Health professionals make difficult decisions on a daily basis concerning patients care. The major ones include the patient diagnosis, its diagnosis, and the best intervention afterwards. One of the greatest challenges is communication between the medical experts and patients concerning patient safety. In order to overcome this barrier, the nurses need to adapt a universally accepted language as opposed to the traditional narrative format when. One of the steps that can help in overcoming the challenges of communication is the use of NANDA language.
In the nursing profession, the key element that relates to everything else is communication. The health care profession has a unique diction and jargon, which no other profession can comprehend. Within the medical profession, there are different specialties, such as pharmacy, nursing, and medicine. In addition, each therapy and subspecialty, such as the operating room, ICU, and emergency room, has its own language (Hamric, Hanson, Tracy & O'Grady, 2014). Each of the languages is maintained, updated, and defined by NANDA-I. This body reflects the terminology used for diagnosis to enable nurses worldwide to communicate their diagnosis, outcomes, and proposed interventions. There is enhanced communication between institutional administrators, health care personnel, and the nursing staff when NANDA-I language is used. Doctors only draft medical diagnoses, but NANDA is used as an instrument to create a suitable health care plan for the patient.
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What it means is that there is a breach in communication between the doctors and the nurses due to the language variation. However, using NANDA, nurses can communicate with each other and with the doctors so that all of them can monitor the progress of the patient. In the healthcare facilities, a nurse has to evaluate the health care plan recommended for a particular patient during each shift and write next to the diagnosis a letter. For example, C, I, or R stand for continue, improve, and resolve respectively. This way, both the nurses and the doctors can easily monitor the patients progress and determine the more effective treatment. The examples of diagnosis that utilize such form of communication in most medical facilities include cardiac output decrease and mobility impairment.
The approach used for the development of NANDA terminology included inventing adjectives, verbs, and nouns and their semantics and syntax that were specific to the nursing profession. The aim was to help the exchange of information between the nursing professionals irrespective of the geographical gaps. This led to functional interoperability of information and semantic interoperability among the nursing staff. In order for the NANDA to be a standardized language, certain aspects were incorporated, such as the need for integration, harmonization, cross mapping, term generation, computability, and understanding. The terminologies used in NANDA are unambiguous for the sake of veracity of communication. NANDA sustains the nursing practice by availing terminologies that are clinically useful to the profession.
The language of NANDA was developed and approved in 1982 by the North American Nursing Association (Townsend, 2014). The language was later adapted in 1984 to define nursing diagnosis as a clinical judgment made about the community, family, or individual responses to the potential or actual health problems. Selected in a particular scenario nursing interventions are developed from the diagnosis conducted with a view to achieving certain outcome. In 1973, NANDA sprung up from the National Conference Group and grew tremendously ("NANDA International History", 2016). The conference was an initiative of the task force that organized the First National Conference during that year in Missouri. Their main task was to undertake the classification of the nursing diagnoses (Falk & Bjorvell, 2012). Later in 2002, NANDA-I (NANDA International) substituted the NANDA owing to the global increase in the interest in the nursing profession. During the proceedings, over two hundred nursing diagnoses were approved to be used.
NANDA as a standardized terminology in nursing can capture the nursing practice to a great extent. The use of a standardized language in nursing profession is essential for the documentation purposes. There are about 13 languages that have gained approval from the ANA, and they are currently being used in the nursing practice. However, only ten are considered suitable for the nursing specialty, and NANDA is one of them. It can be used along with the documentation tools. The most widespread documentation tool used today is an electronic health record (EHR). EHR are computer-based information systems that are used to store, manage, and retrieve patients health records in a health care facility. It shows details on the patients progress, their demographical records, medical history, complications, and test results. In other words, it helps clinicians to facilitate their work and ensure that it is not interrupted. The stored data can be retrieved to maximize the efficiency of the offered care, monitor and evaluate its quality, and determine the needs of the nursing staff.
One of the methods that should be used to ensure the appropriate implementation of the NANDA terminology and its consistent usage includes its integration in the EHR by the health facilities. The second method that would ensure the appropriate application of the NANDA-I language is the introduction of in-service training for the nursing personnel. Through such consistent training, the nurses will be able to underscore the need to adopt a language that can be internationally comprehended by people of any profession. The trainings will ensure that the nurses use the same language in diagnosis, outcome, and interventions. The adoption of the such language will, therefore, lead to maintaining the standards of care, achieving outcomes, and collecting data. The third method of ensuring appropriate application of the NANDA-I is the formulation of rules and regulations. In order to guarantee a strict adherence, the departmental heads should regularly look into the records that are kept by the nursing staff.
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NANDA supports data collection or meaningful use in various ways. The first way is the meaningful utilization of the certified EHR. The second one is the electronic exchange of medical data with the aim of ensuring the betterment of quality of the patient care. The third way is the utilization of the certified EHR in the submission to the clinical measures (Thede & Schwirian, 2014). The outcomes of the data collection using NANDA can be measured in many ways. According to VanDeVelde-Coke et al. (2012), the most common ways include NQuiRE, C-HOBIC, and NNQR (C). The latter measures the outcome, process, and nursing structure. C-HOBIC, on the other hand, measures chronic care, home care, long-term care, and acute care settings of patients. Similarly, NQuiRE measures various clinical decisions and interventions.
One of the benefits of the standardized nursing terminologies implementation in the EHR is that the patients enjoy the stability of care because of unambiguous and improved communication between the caregivers. The health care organizations also benefit from it: they are able to determine the type of the nursing care interventions that are offered to the patients. It also impacts on the care by enabling the nurses to scrutinize the patient records. The nursing professionals, on the other hand, benefit from the standardized nursing terminology by helping to validate the nursing staff contribution to patients safety and healthcare. One of the issues that affected the performance of the medical facilities is the inability to share the patients medical records between departments. Furthermore, there was a challenge of data transferability between hospitals and among doctors due to the problem of interpretation. Therefore, NANDA-I language that is integrated in the EHR system breaks this stalemate.
On the other hand, there are barriers to integrating standard language in the health care system. The major barrier entails lack of time to carry out the process of documentation, especially when integrated into the EHR system, and the inability to undertake reimbursement (Conrad, Hanson, Hasenau & Stocker-Schneider, 2012). The second barrier is lack of motivation of the nurses who are already practicing. Adjusting to the new terminologies after graduating and joining the nursing profession becomes a challenge to most of the nurses. Besides, they find it generally difficult to adjust to the use of a standard language because it may not necessarily reflect what was learnt in class. The third barrier is the complexity of the process of operationalizing the language into the EHR system. The reason is the need for ambulatory access to the Electronic Health Record terminologies, specifically, the terminologies in the category of SNOMED-CT that became a challenge in the process of integrating them into the EHR system.
There should be a standard nursing language for the documentation of the interventions of the nursing care. The documentation assists the bedside nurse and the nursing fraternity in many areas, such as diagnosis, outcome, and intervention. Standardization of the nursing language is necessary to improve the communication among the health care professionals. For instance, heart attack or failure is medically known as myocardial infarction to facilitate communication between health professionals. Another good example of the application of standardized nursing terminologies is the case of telemetry nurses. They care for the patients that suffer from acute diagnoses, such as diabetes, heart failure, and gastrointestinal infections, and monitor the patients vital signs with an electrocardiogram. Due to the severity of such medical conditions, language veracity is imperative in order to communicate the exact data.
Also, standardization increases the precision of the employed nursing intervention and enhanced data collection for evaluating the outcomes of the nursing care in order to ensure improved patient care (Tubera, 2015). Moreover, it helps to establish strict adherence to the set health care standards, which creates room for the assessment of the nursing personnel competency. However, the major reason for standardization of the nursing language is to ensure patients safety. When the language used for diagnosis, drafting of the outcome, or prescription is not standardized, there are may be serious or even fatal consequences.
Communication is a hallmark of the nursing profession. There are three fundamental aspects of nursing that require communication: diagnosis, outcome, and intervention. There is a global need for the nurses to convey their diagnostic procedures to facilitate transferability of the patients records. It is also necessary to communicate with pharmacists and other subspecialists. In addition, this profession entails ensuring that the interventions will be met with the appropriate reaction from the personnel. In order to follow these procedures, the nurses need a language that enhances their communication of the findings and recommendations. One of such languages is the NANDA-I that was instituted to internationally help the nurses to communicate effectively. In the past, nurses used to communicate using the conventional narratives that were complicated to the patients and other medical professionals. In order to be effective, the NANDA-I should be integrated in the Electronic Health Records (EHR) so that the data collected from the patients can easily be transferred between departments and medical personnel.