Toward standardized nursing terminology: the next steps.Abstract
The use of a standardized nursing language along with advances in information technology can enhance nursing efficiency, accuracy and effectiveness, and can significantly improve patient care. However, the consistent use of a standardized nursing terminology is still minimal in both the clinical and nursing academic settings. Important steps must be taken to overcome the barriers to universal acceptance and use of standardized nursing terminology. Successful implementation of standardized nursing terminology will provide nursing visibility to other healthcare professionals, to consumers, and to healthcare policy makers, and most importantly, will promote best nursing practice.
The use of standardized nursing terminology has been shown to increase the quality of patient assessment, to promote consistent documentation of nursing practice and to provide the framework for qualitative improvements to patient care (M[u..]ller-Staub, Needham, Odenbreit, Lavin, & Van Achterberg, 2007). The need for a standardized terminology has long been recognized, but the use of standardized nursing terminology within healthcare computer applications is still minimal (Saba, 2007). The implementation of a standardized nursing terminology and its incorporation into the electronic medical record (EMR) can transform the profession by:
* Describing the care delivered by nurses in a variety of settings.
* Enabling the comparison of nursing data across clinical populations, settings, geographical areas and time.
* Facilitating communication among nursing and other healthcare professionals.
* Providing easy access to evidence-based knowledge stored in national and international databases.
* Allowing measurement of the impact of nursing interventions in relation to patient outcomes.
Recently, Smith and Smith (2007) described several examples in which the implementation of a standardized nursing terminology made a significant impact on patient outcomes. The study found that the use of standardized nursing terminology incorporated into the electronic nursing care plan supplies the necessary tools to effectively disseminate evidence-based protocols, to list pertinent nursing interventions and to provide consistent methods to track patient outcomes. The study showed nurse-driven care supported by a standardized nursing terminology decreased the number of average ventilation days for all ventilator-associated pneumonia patients from fourteen to ten days. Furthermore, the study showed a decrease in the number of ventilator-associated pneumonia from orally colonized types of pathogens (pseudomonas, acinetobacter or klebsiella) from fifty-five to zero.
Unfortunately, the implementation of a standardized nursing language is not easy. According to one survey (Stocker, 2001) the most common barriers to the use of standardized nursing terminology are lack of understanding of what it is, and the lack of recognition of its importance. Other barriers mentioned in the study are the difficulties in learning up to thirteen different nursing terminologies and the lack of education about nursing terminologies in the nursing academic curricula (Figure 1).
The following steps can encourage universal acceptance and implementation of standardized nursing terminologies:
Step 1: Nursing terminologies must adhere to better ontology principles.
Current nursing terminology sets must be reviewed to ensure they adhere to consistent clinical terminology principles. These principles will establish a strong foundation and provide the tools to better manage the terminology, to accurately incorporate updates and to support data analysis and mapping projects.
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According to James Cimino (1998), components of a well-functioning medical terminology include:
* A single, coherent meaning for each concept in the vocabulary.
* Permanence of each concept even if it becomes inactive, and retention of its meaning within the vocabulary.
* A unique identifier for each concept free of hierarchical or other implicit meaning.
* Formal, explicit and reproducible methods to provide gap recognition, to perform content updates and to allow the addition of new concepts.
Nursing terminology sets must be examined for good practices such as the management of new concepts and the retirement of duplicate or erroneous concepts.
The nursing profession must stop inventing new terminologies. Instead, current nursing terminologies must grow to encompass all specialty nursing practices, such as recovery room and endoscopy nursing, and expand to include languages, cultures and nursing practices from around the world.
Step 2: Mapping efforts between nursing terminologies as well as with other healthcare terminologies must continue.
The American Nurses Association officially recognizes thirteen data element sets and terminologies that support nursing practice (American Nurses Association, 2006) (Table 1). Because nursing data cannot be compared and analyzed if different hospitals and institutions use different terminologies, mappings between nursing terminologies can provide links between disparate sets (Figure 2).
Communication among healthcare professionals can also be strengthened with mappings between different healthcare terminologies. For example, a patient might forget to mention to the nurse a history of venous thrombosis. The physician, being familiar with the patient's history, documents this history in the EMR. The EMR links the physician's notes to the SNOMED CT concept (H/O: thrombosis) or an ICD-9-CM concept (personal history of venous thrombosis and embolism). If there is a mapping between nursing terminologies and these terminologies, an EMR decision support system can trigger an alert so that the nurse is aware of the nursing observations and interventions relevant to thrombosis. Without such mapping, the nurse might not become aware of the history and patient care could be compromised.
All mapping projects must develop guidelines and rules that respect the conventions of each terminology in order to preserve the granularity and flexibility of both terminology sets (Giannangelo and Berkowitz, 2005). Each mapping project will also require ongoing maintenance to incorporate updates, to review mappings when concepts are revised and to create new mappings when new concepts are added or retired. Step 3: Nursing terminology education must be required for all nurses in both academic and clinical settings.
Education can emphasize the importance of adopting a standardized nursing terminology and teach the necessary skills for its successful implementation. Nurse educators themselves must be educated about nursing terminologies and must be responsible for integration of standardized nursing terminology into the nursing curricula. In addition, they must mentor students on incorporating terminology in the patient's plan of care and encourage the use of standardized nursing terminology by all nurses in the patient care setting.
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Of course, it is insufficient to implement standardized nursing terminology only in academic nursing curricula. Continuing education in and practical use of standardized nursing terminology must also occur for all nurses in the clinical setting. If students discover that standardized nursing terminologies are not used in everyday nursing practice, knowledge acquired and enthusiasm generated in school will quickly dissipate. Terminology education in both academic and clinical settings will help overcome many of the current barriers surrounding the use of a standardized nursing terminology.
Step 4: Nursing informaticists must provide the leadership for incorporating standardized nursing terminology into everyday nursing practice.
Everyday use of standardized nursing terminology in the clinical setting will require a change in nursing attitude, and strong leaders will be needed to champion this change. Change does not occur simply through the appearance of a new idea but through the commitment of practitioners to change the current culture (Rogers, 1995). Nurse informaticists must rally to become an important force and to teach and advocate standardized nursing terminology as the foundation for nursing practice documentation.
The use of a standardized nursing language along with advances in information technology can enhance nursing efficiency, accuracy and effectiveness, and can significantly improve patient care. Use of standardized nursing terminology supports evidence-based practice improvement and provides the right information, at the right time, in the right context at the point of care. The value standardized nursing terminology provides to the nursing profession is nursing visibility to other healthcare professionals, to consumers and to healthcare policy makers.Most importantly, consistent use of standardized nursing terminology across healthcare systems will promote best nursing practice.
American Nurses Association. (2006, May 11). ANA Recognized Terminologies and Data Element Sets. Retrieved September 9, 2008, from http://www.nursingworld.org/npii/terminologies.htm
Cimino, J. J. (1998). Desiderata for controlled medical vocabularies in the twenty-first century. Methods of Information in Medicine, 37 (4-5), 394-403.
Giannangela, K., & Berkowitz, L. (2005). SNOMED CT helps drive EHR success. Journal of American Health Information Management Association, 76 (4), 66-67.
Muller-Staub, M., Needham, I., Odenbreit, M., Lavin, M.A., & VanAchterberg, T. (2007). Improved quality of nursing documentation: Results of a nursing diagnoses, interventions, and outcomes implementation study. International Journal of Nursing Terminologies and Classifications, 18 (1), 5-17.
Rogers, E. M. (1995). Diffusion of Innovations (4th Edition). New York: The Free Press. Saba, V. K. (2007). Moving past theory: Use of a standardized, coded nursing terminology to enhance nursing visibility. Computers, Informatics, Nursing, 25 (6), 324-331.
Smith, V. & Smith, K. (March 28, 2007). Supporting evidence-based practice through the use of standardized nursing language. HIMSS webinar.
Stocker, Julia (2001). Forces surrounding the use of standardized nursing language.Michigan Nurse, 74 (10), 13.
ANIA CARING 2009 Annual Conference Preconference April 23, 2009 Conference April 24-25, 2009 * Las Vegas Hilton Planning is now underway for another action packed, informatics intensive conference in Las Vegas, Nevada! CALL FOR ABSTRACT & POSTER SUBMISSIONS
Four educational tracks will be concentrated around the theme: "Raising the Stakes for Nursing Informatics."
* Paper and Presentation topics are encouraged to address any of the following educational tracks to include:
1. Leadership and Governance
2. Education and Career Development
3. Implementation Methodology
4. Evaluation and Outcomes
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By Barbara J. Kripps, RN, BSN, MS
Barbara Kripps, is a Clinical Content Analyst for Health Language Inc (HLI). HLI is a worldwide leader in the development, delivery and marketing of software that reduces the complexity of incorporating medical vocabulary and coding standards into healthcare information technology (HCIT) applications. Ms. Kripps is engaged in custom mapping projects, standardized terminology code and classification updates, as well as creation of content offerings to make administrative codes more understandable to the consumer. Ms. Kripps has previously worked for Thomson Micromedex and has extensive knowledge of mapping drug data to SNOMED CT as well as LOINC. Ms. Kripps is a registered nurse with over 20 years clinical nursing experience in the perioperative setting at a variety of institutes, including University of Wisconsin-Eau Claire and obtained her Masters of Science in Nursing Informatics from the University of Colorado.University of Colorado Hospitals and Sharp Memorial Hospital. She has a Bachelor of Science in Nursing from the University of Wisconsin-Eau Claire and obtained her Masters of Science in Nursing Informatics from the University of Colorado.
Table 1: Data Element Sets and Terminologies Data Element Sets 1. NMDS Nursing Minimum Data Set 2. NMMDS Nursing Management Minimum Data Set Terminologies 3. CCC Clinical Care Classification 4. ICNP[R] International Classification of Nursing Practice 5. NANDA NANDA International 6. NIC Nursing Intervention Classification 7. NOC Nursing Outcome Classification 8. Omaha System Omaha System 9. PNDS Perioperative Nursing Data Set 10. ABCCodes ABC Codes 11. LOINC Logical Observation Identifiers Names and Codes 12. SNOMED CT Systematic Nomenclature of Medicine Clinical Terms 13. PCDS Patient Care Data Set (Retired)