The purpose of this study was to explore nurses’ perceptions of the strengths and limitations of standardized nursing languages in the electronic health record to communicate a clinical event. Limited examples of research exist exploring the effectiveness of the electronic health record with embedded standardized nursing languages as a communication system. Therefore, their effect of standardized nursing languages on nurse-to-nurse communication remains largely unknown. Data from a larger study were analyzed using qualitative content analysis. Fifty-seven thematic units represented nurses’ perceptions of the electronic health record with NANDA, NIC, and NOC for documenting and retrieving patient information associated with a clinical event. These thematic units were further analyzed, and three categories emerged: language comprehension, inexactness of the languages, and language usefulness. Standardized nursing languages were perceived to support planning care but also posed semantic challenges and fostered inaccuracies in patient information. Standardized nursing languages may constrain nurse-to-nurse communication related to a clinical event. For languages to support nurse-to-nurse communication and avoid potential safety issues, facilities must deal with inaccuracies and semantic misunderstandings to provide safe patient care.
Author Affiliation: College of Nursing, University of Colorado Anschutz Medical Campus.
This research was supported by the Department of Veterans’ Affairs.
Portions of the data in this article were presented at the Western Institute of Nursing Research, April 2009.
The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.
Corresponding author: Jane M. Carrington, PhD, RN, Mail Stop C288-19,13120 E 19th Ave, Room 4227, Aurora, CO 80047 (firstname.lastname@example.org).