The Importance of Standardized Nursing Terminologies ...

Running head: THE IMPORTANCE OF STANDARDIZED NURSING TERMINOLOGIES 1

The Importance of Standardized Nursing Terminologies Students Name:

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Importance of Standardized Nursing Terminologies

Standardized nursing terminologies can be defined as common agreed upon terms that are easily understood by all nurses. It has been argued that nursing does not have the hallmarks of a true profession. One characteristic that has been used in defining true professions is vocabularies that are specialized which are understood and utilized worldwide (Schwirian, 2013). Law and medicine are professions that have long-standing specialized vocabularies and standardized nursing terminologies are important as they can delineate nursing practice as a true profession. The use of these terminologies also makes it possible to differentiate the contributions of nursing in care settings. They reflect the uniqueness of nursing and make it possible to identify how best to incorporate its elements in the EHR.

Benefits of Implementation in Nursing Practice

The first benefit is enabling better communication. They enable improvement of communication among nurses, administrators and other healthcare providers who collaborate with nurses. Communication that is effective is critical in nursing as nurses have to quickly share information about the patient to doctors, other nurses and practitioners. Standardized terminologies enable the delivery of information in a clear, swift and effective manner (McCormick et al., 2015). Physicians have known this value for many years and this began with medical diagnosis standardization which is now known as the International Classification of

Diseases (ICD-10) which provides a common language that is easily understood. For example,

when a diagnosis is named `paranoid schizophrenia' on the chart of a patient, other physicians

and practitioners, as well as payers, quickly and easily understand the diagnosis of the patient.

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The second benefit is that the terminologies will make nursing interventions visible. It

has been pointed out that the work of nurses remains invisible due to their utilization of word of

mouth in handing down knowledge and information to one another as well as the use of informal

notes. With the increased use of computerized documentation systems in nursing, there will be

increased sensitivity to activities of nursing care (McCormick et al., 2015). This will increase

nursing visibility by helping highlight the contributions of nursing in the outcomes of the patient.

Interventions performed and which show the depth of nursing judgement will be incorporated in

standardized nursing terminologies. An example is labor induction in the Nursing Intervention

Classification (NIC) language which guides nurses in assessing the cervix before making a

judgement on continuing with the procedure of induction.

The third benefit is that it enhances the collection of data needed in evaluating the outcomes of nursing. When used in recording nursing care, the terminologies provide the consistencies required for comparing the quality of nursing interventions. With more organizations now using EHR systems, the use of standardized nursing terminologies makes it possible to create a data repository that will enable benchmarking of nursing care.

Challenges of Implementation in Nursing Practice

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One challenge is the lack of alignment and harmonization in terminology standards for

nursing content. This limits the goal of sharable and interoperable data that can move the patient

across settings of care (HealthIT, 2017). Multiple scales of nursing assessment which represent

the same concept exist and these make it difficult to standardize clinical content. Customization

of EHR systems is another challenge where unique data elements are created to meet local

preferences resulting in non-standard and non-mapped vocabularies.

References

HealthIT (2017).Standard Nursing Terminologies: A Landscape Analysis. Retrieved from

McCormick, K., Sensmeier, J., Dykes, P., Grace, E., Matney, S., Schwartz, K., & Weston, M. (2015). Exemplars for advancing standardized terminology in nursing to achieve sharable, comparable quality data based upon evidence. On-Line Journal of Nursing Informatics, 19(2).

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Schwirian, P. M. (2013). Informatics and the future of nursing: Harnessing the power of

standardized nursing terminology. Bulletin of the American Society for Information

Science and Technology, 39(5), 20-24.

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