Standardised nursing languages and the nursing process, in general terms
- Fundamental
Standardised nursing languages are shared sets of terms for naming nursing problems, interventions and outcomes, so that care can be recorded and compared.
What it is
When each nurse writes care in her own words, the record is hard to share, count or study. Standardised nursing languages (or terminologies) solve this with agreed terms for the three things nurses record in the nursing process: the problems or diagnoses they identify, the interventions they carry out and the outcomes they measure. Several exist. NANDA International (NANDA-I) publishes a classification of nursing diagnoses; the Nursing Interventions Classification (NIC) and the Nursing Outcomes Classification (NOC) cover interventions and outcomes; the International Council of Nurses publishes the International Classification for Nursing Practice (ICNP); others include the Omaha System and the Clinical Care Classification. Their labels and definitions are protected and are not reproduced here.
Key points
- Diagnosis terms name the person's response that nursing can address (an actual problem, a risk or readiness to improve).
- Intervention terms name what the nurse does, so the same action is recorded the same way everywhere.
- Outcome terms name the result that is measured, so progress can be compared over time.
- Linking the three lets a plan go from problem to action to result in a traceable way.
- Some languages are licensed; institutions choose one and use it as its owners specify.
What it is for
- They make nursing's contribution visible in records, quality reports and research.
- They let electronic health records exchange nursing data between services and institutions.
- They support research and large data analyses on what nursing achieves.
- They help students learn the logic of the process: problem, action, result.
Step by step
- Collect data with the institution's assessment frame — the language names what the data show, not instead of them.
- Choose the term that matches this patient's data — never pick a label without evidence.
- Link each problem to interventions and to an outcome to measure — the plan becomes traceable.
- Record in the electronic record with the agreed terms — so the data can be shared and analysed.
- Evaluate with the chosen outcome and update the terms when the situation changes.
Where standardised languages fit in the nursing process (general terms)
| Phase | What gets a shared term | Why it helps |
|---|---|---|
| Assessment | Data collected (often with the frame of a theory) | The same areas are assessed in every patient |
| Diagnosis | The person's response that nursing treats | Problems are named the same way by every nurse |
| Planning and implementation | The interventions chosen and done | Actions can be counted and compared |
| Evaluation | The outcomes measured | Results can be tracked and studied |
In nursing practice
- Example: two nurses on different shifts care for a man at risk of falling. Using the same agreed terms, both record the risk, the prevention measures and the result, and the next shift sees the trend.
- A theory and a language can work together: a Colombian programme assessed with Orem's frame and named diagnoses with a standardised diagnostic language.
- Each institution decides which language it uses; the student follows the institution's system.
Common mistakes
- Choosing a label from a list without data from the patient to support it.
- Treating the language as a theory: it names things, but does not explain care.
- Recording terms but not measuring the outcome.
- Copying protected labels or definitions into teaching material without permission.
Test yourself
Think of the answer, then tap the question to see it.
Which three parts of nursing care do standardised languages name?
Nursing diagnoses or problems, nursing interventions and nursing outcomes.
Which classifications are usually linked for diagnoses, interventions and outcomes?
NANDA-I for diagnoses, NIC for interventions and NOC for outcomes; the ICNP and the Omaha System are other examples.
Why do standardised nursing languages matter for electronic health records?
Shared terms let records exchange and analyse nursing data, and make the work of nurses visible.
What did a systematic review find about the evidence for these terminologies?
Most studies were descriptive, and little research linked their use to patient outcomes.
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Evidence for the Existing American Nurses Association-Recognized Standardized Nursing Terminologies: A Systematic Review (International Journal of Nursing Studies (PubMed Central), 2014); Future advancement of health care through standardized nursing terminologies: reflections from a Friends of the National Library of Medicine workshop honoring Virginia K. Saba (Journal of the American Medical Informatics Association (PubMed Central), 2023); Cuidando al adulto y al anciano. Teoría del déficit de autocuidado de Orem (Aquichan, Universidad de La Sabana, 2003).
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Representative model, for educational purposes only.