Nurses and other health care providers are increasingly using clinical technology and informatics to improve service delivery. Consequently, healthcare organizations have invested in the systems that are used across hospital departments and units. However, effective use of informatics comes with a considerable challenge for nurses because of the need for standardization. Experts recommend the invention and use of a standardized nursing language to support their work. Such a language makes it possible for nurses to collaborate with peers and other professionals to support electronic documentation and data management (Macieria et al., 2017). Although standardized nursing terminologies are useful and beneficial to health care, application of such terms can pose challenges that nurses should understand and overcome.
The Significance of Standardized Nursing Terminologies
Nurses can only use standardized nursing terminologies effectively once they understand their importance. Nursing informaticists and other technology experts should explain the role of nursing terminologies, especially their use in standardizing their care. The system helps nurses to work together with their peers and other professionals to improve care. Besides, they enable efficient communication to improve care delivery to diverse patients (McGonigle & Mastrian, 2017). In general, a standardized language would help nurses to collect, manage, and share information.
Besides, standardized nursing terminologies assist nurses in obtaining and managing patient records. The modern-day health care has increased the use of electronic health records to improve patient outcomes (ANA, 2018). Therefore, standardized language would help nurses to gather information and manage it using clinical systems across the healthcare facility. Providers should ensure that the uniformity and consistency of data used in the hospital are maintained. For instance, data collected at the beginning of the case process, such as patient history, should remain consistent and sharable throughout the continuum of care for the same patient.
Benefits and Challenges of Standardized Nursing Terminologies
Nurses could have significant benefits of using standardized nursing terminologies in electronic documentation. The benefits include reliable patient data collection, improved quality and safety of care, enhanced communication and collaboration through information sharing, advanced assessment and treatment of diverse patients, and better discernibility of interventions (Rutherford, 2008). For example, nurses can work with other professionals efficiently, such as doctors and pharmacists, to manage health conditions through information sharing. Interprofessional collaborators can understand patients’ condition through data collected and managed using a standardized language.
On the other hand, nurses could face challenges when using standardized nursing terminologies in electronic documentation. For instance, nurses use many terminologies to achieve diverse objectives in care delivery (McGonigle & Mastrian, 2017). The multiple terms render it hard to attain the consistency objective, which is necessary to share and use data across clinical settings. Besides, it is a challenge to generate one or a few terms to use in health care delivery. The lack of actual standardization affects the use of nursing informatics. Nurse administrators should deal with the challenge to benefit from standardization.
The healthcare system has grown and capitalized on the use of clinical systems and informatics in care delivery. One of the significant changes is the need for standardized nursing terminologies to improve the collection and management of electronic health records. However, health providers should address standardization challenges to achieve the benefits of using nursing terminologies. The changes are necessary to improve communication and collaboration for efficiency and quality outcomes. Overall, nurses should research to use evidence in the development and use of standardized nursing terminologies.