Assignment: The Impact of Standardized Nursing Terminology Paper

Assignment: The Impact of Standardized Nursing Terminology
Among the Resources in this module is the Rutherford (2008) article Standardized Nursing Language: What Does It Mean for Nursing Practice? In this article, the author recounts a visit to a local hospital to view the recent implementation of a new coding system.
During the visit, one of the nurses commented to her, “We document our care using standardized nursing languages but we don’t fully understand why we do” (Rutherford, 2008, para. 1).
How would you respond to a comment such as this one?
To Prepare:
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.
The Assignment:
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.
By Day 7 of Week 5
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Module 4

Standardized Nursing Terminologies
Standardized nursing terminologies refers to the commonly agreed terms and words that health professionals use to communicate, define healthcare services, apply in research and make contributions to patient care. I would inform the nurse that it is almost impossible for the nurses to operate efficiently without a common language. Lack of a common language or terminologies would lead to confusion and lack of continuity in quality healthcare (Rutherford, 2008). It is also important to emphasize that standard nursing terminology is used to communicate efficiently among nurses. Nurses also need to communicate with other healthcare providers thus the need for common terms. Additionally, nurses are obliged to share ideas or borrow techniques used in other healthcare organizations (Ziebarth, 2018). The idea of sharing the best ideas is made possible with the help of standardized terminologies. For example, ICD-10 and DSM-IV are terminologies used in healthcare to define billing and psychiatric issues respectively. When healthcare providers can easily identify the terminologies used, they will definitely improve patient care.
Nurses have been using informal notes to report to each other about their interventions. As a result, their work has not been recognized by other professionals. Therefore, according to Rutherford (2008), it is essential to have common terminologies which will show the interventions that nurses take. Additionally, computerized documentation of their work can be handed over to another generation. It is also essential to note that when the terminologies are well documented, they can be used to improve patient care. The reason is that they will be reviewed and all the gaps will be clearly identified. The practices can also be compared with those of other hospitals or countries which makes it easy to realize the gaps and fix them appropriately. The sharing and comparing of nursing notes or reports are made possible with the help of standardized terminologies (Gonen, Strauss & Oren-Landes, 2017). On the other hand, data collection will be improved when the common terminologies are being used. It will be easy to study an issue and make observations. It is also easy to carry out systematic reviews from other reports or research studies. Therefore, I would emphasize to the nurse that they need to understand the terminologies and use them all the time.
Implementing Standardized Nursing Terminologies
Implementing standardized nursing technologies is essential to an organization since it facilitates the assessment of nursing competency. The Joint Commission has laid down the requirements during the assessment. For example, while carrying out a vaginal examination, it is required that a nurse will later make a standard report of the condition of a woman. The report should comprise of the terminologies that can be easily understood by other healthcare providers (Rutherford, 2008). Beyond improving the standard of care and reporting, it enhances education to the nurse trainees. The trainees need to learn all the standardized terminologies they can apply when they start practicing nursing.
It is crucial to note that the implementation of standardized nursing terminologies is faced by a number of challenges. One of the major challenges is the lack of funds to compensate professionals who document the terminologies (Rutherford, 2008). In most cases, the terminologies are scattered due to the long tradition of submitting informal reports to fellow nurses and other healthcare providers. Therefore, a healthcare organization might realize that it needs to document the terminologies. Additionally, the common terms are many and thus it will require time to compile them. Therefore, undertaking such a project will require finances, time, and human power, which is rarely provided. On the other hand, the people who commit to carrying out the documentation have to start from scratch since most organizations do not have an elaborate Electronic Health Record. The experts have to get the terminologies from files. They cannot also easily compare the terms with other institutions due to lack of Electronic Health Records (Ziebarth, 2018). Unlike today where nursing notes are share electronically, in the past they were shared informally through pieces of paper. In this case, to document the common terms requires time and dedicate to dig from past records to find all the standardized terminologies.
Another challenge in the implementation of standardized nursing terminologies is the lack of sufficient research studies on some areas of nursing care. The research studies, systematic reviews, and meta-analysis are used as benchmarks to derive meaning from various health organizations (Ziebarth, 2018). They are also used to show what retired nurses used in their communication. Therefore, due to insufficient research, it becomes hard to compile the terminologies appropriately. It is also crucial to note that the attitudes of the nurses in the application of standardized terminologies has played a major role in hindering the implementation. If a section of nurses feel that they have to comply with the specific standard they take it as a burden. However, it is not a burden, but a way of improving patient care now and in the future (Gonen, Strauss & Oren-Landes, 2017). Nursing standardized terminologies are crucial since they can be understood by the nurses. For example, North American Nursing Diagnosis Association (NANDA) Taxonomy I comprises of specific terms that allow nurses to practice freely around North America.

Gonen, A., Strauss, E., & Oren-Landes, S. (2017). Promoting the use of nursing terminology classification among nursing students-an action study. J Nursing Health Stud, 2(3), 18.
Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice? OJIN: The Online Journal of Issues in Nursing, 13(1), 243-50.
Ziebarth, D. J. (2018). Exploring Standardized Nursing Languages: moving toward a faith community nursing intervention. International Journal of Faith Community Nursing, 4(1), 2.

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