This paper will offer up a discussion of nursing documentation as it relates to patient discharge abstracts and the identification of nursing sensitive outcomes. It will explore the process for developing standards and the role of the American Nurses Association in promoting standardized terminologies, detailing some of the benefits of the same. It will explore the International Health Terminology Standards Development Organization (IHTSDO), and it will discuss the focus of development and adoption of standard clinical terminology and identify the manner in which this information will be of value to an informatics nurse.
Keywords: informatics nursing, invisibility of nursing, benefits, challenges, standard terminologies, creating stronger visibility in nursing
The invisibility of nursing refers to the lack of attention given to nursing practices in language standardization, administrative reporting, and epidemiologic reporting systems, and can even at times be used to refer to the overall lack of attention given to the nursing field in general, acknowledged as a profession, but ultimately overlooked when it comes to the practical application and unification of knowledge therein (Henry, Warren, Lange, & Button, 1998). This distinct lack of knowledge and standardization in language and practices commonly used within the nursing field has been a long-standing challenge for the industry, in spite of the fact that this concept is pivotal to a host of issues present within the healthcare field (Rezaei-Adaryani, Salsali, & Mohammadi, 2012). In order to explore this phenomenon, particularly in the field of informatics nursing, the attempts at standardization within the standards applied and standard terminologies will be discussed, including the benefits and challenges associated therewith and an analysis of the potential value of standardization to informatics nursing (Werley, Devine, Zorn, & Westra, 1991).
Standards and Standard Terminologies
The promotion of standards and standard terminologies within the medical field is not a new desire within the medical field, or even within the field of nursing (Henry et al., 1998; Rezaei-Adaryani, Salsali, & Mohammadi, 2012; Werley et al., 1991). With the increasing pressures being placed upon the nursing profession within the 21st century, however, standardization of terminology is becoming more important now than ever (Nelson, 2011). In order to ensure a streamlining of technologies used in the treatment of care and a uniformity in the care and treatment of patients, over the course of the past several decades, there has been a targeted application toward the promotion and development of standards and standard terminologies within the field (Clark, 1998; Tseng, 2012). In fact, “the rationale for standardized languages and classifications for nursing applies all over the world,” and development only occurred earlier in the USA than in other countries due to the “imperatives of reimbursement systems, accreditation, and litigation,” though the process is far from complete and the standardization of such linguistics is a process that is still ongoing to this day (Clark, 1998, p. 1; Tseng, 2012).
There are certain benefits associated with the use of standardized terminologies as related to creating a stronger visibility of nursing. Not only does the standardization of terminologies work to create a certain uniformity in practice and ensure that the care received for a given service will be the same regardless of the location within the country in which the individual chooses to obtain care, but this also works to ensure that, through the standardization of terminologies, that the appropriate fees may be charged to each patients, working to ensure that all offices, regardless of location, receive the same compensation fro ma patient for similarly provided services (Clark, 1998). This works to ensure that there is a degree of standardization in the pay rates of nurses based on the type of work being completed within the different specialty being performed (Clark, 1998). In so doing, this allows for an even distribution of the nursing population across the country, to the degree possible, as opposed to a glut in one area due to higher rates of pay for the provision of the same services that are completed within other areas for lower rates of pay (Clark, 1998). In addition to working to assure uniformity in distribution of the nursing population and a uniformity in practice, the standardization of terminologies works to increase the ease at which it becomes possible to defend various legal cases. In working to standardize terminologies, a person cannot bring a lawsuit against one nursing staff or doctor’s office because he or she expected a certain procedure to be done, and while a procedure with the same name was done, the procedure entailed different results (Clark, 1998). In a non-standardized terminology, this would create the potential for additional litigations, but with standardization, this means that only those who fail to uphold the standards set forth are those that would have to face the potential for a lawsuit, stemming from the poor provision of care (Clark, 1998).
This is not to state that there is not a certain standardization in nursing terminology at the current time. Since the inception of the nursing field, there has been an effort toward a standardization in the nursing terminologies used, with organizations like the International Health Terminology Standards Development Organization (IHTSDO) working to increase overall standardization in nursing practices (Beeler, 1998; Clark, 1998; IHTSDO, 2016). More accurately, this is to state that with the evolution of nursing care, and with the addition of additional technologies to assist in the nursing practice, there is a need for the continued assurance of standardization in nursing terminologies to continue to maintain high quality standards of care (Beeler, 1998; Clark, 1998; IHTSDO, 2016). Such standardization is particularly important within the field of informatics nursing, a relatively new discipline of “science and practice that integrates nursing, …(through the) management of information and communication technologies to promote the health of people, families, and communities worldwide” (AMIA, 2016, p. 1).
Standardization in Informatics
Due to the continually changing and updating practices associated with the application of these technologies, there are certain challenges present in maintaining these standards, given the fact that as new technologies come out and become part of the daily activities of the nursing staff, terminologies and practices must be standardized across the whole of the nursing profession (AMIA, 2016; IHTSDO, 2016). In spite of these difficulties, particularly with the coordination of such knowledge and standardization on a global scale, there is a great potential value for the standardization of the same, allowing for the wider application of nursing care and practice (AMIA, 2016; IHTSDO, 2016). To this end, regardless of the difficulties, or a lack of visibility associated with those difficulties in the public eye or in policymaker concerns, there is a need to continue to work toward the advancement and application of such standards, as to do so will allow for the similar degree of uniformity that is present within the basic nursing lexicon, the same benefits afforded to that uniformity as pertaining to the use of available technologies, and the increased benefits in treatment and care, regardless of global location (Rezaei-Adaryani, Salsali, & Mohammadi, 2012).
In working to ensure that such standardization is present, regardless of the attention given by the public eye or the level of invisibility nursing may have within public policy, quality of care is increased for patients without the need to pay for additional services that would otherwise be included in the completion of a given activity. As the field of nursing continues to advance and grow, there is a need, perhaps now more than ever, to continue to ensure that such standardization exists and efforts at a communal lexicon continue. Failure to do so has the potential to create a host of additional issues in al already overworked field, resulting in detriments to patient health. Thanks to the continued advancement of the medical field, this is never a matter that will be fully solved, but it is one in which there is a need to remain continually up to date through the combination of the continued creation of standards and the need to continually shed light on this pressing matter.
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