The use of informatics in nursing has become essential and critical in the provision of quality health services to patients. Consequently, various terminologies have emerged to achieve effective implementation of health information systems for use by nurses in providing safe and quality care. Hence, to use information systems effectually, some experts recommend the application of a standardized nursing language. Such language supports the integration of electronic documentation into the healthcare system. It enables nurses to collaborate in collecting, managing, and using data in the continuum of care. The use of standardized language is critical in bedside and direct care (Strudwick & Hardiker, 2016). Regardless of the necessity of the standardized nursing language in electronic documentation, some nurses fail to understand the importance. Therefore, a review of documentary evidence explores the benefits and challenges of the standardized nursing language in achieving informatics objectives in nursing.
The Importance of Standardized Nursing Terminologies
Nurses should understand the importance of standardized terminologies in electronic documentation. Implementers should not merely insist on the application of language without explaining the reasons behind its use to support the care process. One of the hallmarks of success in the nursing profession is the global application of a specialized vocabulary that enables nurses to collaborate in providing patient care. The use of standardized nursing terminologies enables healthcare providers to communicate effectively in nursing research and practice (Schwirian, 2013). The exercise has the benefit of having a set of recognized terminologies that serve various purposes and support the consistency objective. Nurses should use standardized language to ensure that they are consistently and efficiently working towards the goal of patient care.
Apart from supporting communication and collaboration, standardized nursing terminologies allow the meaningful use of electronic information in health care. Nurses rely on electronic health records to achieve safety and quality goals in care. Therefore, these terminologies integrate the Nursing Management Minimum Data Set into the information systems when offering care. The system also enables the use of standardized data that can be used across nursing settings (Westra et al., 2010). It is critical to ensure consistency in nursing through the standardization process. For example, nurses should have a systematic way of communicating with other professionals in the continuum of care. They should use a language that they all understand to prevent errors in the care process. Therefore, the use of standardized nursing terminology is critical to achieving nursing objectives amid the fragmented healthcare system.
Benefits and Challenges of Implementing Standardized Nursing Terminologies
The implementation of standardized nursing terminologies in nursing practice has various benefits. The advantages of using the language include improved data collection to evaluate the outcome of patient care; achievement of safety and quality objectives through effective communication and collaboration; better adherence to patient care needs through access to critical patient data; proper assessment of performance and evaluation of competency among nursing professionals; and improved visibility of interventions to various patient populations (Rutherford, 2008). For example, when nurses use standardized terminology when providing care to patients, they can easily share knowledge among professionals working in the same case. The use of the language will allow the members of the interprofessional team to understand patients’ needs and implement an effective intervention. It saves time that would be taken to understand the electronic record by other providers who are not involved in the collection and recording of information.
Regardless of the benefits of standardized nursing terminology in electronic documentation, some challenges emerge that should be addressed to achieve the benefits of informatics in patient care. For example, nursing involves the use of seven known term sets that serves various purposes (McGonigle & Mastrian, 2017). The existence of these terms undermines the objective of consistency that is necessary to support general recognition and acceptance by all nursing professionals (Thede & Schwirian, 2013). Consequently, it becomes challenging for the professional to adapt a single vocabulary to support electronic documentation. Implementation of standardization in the highly fragmented healthcare system is not easy for nurses and other providers. Therefore, nurse executives and informaticists should collaborate to address the challenges and achieve standardization.
Growth in the use of informatics in nursing and healthcare, in general, has created other changes. One of the developments is the need for standardized nursing terminologies in electronic documentation. The move is vital because it supports communication and use of information records. However, regardless of the importance and benefits, the development poses some challenges that should be addressed to achieve the benefits of nursing informatics. Research shows significant improvements towards the achievement of increased use of standardized nursing terminologies. The change will be accepted with time, used consistently, and incorporated into nursing research, education, and practice. Besides, the change will require cross mappings to significant medical terms to achieve interoperability and support application in nursing informatics. Concerted research is critical to meet the information management goals in the modern era of information and informatics.