Standardized Nursing Terminologies in Nursing Practice Essay

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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.Standardized Nursing Terminologies in Nursing Practice Essay

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.

Required Readings
McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones & Bartlett Learning.
• Chapter 25, “The Art of Caring in Technology-Laden Environments” (pp. 525–535)
• Chapter 26, “Nursing Informatics and the Foundation of Knowledge” (pp. 537–551)Standardized Nursing Terminologies in Nursing Practice Essay

American Nurses Association. (2018). Inclusion of recognized terminologies supporting nursing practice within electronic health records and other health information technology solutions. Retrieved from

Macieria, T. G. R., Smith, M. B., Davis, N., Yao, Y., Wilkie, D. J., Lopez, K. D., & Keenan, G. (2017). Evidence of progress in making nursing practice visible using standardized nursing data: A systematic review. AMIA Annual Symposium Proceedings, 2017, 1205–1214. Retrieved from

Office of the National Coordinator for Health Information Technology. (2017). Standard nursing terminologies: A landscape analysis. Retrieved from

Rutherford, M. A. (2008). Standardized nursing language: What does it mean for nursing practice? Online Journal of Issues in Nursing, 13(1), 1–12. doi:10.3912/OJIN.Vol13No01PPT05. Standardized Nursing Terminologies in Nursing Practice Essay
Note: You will access this article from the Walden Library databases.

Thew, J. (2016, April 19). Big data means big potential, challenges for nurse execs. Retrieved from

Topaz, M. (2013). The hitchhiker’s guide to nursing theory: Using the Data-Knowledge-Information-Wisdom framework to guide informatics research. Online Journal of Nursing Informatics, 17(3).
Note: You will access this article from the Walden Library databases.
Wang, Y. Kung, L., & Byrd, T. A. (2018). Big data analytics: Understanding its capabilities and potential benefits for healthcare organizations. Technological Forecasting and Social Change, 126(1), 3–13. doi:10.1016/j.techfore.2015.12.019.
Note: You will access this article from the Walden Library databases

Nursing practitioners should be equipped with information regarding the importance of documenting care by use of standardized nursing languages, particularly because an increasing number of institutions are shifting to the electronic data recording and processing. It is difficult for healthcare professionals to implement the use of electronic documentation without the utilization of standardized terminologies to explain crucial sections of healthcare services. It is significant to comprehend several methods in which the use of standardized terminologies will offer benefits to the nursing profession and subsequently patient care. Processes need to be named first before they can be taught, financed or implemented into public guidelines hence the importance for the use of terminologies (Korda & Eldridge, 2011).Standardized Nursing Terminologies in Nursing Practice Essay

Standardized nursing terminologies ought to be appropriately explained so that the care practices are effectively communicated among nurses and other staff. This paper seeks to offer an in depth analysis of the utilization of the standardized language in the provision of care and evaluate the applications in the care service and illustrate the advantages of the linguistics. The standardized linguistics impacts different sectors such as training, research and general management. Presently, there are seven languages available for nursing profession recognized by the American Nurses Association (Jones, Schilling & Pesut, 2011). Some of them include: the Omaha System, the Nursing Interventions Classification and Nursing Outcomes Classification. This research will pay attention to two languages, Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC). NIC is available in the fourth edition (Cruz, Bonfim, Gaidzinski, Fugulin & Laus, 2014). The most recent NOC edition is the third edition. The above languages are applied in multiple setups.

The utilization of standard terminologies has enhanced the level of patient care services. According to the study conducted by the National Association of School Nurses this happens in order to derive their perception of the common abdominal pain symptoms. NOC and NIC were used to predict the treatment of children and its possible results after exempting acute abdominal conditions. The major complaints, common causes, common management practices from the NIC were pointed out. The main symptoms were nausea, headache and vomiting; pain description was mild or moderate and the most common causes were psychosocial, viral syndromes and association with menstruation. Psychosocial problems were test anxiety, withdraw anxiety and relationship problems.Standardized Nursing Terminologies in Nursing Practice Essay  Poor diet was for the cause of a massive number of complaints. The chief pain management practices from NIC were observing pain signs, carrying out complete pain tests regarding the site, features, a period of time, quality and severity, and decreasing or eradication of elements that increase pain, such as fear and ignorance (Jensen, Johnson, Gertz, Galer & Gammaitoni, 2013).

The survey demonstrated a reduction in complaints, according to the NOC severity indicators after management. Symptom intensity reduced by 6.25%, symptom duration reduced by 4.69 and symptom occurrence reduced by 6.25% and the related pain reduced by 41.06%. The survey is a source of evidence that particular nursing interventions promote patient outcomes.Standardized Nursing Terminologies in Nursing Practice Essay

Additionally, the languages have been associated with the degree of compliance with the standards of patient care. NIC and NOC depend on the input of nursing practitioners and the standards of care for different professional institutions. An illustration is that of NIC intervention in electronic fetal assessment which is supported by scientists of fetal assessment and by Standards of care bodies connected with women health and Neonatal nurses (Cruz, Bonfim, Gaidzinski, Fugulin & Laus, 2014). The initial practice in intrapartum is the assessment of maternal and fetal heart rates prior to monitoring, which is considered to be a crucial standard for intrapartum. When the heart rates are assessed, the fetal and maternal rates should be distinguished. Additionally, it is critical to determine the exact fetus position before placing the assessment transducer. The above example demonstrates how the significant standards are implemented by the NIC practices.
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The body that acknowledges the standardized terminologies, which develop the nursing activities, is the American Nurses Association. The body of ANA, known as the Nursing Information and Data Evaluation Center (NIDSEC), is tasked with the recognition and approval of the terminologies submitted (Pearson, 2011). The body evaluates the parts of the terminologies. The developers willingly submit the languages to NIDSEC in order to be approved. Approval means that the standardized terminology is in line with the nursing care and complies with the standards of the electronic documentation.Standardized Nursing Terminologies in Nursing Practice Essay

The procedure applied by ANA to analyze the language depends on the vocabulary used, how terms are linked, how it enables easy and fast storage and retrieval and how the level of security and privacy of documents are maintained. Approval is used for three years, after which a fresh application is submitted.

Standardized Nursing language is utilized in the recording nursing care, offering the consistency required for comparison of the level of outcomes for different nursing interventions. More institutions are shifting to digital documentation and digital recording. When the nursing practice information stored in the computers is in a standardized language, any kind of data can be developed that will enhance benchmarking with other institutions that offer nursing care. Patient outcomes are linked to the uniqueness of the person, the service offered and the surrounding. National Center for Nursing Quality maintains information for quality indicators. This enables the comparison of the data from different organizations of the same size. The practice also enhances longitudinal benchmarking. The NOC system results are nurse-related and the most recent NOC edition monitors the implication of nursing care on the patient, relatives and society at large (Pearson, 2011).Standardized Nursing Terminologies in Nursing Practice Essay

The benefits accrued to the utilization of Standardized Language are enhanced exchange of information among nursing practitioners and other care professionals, and the promotion of better patient care (Fasoli, Fincke & Haddock, 2011). Moreover, there is an improved information collection for care analysis results, better compliance to the levels of care, enhanced monitoring of competence and heightened clarity of nursing interventions. The benefits are achieved via the enhancement of interventions, treatment and practices such as observation decision making.Standardized Nursing Terminologies in Nursing Practice Essay

There is a challenge to the development of the standardized language that can be utilized by all nurses. The International Classification for Nursing Practice has been established in an effort to develop a common terminology. There is a massive terminology combination that encompasses vocabularies, classifications and local terminologies (Jansen, Molstad, Marek & Naess, 2011). The vast terminology combination slows down the development of the terminology.

Standardized Nursing Language should be available since the nursing practice has always been related to clinical assessments. Nurses require unique terminology to appropriately initiate and develop standards and determine the guidelines that dictate their line of duty (Fasoli, Fincke & Haddock, 2011). Nurses globally can exchange information with their colleagues, subsequently promoting care for clients worldwide. The language has a fundamental impact on nursing training, administration and research.Standardized Nursing Terminologies in Nursing Practice Essay

The NOC and NIC were initiated as complementary languages. They have connections to different nursing terminologies such as; Omaha System and NANDA. NOC and NIC are involved in the Systematized Nomenclature of Medicine’s, a multiple subject record system. NIC and NOC were translated into nine and seven foreign languages respectively. By utilizing a common standardized nursing language, nurses will be able to pass the critical duties they perform ensuring that the profession is visible. Enhanced communication will consequently promote the level of healthcare services extended to the patients around the world.Standardized Nursing Terminologies in Nursing Practice Essay


As a result of the introduction of computer technology and the combination of evidence-based practice in nursing; standardization of terminologies has become imperative in the classification of nursing diagnosis, interventions and expected outcomes. The most popular and successful systems are the North American Nursing Diagnosis Association International (NANDA-I), Nursing Outcomes Classification (NOC), and Nursing Intervention Classification (NIC) (de Lima Lopes, de Barros, & Marlene Michel, 2009). This paper aims to provide a brief outline of these standardized terminologies (STs) as they relate to a…show more content…
Nurses should take care to select the proper outcomes to ensure optimum care is provided to patients with CHF. The plan of care is dependent on the nursing diagnosis and the desired nurse-sensitive outcomes. The priority NOC outcome for the diagnosis of CHF is Fluid Balance and Fluid Overload Severity. Other related NOC outcomes are Knowledge: Cardiac Disease Management, Knowledge: Energy conservation, Knowledge: Medication, Knowledge: Prescribed Activity, Knowledge: Treatment, and Knowledge: Weight Management (Johnson et al., 2012). These are only a select few of the multiple outcomes available; care should be modified as the disease progresses through the problems which evolves over the lifetime of patients diagnoses with CHF. Once all these determinants are established, the nurse will be prepared to determine which level of NOC is essential to effectively manage the disease.Standardized Nursing Terminologies in Nursing Practice Essay

Standardizing Terminologies in Nursing

Nursing care planning is one of the most impacted areas by standardized nursing terminologies. The standardizing language in nursing here denotes the use of a common language that all nurses can understand in describing care (Rutherford, 2008). A survey conducted on nursing practitioners revealed a myriad of nursing functions including organizing care, interventions generation, and information retrieval on the same terms for many patients, planning care and generating appropriate outcomes as areas highly impacted on by standardized nursing terminologies (Walker, Cleondon & Nelson, 2015). However, as Rutherford (2008) reveals, some nurses are not aware of the need for these terminologies and exhibit ignorance on the critical roles that standardized nursing terminologies play in their practice. This paper delves into the importance of these terminologies as well as the benefits and challenges of implementing them in nursing practice.Standardized Nursing Terminologies in Nursing Practice Essay

Essence of standardizing language in nursing

Rutherford (2008) explores why the standardization of nursing language for documentation is crucial in healthcare and most significantly to the direct care nurses dealing with patients. By documenting planning of care and clinical outcomes in a nursing language that is standardized, nurses benefit the entire profession by contributing immensely towards the improving patient care and also contribute to the evidence-based outcomes that can be shared by all nurses (Rutherford, 2008).Standardized Nursing Terminologies in Nursing Practice Essay

In the era of electronic documentation of health records, peer sharing of information is critical in achieving the highest standards of care. Moreover, details about information across organizations that deal with patient care has been necessitated by the law (Balestra, 2017). The implementation of electronic documentation by any healthcare cannot happen without adopting standardized nursing care as EHR incorporate templates that describe the key components of nursing care. These records ought to be shared and read across all healthcare organizations making it a must for healthcare providers to adopt them (Rutherford, 2008).

Standardized nursing terminology use in nursing care is also crucial in aiding accurate communication of care among nurses and other healthcare providers. Nursing outcomes generated by one nursing practitioner adds to the evidence-based care that helps in easier diagnosis of issues and provision of care. As such, it is important that it is documented in such a manner that they are easy to understand and interpret by other nurses. Also, HIPAA mandates healthcare providers to share patients’ healthcare data needed in the provision of services by other players in the health sector (Olatubi et al., 2018). The use of standard nursing language, in such a case, makes it easier for the sharing of such information as the law dictates.Standardized Nursing Terminologies in Nursing Practice Essay

Benefits and challenges of Standardizing Terminologies in Nursing

First, standardizing terminologies in nursing improves patient care. For a population of surveyed members of the National Association of School Nurses, there was evidence of improved nursing outcomes and interventions for the nurses that adhered to NOC and NIC standards (Rutherford, 2008).

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Standardized nursing terminologies also facilitates in collection of data that is used in evaluating the quality of care outcomes. Standardizing language in nursing offers a consistent means of comparing the quality of care used under the various nursing interventions. Data repositories can also be established when data is stored in the EHR under the standardized nursing language to serve as a benchmarking tool for the profession of nursing (Rutherford, 2008).

It also through the contribution of standardizing language in nursing that has developed better improved engagement among nurses and with other professional in healthcare provision. The sharing of information to improve nursing outcomes as well as document evidence-based practice outcomes has become a vital part of nursing practice today. This is being aided by adopting a standardized nursing language that can be used by nursing from all over the world.Standardized Nursing Terminologies in Nursing Practice Essay

There is also an improved adherence to the standards of care. For instance, the use of NOC and NIC standardized nursing languages that are based on the inputs of the nurses and the standards of care from other professions in health care is reinforced by nurses that have adopted these languages (Rutherford, 2008).

It provides a framework to facilitate assessment of practitioners on account of their competency. Nursing interventions obtained from the standardized languages in nursing may equally be employed as the standard for assessing nurses’ competence in performing the given interventions

As revealed in Rutherford (2008), the ignorance among the nurses on the role that standardizing terminologies in nursing play while attending to patients is the main challenge. The lack of understanding and knowledge on how standard nursing language affects the outcomes in healthcare provision limits the level of exploitation of the benefits conferred by the system. Nurses that are not aware of the capabilities of standardizing terminologies in nursing in the documentation of nursing outcomes are less likely to adopt the use of systems that store health records electronically, which contribute to the overall slow intake of technology in healthcare (Shwiran & Thede, 2011).Standardized Nursing Terminologies in Nursing Practice Essay

In conclusion, standardized nursing technologies play a critical role in the documenting of nursing outcomes. This system is important in the implementation of EHR systems as well as in aiding communication in the nursing profession and with healthcare providers. Benefits of standardizing language in nursing include; the facilitating of assessment of nurses based on competency, ensuring that nursing standards have been adhered to, enhancing data collection that is used in assessing nursing care outcomes and helps in improving patient care. The main challenge to this is the lack of knowledge and understanding of the role that standardized nursing terminologies play in the provision of nursing care.

Based on my chosen specialty, the standardized terminology that I will most likely adopt in my nursing practice is the National American Nursing Diagnosis Association (NANDA) terminology set. The reason for this is because it is a highly successful model when it comes to planning patient care. NANDA is also very useful when it comes to making decisions about appropriate interventions. It is a comprehensive standardized nursing terminology set. The TIGER initiative is very important to consider when discussing standardized terminologies in nursing practice because it will furnish all nurses with a set of skills related to informatics, from basic computer skills to advanced-level technology literacy.Standardized Nursing Terminologies in Nursing Practice Essay

Various evidence that clearly supports the need for standardized terminology in nursing practice exists; one such research paper is ‘Evidence for the existing American Nurses Association-recognized standardized nursing terminologies: A systematic review’ (Tastan et al, 2014). This study discusses the increase in number of standardized nursing terminology publications in recent years, with a particular focus on NANDA. These studies enable the understanding of the concepts that underpin these standardized terminologies. This study has found that such study designs enhance the overall efficacy of standardized terminologies and their use in clinical nursing practice, and thus should be continued. With regard to informatics, the results of this scholarly research indicate that standardized nursing terminology sets, including NANDA, can successfully integrate and use electronic health records.Standardized Nursing Terminologies in Nursing Practice Essay

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