Standardized Nursing Languages

1. Standardized Nursing Languages Foundation for the Information Infrastructure of Nursing

2. 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 information • To assert that standardized nursing languages are the only rational means of capturing nursing information reliably and efficiently • To give a brief comparison of NANDA,NIC, NOC and ICNP taxonomies

3. 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

4. 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)

5. 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

6. 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).

7. 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

8. 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

9. 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

10. 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.)

11. 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

12. A classification of sets of concepts is called a taxonomy

13. Other examples of taxonomies • In biology – genus, family, kingdom • In library science – Dewey decimal system • In medicine – ICD10 • In nursing – NANDA, NIC,NOC, ICNP

14. 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

15. 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

16. Nursing information • Production sources • Research and theories – if published • Guide practice • Teach students • Clinical experiences – often informal • Shared in writings • Passed down from nurse to nurse • Clinical records • Patient records and care plans • Procedure manuals

17. Nursing information • Accumulation • Research 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

18. Nursing information • Storage • Research – archives, libraries, databases • Clinical experiences – if not published, this information dies with the knower • Clinical records – paper records, electronic data bases (In the case of paper records, the nurses notes, care plans, etc are often systematically thrown away)

19. Nursing information • Retrievable • Research – 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

20. Nursing information • Usable for various purposes • clinical information support • outcomes measurement • effectiveness evaluation • case mix assessment • administrative decisions • Updated regularly

21. 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 retrievable • The 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

22. Nursing information • “Free text” nursing notes can not be coded • Nursing information is therefore systematically “facilitated out of the equation” of medical information (Bowker, 2003) • This problem, in effect, makes nursing invisible

23. 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)

24. 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

25. 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

26. 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

27. 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

28. 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

29. Nightingale was an informatician • She changed the focus of the military from • mortality as a function of wounds • TO • Mortality as a function of • Lack of food • Lack of blankets • Lack of clean water to drink • Lack of shelter • Lack of sanitation

30. 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)

31. Cold Frostbite Hunger Scorbutus Lack of clothing Lack of shelter Excessive fatigue Diarrhea Dysentery Fever Nightingale’s list of concerns for the soldiers

32. Health of houses Ventilation and warming Light Noise Variety Bed and bedding Personal cleanliness Nutrition and taking food Chattering, hopes, and advice Social considerations Nightingale’s list of nursing concerns for all patients

33. 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

34. Health promotion Health awareness Health management Nutrition Ingestion, digestion, absorption, metabolism, hydration Elimination Urinary Gastrointestinal Integumentary pulmonary Activity/Rest Sleep/rest Activity/exercise Energy balance Cardiovascular/pul-monary responses Perception/cognition Attention Orientation Sensation/perception Cognition communication NANDA Taxonomy II Domains and Classes

35. Self-perception Self concept Self esteem Body image Role relationships Caregiving roles Family relationships Role performance Sexuality Sexual identity Sexual function Reproduction Coping/Stress tolerance Post trauma responses Coping responses Neurobehavioral stress NANDA Taxonomy II

36. Life Principles Values Beliefs Value/belief/action congruence Safety/Protection Infection Physical injury Environmental hazards Defensive processes thermoregulation Comfort Physical comfort Environmental comfort Social comfort Growth/Development Growth development NANDA Taxonomy II

37. NANDA Axes • Diagnostic concept • Descriptors • Age • Time • Topology • Health status • Unit of Care

38. 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

39. Functional Domain Activity/Exercise Comfort Growth and Development Nutrition Self care Sexuality Sleep/rest Values/beliefs Physiological Domain Cardiac 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

40. Psychosocial Domain Behavior Communication Coping Emotions Knowledge Roles/relationships Self-perception Environmental Domain Health care system Populations Management NNN Taxonomy of Nursing Practice Domains and Classes

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

42. ICNP Domains and Classes for Phenomena Classification • Nursing Phenomena • Human Being • Individual • Function • Organ • Person • Plan of Action • Action • Group • Family • Family process • Family composition • Family size

43. ICNP Domains and Classes • Community • Community Process • Community Composition • Environment • Nature • Physical environment • Biological environment • Human Made Environment • Infrastructure • Land Development • Supply System • Norms and Attitudes • Polity

44. Nursing Phenomena Classification • Axes • Focus of nursing practice • Judgment • Frequency • Duration • Topology • Body site • Likelihood • Bearer

45. 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

46. 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

47. ICNP:A conceptual problem • Judgement • To a high degree • To a lesser degree • To a very high degree • To some degree • Likelihood • Risk for

48. ICNP Nursing Action Classification • Axes • Action type • Target • Means • Time • Topology • Location • Route • Beneficiary

49. Nursing Action • A nursing intervention must include a term from the action type • Terms from the other axes are optional

50. Nursing Action example • Action type: alleviating • Target: pain • Beneficiary: individual • Means: cold pack • Alleviating an individual’s pain with a cold pack