Healthcare Informatics Theories and Policies: Standard Nursing Language - Essay Example

STANDARD NURSING LANGUAGE Standard Nursing Language Introduction There are different standardized nursing terminologies thathave been developed to enable nurses to communicate with other medical practitioners. A nursing terminology is a body of terms used in nursing (Thoroddsen, Ehnfors & Ehrenberg, 2010). The first standardized nursing terminology, North American Nursing Diagnoses Association (NANDA), came to life in the early 1970’s (“About NANDA”, n.d.). Since then and now, the American Nurses Association (ANA), has approved other standardized terminologies, for example, the Omaha System, Clinical Care Classification (CCC), Perioperative Nursing Data Set (PNDS), the Nursing Minimum Data Set (NMDS), The Nursing Interventions Classifications (NIC), International Classification for Nursing Practice (ICNP), the Nursing Outcomes Classification (NOC). The American Nurses Association has approved thirteen, but only ten are considered particular to nursing care. NANDA-I will be the main considered terminology in this essay. NANDA-I maintains an agreed set of diagnoses, which are then used to select appropriate nursing interventions and develop desirable patient outcomes. Its taxonomy is organized into 13 domains of nursing practice, 46 classes, and 216 diagnoses. NANDA-I has been found to be used extensively both in the United States and globally (About NANDA”, n.d.). Approach used for the development of NANDA-I NANDA opened up the way of diagnostic taxonomy in nursing. During the first National Conference on Classification of Nursing Diagnoses, 1973, a task force was formed. It later evolved into an incorporated Association in 1982 to help nurses who were in the United States and Canada. The work on classification was begun by Kristie Gebbie and Mary Ann Lavin, faculty at St. Louis University, by calling a classification conference. They influenced the current decisions of the identification-classification process through their belief that nurses should be involved in the development process. A diagnosis is a clinical decision about an individual’s response to real or possible health problems. It is the foundation for choosing the appropriate nursing intervention to get an outcome for, which the nurse is accountable. Gordon’s observation was of diagnosis being a model that puts a meaning on a set of observations therefore triggering understanding and thinking about the set. This phenomenon forms the basis of every diagnostic concept of today (Speksnijder et al., 2011). Subsequent to specifying the goals of a proposed system, the identification process begins. The subject phenomena are identified. NANDA initially used an inductive approach to identifying the categories. At the 1973 conference, 100 participants who included nurses, medical practitioners, researchers, educators and administrators created a set of nursing diagnoses, definitions, and used their nursing expertise stored in their memory to define characteristics (Bernhart-Just, Lassen & Schwendimann, 2010). These diagnoses represented twenty-nine conceptual areas with approximately 100 terms, which were later condensed (“Nursing Nomenclature”, n.d.). This can be contrasted with the current classification system, which has grown tremendously with an outstanding 216 terms (“Nursing Nomenclature”, n.d.). Continued development through qualitative, quantitative and epidemiological research is essential due to the continued evolution of the medical and nursing field. Today the concept and terminologies must first be standardized and accepted by organizations such as the American Nurses Association (ANA). Extent to which this NANDA is captured in Nursing Practice and the Organization or Group That Approved the Language The extent to which NANDA International would be captured would probably be in making diagnoses in nursing practice. A diagnosis according to NANDA-I is a clinical judgment about an individual, family, or community response to a potential health problem/life process. Nursing diagnosis provides the basis for the choosing of nursing interventions to achieve outcomes for which the nurse is accountable. It contains an approved framework known as “NANDA Classifications” which are used by nurses when making diagnoses in such a way that they can be understood by other nurses, medical practitioners and other in members of the healthcare team. NANDA enhances implementation of the second step in the nursing process. Through NANDA, care becomes patient focused rather than more of medicine or nursing focused. It also ensures continuity care and treatment in case of transfers to different facilities. NANDA-I is used together with Nursing Interventions Classifications (NIC) and Nursing Outcomes Classification (NOC) to describe nursing judgments, treatments, and nursing-sensitive patient outcomes (Kim, 2010). They are commonly known as the NNN classifications. Another way in which NANDA-I has been integrated in nursing practice is in the enhancement of the electronic health record system ((Bernhart-Just, Lassen & Schwendimann, 2010). In Zurich, the data model (DAPEP (1) data model) developed on behalf of the Nursing Service Commission uses the Nanda nursing diagnoses, the NOC and the NIC (NNN classifications). It enables a form of procedure where the nurses can trace the diagnoses, outcomes and interventions to a specific patient. NANDA-I has therefore been implemented extensively in nursing practice. NANDA-I has been approved by the American Nurses Association (ANA), which continues to develop and perform amendments on the standardized language. ANA has several committees: the Committee for Nursing Practice Information Infrastructure (CNPPII), which recognizes standard languages and the Nursing Evaluation and Data Set Evaluation Center (NIDSEC) evaluates implementation of terminologies by merchants. Methods Used to Ensure Appropriate Implementation and Terminology Consistent Usage In order for terminologies to fulfill their objectives, they have to be used. Owing to the fact that they continue to evolve, they in turn become more and more complex (Cowen & Moorhead, 2011). This sometimes makes it quite a task to implement them. It is evident that some nurses don’t understand the use of standardized language. It would, therefore, be very helpful to come up with ways of ensuring appropriate implementation and use of terminologies. The health facilities should offer education and training to their staff on the terminologies they intend to use. This can be done through reviewing cases in order to develop their skill to diagnose. When recruiting and selecting staff for the facility, they should be gauged on their diagnostic capability and also on their knowledge of terminologies. This would in turn ensure that there is continued and correct use of terminologies (Cowen & Moorhead, 2011). The facility heads and trainers should ensure that they ensure continued practice of the terminologies used in the facility by the nurses (Cowen & Moorhead, 2011). This results in more competent nurses in using terminologies. Administrators should be taught to track data to show what nurses do and their impact on patient outcomes. On doing that, they should regularly share data with the nurses and other medical staff to show the impact of nursing care, using standardized national language, on clinical results. Facilities should formulate shareable models of terminology to match with their standardized terminologies. These models may include archetypes, templates, care information models, clinical statements and detailed clinical models. When these models are used together with nursing terminologies, the terminologies become less complex, clearer and shareable since they are easier to understand (Cowen & Moorhead, 2011). Nursing Language and Its Support in Data Collection for Meaningful use. How Outcomes are measured or used in Advance Nursing Practice. The Electronic Health System is used to record data such as diagnoses, outcomes and interventions through electronic documentation (ED) and electronic health records (Bernhart-Just, Lassen & Schwendimann, 2010). Nursing language and terminologies led to the need for an electronic record keeping system where information could easily be shared. Data is collected from the patient through assessment; then diagnosis and finally together with outcomes and interventions, the information about the person is fed into the computer. Collection of this data ensures proper filing and record keeping (Bernhart-Just, Lassen & Schwendimann, 2010). It also enables following up of the situation of each patient effectively. Data stored in a standardized nursing language can make possible construction of large local, state and national data records that can be used for benchmarking with other hospitals. The electronic health system has therefore been prompted by collection of data and need to share data. Through it, operations in nursing practice have been made very proficient. The data collected could later be used to improve healthcare through research, expand knowledge about diseases and treatment and to produce quality metrics (Griffiths & Bridges, 2010). The American Nurses Association’s National Center for Nursing Quality keeps a database, started in the 1990s called the National Database of Nursing Quality Indicators (NDNQI), which collects nurse-sensitive and unit-specific indicators from various health organizations and later compares this data with organizations of similar size. Feedback is then sent to the participating organizations, thus enhancing longitudinal benchmarking (Bernhart-Just, Lassen & Schwendimann, 2010). The NOC system also measures outcomes on a numerical rating scale thus facilitating benchmarking of nursing practices across facilities and countries. Advanced practice nurses use outcomes to measure the effectiveness of diagnoses, to improve following outcomes, prevent worsening of existing conditions and to reduce costs as compared to usual nursing care (Griffiths & Bridges, 2010). Benefits and Barriers to Using Standardized Nursing Terminology and What Makes This Use Beneficial or What Prevents the use of a Terminology Without standardized nursing terminology, it would be difficult to exchange information between different medical practitioners and nurses. This would result in a lack of understanding. Standardized terminologies, therefore, provide a leeway for efficient communication and understanding since the terminologies are known to all, computability, term formulation, synchronization, and assimilation. Standardized nursing terminologies could also be used as a basis for measuring the competency of nurses. The nursing systems and terminologies used can be used as a tool to assess whether its nursing staff is competent as they are required to show their competence for the Joint Commission. They also ensure enhanced data collection to evaluate nursing care outcomes, improve patient care, and increased visibility of nursing interventions. The knowledge of standardized language can form a base for education of future nurses. For example, teaching students to use CCC and Omaha system while in community health fields and NANDA-I, NIC and NOC terminologies when in a sensitive care setting. Some of the barriers to effective use of nursing terminologies are that due to constant evolution of nursing terminologies, they may become so complex that nurses find it difficult to use (Conrad et al., 2012). Another barrier is that terminologies may face rejection due to their lack of flexibility, that is, they cannot be changed to suit a particular facility since they have to be approved by the American Nurses Association (Conrad et al., 2012). Some of the education policies made do not favor an implementation of standard language in teaching. This is a major barrier (Conrad et al., 2012). Should There Be a Standard For Nursing Language? A standard for nursing language is very important in nursing practice as seen in the essay. It is thus critical to have a standard language. Prior to standardization of nursing language, it was very difficult communicating with nurses and involved practitioners in the medical field. Information shared could not be understood easily by the end user. Medical inferences were therefore made based on unclear foundations. Any nurse would agree that NANDA-I, NIC, and NOC have helped them greatly in making accurate diagnoses, enhanced outcomes and interventions (Thoroddsen, Ehnfors & Ehrenberg, 2010). This has therefore contributed positively to their competency. Standardized language has solved all these issues and improved overall efficiency in nursing practice. References About NANDA International, Inc. (n.d.). Retrieved from http://www.nanda.org/about-nanda-international.html Conrad, D., Hanson, P., Hasenau, S., & Stocker-Schneider, J. (2012). Identifying the barriers to use of standardized nursing language in the electronic health record by the ambulatory care nurse practitioner. Journal Of The American Academy Of Nurse Practitioners, 24(7), 443-451. Cowen, P., & Moorhead, S. (2011). Current issues in nursing. St. Louis, Mo.: Mosby Elsevier. Griffiths, P., & Bridges, J. (2010). Nursing research methods. Los Angeles: Sage. Nursing Nomenclature and Classification System Development, (n.d.). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol31998/No2Sept1998/NomenclatureandClassification.html Thoroddsen, A., Ehnfors, M., & Ehrenberg, A. (2010). Nursing specialty knowledge as expressed by standardized nursing languages. International Journal of Nursing Terminologies and Classifications, 21(2), 69-79. Kim, J. K. (2010). A study on nursing diagnoses, interventions, outcomes frequently used and linkage to NANDA-NOC-NIC in major nursing departments. Journal of Korean Academy of Nursing Administration, 16(2), 121-142. Bernhart-Just, A., Lassen, B., & Schwendimann, R. (2010). Representing the nursing process with nursing terminologies in electronic medical record systems: a Swiss approach. Computers Informatics Nursing, 28(6), 345-352. Speksnijder, H. T., Mank, A. P., & van Achterberg, T. (2011). Nursing Diagnoses (NANDA‐I) in Hematology–Oncology: A Delphi‐Study. International Journal of Nursing Terminologies and Classifications, 22(2), 77-91. Read More