Academic journal article Online Journal of Issues in Nursing

Standardized Nursing Language: What Does It Mean for Nursing Practice?

Academic journal article Online Journal of Issues in Nursing

Standardized Nursing Language: What Does It Mean for Nursing Practice?

Article excerpt

Abstract

Use of a standardized nursing language for documentation of nursing care is vital both to the nursing profession and to the bedside/direct care nurse. The purpose of this article is to provide examples of the usefulness of standardized languages to direct care/bedside nurses. Currently, the American Nurses Association has approved thirteen standardized languages that support nursing practice, only ten of which are considered languages specific to nursing care. The purpose of this article is to offer a definition of standardized language in nursing, to describe how standardized nursing languages are applied in the clinical setting, and to explain the benefits of standardizing nursing languages. These benefits include: better communication among nurses and other health care providers, increased visibility of nursing interventions, improved patient care, enhanced data collection to evaluate nursing care outcomes, greater adherence to standards of care, and facilitated assessment of nursing competency. Implications of standardized language for nursing education, research, and administration are also presented.

Key words: communication, North American Nursing Diagnosis Association (NANDA), Nursing Intervention Classification (NIC), Nursing Outcome Classification (NOC), nursing judgments, patient care, quality care, standardized nursing language

Citation: Rutherford, M., (Jan. 31, 2008) "Standardized Nursing Language: What Does It Mean for Nursing Practice? "OJIN: The Online Journal of Issues in Nursing. Vol. 13 No. 1. Available: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/StandardizedNursingLanguage.aspx

Recently a visit was made by the author to the labor and delivery unit of a local community hospital to observe the nurses' recent implementation of the Nursing Intervention Classification (NIC) (McCloskey-Dochterman & Bulechek, 2004) and the Nursing Outcome Classification (NOC) (Moorehead, Johnson, & Maas, 2004) systems for nursing care documentation within their electronic health care records system. ...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.During the conversation, one nurse made a statement that was somewhat alarming, saying, "We document our care using standardized nursing languages but we don't fully understand why we do." The statement led the author to wonder how many practicing nurses might benefit from an article explaining how standardized nursing languages will improve patient care and play an important role in building a body of evidence-based outcomes for nursing.

Most articles in the nursing literature that reference standardized nursing languages are related to research or are scholarly discussions addressing the fine points surrounding the development or evaluation of these languages. Although the value of a specific, standardized nursing language may be addressed, there often is limited, in-depth discussion about the application to nursing practice.

Practicing nurses need to know why it is important to document care using standardized nursing languages, especially as more and more organizations are moving to electronic documentation (ED) and the use of electronic health records. In fact, it is impossible for medicine, nursing, or any health care-related discipline to implement the use of ED without having a standardized language or vocabulary to describe key components of the care process. It is important to understand the many ways in which utilization of nursing languages will provide benefits to nursing practice and patient outcomes.

Norma Lang has stated, "If we cannot name it, we cannot control it, practice it, teach it, finance it, or put it into public policy" (Clark & Lang, 1992, p. …

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