Formal Nursing Languages and Nursing Informatics

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.