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CNC - NIC: Frequently Asked Questions

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The following information is taken from the third and fourth editions, Nursing Interventions Classification (NIC):

Dochterman, J.C., & Bulechek, G.M. (Eds.). (2004). Nursing Interventions Classification (NIC) (4th ed.). St. Louis , MO : Mosby.

In this section we have tried to answer some of the common questions about NIC. Understanding the reasons why things have been done in a certain way will assist in better use of the Classification. We began this section in the second edition of NIC and have just added to it; the order of the questions, to some extent, reflects the order in which we have encountered them and the evolving types of concerns as use becomes more extensive.

1. Why are certain rather basic activities included in the activity list for some interventions but not others? For example, why should an activity related to documentation be included in the labels Discharge Planning and Referral and not in every label? Or, why should an activity related to evaluation of outcomes be included in Discharge Planning and not in all intervention labels? Or, why should an activity on establishing trust be included in the labels Reminiscence Therapy or Support Group but not in other intervention labels?

Basic activities are included when they are critical (i.e. absolutely essential to communicate the essence of the intervention) for the implementation of that intervention. They are not included when they are part of the routine but not an integral piece of the intervention. For example, hand washing is a routine part of many physical interventions but is not critical to interventions such as Bathing or Skin Care. (We are not saying that washing your hands should not be done for these interventions, just that this is not a critical activity.) Hand washing is a critical part, however, of such interventions as Infection Control and Contact Lens Care.

2. How do I decide which intervention to use when one intervention includes an activity that refers to another intervention? In some NIC interventions there is reference in the activity list to another intervention. For example, the intervention of Airway Management contains an activity that says "Perform endotracheal or nasotracheal suctioning, as appropriate." There is also an intervention in NIC called Airway Suctioning which is defined as "Removal of airway secretions by inserting a suction catheter into the patient's oral and/or trachea" and has 25 activities listed under it. Another example is the intervention of Pain Management which contains an activity that says "Teach the use of nonpharmacologic techniques (e.g. biofeedback, TENS, hypnosis, relaxation, guided imagery, music therapy, distraction, play therapy, acupressure, hot/cold application, and massage) before, after, and, if possible, during painful activities; before pain occurs or increases; and along with other pain relief measures." Nearly all of the techniques listed in the parentheses of this activity are listed in NIC as interventions, each with a definition and a set of defining activities. The two examples demonstrate that the more abstract, more global interventions sometimes refer to other interventions. Sometimes one needs the more global intervention and sometimes the more specific one, and sometimes both. The selection of nursing interventions for use with an individual patient is part of the clinical decision making of the nurse. NIC reflects all possibilities. The nurse should choose the intervention(s) to use for a particular patient using the six factors discussed in Chapter 3 of the Nursing Interventions Classification (2000).

3. When is a new intervention developed? How is it that we believe that each of our interventions is different from others in the classification? Maybe they are the same only called something different? We developed the guiding principle, a new intervention is added if 50% or more of the activities are different from another related intervention. Thus, each time a new intervention is proposed, it is reviewed against other existing interventions. If 50% or more of the activities are not different, it is not viewed as significantly different to be added to the classification.

With interventions that are types of a more general intervention (e.g. Sexual Counseling is a type of Counseling; Tube Care: Gastrointestinal is a type of Tube Care), the most pertinent activities are repeated in the more concrete intervention so that this intervention can stand alone. This should not be all the activities, rather just those that are essential to carrying out the intervention. In addition the intervention must have at least 50% new activities.

4. Does NIC include the important monitoring functions of the nurse? Very definitely, yes. NIC includes many monitoring interventions (e.g. Electronic Fetal Monitoring: Antepartum, Health Policy Monitoring, Intracranial Pressure (ICP) Monitoring, Neurologic Monitoring, Newborn Monitoring, Surveillance, Surveillance: Late Pregnancy, Surveillance: Safety, Vital Signs Monitoring). These interventions consist mostly of monitoring activities but also include some activities to reflect the clinical judgment process or what nurses are thinking and anticipating when they monitor. These interventions define what to look for and what to do when an anticipated event occurs. In addition, all interventions in NIC include monitoring activities when these are done as part of the intervention. It will be noted that monitor or identify are the words we use to mean assessment activities that are part of an intervention. We have tried to use these words rather than the word assess in this intervention classification because assessment is the term used in the nursing process to refer to those activities that are pre diagnosis.

5. Does NIC include interventions that would be used by a primary care practitioner, especially those designed to promote health? Yes indeed. While these are not grouped together in one class, NIC contains all of the interventions nurses use to promote health. Examples include: Anticipatory Guidance, Decision-Making Support, Developmental Enhancement, Exercise Promotion, Health Education, Immunization/Vaccination Administration, Learning Facilitation, Nutrition Management, Weight Management, Oral Health Promotion, Parent Education, Risk Identification, Smoking Cessation Assistance, Substance Use Prevention, and Self Responsibility Facilitation.

6. Does NIC cover treatments used by advanced practice nurses practicing in specialty areas? Definitely yes. Many of the interventions in NIC require advanced education and experience in a clinical practice. For example, the following interventions may reflect the practice of an advanced practice nurse working in obstetrics: Amnioinfusion, Birthing, Electronic Fetal Monitoring: Antepartum, Grief Work Facilitation: Perinatal Death, High Risk Pregnancy Care, Labor Induction, Labor Suppression, Reproductive Technology Management, and Ultrasonography: Limited Obstetric. A similar list can be identified for most specialties. Medication Prescribing is an intervention used by all nurses in advanced practice.

7. Does NIC include alternative therapies? We assume this question refers to treatments that are not part of mainstream medical practice in this country. Interventions in NIC that might be listed as alternative therapies include Autogenic Training, Biofeedback, Calming Technique, Hypnosis, Meditation, Simple Guided Imagery, Simple Relaxation Therapy, and Therapeutic Touch. Many of these interventions are located in the class Psychological Comfort Promotion. We will consider and add other alternative therapies as they become part of accepted nursing practice.

8. How do I find the interventions I use when there are so many interventions in NIC? At first glance, NIC with nearly 500 interventions, may seem overwhelming. Remember, however, that NIC covers the practice domain of all nurses. An individual nurse will use only a portion of the interventions in NIC on a regular basis. These can be identified by reviewing the classes in the taxonomy that are most relevant to an individual's practice area. In those agencies with nursing information systems, the interventions can be grouped by taxonomy class, or by nursing diagnosis, or by patient population (e.g. burn, cardiac, maternity), or by unit. Many computer systems will also allow individual nurses to create and maintain a personal library of most used interventions. We have been told by nurses using the Classification that they quickly identify a relatively small number of interventions that reflect the core of their practice.

9. Can I change the activities in an intervention when I use it with my patient? The standardized language is the label name and the definition and these should remain the same for all patients and all situations. The activities can be modified to better reflect the needs of the particular situation. This is one of the advantages of NIC: it provides both a standardized language that will help us communicate across settings about our interventions, and it allows for individualized care. The NIC activities use modifiers "as appropriate", "as needed", and "as indicated" to reflect the fact that individuals are unique and may require different approaches. The NIC activities include all ages of patients and when used with adults some of the activities directed at children may not be appropriate (and vice versa). In this case these can be omitted from an agency's list of activities. Also, the NIC interventions are not at the procedure level of specificity and some agencies may wish to be more specific to reflect particular protocols developed for their populations. The activities can easily be modified to reflect this. At the same time that we believe that the activities can and should be modified to meet individual needs, we caution that activities should not be changed so much that the original NIC list is unrecognized. If this is done, then the intervention may in fact not be the same. Any modified or new activities should fit the definition of the intervention. In addition, when an activity is being added consistently for most patients and populations then it may be needed in NIC's general listing of activities. In this case, we would urge the clinician to submit the proposed activity addition or change. In this way the activity list continues to reflect the best of current practice and is most useful in teaching the interventions to new practitioners.

10. How does NIC contribute to theory development in nursing? The intervention labels are the concepts, the names of the treatments provided by nurses. The definitions and activities that accompany the labels provide for definition and description of the interventions. Clarification of intervention concepts contributes to the development of nursing knowledge and facilitates communication within the discipline. As nursing's ability to link diagnoses, interventions, and outcomes grows, prescriptive theory for nursing practice will evolve. The Nursing Interventions Classification is a crucial development because it provides the lexical elements for middle-range theories in nursing that will link diagnoses, interventions, and outcomes. Interventions are the key element in nursing. All other aspects of nursing practice are contingent upon, and secondary to, the treatments that identify and delineate our discipline. This intervention-centric approach does not diminish the importance of the patient, but from a disciplinary perspective, the phenomenon of interest of the patient is important because it can be affected by nursing action. We believe that use of standardized languages for nursing diagnoses, interventions and outcomes heralds a new era in the development of nursing theory, moving from the past focus on grand theory to the development and use of nursing middle range theories. (See the articles with first authors of Blegen or Tripp-Reimer on the Annotated Publications list on this website for more discussion about this.) Although we believe that, in the future, nursing grand theories will be replaced by nursing middle range theories, for the present NIC can be used with any existing grand theory. NIC can be used by any institution, nursing specialty, or care delivery model regardless of philosophical orientation.

11. Does the classification include administrative interventions? The Classification includes indirect care interventions done by first line staff or advance practice nurses but does not include, for the most part, those behaviors that are administrative in nature. An indirect care intervention is a treatment performed by a direct care provider away from the patient but on behalf of a patient or group of patients; an administrative intervention is an action performed by a nurse administrator (nurse manager or other nurse administrator) to enhance the performance of staff members in order to promote better patient outcomes. Some of the interventions in NIC, when used by an administrator to enhance staff performance, would then be administrative interventions. Most of these are located in the taxonomy in the Health System domain. It should be noted that the borders between direct, indirect, and administrative interventions are not firm and some NIC interventions may be used in various contexts. For example, the nurse in the hospital may provide Caregiver Support as an indirect intervention administered to a relative of the patient being cared for, but the nurse in the home, treating the whole family, may provide this intervention as direct care. With the addition of more interventions for communities, we have added interventions that are more administrative in nature, for example Cost Containment and Fiscal Resource Management. These are, however, delivered by the primary care nurse in the community setting or by the case manager who have a larger administrative role.

12. Does my health care agency need to be computerized to use NIC? No, NIC can be used in a manual care planning and documentation system. If the system is manual then nurses unfamiliar with NIC will need ready access to the NIC book. The book should also be available for nurses working in agencies that have computerized NIC (We think every unit should have one and we encourage individual nurses to have their own copies.) but with a computer, NIC can be stored and accessed electronically. Computers make it easy to access NIC interventions in a variety of ways (for now, by taxonomic classes and by nursing diagnoses, but it is also possible by patient population, by unit type, by outcome, by clinical path, and so on). Computers can easily accommodate a variety of clinical decision support screens for nurses. Documenting what we do for patients using a standardized language on computers makes it possible for nursing to build agency, state, regional, and national databases to do effectiveness research. If your agency is not computerized, help it to become computerized. But you don't have to wait for the computer to use NIC. NIC is helpful to communicate nursing care with or without a computer.

13. When do I need to obtain a license? Other related questions include: Why do I need a license? Why isn't NIC in the public domain? Why is the copyright for NIC held by a publisher? A license is needed if you put NIC on a nursing information system or if you will use a substantial part of the Classification for commercial gain or advantage. NIC is published and copyrighted by Mosby-Year-Book located in St. Louis and they process requests for permissions to use the Classification. When we first began working on the NIC classification we had little idea of the magnitude of the work or its current widespread use or that it would be followed by NOC (Nursing Outcomes Classification). We were looking for a way to get the work in print and disseminated quickly. As academics, we were familiar with the book publishing world and after some very serious review of alternative mechanisms and talks with other publishers, we selected Mosby as the publisher. Publication with Mosby has several advantages. First, they have the resources and the contacts to produce a book, to market it, and to sell it. In addition, Mosby has the legal staff and resources to process requests for permission and protect the copyright. This is especially important with standardized language where alteration of terms will impede the goal of communication among nurses across specialties and between delivery sites. We continue to have a good relationship with Mosby that involves frequent and active participation in permissions requests. We view our relationship as a partnership.

Copyright does not restrict fair use. According to guidelines by the American Library Association, fair use allows materials to be copied if: 1) the portion copied is selective and sparing in comparison to the whole work; 2) they are not used repeatedly; 3) no more than one copy is made for each person; 4) the source and copyright notice is included on each copy; and 5) persons are not assessed a fee for the copy beyond the actual cost of reproduction. The determination of the amount that can be copied under fair use policies has to do with the effect of the copying on sales of the original material. The American Library Association says that no more than 10% of a work should be copied.

When someone puts NIC on an information system that will be used by multiple users, copyright is violated (a book is now being "copied" for use by hundreds of nurses) and so a licensing agreement is needed. Also, when someone uses large amounts of NIC in a book or software product that is then sold and makes money for that individual then a permissions fee is necessary. Schools of nursing and health care agencies that want to use NIC in their own organizations and have no intention of selling a resulting product are free to do so. Fair use policies exist however. For example, NIC and NOC should not be Xeroxed and used in syllabi semester after semester--the classification books should be adopted for use. Similarly, health care agencies need to purchase a reasonable number of books (say, one per unit) rather than Xerox and put the interventions in some procedure manual.

Requests for use of NIC and NOC should be sent to the permissions department of Mosby (see the front of the book for the address). Many requests for permission to use do not violate copyright and permission is given with no fee. Fees for use in a book depend on the amount of material used. Fees for use in information systems depend upon the number of users and averages about $5.00 per user for two years. There is a flat fee for incorporating NIC into a vendor's database and then a sublicense fee for each sublicense undertaken based on the number of users. The fees are very reasonable and a substantial portion of the fees are being forwarded to the Center for Nursing Classification for development and refinement of NIC.

14. How do I explain to the administrator at my institution that a license is needed? First of all, we want to repeat that it is only use in an information system that requires a license and a fee; if you want to use NIC manually or for a particular project that does not violate copyright, please go ahead. In our experience it is nurses and not health care administrators who are unfamiliar with licenses and fees. Most other health care classifications are copyrighted and fees are required for use. For example, the CPT (Current Procedural Terminology) is copyrighted by the American Medical Association, DSM (Diagnostic and Statistical Manual of Mental Disorders) is copyrighted by the American Psychiatric Association, and SNOMED (Systematized Nomenclature of Medicine) is copyrighted by the College of Pathologists. Health care institutions regularly pay license fees now, only most nurses are not aware of these. For example, at one tertiary care hospital that we know of, there are 97 vendor software products installed and more than $1,220,000 is spend annually in software license fees.

License fees are often included as part of the software costs. NIC can be licensed from Mosby (use of the language) for incorporation in an existing information system or purchased from a vendor with software (the vendor has purchased the license from Mosby and the software price includes the cost of the license). As more nurses understand the advantages of using standardized language and desire this in purchases of new information systems, more vendors will include NIC in their products.

In nursing, none of the professional organizations have the resources to maintain NIC so another avenue was needed. We have been told by those in the medical field that having the Classification housed in a university setting has advantages over the professional organizational model whereby politics (what is in and what is out) come into play. Ongoing development and maintenance, however, require resources. Classifications and other works in the public domain are often those for which there will be no upkeep-you can use what is there but don't expect it to be kept current. We have attempted to make NIC as accessible as possible but to also collect fees so that we can have a revenue stream to finance the maintenance work that must continue.

15. Should we use a nursing classification when most of health care is being delivered by interdisciplinary teams? Occasionally we hear something like "we can't use anything that is labeled nursing and comes from nursing when everything is now going to be interdisciplinary." We hear this, by the way, from nurses rather than from physicians or other power holders in the interdisciplinary arena. At the same time, it is assumed that using medical language does not violate this artificial interdisciplinary principle. We believe that nurses who are members of an interdisciplinary team addressing the development and implementation of a computerized integrated patient care record should be, in fact, must be, the spokespersons for use of NIC and NOC. Yes, these have the nursing word in their titles because they were developed inductively through research based on the work of nurses by nurses. Taken as a whole they reflect the discipline of nursing but any one individual intervention may be done by other types of providers and any one outcome may be influenced by the treatments of other providers as well as by many other factors. This is a situation where nursing has something of value which the other providers, for the most part, do not, which can document the contributions of nurses and can be used or adapted and used by others if they wish. Nurses should not shrink from talking about these nursing initiatives; rather they should stand tall and offer them as a nursing contribution to the interdisciplinary goal of a computerized patient record that can cross settings and specialties.

This is NOT inconsistent with being a good team member in an interdisciplinary environment. It is essential for successful outcomes to be achieved by interdisciplinary teams that nurse members communicate their unique perspective and knowledge. What is a good team member anyway? There are three essential qualities: 1) the person has something that contributes to the overall functioning of the team, 2) the person is good at what he or she does, and 3) others understand what the person can do. Would a baseball team welcome a member who could not play any position and was a poor batter? Definitely not. Would they welcome someone who was eager to help but unable to say how they could help? Maybe, but this person would end up being water boy/girl rather than playing a position. Being a good team member means that the person has something to contribute and communicates ideas. Baseball teams emphasize the importance of specific and different roles and skills of members. No one suggests that because a team member is called a pitcher or a short-stop the member is not a team player. Players are not told that they are not good team members if they sharpen their individual knowledge and skills and are acknowledged for individual performance. A baseball team, or any team for that matter, improves effectiveness by maximizing and integrating the contributions of individual members. Baseball managers would undoubtedly get a good laugh from the notion that they should conceal and minimize the contributions of individual team members to increase the effectiveness of the team.

We have heard a few individuals say that there should be only one language that is shared by all health disciplines. If this is possible we believe that the one language should develop inductively through the sharing and adding on to the current languages that exist. Perhaps, over time, we will build one large common language whereby some intervention and outcome terms are shared by many providers. But even if we can build one large common language, it will always be used in parts because the whole is too great to learn, communicate, and study, and all interventions and outcomes are not the business of every discipline. The one very large language will be broken down and used in parts for the same reasons that there are disciplines-the whole is too large and complex to be mastered by any one individual, hence different disciplines represent different specialized perspectives.

16. I want to implement NIC in our agency/facility. What is the best way to go about this? Other related questions include: Should I implement NIC and NOC together? Should I implement NIC at the same time I orient nurses to a new computer system? Should we do this on just a pilot unit first or put this up "live" for everyone at the same time?

This is what Chapter 3 is all about. In particular see the Steps for Implementation in Box 3-2 for practice agencies and Box 3 - 9 for educational facilities. There are also other helpful materials in Chapter 3, such as a list of helpful readings related to change and evaluation as well as many examples of implementation forms used by practice agencies that have implemented NIC. As for the questions related to how much to do at one time, there is no one right way; it truly does depend on the situation and the amount and nature of the changes, the resources and support available, and the time constraints. The companion NOC book has many helpful suggestions about implementation of NOC. We would caution not to make too many changes at once for this is often more than most can handle. On the other hand, don't drag a change out in small pieces for a long time. Duplicate charting (recording the same thing in more than one place) is a no no. Piloting a change to work the bugs out (say, starting on one unit where the nurse manager and staff are supportive) is always a good idea. Providing time for training and having support staff available when the change is first made is important. The Center for Nursing Classification and Clinical Effectiveness has available a 4 hour web course on the basics of standardized language and NIC and NOC as well as a film made by the National League for Nursing on the development and purpose of NIC that are helpful teaching aides. It is important in the beginning to think about the uses of the data in the future, beyond the initial care planning or documentation purposes. Chapter 3 also covers the idea of setting up a comprehensive database for effectiveness research in the future.

17. How does NIC compare to other classifications? Usually this question has a specific "other" in the question, most often the International Classification of Nursing Practice (ICNP), or Omaha , but sometimes the Home Health Care Classification, the Perioperative Data Set, or the Patient Care Data Set. We include brief information about these here to help the reader make a comparison.

International Classification of Nursing Practice --The need for language to facilitate communication by and among nurses is a worldwide concern. In 1996, the International Council of Nurses (ICN) published the Alpha Version of the International Classification of Nursing Practice (ICNP) 9 and in 1999 the Beta 1 Version 10 . The initial intent was to construct an organizing structure for existing classifications but, under the direction of Randi Mortensen amd Gunnar Nielsen of Denmark , the ICNP developed into a separate classification. The Beta Version has three components: nursing phenomena, nursing outcomes, and nursing actions. Each component consists of axes, for example, the nursing phenomena classification axes are: focus of practice, judgment, frequency, duration, body site, topology, likelihood, and distribution. The outcomes classification is simply the status of a nursing diagnosis at some point in time after a nursing intervention. The nursing actions classification consists of action type, target, means, time, location, topology, route and beneficiary. While each of the axes has a definition, there are no standardized lists of terms for each of the axes. The development and testing of the ICNP has raised awareness of the need for nursing terminology around the globe, but the Classification itself is difficult to use clinically. In our opinion, the components are most useful for the development of a Reference Information Model (see question 19) that can assist with the transfer of languages across differing computer systems. Information can be found at the ICN web site: http://www.icn.ch/icnp.htm

Omaha System--The Omaha System is the oldest of the nursing classifications and was developed in the 1970s by Karen Martin and colleagues for use in community health 15, 23

It consists of three parts: problems, interventions, and outcomes. The Problem Classification Scheme consists of four domains (Environmental, Psychosocial, Physiological, and Health Related Behaviors) that include 40 problems or diagnoses. Modifiers for the diagnoses identify the problem as either an individual or family problem and as either a health promotion, potential, or actual problem. There are also signs and symptoms specific to each problem. The Intervention Scheme is composed of four categories (Health Teaching, Guidance and Counseling; Treatments and Procedures; Case Management; and Surveillance) that include 62 targets defined as objects of health related interventions or activities. The third part is the Problem Rating Scale for Outcomes, a simple 5 point, ordinal scale comprised of Knowledge, Behavior and Status subscales. Each of the three concepts is rated for degree of response. Ratings are done at appropriate intervals and when the patient is discharged from service. The three parts of the system are not linked to each other; a nurse makes an independent selection in each of the parts.

The Omaha system is used in numerous community health settings and in some educational settings. In 1994 a software program called the Nightingale Tracker, was developed based upon the Omaha system and funded by the Helene Fuld Health Trust. An article by the development team overviews the software and some of the issues in its development. The classification has been translated into Danish and Japanese and the problem scheme has been linked to both NIC and NOC by the Iowa researchers with a review by Karen Martin. While the Omaha system has received widespread recognition in multiple arenas, it has not changed substantially since the original work. The On-line Journal of Nursing Informatics in the winter of 1999 contains a series of articles about the system.

Home Health Care Classification (HHCC)--The Home Health Care Classification, developed by Virginia Saba at Georgetown University in the late 1980s for use in home health care, consists of two vocabularies for diagnoses and interventions.

The diagnoses vocabulary consists of 50 major categories and 95 subcategories; the interventions vocabulary consist of 60 major categories and 100 subcategories. Each vocabulary uses modifiers to expand the codes. The diagnoses can be modified by the terms improved, stabilizedor deterioratedto indicate the expected or actual outcomes of care. The interventions can be modified by the terms assess, care, teach, or manageto indicate the type of nursing action. The two vocabularies are organized by twenty care components, similar to the classes of NIC and NOC and include a coding scheme. The classification has been widely disseminated but the extent of use is unclear. More information can be found at the web site: http://www.dml.georgetown.edu/research/hhcc. An article comparing the first edition of NIC to the intervention schemes of Omaha and the Home Health Care Classification was published in the Journal of Nursing Administration in 1993. To our knowledge the Health Care Classification has not been updated sine the original publication.

Perioperative Data Set--This was developed by the Association of periOperative Registered Nurses (AORN) in the early 1990s. It contains diagnoses, interventions, and outcomes identified for the specialty of perioperative nursing. The interventions in it are at the discrete activity level of NIC. In an article in Nursing Diagnosis in 2001, Suzanne Beyea, then the Director of Research for the Association who spearheaded the development of the dataset, explains the reasons for development of the specialty data set and then puts forth the case that, since the development of the comprehensive classifications of NIC and NOC, specialty organizations should not develop their own vocabularies and data sets but should use and help refine existing classifications

Patient Care Data Set--The Patient Care Data Set was developed by Judy Ozbolt at the University of Virginia and then underwent substantial revisions at Vanderbilt University Medical Center . It began in 1994 as a comprehensive catalog of terms used in patient care records of nine hospitals to name the phenomenon of care: problems, actions, and goals. In 1998 version 4 consisted of a data dictionary and 363 terms for problems, 311 terms for goals and 1357 terms for patient care orders organized into 22 components modified from those identified by Virginia Saba. These terms are now being parsed into atomic-level elements and rules are being established for combining these into more complex concepts. For example, the atomic elements proposed for the problem concepts are: subject, object, likelihood, status, degree, duration, value, frequency, body site, and laterality. The Patient Care Data Set is different from the other classifications that have been previously described. It is not in a clinically useable form but, rather, may prove to be a helpful model for the development of a behind-the-scenes information model that can facilitate the translation of one vocabulary to another. In June of 1999, Osbolt organized an invitational conference on nursing vocabularies with the goal of developing a Reference Information Model. The idea is similar to what she is attempting to develop with the Patient Care Data Set the identification of components of diagnoses, interventions and outcomes so that standardized language concepts in any of the classifications can be parsed behind the scenes to facilitate transfer and comparision between different computer systems. Representatives of each of the nursing classifications, as well as representatives from standards organizations, were at the conference. A similar conference has been held yearly since 1999 to continue the dialogue.

In summary then, compared with other classifications, NIC is the most comprehensive for interventions. Of all the classifications, only NANDA, NIC and NOC are comprehensive and have ongoing research efforts to keep them current. The relationships that link these classification and the proposal for a common organizing structure present users with a comprehensive classification system that can be used to document care across settings and specialties.

18. In a care plan, whats the structure for NIC and NOC? What do you choose and think about first?

The answer to this reflects the clinical decision making of the provider planning and delivering the care. Individuals have different approaches to this, reflecting how they learned to do this in school refined by what they find works best for them and their typical patient population. As a general approach we suggest first making the diagnosis(es), then select outcomes and indicators, rate the patient on these, then select the interventions and appropriate activities, implement these, and then rate the outcomes again. If you want to set goals, these can be derived from the NOC outcomes, e.g. the patient is at 2 on X outcome and by discharge he should be at a level of 4.

Sometimes, in some situations, this process is not possible or even desirable and one would want to use a different order. For example, in a crisis one would move immediately to the implementation of the intervention with the diagnosis and outcome left for later. The advantage of the standardized classifications is that they provide the language for the knowledge base of nursing. Educators and others can now focus on teaching and practice of skills in clinical decision-making; researchers can focus on examining the effects of interventions on patient outcomes in real practice situations. See the model in Chapter 3 that shows how standardized language can be used at the individual level, the unit/organizational level and the network/state/country level.

19. What is a reference terminology model? Why are these being developed? Will they make classifications such as NIC obsolete?

A reference terminology (RT) model identifies the parts of a concept (i.e. the parts of any diagnosis or any intervention) that can be used behind the screensin computer systems to assist these systems to talk with each other. For example an intervention might consist of an action, a recipient, and a route. When we went to high school in the 60s we were asked to diagram sentences in order to learn the parts of a sentence (e.g. the noun, verb, adverb, etc.); an RT is to help represent concepts in a similar way. Theoretically, a Reference Terminology Model enables differing vocabularies (e.g. NIC and Omaha ) to be mapped to one RT and thus, compared with each other. We say theoretically because this approach has not yet been tested in practice. In 1999, Judy Ozbolt organized the Nursing Vocabulary Summit Conference that has been held yearly at Vanderbilt with the identified need to develop and test a reference terminology model. In the late 1990s and early 2000s there have been a mushrooming of terminology models, example include HL7 (in the US for all of health care), CEN (in Europe for all of health care), SNOMED (for use in US and Great Britain ) and ISO-Nursing (for nursing internationally). As we stated earlier, we consider the International Classification of Nursing Practice (ICNP) in the Beta version with its axes a Reference Terminology Model that is more helpful behind the screensthan useful to practicing nurses as a front end terminology. A Reference Terminology Model is sometimes called a Reference Information Model; although those in the informatics standards area say that there are differences between the two, it is hard to distinguish the differences.

A second part of this question is whether the creation of an RT will make classifications like NIC obsolete. No, NIC is a front endlanguage designed for communication among nurses and between nurses and other providers. We want nurses to be able to write and talk NIC. On the other hand RTs are for use behind the screens: if they do succeed they will help vendors to build computer systems that can use and compare different front endlanguages. RTs are pretty hard to understand and not clinically useful. Even if they allow the user to document care in their own words (versus standardized language) this is not desirable (except in a free text notes section that supplements and elaborates on the standardized language) for the profession as we would still have the problem of lack of communication among ourselves and between ourselves and others as to what we do. We do not want to leave the impression that you need an RT in order to have a computer system; you dont. You can put the clinical classifications in certain fields and use the identified linkages to help users access these. But we will always need a common language to communicate the work of nursingNIC is intended to be just that.

20. Is there commercial software available with NIC in it? Are there vendors that have clinical nursing software with NIC?

Yes. This is a growing area. First, when a licensing agreement for NIC is made from Mosby, the user is sent a CD-Rom to make it easier to transfer the language to a computer system. Available from Mosby in 2003, NANDA, NIC and NOC are linked in care planning software (NANDA, NOC, and NIC: Electronic Linkages) based on the linkage book. A growing number of vendors are including NIC in their information systems. In 2003 the vendors who had signed licensing agreements to use NIC are: Ergo , Lake Quivira, Kansas [http://www.ergopartners.com]; Nurse's Aide (for school nurses), Keller Texas [http://www.nursesaide.net]; McKesson , Alpharetta, Georgia; [http;//www.mckesson.com], Tech Time , Billings Montana[http://www.techtimeinc.com]; DXR Development Group , Carbondale Illinois[http;//www.dxrgroup.com], Purkinje , Montreal Canada [http://www.purkinje.com], Dairyland Healthcare Solutions, Glenwood, Montana [http://www.dhsnet.com].

Additional licensing agreements are in process. We do not endorse any particular product; prospective users should contact the vendors directly for review of their products. Other software has been developed for specific purposes and is not available commercially, at least not at this date, for example the government of Iceland has mandated the use of NANDA, NIC and NOC in all of their facilities and have built software (eMR) (personal communication Asta Thoroddsen, Assistant Professor Nursing, University of Iceland, November 14, 2002) to document care and collect data. Another example is the software build for research data collection by Gail Keenan and her colleagues in Michigan 14 . We believe that the inclusion of NIC in SNOMED will facilitate and encourage the incorporation of NIC in vendor products. If your vendor does not include NIC, ask about future plans at their user meetings. Vendors will build their products according to user demand. Nurses need to speak up and ask for standardized language to be included in clinical information systems.