Against the healthcare backdrop, nurses are the standouts. Men and women in nursing careers comprise the largest segment of healthcare workers, with frequent patient interactions—up to half of the hours worked by hospital-based nurses.1
Because of the depth and breadth of the role of these nurse leaders, effective communication is critical. Nurses must quickly share patient information with other nurses, doctors, and healthcare professionals. To accomplish this, the nursing profession has developed standardized languages—agreed-upon terms for clinical assessments—that help them to deliver information in a swift, clear, and effective way.
Dr. T. Heather Herdman, executive director of NANDA International, an organization dedicated to clinical terminology in nursing, explains, “Rather than having to have a 5-minute conversation about … ‘I’m seeing this, this, and this in my patient,’ I can very easily say, ‘My patient has anxiety.’ We all know what anxiety is; at least in healthcare, we have a definition for that. And it gives me a way to very quickly communicate what I’m doing, why I’m doing it, and what I’m trying to achieve without having to have a lot of discussion or having to write a lot of information.”2
The terminology nurses use to convey information is a topic in Walden University’s course Transforming Nursing AND Healthcare Through Technology. Students in Walden’s online MSN program learn ways to organize, evaluate, and use health information to enhance evidence-based practice. In “Benefits of Standardized Nursing,” an article from the peer-reviewed The Online Journal of Issues in Nursing, MSN degree-seekers become acquainted with the accepted and widely used terminologies that lead to improved patient care. Read along with our nursing school students to expand your RN language skills:3
The use of standardized nursing languages has many advantages for the direct care/bedside nurse, including better communication among nurses and other healthcare providers, increased visibility of nursing interventions, and improved patient care. These advantages for the bedside/direct care nurse are as follows:
Improved communication with other nurses, healthcare professionals, and administrators of the institutions in which nurses work is a key benefit of using a standardized nursing language. Physicians realized the value of a standardized language in 1893 (The International Statistical Classification of Diseases and Related Health Problems, 2003) with the beginning of the standardization of medical diagnosis that has become the International Classification of Diseases (ICD-10) (Clark & Phil, 1999).
A more recent language, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), provides a common language for mental disorders. When an obstetrician lists “failure to progress” on a patient’s chart or a psychiatrist names the diagnosis “paranoid schizophrenia, chronic,” other physicians, healthcare practitioners, and third-party payers understand the patient’s diagnosis. The ICD-10 and DSM-IV are coded by a system of numbers for input into computers. The IDC-10 is a coding system used mainly for billing purposes by organizations and practitioners while the DSM-IV is a categorization system for psychiatric diagnoses. The DSM-IV categories have an ICD-10 counterpart code that is used for billing purposes.
Nurses lacked a standardized language to communicate their practice until a task force that later became the North American Nursing Diagnosis Association (NANDA) was formed in 1973. Since then several more languages have been developed. The Nursing Minimum Data Set (NMDS) was developed in 1988 (Prophet & Delaney, 1998) followed by the Nursing Management Minimum Data Set (NMMDS) in 1989 (Huber, Schumacher, & Delaney, 1997). The Clinical Care Classification (CCC) was developed in 1991 for use in hospitals, ambulatory care clinics, and other settings (Saba, 2003). The standardized language developed for home, public health, and school health is the Omaha System (The Omaha System, 2004). The Nursing Intervention Classification (NIC) was published for the first time in 1992; it is currently in its fourth edition (McCloskey-Dochterman & Bulachek, 2004). The most current edition of the Nursing Outcomes Classification system (NOC), as of this writing, is the third edition published in 2004 (Moorhead, Johnson, & Maas, 2004). Both the NIC and the NOC are used across a number of settings.
Use of standardized nursing languages promises to enhance communication of nursing care nationally and internationally. This is important because it will alert nurses to helpful interventions that may not be in current use in their areas.
Nurses need to express exactly what it is that they do for patients. Pearson (2003) has stated, “Nursing has a long tradition of over-reliance on handing down both information and knowledge by word-of-mouth” (p. 271). Because nurses use informal notes to verbally report to one another, rather than patient records and care plans, their work remains invisible. Pearson states that at the present time the preponderance of care documentation focuses on protection from litigation rather than patient care provided. He anticipates that use of computerized nursing documentation systems, located close to the patient, will lead to more patient-centered and consistent documentation. Increased sensitivity to the nursing care activities provided by these computerized documentation systems will help highlight the contribution of nurses to patient outcomes, making nursing more visible.
Nursing practice, in addition to the interventions, treatments, and procedures, includes the use of observation skills and experience to make nursing judgments about patient care. Interventions that should be undertaken to support nursing judgments and demonstrate the depth of nursing judgment are built into the standardized nursing languages.
The use of a standardized nursing language can improve patient care. Cavendish (2001) surveyed 64 members of the National Association of School Nurses to obtain their perceptions of the most frequent complaints for abdominal pain. They used the NIC and NOC to determine the interventions and outcomes of children after acute abdomen had been ruled out. Nurses identified the chief complaints of the children, the most frequent etiology, the most frequent pain management activities from the NIC, and the change in NOC outcomes after intervention.
The three chief complaints were nausea, headache, and vomiting; the character of the pain was described as crampy/mild or moderate; and the three most identified etiologies were psychosocial problems, viral syndromes, and relationship to menses. The psychosocial problems included test anxiety, separation anxiety, and interpersonal problems. Nutrition accounted for a large number of abdominal complaints, such as skipping meals, eating junk food, and food intolerances. Cultural backgrounds of the children, such as the practice of fasting during Ramadan, were identified as causes for abdominal complaints.
The three top pain management activities from NIC were: observe for nonverbal cues of discomfort, perform comprehensive assessment of pain (location, characteristics, duration, frequency, quality, severity, precipitating factors), and reduce or eliminate factors that precipitate/increase pain experience (e.g., fear, fatigue, and lack of knowledge) (Cavendish, 2001). Cavendish described a decrease in symptoms, based on the Nursing Outcomes Classification Symptom Severity Indicators, following the intervention. Symptom intensity decreased 6.25%, symptom persistence decreased 4.69%, symptom frequency decreased 6.25%, and associated discomfort decreased 41.06% (p. 272). Similar studies are needed to provide evidence that specific nursing interventions improve patient outcomes.
As a practicing RN, you know the value of a quality nursing education. When you pursue a master’s degree in nursing, you’ll learn the latest forms of communication, broaden your knowledge base and skills, and expand your career opportunities. Walden’s master’s in nursing online offers eight specializations including nursing informatics, where healthcare professionals use technology to accurately and swiftly deliver patient information to ensure effective communication and quality care. Join Walden’s diverse community of students and doctorally prepared MSN teaching faculty to earn a degree that can lead you to nursing management or into a new career, perhaps as a nurse practitioner. The options are yours. Let Walden’s degree programs and your imagination and ambition lead you to a gratifying and remunerative career.
Walden University is an accredited institution offering a Master of Science in Nursing online. Expand your career options and earn your degree in a convenient, flexible format that fits your busy life.
3Walden curriculum source: http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/StandardizedNursingLanguage.html
Walden University is accredited by The Higher Learning Commission, www.hlcommission.org.