In any kind of patient care setting communication is vastly important. A standardized nursing language allows all healthcare providers to communicate effectively between each other regarding the patient. Vital information can be missed if another healthcare provider does not understand what information is trying to be communicated. Essentially, implementing standardized nursing terminologies in nursing practices has various benefits including enhanced communication between nurses as well as other healthcare providers, higher nursing interventions visibility, enhanced patient care, improved collection of data for evaluating nursing care outcomes, higher adherence to care standards, and facilitated evaluation of nursing competence (Rutherford, 2008).
The recent trend of the electronic medical record has made it easy for all healthcare providers to communicate. The American Nurses Association (ANA) has a committee named the Nursing Information and Data Set Evaluation Center (NIDSEC) that assesses terminology and gives a seal of approval based on the vender using standardized nursing languages. Currently the Cerner Corporation is the only vendor of the electronic medical records that received a good seal of approval from the ANA (Rutherford, 2008). I know from experience with Cerner at my place of practice it work very well with communication. Documentation can be looked up from all areas of the hospital and it is clear in the chart what happened to the patient for their entire stay. Nursing interventions are easily documented when there is a standardized nursing terminology, especially when using an EMR. For decades nurses used word of mouth to communicate, based on giving report of their notes. The electronic medical record allows all nurses involved in the patient care to look up exactly what interventions were performed and the patient response (Lundberg et al., 2008) . Standardized nursing languages also improves patient care, improves documentation and research, and a better adherence to standards of care (Rutherford, 2008).
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The international Council for Nurses has begun to try to develop one standardized nursing language for all nurses. Currently there are 13 different standardized nursing languages. It would not be fair to document differently based on different types of units. Ultimately at some point all nurses end up communicating from different areas of nursing (Rutherford, 2008). For the obstetric nurses to have a different idea then Emergency Department (ED) nurses of what a medium amount of blood means could cause miscommunication. Miscommunication could ultimately cause a mistake in a patient care. A standardized nursing terminology contributes to the safety of patients in regards to identifying and interpreting nursing care in all aspects of the medical record ( Jones, Lunney, Keenan and Moorhead, 2010 ). In the ED we are to stabilize the patient and send them to another area of the hospital for continuation of care. The receiving nurse needs to clearly understand the intervention performed in the ED and what interventions may still need to be done. Even with different hospitals and states nursing language should be standardized. For example, I have actually transferred patients out of my ED to another state. The nurse in the other state is taking over my patients care and still needs to understand exactly what I am telling them and sending to them in the form of the printed electronic medical record. It would be hard for all nurses to keep up with and create new research and development without a standardized nursing language. A standardized language makes new research and evidence easier to understand. According to Schwiran and Thede (2011 ), this affects emergency departments and critical care areas as they will be the areas mostly to see all types of patients from all areas of nursing.
References
Jones, D., Lunney, M., Keenan, G., & Moorhead, S. (2010). Standardized nursing languages: essential for the nursing workforce. Annual Review Of Nursing Research , 28 253-294. doi:10.1891/0739-6686.28.253
Lundberg, C., Warren, J., Brokel, J., Bulechek, G., Butcher, H., McCloskey Dochterman, J., ... & Spisla, C. (2008). Selecting a standardized terminology for the electronic health record that reveals the impact of nursing on patient care. Online journal of nursing informatics , 12 (2).
Rutherford, M. A. (2008). Standardized nursing language: What does it mean for nursing practice? OJIN: The Online Journal of Issues in Nursing, 13 (1). Retrieved from http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/ OJIN/TableofContents/vol132008/No1Jan08/ArticlePreviousTopic/StandardizedNursing Language.html
Schwiran, P. M., & Thede, L. Q. (2011). Informatics: The standardized nursing terminologies: A national survey of nurses’ experiences and attitudes—Survey I. The Online Journal of Issues in Nursing , 16 (2), 12.
