What is the importance of using classification systems for nursing nomenclature to describe nursing practice?

Role of Terminologies in Health Care

A terminology is the body of terms used with a particular technical application in a subject of study, theory, or profession. Terminologies vary in their purposes, scopes, and structures. This is especially true in health care where there is a high degree of specialization. Although there exists a nearly universal terminology for human anatomy that is taught to a variety of health professions, there is a wide array of specialized terminologies used in health-care settings. Nursing, for example, has three major terminologies: NANDA International (NANDA-I), the Nursing Interventions Classification (NIC), and the Nursing Outcomes Classification (NOC). The nursing terminologies provide sets of terms to describe nursing judgments, treatments, and nursing-sensitive patient outcomes.

Terminologies in health-care support the documentation of observations, treatments, and outcomes that clinicians put in the patient chart—which is increasingly performed using electronic health record (EHR) systems. Although there exist a fair number of “major” or standard terminologies like the NIC and NOC, there are many more terminologies developed for specific purposes. A local terminology is one that is created for a specific purpose by a single organization, such as a laboratory, hospital, clinic, or pharmacy. For example, a local terminology may be used by the laboratory supporting a large health system to provide “user friendly” terms to physicians who order the tests.

Although useful to providers in a particular health system, a local terminology may be difficult to interpret by providers in another health system. For example, Health System A might refer to a glycated hemoglobin (HbA1c) test as “Glycohemoglobin,” whereas Health System B may refer to a similar test as “Hemoglobin A1c.” Although a human clinician can use his or her clinical knowledge and expertise to reason that the two tests likely mean the same thing, computers cannot perform such reasoning in isolation. Therefore, to ensure that meaning or semantics are transferred along with the test results during HIE, health information systems should use a reference terminology. A reference terminology is a formal, canonical terminology developed and maintained by a national or international standards development organization (SDO). A reference terminology is often referred to as a standard, terminology standard, or standard terminology. SDOs and the development of standards is described in the chapter “Standardizing and Exchanging Messages”.

Terminologies consist of terms which are also referred to as concepts. A term can represent a clinical observation (eg, weight, blood pressure, response to a question asked of a patient), a laboratory result, or a clinical diagnosis. Most terms, especially those in standard terminologies, are represented by both a code and a description. The code is often a unique, numeric identifier that abstractly represents the concept. A description can be a shorthand name or descriptor that is human-readable. For example, a code 12345 might have a description of “Hemoglobin A1c.” Some standard terminologies often have multiple axes or dimensions for each term to more precisely define them.

1 Introduction

Nurses and midwives represent the largest proportion of the healthcare workforce globally [1,2] and they routinely capture a large volume of patient data across the entire life span [3,4]. The evolution of Electronic Health Records (EHRs) has further enhanced the potential of nursing clinical documentation to generate valuable knowledge [5,6]. However, despite nurses spending an estimated 13–28 % of total shift time recording clinical care [7], nursing documentation has remained largely untapped and undervalued [8]. This is perhaps amplified by reportedly low quality nursing documentation [9,10] containing few formulated nursing diagnoses [11] and patient needs [12]. Quality information is critical to patient safety, high quality care [8,9,13–15], in quality assurance and to demonstrate the nursing and midwifery contribution to patient care [3]. These requirements and issues are not unique to nurses and midwives, and exist across the healthcare disciplines [16].

As part of a concerted effort to promote consistency in professional vocabularies and high quality documentation, Standardized Terminologies (STs) have been developed and employed [17]. According to the World Health Organization (WHO), a ST is a “compilation of terms used in the clinical assessment, management and care of patients, which includes agreed definitions that adequately represent the knowledge behind these terms and link with a standardized coding and classification system” [18]. STs usually represent defined aspects of clinical practice [19–21] and facilitate semantic interoperability across geographical boundaries, irrespective of language [16,20,22,23]. Standardized nursing terminologies, which are often used interchangeably with standardized nursing languages, systematically group, define and encode nursing care as nursing diagnoses, interventions and/or outcomes [24–27], and link nursing diagnoses with evidenced-based interventions and outcomes [7]. No universal ST has been determined and several nursing-specific and multidisciplinary STs have been approved for clinical use by the American Nurses’ Association [28,29]. Additionally, Nursing Minimum Data Sets (NMDS) and other terminologies are being locally-developed to meet specific requirements.

Nursing has a long history of ST use. One of the first nursing STs, the North American Nursing Diagnosis Association (NANDA) was pioneered in the 1970s [17]. To date, literature reviews have evaluated single [6,30] or several nursing-specific STs [31–35] and have largely focused on the secondary use of STs in nursing and midwifery practice [32,33,35]. Few of the studies identified by these reviews had evaluated the use of STs within clinical practice [6,34]. Additionally, the importance of interoperability and data continuity across disciplines and settings, is now widely recognised, necessitating consideration of multidisciplinary STs such as the Systemized Nomenclature of Medicine – Clinical Terms (SNOMED-CT). The potential use of STs in nursing and midwifery practice within EHRs has become a priority for the Five Country Nursing and Midwifery Digital Leadership Group (DLG) with representatives from England, Wales, Scotland, Northern Ireland and the Republic of Ireland. The DLG commissioned a literature review with the aim of exploring the use of STs in nursing and midwifery practice. The objectives of this scoping review are to:

Identify the STs being used in nursing and midwifery practice across different healthcare contexts.

Review the impact of STs on nursing and midwifery practice.

6 Conclusion

In summary, ICNP® was used as a case in the exploration of the extent to which nursing terminology and classification systems have been utilized in published research. Using published empirical work on ICNP® as a way of measuring this, the authors were able to obtain a picture of the state of uptake and use of nursing terminologies and classifications systems within the last decade. Although studies may have been published that showcase the use of nursing terminologies to better understand the relationship between nursing practice and clinical outcomes in a few scenarios, in the case of ICNP® as with other nursing and healthcare terminologies, most of the publications appear to relate to the development and validation of the system. With work well-advanced on the development, validation and assessment related to the appropriateness of nursing terminologies for various care settings, now is an opportune time for nursing terminologies to be leveraged in the generation of nursing knowledge and evidence. The authors call for organizations that have adopted nursing terminology and classification systems to use their data to answer meaningful questions about nursing practice, and to publish their findings widely. With the information available to date, it is difficult to assess what impact these systems have yet had.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Summary table

What was already known on the topic

The terminology Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) contains nursing terms that have been previously mapped to it from recognized nursing terminologies.

SNOMED CT is the terminology currently supported by organizations to standardize nursing practice in electronic applications, such as electronic health records.

No prior studies have actually assessed the stage of implementation of SNOMED terminology (Pre-SNOMED CT and SNOMED CT) in nursing practice.

What this study added to our knowledge

A comprehensive overview of the efforts underway to ensure representation of nursing in SNOMED terminology (Pre-SNOMED CT and SNOMED CT).

A description of the developmental/implementation stages of the usage of SNOMED terminology in nursing.

There is no evidence of the use of SNOMED CT in nursing practice. Considerable work is still needed to achieve widespread generation of interoperable SNOMED terminology coded nursing data.

Abstract

Aim

The aim of this systematic review was to synthesize evidence on the application of the Omaha System in the education of nursing students and to provide advice for educators to apply the Omaha System to practice and research effectively and meaningfully.

Background

It is a necessary part of nursing education to provide students with informatics experience. The Omaha System is a standardized nursing terminology designed to enhance practice, documentation, and information management.

Design

A systematic review and narrative synthesis.

Methods

Studies from eight databases (PubMed, Web of Science, Embase, CINAHL, PsycINFO, China Biology Medicine disc, CNKI, Wanfang Data) were systematically retrieved. Twenty-three articles were found and synthesized.

Results

Existing studies showed that the Omaha System was mainly applied in student community practice as a tool for guiding practice and collecting information, and the practice data were used by educators to analyse the outcomes of nursing education. Recently, the Omaha System was introduced into the classroom environment and achieved positive results in terms of teaching. Students’ feedback on the use of the Omaha System was generally positive.

Conclusions

The Omaha System can be an active teaching and learning tool for nursing education, and further research is needed to explore and realize its potential in the field of education.

Impact on nursing practice

When evidence-based medicine was proclaimed in 1992 in Canada, the concept of evidence-based nursing was not really new for the nursing profession. Before 1992, a range of key publications paved the way for the development of evidence-based nursing. A few examples are the “Conduct and Utilization of Research in Nursing” report25 and the much discussed booklet, “Nursing Rituals. Research and Rational Actions.”26 In 1975, the RCN launched the slogan, “Nursing is a researched based profession.”27 Several international nursing journals were launched well before 1992 (eg, American Journal of Nursing, International Journal of Nursing Studies, Canadian Journal of Nursing Research, to name a few). These publications all raised awareness of the importance of nursing research and the use of research findings in practice. It caused a gradual shift of the focus of the nursing process from the process over language and nursing terminology to nursing-sensitive patient outcomes. Patient outcomes that are determined to be nursing sensitive are those that improve if there is a greater quantity or quality of nursing care (eg, pressure ulcers, falls, intravenous infiltrations, and adverse events, to name a few).28 Some patient outcomes are more highly related to other aspects of institutional care, such as medical decisions and institutional policies (eg, frequency of primary C-sections, cardiac failure) and are therefore not considered “nursing-sensitive.”28

Nurses have probably always known that their decisions have important implications for patient outcomes. Increasingly, however, they are being cast in the role of active decision-makers in health care by policymakers and other members of the multidisciplinary health care team.29 In the United Kingdom, for example, the Chief Nursing Officer outlined 10 key tasks for nurses as part of the National Health Service’s modernization agenda and the breaking down of artificial boundaries between medicine and nursing. Nurses are expected to access, appraise, as well as incorporate research evidence into their professional judgment and clinical decision-making.30 However, despite the huge increase in the amount of research being generated within the nursing profession, the integration of research findings into practice remains problematic and the actual utilization of research is still sparse.31,32 Many authors from different countries and contexts have explored barriers obstructing evidence-based nursing. They include time pressure, limited access to the literature, the absence of relevant literature, lack of confidence in the staff’s ability to critically evaluate empiric research, limited interest in scientific inquiry, a work environment that does not support or value EBP, inadequate research resources, lack of evidence and limited authority or power to change practice based on research findings, and lack of professional attitudes toward the nursing profession.8,19–21,33–36 A recent survey of the state of EBP in nurses indicated that, although nurses had positive attitudes toward EBP and wished to gain more knowledge and skills, they still faced significant barriers in using it in practice.37 Hence, for EBP to be successfully adopted and sustained, nurses and other health care professionals recognize that it must be adopted not only by individual health care providers but also by microsystems and system leaders, as well as policymakers. Federal, state, local, and other regulatory and recognition actions (eg, the Magnet Recognition Program or Team Strategies and Tools to Enhance Performance and Patient Safety [TeamSTEPPS])38 are necessary for EBP adoption. Another example is the Magnet Learning Communities (MLC). The MLC is an Internet-based collaborative for nurses engaged in improving patient care outcomes and excellence in nursing practice. The MLC provides an opportunity for nurses to connect and share best practices, resources, research, experiences, and strategies that have led to quality patient care, nursing excellence, and innovations in professional nursing practice (http://www.nursecredentialing.org/Magnet/Magnet-Learning).

At the start of the new millennium, there was a belief that nurses might underestimate the implications of the evidence-based movement.39 Today, the increasing international engagement of nurses, and others associated with nursing care, offers much potential for advancing the uptake of relevant evidence into nursing practice.