Abstract
Background
Standardised Nursing Terminologies (SNTs) provide a set of agreed terms that are aligned to nurses’ assessments, interventions, and nurse-sensitive patient care outcomes. The use of such a terminology allows for improved visibility of nursing care and comparisons of interventions and outcomes to support and assess evidence-based practice. Whilst SNTs have been in use internationally for decades, there is a gap in practice and literature related to SNTs throughout Australia.
Purpose
The objectives of this review were to explore recent literature to identify and understand (i) the benefits of SNTs, (ii) the limitations of SNTs, and (iii) the potential scope of SNTs for the Australian context.
Methods
A scoping review was undertaken to search relevant literature in CINAHL, Cochrane Review, EMBASE, IEEE Xplore, Medline Complete, and Scopus databases using a date range of 2015–2023.
Findings
A total of 36 studies were reviewed, none of which were Australian. Main benefits associated with integrating SNTs into health records include improved nursing documentation quality, facilitate visibility of nursing care, and enable nursing practice quality improvement. Key limitations identified were the lack of evidence about correlation between nurses’ knowledge level and the use of SNT in practice, lack of strong evidence related to benefits in terms of patient outcomes, workflow efficiencies or enhanced communication, poor representation of nursing practice in SNTs, and mapping limitations to achieve interoperability.
Conclusions
In order to support SNT implementation and adoption throughout Australia, there is a need for Australian research as well as a national strategy for the adoption of an SNT taxonomy in Australia. This requires stakeholder policy development, government support to ensure standardisation, and broad education at academic and local level to enable comprehensive systems’ integration.