NOW FOR AN ORIGINAL PAPER ASSIGNMENT:Case Study: Trends in Patient Care

When the bedside nurse documents via a nursing information system having a standardized language, the data are stored by the hospital, usually in a data warehouse. When the aggregate data are accessed by administrators and researchers, trends in patient care can be uncovered (Zytkowski, 2003), best practices of nursing care unlocked, efficiencies in nursing care discovered, and a relevant knowledge base for nursing can be built. Nursing research performed with these larger sample sizes achieved by using databases may reveal more powerful patterns with stronger implications for practice than can past research that depended on small samples.

Kennedy (2003) states that one byproduct of accurate documentation of patient care is an estimation of acuity level. Patient care data entered into a computer and stored in a database can be used to help develop and adjust nursing schedules based on the projected patient census and acuity. Utilizing a standardized nursing language to document care can more precisely reflect the care given, assess acuity levels, and predict appropriate staffing. Use of a standardized nursing documentation system can provide data to support reimbursement to a health care agency for the care provided by professional nurses.

Summary

The ultimate goal should be the development of one standardized nursing language for all nurses. Use of a standardized language is not something that is done just because it will be useful to others. Use of a standardized language has far reaching ramifications that will help in the delivery of nursing care and demonstrate the value of nursing to others. The benefits of a standardized nursing language include: better communication among nurses and other health care providers, increased visibility of nursing interventions, improved patient care, enhanced data collection to evaluate nursing care outcomes, greater adherence to standards of care, and facilitated assessment of nursing competency.

The ultimate goal should be the development of one standardized nursing language for all nurses. Although that goal has not yet been attained, examples of work toward it can be demonstrated. The International Council of Nurses (ICN) has developed the International Classification for Nursing Practice (ICNP) (ICN, 2006) in an attempt to establish a common language for nursing practice. The ICNP is a combinatorial terminology that cross-maps local terms, vocabularies, and classifications.