with clients, and actively participate in processes for change.”3

Journey to Standardization

The nursing process became the single and most common vehicle for the delivery of nursing care. It is a problem-solving approach to human responses to health problems and issues. It has provided a framework on how the 5-step process – Assessment, Problem Identification/Diagnosis, Outcomes/Planning, Implementation, and Evaluation – is captured and documented. Documentation has been an integral part of the nursing process that it is now considered the sixth step of the process. Although it is considered to be important, there have been challenges to compliance and standardization.

The traditional method of nursing documentation, in describing nursing care, is in the form of hand-written notes or sometimes known as free-text. Although this type of documentation is flexible and requires no additional training, it is open to subjectivity and misinterpretations. The lack of consistency in nursing documentation have hindered communication and limited the comparison and analysis of nursing care. Clark and Lang emphasized the importance of standardized nursing terminology and taxonomy. Furthermore, Clark and Lang stated that, “If you can’t name it, you can not 1) Control, 2) Finance, 3) Research, 4) Teach, and 5) Put in policy.4” Faced with challenges on the need for common language, several national and international nursing organizations have identified the need for a common language to describe, compare, and communicate nursing activities in a multi-faceted settings, population, groups, and countries.5

Standardized Language Defined

Nurses commonly document amount of bleeding as small, medium, or large.  The bleeding can also be described in relation to dressing applied as dry, moderately soaked, fully soaked, or heavily soaked. These assessments and descriptions are perceived differently by nurses leading to varied interpretations; hence, varied practices and outcomes. Keenan defined standardized nursing language as a “common language, readily understood by all nurses, to describe care.6” Additionally, The Association of Perioperative Registered Nurses (AORN) explained that a standardized language provides nurses a common means of communication.7 In essence, standardized language is a list of terms with agreed upon definitions so that when it is used, it means the same thing for everyone. This way every nurse can describe an assessment, identify a problem, intervention, and outcome that is common and universally understood by the nursing profession.

 

Current Standardized Nursing Language

There are 13 standardized nursing languages that are recognized by the American Nurses Association (ANA) (ANA, 2006).8 See Table below.

 

 

Benefits of Standardized Nursing Language

Rutherford discussed the advantages and benefits of standardized nursing language. These include, “1) better communication among nurses and other health care providers; 2) increased transparency of nursing interventions; 3) improved patient care; 4) enhanced data collection to evaluate nursing care outcomes; 5) greater adherence to standards of care; and, 6) facilitated assessment of nursing competency.9”

 

Future Application

Our organization’s journey to Standardized Nursing Language has begun. The Nursing Informatics Council has adapted the Standardized Nursing Language using the Clinical Classification Care (CCC) system framework in designing the content of our clinical documentation. By shifting to this paradigm, our organization will capture nursing activities accurately, measure nurse-sensitive outcomes efficiently, and compare and benchmark nursing data; thus, improving patient care.

 

References:

1. Nightingale, F. (1859).Notes on Nursing: What It Is and What It Is Not (Facsimile edition). Philadelphia: J.B. Lippincott, 1946.

2. Jacobi, E.M. (1976). Foreword. In Flanigan, L.(ed.). One Strong Voice: The Story of the American Nurses’ Association. Kansas City, MO: American Nurses’ Association.

3. Erickson, H.C., Tomlin, E.M., Swain, M.A.P. (1983). Modeling and Role-Modeling. Englewood Cliffs, NJ: Prentice-Hall

4. Clark, J., & Lang, N.M. (1992). Nursing's next advance: An international classification of nursing practice. International Nursing Review, 39, 109-111

5. Gassert, C.A. & Salmon, M. (1998). Setting a national informatics agenda for nursing education and practice to prepare nurses to develop and use information technology. In B. Cesnik, A.T. McCray, & J.R. Scherrer (Eds.), MedInfo '98: 9th World Congress on Medical Informatics, (pp. 748-751). Amsterdam: IOS Press

6. Keenan, G. (1999). Use of standardized nursing language will make nursing visible. Michigan Nurse, 72(2), 12-13.

7. Association of Perioperative Registered Nurses (n.d.). Perioperative nursing data set. Retrieved September 30, 2004, from http://www.aorn.org/PracticeResources/NursingResearch/

8. American Nurses Association. ANA recognized terminologies and data element sets. Retrieved August 1, 2010 from http://www.nursingworld.org/npii/terminologies.htm

9. Rutherford, M., (Jan. 31, 2008) “Standardized Nursing Language: What Does It Mean for Nursing Practice?”OJIN: The Online Journal of Issues in Nursing. Vol. 13 No. 1.

In This Issue


Great Moments

Shining Stars

Pediatric Early Warning Tools

Patient Safety Survey

Informatics: The Language of Nursing

Nursing Peer Review

NICU Outreach Education

What is “Just Culture”?

Patient Satisfaction Comments