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Standardized terminology, also known as standardized nursing language is a set of commonly used and understood terms that are used in clinical documentation such as diagnoses. The use of standardized terminology allows for a faster examination of data when multiple healthcare institutions collaborate with each other, as well as a faster period of adaptation for new employees and lack of confusion between the nursing staff. Before such language was implemented, terminology could vary even within one hospital, which led to a variety of issues that could otherwise be prevented. This paper will examine the way that standard terminology is used in modern hospital settings, as well as provide my perspective on the use of this information system.
The Use of Standard Terminology
The use of standardized terminology has become essential for nursing documentation. While there is not one but over a dozen of standard nursing care languages, their use has already provided a number of benefits to the communication between nurses. It allowed for easier understanding between nurses and health providers; higher clarity of nursing interventions; improved data collection and evaluation; a larger focus on standardized care; and an improvement of patient care overall (Luann & Aunchisa, 2016). The popularity of standardized nursing terminologies stretches all over the world as various countries begin developing their own standardized terminologies. Their effectiveness has shown to be high in the various studies on the subject.
Each language chooses a set meaning for specific acronyms, which may be different between two different facilities. Due to the constantly increasing lexicon of scientific terms, it is impossible to shorten all of them into simple acronyms. Eventually, two or more different terms will have to share the same combination of letters if a specific standard is not set. This could lead to major issues such as misdiagnosis and prescription of wrong treatments or at the very least it could make simple work with documents a much more time-consuming process. Standardized nursing terminology is also seen in a positive light by nurses. In situations when professionals from multiple medical fields have to cooperate to resolve an issue, standardized terminology allows for a smooth flow of information between the participants (Saranto et al., 2014).
However, it is important to consider that standardized terminology is not a perfect solution to the issue. There are relatively small problems with standard terms that could lead to more difficult evaluation of nursing care. To evaluate a document written in a certain standardized nursing language, a person must first understand its use of terminology. Although the information about the languages is usually easily accessible, the process of deciphering the terminology of the paper may be more time consuming than it was originally intended (Törnvall & Jansson, 2017). Nevertheless, the use of standardized terminology is considered essential, even in cases where it could lead to an extended period of evaluation.
Personal Experience
When I was a child, my family moved between states, which forced us to change the family physician that previously worked for my family and me. It was before standardized terminology became widely used by healthcare institutions and I have experienced firsthand how important it may be for both medical professionals and patients. In the first few months of living in the new state, our new family doctor was not able to fully understand the documentation provided by our last doctor and had to contact him on multiple occasions for confirmation and clarification of our medical history. While he never misdiagnosed anyone in my family, his inability to reliably tell the meaning of various acronyms has led to prolonged visits to his office, which would be much shorter if the standardized terminology was already widely used.
I have also experienced the benefits of standardized nursing language during my work. Due to unfortunate events caused by a natural disaster, a lot of my colleagues had to move to a different location, and the hospital started experiencing severe staff shortages. To resolve this issue, management approached nurses from other hospitals with a proposal to transfer to ours. Some agreed and joined our staff. Despite the initial worry about their adaptation (the hospital needed new staff in a very short order), all new members of the staff adjusted in record time. When asked about the reasons for such quick transition, they explained that our hospital utilized the same standardized terminology as their previous places of work. The shortage was eliminated before anyone could experience burnout and only positive outcomes were recorded during this process.
Conclusion
The use of standard terminology has become essential for all healthcare institutions. Its popularity has spread all over the world, and it has become widely accepted by the medical community. It allows for better communication, data collection, and a variety of other benefits that were previously unattainable. I have experienced the benefits of standardized nursing languages not only as a nurse but also as a patient, and I can say definitively that for me they are an essential part of modern medicine and further work with them is required.
References
Luann, W., & Aunchisa, M. (2016). Electronic nursing documentation: Patient care continuity using the clinical care classification system (CCC). Studies in Health Technology and Informatics, 225, 1317.
Saranto, K., Kinnunen, U.-M., Kivekäs, E., Lappalainen, A.-M., Liljamo, P., Rajalahti, E., & Hyppönen, H. (2014). Impacts of structuring nursing records: A systematic review. Scandinavian Journal of Caring Sciences, 28(4), 629647.
Törnvall, E., & Jansson, I. (2017). Preliminary evidence for the usefulness of standardized nursing terminologies in different fields of application: A literature review. International Journal of Nursing Knowledge, 28(2), 109119.
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