JUNLI M. AWIT, RN MSN-MSN Developing Standardized Terminologies in Nursing Informatics

Why is there a need for standardized nursing terminologies ? The birth of electronic health records Incorporation of descriptions of nursing care into electronic health records in a manner that is proportionate with it’s importance to patient’s welfare

The benefits of using standardized nursing terminologies: Better communication among nurses and other healthcare providers Increased visibility of nursing interventions Improved patient care Enhanced data collection to evaluate nursing care outcomes Greater adherence to standards of care Facilitation of assessment of nursing competency

Standardized Nursing Terminologies ABC Codes (Alternative Billing Codes) CCC (Clinical Care Classification) NMDS (Nursing Minimum Data Set) NANDA (North American Nursing Diagnosis Association) NIC (Nursing Intervention Classification) NOC (Nursing Outcomes Classification)

Standardized Nursing Terminologies Omaha System PNDS (Peri-operative Nursing Data Set) ICNP (International Classification of Nursing Practice) LOINC (Logical Observation Identifiers Names & Codes) SNOMED (Systematized Nomenclature of Medicine)

Study by Schiran and Thede (2011) Informatics: The Standardized Nursing Terminologies: A National Survey of Nurses’ Experience and Attitudes

Results: No significant difference between the clinical nurses and academic nurses in terms of their experience with SNT No significant difference between informatics and non- informatics nurse on their experience with selected SNT. (Informatics nurses reported more familiarity with NIC than did non-informatic nurses but the numerical difference is not enough to be considered statistically significant

Results: Of most interest was the comparison between those who were first licensed before 1990 and those licensed from 1990 though This ‘cut date’ was seen as significant because Harriet Werley had convened the Minimum Data Set Conference in Milwaukee in 1985 – A landmark event in the evolution of Nursing Informatics Pre 1990 board exam-20% reported no knowledge of NANDA; less than 10% for post 1990

Though Provoking Questions What do you believe are the advantages and disadvantages of having a single shared consensus-driven model of terminology use? How can a single agreed model of terminology use help to integrate knowledge into routine clinical practice?

References Alexander (2011). Standardized Nursing Terminology. Date retrieved, May 3, 2013, from g_terminology g_terminology Werly, H. H., & Lang, N. M. (Eds.) (1988) Identification of nursing minimum data set. New York: Springer Publishing. Schwirian and Thede. Informatics: The Standardizes Nursing Terminologies: A National Survery of Nurses’ Experience and Attitudes – Survery I. Date retrieved, May 3, 2013 from tplace/ANAPeriodicals/OJIN/Columns/Informatics/Stand ardized-Nursing-Terminologies.html tplace/ANAPeriodicals/OJIN/Columns/Informatics/Stand ardized-Nursing-Terminologies.html