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Information and Nursing Terminology in Health Care

Information and Nursing Terminology in Healthcare

Information has been a vital component of delivering quality healthcare services. Since the early 1970s, the healthcare information system has been critical in supporting the drive to manage healthcare resources more efficiently and effectively. The continued technological advancement in healthcare settings increases the demand for information. The information must be available and accessible to many people, have a lifespan that expands beyond the clinical encounter, and serve multiple and varied purposes. In the last few years, information and communication technologies have expanded the role of healthcare-related information, including knowledge management for healthcare service users and medical personnel. In the healthcare setting, handwriting, speech and text are powerful and flexible sources that do not require changing one’s perception of information. However, these traditional ways of receiving information can no longer meet the modern and future demands placed on the information, particularly in the wake of advances in natural language processing. As a result, such shortcoming, among others, has led to the development of several healthcare terms.

Nursing Terminology Used in My Area

Four years ago, my hospital initiated a new computer software system called EPIC that promised to simplify the complex hospital system and incorporate the diversity of human recourses involved in patient care. This new software provides a visual and friendly program allowing nurses and other interdisciplinary team members to share and receive real-time orders and data from on-site and remote places. NANDA is the source of nursing terminology used in my practice, founded in the early 1980s. It develops research and disseminates criteria and taxonomy for nursing diagnosis. The terminology offers a starting point for evaluating the nursing diagnosis. It is essential since it offers multiple perspectives on diagnosis and recognizes that using an accredited nursing valuation framework is essential to identify patients’ problems and outcomes. Moreover, NANDA supports applying more than one assessment tool and embraces an evidence-based model such as Gordon’s Functional Health Pattern assessment that supports the nurses in determining the NANDA nursing diagnosis. For a more accurate and precise diagnosis, a useful evidence-based assessment is essential, and NANDA defines the patient as an individual, group or community that makes it possible to establish an efficient diagnosis.

Development of NANDA Terminology

NANDA was established in the early 1980s. The terminology grew out of the National Conference Group, a committee instituted in 1973 at the first conference on the classification of nursing diagnostic strategies held in Missouri. The conference participants developed a classification composed of an alphabetized list of nursing diagnoses. Following several periodic meetings, the classification committee realized the need for new comprehensive taxonomic structures. The committee determined whether the classification emerged naturally from the recognized diagnosis data. In 1994, Round 1 of a naturalistic Q-sort was instituted in Nashville, USA. After that, the second round of the list was developed, and the analysis was submitted during the 12th conference held in Pennsylvania in 1996. However, the Q-sort yielded 21 categories that were excessive for any practical use.

In 1998, the committee submitted four different Q-sorts using four varied frameworks to the NANDA board. Thus, there was Framework 1, which was grounded on the naturalistic styles, Framework 2, which was based on Jenny’s ideas, Framework 3, based on Nursing Outcome Classification and Framework 4, which used the Gordon Functional Health Patterns. Although none of the frameworks was adequate, Gordon’s was considered efficient. Therefore, with Gordon’s consent, the committee modified the framework to develop Framework 5, presented at the conference in 1998 in Nashville, and ultimately 40 different usable data sets for analysis were established.

Based on the data analysis and field notes, further modifications were implemented in the framework. Now, one domain of the original framework was divided to reduce the number of classes and diagnoses within its realm. Therefore, a separate domain for growth and development was added since the original framework lacked it. Moreover, other multiple domains were revised to ensure they better reflected the content of the diagnoses. Although the taxonomic structure is much less like Gordon’s original framework, with reduced misclassification error and redundancy that is close to zero, this variant is much desired in taxonomic structures.

Concerning the meanings, they were established for all fields and classes within the classification structures. The definition of each diagnosis was compared with that of the class and domain within which it was placed. In 2002, following the NANDA conference in Chicago, the approved diagnoses were placed under Taxonomic II, which entails 11 health promotion and newly certified nursing diagnoses.

How This Standardized Nursing Terminology Is Captured in Nursing

NANDA has enormous significance in the enhancement of nursing diagnostics. The historical importance of NANDA as the basic element in nursing care has been reviewed and certified by different health bodies. Its wide application in the nursing setting is based on its ability to describe judgments made by nurses in the provision of care. Such diagnoses form the basis for selecting appropriate nursing interventions and establishing appropriate patient outcomes. Moreover, its acceptability is founded on its dynamic nature since it is updated every two years.

Furthermore, since 1992, NANDA has been recognized by the American Nursing Association (ANA) to establish standardized terms for use in the nursing context. Its wide use in nursing is largely based on its standardized model derived from evidence-based research. NANDA is also constantly revised to reflect the most current needs within the nursing environment; therefore, it collaborates with nursing professionals and other stakeholders, such as Nursing Intervention Classification System (NIC) and Nursing Outcomes Classification (NOC). Consequently, NANDA emerges as the ultimate terminology that nurses widely use.

In addition, NANDA can extensively be used in the dynamic nursing environment since its terms are reviewed and transformed based on the changes in public policies, evidence-based research and emerging needs within nursing care. Many healthcare professionals that employ registered nurses use NANDA definitions and classifications in the documentation. For instance, the NANDA documentation standards reflect the patient safety objectives of the joint commission, a firm that offers accreditation services to hospitals within the USA. Moreover, most nursing programs require the application of NANDA-approved languages for use in the student’s care plan and other paperwork. Nursing schools using NANDA vocabulary educate the student about the nursing process through the ability to use systematic clinical judgment.

Insuring Appropriate Implementation and Consistent Terminology Usage

Although nursing care has historically been associated with medical diagnoses, a nurse requires explicit language to establish their standard and influence the legal framework governing the practice. To ensure consistent use, the terminology must be defined so that the nursing care can communicate accurately with the nurses and other allied healthcare professionals. Moreover, it is recommended for the terminology be standardized to ensure that a term can be coded and measured. The measurement of the terminology through Electronic Documentation (ED) will permit the establishment of large databases that enhance evidence-based standards for validating the contribution of nurses to patient incomes. Furthermore, it is essential to describe how a standardized nursing language will be used in the clinical field, including the benefits and consequences for the nursing administration. Thus, this will ensure appropriate frameworks are established to ensure correct implementation and use of the terminology in enhancing nursing care.

Data Collection Using Standardized Nursing Language

Using a standardized language permits data gathering in a consistent way that facilitates comparisons of the outcomes of various nursing interventions. Since more organizations have started using electronic documentation (ED), there is an increased need to collect critical nursing data whose analysis influences the decision. When nursing care data is gathered and preserved in computer systems, it permits the establishment of large data stores that facilitate comparison with other nursing care institutions. In addition, using NSL permits the collection of nursing-sensitive outcomes using the Nursing Outcomes Classification (NOC). Since NOC measures the nursing outcome using numerical rating scales, it enhances the provision of comparisons of nursing practices with other healthcare settings. The NOC outcome experienced by labor nurses is usually the pain levels related to the sternness of the pain during contractions. The pain level is evaluated throughout the application of the intervention. Therefore, indicators such as moaning, crying, and respiratory rate are rated on a scale from severe to none. The variation between the numerical ratings for indicators is used to estimate the success of the intervention, thereby achieving the required objectives.

Benefits and Barriers of Using Standardized Nursing Terminology

Standardized Nursing Terminology benefits the nursing environment by enhancing the outcome of nursing care. It makes it efficient to assess the nurses’ competency in performing nursing roles in an efficient and structured way. Moreover, using standard terminology ensures a shared understanding of collected information across the continuum of care, thereby creating common links to clinical knowledge bases. NANDA offers a wide range of benefits since it sets terms for describing nursing judgments, treatment, and nursing-sensitive patient outcomes. Moreover, it permits clinical judgment through standardized definitions for all terms and facilitates the selection of appropriate diagnoses.

Furthermore, it populates electronic health record assessments with evidence-based criteria supporting effective medical decision-making and individualized intervention. Nevertheless, several obstacles limit the use of standard nursing terminology. Thus, the two greatest barriers include the need for more resources to pay for the necessary equipment to document nursing care, including the licensing fees and lack of understanding of the standard nursing terminology by all healthcare personnel. Furthermore, the lack of electronic documentation (ED) poses huge barriers since it is only possible for nursing, medicine or any other health-related discipline to implement standardized terminology with a well-established electronic document system (ED).

Standardized Nursing Language

Standardized Nursing Language (SNL) should be used to document nursing care. In the modern healthcare environment, the requirement to offer-cost effective and safe patient care remains paramount and is fundamentally embedded in all health reform policies. Therefore, communicating the contributions of professional nursing practices with other nurses and healthcare members requires articulating nursing’s focus of concern and responses to these concerns to improve patient outcomes. Furthermore, the visibility of the Electronic Health Record (EHR) in the nursing practice increases the need for nurses to communicate within the realm of the electronic format. Therefore, integrating the SNLs into the patient record will allow the nurses to describe the focus of their practice by identifying the nursing diagnosis, intervention, and outcomes. Continued refinement of the SNLs will further offer the nursing with an accurate, precise and reliable way of using data elements across the populations and settings to communicate the nursing practice as well as enable the nursing administrators to delineate needed resource with greater precision and accurately reflects the nursing impact on patient care and the healthcare system.


In conclusion, information plays a major role in enhancing the quality of nursing care. In today’s dynamic and changing health environment, delivering quality, safe, evidence-based patient care is an absolute requirement. For the nurses to perform duties effectively, they must be able to freely share their contribution to the patient with other nurses and healthcare professionals. Furthermore, they need to be able to update the new and changing clinical evidence practice. However, the use of appropriate and widely accepted nursing terminology remains critical. NANDA terminology has significantly revolutionized nursing diagnosis since it offers multiple perspectives on the diagnosis that focuses on patient problems, risk, and outcomes. However, due to barriers associated with the terminology, developing a standardized Nursing Language (SNL) that will be universally applicable across nursing care is recommended.

📎 References:

1. Herdman, T. H., & NANDA International. (2012). Nursing diagnoses: Definitions & classification 2012-2014. Chichester: Wiley-Blackwell.
2. Hill, A. E., Davidson, B. J., & Theodoros, D. G. (2013). The performance of standardized patients in portraying clinical scenarios in speech-language therapy. International Journal of Language & Communication Disorders, 48(6), 613-624.
3. NANDA International. (2014). Nursing diagnoses 2015-17: Definitions and classification. Hoboken, NJ: Wiley.
4. North American Nursing Diagnosis Association. (2011). Nursing diagnoses: Definitions and classifications, 2012-14. Hoboken, NJ: John Wiley and Sons.
5. Rutherford, M. (2008). Standardized nursing language: What does it mean for nursing practice? The Online Journal of Issues in Nursing, 13(1).
6. Ryan, C. A., Walshe, N., Gaffney, R., Shanks, A., Burgoyne, L., & Wiskin, C. M. (2010). Using standardized patients to assess communication skills in medical and nursing students. BMC Medical Education, 10(24).