Nursing Process and Nursing Standardized Languages: Art and Science of Nursing Education. Omaha Classification System (OCS). The Nursing Interventions Classification (NIC). The Nursing Outcomes Classification (NOC)
Art and Science Of Nursing Education: Nursing Process and Nursing Standardized Languages
While the nursing process may be helpful to a novice nurse in developing an initial plan of care for a patient, it has been difficult for students to capture the detailed judgments and decisions that expert nurses make. Thus, supplements to describe nursing action have been formed. The original impetus to develop a standard vocabulary for describing health-care phenomena in nursing was to facilitate more widespread use of computers in documentation of care (Werley, Devine, Zorn, Ryan, & Westra, 1991).
A standard permit vocabulary the coding of nursing information so that data are available, reliable, valid, and comparable across settings. More importantly, use of a standard vocabulary as opposed to free text notes, ensures that information regarding categories of nursing diagnoses, interventions, and outcomes are easily retrievable and tractable across settings.
In order to have the capacity to track a nurse’s contribution to these outcomes, a standard vocabulary for nursing is essential. These context-free elements of the process, organized into taxonomic structures for diagnosing, treating, and organizing nursing care are based upon research evidence that can be used to direct nurses’ clinical decision-making (Jadad, Haynes, Hunt, & Browman, 2000 ; McCloskey & Bulechek , 2000).
NMDS
To respond to the need for developing a standard vocabulary, a minimum set of nursing essential core data was developed to allow for grouping and comparison of nursing data collected across various populations, settings, geographic locations, and time. The Nursing Minimum Data Set (NMDS) is a minimum set of items of information with uniform definitions and categories concerning the specific dimension of nursing. The NMDS includes three broad categories of elements:
(1) nursing care,
(2) patient or client demographics, and
(3) service elements.
Elements that are also included in the Uniform Hospital Discharge Data Set (UHDD) are indicated by an asterisk (University of Iowa Nursing Informatics, 2006). The nursing care elements of the NMDS include nursing diagnosis, nursing intervention, nursing outcome, and intensity of nursing care. The NMDS provides access to nursing core data while also meeting the information needs of multiple data users in the health-care system.
Its primary contribution to practice is that it provides data for quality improvement and trend tracking. NMDS contribution to education comes from facilitating awareness in students of the need to document care appropriately using the nursing process model, and ensuring integration of information management in the undergraduate and graduate curricula. Unfortunately, no single classification system for the NMDS nursing elements is widely and universally accepted. A number of competing systems have emerged.
Classification schemes for nursing diagnosis, interventions, and outcomes of care include:
(1) the North American Nursing Diagnosis Association (NANDA, 1992)
(2) the Omaha Community Health Problem and Intervention Classification System (Martin & Scheet, 1992)
(3) the Nursing Interventions Classification (McCloskey & Bulechek , 1992)
(4) the Nursing Outcomes Classification (Johnson & Maas, 1997).
These four classification systems were recognized by the American Nurses Association Steering Committee on Databases to Support Clinical Nursing Practice as usable for documenting nursing practice (McCormick et al., 1994).
NANDA
The focus of this classification scheme is on the NMDS nursing element diagnosis. Of the four classification schemes, NANDA has the longest history. In the 1970s, the association was formed to develop labels for nursing diagnosis. At present, more than 167 diagnosis labels have been developed. An organizing framework of nine general patterns was developed in 1991.
Diagnoses are arranged alphabetically in the taxonomy and are coded using the International Classification of Disease (ICD) framework (NANDA International, 2005). New terminology is included via a systematic and rigorous process. The labels are easy to use clinically. NANDA bridges the gap between theory and clinical practice to help apply nursing diagnosis concepts to patients (Lunney, 2005).
A nursing diagnosis helps the nursing student to organize his assessment information into a coherent pattern described by the diagnosis taxonomy. The taxonomy is research-based; Hence the student’s clinical judgment about the patient’s responses to actual or potential health problems or life processes is linked to empirically validated concepts.
Omaha Classification System (OCS)
The Visiting Nurses Association of Omaha developed the Omaha Classification Scheme for nurses in community and public health service. The project was supported with a contract from the Division of Nursing, PHS, US DHHS (McCormick et al., 1994). The Omaha system was designed to provide a framework for integrating a clinical practice and documentation system (Martin, Leak, & Aden, 1992). The problem classification scheme has four domains:
(1) environmental (eg, sanitation )
(2) psychosocial (eg, caretaking )
(3) physiological (eg, circulation)
(4) health-related behaviors
The classification scheme includes a rating scale for outcomes that uses a numerical measurement to evaluate changes in the client’s knowledge and behavior status in relation to specified health-related problems and selected time frames (Martin, Scheet, and Stegman, 1993). The intervention scheme is divided into four broad areas: health teaching, treatment and procedures, case management, and surveillance.
Because this system was developed for community health, most of the users are practicing in that setting. In a survey conducted from 2001 to 2005, approximately 75% of home care and public health organizations reported using Omaha System software (Martin, 2005). The OMAHA classification system has been linked to the NANDA and other classification systems.
The Nursing Interventions Classification (NIC)
Researchers at the University of Iowa developed the Nursing Interventions Classifications (NIC) with a grant from the National Center for Nursing Research. The authors used a national Delphi survey of masters-prepared nurses to generate the original list of 336 specific interventions (Moorehead, McCloskey, & Bulechek , 1993).
Currently, the NIC contains more than 514 research-based, standardized clinical interventions grouped into seven categories:
(1) basic physiological
(2) complex physiological
(3) behavioral
(4) safety
(5) family
(6) health system
(7) community (Dochterman & Bulechek 2004; McCloskey & Bulechek , 2000)
The NIC has been validated by a sample of 121 nurses from the Midwest Nursing Research Society. NIC’s creators used input from this survey to revise the original taxonomy. NIC is continuously updated and has an ongoing process for feedback and review (McCloskey & Bulechek , 2000). NIC is designed to be used by all nursing specialties in any setting.
It can also be used by other providers to document their interventions (Dochterman & Bulechek , 2004). NIC is included as one data set that will meet the uniform guidelines for information system vendors in the American Nurses Association’s Nursing Information and Data Set Evaluation Center (NIDSEC).
The NIDSEC was established by the American Nurses Association (ANA) to review, evaluate against defined criteria, and recognize information systems from developers and manufacturers that support documentation of nursing care within automated Nursing Information Systems (NIS) or within Computer-based Patient Record systems (CPR).
The Nursing Outcomes Classification (NOC)
In order to complete the requirements for documentation of a nursing clinical encounter, researchers from the NIC team realized the necessity of a system to classify patient outcomes. Johnson and Maas published the Nursing Outcomes Classification (NOC) in 1997. The 330 outcomes can be used across episodes of care and in various settings.
The outcomes have been linked to NANDA International diagnoses, Gordon’s functional patterns, the Taxonomy of Nursing Practice, the Omaha Classification System, resident admission protocols used in nursing homes, the OASIS System used in home care, and NIC interventions.
Although the classification system is mostly individually focused (311 of the 330 outcomes are at the individual level), the outcomes can be aggregated to provide some measure of community and family outcomes and an additional 10 family and nine community level outcomes have been developed (Iowa Outcomes Project, Johnson, Maas, & Moorhead, 2000).
Before the development of the classification taxonomies, there was no systematic way to document nursing actions in a common language that novice nurses could use as a guide to the wide array of possible diagnoses, interventions, and outcomes. Although nursing diagnoses have been a part of the organization of most major care planning textbooks since NANDA’s inception, there has been no easy way to link nursing diagnosis and intervention with the patient’s signs and symptoms, demographic characteristics, medical diagnoses, and therapies.
The NIC/NOC system can be used by the nursing instructor to facilitate teaching beginning nurses how to assess a patient and then link that assessment to a list of potential interventions and hopes-for outcomes (McCloskey & Bulechek , 2000). Because the lists are not proscriptive, the student nurse, along with the instructor, must exercise clinical judgment when selecting the intervention.
The classifications cannot replace nursing judgment, nor are they absolutely necessary for nursing decision making to take place, they simply provide one possible systematic way to document and communicate about nursing actions. Each of the databases has different advantages for different users. The NANDA diagnosis classification scheme is probably the most widely recognized method for categorizing nursing diagnoses.
This scheme, however, does not offer taxonomy for interventions and outcomes. The OCS is a more complete classification system because it does include taxonomies for diagnoses, interventions, and outcomes, but it has not changed substantially since the original work. The NIC/NOC, unlike the systems derived in community health settings, was designed to be universally applicable in any care environment.
The NIC/NOC employed panels of nursing experts to develop its taxonomy. The NIC/NOC have evolved after several stages of development and validation. Only NANDA, NIC, and NOC have ongoing research efforts to keep them current (Dochterman & Bulechek , 2004). The three systems have now been integrated since the formation of the NIC/NOC/NANDA (NNN) Taxonomy of Nursing Practice.
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