1 Why a standard system would be of value to my practice
• Consistent clinical documentation. Documentation is consistent and clearly understood in the hand off between nursing care providers
• Evaluating patient outcomes. Patient outcomes can be evaluated consistently and accurately in providing quality as well as safe care to patients in the perioperative setting.
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2. I believe that it is possible and essential to have one standard system for nursing. It is the means of sharing vital information. As with many ‘languages’, this information may get lost in translation. As nursing moves forward with evidence based practices, healthcare outcomes rely on data at the point of care but also this information must be “retrievable, comparable across settings and measurable” to impact future outcomes through education and research. (Thede, p.204).
3. Thede states that there is no data to support these activities. Without this data these activities cannot be charged for. Therefore these autonomous nursing activities are perceived as having no ‘value’.
“Despite this evidence on nursing's contribution to the quality of care, much of what nurses "do" remains essentially invisible. Lang repeatedly challenges that "If we cannot name it (nursing) we cannot control it, teach it, finance it, research it, or put it into public policy" (Clark & Lang, 1992). How can nurses continue to improve their diagnosing and interventions in practice so that health care consumers are accessing and receiving quality care and nurses' interventions are identifiable and measurable? One way is to use a unified or standardized language to describe the care that is provided and also to be able to take advantage of exploding clinical information system technology”
Swan. B.A., Lang N. M. & McGinley A.M. (2004).Access to quality health care: Links between evidence, nursing language, and informatics. Nursing Economics. 22 (6): 325-332
4. There are 3 systems in...