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Discussion: Standardized Nursing Terminology

Discussion: Standardized Nursing Terminology

Discussion: Standardized Nursing Terminology

Question Description

Assignment: The Impact of Standardized Nursing Terminology

The Rutherford (2008) article Standardized Nursing Language: What Does It Mean for Nursing Practice is one of the resources in this module. The author recounts a visit to a local hospital to observe the recent implementation of a new coding system in this article.

During the visit, one of the nurses said to her, “We document our care using standardized nursing languages, but we’re not sure why” (Rutherford, 2008, para. 1).

How would you respond to a comment like this?

To Get Ready:

Examine the informatics concepts presented in the Resources, particularly Rutherford, M. (2008) Standardized Nursing Language: What Does It Mean for Nursing Practice?
Consider a nurse leader’s role as a knowledge worker.
Consider how data that is collected/accessed can inform knowledge.
The task at hand:

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Address the following in a 2- to 3-page paper:

Describe how you would inform this nurse (and others) about the significance of standardized nursing terminologies.

Describe the advantages and disadvantages of using standardized nursing terminologies in nursing practice. Provide specifics and examples.
Make sure to back up your paper with peer-reviewed research on standardized nursing terminologies from the Walden Library.
Resources:

1. M. A. Rutherford (2008). What does standardized nursing language mean for nursing practice? Issues in Nursing Online, 13(1), pp. 1-12.

2.https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/Inclusion-of-Recognized-Terminologies-Supporting-Nursing-Practice-within-Electronic-Health-Records/

3.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5977718/

4.https://www.healthit.gov/sites/default/files/snt final05302017.pdf

5. https://www.healthleadersmedia.com/nursing/big-data-means-big-potential-challenges-nurse-execs

Standardized Nursing Terminology

The nursing profession and direct/bedside nurses benefit immensely from the adoption of standardized nursing terminologies especially with regards to the documentation of nursing care. The American Nurses Association has provided approval to thirteen nursing terminologies that should be adopted in nursing; however, only ten of those terminologies have specificity to nursing care. The purpose of the present essay is to elucidate on the manner in which nurse leaders and other nurses may be informed about the importance of standardized nursing terminologies as well as explaining the pros and cons of implementation these terminologies in the practice of nursing.

Informing nurse of the importance of standardized nursing terminologies

            Informing the nurse leader and other nurses of the importance of nursing terminologies is of utmost importance to the success of the endeavor. Studies have revealed that most nurses do not comprehend the usage and import of standardized nursing terminology in care, which raises serious queries regarding its application. However, these nurses should be informed that standardized nursing terminologies create uniformity in the delivery of care. The provision of the common means of communication amongst nurses from various countries and or geographical locations makes the practice easier and the documentation of nursing care safer (Ivory, 2016). Moreover, the implementation of standardized nursing terminologies will enable nurses from varied units and even hospitals to have an understanding of the implied problem or specific problem identified in the observed outcome.

Moreover, I would explain to the nurse leader and other nurses of the rigorous process that the standardization has undergone to make them buy the idea. The American Nurses Association has several committees such as the Nursing Information and Data Set Evaluation Center (NIDSEC), which oversee the implementation of the standardized nursing terminology (Saranto, Saba, Dykes,  Kinnunen, & Mykkänen, 2016). These committees not only choose the terminologies, but also evaluate their implementation to ensure superior patient care and ease of work in nursing care. The evaluation of the terminologies occurs against the provisions of the Joint Commission’s Recommendations, which makes the terminologies friendly to nursing.

The benefits and challenges of implementing standardized nursing terminologies

            The implementation of SNTs in nursing practice comes with associated benefits and challenges to the practice environment and the nurses therein. Amongst the many benefits of the standardized nursing terminologies in care practice include improved communication amongst them as well as other care professionals. The adoption of the standardized nursing terminologies leads to improved communication both internationally and locally as well (Strudwick & Hardiker, 2016). The significance of cross-border usage of the terminologies is that it will alert the nurse regarding useful interventions that they may not be having in their area of practice. For example, a study by Baena de Morales Lopes and his colleagues in 2004 provided insights into how victims of sexual violence in Sao Paolo in Brazil would be diagnosed and treated. The major nursing diagnoses amongst that population were acute pain, rape-trauma syndrome, risk for infection, fear/anxiety, impaired skin integrity, as well as altered comfort. The accompanying intervention terminologies including administration of apt medications alongside explanations of anticipated adverse events, emotional support, aiding the client to clean clothes after showering, as well as referrals to needed agencies featured. The application of the same in other patient populations revealed that a creation of bonds with the clients was the consequence. Thus, standardized nursing terminologies can be used across countries and specialties with an understanding accruing.

Moreover, enhanced visibility of the interventions offered by nurses also occur as a consequence of using standardized nursing terminologies.  The adoption of computerized nursing documentation systems will result to a nursing intervention that is more patient-centered and consistency in documentation (Ivory, 2016). The resultant increased sensitivity of the interventions offered courtesy of the computerized system will lead to the revelation of the contributions offered by nurses in the provision of patient care, which will result into a more visible nursing role. For instance, nurses will need to re-evaluate cervical status and verify presentation as a prelude to initiating additional induction measures.

The usage of standardized nursing terminologies can also lead to improved patient care. The usage of the terminologies can lead to nurses understanding the most frequent symptoms associated with say abdominal pain (Strudwick & Hardiker, 2016). The usage of terminologies as provided by the NIC and NOC will help them to determine appropriate interventions and the resultant outcomes after the elimination of acute abdomen. Thus, as a consequence of using the two terminologies, nurses can comfortably identify the chief complaints, the frequently appearing etiology and pain management undertakings from the NIC terminologies as well as the alterations in the outcomes of NOC after the interventions have been adopted.  All these lead to improved management of the abdominal issue hence patients.

Nevertheless, the adoption of standardized nursing terminologies is also associated with certain disadvantages. However, the most significant disadvantage of using the terminology relates to confidentiality. The adoption of the electronic system as a nursing technology has the potential to be hacked or mismanaged by nurses in practice. This leads to a real possibility of patient data falling in the wrong hands, which may lead to costly lawsuits against healthcare facilities (Törnvall & Jansson, 2017). Further, the usage of such a system is hampered by a lack of harmonization across standards as well as the absence of a centralized system also exist (Törnvall & Jansson, 2017. The adoption of different charting by various facilities and varied assessments across facilities and locations makes it difficult for software developers to come up with a unitary system.

Conclusion

The adoption of standardized nursing terminology is associated with certain advantages and disadvantages in healthcare. Studies reveal that adoption of the same may lead to improved patient care, communication and offer visibility concerning nursing. However, the threat of confidentiality breach is real given that it adopts the use of the electronic health records.

 

 

References

Ivory C. H. (2016). Mapping Perinatal Nursing Process Measurement Concepts to Standard Terminologies. Computers, informatics, nursing : CIN, 34(7), 312–320. https://doi.org/10.1097/CIN.0000000000000243

Saranto, K., Saba, V., Dykes, P., Kinnunen, U. M., & Mykkänen, M. (2016). Milestones and Experiences of Standardized Documentation. Studies in health technology and informatics, 225, 748.

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 informatics, 94, 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 knowledge, 28(2), 109-119.