“When I use a word” S tandardised language for nursing practice Professor Dame June Clark Professor Emeritus University of Wales Swansea Naming Nursing in an Information Age Bodelwyddan Castle, 21 October 2005

Humpty Dumpty: “When I use a word it means just what I choose it to mean - neither more nor less.” “The question is”, said Alice, “whether you can make words mean so many things.” “The question is” said Humpty Dumpty, “which is to be Master - that’s all.” Lewis Carroll: Alice Through the Looking Glass

Aims of this session l To explain why we need standardised language for nursing l To dispel some of the myths about standardised language in nursing l To introduce some of the terminologies in current use

Why do we need standardised terminology ?

“I use the word nursing for want of a better” “The elements of nursing are all but unknown” Florence Nightingale

6 “ If we cannot name it, we cannot control it, finance it, teach it, research it, or put it into public policy.” Lang 1991

Why we need it l Clinical practice l Political strength l Technological advances l Knowledge development

Clinical Practice: to communicate care l “Nursing is the use of clinical judgement in the provision of care” (RCN 2003) l To ensure continuity of care, decisions have to be communicated to other people l The main vehicle for communication is language l Understanding depends on agreement about terms l Documentation: the patient record

9 Contains key elements Is structured (links key elements) Is expressed in standardised language Saves time We need a patient record which...

10 …..contains key elements The elements of nursing are: nursing diagnoses nursing interventions nursing outcomes We need a patient record which…

11 Intervention Problem/ Diagnosis Outcome i.e. Links the elements Is structured….

12 Intervention Problem/ Diagnosis Clinically Effective Outcome Natural Outcome Generalised Outcome Model

………is expressed in standardised language l Nursing terminologies l Multidisciplinary terminologies that contain nursing concepts

……saves time l Avoids long narratives l Data which can be aggregated l “Collect once, use many times for multiple purposes”

Layer 4: Aggregated data (N) MDS national/ international Management decisions Clinical decisions Structural characteristics; service items etc. Standardised nursing terminology Policy decisions Layer 3: Aggregated data NMDS (local) Layer 2: Nursing interpretations Nursing diagnoses Nursing interventions Nursing outcomes Layer 1: Facts: - Demographic data - Observations: signs and symptoms The Nursing Information Reference Model - Epping and Goosen 1997

Why we need it: Political strength l To make the contribution of nursing visible eg the problems we deal with, identifying nursing outcomes; l To provide the evidence for arguing skill mix, allocation of resources, pay.

Why we need it: Technological advances l Computerisation l Electronic patient record

18 “In the future nursing will be defined, managed and controlled by the information about it that is held in computerised information systems.” Clark 1995

The electronic patient record “Health professionals will need to reach agreement on the structure, terminology, communications and access standards necessary” Better Information Better Health para 44

Terminology requirements for electronic patient records l Agreed data set l Architecture that enables concepts to be located and linked l Standardised terminologies that include concepts used by patients, doctors, nurses, other health professionals, drugs, equipment, etc l Supports data entry, retrieval and analysis of data

Why we need it: Knowledge development l For identifying, naming and linking our phenomena of concern. l To identify and measure the outcomes of nursing practice (clinical effectiveness). l To build databases for retrospective analysis.

22 We need databases to enable… Studies of specific diagnoses and interventions A nursing epidemiology Health outcomes Linkages between interventions and outcomes Skill-mix Audit Decision support systems

“It may be emphasised here that if nursing is ever to make even a remote claim to being a science, or even to being conducted on a scientific basis, it must be built up like all branches of sciences: that is by the most careful unbiased observation and recording of seemingly trivial details, from which - by organising, classifying, analysing selecting, inferring and drawing conclusions - a body of knowledge or principles are finally evolved” Harmer 1926

“ The nomenclature is as of as much importance in this department of enquiry as weights and measures in the physical sciences, and should be settled without delay” William Farr. First report of the Registrar-General of Births, Marriages and Deaths 1839

“There are thousands of LEGO elements and knowing their proper names helps you to organise and use them more efficiently. When you create a naming system for something to help you stay organised, you are creating a nomenclature. Learn the LEGO nomenclature and build on!”

Dispelling the myths

Standardised nursing language is not…... l Standardising nursing practice l Nursing trying to create its own semantic empire l A language that only nurses can use l Nursing jargon

Standardised nursing language is….. l A means of including nursing concepts in the language of health care, which until now has contained only medical concepts l Terminology that anyone can use to describe nursing l A technical language

Core messages l Language is the means by which we communicate ideas (concepts) l Words (terms) represent objects and concepts l Understanding depends on agreement about terms l We use different languages for different purposes l We already use standardised language

Is this a hammer? No. It is a representation of a hammer A concept may be represented by a word (term)

H2oH2o Is this water? No. It is a representation of water. ….. Or a formula

Is this time? No. It is a representation of time …..or a picture

l But to tell the time (read the message) requires understanding l And children have to learn how to do it

We use different languages for different purposes Informal Formal ClinicalClinicalLocalNationalPlanning carerecordauditstatistics (Adapted from Hoy 1995)

We already do it…… …..but only in our heads

36 think name elaborate by rules sort by rules record and store Interpret terms Nursing knowledge/science Analyse Compare NURSING PRACTICE Concepts nomenclature vocabulary classification minimum data set

Nursing terminologies in current use

Nomenclatures recognised by the American Nurses Association NANDA NIC NOC HHCC (Saba) OMAHA (Martin) VIPS (Ehnfors) ICNP SNOMED-RT and SNOMED-CT

Standardised nursing languages: NANDA-I l 167 nursing diagnoses classified into 13 domains and 46 classes. l Each diagnosis consists of a label, definition, defining characteristics or risk factors, and related factors. l eg. ineffective coping l

SNOMED-CT l Multi-disciplinary clinical terminology for use in computer systems l includes ANA recognised terminologies l more than 350,000 concepts l developed from SNOMED RT and Read Codes (version 3) l licensed to ensure version control and to pay for distribution, development, updating l mandatory for use in NHS UK l www

So where are we now?  We have a national strategy for the development of electronic health records: Informing Health Care  We have a standardised terminology  We do not use structured documentation  We do not use nursing diagnoses

So what do we need to do?  Recognise that nursing is about decision making, which is communicated through (standardised) language  Understand the links between our decision making processes, our documentation, and computerised information systems (today’s model)  Start using nursing diagnoses and structured documentation  Improve our IT awareness, understanding, and skills.

………and Join eNWI (and NANDA and ACENDIO and the IN Group)