Standardized nursing terminology
Nursing Terminology Standards
should be part of Unified Medical Language System (UMLS).
In the early 1970s the first standardized nursing terminology, the North American Nursing Diagnoses Association (NANDA) was created (NANDA International, 2010). NANDA is a set of nursing diagnosis helping a practitioner to codify a clinical judgment about an individual, family, or community and their response to actual or potential health problems. This differs from a medical diagnosis, which deals with a disease or medical condition rather than a human response to symptoms or conditions (NANDA International, 2010).
Shortly thereafter, in 1975, the Division of Nursing of the Department of Health and Human Services funded the creation of the Omaha System. The Omaha System is a practice and documentation standardized taxonomy designed to assist in the documentation of care throughout the continuum of clinical care, including home health, ambulatory clinics, and hospital settings (Omaha System, 2010). It focuses not just on identifying problems, but also on interventions and outcomes. This system outlined the need to codify information beyond just a diagnosis, but also the steps taken to improve health, allowing a method to correlate interventions to outcomes over time and varied patient populations.
The next nursing set of standards, arising in 1985, is the Nursing Minimum Data Set (NMDS). This was the first attempt to make standard the core data elements that nursing collects. It differed from NANDA and Omaha in that it attempted to define a standard set of all of the types of data nursing collects or contributes to patient care (Werley, Devine, Zorn, Ryan, & Westra, 1991). This is also when we begin to see more emphasis on using these standards not just to compare data across populations or over time, but to use it for predicting nursing resource needs and capturing a measure of nursing intensity across populations or health problems. The NMDS contains 16 data elements, broken into three groups: Nursing Care Elements, Patient or Client Demographics, and Service Elements. The Nursing Care Elements contains four items of nursing diagnosis, intervention, outcome, and intensity. The remaining elements are not strictly in the nursing domain, but help quantify populations of care. They include demographic data such as patient ID, date of birth, sex, race/ethnicity, residence, as well as institutionally required data like date of service, identification of an encounter, facility ID, etc (Werley, Devine, Zorn, Ryan, & Westra, 1991).
In light of these new terminologies, the American Nurses Association created a Steering Committee on Databases to create a set of criteria for officially recognizing different nursing terminologies. Over the next ten years, as the discussion and debate over the creation of nursing standards continued, the committee adopted the International Standards Organization (ISO) standards for terminologies, thus allowing the standards to be applicable internationally as well as domestically (Westra, Delaney, Konicek, & Keenan, 2008).
The next wave of terminologies, dubbed interface terminologies, or point of care terminologies, “include the actual terms/concepts readily used by nurses for describing and documenting the care of patients (individuals, families, and communities).” (Westra, Delaney, Konicek, & Keenan, 2008) The reason there are so many sets of terminologies is that there are several that are for specialized areas of care. The interface terminologies often represent a way to capture one or more of the four nursing elements of the NMDS. NANDA has since been categorized as one of these interface terminologies and is often paired with two classification systems that came along in 1987. The Nursing Interventions Classification (NIC), and the Nursing Outcomes Classification (NOC) categorize interventions and outcome assessments respectively.
NANDA, NIC, and NOC are frequently used in combination in the hospital setting, whereas the Omaha system and some of the other interface terminologies, such as the Perioperative Nursing Data Set, or the Clinical Care Classifications, are used in community, home health or other specialized clinical settings.
NIC contains the interventions that nurses do for patients, either independently or collaboratively. An intervention is defined as "any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes." (Center for Nursing Classification & Clinical Effectiveness, University of Iowa, 2010) NOC contains a listing of patient/client outcomes which are designed to evaluate the effects of nursing interventions. The Center for Nursing Classification and Clinical Effectiveness states that “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.” (Center for Nursing Classification & Clinical Effectiveness, University of Iowa, 2010) They define an outcome as a measurable individual, family, or community state, behavior or perception that is measured along a continuum and is responsive to nursing interventions. Use of this outcomes classification tool aids in measuring progress toward patient care goals.
Center for Nursing Classification & Clinical Effectiveness, University of Iowa. (2010). Center for Nursing Classification. Retrieved November 20, 2010, from http://www.nursing.uiowa.edu/excellence/nursing_knowledge/clinical_effectiveness/nic.htm NANDA International. (2010). History of NANDA. Retrieved November 20, 2010, from www.nanda.org: http://www.nanda.org/AboutUs/History.aspx
NANDA International. (2010). NANDA FAQ. Retrieved November 20, 2010, from www.nanda.org: http://www.nanda.org/NursingDiagnosisFAQ.aspx#NDxBasics
Omaha System. (2010, April 10). Omaha System. Retrieved November 20, 2010, from www.omahasystem.org
Regenstrief Institute. (2010, January 15). Background of LOINC. Retrieved November 20, 2010, from LOINC.org: http://loinc.org/background
US National Library of Medicine. (2010, May 12). Unified Medical Language System. Retrieved November 20, 2010, from National Library of Medicine: http://www.nlm.nih.gov/research/umls/Snomed/snomed_main.html
Werley, H. H., Devine, E. C., Zorn, C. R., Ryan, P., & Westra, B. L. (1991). The Nursing Minimum Data Set: Abstraction Tool for Standardized, Comparable, Essential Data. American Journal of Public Health , 81 (4), 421-426.
Westra, B. L., Delaney, C. W., Konicek, D., & Keenan, G. (2008). Nursing standards to support the electronic health record. Nursing Outlook , 56 (5), 258-266.
Submitted by (Jessica M. Alexander)