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?
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.
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.
Background: Nursing has always faced two significant challenges: (a) how to distinguish nursing’s contributions to patient care from those of medicine; and (b) how to incorporate descriptions of nursing care into the health record in a way that is commensurate with its importance to patients’ well-being.
As the development of the Electronic Health Record (EHR) and the Nationwide Health Information Network (NHIN), both of which rely on the EHR, accelerates, these issues become even more pressing.
Nursing’s contribution to patient care must be identified, and the optimum strategy to include parts of nursing care into the EHR must be determined.
Fortunately, the solution is already in place; it is found in the application of standardized nursing terminologies (SNTs).
The adoption of standardized terminology that reflect the uniqueness of nursing care is required to capture nursing’s independent contributions.
The professional languages used and understood within and between both professions are a major factor in distinguishing between the goals and practices of nursing and medicine.
The following are some of the advantages of using standardized nursing terminologies: (a) improved communication between nurses and other healthcare providers, (b) increased visibility of nursing interventions, (c) improved patient care, (d) improved data collection to evaluate nursing care outcomes, (e) greater adherence to standards of care, and (f) facilitation of nursing competency assessment.