About this Activity

MNA is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center Commission on Accreditation. A certificate awarding 1.5 contact hours will be mailed to participants who:

• Read the entire article
• Complete the evaluation form and post-test, indicating responses on the answer sheet.
• Complete the registration form.
• Mail the answer sheet and fee ($5/MNA members; $10/non-members) to MNA. Forms may be faxed if a credit card is used for payment.

Complete this activity prior to December 31, 2008.
Participants who achieve a minimum passing score of 70% (6 correct answers) will receive a certificate awarding 1.4 contact hours. Certificated will be mailed within six weeks. Participants who do not achieve a passing score will have the option to retake the test at no additional cost.

Goal
The intent of this self-study module is to provide RNs with information on Standardized Nursing Languages.

Objectives
After the completion of this self-study material on Standardized Nursing Languages the participant will:

• Explain the rationale for using a standardized nursing language.
• Identify barriers that have influenced the concealing of nursing's contributions to healthcare.
• Identify the role of the nursing informatics, and the Nursing Information & Data Set Evaluation Center in assisting with the Standardized Nursing Languages.
• Identify the Standardized Nursing Languages approved by the American Nurses Association.
• Compare and contrast taxonomy with a nomenclature.
• Describe NANDA, NIC and NOC.

Naming It

The shift is winding down, and so far without a major crisis. Today is Friday, and while the day has been busy, it is now quiet as the shift comes to completion. Today had witnessed an unusually high number of discharges, few new admissions and was lacking the typical crises. However, the unit secretary approaches and without hesitation offers a serious expression. An emergency admission is in route to your unit, and the gentleman is assigned to the last remaining bed in your area.

Mr. Gonzales, a 56-year gentleman would be arriving momentarily. He is a frequent readmission to the unit, and has a long-standing history of congestive heart failure. He and his devoted wife, Rosa, are grandparents to several grandchildren. Before Mr. Gonzales last discharge she expressed to you her many fears regarding the serious changes exhibited by her husband and the possibility of his death.

Mr. Gonzales and his wife arrive on the unit at 2:10 PM. Assisting Mr. Gonzales into his bed, the nursing assessment begins. His color is ashen, his breathing is labored, and his diaphoresis is particularly noticeable. Realizing the serious nature of his condition, oxygen is applied, followed by cardiac electrodes and pulse oximetry. Mr. Gonzales explains that his chest pain began after he did some "tinkering in the garage". He admits that he had been experiencing some "puffing" for the last three days. Bi-basilar rales, and a rapid, irregular heart rate are auscultated. The ECG waveform reveals rapid atrial-fibrillation. While assisting Mr. Gonzales into his patient gown, the +3 edematous ankles are obvious. The pulse oximeter reads 90%. Explaining what he can expect, intravenous equipment is assembled. Mr. Gonzales comments, "Happy you are here". Smiling at Mr. Gonzales, and his wife, you note the time, 2:20; ten minutes have elapsed since his admission process began.

Rationale for using a standardized nursing language

It is not unusual that nurses, such as the nurse in the scenario, perform multiple interventions simultaneously. In this scenario, in a few brief minutes, the nurse mentally engaged in the steps of the "nursing process", and efficiently extracted cues and necessary data. Similarly, the nurse in the scenario identified precise interventions to assist Mr. Gonzales in achieving a desired outcome. Not surprisingly, a home care nurse performed a basic nursing assessment, detected and interpreted subtle changes in his physiologic status during a routine home care visit. Following the steps of the nursing process, the home care nurse prioritized Mr. Gonzales' problems, identified an outcome, and initiated interventions that afforded Mr. Gonzales a smooth transition to the acute care setting. Using the nursing process, both nurses were able to significantly influence outcomes for Mr. Gonzales.

As in the past decade, today nurses are called upon more frequently to document numbers and types of client outcomes, as well as the effectiveness of nursing interventions. Some nurses may find documenting the "nursing process" cumbersome and time-consuming. And some nurses may question that the nursing process reflects or is "evidence" of what it is they do in their practice. Yet, just as the two nurses in the above scenario utilized every step of the nursing process, much of the documented evidence of nursing practice can be overlooked, and devalued without evidence. We notice that even with some documentation systems, evidence of the value of a "nurse" performed behavior may be reduced to discredited without a consistent terminology. Interestingly, Patricia Benner recognized that nurses develop sets of information, or chunks of data that go hand in hand (1984). These sets of data are collected after having observed the clinical course of many similar and dissimilar patients over time and in a variety of situations. Thus, according to Benner, nurses learn to expect and anticipate a course of events, or a set of information, but may never formally identify those sets. She further stated that "Clinical expertise has not been adequately described or compensated in nursing, and the lag in description contributes to the lag in recognition and reward" (1984, p. 11).

The scenario with Mr. Gonzales provides a backdrop for demonstrating how consistent nursing languages can assist professional nurses in capturing their contributions. This affords nurses clarity in communication of their efforts, decreases communication errors, and prevents blurring of professional nursing behaviors. Standardized nursing languages (SNLs) provide connections that link nursing assessment databases, with expected patient/client outcomes, and nursing interventions. The languages are documentation of nursing's contributions. When nurses communicate with one another and with other disciplines using the same terminology, it documents the "evidence" of their practice.

Nurses should be recognized and compensated for their efforts, and clients should have the best opportunity to achieve desired positive outcomes associated with the most efficacious nursing interventions. Expert nurses, from diverse practice settings, have developed an intuitive grasp of clinical situations, and an almost telepathic ability to sift through extraneous and sometimes irrelevant data, while being sensitive to the most effective interventions associated with achieving positive and fruitful outcomes. In this new century, as in the previous century, the nursing profession is challenged to accurately describe evidence of their contributions. Reflecting backwards, history had provided evidence of events that have influenced the direction and evolving nature of this situation.

Historical markers

Gordon (2000, p. 4) explained that a method of classifying dates back to the book of Genesis when "God divided the light from darkness". Nearly a century ago plans were set into motion that would lay the foundation for nursing's standardized languages. In 1909, Robb prophesized that the nursing profession would eventually be compelled to develop a universal nursing language (as cited in Clark, 2000). Nearly a 100 years later, Bond and Thomas (1991) predicted that if specific contributions of nurses were not identified, nursing would "remain invisible and potentially dispensable" (p. 1492). And later, McCloskey testified at the National Center for Vital and Health Statistics (NCVHS, 1999) that, in spite of the nations 2.6 million registered nurses spending the most time with patients, the nature and impact of nursing services were virtually unknown and invisible. Today nursing practice is conducted in the midst of the technological and informational revolution. Given the tools we currently have available, the time to recognize nursing's consistent contributions is long overdue.

Does every patient deserve a nurse?

How are the efforts of nurses distinguished from other professions or healthcare providers? Curiously some have questioned, how is nursing care unlike care delivered by other disciplines? While some have questioned the foundation of the art and science of nursing, others find a heritage present in nursing's history and in scholarly publications. The nursing profession is often held accountable by a gold standard for nursing practice. This document is the ANA's Standards of Nursing Practice (1998). Clearly woven into these standards are the steps of the nursing process, of which we are all familiar. A recent article (Lee, Chang, Pearson, Kahn, & Rubenstein, 2000) proposed a model of nursing care identifying three major processes involved in nursing care delivery: (a) assessment, (b) problem identification and (c) problem management. In this model, the authors proposed that the process of problem management includes identification of expected outcomes, interventions, and evaluation. During evaluation the nurse makes a clinical decision regarding the resolution of a problem and or the achievement of an outcome. Clearly, both the ANA's Standards of Nursing Practice (1998) and the contemporary proposal of Lee and colleagues (2000) are examples where the nursing process is evident. Despite these and other examples, nursing wonders how could efforts go unnoticed, be overlooked or even be devalued? Given the existence of nursing's contributions and efforts within the framework of the nursing process, and if clients deserve a nurse, should these contributions be noticeable and verifiable? When the efforts are documented the data will speak for itself, permitting nursing administrators the ability to cost out nursing's contributions and nurse researcher the opportunity to document client outcomes and nursing interventions.

Why standardize nursing languages (SNLs)?

When the work of nursing is not recognized, outcomes and interventions may be concealed, packaged, or at least seen as a collective part of other healthcare disciplines. As a result of invisibility, data reflecting nursing's contributions in multiple settings may be disregarded, misrepresented or absorbed into other disciplines or services. But ultimately the results are a lack of or evidence reflecting nursing's presence and distinguishing efforts. Eventually decisions are made that impact on resource allocation for nursing at all levels. These decisions may have been made without collecting or utilizing nursing data in managerial or administrative decision-making. Regardless of motivation(s) behind decisions that may have overlooked the contributions of nursing, results are the same. When specific practice behaviors are not included, then nursing's efforts are never visualized, appreciated, and may not be compensated. It is helpful to identify factors that may have contributed to, or may still be contributing to concealing or diluting the work of the nursing profession.

Barriers

A major barrier that has contributed to this situation is a lack of a common vocabulary in nursing. Standardizing terms that communicate nursing behaviors in multiple healthcare settings tends to illuminate and heighten an awareness of nursing's distinct role on the healthcare team. A metaphor posed by McCloskey (1995) comparing members of a healthcare team to players on a baseball team, may be useful in this discussion. Players on a baseball team are equal partners, pointed out McCloskey, each of whom brings unique skills and knowledge, which they share for the good of the team. The role of nursing on a healthcare team should be valued and regarded equally unique and unparalleled in contributing specific knowledge and skills, much like players on the baseball team.

McCloskey emphasized that members of a baseball team are colleagues, or equal partners, who bring substantive value to the overall functioning of the team. If nurses have always brought value to healthcare teams, then shouldn't it be reasonable to expect that, their knowledge, skills and efforts can be articulated? When nurses use multiple and/or different terms to describe the exact same behavior, then it is confusing. Confusion in describing conditions, outcomes, and interventions can further obscure or dilute substantive knowledge and skills that nursing brings to the healthcare team. How then can every patient deserve, or need what a nurse brings to the team?

Consider for a moment the importance of the shortstop as an individual player on the baseball team. The shortstop has the ability to be an initiator of a double play, to assist in preventing opponents from getting on base, advancing bases, or preventing a scoring opportunity. No doubt the player also brings additional benefits in terms of potential scoring contributions when the team is at bat. Few would question the importance of the shortstop in assisting the team in obtaining positive outcomes. One must question how many teams would be willing to play without their shortstop? Perhaps a baseball team would consider extending the hours that the shortstop plays, while keeping all the other players on a more judicious schedule of play? Would the team manager expect the shortstop to cover second, third or center field, while consistently playing without other key players? Knowledgeable shortstops, and nurses, benefit when they clearly communicate their unique contributions time after time. Communicating with clarity is a key to describing the contributions of nursing.

Using the earlier scenario, imagine possible descriptions of Mr. Gonzales' admission condition. One nurse may have described his condition to include difficulty breathing, chest pain, bi-basilar crackles and diaphoresis. However another nurse may have instinctively assessed Mr. Gonzales and mentally compared his condition to the defining characteristics provided by the North American Nursing Diagnosis Association (NANDA, 2001) that are associated with the person experiencing decreased cardiac output. Those characteristics included fatigue, rales, orthopnea, dyspnea, jugular vein distention, decreased peripheral pulses, cold clammy skin, arrhythmias, edema, skin color changes, chest pain, etc. While initial descriptions may have been close, there were some differences. When the same criteria are utilized for one problem, we are all playing on the same playing field, and we can all "see" the same condition (s) mentally.

It is highly likely that once visualizing the same client problem or condition mentally, then visualizing expected data as a result of interventions is also more likely. Perhaps changing Mr. Gonzales position by elevating the head of his bed would assist in his breathing? Digress for a moment to the shortstop metaphor. When the shortstop sees that a batter is stepping up to the plate that is left-handed, he would naturally adjust his position on the field. And if he is familiar with the history of a particular batter, perhaps adjust his position further or make other changes. Anticipating client needs is not new to nursing, however the Nursing Outcomes Classification (NOC, Johnson, Maas & Moorhead, 2000) is relatively new. NOC represents client outcomes stated in a clear and succinct manner. In the case of Mr. Gonzales, the nurse was no doubt looking for specific outcomes (NOCs) such as respiratory status, circulatory status, and tissue perfusion.

As a further example of how language can capture nursing behaviors, attempt to identify specific interventions you might have performed, had you admitted Mr. Gonzales. Write them in the margin of the paper. Ready? Now, do the interventions that you've listed document nursing specific contributions in the care of Mr. Gonzales? Are those interventions unique or unlike other members of the healthcare team? The nurse for Mr. Gonzales implemented many interventions, some of which included admission care, delegation, monitoring vital signs, cardiac care, data interpretation, positioning, oxygen therapy, respiratory monitoring, intravenous insertion, and order transcription. Additional interventions for Mr. Gonzales may have included medication administration, intravenous therapy, physician support, bedside lab testing, technology management, caregiver support and staff supervision. How many of the interventions performed by the nurse would be accounted for a typical documentation system? How can, and when will, nurses be recognized or compensated for their efforts? Or will the work of nursing continue to be diluted, and overlooked?

Standardized languages can facilitate the traversing of clients, families and their significant others across healthcare boundaries. The notion of seamless care is not new to nursing. What interventions did the nurse in the community who visited the Gonzales' family utilize? This nurse was the first to identify the need for acute care, and made arrangements for transport to the acute care setting. Significant contributions of this nurse and other similar nurses should be illuminated, utilized for the benefit of clients, for the nursing profession and for healthcare. Consider the potential impact when similar actions are multiplied by the contributions of 2.6 million nurses.

Collective Nursing Data

An additional factor that has contributed towards concealing nursing's efforts has been the absence of collective nursing data. We are all too familiar with the need for data to substantiate decision making for managers at the unit and higher administrative levels, particularly with respect to resource allocation. In today's complex and technological world, reimbursements can drive resources. Nurses and their patients depend on resource allocation to provide necessary care. Many settings have become depleted in terms of resources nurses are permitted to utilize in their care delivery. Data are also needed to make or change policy, at managerial and legislative levels. Without data we are like the shortstop that opens his glove to make a double play, only to find it empty. Finally, the costing out of services provided by nursing is holds true potential when using the standardized languages.

Documented data that reflects nursing practice represents the knowledge and skills that belong uniquely to nursing, as well as knowledge that nursing shares in collaboration with disciplines. While a selected individual on a baseball team commonly collects player statistics and records numbers of hits, runs, and errors etc., this role may fall to a nurse, but many times to others in the healthcare field. Just as in baseball, players, coaches, teams and leagues value statistics, and collectively those statistics become an important and beneficial factor in future bargaining situations. In the baseball team example, a shortstop represents value added to a team. After all, the shortstop can sprint into position for a line drive, preventing a runner on third from advancing to home and scoring. Obviously the team stands to benefit, and the shortstop is no doubt pleased to have this data to his credit. What if the "stats person" on the team neglected to award this honor to the shortstop? His efforts are left without documentation. Similarly, a player at bat who gets a hit, may not only land safely on first base, but at the same time affords a player on third base the opportunity to score a run. Assume that the "stats person" records the batter got a "hit". In actuality the player should be credited with a hit AND a 'run batted in' (RBI), assuming the player on third scored. Naturally the team, the player, the owners (no doubt the ballpark!) can see the value and benefit associated with the contributions of this player both today and at the end of the season when the statistics are summarized.

Similarly all the shareholders of a healthcare team would also stand to benefit from collecting such data and statistics. When numerous terms are utilized for what may be the same behaviors in nursing, there is a lack of consensus for accomplishments and contributions. Standardizing vocabulary used by nurses permits comparison of data, within and across systems. Modern healthcare systems have struggled to identify the most efficacious interventions associated with quality client outcomes (Clingerman, 2000). While similar outcomes with similar patients may be desired, this is not always possible. It would be helpful to identify those clients who present unusual circumstances, and to anticipate necessary interventions. McCormick and Jones (1998) identified that nursing care delivery, practice patterns, roles, responsibilities, and client or system outcomes are affected. Everyone stands to benefit, colleagues, teams and patients, when we standardize the terminology we use in conducting our professional work.

Nurses are often expected to document their effectiveness in specific situations. As an example, nurses are interested and concerned about a patient's balance (NOC, p. 120). Balance is one of 260 currently identified NOCs. When nurses use different terms, such as fall-risk, unsteady on feet, or safety status, to describe balance, the information may never be examined or included as an appropriate client outcome. Similarly the most appropriate and effective nursing interventions, such as "Fall Prevention" (NIC, p.326), may be documented as side rails up, or bed is in a low position. A lack of standardized terminology in documentation may lead to questions regarding the efficacy of care. Little confusion can arise when "Fall Prevention" (NIC, p.326) means the same thing from one organization to the next, from one state to the next, or one country to the next. Additionally, using the same term and indicators for an outcome can increase consistency, bring acknowledgement to nurses who contribute to this outcome, and provide a foundation for effectiveness research.

In our global environment nurses are traveling across and around the world in unique working situations, consistently needing to validate their clinical competencies. Similarly nursing educational environments often struggle to identify accreditation competencies. The Nursing Interventions Classification holds potential as one area where nurses, and nursing students, may be able to validate competencies using identical language associated with their behaviors.

The lack of efficient and automated electronic systems that cross boundaries is an additional impediment preventing evidence of nursing's contributions. "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 (Clark, 2000, p.32). Contemporary healthcare systems rely heavily on automated information systems for documentation, data collection and analysis. Yet, it is difficult to provide evidence of nursing practice without systems that collect nursing specific information in an efficient manner. This lack of standardized, nursing sensitive data has hindered the ability to compare nursing practice across settings (Coenen, Ryan & Sutton, 1997; Keenan & Aquilino, 1998). Recently researchers (O'Connor, Hameister & Kershaw, 2000) suggested that a computerized database of standardized, discipline-specific language could have facilitated data collection and coding schemes that were used in a study describing the ambulatory care practice of adult nurse practitioner students in a primary care setting. It is time for a common vocabulary that promotes electronically retrieving nursing data in efficiently.

Vendors who create, package and market computerized databases need encouragement to utilize an approved standardized vocabulary that recognizes nursing sensitive data, which consistently and accurately reflects nursing practice across healthcare systems. Likewise, health care systems need encouragement to purchase and utilize similar software. Legislative and political systems can be influenced to include nursing driven databases.

Role of Informatics

In an effort to encourage the use of SNLs, and to assist vendors in identifying essential design characteristics the ANA developed a mechanism and a set of standards that facilitates capturing essential nursing specific data (Delany, 1999; Aquilino & Keenan, 2000). The Nursing Information & Data Set Evaluation Center (NIDSEC; ANA, 1997) was established within the ANA in 1995 to lead nursing's initiative with data systems. The role of NIDSEC is to review, evaluate and officially recognize information systems that support documentation of nursing care with automated Nursing Information Systems (NIS), or for use with computer-based Patient Record systems (CPR). To date NIDSEC has recognized NANDA, NIC and NOC as well as six other nomenclatures. Around the globe, the International Council of Nurses (ICN) developed the International Classification for Nursing Practice (ICNP) Beta Version, a classification system to cross map three core aspects (nursing phenomena, actions and outcomes) of nursing practice across countries. ICNP's objectives include the establishment of an international nomenclature for nursing practice. Additional information regarding NIDSEC or ICNP is available by visiting http://nursingworld.org/nidsec and http://icn.ch/icnpupdate.htm websites. Key abbreviations relevant to this discussion are shown in Table 1.

Let us not conceal the work of even one nurse on a healthcare team, any more than we would ignore the contributions of a shortstop on a baseball team. Just as every member of the baseball team throws a ball, other members of the healthcare team may perform core-nursing interventions. It is time to unmistakably document what nursing uniquely brings to every healthcare team, and using a SNL affords nurses this opportunity.

State of the Art: ANA recognized languages

To date the ANA has recognized several standardized nursing nomenclatures, including: the Georgetown University Home Health Care Classification (HHCC; Saba, 1992), the North American Nursing Diagnosis Association (NANDA; 2001), the Nursing Interventions Classification (NIC; McCloskey & Bulechek, 2000), the Nursing Outcomes Classification (NOC; Johnson, Maas, & Moorhead, 2000), the Omaha System (OS; Martin & Scheet, 1992) the Ozboldt nomenclature in conjunction with the University Hospital Consortium (UHC; Ozboldt, 1995). Of these nomenclatures, the OS, HHCC and UHC are designed for a specific client population, while NANDA, NIC and NOC are comprehensively designed for use across systems and settings. While some diagnoses, interventions and outcomes are common to all of nursing, others are designed for use in specialty practices across the healthcare continuum. The SNLs of NANDA, NIC and NOC are "well-suited for integrated health systems" (Keenan & Aquilino, 1998, p. 82), and are for use at individual, family and community or population levels (Johnson et al., 2000).

In contemporary healthcare settings numerous disciplines and healthcare providers contribute to client outcomes in a variety of locations. Terminology that consistently reflects nursing practice, and is somehow sensitive to nursing's vocabulary, will assure that nursing is both represented and considered essential when making decisions that impact on access, supply and demand of health care resources. In this era of rapidly changing technological advancements there is evidence of continuing efforts to develop a multi-disciplinary computer-based patient record (CPR). Collecting, summarizing and analyzing nursing specific behaviors, and effectiveness of interventions is required if nursing is to remain visible in the new millennium. The standardized nursing languages heighten an awareness of nursing's presence, can serve to identify the most efficacious interventions, and can be utilized as a rich source of data in decision-making at all levels. Common nursing languages, in particular those languages which can communicate across nursing specialties, and in collaboration with other disciplines, can bring America's 2.6 million nurses together and document their work in multiple settings across the lifespan of individuals, families and communities. NANDA, NIC and NOC are SNLs that have been developed with computer automation in mind. In the United States, these languages have remained cognizant of governmental health care reform legislation and have worked closely with World Health Organization (WHO) and the ICNP. The leaders in developing an international language for the ICN are predominately European. Both the ANA and NANDA have been included as reviewers of the work coming from ICN.

Nomenclature or Taxonomy?

What is in a word? As an example of how confusing words can be, consider the word "bit". We may ask for a drill bit, or place a bit in the horse's mouth. Or we may be asking for a small morsel of food. Years earlier we may have been referring to "bits" as money, and today people may be referring to the amount of space (also referred to as bytes) stored on computers and diskettes. Obvious misinterpretations occur in use of language. The world of healthcare requires coding and transmittal of information for claims, medical records, and billing. Misinterpretations are costly for clients, nursing, the government, and society as a whole.

It is important to consider both nomenclature and taxonomy in any discussion of SNLs. Merriam-Webster (2000) differentiates taxonomy as, "the study of the general principles of scientific classification", from nomenclature, which is "a system or set of terms or symbols, especially in a particular science, discipline or art". A nomenclature can be thought of as the words or verbiage employed to describe a particular phenomena. Lang 91995) has identified a taxonomy is the actual principles, or methods that governing a classification process.

Nomenclature

The very selection of a specific word conjures up in our minds a specific mental image. The mental image we envision when someone describes an immobile patient varies and is sometimes context specific. The immobile patient may be a client who is completely or totally paralyzed, comatose, or waking up from anesthesia. Similarly, the words selected to documentation an immobile condition may vary., Word selection in documenting this condition may alter our mental image, or the image of others reading the documentation. Automated information systems may not be equipped to capture multiple or similar terms, thereby not capturing essential information. Selecting terms that accurately describe a client, or our interventions encourages clarity, avoids confusion, and promotes retrieval of information. The selection of one term versus another indicates that nurses can and do differentiate between concepts, for example anxiety and fear.

Taxonomic Structure

In contrast to nomenclature, taxonomy is a method of organizing or classifying into groups, and further into subgroups, or classes. The classification of animal life, and the principles that govern the manner in which animal life is classified is one example. If the classification system, that is the taxonomic structure and process, not been clearly identified there would be no definitive way to separate squirrels from say rabbits, or further, the gray squirrel from the black squirrel. In a similar manner the taxonomic structure created for the SNLs are evident. The SNLs are classified beginning from a broad perspective and narrowing to a more specific focus. An example associated with the NOC classification system is provided in Table 2.

Nursing Outcomes Classification

Each NOC is clearly defined, and contains a list of indicators (specific criteria) and measurement scales. The example in Table 2 reflects two of seven NOC domains: those from functional health domain, and those from family health domain. The NOCs selected in this example (Table 2) reflect a further subdivision associated with two classes: Energy Maintenance, and Family Member Health Status. The complete taxonomy contains 29 classes, and 260 outcomes (Johnson et al., 2000).
Specific indicators, measurement scales, accompany all of the NOCs provided in the Nursing Outcomes Classification and they have been conveniently assigned a coded number. Coding, inherent in the Nursing Outcomes Classification system, represents various taxonomic levels (domains, classes, outcomes). Scales serve to further quantify each outcome. Scales are uniform 5-point. This coding structure, similar to that of NIC, further facilitates use in computerized systems and care maps. Use of NOC can assist in the creation of data sets that can link with other national databases (NOC, 2000). The Nursing Outcomes Classification contains a collection of outcomes for individual, family and community clients. NOC is representative of all clinical practice settings across a seamless plan of care.

Nursing Interventions Classification

A similar taxonomic structure exists for the Nursing Interventions Classification (NIC). NIC , which to date contains 7 domains and 30 classes, 486 interventions and more than 12,000 activities. Each NIC is accompanied by specific activities, and is assigned a coded number, facilitating the capturing of data in automated electronic systems. Many believe that NIC offers an opportunity for the reimbursement of nursing, and for effective planning and use of resources (NIC, 2000). Similarly to the NOC example, one example that demonstrates NIC's taxonomic structure is Domain 7: Community. This domain describes nursing care that supports the health of the community. At a sub-level within this domain, two classes have thus far been identified: Community Health Promotion, and Community Risk Management. Within each of the classes nursing interventions are classified. For example, Environmental Management: Community (#6484) is located within the class of Community Risk Management, and Program Development (#8700) is located within Community Health Promotion. Each of the interventions contains specific activities.

North American Nursing Diagnosis Association (NANDA)

A taxonomic compilation of nursing diagnoses has been developed, and is consistently being refined by the North American Nursing Diagnosis Association (NANDA, 2001). As identified by the organization, the nursing profession diagnoses and treats human responses to health conditions, and does not focus on treating the disease process itself. Thus NANDA nursing diagnoses reflect the work of nursing across a client's lifespan and across the continuum of healthcare. Examples include diagnoses such as Parent-Infant Attachment, Health-Seeking Behaviors, Impaired Physical Mobility, Social Isolation, or Risk for loneliness.

Initially NANDA's diagnostic taxonomy contained 9 human response patterns, while a new revised taxonomic structure (Taxonomy II) reveals 13 domains of health patterns, with 46 classes (NANDA, 2001).While the new structure may be observed in NANDA's (2001)latest edition of diagnoses (pp214-215), domains include Health Promotion, Nutrition, Elimination, Activity/Rest, Perception/Cognition, SelfPerception, Role Relationships, Sexuality, Coping/Stress Tolerance, Life Principles, Safety/Protection, Comfort and Growth/Development. Domains and Classes are accompanied by a definition, and include coded diagnostic concepts. This taxonomic structure further facilitates the discrimination of similar concepts within a class or domain.

The new Taxonomy II also includes a system for coding nursing diagnoses that facilitates efficient use in automated systems and provides a more user-friendly ability to allow additions and modifications than Taxonomy I. While practicing clinicians may not require the complete use of a multiaxial coding scheme, it is to an advantage to know of its presence and the benefits it affords. The new taxonomic structure has been referred to as multiaxial in nature, that is, it contains7 axes, or dimensions, of a human response that nurses consider when making a nursing diagnosis. The first dimension (Axis 1) is the diagnostic concept, or diagnosis, (e.g. Parenting). Axis 2 refers to Time, referring to the duration of care (e.g. a level of acuity, such as. acute, chronic etc.). A unit of care is represented as Axis 3, and reflects a unique population, such as the individual, the family, group or a community. Axis 4, is physical age, or time the individual has existed, while Axis 5 identifies health status such as Wellness, Risk or Actual. Axis 6 contains modifiers or descriptors that have commonly been identified by NANDA and that further clarify the concept. Examples include modifiers such as Increased, Decreased, Disorganized, Dysfunctional, Impaired, and Readiness for Enhanced. Finally Axis 7 contains parts or regions of the body such as Urinary, Bowel, Oral and Renal. Further information about this new taxonomic structure can be located at http://www.nanda.org/html/taxonomy2.html, or within NANDA's official publication (NANDA, 2001).

Conclusion

It is both interesting and helpful that NANDA, NIC and NOC are complementary to one another. Both NOC and NIC have published linkages with NANDA diagnoses, facilitating diagnostic reasoning and clinical decision-making. Additional published linkages have been provided between NIC and NOC (Johnson, Bulechek, Dochterman, Maas, & Moorhead, 2001). Nursing research continues to focus on the linkages believed to exist between the three commonly accepted standardized nursing languages of nursing. These languages are also available in numerous written texts, and appear in English as well as other languages.

With the exception of recent advanced practice nurses achieving the ability to charge for service using CPT 4, 80-90% of the nurses in this country have no administrative codes to cover their practice, while administrators may have difficulty capturing proof of nursing's cost benefit. Clinical nursing codes have never been used in administrative transactions. Nursing care has historically been embedded in room charges, a flat rate fee or other fees. The current documentation system in the U.S. does not accurately reflect nursing's contribution to patient outcomes (Warren, 2000). Nurses from a wide variety of settings contribute to the health and well being of clients. In addition to caring for persons who are acutely and chronically ill, nursing care has been extended to health promotion and wellness settings, across communities and populations. Despite these contributions, nursing care may be overlooked in more contemporary settings, and may not be included in nursing sensitive data. It is critical that the work of all nurses is acknowledged. The efforts of NANDA, NIC and NOC provide a foundation to go forward with this initiative.

The coding framework of NANDA, NIC and NOC is keeping pace with the complexity of clients, and their healthcare needs. Using these SNLs prevents the ambiguous use of terminology, and encourages the documentation of client and nurse data. These coding schemes are available for vendors in creating and marketing nursing automated systems.

The SNLs of NANDA, NIC and NOC have been linked and can be utilized in an integrated plan of care that can traverse across the healthcare continuum and the lifespan. Nursing research efforts continue to explore and validate all possible linkages in the nursing process. Consistent use of nursing sensitive languages affords individuals collecting data to document evidence of nursing's contributions. The languages of NANDA, NIC and NOC are applicable in states of wellness, illness, or in chronic situations, and can be utilized in multiple and different settings, across the lifespan, and in a vast range of clinical practices.

As political and legal changes continue to influence the allocation of healthcare dollars, nursing cannot afford to go unnoticed as a key contributor on the healthcare team. The efforts of all 2.6 million nurses should be acknowledged. Data must be collected that substantiates the value of all nurses in all settings. Collecting data with the standardized nursing languages of NANDA, NIC and NOC offers this opportunity. Nurses who understand and speak the languages give proof of their contributions. When nurses educate new nurses and bring additional colleagues along, they increase the worth of the team. It is time for nurses to consider what is important in choosing a word or words.

Post Test Questions: Nursing's Professional Languages

1. The primary reason that standardized nursing languages are necessary is to:

2. One purpose of collaborating with vendors in the development of a nursing
database is to:

1. Avoid duplication in surveying nurses who use a Standardized Nursing Language.
2. Acknowledge nursing practice by including nursing sensitive data in the development of a computerized database.
3. Encourage financial investment in computerized software.
4. Ensure quality client care is being administered in all settings.

3. Taxonomy is:

a. A method of classifying.
b. A database.
c. A nomenclature.
d. A definition.

4. The purpose of NIDSEC is to:

a. coordinate the development of all additional standardized nursing languages.
b. Act in behalf of the ANA to assist vendors in establishing standards to evaluate nursing data systems.
c. Is to identify nursing acuity systems for the ANA, and to work with the governmental arm of reimbursement.
d. Create a nursing database that collects information for Medicare reimbursement.

5. The international organization that is working on establishing an international
nomenclature for nursing practice is :

a. ICNP
b. NIDSEC
c. ICN
d. NIC

6. A published taxonomy of client outcomes that identifies seven domains, 29
classes and 260 outcomes is:

a. ICN
b. NANDA
c. NIC
d. NOC

7. NIC is taxonomy of:

a. Nursing interventions
b. Nursing diagnoses
c. Client problems
d. Client outcomes

8. NANDA's nursing diagnoses are:

a. Printed only in English.
b. Formally linked with both NIC and NOC.
c. Are limited for use in acute care settings only.
d. Are limited for use with adults only.

Do not mail this post-test to MNA. Keep it for your records. Mail in the answer sheet only.

Post-Test Answer Sheet - Print and Return to MNA

References

American Nurses Association. (1998). Standards of Clinical Nursing Practice, (2nd ed) Washington, DC: ANA.

American Nurses Association. (1997). Nursing Information & Data Set Evaluation Center: Standards & Scoring Criteria. Washington, DC: ANA.

Aquilino, M.L., Keenan, G. (2000). Having our say: Nursing's standardized nomenclatures. American Journal of Nursing, 100(7), 33-38.

Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park, CA.: Addison-Wesley Publishing Company.

Bond, S., & Thomas, L.H. (1991). Issues in measuring outcomes of nursing. Journal of Advanced Nursing, 16, 1492-1502.

Clark, J. (2000). "The International Classification for Nursing Practice Project". Retrieved 02/09/00 from the World Wide Web: http://nursingworld.org/mods/mod30/cec2full.htm

Clingerman, E. (2000). Nurses in the new millennium. Michigan Nurse.

Coenen, A., Ryan, P., & Sutton, J. (1997). Mapping nursing interventions from a hospital information system to the Nursing Interventions Classification (NIC). Nursing Diagnosis, 8(4), 145-155.

Delaney, C.W. (1999). Informatics Literacy-A key tool for empowerment in the twenty-first century. In Andersen, C.A.F. (Ed.), Nursing student to nursing leader: The critical path to leadership development (pp. 241-255). Albany: Delmar Publishers.

Gordon, M. (2000). "Nursing nomenclature and classification system development". Retrieved 02/09/00 from the World Wide Web: http://nursingworld.org/mods/mod30/cec2full.htm

Johnson, M., Bulechek, G., Dochterman, J.M., Maas, M., & Moorhead, S. (Eds.) (2001). Nursing diagnoses, outcomes, and interventions: NANDA, NOC, and NIC linkages. St. Louis: Mosby.

Johnson, M., Maas, M., & Moorhead, S. (Eds.). (2000). Nursing outcomes classification (NOC) (2nd ed.). St. Louis: Mobsy.

Keenan, G., & Aquilino, M.L. (1998). Standardized Nomenclatures: keys to continuity of care, nursing accountability and nursing effectiveness. Outcomes Management for Nursing Practice, 2(2), 81-86.

Lang, N.M. (Ed.). (1995). Nursing data systems: The emerging framework. Washington, D.C.: American Nurses Publishing.

Lee, J.L., Chang, B.L., Pearson, M.L., Kahn, K.L., & Rubenstein, L.V. (2000). Does what nurses do affect clinical outcomes for hospitalized patients? A review of the literature. HSR: Health Services Research, 34(5), 1011-1032.

Martin, K.S. & Scheet, N.J. (Eds.). (1992). The Omaha System: Applications for community health nursing. Philadelphia: W.B. Saunders.

McCloskey, J.C. (1995). The nurse executive: the discipline hearts of a multidisciplinary team. Journal of Professional Nursing, 11(4), 202.

McCloskey, J.C., & Bulechek, G.M. (Eds.). (2000). Nursing interventions classification (NIC) (3rd ed.). St. Louis: Mobsy, Inc.

McCormick, K.A., & Jones, C.B. (2000). Part Two: "Is one taxonomy needed for health care vocabularies and classification?" Retrieved 02/09/00 from the World Wide Web: http:/nursingworld.org/mods/mod7/ceu1full.htm

Merriam-Webster (2000). Merriam-Webster's Dictionary [On-line]. Available: http://www.m-w.com/cgi-bin/dictionary

North American Nursing Diagnosis Association (NANDA). (2001). Nursing Diagnoses: Definitions & Classifications 2001-2002. Philadelphia: Author.

National Center for Vital and Health Statistics. Hearings on medical terminology and code development. (May 18, 1999) (Testimony of Joanne McCloskey).

O'Connor, N.A., Hameister, A.D., & Kershaw, T. (2000). Developing a database to describe the practice patterns of adult nurse practitioner students. Image: Journal of Nursing Scholarship, 32(1), 57-63.

Ozboldt, J.G. (1995). From minimum data to maximum impact: using clinical data to strengthen patient care. Advanced. Practice Nursing Quarterly, 1, 62-69.

Saba, V.K. (1992). The classification of home health care nursing diagnoses and interventions. Caring, 11(3), 50-57.

Warren, J. (2000). Testimony to the National Center for Vital and Health Statistics Hearing on Clinical Coding and Classification Issues. Retrieved 09/30/00 from the World Wide Web: http://aspe.os.dhhs.gov/ncvhs/97041617.htm

Table 1
Abbreviations

Table 2- Example of the Taxonomic Structure for NOC