Expiration Date: December 31, 2001. No CE credit will be given after this date.
Table of Contents
The deadline for completion of this module is Dec. 31, 2001. AbstractNote: This independent study module encompasses several articles from one issue of the Online Journal of Issues in Nursing. "Nursing Nomenclature and Classification System Development"by Marjory Gordon, PhD, RN, FAAN Classification is a rather new idea in nursing. It began as a movement to develop a language that would describe the clinical judgments made by nurses. There was great support by clinicians for describing problems that nurses are educated and licensed to treat which are not in medical language systems. Currently there are major efforts nationally and internationally to develop a nursing language system that includes nursing diagnoses, interventions and outcomes. These are the basic elements in a nursing classification for practice, minimum data set for health statistics, in costing out patient care, developing computerized patient records, and for education and research. "The International Classification For Nursing Practice Project"by June Clark, DBE, PhD, RN, RHV, FRCN The rationale for standardized languages and classifications for nursing applies all over the world. Development in the USA was earlier than in other countries because of the imperatives of reimbursement systems, accreditation; and litigation. However, translation of languages developed in and for the USA may not be appropriate for other countries' practice; cultures, or health care systems. Many countries are already developing their own systems in their own languages, but others have no system. The International Council of Nurses' project to develop an International Classification for Nursing Practice will provide a unifying framework for existing systems and a system which can be used in countries which have none. Only when we have such a tool will we be able to describe and compare nursing practice across nations, and test the commonalties and differences of its concepts, values and practices. The deadline for completion of this module is Dec. 31, 2001. Objectives
"Nursing Nomenclature and Classification System Development"by Marjory Gordon, PhD, RN, FAAN Article originally published Sept. 30, 1998 IntroductionThe world is complex. Human beings tend to manage the complexity by breaking up experiences into manageable components that have meaning. These components are stored as mental representations, or concepts, that permit thinking when the object is not present. Naming of concepts permits recognition and communication with others; grammatical rules for combining concepts permits thoughts to be shared through language, and concepts within a classification system permit organization of ideas. A fundamental part of learning concerns concepts, categories, and classification systems. Saying "that is a dog and this is a cat" requires classifying sensory impressions. To know that both of these fall into the taxonomic category of animals is even higher level classification and to know that angry dogs bite involves accessing a network of concepts. This is similar to the situation in nursing practice when patients are deemed "difficult" or when a health problem is classified as preoperative fear. Recognition occurs when what is observed is placed into previously learned classes, or categories, on the basis of observed characteristics. Human beings think of ideas as related to each other and the world as a somewhat orderly place. The relationship among concepts is the basis for a hierarchical classification system and the organization of knowledge in a discipline. Science develops formal concepts to classify animals, plants, chemicals, minerals, and other things of scientific interest. In a science when concepts are considered important they become formal, standardized classifications within a system. For example, classifying a person as a citizen of the United States is important for determining rights and responsibilities. Similarly classifying signs and symptoms as "High Risk for Pressure Ulcer" or "Risk for Other-Directed Violence" is important for identifying risk management activities in nursing. In the last half of the 20th century, nursing has recognized the importance of its clinical science and has constructed concepts, theories, and classification systems to further scientific development and patient care. These developments come nearly 100 years since Nightingale wrote that the "very elements of nursing are all but unknown" (Nightingale, 1859). The purpose of this paper is to examine from a historical perspective the development of classification systems in nursing and the interdisciplinary and intradisciplinary issues that influence development. The focus will be limited to
History of ClassificationA brief examination of the history of classification will serve as a reference point for nursing classifications. It is sometimes stated that the idea of classification dates back to the book of Genesis. Out of chaos "God divided the light from darkness." Primitive cultures, as well as more advanced societies, have classified health-related ideas important to the culture. In his studies of world cultures Murdock (1980) classified theories of illness into theories of natural causation and theories of supernatural causation. (Information for Murdock's subcategories listed in Table 1 are based on information from pages 8-20 of his book.) The Hippocratic School of ancient Greece explained disease using the concept of "humors" rather than supernatural or magical forces.
The first systematic attempt to classify disease is credited to Francois Bossier de Lacroix with the publication of Nosologia Methodica in the mid-1700s. Interest in the 18th and 19th century centered on the classification of causes of death, although many thought the classification should also include non-fatal conditions. Florence Nightingale delivered a paper titled Proposals for a Uniform Plan of Hospital Statistics at the fourth International Statistical Congress in London, 1860, urging the inclusion of non-fatal conditions. By 1893 the International Classification of Diseases and Causes of Death was being used and in 1946 the World Health Organization (WHO) assumed responsibility for reviewing and revising this system every 10 years. The WHO recommended that countries establish national committees on vital and health statistics in 1948 to encourage international cooperation and to be used as a resource by WHO for future revisions of the classification (Zernott, 1982). This structure for international cooperation in classification system development has many similarities to that which is evolving in nursing. Similarities exist also between nursing and medicine in the number of classification systems with different foci. In medicine morbidity and mortality statistics are compiled using the International Classification of Diseases (ICD). The ICD is adapted for the United States and has been further adapted for hospitals' statistical reports (H-ICDA). For example, in the United States the category "chronic ulcer of the skin" has been differentiated into "decubitus ulcer" and "leg ulcer." Other countries have other needs for specificity. In an international, nursing classification system, adaptations, such as these, will occur when a country wishes more or less specificity, relative to epidemiology or cultural needs. Some of the other nomenclature systems used in medicine include Standard Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), International Classification of Injuries, Disabilities, and Handicaps (ICIDH), Standard Nomenclature of Disease and Operations (SNODO), Systematized Nomenclature of Pathology (SNOP), and Systematized Nomenclature of Medicine (SNO MED III). As may be noted from the names, classification systems are designed for specific purposes to meet the needs of particular users. The idea of systems for specific purposes is also a trend in nursing classification; there are systems which are multipurpose and systems for particular settings, such as home care nursing. Historical Perspective on Nursing Classification SystemsHistorically, modern nursing based on the Nightingale model used disease entities from medical classifications to organize their thinking, speaking, and writing. These were the only concepts available in health care delivery up to the middle of the 2Oth Century. Only recently has there been an interest in the substantive structure of nursing knowledge (Tripp-Reimer, Woodworth, McCloskey, Bulechek, 1996) and, consequently, middle range theory development of diagnostic concepts (Eakes, Burke, and Hainsworth, 1998). With an increase in nursing research there has also been a search for useful classification systems for coding studies (Larson, Dear, and Keitkemper, 1991). It is well to remember that classification system development parallels knowledge development in a discipline. Even basic structures for knowledge development in nursing had to await the introduction of theories and philosophies of nursing in the 1950s. Today many of the difficulties experienced in classification development are due to, but also are enriched by, the theoretical pluralism in nursing. National nursing organizations have advanced the idea of classifications for nursing practice. Dr. Gertrude Torres (National League for Nursing) and Dr. Roberta Thiery (American Nurses Association-ANA) were liaisons from two organizations during the early decades of classification work in the United States. ANA has developed criteria for recognizing nursing classifications (Warren, 1997) and has recognized the work of NANDA and the Iowa projects discussed below, as well as the home health care (Saba, 1992) and community classifications (Martin and Sheet, 1992). This permitted the nomenclatures (diagnostic labels) to be added to the literature search terminology of the National Library of Medicine, the Unified Medical Language System (UMLS). A Unified Nursing Language System (UNLS) "would allow linking or mapping of similar terms while maintaining the integrity and purpose of each classification system. The UNLS is the foundation on which the nursing profession develops, analyzes, and uses national data sets" (Warren, 1997). Hoskins (1997) has reported on the mapping of the aforementioned diagnostic classifications. Early ClassificationsSimply stated, classification is the ordering of entities into groups or classes on the basis of their similarity, minimizing within-group variance and maximizing between-group variance (Bailey, 1994). As nursing knowledge development increased and "entities" (diagnostic categories) were identified, interest in organizing knowledge for practice, education, and research also increased. A very, early reference to building knowledge in nursing is found in Bertha Harmer's Methods and Principles of Teaching and Principles and Practice of Nursing published in 1926 (Aydelotte & Peterson, 1987). She asked
As nursing theories and nursing process problem-solving were introduced in mid-20th century, concepts of practice emphasized procedures, tasks, and functions. It was in this practice milieu that Abdellah (1959) reported a classification of nursing problems based on a survey of 40 schools of nursing. Consistent with the times, the 21 problems were therapeutic problems that described therapeutic goals of the nurse, rather than health problems of the patient or family. The classification of these goals of nursing served to organize curricula and practice for many years. A second classification of basic, functional needs was developed by Henderson (1966). The components describe problem-areas; thus it is a conceptual classification into which empirical entities may be classified. At the time no entities, such as nursing diagnoses, existed. These two, early classification systems and the developing theories or philosophies of nursing were influential in setting the stage for the next phase of knowledge development: diagnostic, intervention, and outcome concepts. The process of classification will be discussed in the context of diagnostic classification. When processes are similar, only differences will be considered in the discussion of intervention and outcome classifications. Diagnostic ClassificationHistorical Perspectives: Diagnostic ClassificationThe North American Nursing Diagnosis Association (NANDA) is recognized in this and other countries as the pioneer in diagnostic classification in nursing. It began as a Task Force that was created at the First National Conference on Classification of Nursing Diagnoses, 1973, and evolved into an incorporated Association in 1982 to assist nurses in the United States and Canada in classification (Gordon, 1998). Initiation of work on classification for the nursing profession can be attributed to the foresight of two faculty at St. Louis University, Kristine Gebbie and Mary Ann Lavin who called the first conference on classification. Their belief that all nurses should have the opportunity to participate in the development of classifications used in nursing practice has influenced many decisions about the process of identification and classification of nursing. Diagnostic Concept DevelopmentDiagnoses are concepts that are given a word-label. Gordon observed that a diagnosis is a conceptual model for interpreting a set of observations and therefore provides a way of understanding and thinking about the set. The conceptual basis of a diagnostic concept is summarized in four dimensions: the definition, defining characteristics, and related (contributing, etiological) factors. Ideally, the conceptual base of each diagnostic concept is firmly grounded in studies of the phenomenon (Gordon, 1990). In 1973 when the first classification conference was held, research was minimal and substantive literature on concepts of this type, negligible. After specifying the purpose of a proposed system, the first step in classification is to identify the phenomena of concern to be classified. It was clear at the First Conference in 1973 that the purpose of classification was to develop a classification system of use to all nurses in their practice, education, and research. Since that time the use in practice, alone, has been considerable. Examples of applications are quality assurance (McCourt,1986; Gordon, 1980), staffing (Halloran, 1985), nursing minimum data set (Werley and Lang, 1987; Mehmert & Delaney, 1991) identifying trends (Rantz and Miller, 1987), and information systems (Warren, 1997; Warren, Delaney, and Ryan, 1997). An inductive approach was used initially by NANDA to begin to identify classes/categories. This is in contrast to deduction of elements from a nursing theory. Theoretical pluralism prevails and the choice of one theory would negate the others. The 100 participants (staff nurses, clinical specialists, educators, researchers, administrators, theorists, and consultants) at the 1973 conference generated a set of nursing diagnoses, definitions, and defining characteristics from their nursing practice expertise stored in memory. These diagnoses represented 29 conceptual areas with approximately 100 terms which were later condensed. This can be compared to the current classification system that contains 71 conceptual areas and 143 terms (North American Nursing Diagnosis Association, In Press). Definition and Criteria for Classification. Certain questions are important and should be asked early in classification development: At an abstract level, what is to be classified? How does a concept (notion) become a diagnosis, accepted for classification? The NANDA definition of a nursing diagnosis was accepted by the NANDA membership in 1988; it is adapted from a national, Delphi study by Dr. Joyce Shoemaker (1984): Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable (North American Nursing Diagnosis Association, 1997). Because the focus of nursing diagnosis is abstract, this definition is acceptable to nurses of different theoretical persuasions and colleagues in other professions. In nursing it is challenged by some because of the implications for the scope of nursing diagnosis. A discussion of this controversy over the last sentence is better left to a discussion of issues below. A diagnostic concept, or category, is formed from a set of empirical indicators (signs/symptoms) observed together frequently enough to capture nurses' attention. The set of indicators is given a name and definition. Ideally, as in other professions, clinicians would report their observations in a journal to alert others to the phenomena. Further observation leads to identification of contributing factors which will be the focus of nursing intervention. Qualitative studies using grounded theory or other methods, should follow. Quantitative research methods are useful when there is a tentative formulation of the concept and contributing factors or when the category is ready for epidemiological studies. Norris (1982) has offered methods of concept clarification and Gordon (1990) has proposed a cycle of development for determining the conceptual base of a diagnostic category. Recent work in cognitive theory suggests ways of looking at concepts that will be useful for studies of the developmental, cultural, gender, and illness-related variables which influence defining characteristics of a diagnostic concept. Research and development in this area has to be informed by the research on human cognitive architecture, concept learning, and diagnostic reasoning (Rosch and Lloyd, 1990; Van Mechelen, Hampton, Michalski, and Theuns, 1993; Gordon, 1994). Research on the validity and reliability of diagnostic categories has increased considerably in the last decade but is still insufficient. This is a serious problem. Diagnostic reasoning and judgment require valid and reliable diagnostic concepts that facilitate, rather than inhibit, thinking. Large scale funding for the basic research that is needed to identify, develop, and validate diagnostic categories has not been available in grants or contracts in the USA or Canada. In contrast, in other regions of the world large scale validation projects have been funded (Mortensen, 1996). Although nursing diagnosis always has been one of the standards for professional practice (American Nurses Association, 1973) and part of the profession's contract with society (American Nurses Association, 1980; Canadian Nurses Association, 1993) leaders in nursing research have not always supported the need for a language and classification system that differs from medicine. Source of Diagnoses. Now to further answer the question of how an idea becomes an accepted nursing diagnosis in the NANDA system. The NANDA is the only group in nursing classification that has a formal review process. Diagnoses for review and possible classification are accepted from any nurse or group of nurses. Submission and staging guidelines are published (North American Nursing Diagnosis Association, 1997, pp.89-94). Staging reflects multiple levels of development and research. For example, guidelines begin with a "received for development" category in order to offer consultation from the Diagnosis Review Committee to the submitter. Publication during the review of a submitted diagnosis in the Nursing Diagnosis journal offers opportunities for comments from other nurses. The review of a submitted diagnosis is coordinated hy the NANDA Diagnosis Review Committee consisting of seven elected members. The reviewer uses
Participation of nursing specialty organizations is important. Some organizations have submitted high frequency diagnoses in their specialty that are not already classified (Association of Rehabilitation Nurses, the former ANA Council of Psychiatric-Mental Health Nurses, Holistic Nurses, Association of Operating Room Nurses, etc.). The Association of Rehabilitation Nurses submitted new diagnoses from a research study that involved a national, random sample of members. This Association also funded a study that resulted in publication of 21 rehabilitation nursing diagnoses-intervention-outcome linkages (Rehabilitation Nursing Foundation, 1995). A recent, but major source of diagnostic submissions is the collaborative project between NANDA and project directors, Drs. Martha Craft-Rosenberg and Connie Delaney, at University of Iowa. The Nursing Diagnosis and Extension Classification (NDEC) Project is designed to refine current diagnoses, reference the source of defining characteristics, and extend the classification (Craft-Rosenberg and Delaney, 1997). Teams working on the project review the literature, do concept analysis of existing diagnoses, and generate new concepts when suggested by the literature. This work sets the stage for clinical validation and epidemiological studies. Enduring Controversies. NANDA has been criticized for the multiple levels of abstraction in the diagnostic categories. For example, the category "altered parenting" requires further specification of a taxonomy of "parenting" diagnoses. Fatigue and nausea are diagnoses at a concrete level of abstraction. Two other nagging issues that have followed developers down through the years are associated with the definition of a nursing diagnosis. These issues are the "physiological" diagnoses and "wellness" diagnoses. This controversy surrounding "what is a nursing diagnosis, and what is not," relates to the basic principle of classification: "... successful classification, then, is the ability to ascertain the key or fundamental characteristics on which the classification is to be based" (Bailey, 1994, p.2). Bailey goes on to say that there is no specific formula for identifying key characteristics. Clinicians' comments regarding "physiological" diagnoses suggest an underlying need for a classification of physiological problems (Kim, 1984). These are treated in collaboration with the physician using both physician-initiated and nurse-initiated interventions. Many of the conditions are not diseases, but rather problems or the potential for complications that require frequent monitoring by the nurse. Decreased cardiac output and impaired gas exchange are examples. Yet, many nurses contend that these collaborative problems (Carpinito, 1995) are not nursing diagnoses, according to the NANDA definition that specifies accountability for the outcome(s). A second issue concerns the diagnoses relating to "wellness" or health. On one side of the controversy the argument is that prevention involves potential problems or risk states that the nurse is expected, has a duty, and possibly is reimbursed, to treat. Risk states, for example "High Risk for Injury or Falls," describe conditions that require risk reduction through health promotion and preventive intervention. They ask: Why do we need "wellness" diagnoses? The argument continues, if a person does not have a problem, don't diagnose an "effective" state or "potential for enhancement." On the other side of the controversy nurses argue that there is a need for categories such as "Effective Breastfeeding" and "Potential for Enhanced Community Coping." These guide health promotion and health protection interventions and the identification of strengths (Popkess, 1981). They are particularly important in community nursing, school nursing, and general programs emphasizing health (Lunney, Cavendish, Luise, Richardson, 1997). The counter argument that is given is: Do all persons have "potential for enhanced..." and thus, the diagnosis is a routine? Do some patients not have the potential? Would the term "Desire for Enhanced...," with a defining characteristic that the patient requested help to achieve higher levels of wellness capture the idea? In regard to the second type of "wellness" diagnosis, Effective Breastfeeding, is this an outcome? Will there be reimbursement for "treatment" if the behavior is already effective? Similarly, will reimbursement be scant for "enhancing potential?" From the theoretical perspectives of some nurses, enhancing potential is the essence of the nurse-patient relationship. The wellness and physiological diagnoses would be excellent topics for a national consensus conference on conceptual (Gordon, 1990) and semantic issues (Nielsen, 1995). It may be noted that controversies about inclusion and exclusion are not unique to nursing. They involve both nomenclature and taxonomy issues that are experienced by classifiers in medicine and the sciences. The criticism on the "wellness" side that the NANDA taxonomy is acute care- rather than community-care oriented has to be balanced with the criticism from some nurses on the "physiological" intensive care side that the taxonomy does not sufficiently represent this area of practice. These are some of the issues that make the classification of nursing practice phenomena so intellectually challenging for those involved. Classification of Nursing DiagnosesA classification system can be as simple as an alphabetical listing or as formal as a numerical taxonomy. The ideal classifications of mathematics and logic with mutually exclusive categories are seldom found in other disciplines (Bailey, 1994). Biology struggles to distinguish between the animate and inanimate and medicine finds obesity in its classification of diseases (Webster, 1984). Classification is not a simple task with the complexity of nursing, phenomena of concern. How did the current North American classification system grow? It was nurtured through the efforts of NANDA Taxonomy Committee chairpersons, Drs. Phyllis Kritek, Joyce Fitzpatrick, and currently Kay Avant. Models and frameworks (Maslow, Abdellah) for organizing nursing diagnoses were suggested by participants at the First National Conference and later (Lunney, 1984; Loomis, 1987) but from 1973 to 1986 diagnoses were arranged in an alphabetical listing. In retrospect this was a wise decision for that time period. NANDA currently classifies nursing diagnoses into Taxonomy I, Revised using the structure of Human Response Patterns, as seen in Table 2. This structure for a classification system was accepted by participants in 1986 at the Seventh Conference.
Taxonomy is a term used interchangeably with classification system, such as in biology and other disciplines. Yet it is actually defmed as the study of classification including its bases, principles, procedures and rules (Sneath & Sokal, 1973, p.3). Similar to the term, classification system, taxonomy can refer to both the process of classification and the end product. In the NANDA taxonomy, the roots of the term "human response" lie in the ANA Social Policy Statement (Kritek, 1989). In this document nursing is defmed as the diagnosis and treatment of human responses to actual or potential health problems. (The term "problems" is used in a very broad, generic sense, such as that which is of therapeutic concern to the nurse, the patient, or both.) Human responses are the indicators of patterns (actual or potential health problems). Between 1977 and 1982 a group of 14 prominent nurse-theorists developed an organizing framework from which the patterns in Table 2 are taken (Roy, 1982a, 1982b). Sister Callista Roy, a member of the National Task Force that preceded NANDA, coordinated the work of this group at national conferences and by mail. It was the first time that these leaders in nursing theory
Kerr (1991) outlined methods for taxonomy validation but the literature does not reflect the use of these methods in validating the NANDA Taxonomy or further developing the pattern-definitions in Table 2. Clinicians have attempted to use the patterns as an assessment tool or in information systems and, on this basis, many have rejected their abstract nature. In 1998, the Taxonomy Committee under the leadership of Dr. Kay Avant explored other typologies for organizing diagnoses that may be more useful (North American Nursing Diagnosis Association, In Press). A second factor for re-examining the nine key concepts was the difficulty classifying diagnoses that crossed patterns, such as syndromes (Avant, 1997; McCourt, 1991.). Comments and suggestions will be elicited from the profession prior to the Taxonomy Committee's report to the Fourteenth NANDA Conference in 2000. Similar to diagnosis review, taxonomy review is based on the philosophy that all nurses should have an opportunity to participate in the development of a classification system for the profession. Outcome ClassificationHealth care providers have appreciated the importance of outcomes as requirements for measuring economic efficiency and system effectiveness in a cost-control environment. The concept of outcome has not been analyzed in nursing resulting in a multiple terms or variations in the basic term. In addition to the term "result", eight terms are commonly used in the literature to modify, an outcome: patient, nurse-sensitive, desired, effective, expected, predicted, projected, and actual outcome (van der Bruggen & Groen, 1995). Outcomes may defined as the end results of care, yet when quality of care is being measured outcomes are linked to diagnoses. From this perspective, outcomes are indicators of problem resolution or progress toward resolution. Historical Perspective: Outcome ClassificationAydelotte (1962) was an early pioneer in the measurement of patient outcomes. She was the first in nursing to use changes in characteristics of patients to evaluate nursing care delivery. In 1988 Heater, Becker, and Olson completed a meta-analysis of studies that suggested a growing interest in nursing goals and outcomes during the previous decade. Outcomes at this time were general, such as "the patient's self care skills" (Hover and Zimmer, 1978). Johnson and Maas summarized the multiple reports of outcome generation that were characteristic of the 1980s and early 1990s and concluded that identification of outcomes was based mainly on literature reviews and practical experience rather than research or conceptual frameworks" (1997, p.5). These authors also note that nursing outcomes differ in content from medical outcomes. Nursing includes client knowledge and behaviors, safety, use of resources, home maintenance, and caregiver status (1997, p.5). In a large, funded project Johnson and Maas (1997) and a team of investigators at the University of Iowa developed a set of outcomes and proposed their linkages to nursing diagnoses. Outcomes and their indicators are the concepts, or elements, to be used in classification. Outcome Concept DevelopmentAs previously discussed it is important in classification to clearly define that which is to be classified. Secondly, whether the classification is outcomes, diagnoses or interventions, each category at a particular level in a classification system should be at the same level of abstraction. In the Johnson-Maas study three characteristics of outcomes are identified: a variable state, a consequence, and a level of abstraction. For the team's research, a nurse-sensitive patient outcome is defined as a variable patient or family caregiver state, behavior or perception that is responsive to a nursing intervention and conceptualized at middle levels of abstraction (e.g., mobility level, nutritional status and health beliefs). Nursing-sensitive outcome indicators are defined as variable patient or family caregiver states, behaviors, or perceptions at a low level of abstraction that are responsive to nursing interventions and used for determining a patient outcome (e.g., for the outcome Mobility Level, indicators include "joint movement, "transfer performance," and "ambulation: walking"(1997, p.21). This shares some of the characteristics of van der Bruggen and Groen's (1996) definition contained in an interim report of an internafional, Delphi study of nurse-experts. Further specification of outcome-concepts in the Johnson-Maas report includes measurability on a numerical scale (1997, p.22). This latter characteristic allows
As required in classification development, methods for developing the elements for classification and guidelines for decisions are clearly delineated in the Johnson-Maas report (1997). Methods included review of the literature, information systems and other sources. Concept analysis and graduate student surveys were used to determine the validity of the concepts and their indicators. Field testing is planned in multiple settings which will evaluate "frequency of use and sensitivity to nursing interventions" (1997, p.26). Outcomes in the Johnson-Maas study were limited to individuals and family-caregivers. Plans exist to expand the nomenclature to include family community, and organization. Also further work on linkages is planned (1997). Classification of OutcomesNurses have been developing outcome typologies in various specialty areas of practice for at least three decades. Early typologies (conceptual groupings) used general terms. Quality assurance programs provided the major impetus to development in the 1970s and 1980s. Currently, diagnosis-specific standards/guidelines for practice, cost containment, and development of computerized patient records give further impetus. Additionally, large projects were funded in nursing; outcomes were not as controversial as the term, nursing diagnosis (Simmons, 1980; Horn & Swain, 1978, Johnson & Maas, 1997). Johnson and Maas have used similarity ratings and hierarchical clustering techniques to develop a taxonomy with 24 classes and six domains. These were used to classify the more than 200 outcomes and outcome indicators developed in their project. The domains are
It is claimed that nursing is invisible in health care delivery because we have not articulated our contribution. Although recognized as incomplete, it is impressive to see a list of nurse-sensitive outcomes and know that this list represents a visible "image" of nursing's contribution to the nation's health. Intervention ClassificationIn the previous sections emphasis has been on descriptive concepts and their classification. Interventions, or prescriptive concepts, complete the diagnosis-intervention-outcome linkage that specifies the major elements and relationships that need to be developed for a nursing classification. Historical Perspective: Intervention ClassificationNurses and administrators have always been interested in identifying what nurses do, perhaps for different reasons. At various points in time, even industrial task analysis was common. Assessing and monitoring medical treatments and technology, administering medications, and assisting the patient to carry out the physicians orders were high priority in the traditional typology of nursing interventions. This situation changed with the publication of nursing theories and philosophies beginning at mid-century and the introduction of nursing diagnosis and clinical judgment. "Independent" nursing interventions that were nurse-initiated were given increased emphasis in curricula and in practice. In the 1980s textbooks began to name nurse-initiated interventions and relate these to nursing diagnoses (Bulechek and McCloskey, 1992; 1985; Maas, Buckwalter, and Hardy, 1991; Snyder, 1985). Intervention Concept DevelopmentThe first systematic approach to naming classes of interventions was reported by McCloskey and Bulechek in 1992 and updated in 1996. The nursing intervention classification (NIC) research team identified a set of intervention concepts through content analysis of the literature and other sources, project team focus groups, and graduate student ratings. Validation procedures included surveys of specialty organizations, individual nurses, nurse experts in theory development (taxonomy and content), and clinical field testing. Currently, over 433 intervention concepts and over 3000 nursing activities have been identified by the research team. Field testing continues in a variety of settings, an important factor when the claim is generalizability to all nursing areas (McCloskey and Bulechek, 1996). The structure of an intervention includes the concept label, definition, and activities. The close involvement of one of the directors of both the NIC and NOC projects in the NANDA work may have influenced decisions about the structure of interventions and outcomes. All three classification elements consist of a
Three types of interventions have been classified by the McCloskey and Bulechek research team in the Iowa project (1992). They are defined as follows: A nursing intervention is any direct care treatment that a nurse performs on behalf of a client. These treatments include nurse-initiated treatments resulting from nursing diagnoses, physician-initiated treatments resulting from medical diagnoses, and performance of the daily essential functions for the client {who} cannot do these (1992, p.21). This definition provides clear direction for what is to be classified and, similar to the outcome project, procedures and criteria used in the classification project are clear. Critique of the intervention elements in the NIC includes:
Classification of Nursing InterventionsThe number of interventions and activities (N=>3000) identified in the Iowa project required the use of a computer clustering. Similarity ratings and hierarchical clustering techniques were used to develop a taxonomy with 34 classes and six domains. The domains are physiological: basic, physiological: complex, behavioral, safety, family, and health system (McCloskey and Bulecheck, 1996, pp. 56-57). The use of nursing's tradifional terms may be necessary when classifications (intervention and outcome) contain both medical and nursing conditions. This is in contrast to the more abstract, but internally consistent, concepts, such as the nine Human Response Patterns (North American Nursing Diagnosis Association, 1996) or the 11 functional health patterns (Gordon, 1994). Perhaps with the start in 1998 of biennial NANDA-NIC-NOC Conferences there will be more contact among developers and a common way of looking at taxonomic structure may emerge. Multidimensional scaling, factor analysis, and other procedures were used to analyze the dimensional structure of 26 NIC intervention classes. Results suggest that the embedded structure of interventions contains three components: complexity (urgency and skill and knowledge needed), intensity (acuity), and focus of care (target: individual to system) (Tripp-Reimer, Woodworth, McCloskey, and Bulechek, 1996). These are similar in nature to the taxonomic branches proposed for the NANDA classification: acuity, developmental level and individual-family-community. Similar to a diagnostic and outcome classification, the intervention concepts within the classification represent first level, factor-isolating theory. This is the base for middle range theory development and the structure of nursing science Summary of Major ClassificationsIn summary, it may be noted that these three systems have been developed separately but can be linked, provisionally (Daly, 1993). Outcomes are linked to the problem (nursing diagnosis) in a diagnostic statement. Interventions are linked to the related or contributing factors. Diagnosis-intervention linkages (McCloskey and Bulechek, 1996) assume that a nursing diagnosis is being used as a contributing factor for another nursing diagnosis and that the classification is similar to a dictionary of terms. Linkages are more easily seen when diagnosis, intervention, and outcomes are identified within one project, such as the Home Health Care Classification (Saba, 1992) which shares many concepts with the NANDA Taxonomy or the Omaha Classificafion System (Martin and Sheet, 1992) for community health, which also overlaps considerably with the NANDA Similar difficulties have been encountered by the three groups of classifiers. These were
In the 25 years since the national effort began in a volunteer organization to systematically classify nursing diagnoses, and later interventions and outcomes, great progress has been made. Perhaps now, the time nurses spend on documenting the care they give can result in documentation that is systematically organized to advance nursing knowledge, develop nursing practice, and improve patient care. The International Perspective on ClassificationThe International Council Of Nurses (ICN) in Geneva is preparing an International Classification for Nursing Practice (ICNP) that eventually will be submitted to the World Health Organization for classification of conditions necessitating nursing care. WHO will be use this coding schema for statistical purposes. Dr. Margarita M. Styles, Chair of the ICN Professional Services Committee began the project in 1991 and supported it through her Presidency in the years that followed. Through the leadership of Dr. Styles, and Dr. Fadwa Affara, the work of consultants Drs. Norma Lang (USA), June Clark (UK), and Randi Mortensen (Denmark) and advisors, G. Neilsen (Denmark) and M. Murphy and M. Wake (USA) an alpha version of the ICNP is available (International Council of Nurses, 1996). The ICN is very aware that "without a language, nursing is invisible in health care systems and its value and importance go unrecognized and unrewarded" (1993, p.2). They have emphasized the importance of the work to every country and Lang has said that "If we cannot name it, we cannot control it, finance it, research it, teach it, or put it into public policy" (International Council of Nurses, 1993, p.2). An ICNP requires the collaboration of all nations. International interest is high and regional groups, similar to NANDA, have formed to work on classification. For example, there is a European organization, including formal organizations of Francophone nurses (Europe and Quebec) and Spanish nurses (Spain and Cuba). For a number of years Japan has had a national organization for classification and plans to develop an all-Asia organization. Debate is lively among nurses from various nations at conferences (Japan Academy of Nursing Science, 1997), in unversities, and in health care agencies. The high participation of internationals in the biennial NANDA classification conferences and the participation of Americans in European and Asian conferences provide opportunities for sharing ideas. Concept Development and ClassificationThe elements to be classified in the ICNP are diagnoses, interventions, and outcomes. This will foster hypotheses about linkages. Classifications from all member countries were collected and comprised the elements for the alpha classification (International Council of Nurses, 1993;1996). Principles of division, rules, and procedures have been developed for classification. These are described in the European Telenurse Project that has been funded by the European Union for Telematics in Health Care to study the validity of the elements and classification system in European nurses clinical practice (Mortensen, 1996). (A comparable validation project in North America will have to be done eventually.) The architecture of the alpha version is based on classification principles but appears complex (ICN, 1995) in comparison with the alphabetical listing of the first report (ICN, 1993). Key concepts for organizing elements are neutral. The orginal definitions of diagnoses and interventions are concise and are available for all terms at all levels of the classification. The beta version of ICNP is due for publication in the near future. As the ICN has stated the ICNP "provides a vocabulary, a new classification for nursing and a framework into which existing vocabularies and classifications can be cross-mapped to enable comparison of nursing data collected using other recognised nursing vocabularies and classifications. For this reason the ICNP is referred to as A Unifying Framework" (International Council of Nurses, 1996, p.13). SummaryDiscussion has focused on historical perspectives in diagnosis, intervention and outcome classification in nursing and the current status of the major developers' projects. These classifications supplement medical classifications and will permit statistical coding of functional problems that are so common in an aging population. Classifiers in North America have encountered the major types of problems identified by van Mechelen and his colleagues (1993, p.2): creating categories (clustering problems) and inducing general classification rules from descriptions of members and non-members (rule induction problems). Classification of the phenomena of concern in nursing is a complex task. It is complex because of the inherent complexity of persons, the phenomena of concern in nursing. It also is complex because it requires clarity of language; concepts and definitions that are understood in North America may be unknown or unclear in other countries and the opposite is also true. If regional groups around the world are to contribute to an international classification used by nurses in many language groups, attention has to be paid to the construction of clear, concise, translatable terms. Countries adopting nursing classifications from regions and cultures, other than their own, have to determine the cultural-sensitivity of the concepts. This has been evident as countries have adopted the North American work. Clarity of the work is also an important factor in developing information systems which are being developed world-wide. Will historians say that in the last half of the 20th century the developing classifications revolutionized nursing practice? Perhaps so. Nursing diagnosis encouraged thinking to move from the notion of a work-task to a conceptualization of a patient's problem. It provided a language to communicate and a tool for critical thinking at a time when documentation was characterized by statements such as "appears to be bleeding" or "appears to be dead." The development of a language for interventions and outcomes revolutionized the "work-tasks" at a time when nurses thought of intervention as "provide emotional support" and outcomes as "slept well." The profession has come a long way in this past century. One wonders what the 21st century will bring. "The International Classification For Nursing Practice Project"by June Clark, DBE, PhD, RN, RHV, FRCN Article originally published Sept. 30, 1998 Development of Standardized TerminologyNinety years ago an English-speaking nurse who attended a meeting of the (then) recently established International Council of Nurses wrote:
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. The International Classification for Nursing Practice ProjectA resolution of the ICN's Council of National Representatives in 1989 asked that ICN encourage member National Nurses Associations (NNA's) to become involved in developing classification systems for nursing care, nursing information management systems and nursing data sets, and to provide tools that nurses in all countries could use to identify nursing practice and describe nursing and its contributions to health. The International Classification for Nursing Practice Project, begun in 1990 by the International Council of Nurses, aims to develop a standardized vocabulary and classification of nursing phenomena (nursing diagnoses), nursing interventions, and nursing outcomes which can be used in both electronic and paper records to describe and compare nursing practice across clinical settings. An Alpha Version of the Classification of Nursing Phenomenon and Nursing Interventions was released for further development and field testing in 1996 and an outline for a classification of Nursing Outcomes in 1997. Nurses around the world, and other classification experts, have been invited to participate in the development of the Beta Version which it is hoped will be ready for release in 1999. The goals of the project, which were set out in the initial proposal to the ICN Board of Directors are:
These goals continue to provide the mission and the framework for the project. Testing the Alpha VersionThe Alpha Version is currently being tested in various ways and further participation is welcomed. All member National Nurses Associations have been asked for feedback, and documentation for submission of new terms and changes to existing terms is available. A process for managing feedback is being developed. In Europe the TELENURSE project has enabled the Alpha Version to be translated into several languages and is testing aspects of the use of ICNP in electronic patient records. Validation studies are being undertaken at Marquette University and by individual researchers in several countries. The ICNP Country Project, funded for 3 years by the W K Kellogg Foundation, will assist ICN to focus particularly on describing nursing practice in community-based practice and primary health care. Country work groups in several countries of Africa and Latin America will explore and develop new processes and look critically at the nature and structure of ICNP as well as contributing new terms. The project also includes publication of a newsletter to disseminate information and ideas. What Kind of Classification?The form and content of any classification reflects its purpose, and it is recognized that no one classification can meet all needs. The World Health organization has developed the concept of a "family of classifications" built around the core of the ICD itself (1992). The "peripheral" members of the family would include specially based adaptations of ICD, (e.g. for psychiatry, oncology, dentistry and stomatology), the International Nomenclature of Diseases (the purpose of which is to provide a single recommended name for every disease entity), and other health-related classifications such as the International Classification of Impairments, Disabilities and Handicaps (ICIDH). It is an explicit goal of the ICNP project that ICNP should join the "family," probably among the "Other Health Related Classifications." It is already clear that the ICNP cannot serve all the purposes that all nurses in every country would like. Its explicit purpose, as stated in the Alpha Version (ICN, 1996), is to "provide a vocabulary, a new classification for nursing, and a framework into which existing vocabularies and classifications can be cross-mapped to enable comparison of nursing data collected using other recognized nursing vocabularies and classifications." Even these three purposes are difficult to achieve by means of a single tool. Meerabeau et al (1997) point out that nurses already use different languages for different purposes. They note that the U.S. National Center for Nursing Research (1993), distinguishes between clinical terms (the language of practice) and definitional terms (the language of nursing knowledge — theory and research). Hoy (1995) sets out a continuum of steps between "informal language" which nurses use to communicate information about patients whose care they share, and the "formal language" which is necessary for remote communication such as anonymised aggregated data for research or statistical purposes. It has been suggested that as nurses learn to articulate more precisely their phenomena of concern, the gap between the two extremes of Hoy's continuum will narrow, but it is unlikely that they will ever merge. Classification brings even greater problems. The existing nursing classifications, like the ICD, are first-generation mono-axial classifications, and have usually been inductively developed. The ICNP Alpha Version classification of nursing phenomena was also mono-axial, but it differs from the other nursing classifications in that it is built according to strict rules of classification based on generic relations — that is, the concepts are arranged in a strict hierarchy in which each subordinate term is related to each superordinate term (the genus) by a principle of division, and distinguished from other terms on the same level by its special characteristics (the characteristic of the species). The meaning of the concept is, therefore, defined by its place in the classification as well as by any other definition it may be given. The ICNP Beta version will use multi-axial classification in which each complex concept (e.g. impaired mobility) is broken down into separate axes, (e.g. mobility : impaired). This kind of classification increases richness and flexibility because it allows the terms in different axes to be combined in various ways, but the penalty is that the increased complexity limits use to computerized systems, to which nurses in many countries have no access. Is It Feasible?Problems such as these raise the challenge that even if an international classification is desirable, it may not be feasible. Such a view is, however, unduly pessimistic. One cause for optimism is the integration of a Unified Nursing Language System (UNLS) within the Unified Medical Language System (UMLS) which is being developed by the National Library of Medicine (Lindberg, Humphreys & McCray, 1993). The UMLS includes concepts, terms, strings and semantic relationships which enables terms from different vocabularies to be mapped from one language to another. The UMLS already includes the ANA recognized languages, the UK Read terms (which include nursing terms), and the vocabularies used in some non-English speaking countries. The most important step, however — a pre-requisite for the successful international use of any standardized language or classification — would be the international adoption of an agreed nursing minimum data set. Until countries agree on the data elements to be described, the availability of standardized terminology and classification is irrelevant. It is 10 years since Werley and Lang (1988) identified as essential the four nursing elements of nursing diagnosis, nursing interventions, nursing outcomes and nursing intensity. Goosen (1998) has recently reviewed the minimum data sets developed in several countries. Nurses in most countries record nursing interventions in some form, but the concept of nursing diagnoses is not widely used in Europe and the only "problems" which nurses record are usually medical diagnoses. The recording of outcomes is rare in all countries, and although some system of predicting nursing workload is common, there is no agreed measure for nursing intensity. Criteria for an International ClassificationThe ICNP project set criteria for its own classification as follows:
These criteria describe the challenge for any classification for nursing practice. They are not easy to meet, and success will not be quick. The ICNP has been described as "the kind of project that never ends but for which the need is urgent." It is certainly a goal worth aiming for. References"Nursing Nomenclature and Classification System Development"
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