“When I use a word”
Standardised language for
nursing practice
Naming Nursing in an Information Age
Bodelwyddan Castle, 21 October 2005
Professor Dame June Clark
Professor Emeritus
University of Wales Swansea
Humpty Dumpty: “When I use a word
it means just what I choose it to
mean - neither more nor less.”
“The question is”, said Alice, “whether
you can make words mean so many
things.”
“The question is” said Humpty
Dumpty, “which is to be Master that’s all.”
Lewis Carroll: Alice Through the Looking Glass
Aims of this session
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To explain why we need standardised
language for nursing
To dispel some of the myths about
standardised language in nursing
To introduce some of the terminologies in
current use
Why do we need
standardised terminology?
“I use the word nursing for
want of a better”
“The elements of nursing are
all but unknown”
Florence Nightingale
“If we cannot name it, we
cannot control it, finance it,
teach it, research it, or put it
into public policy.”
Lang 1991
6
Why we need it

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Clinical practice
Political strength
Technological advances
Knowledge development
Clinical Practice:
to communicate care
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“Nursing is the use of clinical judgement in the
provision of care” (RCN 2003)
To ensure continuity of care, decisions have to
be communicated to other people
The main vehicle for communication is
language
Understanding depends on agreement about
terms
Documentation: the patient record
We need a patient record which...
• Contains key elements
• Is structured (links key elements)
• Is expressed in standardised language
• Saves time
9
We need a patient record which…
…..contains key elements
The elements of nursing are:
• nursing diagnoses
• nursing interventions
• nursing outcomes
10
Is structured….
i.e. Links the elements
Intervention
Problem/
Diagnosis
Outcome
11
Generalised Outcome Model
Intervention
Clinically
Effective
Outcome
Problem/
Diagnosis
Natural
Outcome
12
………is expressed in
standardised language

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Nursing terminologies
Multidisciplinary terminologies that
contain nursing concepts
……saves time

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Avoids long narratives
Data which can be aggregated
“Collect once, use many times for
multiple purposes”
The Nursing Information Reference Model - Epping and Goosen 1997
Structural
characteristics;
service items
etc.
Standardised
nursing
terminology
Layer 4:
Aggregated data
(N) MDS
national/
international
Policy decisions
Layer 3:
Aggregated data
NMDS (local)
Layer 2: Nursing interpretations
Nursing diagnoses
Nursing interventions
Nursing outcomes
Layer 1: Facts:
- Demographic data
- Observations: signs and symptoms
Management
decisions
Clinical
decisions
Why we need it: Political strength

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To make the contribution of nursing
visible eg the problems we deal with,
identifying nursing outcomes;
To provide the evidence for arguing
skill mix, allocation of resources,
pay.
Why we need it:
Technological advances

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Computerisation
Electronic patient record
“In the future nursing will be
defined, managed and controlled
by the information about it that is
held in computerised information
systems.”
Clark 1995
18
The electronic patient record
“Health professionals will need
to reach agreement on the
structure, terminology,
communications and access
standards necessary”
Better Information Better Health para 44
Terminology requirements for
electronic patient records
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Agreed data set
Architecture that enables concepts to be
located and linked
Standardised terminologies that include
concepts used by patients, doctors,
nurses, other health professionals, drugs,
equipment, etc
Supports data entry, retrieval and
analysis of data
Why we need it:
Knowledge development

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For identifying, naming and linking
our phenomena of concern.
To identify and measure the
outcomes of nursing practice
(clinical effectiveness).
To build databases for retrospective
analysis.
We need databases to enable…
• Studies of specific diagnoses and interventions
• A nursing epidemiology
• Health outcomes
• Linkages between interventions and outcomes
• Skill-mix
• Audit
• Decision support systems
22
“It may be emphasised here that if
nursing is ever to make even a remote
claim to being a science, or even to being
conducted on a scientific basis, it must be
built up like all branches of sciences: that
is by the most careful unbiased
observation and recording of seemingly
trivial details, from which - by
organising, classifying, analysing
selecting, inferring and drawing
conclusions - a body of knowledge or
principles are finally evolved”
Harmer 1926
“ The nomenclature is as of as
much importance in this
department of enquiry as
weights and measures in the
physical sciences, and should be
settled without delay”
William Farr. First report of the Registrar-General of
Births, Marriages and Deaths 1839
“There are thousands of LEGO elements
and knowing their proper names helps
you to organise and use them more
efficiently. When you create a naming
system for something to help you stay
organised, you are creating a
nomenclature. Learn the LEGO
nomenclature and build on!”
Dispelling the myths
Standardised nursing language
is not…...
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Standardising nursing practice
Nursing trying to create its own semantic
empire
A language that only nurses can use
Nursing jargon
Standardised nursing language
is…..
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A means of including nursing concepts in
the language of health care, which until
now has contained only medical concepts
Terminology that anyone can use to
describe nursing
A technical language
Core messages
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Language is the means by which we
communicate ideas (concepts)
Words (terms) represent objects and
concepts
Understanding depends on agreement
about terms
We use different languages for different
purposes
We already use standardised language
A concept may be represented
by a word (term)
Is this a hammer?
No. It is a representation
of a hammer
….. Or a formula
H2o
Is this water?
No. It is a representation of water.
…..or a picture
Is this time?
No. It is a representation of time

But to tell the time (read the
message) requires understanding

And children have to learn how to do
it
We use different languages for
different purposes
Informal
Formal
Clinical
Clinical
care
record
Local National
audit
Planning
statistics
(Adapted from Hoy 1995)
We already do it……
…..but only in our
heads
Analyse
record
and store
minimum data set
Compare
classification
sort by
rules
elaborate
by rules
nomenclature
vocabulary
Interpret
terms
name
Concepts
think
NURSING PRACTICE
Nursing
knowledge/science
36
Nursing
terminologies in
current use
Nomenclatures recognised by the
American Nurses Association
•NANDA
•NIC
•NOC
•HHCC (Saba)
•OMAHA (Martin)
•VIPS (Ehnfors)
•ICNP
•SNOMED-RT and
•SNOMED-CT
Standardised nursing languages:
NANDA-I
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167 nursing diagnoses classified into 13
domains and 46 classes.
Each diagnosis consists of a label,
definition, defining characteristics or risk
factors, and related factors.
eg. ineffective coping
www.nanda.org
SNOMED-CT
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Multi-disciplinary clinical terminology
for use in computer systems
includes ANA recognised terminologies
more than 350,000 concepts
developed from SNOMED RT and Read
Codes (version 3)
licensed to ensure version control and to
pay for distribution, development,
updating
mandatory for use in NHS UK
So where are we now?
 We have a national strategy for the
development of electronic health records:
Informing Health Care
 We have a standardised terminology
 We do not use structured documentation
 We do not use nursing diagnoses
So what do we need to do?
 Recognise that nursing is about decision
making, which is communicated through
(standardised) language
 Understand the links between our decision
making processes, our documentation, and
computerised information systems (today’s
model)
 Start using nursing diagnoses and structured
documentation
 Improve our IT awareness, understanding, and
skills.
………and
Join eNWI
(and NANDA
and ACENDIO
and the IN Group)
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