Standardized Nursing Languages Foundation for the Information Infrastructure of Nursing.

Standardized Nursing Languages

Foundation for the Information Infrastructure of Nursing

My purpose today:

To discuss the idea of nursing information and how that information is structured and used To argue that nursing language is the core of nursing informationTo assert that standardized nursing languages are the only rational means of capturing nursing information reliably and efficientlyTo give a brief comparison of NANDA,NIC, NOC and ICNP taxonomies

Information is essential

Information work is crucial to almost every enterprise in today’s society

Information provides multiple bridges between worlds (Bowker, 2003) such as medicine, nursing, policy makers and the public

Central to all information work is the need to classify or categorize

Categorize (definition)

To categorize is “to treat a set of things as somehow equivalent;

to put them in the same pile,

or call them by the same name,

or respond to them in the same way” Neisser (1987)

Concepts are the way we categorize sensory information

An idea in one’s mind formed by a generalization from specific concrete experiences - a categorization

Concepts are expressed in words that allow us to communicate with each other about the ideas or images we have in our minds

Language plays a key role in establishing concepts and categories, both developmentally and culturally

Concepts play a central role in all forms of knowledge

1. Concepts are needed to perceive subtle details in facts (describe).

Concepts are needed to identify appropriate responses (adapt).

Concepts are needed to comprehend principles when they are stated (learn).

Concepts are needed to interpret facts and relate them to principles (diagnose).

Concepts are the basis for language

Language affects thoughts, actions, communications and cooperation with others

Language is the basis for information transfer

It is important for language to be precise in order to communicate clearly and accurately

Experience plays a role in getting concepts right

As experience shifts from naivete to expertise, the basis of categorizations also shifts

novices tend to rely on well-known characteristic features

experts use more sophisticated criteria, often explicitly theory based

Concern about getting concepts right is not new

“If names are not correct, language will not be in accordance with the truth of things”. Confucius, c 500 BC

There are consequences if we don’t get concepts right

“If we cannot name it, we cannot control it, finance it, teach it, research it or put it into public policy”. (Clark, J, & Lang,NM. (1992). Nursing’s next advance: an International Classification for Nursing Practice. International Nursing Review 39(4): 109-112, 128.)

Sets of concepts can also be categorized

The categories are determined by the “likeness” of the sets of concepts

Sharing a genetic heritage

Sharing a common characteristic

Beginning with the same letter of the alphabet

A classification of sets of concepts is called a taxonomy

DOGS

Working class Terrier class

Sporting class Toy class

Hunting classNon-classifiableaka street dogs

Pet class

Other examples of taxonomies

In biology – genus, family, kingdom

In library science – Dewey decimal system

In medicine – ICD10

In nursing – NANDA, NIC,NOC, ICNP

Categorizations and taxonomies:

form the basis for information that allows us to

understand phenomena

exchange information about relevant concerns

build a knowledge base

build an evidence base

teach novices

Information must be communicated to be relevant

In order to be communicated, information must be

Produced

Accumulated

Stored somewhere

Retrieved when needed

Usable for various purposes

Updated regularly

Nursing information

Production sourcesResearch and theories – if published

Guide practiceTeach students

Clinical experiences – often informalShared in writingsPassed down from nurse to nurse

Clinical recordsPatient records and care plansProcedure manuals

Nursing information

AccumulationResearch evidence - in journals, books, papers presented, standards of care

Clinical experiences - in published sources such as case studies or handed down over time, standards of care

Clinical records – in nurses’ notes, care plans, Kardexes, procedure manuals

Nursing information

StorageResearch – archives, libraries, databasesClinical experiences – if not published, this information dies with the knowerClinical records – paper records, electronic data bases (In the case of paper records, the nurses notes, care plans, etc are often systematically thrown away)

Nursing information

RetrievableResearch – yes from the original or secondary sources

Clinical experiences – often no unless the experiences are published or written down somewhere

Clinical records – usually no, unless stored electronically – even then, maybe not

Nursing information

Usable for various purposes clinical information support

outcomes measurement

effectiveness evaluation

case mix assessment

administrative decisions

Updated regularly

Nursing information

The only way for nursing clinical information to be usable for these purposes is if it is accumulated and stored electronically in a manner so as to be retrievableThe only way it can be retrievable is if it is coded The only way for it to be coded is if it is in a standardized language

Nursing information

“Free text” nursing notes can not be codedNursing information is therefore systematically “facilitated out of the equation” of medical information (Bowker, 2003)

This problem, in effect, makes nursing invisible

And Yet

Although nursing acts as a memory system for the entire health care team

Institutional memory – filing forms, updating charts

Local memory – where things are kept, who needs particular things for their care

Our “official memory” – is denied to us (Bowker, 2003)

Thus

We need to make our activity visible within information systems that have factored us out of their equations and acquire an official memory

The only way to do that is to make a case for the need for good nursing information to accomplish the goals of the institution

AND

The only way to get good nursing information is to have it coded and stored where it is retrievable and usable

Using standardized languages is the only efficient way to accomplish that goal

Therefore, nursing needs

A cadre of well-prepared nurses who can develop and use standardized languages to record their judgments (diagnoses), their interventions, and the outcomes of those interventions

And

A cadre of well-prepared nurse informaticists who can help get nursing data into medical information systems and who know how to use it to make nursing visible to the system

Nightingale was the first nurse informatician

Nightingale “...was not the lady with the lamp, she was the lady with the brain; she made nursing a science”.(Gardiner 1908)

She used information to change health care policy in the British military

Nightingale was an informatician

She changed the focus of the military from

mortality as a function of wounds

TOMortality as a function of

Lack of foodLack of blanketsLack of clean water to drinkLack of shelterLack of sanitation

Nightingale used information to

Describe “the conditions required for preserving health among large bodies of men”Describe “the conditions required for the recovery of the sick in the Hospital” (Sanitary History, 1859:9-11)

Nightingale’s list of concerns for the soldiers

Cold

Frostbite

Hunger

Scorbutus

Lack of clothing

Lack of shelter

Excessive fatigue

Diarrhea

Dysentery

Fever

Nightingale’s list of nursing concerns for all patients

Health of houses

Ventilation and warming

Light

Noise

Variety

Bed and bedding

Personal cleanliness

Nutrition and taking food

Chattering, hopes, and advice

Social considerations

Nursing Concerns or Phenomena

The focus of nursing concerns has not changed much over time

NANDA and NNN taxonomies reflect many of Nightingale’s original concerns

ICNP does as well

NANDA Taxonomy II Domains and Classes

Health promotionHealth awarenessHealth management

NutritionIngestion, digestion, absorption, metabolism, hydration

EliminationUrinaryGastrointestinalIntegumentarypulmonary

Activity/RestSleep/restActivity/exerciseEnergy balanceCardiovascular/pul-monary responses

Perception/cognitionAttentionOrientationSensation/perceptionCognitioncommunication

NANDA Taxonomy II

Self-perceptionSelf concept

Self esteem

Body image

Role relationshipsCaregiving roles

Family relationships

Role performance

SexualitySexual identity

Sexual function

Reproduction

Coping/Stress tolerance

Post trauma responses

Coping responses

Neurobehavioral stress

NANDA Taxonomy II

Life PrinciplesValues

Beliefs

Value/belief/action congruence

Safety/ProtectionInfection

Physical injury

Environmental hazards

Defensive processes

thermoregulation

ComfortPhysical comfort

Environmental comfort

Social comfort

Growth/DevelopmentGrowth

development

NANDA Axes

Diagnostic concept

Descriptors

Age

Time

Topology

Health status

Unit of Care

NANDA,NIC and NOC Taxonomy of Nursing Practice

In 2001 NNN representatives met to attempt to reconcile the three taxonomies of NANDA, NIC and NOC

It is still in development and will likely be changed over time

Currently it does not replace the individual taxonomies but we hope it will eventually

NNN Taxonomy of Nursing Practice: Domains and Classes

Functional DomainActivity/Exercise

Comfort

Growth and Development

Nutrition

Self care

Sexuality

Sleep/rest

Values/beliefs

Physiological DomainCardiac function

Elimination

Fluid and electrolytes

Neurocognition

Pharmacological function

Physical regulation

Reproduction

Respiratory function

Sensation/perception

Tissue integrity

NNN Taxonomy of Nursing Practice Domains and Classes

Psychosocial Domain

Behavior

Communication

Coping

Emotions

Knowledge

Roles/relationships

Self-perception

Environmental Domain

Health care system

Populations

Management

ICNP

It is difficult to make direct comparisons between NANDA, NIC, and NOC and the ICNP since ICNP is set up differently

ICNP Domains and Classes for Phenomena Classification

Nursing PhenomenaHuman Being

Individual– Function

» Organ– Person

» Plan of Action» Action

Group– Family

» Family process» Family composition» Family size

ICNP Domains and Classes

Community– Community Process– Community Composition

EnvironmentNature

– Physical environment– Biological environment

Human Made Environment– Infrastructure– Land Development– Supply System– Norms and Attitudes– Polity

Nursing Phenomena Classification

AxesFocus of nursing practiceJudgmentFrequencyDurationTopologyBody siteLikelihoodBearer

ICNP Phenomena classification

The terms in the Focus of Nursing Practice axis must be combined with terms in the Judgment axis or the Likelihood axis to produce a nursing diagnosis

Terms from the other classifications may be used as needed

Nursing diagnosis: an example

Focus of nursing practice: pain

Judgment: extreme (to a very high degree)

Frequency: intermittent

Topology: right

Body site: foot

Extreme intermittent pain in right foot

ICNP:A conceptual problem

JudgementTo a high degree

To a lesser degree

To a very high degree

To some degree

LikelihoodRisk for

ICNP Nursing Action Classification

AxesAction typeTargetMeansTimeTopologyLocationRouteBeneficiary

Nursing Action

A nursing intervention must include a term from the action type

Terms from the other axes are optional

Nursing Action example

Action type: alleviating

Target: pain

Beneficiary: individual

Means: cold pack

Alleviating an individual’s pain with a cold pack

Comparing ICNP with NNN

NNNProvide a set of domains and classes

Provides a list of terms with accompanying class codes

ICNPProvides a set of classes in the axes

Provides a list of terms with accompanying class codes

Comparing ICNP Phenomena Axis NANDA,NIC, and NOC

NNN

Have a large number of terms and all are evidence based and systematically reviewed

All terms have defining characteristics or activity lists

ICNP

Has many terms but there is no evidence base. There is peer input.

The terms have definitions of a sort but no defining characteristics

Comparing ICNP Phenomena Axis with NANDA

NANDANANDA uses a multiaxial approach

ICNPUses a multiaxial approach

In Summary

Nursing information is important to produce, store, retrieve, and use for the purposes of research, theory building, policy making and decision support

Nursing information requires language in which it can be expressed

In Summary

The most useful type of language in which nursing information can be expressed and stored, retrieved and used is standardized language

NANDA, NIC and NOC provide a linked system of standardized, evidence based nursing languages

In Summary

In an age when electronic health records are fast becoming mandated, nurses need to understand and use standardized language to capture nursing information

Nursing information is crucial to making sound nursing decisions

In Summary

Using standardized nursing language can

Describe the content of our discipline to ourselves and others

Define the elements of care and assigned cost based on parameters such as complexity and acuity

Provide a data base that can be used to predict staffing mix and care requirementsAllow us to articulate the focus of nursing practice and nursing’s unique contributions to patient care outcomes to other disciplines (Dochterman & Jones, 2003)