NURS 6051 Module 3 Assignment; The Impact of Standardized Nursing Terminology: {GRADED A}

Standardized Terminology: A Nursing Language Prepared by: NURSE JOLLY The purpose of this assignment is to explain the importance of standardized nursing terminologies and to describe the benef its and challenges of implementing those terminologies into practice. Standardized nursing terminologies are necessary for documentation of nursing care. Using standardized nursing language has many benefits for patients, nurses, and all medical professionals. Rutherford stated that “the definition of a nursing language is a common language describing patient care that is understood by all nurses” (as cited in Keenan, 1999, p. 12). The benefits of using a standardized language improve patient outcomes and communication among nurses and physicians. According to Hardiker & Strudwick (2016), “in the era of evidenced based healthcare, nursing is required to demonstrate that care provided by nurses is associated with nursing language, nurses’ documentation will be in terminology that all nurses and physicians optimal patient outcomes, and a high degree of quality and safety”. By using a standardized nursing language, nurses and physicians can learn the terminology and interpret it in the same clear, concise manner that will limit confusion about the documented patient care and interventions. Enforcing the Importance of Standardized Nursing Terminology To inform nurses of the importance of utilizing standardized nursing terminologies I would provide educational classes as part of orientation when nurses are hired. By passing on the importance of using nursing language and providing examples of why the language is beneficial, nurses will understand the importance of applying nursing language to their everyday practice. For example, I would provide a scenario and then ask the nurses to chart their “interventions” and expected patient responses to the care provided. Then as a group we would compare our charting to see if each nurse is using standardized nursing terminology. By making these comparisons, we can identify any charting or terminology that may be vague or unacceptable terminology. Also, I would send out reminders in memo monthly for nurse managers to remind nurses to make sure they are utilizing the standardized nursing language in their charting. After six months passes since the nurses were educated at the time of orientation, I would perform chart reviews to evaluate nurses’ charting and look for areas that need to be improved upon. After identifying any specific needs for improvement, I would meet individually with each nurse to discuss the need for using standardized nursing terminology. Benefits and Challenges of Standardized Nursing Terminology The benefits of using a standardizes nursing terminology not only benefit nurses and physicians, but also the patients that nurses care for. According to Rutherford (2008), using a standardized nursing language “improves communication among nurses and other healthcare providers, increased visibility of nursing interventions, improved patient care, enhanced data collection, improved adherence to standards of care, and increased assessment of nursing competency”. For example: A patient admitted for colitis has been complaining of abdominal discomfort since the start of night shift. The day shift nurse did not document correctly that during her shift the patient chose to eat hot wings for supper instead of the bland diet that was ordered. She simply charted patient tolerated 100% of supper. The day shift nurse also failed to report that the patient was noncompliant with his bland diet to the oncoming night shift nurse. This lack of adherence to standardized nursing language causes a break in communication between nurses that is important for patient care. There are challenges to implementing standardized nursing terminology, especially with an electronic health record. According to The Office of the National Coordinator for Health Information Technology (2017), “a lack of data standardization in nursing content, and clinical content in general, exists within many installed electronic health record systems”. Sometimes lack of standardization comes from customer preferred demands for customization which can cause gaps in consistency of program formatting to include incorrect terminology that is specific to local preference. Conclusion In conclusion, standardized nursing terminology is essential for communication among nurses and healthcare professionals, improved patient outcomes, enhanced data collection, improved adherence to standards of care, and increases assessment of nursing competency. Although the implementation of this standardized language can come with challenges that slow the growth of spreading the use of this language among nurses, it is crucial that we continue to educate new and older nurses alike of the importance of using standardized nursing terminology. By continuing to strive to make this nursing language universal, we can continually improve our continuity of patient care, therefore reaching the goal of improved patient outcomes. References Hardiker, N. R., & Strudwick, G. (2016). Understanding the use of standardized nursing terminology and classification systems in published research: A case study using the International Classification for Nursing Practice (®). International Journal of Medical Informatics, 94, 215–221. https://doi-