Standardized Nursing Terminologies play an integral role in defining and describing nursing care. They offer the concept and clear definitions of nursing, phenomena of nursing and ensuring that nursing care is enhanced to adopt the same terminology when it comes to describing patient challenges, patient outcomes, and nursing interventions in different settings both internationally and nationally. However, the standardized nursing terminologies enhance the development of the middle range theories as a result of the nursing diagnoses.
Responding to the great need to offer support to complex and diverse information requirements, nursing has come up with various terminology systems. The two-major type of systems that have been developed include the combinatorial and enumerative systems, even though some of the systems are sharing characteristics of both the approaches. The difference is experienced in the content and the structure of the terminology systems, while important at a local level when it comes to preventing effective broader communication, integration of the systems records, and comparison of healthcare information that pertains to nursing at an international level. In most cases, formal nursing terminology has played a significant role in presenting an alternative approach (Thede & Schwirian, 2014).Relating to other health care professionals, nurses need different information when it comes to carrying out their work. Such information includes one used for making decisions, communicating with others, information for making of new knowledge through finding out more about other information and for aggregation purpose. Technically most of the information used is generated traditionally and adopted by nurses, and it takes a form of a natural language for example through handwriting and speech. On the other, the adoption of electronic record system has also been significant, and the only challenge that has been rising is how to this information can be recorded to accurately show the reflection of nursing phenomena and the general nursing experiences (Tang & McDonald, 2006). Being that natural language has made clinical information to be mostly available; it has been hugely inaccessible to most system applications that regularly manipulate the represented clinical information symbolically. For such system applications data that are encoded are needed to ensure that data structures and terminology systems are standardized (Thede & Schwirian, 2014).
Since the period of 1990s terminology system has been existing for a great period, with a different number of factors conspiring to offer good environment when it comes to the development of nursing terminology systems. Some of the development of nursing terminology system includes enumerative systems where many terminologies that are used being presented as the restricted user or even indexed set of phrases the pre-coordinated in a terminological manner with the arrangement made based on hierarchy or alphabetical manner. The nature of such terminology systems is enumerated, and they include the Nursing Interventions of Classification (NIC) and North American Nursing Diagnosis Association Taxonomy(NANDA) (Hardiker et al.2002).
NANDA is recognized as one major example of an enumerative terminology system that plays important role in nursing diagnoses. A nursing diagnosis that represents a clinical judgment about health issues and clients response is recognized with NANDA. The existing version entails one hundred and fifty-five nursing diagnoses with each of the diagnoses possessing the label of a phrase is pre-coordinated for example the ineffective individual coping. A definition that is encoded in a natural language rather a representation of relationships and concept that is more formal relationships that define risk factors, characteristics and other factors that are related. Ideally, every diagnosis of nursing is located within a structure that is simply organized entailing a nine human response patterns (Hardiker, 2011).Comparatively, NIC is also recognized as another example of enumerative terminology system that has a major focus on nursing intervention. Majorly NIC has its main focus on nursing interventions, and within NIC the nursing intervention represents one the treatment that is focused on the clinical judgment which shows that a nurse is performing to create enhancement to the results. Ideally, the existing version of NIC entails four hundred and eighty-six nursing interventions with every nursing intervention having a label when it comes to an informal definition. Additionally, it involves various activities that are listed with the activities describing what a nurse is doing when it comes to the implementation of the intervention and a short list of background readings. Notably, the common element that NANDA is sharing with NIC is that the allocation of each intervention is recognized within a simple taxonomy and in this case, it consists of thirty domains and seven classes (Tang & McDonald, 2006).
Focusing on the combinatorial systems, other different nursing terminology systems adopt the combinatorial approach. In this case, we recognize the complicated terminological phrases that may be developed from the elementary concepts. NANDA phrase is one of the nursing terminologies that can be represented in the combined concept that include three major elements such as the individual from the client set of concept, ineffective from the set of judgment concepts and copying from human response concept set. To add on top, some of the additional combinatorial terminology systems include the Home Health Care Classification System (HHCC), the Omaha System and the Home Health Care Classification system (HHCC) (Rutherford, 2008).
Ideally, during the phase of assessment nurses make use of the systematic and dynamic way to analyze and collect the data of a patient. Nurses, in this case, participate in the selection through the use of NANDA one of the I terminology which is based on patients potential and actual needs and conditions. Based on the patients diagnosis and the desirable goals, the patient and nurses set desirable and achievable goals. On the other hand, the nursing care is documented and adopted by the use of NIC interventions during the hospitalization. Through the two terminologies, the outcome of care is measured by comparison of the status of the patient as part of the phase of the evaluation process. The taxonomies with codes are capable of storing, capturing, transporting and retrieving of nursing care data into electronic health records and the accumulated data from the linkage between the two terminologies end up becoming information which are has great meaning, and information that later turn into knowledge when the data relationships between information and data are formalized with the knowledge supporting decision making of nurses (Hardiker, 2011).
Currently, there are two hundred and two diagnoses in NANDA and five hundred and forty-two interventions in NIC that have with time refined and developed with systematic processes. On the other hand, during the nursing process, critical thinking skills are important for nurses to ensure the selection of accurate nursing interventions, diagnoses, and results using the nursing terminologies based on the situation of the patient.
In the current health set up, there have been increasing demands for detailed, accessible record keeping system and health care information to both patients and providers that make information available a cross support quality measurement and the continuum of care. Ideally, the obstacle to identifying the advantages of documentation including different un standardized formatting, inaccessible documentation, and differing terminologies. Making essential tools available is significant when it comes to making sure that the quality of care, safety and continuity are supported across various handovers between the different providers that are involved in a patients care (Tang & McDonald, 2006).
The general requirement when it comes to internal control, quality patient care, cost containment, efficiency and made it all significant to bring out the knowledge of nursing in a meaningful manner that can make sharing quite easy across the care settings and disciplines. Standardizing the knowledge of nursing is one of the significant ways that can facilitate communication among nurses and between the providers of health care, improved patient care, comprehension of nursing interventions, enhanced data collection and evaluation of care. Standard nursing language provides allowance and enables continuous analysis and document retrieval over time and across the care settings to support evidence based practice, improve quality and to bring out the desired results (Hegney et al. 2007).
Technically, the argument that has been raised is that Nursing Minimal Data Sets (NMDSs) has a serious advantage more so to the nursing profession. Focusing on most countries in the world, though the NMDSs possess different features in common, in most cases, they share the difference in developmental stages, content, purpose, collection approach and collection approach as well. What is amazing is that although the different systematic collection of data that is relating to health care exists globally, the challenge of data absenteeism still exists from these systems and for the solution to be identified, NMD can be adopted when it comes to delivering nursing care visible. Some of the NMDS includes the particular dimension of nursing which can fulfill the information need of many users (Tang & McDonald, 2006). There exists the high need for codification since standardized nursing terminologies are in the broad spectrum used in EHRs and there has been increasing utilization in the various settings. NIC and NANDA shows a representation of nursing information, data, and knowledge that has the capability of being stored in the clinical system to ensure easy reuse by the nurses.
Hardiker, N. R. (2011). Developing standardized terminologies to support nursing practice.
Hardiker, N. R., Bakken, S., Casey, A., & Hoy, D. (2002). Formal nursing terminology systems: a means to an end. Journal of biomedical informatics, 35(5), 298-305.
Hegney, D., Buikstra, E., Eley, R., Fallon, A. B., Gilmore, V., & Soar, J. (2007). Nurses and information technology.
Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice. OJIN: The Online Journal of Issues in Nursing, 13(1), 243-50.
Tang, P. C., & McDonald, C. J. (2006). Electronic health record systems. Biomedical informatics, 447-475.
Thede, L., & Schwirian, P. (2014). Informatics: The Standardized Nursing Terminologies: A National Survey of Nurses Experience and AttitudesSURVEY II: Participants Perception of the Helpfulness of Standardized Nursing Terminologies in Clinical Care. OJIN: The Online Journal of Issues in Nursing, 20(1).
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