The international classification for nursing practice: a tool to support nursing practice?

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1 The international classification for nursing practice: a tool to support nursing practice? Moya Conrick, Griffith University Nurses have been slow to realise the uniqueness of their data and the importance of data management across the profession. This has resulted in nursing being neglected as a partner in healthcare because the data nurses collect cannot be easily retrieved from the patient record and is not widely used to support nursing practice. Nurses, as they should, have rejected language classification systems that are inadequate or inappropriate, but with the implementation of electronic health records, consensus on language classification must be achieved. One problem has been finding an appropriate terminology/s that represents the spectrum of nursing practice while making sense to both the user and computer. In 1989 the International Council of Nurses began work to achieve this and the International Classification for Nursing Practice (ICNP ) was born.this paper provides an insight into language classification, explores the ICNP as a tool for nursing practice and discusses some of the projects undertaken thus far. Keywords: Nursing language, concept representation, informatics, nursing practice Moya Conrick RN PhD, Lecturer, School of Nursing, Griffith University M.Conrick@griffith.edu.au The need for standard data and concepts in nursing It is recognised that nurses are the key collectors, generators and users of patient/client information (Currell et al 2002, Hovenga & Hindmarsh 1996) and that the delivery of good nursing care is dependent upon the quality and timeliness of the information available to the nurse. We also know that if patient care is not consistently and accurately recorded, the possible adverse effects on patient care, nursing practice and the development of nursing knowledge may be highly significant (Currell et al 2002). The patient record should contain a complete record of nursing work, and in fact this is the only place that it can be captured, but frequently the care given and outcomes of nursing care are poorly reported. Nursing data is infrequently used to support nursing practice because its lack of structure makes retrieval from the patient record very difficult. Without some type of organisation or classification, the differences in nursing language can be quite marked, resulting in inappropriate interpretations of the patient record and the key process of nursing care being measured in different ways. To redress these problems, the International Classification for Nursing Practice (ICNP ) project was commenced in Since then, member National Nurses Associations of the International Council of Nurses (ICN) have participated in the development of the ICNP classification system for nursing care, nursing information management systems, and nursing data sets (ICN 2001). Language classification Undoubtedly, the language of healthcare across the various health professions has similarities, but each profession has its unique language and nursing is not exempt. Collecting a list of terms or concepts is a reasonably easy task, but before these can be made useful (that is, stored or retrieved) they need to be structured or classified in some way. The general term encompassing health languages is clinical terminology and subsumed under this are: interface terminologies; reference terminologies; and aggregate terminologies (or classifications). Collegian Vol 12 No

2 Interface terminologies are a more structured form of natural language. They are detailed (fine grained) and allow users to interact with computerised health records using familiar language or words. These standardised interface terms and the concepts they identify can be related to each other in a reference terminology, which is designed to uniquely represent concepts. It does this by listing the concepts and specifying their structure, relationships and, if present, their systematic and formal definitions (Scott 2002). Classifications are a type of aggregate terminology that categorise relevant natural language for the purposes of systematic analysis and a logical system for arranging knowledge (Standards Australia 2003). A fully developed classification scheme specifies categories of knowledge. They provide the means to relate the categories to each other and to specify all or the most important of the aspects and facets of a subject (US Library of Congress in Standards Australia 2003). The purpose of the classification determines the form of the axes or ordering principles that will be used. The classification of data is a necessary part of electronic health records because it enables the systematic identification and arrangement of records (that is, data) into categories according to logically structured conventions, methods, and procedural rules (Scott 2002). The unambiguous denoting of health concepts and positioning of concepts in hierarchies of relationships help to create knowledge that computer systems can then use to enter, retrieve, manipulate and analyse health information. Naming what nurses do The rigorous classification methods outlined by the European Standards Organisation (CEN) guided the development of the ICNP, which has the potential to fulfil several purposes because it facilitates the cross mapping of local terms and existing nursing vocabularies and classifications. Some of these purposes are to: represent concepts used in local practice, across languages and specialty areas; describe the nursing care of people (individuals, families and communities) worldwide; enable comparison of nursing data across client populations, settings, geographical areas and time; stimulate nursing research through links to data available in nursing and health information; provide data about nursing practice in order to influence nursing education and health policy making; and Project trends in patient needs, provision of nursing treatments, resource utilisation and outcomes of nursing care (ICNP Evaluation Committee 2000). The ICNP reflects the ICN definition of nursing and acknowledges the changing and dynamic nature of nursing, while focusing on nursing practice. The ICN have found the core aspects of nursing practice are shared across countries, but the individual features of the context means that it can also be defined locally. Therefore, factors in a local environment impact on health status and may also be the focus of nursing practice. For these reasons the ICNP is sensitive to cultural variability and broad enough to serve the multiple purposes required by different countries (ICN 2001). The ICNP is seen as an information tool that supports nursing practice in many ways (see Figure 1) and has been translated into around thirty languages. The development, testing and use of the ICNP is ongoing and some of the diverse uses of the ICNP can be seen in the trials being conducted worldwide. For example, it forms the framework for the nursing curriculum in Portugal and, it has been used as the basis for evidence based practice and research (Newman & Lim 2001) and is being rolled out as the basis for electronic health records and is being trialled as the basis for aged care plans in Denmark (Mortensen 2003). In Pakistan, Figure 1: The INCP : an information tool. (ICN, Beta pii) Research Education Practice Management Policy ICNP Phenomena Actions Outcomes Information tool to describe nursing practice Assure quality or change in practice Health information Practice education management policy research Nursing contribution to health care 10 Collegian Vol 12 No

3 its use in midwifery is being tested and similar trials have been carried out in Korea. Some mental health concepts have also been tested in New Zealand (ICN 2003). The development of ICNP The ICNP is a classification of nursing by nurses with the ICN custodian and holder of the copyright. Participation in the development of the ICNP is open to nurses worldwide to enable the construction of a clinically relevant, valid and useful classification for nursing practice that yields data sensitive to cultural variation and local circumstance (ICN 2001). During development, finding consensus between the 120 member countries was difficult; for example, finding a term for the phenomena 'axis' considered appropriate by all members proved a challenge. The ICN were mindful of the problems related to calling an axis Nursing Diagnosis because of the close linkage of the name to the North American Nursing Diagnosis Association (now NANDA International) and the reluctance of the international community outside of North America to use this term. NANDA 1 has undergone several revisions and a new release (Taxonomy II) and is now regarded by its proponents to be more consistent with terminologies in the United States and throughout the world (Hoskins 2002). Because of their experiences, Australian nurses are historically wary of NANDA, describing Version 1 as awkward, cumbersome and restricting professional judgements (O'Connell 1998). They also described both NANDA and the ALPHA release of ICNP as reductionist (O'Connell & Conrick 1998). Rather than optimising communication, NANDA seems to have strengthened many nurses resolve to disregard further attempts to classify their language. The exception is community nursing, which is involved with the Australian Classification and Terminology of Community Health (CATCH). This project captures and provides a common language between community health and terms used by clinicians including nurses, allied health and other data users (Walker et al 2003). The structure of the ICNP Structurally, the ICNP is multiaxial with three classes at the highest level: phenomena, actions and outcomes, which describe nursing practice. Unlike the majority of other nursing classifications, the ICNP does not regard outcomes as separate from the nursing diagnosis or action, but as the change in a clinical judgement over time. Although the ICNP was developed as a classification system, it has been argued that it resembles a reference terminology. It has also been described as lumpy (uneven granularity) but has the potential to support data aggregation into higher-level categories for summarisation, review, research, or administration (Harris & Chute 2003). Although the ICNP is not consistently as fine grained as an interfacel terminology, the translations and trials to date demonstrate that it can be useful in this capacity. It requires augmentation that the next version will hopefully provide. The inevitability of electronic health records means that nursing must define terms with which nurses are comfortable, and that accurately describe nursing practice. To bypass the NANDA controversy and to achieve consensus, the ICN used the term phenomenon instead of nursing diagnosis and this can be interchanged to satisfy local or national language. In Australia, the most accepted term seems to be clinical judgement and in this paper the terms are interchanged. Phenomena or clinical judgement Clinical judgements are the focus of attention described by the social mandates and professional and conceptual frameworks of professional nursing practice. They are composed of concepts contained in the Nursing Phenomena Classification axes of focus, judgment, frequency, duration, topology, body site, likelihood, and bearer. By combining terms from these axes, meaningful statements can be composed that reflect the aspect of health relevant to nursing care (ICN, 2001 piv). As with any classification, there are rules to be followed, and terms from the Focus of Nursing Practice Axis and the Judgement or the Likelihood Axes must be used. Terms from other axes are optional and used to expand or enhance the diagnosis as required. As in any classification, only one term can be used from each of the axes. The example in Table 1 illustrates the combining of terms from selected axes to compose a meaningful clinical judgement statement. Although these representations are semi-formalised, they are structured to the degree that it can be read and understood by both humans and machines and can be used to support nursing practice. Nursing outcomes classification Healthcare outcomes are complex and rely on many factors, however, for nursing to survive as an equal partner in healthcare, it is crucial to identify and distinguish the unique contributions of nursing to health outcomes. In the ICNP, Nursing Outcomes are the assumed result of nursing interventions, measured over time, as changes are effected in clinical judgements (see Figure 2). Therefore, in the ICNP Nursing Outcomes and Nursing Phenomena are the same and they are articulated in similar manner, however, the outcome statement must be made at a point in time after an intervention has been carried out (ICN 2001 pvi). Because the nursing outcome classification provides a measure of outcomes related to clinical judgements, it contributes nursingsensitive information to broader, generic health outcome models (ICN 2001). Table 1: Terms from selected axes (ICN, Beta 2, 2001 piv) Selected Axes Focus of Nursing Practice Judgement Frequency Topology Body Site Selected Terms Pain Extreme (to a very high degree) Intermittent Right Foot Nursing Diagnoses: Extreme, intermittent pain in the right foot Collegian Vol 12 No

4 Nursing actions classification The ICNP definition of a Nursing Action is the behaviour of nurses in practice while a Nursing Intervention is defined as an action taken in response to a nursing diagnosis in order to produce a nursing outcome (ICN 2001 pvi). In the ICNP, a nursing intervention is composed of concepts contained in the Nursing Actions Classification axes, which include action type, target, means, time, topology, location, routes, and beneficiary. As with the clinical judgement, a statement that reflects actions taken in response to the problem/diagnosis statement can be composed. The construction of a nursing intervention must include a term from the Action Type Axis, again terms from the other axes are optional to expand or enhance the statement and only one term can be used from each of the axes for a single intervention (ICN 2001 pviii). Examples in Table 2 illustrate how terms can be combined from select axes to compose meaningful nursing interventions. The ICNP in action There are few large scale published studies that discuss nursing classification systems, and those that do, tend to compare nursing systems with other general classification systems for capturing a particular client type (Campbell et al 1997, Chute et al 1996, Henry et al 1997, Henry et al 1994). Few studies have examined the ability of nursing classification systems to capture nursing practice (Blewitt & Jones 1996, Bowles & Naylor 1996) while others have focussed on community health resource utilisation (Coenen et al 1996, Cox et al 1990). Although a number of ICNP projects are at present being undertaken, only a few have been reported. Mortensen (2003) reports that the Else Marie and the Queen Anne Marie Homes were amongst the first end-users to accept the ICNP at an operational level. In order to improve the daily recording of free text in records by using structured text, a Danish Figure 2: Outcomes as a diagnosis/clinical judgement over time (ICN, Beta 2, 2001 pv.) Outcome evaluation Outcome evaluation Initial Assessment 1st Nursing Diagnosis Nursing Interventions OUTCOME: 2nd Nursing Diagnosis Nursing Interventions OUTCOME: 3rd Nursing Diagnosis Table 2: Example of nursing intervention (ICN, Beta 2, 2001 piv) Selected Axes Selected Terms Example 1 Example 2 Action Type Alleviating Testing Target Pain Water supply Beneficiary Individual Community (collectively) Means Cold pack Protocol Interventions: 1. Alleviating an individual s pain by applying a cold pack 2. Testing the water supply for a community using an established protocol version of the ICNP was installed in Danish electronic health record software, Hygei. Mortensen (2003) reported that the ICNP provided a user-updateable catalogue of coded diagnoses, interventions and outcomes, which were established by crossmapping the concepts identified in nursing practice to the ICNP. At the levels of diagnoses, interventions and outcomes, the ICNP functioned as a feasible reference terminology for these homes. All items could be found either as ICNP expressions or as combined expressions. From this perspective, Mortensen (2003) concluded that the ICNP fulfils the criteria of domain completeness or it has the ability to capture details relating to the three axes of diagnoses, interventions and outcomes. However, she also reports that it was insufficiently comprehensive to capture very detailed clinical concepts, although she is optimistic that future updates might address this shortfall. A study by Loewen (1999) supports the granularity deficit but revealed that the ICNP has potential for capturing an individual client s data, particularly in community health nursing practice, with a respectable 68.9% of concepts identified in the nursing notes considered to be a match with the ICNP. Another study, which focussed exclusively on nursing interventions, found a markedly higher level of coverage with the Nursing Interventions Classification categorising all of the nursing activity terms identified in the sample (Henry et al 1997). Ever since Nightingale s struggle to articulate the essence of nursing in 1859, nursing s inability to describe nursing practice remains. This is exacerbated as nursing becomes increasingly more complex. Nonetheless, experiences in many countries have demonstrated nursing s vulnerability when inappropriate classification systems are used to describe nursing activities, measure outcomes and to allocate nursing resources. These systems have not served nursing well, especially in environments where there is competition for control of resources (Conrick & O'Connell 1998). The studies reported thus far have shown that the ICNP has potential and appears to provide nursing both internationally and in Australia with an appropriate basis to describe its practice. Although some cross mapping of the ICNP has been carried out with acute and aged care nursing notes with moderate success, the ICNP has not been formally trialled in Australia and only further testing will elucidate the place of the ICNP in practice. At this time, neither the nursing notes nor the ICNP can or should claim to capture all aspects of nursing practice. It may be that more 12 Collegian Vol 12 No

5 than one classification system is required to describe all the settings in which nurses work. The release and testing of ICNP V1, with its inclusions and improvements derived directly from practice, will further clarify the ICNP s place both in nursing practice and as the means for capturing nursing data in electronic health records. The advent of electronic patient records and the Federal Government s HealthConnect initiative means that Australian nurses must be vocal about inclusion of nursing data into the electronic patient record. Dataset development is an expensive undertaking and historically, funding for nursing lags far behind other professions in healthcare. Therefore, nursing has few resources available to develop an Australian specific language. The ICNP seems to form a sound basis for further work in Australia and is the only international nursing language that is freely available at this time. Conclusion To enhance nursing and nursing s place in the healthcare system, reporting and documentation must articulate nursing work and contribution to patient outcomes. The rush to electronic health records adds to the pressure for a national nursing language because without it, nursing is at risk of being subsumed in the electronic record under the patient s medical diagnosis. The usefulness of the ICNP in practice has been demonstrated in both the endorsement by nurses worldwide and the results of trials that are now filtering through. It seems broad enough to serve nursing needs in Australia and is culturally sensitive. It may be that a single classification cannot adequately serve the entire profession but this needs to be determined. At the same time, the relationship between nursing and the other health professions cannot and should not be ignored in language development. However, nothing can be resolved without the recognition of nursing as a legitimate partner in healthcare and an appropriately funded research agenda. References Blewitt D, Jones K 1996 Using elements of the minimum data set for determining outcomes. JONA 26(6):48-56 Bowles K, Naylor M 1996 Nursing Intervention Classification Systems. Image: Journal of Nursing Scholarship 28(4): Campbell J, Carpenter P, Sneiderman C, Cohn S, Chute C, Warren J 1997 Phase II Evaluation of clinical coding schemes: Completeness, taxonomy, mapping, definitions, and clarity. Journal of the American Medical Informatics Association 4(3): Chute C, Chon S, Campbell K, Oliver D, Campbell J 1996 The content coverage of clinical classifications. Journal of the American Medical Informatics Association 3: Coenen A, Marek K, Lundeen S 1996 Using nursing diagnoses to explain utilization in a community nursing center. 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