What is a comprehensive research based standardized nursing language useful for standards care plans and competency evaluation?

To explore the use and impact of standardized terminologies (STs) within nursing and midwifery practice.

Introduction

The standardization of clinical documentation creates a potential to optimize patient care and safety. Nurses and midwives, who represent the largest proportion of the healthcare workforce worldwide, have been using nursing-specific and multidisciplinary STs within electronic health records (EHRs) for decades. However, little is known regarding ST use and impact within clinical practice.

Methods

A scoping review of the literature was conducted (2019) across PubMed, CINAHL, Embase and CENTRAL in collaboration with the Five Country Nursing and Midwifery Digital Leadership Group (DLG). Identified studies (n = 3547) were reviewed against a number of agreed criterion, and data were extracted from included studies. Studies were categorized and findings were reviewed by the DLG.

Results

One hundred and eighty three studies met the inclusion criteria. These were conducted across 25 different countries and in various healthcare settings, utilising mainly nursing-specific (most commonly NANDA-I, NIC, NOC and the Omaha System) and less frequently local, multidisciplinary or medical STs (e.g., ICD). Within the studies, STs were evaluated in terms of Measurement properties, Usability, Documentation quality, Patient care, Knowledge generation, and Education (pre and post registration). As well as the ST content, the impact of the ST on practice depended on the healthcare setting, patient cohort, nursing experience, provision of education and support in using the ST, and usability of EHRs.

Conclusion

Employment of STs in clinical practice has the capability to improve communication, quality of care and interoperability, as well as facilitate value-based healthcare and knowledge generation. However, employment of several different STs and study heterogeneity renders it difficult to aggregate and generalize findings.

Wiki Content by: Yong IL Choi, Debbie Crownover, and Lauren Wiseman and GOS (guide-on-the-side)

---

---

GOS Note:  This team has done an awesome job of succinctly summarizing this highly important content.  Here are my take-away comments:  

Remember: 

1.  Terminology standards are incredibly dynamic and changing all the time.  You simply cannot memorize something in this area and expect it to be current next year.  

2.  It is important to recognize that existing nursing language/terminology standards are necessary but not sufficient for good health IT work at present.  Each has strengths and weaknesses.  None of them are good enough to stand alone (IMHO) but there are folks in nursing who argue vehemently for their favorite one!   

3.  SNOMED is sort of becoming the de facto terminology standard.  All the recognized ANA nursing languages are either already included or being added.  Purists will tell you that SNOMED is not adequate for nursing.  Since I'm not an expert on this topic, I'll suggest you do more homework if you need a definitive answer on whether to use SNOMED instead of or in addition to a recognized nursing language.    

4.  Terminology and language standards exist because we desperately need them! But the complexity makes it difficult to have a single standard that meets everyone's needs at present. 

 

Clinical Terminology Standards

Terminology is the study of terms and their use — of words and compound words that are used in specific contexts.

Terminology also denotes a more formal discipline which systematically studies the labeling or designating of concepts particular to one or more subject fields or domains of human activity, through research and analysis of terms in context, for the purpose of documenting and promoting correct usage. This study can be limited to one language or can cover more than one language at the same time (multilingual terminology, bilingual terminology, and so forth). Definitions per Wikipedia.

Terminology can be characterized by its structure into three categories:

      Nomenclature - describes a list of ideas with little structure

      Classification - groups with common or related ideas

      Ontology - most complex structure that designates and defines class and certain relationships between them.

  Background

Standardized terminology has a long history in the scientific community, but in healthcare, clinical terminology has only begun to evolve in the last two decades.  Adoption of a standardized clinical terminology is essential in the development of electronic health records.This is a formidable challenge, requiring many terminologies to encompass the scope of users, including healthcare providers and consumers.  This standards page is devoted to Nursing terminology and its relationship to health information technology.

Terminology Planning and Language Planning

While the focus of language planning is the deliberate manipulation and development of a linguistic entity to improve communication in society or a language community at large, terminology planning may be language independent or in its objective across languages, aiming at the improvement of communication in a specific domain or application thereof.

While terminology planning is an important part of language planning it may be useful for language communities to separate the two activities for simplification of its complexity in order to better focus programs and resources, and thus receive better results.

Because language planning also concerns the development of the lexicon of a language, and because domain communication consists to a great extent of linguistic representations of concepts there exists a large area of overlapping between the two concepts. The biggest difference lies in the different point of view and scope (and goal).

Nursing Terminology Standards

Data Element Set

NMDS (Nursing Minimum Data Set)

Minimum set of items of information with uniform definitions and categories concerning the specific dimension of professional nursing which meet the information needs of multiple data users in the health care system. 

NMMDS (Nursing Management Minimum Data Set ) and US NMDS

Data variables categorized into environment, nurse resources and financial resources that are needed to inform the decision making process of nurse executives related to leading and managing services delivery and care coordination. Relationships to Related National Initiatives: Registered in HL7.

Interface Terminologies

CCC (Clinical Care Classification)

The Clinical Care Classification System is a standardized, coded nursing terminology that identifies the discrete elements of nursing practice. CCC provides a unique framework and coding structure for capturing the essence of patient care in all healthcare settings. 

ICNP (International Conference on Network Protocols)

The ICNP® is a unified nursing language system. It is a compositional terminology for nursing practice that facilitates the development of and the cross mapping among local terms and existing terminologies. 

NIC and NOC are combined onto one web page of the University of Iowa’s Centers for Excellence. Both are recognized by the ANA and have been implemented by several Clinical Information Systems. For more information on these, please contact the University of Iowa. 

        NIC (Nursing Interventions Classification): The Nursing Interventions Classification is a comprehensive, research-based, standardized classification of interventions that nurses perform. It is useful for clinical documentation, communication of care across settings, integration of data across systems and settings, effectiveness research, productivity measurement, competency evaluation, reimbursement, and curricular design. 

       NOC (Nursing Outcomes Classification): The Nursing Outcomes Classification is a comprehensive, standardized classification of patient/client outcomes developed to evaluate the effects of nursing interventions. Standardized outcomes are necessary for documentation in electronic records, for use in clinical information systems, for the development of nursing knowledge and the education of professional nurses.

NANDA (North American Nursing Diagnosis Association)

A nursing diagnoses classification developed to describe the important judgments nurses make in providing nursing care for individuals, families, groups and communities.  These judgments, or diagnoses, are the basis for selection of nursing outcomes and interventions.  The terminology is updated every two years.Relationship to Related National Initiatives: NANDA (2004) included in UMLS 2005AC; HL7 Recognized Terminology.

Omaha System:

Diagnoses, Interventions, and Outcomes. The Omaha System is a research-based, comprehensive practice and documentation standardized classification; it can be used by multidisciplinary health care practitioners in any setting from the time of client admission to discharge. The three components of the Omaha System are described in the Overview, and include an assessment component(Problem Classification Scheme), an intervention component (Intervention Scheme), and an outcomes  component(Problem Rating Scale for Outcomes). PCDS (Patient Care Data Set)Not applicable, being subsumed as integrated content within clinical LOINC.

PNDS (Perioperative Nursing Data Set)

Describes perioperative nursing practice with a sub-set of terms that specifically describe perioperative nursing diagnoses,nursing interventions and patient outcomes in surgical setting for pre-admission until discharge. Relationship to Related National Initiatives: Registered by Health Level 7 (HL7)Included in UMLS at the National Library of Medicine.

Multidisciplinary terminologies

ABCCodes:

Interventions Terminology that describes alternative medicine, nursing and other integrative healthcare interventions. Includes type of provider and recognized level of licensed practitioner by state.

GALEN:

GALEN is the name given to a technology that is designed to represent clinical information in a new way, and is intended to "put the clinical into the clinical workstation". GALEN produces a computer-based multilingual coding system for medicine, using a qualitatively different approach from those used in the past. 

 (International Statistical Classification of Diseases and Related Health Problems)

The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. Every health condition can be assigned to a unique category and given a code, up to six characters long. Such categories can include a set of similar diseases.

LOINC* (Logical Observation Identifiers Names and Codes)

Outcome and Assessments Coding system for the electronic exchange of laboratory test results and other observations.LOINC development involved a public-private partnership comprised of several federal agencies, academia, and the vendor community. This model can be applied to other standards setting domains.

SNOMED CT* (Systematic Nomenclature of Medicine Clinical Terms)

Diagnoses, Interventions, and Outcomes SNOMED-CT (Clinical Terminology) has been created from the combination of SNOMED-RT (Reference Terminology) and Read codes. NLM and others are working to bring coding systems such as this SNOMED-CT (clinical terms) into the public domain.

UMLS (Unified Medical Language System)

The UMLS is a long term research and development project of the National Library of Medicine (NLM) that began in 1986.This project develops and distributes multi-purpose, electronic "Knowledge Sources" and associated lexical programs.System developers can use the UMLS products to enhance their applications -- in systems focused on patient data, digital libraries, Web and bibliographic retrieval, natural language processing, and decision support. Researchers will find the UMLS products useful in investigating knowledge representation and retrieval questions.

* SNOMED is subsuming the ANA recognized nursing terminologies and seems to be coming up as "the" solution for the NHII, probably along with LOINC.

Areas in Need of Further Development

Pediatric terminology: The terminology contained in these previous standard groups are not totally applicable to pediatrics. The literary search showed no data or articles under this subject.

Pharmacology standard

RxNorm:

Pharmacology standard RxNorm provides standard names for clinical drugs (active ingredient + strength + dose form) and for dose forms as administered to a patient. It provides links from clinical drugs, both branded and generic, to their active ingredients,drug components (active ingredient + strength), and related brand names. NDCs (National Drug Codes) for specificdrug products (where there are often many NDC codes for a single product) are linked to that product in RxNorm.   

 Nursing Practice Information Infrastructure

Relationships Among ANA Recognized Data Element Sets And Terminologies There are many instances of relationships among the recognized terminologies and data element sets. Examples include:

• terminologies being used together
• one terminology being integrated into another terminology, and
• a terminology providing a response set for at data element within a data set.

The table below provides a simple rendering of the existence of relationships among the recognized terminologies and data element sets. For further information, use the links located within the table to visit the developers' Web sites or to contact them via e-mail. ● Indicates a relationship between column and row entities. Example: the "●" in row 3. CCC and column 1. NMDS shows a relationship exists between the Nursing Minimum Data Set and Clinical Care Classification. For further information, click on the name which is linked to the developer's Web site or e-mail address. 1.
NMDS2.
NMMDS3.
CCC4.
ICNP®5.
NANDA6.
NIC7.
NOC8.
OMAHA9.
PCDS
retired10.
PNDS11.
ABC12.
LOINC®13.
SNOMED
CTData Element Sets1. NMDS Nursing Minimum Data Set●●●●●●●●2. NMMDS Nursing Management Minimum Data SetInterface Terminologies3. CCC Clinical Care Classification●●●●4. ICNP® International Classification of Nursing Practice●●5.NANDA NANDA International●●●●●6.NIC Nursing Intervention Classification●●●●●7. NOC Nursing Outcome Classification●●●●●8. OMAHA Omaha Home Health Care System●●9. PCDS (Retired) Patient Care Data Set10. PNDS Perioperative Nursing Data Set●●●Multidisciplinary Terminologies11. ABC Alternative Billing Codes●●●12. (LOINC®) Logical Observation Identifiers Names and Codes●●13. SNOMED CT Systematic Nomenclature of Medicine Clinical Terms●●●●●●● 

Notes on Hospitals by Florence Nightingale

    There is a growing conviction that in all hospitals, even in those which are best conducted,there is a great and unnecessary waste of life;. . . In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison. If they could be obtained, they would enable us to decide many other questions besides the one alluded to. . . [I]f wisely used, these improved statistics would tell us more of the relative value of particular operations and modes of treatment than we have any means of obtaining at present. They would enable us, besides, to ascertain the influence of the hospital . . . upon the general course of operations and diseases passing through its wards; and the truth thus ascertained would enable us to save life and suffering and to improve the treatment and management of the sick. . .

 J. Ozbolt, M. Wilson, D. O’Brien

    To obtain “records fit for any purpose of comparison,” we must use the same terms to represent the same concepts and have the same understanding of how the concepts relate to one another. In computer based systems, we must do this so that humans understand the words they read at the interface and that computers understand the unambiguous, abstract formalisms that encode the meanings “behind the scenes.”

References

Levy, B. (2004). Evolving to clinical terminology. J Healthc Inf Manag, 18(3), 37-43.

Nightingale F. Notes on Hospitals, ed 3. London: Longman, Green, Longman, Roberts, and Green; 1863. pp 175-176.

Ozbolt, J., Wilson, M.,  O’Brien, D. Much ado about terminology standards, Journal of PeriAnesthesia Nursing, Volume 22, Issue 4, Pages 280-284

Weblinks

http://en.wikipedia.org/wiki/Terminology 

            Definition of terminology per Wikipedia

http://nursingworld.org/npii/terminologies.htmhttp://

            ANA Recognized Terminologies and Data Element Sets

www.hhs.gov/healthit/community/background/ 

The American Health Information Community (AHIC) is a federal advisory body, chartered in 2005 to make recommendations to the Secretary of the U.S. Department of Health and Human Services on how to accelerate the development and adoption of health information technology.

http://www.ihtsdo.org

            International Health Terminology Standards Development Organization

http://www.bioontology.org

The National Centers for Biomedical Computing (NCBCs) comprise seven centers dedicated to the development of a national infrastructure for biomedical computation.

What is the standardized language used in nursing care?

Why is standardized nursing language important to the nursing profession?

How would standardized nursing terminology be beneficial for patient care?

How does having a standardized nursing language make your interventions and the patients outcome from the care searchable in the documentation?