by June Clark, DBE, PhD, RN, RHV, FRCN

Article originally published Sept. 30, 1998

Development of Standardized Terminology

Ninety years ago an English-speaking nurse who attended a meeting of the (then) recently established International Council of Nurses wrote:

While attending a special meeting of the ICN in Paris, I was naturally at once struck by the fact that the methods and the ways of regarding nursing problems were ... as foreign to the various delegations as were the actual languages, and the thought occurred to me that ... sooner or later we must put ourselves upon a common basis and work out what may be termed a "nursing esperanto" which would in the course of time give us a universal nursing language (Hampton Robb, 1909).

In the 90 years that have passed since then, nursing has developed enormously but the gap identified by Hampton-Robb has not yet been remedied.

In the United States the need to standardize the collection of nursing data through the use of a minimum data set, standardized terminology, and classification systems is well recognized (Iowa Intervention Project 1997). Classification of nursing problems dates back at least to 1959 (Abdella, Beland, & Martin). The North American Nursing Diagnosis Association (NANDA) began in 1973. Werley was writing about the Nursing Minimum Data Set throughout the 1980s (Werley & Lang 1988). The research team which developed the Nursing Intervention Classification (NIC) was established at the University of Iowa in 1987 (McCloskey & Bulechek 1992).

By 1992, the publication of NIC had been joined by Martin and Scheet's OMAHA system, Saba's Home Health Care System, and Grobe's Nursing Intervention Lexicon and Taxonomy. The National Library of Medicine had already begun work on the development of a Unified Medicine Language System (UMLS) and the American Nursing Association (ANA) had established its Steering Committee on Databases to Support Clinical Nursing Practice (1995). Since 1990 the work has rapidly accelerated and the literature is now substantial.

The reasons why this development began first in the United States are probably to be found in the U.S. systems of nursing education and of financing health care. The notion of nursing as a science to be built, as are other sciences, through the identification and analysis of its phenomenon of concern, has been established in U.S. nursing education for many years (Harmer, 1926). However, it is still a novelty in most countries of Europe (with the notable exception of the Netherlands). We have no tradition or system of accreditation similar to that of the Joint Commission on Accreditation in Hospitals, which from its establishment in 1951, stressed the need for adequate patient records and standards of nursing documentation. The threat of litigation was, until recently, rare.

The most powerful imperative, however, is probably to be found in the systems of reimbursement derived from the insurance system and from the Medicare and Medicaid legislation of the mid 1960s, in which the provider's reimbursement for services rendered depends on detailed records of patient diagnoses and professional activities. However, the most significant influence on the manner in which standardized terminology and classification systems for nursing have developed has undoubtedly been the work of the American Nurses Association through its Steering Committee on Databases to Support Clinical Nursing Practice (ANA, 1995). It is significant but unsurprising that the resolution to the International Council of Nurses Council of National Representatives at Seoul in 1989, which led to the project to develop an International Classification for Nursing Practice, was proposed by the ANA.

Developments in other countries began later. When the ICN carried out its first survey about classification and information systems among its member organizations in 1991, it recorded considerable activity in the USA, some in Australia and Canada and almost nothing in the rest of the world (Wake, Murphey, Affara, Clark & Martensen, 1993). Given the long head start of the USA, it might seem obvious that the most efficient way forward would be simply to translate the American systems into other languages as and when each country required. After all, the NANDA taxonomy had already been translated into several languages, and by 1992 NIC was also being translated and promoted in other countries.

There are several reasons why this is not the right solution. At the purely linguistic level, translation is not easy, as the efforts of NANDA, NIC and the OMAHA system have shown. Even within the English language there are problems. When the Chelsea and Westminster Hospital in London decided to use the NANDA taxonomy in its new developed Hospital Information System, it found that it had to translate many of the NANDA words; terms such as regimen and unilateral neglect do not trip easily off English tongues (1998).

Translation must transfer the concepts behind the words, and concepts which are well recognized in one culture may not be recognized in another. Nursing concepts such as self-care which reflect the cultural values and norms of American society may be differently perceived in other (e.g. Asian) cultures. Validation studies undertaken by NANDA members have found that some concepts contained in the NANDA taxonomy simply do not exist elsewhere.

Thirdly, the American terms and taxonomies inevitably reflect the purposes for which they were developed and the American health care system of which they are a product. They, therefore, focus on the individual as client rather than the family or the community, and they do not capture well the practice of primary health care as it is understood in northern Europe or Africa.

Most significantly while the 1991 ICN survey found little activity outside the USA, by 1995 every major country in Europe was developing its own terminology and classifications. The imperatives of health care reform within a market model and the rapid acceleration of information technology are doing for Europe what the Medicare/Medicaid legislation did for America. Moreover since European health care systems tend to be nationally organized and state funded, the systems rapidly extend nation-wide and are likely to become mandatory. Belgium has a mandatory minimum data set which includes a 23-item categorization of nursing activities; a twice yearly census collects data from every Belgian hospital (Sermeus & Delesie, 1994).

The Netherlands has undertaken extensive work on classification for both interventions and diagnoses, the latter based on the WHO-sponsored International Classification of Impairments, Disabilities and Handicaps (1998). The UK has developed a coded multi-disciplinary thesaurus of over 250,000 terms which includes nursing terms integrated with those contributed by medicine, physiotherapy and other disciplines (Casey, 1995). The Read terms are already widely used in primary health care and will soon become mandatory for all parts of the British National Health Service.

Yet many of the political problems which have driven the work in the USA are universal. In almost every country of the world nurses experience problems of "powerlessness" due to the "invisibility" of nursing in the information systems which are used for making decisions about health policy and resource allocation. As nursing education becomes more sophisticated and nursing research activity develops and spreads, nurse managers and policy makers want to be able to compare nursing activities and performance across time and place, and nurse researchers are increasingly frustrated by their inability to compare their results.

At the clinical level, increasing pressure on individual nurses to accept accountability and demonstrate their effectiveness are forcing ordinary clinical nurses to recognize the need to develop ways of recording their practice which give a more comprehensive and accurate picture of what they do. The development and use of standardized terminology and classification systems are an essential pre-requisite for achieving these aims.

Yet, as often happens, the trigger for action was political. Driven by the need to ensure nursing visibility within the information systems which were used in the USA for reimbursement and other purposes, the American Nurses Association approached WHO with a proposal to include the specially adapted version of the NANDA taxonomy in the (then) forthcoming 10th edition of the International Classification of Diseases. The proposal was rejected — not because the proposed content was poor, but because WHO considered it inappropriate to include in the International Classification content which had been developed within and for a single country. In other words, the real reason for an International Classification was the need to avoid cultural imperialism. The ANA, wisely, approached the International Council of Nurses, which is the federation of National Nurses Associations around the world, and the idea of the International Classification for Nursing Practice (ICNP) was born.