Derek Hoy

Standards for Nursing Terminology

Terminology work in nursing has given rise to an increasing number of nursing terminologies. These generally take the form of controlled vocabularies. Because of the limitations of the controlled vocabulary approach, individual terminologies tend to be tuned to meet the specific needs of their intended users. Differences between terminologies are now a significant barrier to the comparison and interchange of health information. To agree on a single, multipurpose terminology would be problematic. However, several options for resolving unnecessary differences between nursing terminologies are currently being explored by international standards bodies and other groups, such as the U.S. Nursing Vocabulary Summit. One such option is the use of a terminology model to facilitate evolution toward a more coherent range of terminologies. The authors describe the motivation behind the development of a standard for nursing terminologies. They explain how a terminology model might form the basis for such a standard through a description of the approach taken by CEN TC251 (the Health Informatics Technical Committee of the European Committee for Standardization). They also discuss possible limitations of standardization.

Formal nursing terminology systems: a means to an end

In response to the need to support diverse and complex information requirements, nursing has developed a number of different terminology systems. The two main kinds of systems that have emerged are enumerative systems and combinatorial systems, although some systems have characteristics of both approaches. Differences in the structure and content of terminology systems, while useful at a local level, prevent effective wider communication, information sharing, integration of record systems, and comparison of nursing elements of healthcare information at a more global level. Formal nursing terminology systems present an alternative approach. This paper describes a number of recent initiatives and explains how these emerging approaches may help to augment existing nursing terminology systems and overcome their limitations through mediation. The development of formal nursing terminology systems is not an end in itself and there remains a great deal of work to be done before success can be claimed. This paper presents an overview of the key issues outstanding and provides recommendations for a way forward.

Collaborative development of clinical templates as a national resource

There is growing interest in the development of standards which structure information round discrete clinical concepts, in a way that supports system development and interoperability. Most notable are the openEHR Archetypes and Templates, and HL7 Templates. A project is described which explored the potential for these to engage and support clinical practitioners in developing clinical information standards in an open and accessible way. The project defined a clinical template as a clinical information model, which could be used to define the content of a form in a health record system, for example a continence assessment. The project followed three phases: professional development, including networking for content development; library implementation, including modelling and processes for managing content and relating to information standards; and implementation in working systems in a manner that is professionally acceptable. The project findings are encouraging although there remain some important issues to be explored in further work. The topic has now emerged as an important area of standards development, and a useful focus for international cooperation.