Final Report Submitted to the Nursing Work Group

Working Group Information
Name of Working Group
Nursing Working Group
Signature of Chair
General Information
Project Title
Nursing Occupations/Roles Revision Project
Potential Project Manager
Cynthia Lundberg, BSN, RN
Start date
January 2010
Name of Working Group Chair
Anne Casey
Date Submitted to IHTSDO Office
Proposed by
Judith Warren PhD, RN, Cynthia Lundberg, BSN, RN
Potential Project Owner
Judith Warren PhD, RN
End date
February 2011
Summary
[2-3 sentence summary of the proposed initiative and its objectives]
The project identified, reviewed and analyzed the nurse occupation concepts that exist in SNOMED CT. This included identifying accurate modeling and location of the concepts and identifying concepts belonging in Core and those belonging in country-specific extensions. The project aligned the
Social Context sub-hierarchy of occupations with national and international quality measures for healthcare.
Context
* Describe the background of the project (e.g. on whose initiative is the project suggested, is this part of another initiative, etc.]
The Anaesthesia SIG noted discrepancies in the locations of various nursing occupations/roles. The brought this to the attention of the Nursing SIG who agreed that there were modelling errors.
* Describe the importance of the project
The problem of electronic health care records not having a standardized terminology that contains distinct, unambiguous, understandable, and useful nurse professional occupations/roles will impact querying. Furthermore, this lack of specifics will impair research analysis for improving

patient safety, quality of care, and cost effectiveness. For example, nursing occupations support research of nursing staff levels required based upon patient acuity. These types of reports can also be used to identify if an inappropriate level of staff contributed to a medical or medication error and identify appropriate levels of nurse needed to improve quality patient care .
The ambiguous and duplicate nursing occupation contained within SNOMED CT has an impact on accurate and complete data collection that is required for research and analysis. The requirement of having the ability to query for professional roles/credentials at the “Is_A” relationship level is essential when assessing if the appropriate level of nursing occupation was performing patient care and how this role affected the quality of patient care. Not having distinct definitions of nursing roles within SNOMED CT results in inaccurate documentation at the point of care resulting in the incapability to collect occupation related research studies.
The need for unambiguous nurse occupation/roles is necessary to post-coordinate ”referral to (observable entity) CID 440379008” and ” referral by (observable entity) CID 440377005” with the appropriate nurse role. Not having distinct definitions of nursing roles within SNOMED CT results in inaccurate documentation at the point of care resulting in the incapability to collect occupation related research studies.
*Describe problems solves through this project.]
Creates a more accurate, less ambiguous representation of nursing occupations/roles; Correct the errors in modelling nursing occupations/roles so that SNOMED
CT will be more accurate and robust when representations and queries are conducted in electronic health records
Target
Who are the immediate beneficiaries of the project?
The patient: When the role of the nurse is specified, then resources can be understood and allocated to patient care.
The Nurse caring for the patient: Knowing the nursing occupation/role will facilitate identification of the impact of care on patient outcomes; Knowing what nurses do in their roles
The researcher: Nursing occupation/role data will be consistent and measurable across multiple enterprises.
Content

1.
The Social Context and other hierarchies will be explored for concepts related to describing nursing occupations and/or roles.
2.
A proposal will be prepared to harmonize the concepts and their locations
3.
The Nursing SIG will validate the results: Nursing concepts, Proposed location of the concepts, Proposed attributes to ensure accurate modelling, and
Concepts belonging to Core and country extensions
4.
Nursing SIG will approve and prioritize the proposal
5.
Nursing SIG will forward to the Content Committee for action
Fit with IHTSDO strategy
This project supports the IHTSDO objectives of contributing to the improved delivery of care and facilitating the accurate sharing of clinical and related health information. Revising the Occupations hierarchy to accurately reflect the role that nurse play in the provision of patient care leverage interoperability between enterprises that use different staffing strategies for the provision of that care. Using nursing roles can assist in benchmarking between institutions who achieve best practices. These concepts are necessary to populate the structure components of quality care measures.
Furthermore, this project is an IHTSDO quality project aimed at correcting errors in SNOMED CT, thus increasing the value of SNOMED CT use.
Deliverables
* Make a list of expected deliverables, e.g. report, software, modeling, and when they are expected to be available. Please list in order of delivery.
* For each, describe essential procedure/methods choices.
1.
A proposal listing all current nursing occupations/roles with a proposal for their correct location within the Social Context hierarchy plus recommendations for which concepts should remain in Core and which concepts should be move to country-specific extensions.
Risks
* Describe key risks that could endanger the process and the result of the project.
1.
Inability to reach consensus of nursing occupations/roles for the Core and the country extensions
2.
The priority given to the work to will be so low as to require years before the content is fixed
3.
Some countries have yet to develop extensions and so the content may be lost

*Indicate how these risks must be handled/mitigated during the project.
1.
The Nursing SIG will validate the proposal
2.
The International Council of Nursing has a representative on the Nursing SIG that can help with resolutions and consensus
3.
Provide a free resource to correct the modeling errors in SNOMED CT
Project organization and environment
Project organization
*Who are the project owner, leader, participants?
Judith Warren –owner and leader
Cynthia Lundberg—co-leader
*How would the project report in the IHTSDO structure (e.g. to which Committee)?
This work will be reported to the Nursing SIG who then reports to the Content Committee. The Content Committee will be responsible for taking action. Various extensions may also want to adopt the work in their countries.
Is a steering or reference group required? If yes, who would the members be and what would their roles be?
No group is needed
Interested parties
*Who are the key interested parties for this initiative?
The Nursing SIG and the nursing community at large
Are the internal (including other Committees, Project Groups, or Special Interest Groups) or external (e.g. other standards development organizations)?
*What are their expectations concerning fulfilment and outcome?
That the errors in the current location of the nursing occupations will be corrected

*What actions are needed to secure involvement from key interested parties?
Communication
*Identify ways of communication - in the group, with the rest of the IHTSDO, and with key external interested parties.
This is a project of the NURSING SIG and the team will report to them (Judith Warren and Cynthia Lundberg are members of the Nursing SIG). The use of the quality metrics will be reported to the Quality Committee (Judith Warren is a member of this committee)
*How often should there be communicated and to whom?
The leaders, Judith Warren, will be responsible for reporting to the Nursing SIG. There will be a standing agenda item for the report until the project is completed.
Plan and key milestones
*Describe key project milestones (e.g. kick off meeting, interim milestones, presentations at IHTSDO conferences, and final deliverables) and their time frames
*What process will be used for tracking and reporting on progress=
*What process will be used to track and report on the results of the initiative (e.g. with relevant Committees, staff, and the Management Board)?
Project Milestones
1.
Proposal idea presented to the Nursing SIG October 2008 (received approval)
2.
Team was formed April 2009 (put on hold due to illness)
3.
Formal proposal presented to the Nursing SIG April 2010
4.
Proposal for revision created by August 2010
5.
Validated by the Nursing SIG by September 2010
6.
Approved by Nursing SIG and forwarded to the Content Committee by October 2010
Process for reporting on progress and results
1.
Post progress on the Nursing SIGs Collaborative WorkSpace
2.
Results will be reported at an IHTSDO meeting

Process for conducting the project:
1.
The hierarchies will be searched for all nursing occupations/roles
2.
Proposal made for correct placement (to include analyses listed below in the quality metrics)
3.
SNOMED code result set will be saved as a value set.
4.
The Nursing SIG will validate the SNOMED CT Nursing Occupations/role revision proposal
5.
Revisions made as necessary and then submitted to the Nursing SIG
Quality measures
*Describe how you intend to incorporate the Quality Framework into the proposed work
*Give some examples of key components that are likely to provide quality metrics related to the work, i.e. measure the degree to which the work meets its specified objectives
NB refer to Quality framework toolkit document for examples
Documentation of the appropriate quality metrics from the IHTSDO Quality Framework:
1.
Number of concepts reviewed: 147 concepts (see Appendix 2)
2.
What are the current location(s) of nursing occupations/roles concepts in SNOMED CT? Social Context Hierarchy
3.
Which hierarchy should contain the nursing occupations/roles concepts? Social Context hierarchy
4.
What attributes should the nursing occupations/roles concepts have for URU modeling and clarity of use? This metric was determined to be outside of scope for this project. However, it should become a new project.
5.
How should they be disambiguated? N/A
6.
Number of nursing occupations/roles concepts located accurately: 129 concepts
7.
Number of nursing occupations/roles concepts needing to be moved: 0
8.
Number of the nursing occupations/roles concepts belonging in the SNOMED CT Core? 129 concepts
9.
Which ones need to be moved to country extensions? 10 concepts
10.
Number of the nursing occupations/roles concepts fully modeled according to the style guide? 129 concepts
11.
What are the obvious missing nursing occupations/roles concepts? 1 concept (see Results)
12.
Number interactions with Nursing SIG participants: two conference calls in 2010; two face-to-face meeting in 2009 and 2010

Resources
IHTSDO resources requested
*Total resources requested (e.g. IHTSDO staff, contractors, or support organization time; meeting costs; investments in tooling): $ [Insert amount in US dollars]
*If there are several phases/deliverables, please provide the budget by phase/deliverable.
We are not requesting IHTSDO resources
Name of IHTSDO resources requested
Limited IHTSDO resources will be required only if proposal is accepted by the Content Committee.
*Describe resources requested and the expected timing
*In case of requests for staff/contractor time, please describe the tasks to be performed, requirements (e.g. hours/weeks) for each resource, when they would be needed, and the qualifications needed to carry out the tasks.
Other significant resource requirements
*Provide an overview of requirements if major contributions from Members/volunteers are expected. Specify nature of contribution expected, timing, and means by which this contribution will be secured."
Judith Warren and Cynthia Lundberg will conduct the analysis and create the proposal
The Nursing SIG members will volunteer time to validate the proposal recommendations
Results (for complete report see Appendix 1)
 Nurse role/occupations are a subtype of the Social Context hierarchy
 SNOMED CT contained 147 nurse role/occupation concepts
 The only defining concepts is the Is_A defining relationship.
 There are no other defining attributes that have been approved by the IHTSDO which means that the occupations cannot be fully defined today.
 Of the 147 total role/occupation concepts 129 concepts have been defined unambiguously, are expressed with a FSN, and have been defined correctly in

the Is_A defining relationship.
 129 concepts are international in scope and are recommended to remain within SNOMED CT core.
 1 concept is being recommended to be submitted as a new IHTSDO request.
 “Chief nursing officer “ is being requested so that nursing officer concepts can be classified under it.
 For example, nursing officer (occupation) CID 158990003 Is_A Chief nursing officer
 10 are being proposed to be moved from SNOMED CT core to an extension file as these concepts have been found to be country specific.
Role/Occupations Being Proposed to be Retired
 Professional providing staff relief during surgical procedure 405685006
 Sanitarian
 Occupational health service manager
45956004
224580005
 Occupational health nursing officer
 Midwifery personnel
 Nursing aid
 Theatre nurse
 Other professional nurse
158989007
106294002
73265009
83189004
224561008
Newly Proposed Is_A Relationships
 SNOMED CT FSN CID New Is_A FSN CID
 Anesthetic nurse 309445003 Perioperative nurse 415075003
 Health visitor

159000000 Professional nurse
Staff midwife 158995008 Staff nurse
106292003
158994007
 Registered midwife 309453006 Health visitor/nurse/midwife 309452001
Role/Occupation Concepts Proposed to be Moved to a Country’s Extension File
 SNOMED CT FSN CID Country Extension
 Integrated midwife 312485001 United Kingdom / Philippines
 Foot care worker 22460300 United Kingdom
 Professional initiating surgical case 405684005 United Kingdom

 Healthcare service manager 224579007 United Kingdom
 Nursing officer – district 158985001 United Kingdom
 Nursing officer – division
 Nursing officer - region
158987009 United Kingdom
158984002 United Kingdom
 Nursing sister 224572003 United Kingdom
 Registered nurse First Assist 372102007 United Kingdom
 Accident and Emergency nurse 224537001 United Kingdom
Recommendations from the Quality Assurance Committee and the Nursing Working Group

For the next project, need to consult HL7, WHO, and Labor Departments of a sampling of countries

Careful using the word Role as in some countries this may mean licensure of permission to do things; thereby being county dependent

How are these concepts used when the occupation of the patient is a nurse

Canada would not use this hierarchy as they have a Provider Registry that would be used. Need to explore if this is the case with other countries.

The Nursing Working Group endorsed the 127 concepts, approved the retirement of 10 concepts; but did not address the issue of moving concpets to the UK extension
IHTSDO Confirmation of Report Received
Comments
Name
Signature
Position
Date

Appendix 1
Occupation Project Final Summary
1/31/2011
The nurse occupations/roles within SNOMED CT Version 20100131 were analyzed for concept ambiguity, redundancy and to adequately to distinguish a nurse’s occupation/role across the globe. In addition, research was performed to ensure that the occupation/role definition was accurately represented within SNOMED CT.
The problem of electronic health records (EHRs) not having a standardized terminology that contains distinct, unambiguous, understandable, and useful nurse professional occupations/roles has a negative impact on data collection and querying. Lack of specifics will impair research analysis for improving patient safety, quality of care, and cost effectiveness. For example, nursing occupations support research of nursing staff levels required based upon patient acuity. These types of reports can also be used to identify if an inappropriate level of staff contributed to a medical or medication error and identify appropriate levels of nurse needed to improve quality patient care.
The requirement of having the ability to query for professional roles/credentials at the SNOMED CT “Is_A” relationship level is essential when assessing if the appropriate level of nursing occupation was performing patient care and how this role affected the quality of patient care. When the role of the nurse is specified, then resources can be understood and allocated to patient care. Knowing the nursing occupation/role will facilitate identification of

the impact of care on patient outcomes, and knowing what nurses do in their roles can be researched and the occupation data will be consistent and measurable across many enterprises across the globe.
The need for unambiguous nurse occupation/roles are necessary for the use case of post-coordinating a referral expression. Currently, SNOMED CT does not represent a pre-coordinated concept for ”referral by” and ”referral to” to all of the potential nursing occupation/roles. The need to create ”referral to (observable entity) CID 440379008” or
”referral by (observable entity) CID 440377005” expressions with the appropriate nurse occupational role is required to create ”Referral by (nurse case manager)” or ”Referral to (referral to nurse practitioner)”. The need to postcoordinate the nurse occupation/roles is required to create all of the potential nurse occupations/roles within
SNOMED CT is necessary as if SNOMED CT contained all the referral to / referral by concepts it would create a database comblatory explosion.
Research
Nurse occupation/roles were analyzed to document the appropriate quality metrics from the IHTSDO
Quality Framework. The quality metrics analyzed included:
1.
Number of concepts reviewed
2.
What are the current location(s) of nursing occupations/roles concepts in SNOMED CT?
3.
Which hierarchy should contain the nursing occupations/roles concepts?
4.
What attributes should the nursing occupations/roles concepts have for Understandability Reproducible Useful
(URU) modeling and clarity of use?
5.
How should they be disambiguated?

a.
Need of new Fully Specified Name (FSN)? b.
Need of a new IsA defining parent?
6.
Number of nursing occupations/roles concepts located accurately
7.
Number of the nursing occupations/roles concepts belonging in the SNOMED CT Core? a.
Which ones need to be moved to country extensions?
8.
Number of the nursing occupations/role concepts fully modeled according to the IHTSDO SNOMED CT User
Guide?
9.
What are the obvious missing nursing occupations/roles concepts?
10.
Number interactions with Nursing SIG participants
The research approach to an international nurse occupation/role was to establish an international set of heuristics that included research from many international sources. For example, the IHTSDO SNOMED CT User Guide, the
International Standard Organization (ISO), and the International Classification of Nursing Practice was used in addition to many online medical and nursing sources both here in the United States and across the globe. The purpose of using the ISO 18104:2003 as a standard was to establish a nursing reference terminology model consistent with the goals and objectives of other specific health terminology models in order to provide a more unified reference health model.
Results
SNOMED CT was analyzed to identify IHTSDO quality measures that have been identified through the nurse occupation/role project. The team began by presenting the issue around the nurse occupation/role concepts at two IHTSDO Nursing Special Interest Group (SIG) face to face meetings, one in 2009 to introduce the project and

obtain agreement of the analysis, and another in 2010 to present the final research findings of the project. One additional IHTSDO Nursing SIG teleconference was held to present the initial findings of the research and to obtain agreement as to the research approach and process used. Once the quality measures of the nurse occupation/roles were agreed upon, research began. The findings of the quality measures were documented and shared with the Nursing SIG. These included the location of nurse occupation/roles were analyzed and was found that all nurse occupation/roles are a subtype of the Healthcare professional (occupation) CID 223366009 which IsA subtype of the Social context (social concept) CID 48176007 hierarchy. SNOMED CT contained 147 nurse occupation/role concepts totally. Concepts under the Social Context hierarchy are only defined using the IsA defining relationship. Currently there are no other defining attributes that have been approved by the IHTSDO which means that the occupations cannot be fully defined. Of the 147 total occupation/role concepts 129 concepts have been defined unambiguously, are expressed with a FSN, and have been defined correctly in the IsA defining relationship. 129 concepts were found to be international in scope and are recommended to remain within
SNOMED CT core. Four concepts required a new defining IsA relationship to disambiguate the meaning. Eight concepts have been proposed to be retired within SNOMED CT due to being represented as duplicates within
SNOMED CT and ten concepts have been proposed to be moved from SNOMED core to a country’s specific extension as they have been identified as only used by that one specific country and not international in scope.
One concept, “Chief nursing officer “has been recommended to be requested to the International Health
Terminology Standards Development Organization (IHTSDO) so that nursing officer type concepts can be classified as a subtype.
 For example, nursing officer (occupation) CID 158990003 Is_A Chief nursing officer

The ten nurse occupation/role concepts being proposed to be moved from SNOMED CT core to a countries extension file are in Table 1.
Table 1 Nurse occupation/roles proposed to become a country extension
_________________________________________________________________
SNOMED CT FSN CID Country Extension
_______________________________________________________________
Integrated midwife
Foot care worker
Professional initiating surgical case
Healthcare service manager
Nursing officer – district
Nursing officer – division
Nursing officer - region
Nursing sister
Registered nurse First Assist
Accident and Emergency nurse
312485001 United Kingdom / Philippines
22460300 United Kingdom
405684005 United Kingdom
224579007 United Kingdom
158985001 United Kingdom
158987009 United Kingdom
158984002 United Kingdom
224572003 United Kingdom
372102007 United Kingdom
224537001 United Kingdom

The eight nurse occupation/roles proposed to be retired within SNOMED CT are noted in table 2.
Table 2 Nurse Occupation/Roles Proposed for Retirement
______________________________________________________________
SNOMED CT FSN CID
______________________________________________________________
405685006
45956004
224580005
158989007
106294002
73265009
83189004
224561008
Professional providing staff relief during surgical procedure
Sanitarian
Occupational health service manager
Occupational health nursing officer
Midwifery personnel
Nursing aid
Other professional nurse
Theatre nurse

The four nurse occupation/role concepts that have been proposed to have a change in its IsA defining relationship are noted in table 3
Table 3 Nurse Occupation/Roles Proposed for a new IsA Defining Relationship
_______________________________________________________________
SNOMED CT FSN CID Proposed Is_A
________________________________________________________________
Anesthetic nurse
Health visitor
Staff midwife
Registered midwife
309445003
159000000
158995008
309453006
CID
Perioperative nurse
Professional nurse
415075003
106292003
Staff nurse 158994007
Health visitor/nurse/midwife 309452001
Glossary
1.
Nurse midwifery - nurse-midwifery care "focuses on the needs of the individual and family for physical care, emotional and social support and active involvement of significant others according to cultural values and personal preferences."

2.
Critical care nursing- is that specialty within nursing that deals specifically with human responses to lifethreatening problems. A critical care nurse is a licensed professional nurse who is responsible for ensuring that acutely and critically ill patients and their families receive optimal care.
3.
Nurse role- Care provider role
4.
Theater nurse - Scrub/Circulating and Recovery nurse
5.
Occupation physician – qualified medical practitioner who has received appropriate training and who is responsible for the supervision of the health work of employees in one or more enterprise.
References
Connexionx Direct. (2009). Health visitor. Retrieved from http://www.connexionsdirect.com/jobs4u/index.cfm?pid=51&catalogueContentID=785
High Beam Research. (2010). The theatre nurse role. Retrieved from http://www.highbeam.com/doc/1P3-
422508101.html
International Classification of Nursing Practice (ICNP). (2010). ICNP C-Space. Retrieved on 12/23/2010 from http://icnp.clinicaltemplates.org/icnp/10013346/
International Health Terminology Standards Development Organization. (2010). SNOMED CT user guide. Retrieved from http://www.ihtsdo.org/publications/implementing-snomed-ct/implementation-guidance/
International Health Terminology Standards Development Organization. (n.d.). SNOMED CT. Retrieved from http://www.ihtsdo.org/snomed-ct/

International Standards Organization (ISO) Concept Database. (2010). Retrieved from https://cdb.iso.org/cdb/termentry!display.action?entry=149066&language=1
McPherson, K., & Reid, D. A. (2007). New roles in health care: what are the key questions? The Medical Journal of
Australia, 186 (12), 614-615. Retrieved from http://www.mja.com.au/public/issues/186_12_180607/mcp10277_fm.html
Slight, C., Mardsten, J., & Raynel, S. (2009). The impact of a glaucoma nurse specialist role on glaucoma waiting lists.
Retrieved May 3, 2009, from http://findarticles.com/p/articles/mi_m5PXL/is_1_25/ai_n45231047/pg_2/?tag=content;col1
The Clinical Information Consultancy. (2010). Clinclue software. Retrieved from http://www.cliniclue.com/software

Appendix 2
Nursing Occupations Hierarchy in CliniClue
Project completed by Cynthia Lundberg and Judith Warren
Nursing roles/occupations are in the Social Context Hierarchy.

The Subtype Hierarchy is Education/Welfare//Health Professions

Nursing Educators are under Education Profession Teacher Further Education Teacher
University AND/OR higher education teacher teacher in medical therapy, advanced nursing and related Arts

Nursing is under Education/welfare/health professions Healthcare professional Health visitors, nurses, and midwives

Nurse anesthetist are not under Nursing but are under Anesthesia