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. 2023 Aug 8;30(11):1878–1884. doi: 10.1093/jamia/ocad156

Future advancement of health care through standardized nursing terminologies: reflections from a Friends of the National Library of Medicine workshop honoring Virginia K. Saba

Karen Dunn Lopez 1,✉, Laura Heermann Langford 2, Rosemary Kennedy 3, Kathleen McCormick 4, Connie White Delaney 5, Greg Alexander 6, Jane Englebright 7, Whende M Carroll 8, Karen A Monsen 9
PMCID: PMC10586049  PMID: 37553233

Abstract

Objective

To honor the legacy of nursing informatics pioneer and visionary, Dr. Virginia Saba, the Friends of the National Library of Medicine convened a group of international experts to reflect on Dr. Saba’s contributions to nursing standardized nursing terminologies.

Process

Experts led a day-and-a-half virtual update on nursing’s sustained and rigorous efforts to develop and use valid, reliable, and computable standardized nursing terminologies over the past 5 decades. Over the course of the workshop, policymakers, industry leaders, and scholars discussed the successful use of standardized nursing terminologies, the potential for expanded use of these vetted tools to advance healthcare, and future needs and opportunities. In this article, we elaborate on this vision and key recommendations for continued and expanded adoption and use of standardized nursing terminologies across settings and systems with the goal of generating new knowledge that improves health.

Conclusion

Much of the promise that the original creators of standardized nursing terminologies envisioned has been achieved. Secondary analysis of clinical data using these terminologies has repeatedly demonstrated the value of nursing and nursing’s data. With increased and widespread adoption, these achievements can be replicated across settings and systems.

Keywords: standardized nursing terminologies, nursing care, population health, health care policies

BACKGROUND

In October 2022, the Friends of the National Library of Medicine (FNLM) convened international leaders to honor the legacy of nursing informatics Dr. Virginia Saba. Dr. Saba, who spearheaded the specialty of nursing informatics and developed the Clinical Care Classification (CCC) system,1 was an innovator, scholar, visionary, leader, and mentor. She inspired many in the nursing informatics community to achieve lofty goals related to development, recognition, implementation, and use of standardized nursing terminologies.

These key leaders provided updates regarding nursing’s sustained and rigorous efforts to develop and use valid, reliable, and computable standardized nursing terminologies over the past 5 decades. This led to an FNLM-sponsored virtual one-and-a-half day workshop titled Honoring the legacy of Virginia Saba through charting a path forward for standardized nursing terminologies in practice and research (See Supplemental File 1 for workshop agenda, recording available at https://www.fnlm.org/product/video-honoring-the-legacy-of-virginia-saba-through-charting-a-path-forward-for-standardized-nursing-terminologies-in-practice-and-research/).2

STANDARDIZED NURSING TERMINOLOGY OVERVIEW AND BRIEF HISTORY

Standardized nursing terminologies are knowledge representation systems that reflect the domain of nursing practice. Unlike terms that focus on medical diagnosis, surgeries, and treatments, nursing diagnoses are terms for health problems in which decisions can be made within the scope and practice of a professional nurse, nursing interventions describe what nurses do to impact patient outcomes, and nursing outcomes are states that are measured on a continuum in response to a nursing intervention. The first conference on the classification of nursing diagnoses was held in 1973.3 In the 1980s, The Nursing Minimum Data Set delineated the information needed about each patient to determine nurses' contributions to patient care, generate new nursing knowledge, and make contributions to public policy.4 This includes demographic elements, nursing care elements (nursing diagnoses, nursing interventions, nursing outcomes, nursing care intensity), and service elements (eg, admission/discharge dates, disposition). The core knowledge representation structures of nursing diagnoses (problems), interventions, and outcomes are captured by terminologies that have been recognized by the American Nurses Association: the Clinical Care Classification (CCC),5 the International Classification for Nursing Practice,6 NANDA-I,7 Nursing Interventions Classification,8 Nursing Outcomes Classification,9 the Omaha System,10 and the Perioperative Nursing Data Set.11

UNPARALLELED SUCCESS OF NURSING TERMINOLOGY IN THE WORLD OF HEALTHCARE STANDARDS

The workshop presenters shed light on the unparalleled success of nursing terminology in the world of healthcare standards, demonstrating the feasibility of the learning health system12 based on standardized data and improving population health through the use of informatics tools and techniques.13 During the workshop, policy leaders and scholars discussed the successful use of standardized nursing terminologies and the potential for expanded use of these vetted tools to advance healthcare. This robust body of work, often funded by NIH and the Agency for Healthcare Research and Quality and other national funders, for example,14–18 shows the power of standardized nursing terminologies to create practice-based evidence that supports nurses’ decision-making at the bedside.19 Standardized nursing terminologies are well positioned to help further nursing advance nursing science,20–22 care quality,23–25 and equity.26–29

VISION

Standardized nursing terminology creators envisioned that the terminologies would be used widely in clinical practice and would create usable data through routine nursing documentation that could make visible the value of nursing care on patient outcomes and advance nursing knowledge.1,30 Their research began with clinical experts proposing and defining comprehensive nursing terms nested in hierarchies,3,30,31 linking diagnoses, interventions, and outcomes,32–35 and progressed to extensive-term validation as well as descriptive research of nursing care provided focusing on different settings and conditions.36 In the last decade, research using large, standardized nursing terminology datasets has advanced to make predictions about patient outcomes and improve intervention effectiveness using various inferential statistics and data science methods.23,37–50

Even so, barriers to this path forward remain. The purpose of this article is to synthesize key takeaways from the FNLM workshop and propose strategic paths forward to optimize standardized nursing terminology use. The most important overall messages from this endeavor are that (1) standardization is as useful as Dr. Saba and the nursing informatics pioneers anticipated it would be and (2) the power of these nursing innovations should not be underestimated or withheld from arenas in which they have yet to be leveraged for the greater good.

STRATEGIC PATH FORWARD

The following takeaways from the workshop are priorities for advancing the adoption and use of standardized nursing terminologies (Figure 1).

Figure 1.

Figure 1.

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Strategic paths forward to optimize standardized nursing terminologies use.

  1. Reduce documentation burden. The urgent need to reduce documentation burden should be prioritized at all levels.51 Implementation of standardized nursing terminology, along with user-centered design and guidance from implementation science is key to this priority. Where standardized nursing terminologies are employed, there is a common language with validated psychometric properties that improves communication, and we see improvement in clinicians’ thought landscape and healthcare quality and outcomes.19,52–56 First and foremost, existing nursing documentation should support the clinician’s workflow and thought processes; enhance interprofessional communication and leveraging the secondary use of their data to improve quality and value.

  2. Advance adoption. There is an immense opportunity to improve population health across the continuum of care by the wide use of these rigorously developed standardized nursing terminologies in EHRs.54,57–59 Industry/vendor leaders should adopt and use these recognized standardized nursing terminologies correctly, rather than proprietary documentation methods that do not reflect the reliability, validity and overall rigor of the existing standardized nursing terminologies. Importantly, proprietary industry/vendor terms are not interoperable with other standardized datasets required to create shareable data and important new knowledge that improves population health.

  3. Partner with practice. Experts in standardized nursing terminology use, implementation, and research must make their expertise accessible to Chief Nursing Officers, educators, practicing nurses, and industry. A think-tank of leaders could be a valuable start to improve partnering to understand stakeholders’ needs and ensure that no stakeholder must “reinvent the wheel” when developing or implementing a value set, EHR, PHR, or consumer-facing data collection tool. Creating a repository of success stories and strategies for diverse uses of standardized nursing terminologies across platforms and settings within the National Library of Medicine UMLS would be a great asset for multiple stakeholders.57,60,61

  4. Enable competency development. There is a critical need for additional nursing informatics faculty, particularly experts in terminologies. Creative collaborations are needed to help share expertise, curricula, and other educational resources.62 This will enable entry-level nurses to describe the importance of standardized nursing terminologies and enable advanced-level nurses to clarify how collecting standardized nursing data will advance the practice of nursing and shed light on the value of nurses’ contributions. The importance of these competencies has recently been endorsed by the American Association of Colleges of Nurses.63

  5. Enhance interoperability. Interoperability issues would be mitigated through embedding standardized nursing terminologies at all points in the care continuum.64 For example, existing documentation could be harvested and embedded into FHIR profiles,60 quality measures, value-based care, or continuity of care documents.65,66 Nursing terminologies all represent the same domain of knowledge. Leaders should make an informed choice on which terminology to use (including evidence base and development rigor) and use it correctly according to specifications for that terminology. Policymakers and nursing leaders must advocate for nursing’s presence in interoperability conversations of all types.

  6. Generate new knowledge. The discipline of nursing has a moral imperative to use our data to create new knowledge and improve the quality of care and population health.67 The collective achievements of all standardized nursing terminologies demonstrate nursing researchers’ responses to this imperative, and a deep respect for the practicing nurses who generate data. We must continue to advance research by developing large shareable nursing terminology datasets toward the goal of optimizing patient and population health outcomes through the highest quality care at the best value.20,68–70

  7. Improve health equity. Although major initiatives are currently underway to identify social and behavioral determinants of health for documentation, standardized nursing terminologies have long-established, robust sets of terms to fit this need, and are yet mostly overlooked outside of, and sometimes even within, the nursing domain.71 Social determinants documentation is another example of the successful reuse of existing data to meet a need that appeared to be novel but in fact was already extant within systems using standardized nursing terminology as a foundation for assessments and documentation.28,29,72–76

  8. Integrate with Industry 4.0 Innovations.77 Industry 4.0 in healthcare involves the use of a wide range of modern technologies including digitization, artificial intelligence, user response data (ergonomics), human psychology, the Internet of Things, machine learning, big data mining, and augmented reality (Figure 2). Together with Industry 4.0, digital healthcare, sensor technologies, management of large datasets, robotics, and AI are forcing a different mindset of where care is delivered, how nurses make decisions, and how value is measured. Care delivery venues are expanding beyond traditional healthcare settings, with nurses practicing in retail pharmacies, virtual care centers, payer settings, and community service centers. These innovations will benefit from the collection of standardized nursing data, analysis, reporting, and quality measurement methods in areas where patients or residents have different sets of nursing interventions that historically were not part of care.27,78–81

  9. Expand interdisciplinary and consumer use. Standardized nursing terminologies may be adopted and used by any health care discipline or consumer group.10,82,83 In this article, we focus on nursing specifically; however, we heartily endorse standardization across disciplines and support all who may be interested in the benefits of standardization to guide, document, evaluate, and improve healthcare. Lessons learned from the 5 decades of standardized terminology development and use in nursing practice, education, and research may be generalizable and should be shared widely. Many of the terms are suitable for physical and occupational therapy, 2 disciplines that primarily rely on narrative documentation that obscures the contributions these 2 disciplines make to patient care outcomes.84 CCC has also been used for Respiratory Therapy documentation. As people with chronic illnesses continue to grow, standardized nursing terminologies can also be simplified to allow consumers to track chronic health concerns and provide meaningful data for visits with providers.

  10. Obtain federal support. Similar to the way SNOMED CT85 and LOINC86 are supported at a federal level or by international organizations, the National Library of Medicine, the Centers for Medicare and Medicaid Services, and/or the Office of the National Coordinator could provide policy support to encourage adoption as well as financial support for use of all nursing terminologies to address licensing issues that create barriers for the use of some standardized terminologies.87 Now that many nurses lead major national initiatives and organizations, the nursing discipline has achieved a level of influence that could successfully address this challenge.

Figure 2.

Figure 2.

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Industry 4.0 Innovations with potential for use of standardized nursing terminologies. © Rosemary Kennedy, all rights reserved, reprinted with permission.

CONCLUSION

Ultimately, standardized nursing terminologies bring value. The FNLM workshop honoring Dr. Virginia Saba’s legacy provided a glimpse into their potential. Standardized nursing terminology leaders see the value in one another’s work and are actively collaborating to support one another’s efforts, agreeing that a “win” for 1 terminology is a “win” for all. In addition, speakers demonstrated that much of the envisioned standardized nursing terminology potential has been achieved; that the value of nursing has been proven repeatedly; that the return of practice-based evidence into practice is real; and that these achievements can be replicated across settings and systems. This can no longer be denied; therefore, let us work together to extend and expand the benefits of nursing terminologies to create the lasting impact that nursing informatics pioneers envisioned.

Supplementary Material

ocad156_Supplementary_Data
Click here for additional data file. (18.6KB, docx)

ACKNOWLEDGEMENTS

We wish to thank the Friends of the National Library of Medicine, Barbara Redman, and the workshop support staff: Ann Hill, The Operations Manager, and Chris Reddall, Director, CIPHER Media.

Contributor Information

Karen Dunn Lopez, Division of Acute and Critical Care, The University of Iowa, College of Nursing, Iowa City, IA, USA.

Laura Heermann Langford, University of Utah, College of Nursing, Salt Lake City, UT, USA.

Rosemary Kennedy, Health Informatics, Connect America, Bala Cynwyd, PA, USA.

Kathleen McCormick, SciMind, LLC, North Potomac, MD, USA.

Connie White Delaney, University of Minnesota School of Nursing, Minneapolis, MN, USA.

Greg Alexander, Columbia University, School of Nursing, New York, NY, USA.

Jane Englebright, Nashville, TN, USA.

Whende M Carroll, Healthcare Information Management and Systems Society (HIMSS), Chicago, IL, USA.

Karen A Monsen, University of Minnesota School of Nursing, Minneapolis, MN, USA.

FUNDING

The following organizations supported the workshop: Columbia University School of Nursing, Saint Louis University, Trudy Busch Valentine School of Nursing, University of Maryland School of Nursing, University of Iowa, Center for Nursing Classification and Clinical Effectiveness, Meditech, University of Minnesota School of Nursing, and the American Nurses Association.

AUTHOR CONTRIBUTIONS

All authors contributed to the conception and design, drafting, final review of submission, and agreed to be accountable for all aspects of the work.

SUPPLEMENTARY MATERIAL

Supplementary material is available at Journal of the American Medical Informatics Association online.

CONFLICT OF INTEREST STATEMENT

The authors have no financial conflict of interest to report.

DATA AVAILABILITY

No data were used in the preparation of this article.

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Associated Data

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Data Availability Statement

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