Nursing Terminology Paper
Meaningful Use was introduced in 2009 in an effort to reform healthcare as well as improve quality, efficiency and safety (Hebda & Czar, 2013). Terminology standardization is one mandate which hospitals are attempting to comply with the meaningful use standards. According to Hebda & Czar (2013), standardized terminologies are “structured and controlled languages that have been developed according to terminology development guidelines and have been approved by an authoritative body” (p. 298). This is not an easy feat for hospitals for numerous systems have their own local terminology that they will need to map to standardized terminology, it is a challenge to determine which terminology to choose and multiple things must be considered such as data entry, presentation and retrieval (Hebda & Czar, 2013).
Nurses play a key role in the implementation of standardized terminologies for they are “central to care planning and communicating vital care information” (Tastan et al., 2014, p. 1162). Over the past four decades, nursing has been developing standardized nursing terminology (SNT). Using SNT improves communication among nurses and other providers, increases visibility of nursing interventions and outcomes, improves patient care, and facilitates greater adherence to standards of care (Schwirian, 2013).
The American Nurses …show more content…
Association has defined a set of recognized terminologies. In 2013, there were 7 recognized terminologies: Clinical Care Classification (CCC), Omaha System, Nursing Intervention Classification (NIC), Nursing Outcomes Classification (NOC), NANDA (Nursing, Diagnoses, Definitions and Classification), International Classification for Nursing Practice (ICNP) and Perioperative Nursing Data Set (PNDS) (Schwirian, 2013). It is not going to be an easy process to adopt just one SNT. The most likely not become obsolete are CCC and Omaha (Schwirian, 2013). According to Schwirian, both have a champion that are outspoken advocates for the terminology. CCC was started for community use but has been adapted to fit all settings and includes nursing diagnosis, interventions and outcomes. Another benefit to this terminology was it was created for computers. The Omaha terminology originated as well in the community setting but quickly adapted to all settings and includes as assessment, intervention and outcome component.
The NANDA is a very commonly recognized terminology used in nursing school programs. It focuses mainly on nursing diagnosis, which places it at a disadvantage in comparison to its competitors. It is still commonly used in nursing schools, where it appears to be most beneficial. Outside of that arena, it is not as common practice. Despite this data, most interestingly enough a study of the most commonly recognized standardized nursing terminologies showed that NANDA-NOC-NIC were most recognized and the perioperative nursing data set (PNDS) was the least recognized, leading me to believe that the PNDS is at risk for becoming obsolete (Tastan et al., 2014).
The NIC is a standardized classification of interventions, while the NOC is a standardized classification of outcomes.
Together these terminologies have been mapped on SNOMED (Systemized Nomenclature of Medicine) (Tastan, et al., 2014). The SNOMED “is a globally recognized controlled healthcare vocabulary that provides a common language for electronic health application” (Hebda & Czar, 2013, p. 301). This program enables the ease of interoperability by providing consistency in capturing, sharing and aggregating data. For nursing interventions and outcomes cannot stand alone, so adding the NANDA diagnosis is an asset to the
SNOMED.
Care plans are an expectation for regulatory agencies such as Joint Commission and DNV. Consequently, I do not believe NANDA will be going anywhere anytime soon. However, I believe it will take systems such as SNOMED to integrate multiple systems such as NIC, NOC and NANDA in order to make a more highly effective working system that can be utilized across the disciplines. As technology evolves so is nursing and the healthcare system as a whole. I think currently, it remains too soon to tell what will be obsolete in the upcoming future, but it is clear which systems are ahead of the game and fighting to stay in the lead.
Nurses play a key role in the implementation of standardized terminologies for they are “central to care planning and communicating vital care information” (Tastan et al., 2014, p. 1162). Over the past four decades, nursing has been developing standardized nursing terminology (SNT). Using SNT improves communication among nurses and other providers, increases visibility of nursing interventions and outcomes, improves patient care, and facilitates greater adherence to standards of care (Schwirian, 2013).
The American Nurses …show more content…
Association has defined a set of recognized terminologies. In 2013, there were 7 recognized terminologies: Clinical Care Classification (CCC), Omaha System, Nursing Intervention Classification (NIC), Nursing Outcomes Classification (NOC), NANDA (Nursing, Diagnoses, Definitions and Classification), International Classification for Nursing Practice (ICNP) and Perioperative Nursing Data Set (PNDS) (Schwirian, 2013). It is not going to be an easy process to adopt just one SNT. The most likely not become obsolete are CCC and Omaha (Schwirian, 2013). According to Schwirian, both have a champion that are outspoken advocates for the terminology. CCC was started for community use but has been adapted to fit all settings and includes nursing diagnosis, interventions and outcomes. Another benefit to this terminology was it was created for computers. The Omaha terminology originated as well in the community setting but quickly adapted to all settings and includes as assessment, intervention and outcome component.
The NANDA is a very commonly recognized terminology used in nursing school programs. It focuses mainly on nursing diagnosis, which places it at a disadvantage in comparison to its competitors. It is still commonly used in nursing schools, where it appears to be most beneficial. Outside of that arena, it is not as common practice. Despite this data, most interestingly enough a study of the most commonly recognized standardized nursing terminologies showed that NANDA-NOC-NIC were most recognized and the perioperative nursing data set (PNDS) was the least recognized, leading me to believe that the PNDS is at risk for becoming obsolete (Tastan et al., 2014).
The NIC is a standardized classification of interventions, while the NOC is a standardized classification of outcomes.
Together these terminologies have been mapped on SNOMED (Systemized Nomenclature of Medicine) (Tastan, et al., 2014). The SNOMED “is a globally recognized controlled healthcare vocabulary that provides a common language for electronic health application” (Hebda & Czar, 2013, p. 301). This program enables the ease of interoperability by providing consistency in capturing, sharing and aggregating data. For nursing interventions and outcomes cannot stand alone, so adding the NANDA diagnosis is an asset to the
SNOMED.
Care plans are an expectation for regulatory agencies such as Joint Commission and DNV. Consequently, I do not believe NANDA will be going anywhere anytime soon. However, I believe it will take systems such as SNOMED to integrate multiple systems such as NIC, NOC and NANDA in order to make a more highly effective working system that can be utilized across the disciplines. As technology evolves so is nursing and the healthcare system as a whole. I think currently, it remains too soon to tell what will be obsolete in the upcoming future, but it is clear which systems are ahead of the game and fighting to stay in the lead.