Assignment: The Impact of Standardized Nursing Terminology

Assignment: The Impact of Standardized Nursing Terminology

Standardized Nursing Terminology (SNTs)

Rutherford made a recent visit to an L&D unit within a local community hospital. During the visit, she was assessing the application of documentation for nursing care within the hospital’s electronic health records system (EHRs) (Rutherford, 2008). She was interested in the assessment of the recent implementation of SNTs. However, her visit was met with unexpected but intriguing nursing experience Assignment: The Impact of Standardized Nursing Terminology. One of the nurses stated that they used to document their care using SNTss (SNLs), but they did not sufficiently understand why they did so (Rutherford, 2008). Such a statement exhibited a plethora of information concerning the impact of standardized nursing terminology in nursing.

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In this case, the nurses need to be informed about the significance of SNTs in the nursing practice. The utilization of the SNTs in documentation within the nursing care profession is crucial for nursing professionals as well as the direct care nurses (Rutherford, 2008). The benefits of using standard nursing care language/terminology including but not limited to effective communication among the nurses and care providers, increased nurse visibility, improvement of patient care, enhancement of data collection techniques for evaluation of nursing outcomes as well as enhanced adherence to the standards of care (Rutherford, 2008). Therefore, the standardized using language improves the facilitation of assessment of the nurses’ competencies. The SNTs. The effective sharing of information supported by the SNTs assists in the sharing of knowledge during research, administration, and education in the field of nursing (Rutherford, 2008) Assignment: The Impact of Standardized Nursing Terminology.

Nursing organizations have outlined various benefits of implementation of the standardized nursing terminologies in nursing. For instance, in 2015, the American Nurses Association (ANA) described its position statement concerning its support for the application of Standardized terminologies in nursing (ANA, 2015). ANA’s position statement indicated that the use of standardized terminologies, especially in the Electronic Health Record (HER), as well as other informatics, enhances the understanding, coordination, control, and transfer of information among different departments. Therefore, all the nursing facilities were instructed to use the standardized terminologies within the EHRs to minimize communication errors. For inatance, mandatory conversion of data during transfer from one care plan to another was emphasized. The universality of communication reduces the risks of medical errors due to inadequate or wrong interpretation. In this case, the health records need to be recorded, stored, retrieved, and presented in a universal manner that is understood across the nursing profession Assignment: The Impact of Standardized Nursing Terminology. For example, the data from an ultrasound scan should be understood by a nutritionist handling the same patient.

For big data science, the combination of multiple sources of data is facilitated by the efficiency in the application of Standardized Nursing Terminologies in EHRs (Macieira, Smith, Davis, Yao, Wilkie, Lopez, & Keenan, 2017). In this concept, a study conducted by Macieira et al. (2017), found out that only 3 out of 5 sets of Standardized Nursing Terminologies were significantly used in the reviewed articles. The CCC and PNDs were absent in the articles. Therefore, the issue of language played a significant role in influencing the research. Since English was not a common language across the study areas Korea, Spain, and America, the discrepancies in the data were explained as a factor of language differences. However, an analysis of the variables, such as diagnosis, outcomes, and interventions, was related to the use of SNTs (Macieira et al., 2017).

Each type of Standardized Nursing Terminology has its unique benefits as well as advantages. For instance, SNOMED Clinical Terms, also called SNOMED CT is applicable in international health care and included the description, clinical meaning, relationship/link between related concepts within the nursing practice. SNOMED CT is highly applicable in the dissemination of multidisciplinary information and enhancement of clinical testing, quality measurement, as well as research initiatives. However, a significant challenge of SNOMED CT is seen in its reluctance to use the updated maps from CAP, unlike in ANA. Therefore, the SNOMED CT doesn’t purchase the maps leading to inconsistency in communication within the nursing practice (MBL Technologies, 2020) Assignment: The Impact of Standardized Nursing Terminology.

The application of electronic health records combined with standardized terminologies has been observed to have positive impacts on the improvement of the quality of nursing. The standardized languages and use of EHRs improve the quality of nursing documentation and quality of services. The improvement in nursing documentation is favored by the improved accuracy in documenting that is provided by the use of the EHRs (De Groot, Veer, Paans, & Francke, 2020).

The application of the SNTs has been evidenced as a major factor in improving the satisfaction of the nurses. The appropriate use of information technology enhances the efficiency in the nursing practice due to the rapid and straightforward sharing of information. The computer networks are used to records, store, manipulate as well as share medical records and reduce the stress of keeping and updating manual files. However, the technology of using EHRs is quite expensive in terms of training and equipment. Each nurse is expected to be computer literate to operate the EHR systems. Furthermore, extra costs of security should be incurred for the effective implementation of EHR systems. Therefore, data management tools and network security officers should be employed to enhance the security of electronic medical records (Chapman, 2016). Other disadvantages of SNTs include the differences in the international application of the terminologies. Each country has a unique language and culture. Therefore, the differences in interpretation of the SNTs between countries affect the efficiency of multicultural nursing care set up. Such differences jeopardize the quality of health as well as the patients’ safety (Olatubi, Oyediran, Faremi, & Salau, 2019).

In another study, Moen, Hakala, Peltonen, Suhonen, Ginter, Salakoski, & Salanterä (2020), focused upon the assignment of standardized subject heading in an automatic manner to the free-text sentences within the clinical nursing notes. The motivational concept behind the study was the establishment of the support nursing system, where patient documentation for care was developed using computer systems. Such a move was important in assisting the incorporation of suitable headlines that are congruent with the document topics. The study used 676 unique headlines derived from the Finish university hospital. Automatically, an evaluation of the methods was done as well as the analysis of the manual error. The results outlined that the short-term memory was significantly relevant in the selection of the headings. A manual analysis indicated that the predictions were better than the results indicated by the automatic evaluation. The reaearch concluded that appropriate subject headings existed on the sentence level category of the data. Therefore, there was feasibility of the development of the text classification system that would assist in supporting the application of standardized terminologies. Furthermore, such an approach would assist in saving the time for the burses to energy and time on care documents (Moen et al., 2020) Assignment: The Impact of Standardized Nursing Terminology.

References

American Nurses Association. (2015). Inclusion of Recognized Terminologies Supporting

Nursing Practice within Electronic Health Records and Other Health Information Technology Solutions.

Chapman, Y. L. (2016). Nurse Satisfaction with Information Technology Enhanced Bedside

Handoff. Medsurg nursing, 25(5).

De Groot, K., De Veer, A. J., Paans, W., & Francke, A. L. (2020). Use of electronic health

records in relation to standardized terminologies: a nationwide survey of nursing staff

experiences. International Journal of Nursing Studies, 103523.

Macieira, T. G., Smith, M. B., Davis, N., Yao, Y., Wilkie, D. J., Lopez, K. D., & Keenan, G.

(2017). Evidence of Progress in Making Nursing Practice Visible Using Standardized Nursing Data: a Systematic Review. In AMIA Annual Symposium Proceedings (Vol. 2017, p. 1205). American Medical Informatics Association.

MBL Technologies, 2020. Standard Nursing Terminologies: A Landscape Analysis. [online] Assignment: The Impact of Standardized Nursing Terminology

Healthit.gov. Available at: <https://www.healthit.gov/sites/default/files/snt_final_05302017.pdf> [Accessed 13 March 2020].

Moen, H., Hakala, K., Peltonen, L. M., Suhonen, H., Ginter, F., Salakoski, T., & Salanterä, S. (2020).

Supporting the use of standardized nursing terminologies with automatic subject heading

prediction: a comparison of sentence-level text classification methods. Journal of the American

Medical Informatics Association, 27(1), 81-88.

Olatubi, M. I., Oyediran, O. O., Faremi, F. A., & Salau, O. R. (2019). Knowledge, perception,

and utilization of SNTs (SNL)(NNN) among nurses in three selected hospitals in Ondo State, Nigeria. International journal of nursing knowledge, 30(1), 43-48.

Rutherford, M. (2008). SNTs: What does it mean for nursing practice.

OJIN: The Online Journal of Issues in Nursing, 13(1), 243-50.

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? Assignment: The Impact of Standardized Nursing Terminology

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.

Learning Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings
McGonigle, D., & Mastrian, K. G. (2017). Nursing informatics and the foundation of knowledge (4th ed.). Burlington, MA: Jones & Bartlett Learning.

Chapter 25, “The Art of Caring in Technology-Laden Environments” (pp. 525–535)
Chapter 26, “Nursing Informatics and the Foundation of Knowledge” (pp. 537–551)
American Nurses Association. (2018). Inclusion of recognized terminologies supporting nursing practice within electronic health records and other health information technology solutions. Retrieved from https://www.nursingworld.org/practice-policy/nursing-excellence/official-position-statements/id/Inclusion-of-Recognized-Terminologies-Supporting-Nursing-Practice-within-Electronic-Health-Records/

Macieria, T. G. R., Smith, M. B., Davis, N., Yao, Y., Wilkie, D. J., Lopez, K. D., & Keenan, G. (2017). Evidence of progress in making nursing practice visible using standardized nursing data: A systematic review. AMIA Annual Symposium Proceedings, 2017, 1205–1214. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5977718/

Office of the National Coordinator for Health Information Technology. (2017). Standard nursing terminologies: A landscape analysis. Retrieved from https://www.healthit.gov/sites/default/files/snt_final_05302017.pdf

Rutherford, M. A. (2008). Standardized nursing language: What does it mean for nursing practice? Online Journal of Issues in Nursing, 13(1), 1–12. doi:10.3912/OJIN.Vol13No01PPT05. Assignment: The Impact of Standardized Nursing Terminology

Note: You will access this article from the Walden Library databases.

Thew, J. (2016, April 19). Big data means big potential, challenges for nurse execs. Retrieved from https://www.healthleadersmedia.com/nursing/big-data-means-big-potential-challenges-nurse-execs

Topaz, M. (2013). The hitchhiker’s guide to nursing theory: Using the Data-Knowledge-Information-Wisdom framework to guide informatics research. Online Journal of Nursing Informatics, 17(3).

Note: You will access this article from the Walden Library databases.

Wang, Y. Kung, L., & Byrd, T. A. (2018). Big data analytics: Understanding its capabilities and potential benefits for healthcare organizations. Technological Forecasting and Social Change, 126(1), 3–13. doi:10.1016/j.techfore.2015.12.019.

Note: You will access this article from the Walden Library databases.

Required Media
Laureate Education (Executive Producer). (2012). Data, information, knowledge and wisdom continuum [Multimedia file]. Baltimore, MD: Author. Retrieved from http://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6051/03/mm/continuum/index.html

Laureate Education (Producer). (2018). Health Informatics and Population Health: Analyzing Data for Clinical Success [Video file]. Baltimore, MD: Author.

Transcript for video
Analyzing Data for Clinical Success
Program Transcript
GRANT SHEVCHIK: Probably the one disorder/disease where information
technology has had the biggest impact and really done a great job is in the
management of diabetes. Diabetes has a lot of complications too it, a lot of
different things that can go wrong. But on the surface, what you\’re managing for
the most part are numbers. Obviously, information technology is very conducive
to measuring numbers.
So you can pull up Joe, and you can see Joe. And you can see his numbers. You
can see the trend over time. You can see all sorts of things. This was magic. This
was one of the reasons why, way back when, we wanted to get an electronic
record, because we were able to look at that.
But the most important thing is not looking at the numbers in isolation, but looking
at them over time and being able to say to you, hey Joe, you\’re doing a great job.
You went from a hemoglobin A1C of 15. Normal is supposed to be 7. You\’re
down to 9. Most people would be unhappy with you. I\’m ecstatic, because 9 is a
lot better than 15.
By saying it in that fashion, Joe has an incentive to get down to 8. Joe\’s last
doctor never even knew what his A1C was the time before, the time before that.
In the paper chart, the chart was never there when Joe was there.
But it also makes a difference if this person shows up in the emergency room
and needs emergency surgery. Is this diabetic a diabetic under good control? Is
this a diabetic that has a lot of problems?
In the past, all we\’ve done is coded them as being diabetes. And we patted the
doctor on the back and said, good job. You let us know they have diabetes.
Now we\’re really asking for the more specific detail. What else is going on? What
else is there? Having some data is good. But then taking that data and looking
and making it more accurate is a more desirable goal and would make a big
difference in that patient in the long run. Assignment: The Impact of Standardized Nursing Terminology
The advantages of the whole community– meaning patients, physicians, et
cetera– becoming electronic and communicating over the internet via
smartphones, via whatever– that\’s what\’s going to really change medicine,
especially in chronic diseases. If you\’re talking about somebody\’s arthritis, they
need to be able to tell you, where does it hurt? How much does it hurt– that sort
of thing. So it\’s not as straightforward. But if you build effective questionnaires,
you can have questionnaires that the computer is smart enough to answer and
analyze for you.
© 2018 Laureate Education, Inc. 1

Analyzing Data for Clinical Success
So the future is great if you take what\’s out there and available, have the
computer work for you, design effective questionnaires, design effective things,
reach out to patients on a regular basis, know who communicates back to you,
but also know the ones who you\’ve lost. It\’s like anything else. The most
important patients are the ones that somehow got lost to follow-up. They\’re the
ones that are going to come back and be the train wreck. They\’re going to be the
ones that come back and show up in the hospital in the emergency room.
IT mean makes it a whole lot better than it used to be with just paper cards,
where he pull the cards out and see who needs to be reminded this month.
However, you still need to have people on your end, meaning the physician\’s
office end, who\’s looking at this and managing this to be able to make sure that
you\’re communicating with your patients, they\’re getting back to you, and you\’re
seeing what needs to be done.
As we get farther along, and more and more people sign onto a patient portal–
that sort of thing– that\’s where the magic comes in, because now, I can reach out
to all my diabetics through the portal. I can remind 1,000 people in 10 minutes by
just writing what I want to write, and send it all 1,000 of them. We didn\’t have that
ability before.
The part that really makes it easier is we\’re now actually getting to people
through their smartphones. And so we need to use these things that are out
there, the things that are available to us, that we can begin to take advantage
and really reach out to our patients. They love the convenience. And most
importantly, they appreciate that we care.
Analyzing Data for Clinical Success
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© 2018 Laureate Education, Inc. 2

Analyzing Data for Clinical Success
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Accessible player
Vinay Shanthagiri. (2014). Big Data in Health Informatics [Video file]. Retrieved from https://www.youtube.com/watch?v=4W6zGmH_pOw. Assignment: The Impact of Standardized Nursing Terminology