Nursing Informatics and Formal Nursing Languages
Formal Nursing Languages,Academic and Clinical Writing, Standardized Coding and System,Framework of Standardized Nursing Language,Computer Based Nursing Documentation,Use of Specific Nursing Terminologies,Historical View,Reference Terminologies Model,Setting Standards for Clinical Terminologies.
Formal Nursing
Languages
The National
Institute of Nursing Research Priority Expert Panel on Nursing Informatics
(1993) defined nursing language as the universe of written terms and their
definition comprising nomenclature or thesauri that are used for purposes such
as indexing, sorting, retrieving, and classifying varied nursing data in
clinical records, in information systems (for care documentation and/or
management), and in literature and research reports.
Determining the way
that nursing data are represented in automated systems is so much in defining a
language for nursing. (p.31)
Academic and Clinical Writing
This report also
differentiated between clinical terms, which represent the language of
practice, and definition terms, which represent the language of nursing
knowledge comprising theory and research.
The distinction between language that
supports practice versus language that supports theory and research is blurring
as the state of the science in this area moves towards definitional, concept
representations that can be processed by computer algorithms and shared among
heterogeneous information systems (Henry & Mead , 1997).
Standardized Coding and System
The research on
standardized language to represent nursing concepts reflects four generations
of inquiry. Initial research focused on the development of standardized coding
and classification systems that represented. the phenomenon of clinical
practice.
Testing of systems for multiple clinical and research purposes by
persons other than the developers followed. As confidence grew that the
nursing-specific systems that had been developed reflected the domain of
nursing and the drivers for multidisciplinary care and care systems grew, some
investigators evaluated the extent to which terminologies not developed for
nursing had utility for nursing practice.
Currently, with the increasing
sophistication in terminological science and the need for data sharing across
heterogeneous information systems, nursing terminology developers, standards
experts, and nursing informatics researchers have collaborated to conduct
research towards the goal of semantic interoperability, ie, that data collected
in tone information system using one terminology can be understood in another
information system that uses a different terminology.
Also reflective of the
current generation is the integration of nursing-specific terminologies into
large concept-oriented terminologies such as SNOMED Clinical Terms (CT) (Bakken
et al., 2002) and the Logical Observation Identifiers, Names, and Codes (LOINC)
database ( Matney , Bakken, & Huff, 2003).
Framework of Standardized Nursing Language
Standardized language
for nursing developed within the framework of the nursing minimum data set,
comprising five data elements specific to nursing:
(a) nursing diagnosis.
(b)
nursing interventions.
(c) nursing outcomes.
(d) intensity of care.
(e)
unique RN provider number ( Werley , Devine, & Zorn, 1988).
Early research
on standardized terminologies focused on the creation of language systems that
represented nursing practice in various settings (Table 1). For example, the
North American Nursing Diagnosis Association Taxonomy I (NANDA) (NANDA, 2004).
Nursing Interventions Classification (NIC) (McCloskey & Bulechek , 2000),
and Patient Care Data Set (PCDS) ( Ozbolt , 1996) were initially developed for
the acute care setting, the Omaha System for the community setting (Martin
& Scheet , 1992) , and the Home Health Care Classification (HHCC) (now the
Clinical Care Classification) for the home care setting (Saba, 1992).
Computer Based Nursing Documentation
The advent of
computer based nursing documentation systems was only one motivation for
standardization of nursing language; Others were to document nursing practice,
articulate nursing contributions to patient care outcomes, and seek
reimbursement for nursing care.
Consequently, a number of studies evaluated
whether a particular nursing terminology was useful in a particular clinical
domain. For example, J. Carter and associates (J. Carter, Moorhead, McCloskey,
& Bulechek , 1995) demonstrated the usefulness of NIC in implementing
clinical practice guidelines for pain management and pressure ulcer management.
Parlocha ( Parlocha & Henry, 1998) reported the usefulness of the HHCC for
categorizing nursing care activities for home care patients with a diagnosis of
major depressive disorder. Several studies demonstrated the capacity of the
Omaha system to predict service utilization (Marek, 1996) and outcomes of care
(Martin, Scheet , & Stegman, 1993).
Moreover, instead of creating new
terminologies from scratch, groups such as the Association of Perioperative
Registered Nurses (AORN) adopted some terms from existing terminologies and
augmented as needed for their specialty practice (Perioperative Nursing Data
Set) (AORN, 1997).
Use of Specific Nursing Terminologies
Other investigators
provided evidence that nursing terminologies were useful to retrospectively
abstract and codify patient problems and nursing interventions from sources of
research data such as care logs (Naylor, Bowles, & Brooten, 2000) or
patient records (Holzemer et al., 1997).
In another investigation, Holzemer,
Henry, Portillo, and Miramontes (2000) based on the documentation of their
nursing-delivered adherence intervention on HHCC in order to determine the dose
of the nursing intervention in a randomized controlled trial.
Historical View
Complementary to
the research that was being conducted, the American Nurses Association played a
significant policy role in recognizing nursing language systems that met specific criteria not only related to utility for nursing but
scientific rigor (McCormick et al., 1994).
This process facilitated the
inclusion of selected nursing terminologies into the Unified Medical Language
System (UMLS) (Humphreys, Lindberg, Schoolman, & Barnett, 1998).
Several research
studies examined whether or not standardized terminologies not designed
specifically for nursing were useful for coding nursing-relevant content such
as diagnoses, interventions, goals, and outcomes. The Current Procedural
Terminology (CPT) comprises more than 7,000 codes designed for reimbursement of
health care services provided by physicians; as such, these terms are present
in numerous state and federal databases (American Medical Association, 2000).
Studies by Griffith and Robinson (1992, 1993) provided evidence that nurses
perform many CPT-coded functions and that some functions are performed multiple
times in a single day. Henry, Holzemer, Reilly, and Campbell (1994)
demonstrated that the Systematized Nomenclature of Human and Veterinary
Medicine (SNOMED) was more comprehensive than NANDA to describe the problems of
persons living with HIV/AIDS.
In another study, Henry and colleagues (1997))
compared the frequencies with which 21,366 nursing activity terms from multiple
data sources (patient interviews, nurse interviews, intershift reports, and
patient records) could be categorized using NIC and CPT codes. There were
significantly (p < .0001) greater numbers of nursing activity terms that
could be categorized in NIC than in CPT, thus providing evidence for the
superiority of NIC in representing
nursing activity data.
In recent years, consistent with the state of
terminological science and the clear indication that a single terminology could
not meet all needs (Cimino, 1998), the focus of inquiry related to nursing
language has been on the creation of computable representations of nursing
concepts and on the subsequent integration with concept oriented terminologies
with broad coverage for the domain of health care.
Reference Terminologies Model
The core of a
concept oriented terminology is the reference terminology model. A number of
nurse researchers focused on developing and testing models for nursing
diagnoses and nursing actions (Bakken, Cashen , Mendonca, O’Brien, &
Zieniewicz , 2000; Hardiker & Rector, 1998; Hardiker & Rector, 2001;
Henry & Mead , 1997; Moss, Coenen , & Mills, 2003).
Under the
leadership of the International Council of Nurses and the Nursing Special
Interest Group of the International Medical Informatics Association, and with
input from many including the Nursing Terminology Summit ( Ozbolt , 2000), the
International Standards Organization developed an international standard for a
reference terminology model for nursing diagnoses and nursing actions (Bakken,
Coenen , & Saba, 2004).
These models facilitated the integration of
selected nursing terminologies (Table 1) into SNOMED CT, a concept-oriented
health care terminology that is currently available for free use in the US
Setting Standards for Clinical Terminologies
SNOMED CT is an
evolving national standard for clinical terminology. Selected nursing
assessments, goals, outcomes, and standardized measurements have also been
integrated into LOINC, a national standard for observation names ( Matney et
al., 2003).
In addition, a number of the nursing terminology developers have
registered their terminologies with the Health Level 7 standards organization
(Table 1) for use in messaging among information systems (Bakken, Campbell,
Cimino, Huff, & Hammond, 2000).
This evolution in nursing language research is important
because concept-oriented terminologies are an essential component of the
evolving National Health Information Infrastructure ( NHII ) and to the four
goals of the related NHII framework for strategic action: 1) inform clinical
practice, 2) interconnect clinicians, 3 ) personalize care, and 4) improve
population health (Thompson, TG, & Brailer , 2004).
Consequently, it is
vital that nursing as well as medical terms are included. Furthermore, the
significant progress through nursing language research has laid the foundation
for other types of research including clinical decision support and data mining
for nursing knowledge development.