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 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
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 wellknown 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 class
Non-classifiable
aka 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 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
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
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)
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
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 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
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
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
TO
Mortality as a function of
Lack of food
Lack of blankets
Lack of clean water to drink
Lack of shelter
Lack 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 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/pulmonary responses
Perception/cognition
Attention
Orientation
Sensation/perception
Cognition
communication
NANDA Taxonomy II
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
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 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 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
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 Phenomena
Human 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
Environment
Nature
– Physical environment
– Biological environment
Human Made Environment
–
–
–
–
–
Infrastructure
Land Development
Supply System
Norms and Attitudes
Polity
Nursing Phenomena Classification
Axes
Focus of nursing practice
Judgment
Frequency
Duration
Topology
Body site
Likelihood
Bearer
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
Judgement
To a high degree
To a lesser degree
To a very high degree
To some degree
Likelihood
Risk for
ICNP Nursing Action Classification
Axes
Action type
Target
Means
Time
Topology
Location
Route
Beneficiary
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
NNN
Provide a set of
domains and
classes
Provides a list of
terms with
accompanying
class codes
ICNP
Provides 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
NANDA
NANDA uses a
multiaxial approach
ICNP
Uses 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
requirements
Allow us to articulate the focus of
nursing practice and nursing’s unique
contributions to patient care outcomes to
other disciplines (Dochterman & Jones, 2003)