Today, standardized nursing language is widely used in the documentation of nursing care in hospital settings and home healthcare services. Rutherford (2008) claims that “it is impossible for medicine, nursing, or any health care-related discipline to implement the use of electronic documentation without having a standardized language or vocabulary to describe key components of the care process” (p. 1). Thus, the comprehension of the concept is crucial since many practicing nurses focus their efforts on processing and documentation of clinical data without a complete understanding of the instruments behind their work.
It might be important to review different definitions of standardized nursing language in order to observe its distinct features and applications. According to Keenan (1999), standardized nursing language is a “common language, readily understood by all nurses, to describe care” (as cited in Rutherford, 2008, p. 2). The Association of Perioperative Registered Nurses (AORN) explains that a standardized language “provides nurses with a common means of communication” (as cited in Rutherford, 2008, p. 2). McCloskey and Bulechek (1992) highlight the value of a common standardized language and its role in helping the medical professionals “to determine which nursing interventions work best for a given population” (as cited in Houston et al., 2019, p. 26). Hence, the definitions state that nurses need common terminology for successful documentation of patient data (i.e., exams, procedures, and outcomes), which helps them identify the best treatment strategy for each patient.
The implementation of standardized terminologies in nursing practice has a number of benefits. Firstly, McGonigle & Mastrian (2017) suggest that a standardized language allows nurses and healthcare delivery systems to “capture, codify, retrieve, and analyze the impact of nursing care on client outcomes” (p. 112). For instance, improved collection of patient documentation such as laboratory testing, physical exams, and interventions, allows a healthcare provider to explicitly demonstrate the impact of nursing care on the outcomes of former and current patients, and assess nursing competency. Secondly, the resources retrieved by nurses might enhance the quality of patient care and outcomes. The database stored and updated in the point-of-care application may be helpful for further diagnostics and treatment of patients with similar symptoms or conditions. Consequently, an elderly male patient with diabetes may be properly diagnosed with renal failure based on the symptoms of some other patient of his age with a similar condition.
Thirdly, a standardized language improves communication among nurses and other medical professionals both nationally and internationally. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) serves as a common language for a variety of mental disorders (Rutherford, 2008). Thus, when a doctor records or codifies the diagnosis of PTSD, other healthcare specialists or third-party members will be able to understand the diagnosis. Finally, a standardized nursing language assures adherence to the standards of care for a given patient. For example, the standards from the Association of Women’s Health, Obstetric and Neonatal Nurses might provide valuable guidance for nurses and other healthcare professionals who specialize in fetal monitoring.
The most prominent challenge associated with standardized nursing terminology is the lack of one universal nursing language. The development of such language is the ultimate goal of nursing informatics. A standardized nursing language, as stated in the guidelines by the Duke University School of Nursing, should “facilitate communication among nurses, be complete and concise, facilitate comparisons across settings and locales, support the visibility of nursing, and evaluate the effectiveness of nursing care through the measurement of nursing outcomes” (Rutherford, 2008, p. 2–3). Therefore, the international community of nursing informaticians might be able to create a future universal language based on the guidelines mentioned above.
References
Houston, S. M., Dieckhaus, T., Kirchner, B., & Lardner, M. C. (Eds.). (2019). An introduction to nursing informatics: Evolution and innovation (2nd ed.). CRC Press.
McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Jones & Bartlett Learning.
Rutherford, M. A. (2008). Standardized nursing language: What does it mean for nursing practice? Online Journal of Issues in Nursing, 10(1), 1–12. Web.