June Clark, DBE, PhD, RN, RHV, FRCN
The rationale for standardised languages and classifications for nursing applies all over the world. Development in the USA was earlier than in other countries because of the imperatives of reimbursement systems, accreditation; and litigation. However, translation of languages developed in and for the USA may not be appropriate for other countries' practice; cultures, or health care systems. Many countries are already developing their own systems in their own languages, but others have no system. The International Council of Nurses' project to develop an International Classification for Nursing Practice will provide a unifying framework for existing systems and a system which can be used in countries which have none. Only when we have such a tool will we be able to describe and compare nursing practice across nations, and test the commonalties and differences of its concepts, values and practices.
Citation: Clark, J. (Sept. 30, 1998): "The International Classification For Nursing Practice Project." Online Journal of Issues in Nursing. Vol 3, No. 2, Manuscript 3. Available: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol31998/No2Sept1998/TheInternationalClassificationForNursingPracticeProject.aspx
Development of Standardised Terminology
Ninety years ago an English-speaking nurse who attended a meeting of the (then) recently established International Council of Nurses wrote:
While attending a special meeting of the ICN in Paris, I was naturally at once struck by the fact that the methods and the ways of regarding nursing problems were ... as foreign to the various delegations as were the actual languages, and the thought occurred to me that ... sooner or later we must put ourselves upon a common basis and work out what may be termed a "nursing esperanto" which would in the course of time give us a universal nursing language (Hampton Robb 1909).
In the 90 years that have passed since then, nursing has developed enormously but the gap identified by Hampton-Robb has not yet been remedied.
In the United States the need to standardise the collection of nursing data through the use of a minimum data set, standardised terminology, and classification systems is well recognised (Iowa Intervention Project 1997). Classification of nursing problems dates back at least to 1959 (Abdella, Beland, & Martin). The North American Nursing Diagnosis Association (NANDA) began in 1973. Werley was writing about the Nursing Minimum Data Set throughout the 1980s (Werley & Lang 1988). The research team which developed the Nursing Intervention Classification (NIC) was established at the University of Iowa in 1987 (McCloskey & Bulechek 1992).
By 1992, the publication of NIC had been joined by Martin and Scheet's OMAHA system, Saba's Home Health Care System, and Grobe's Nursing Intervention Lexicon and Taxonomy. The National Library of Medicine had already begun work on the development of a Unified Medicine Language System (UMLS) and the American Nursing Association (ANA) had established its Steering Committee on Databases to Support Clinical Nursing Practice (1995). Since 1990 the work has rapidly accelerated and the literature is now substantial.
The reasons why this development began first in the United States are probably to be found in the U.S. systems of nursing education and of financing health care. The notion of nursing as a science to be built, as are other sciences, through the identification and analysis of its phenomenon of concern, has been established in US nursing education for many years (Harmer 1926). However, it is still a novelty in most countries of Europe (with the notable exception of the Netherlands). We have no tradition or system of accreditation similar to that of the Joint Commission on Accreditation in Hospitals, which from its establishment in 1951, stressed the need for adequate patient records and standards of nursing documentation. The threat of litigation was, until recently, rare.
The most powerful imperative, however, is probably to be found in the systems of reimbursement derived from the insurance system and from the Medicare and Medicaid legislation of the mid 1960s, in which the provider's reimbursement for services rendered depends on detailed records of patient diagnoses and professional activities. However, the most significant influence on the manner in which standardised terminology and classification systems for nursing have developed has undoubtedly been the work of the American Nurses Association through its Steering Committee on Databases to Support Clinical Nursing Practice (ANA 1995). It is significant but unsurprising that the resolution to the International Council of Nurses Council of National Representatives at Seoul in 1989, which led to the project to develop an International Classification for Nursing Practice, was proposed by the ANA.
Developments in other countries began later. When the ICN carried out its first survey about classification and information systems among its member organisations in 1991, it recorded considerable activity in the USA, some in Australia and Canada and almost nothing in the rest of the world (Wake, Murphey, Affara, Clark & Martensen 1993). Given the long head start of the USA, it might seem obvious that the most efficient way forward would be simply to translate the American systems into other languages as and when each country required. After all, the NANDA taxonomy had already been translated into several languages, and by 1992 NIC was also being translated and promoted in other countries.
There are several reasons why this is not the right solution. At the purely linguistic level, translation is not easy, as the efforts of NANDA, NIC and the OMAHA system have shown. Even within the English language there are problems. When the Chelsea and Westminster Hospital in London decided to use the NANDA taxonomy in its new developed Hospital Information System, it found that it had to translate many of the NANDA words; terms such as regimen and unilateral neglect do not trip easily off English tongues (1998).
Translation must transfer the concepts behind the words, and concepts which are well recognised in one culture may not be recognised in another. Nursing concepts such as self-care which reflect the cultural values and norms of American society may be differently perceived in other (eg. Asian) cultures. Validation studies undertaken by NANDA members have found that some concepts contained in the NANDA taxonomy simply do not exist elsewhere.
Thirdly, the American terms and taxonomies inevitably reflect the purposes for which they were developed and the American health care system of which they are a product. They, therefore, focus on the individual as client rather than the family or the community, and they do not capture well the practice of primary health care as it is understood in northern Europe or Africa.
Most significantly while the 1991 ICN survey found little activity outside the USA, by 1995 every major country in Europe was developing its own terminology and classifications. The imperatives of health care reform within a market model and the rapid acceleration of information technology are doing for Europe what the Medicare/Medicaid legislation did for America. Moreover since European health care systems tend to be nationally organised and state funded, the systems rapidly extend nation-wide and are likely to become mandatory. Belgium has a mandatory minimum data set which includes a 23-item categorisation of nursing activities; a twice yearly census collects data from every Belgian hospital (Sermeus & Delesie 1994).
The Netherlands has undertaken extensive work on classification for both interventions and diagnoses, the latter based on the WHO-sponsored International Classification of Impairments, Disabilities and Handicaps (1998). The UK has developed a coded multi-disciplinary thesaurus of over 250,000 terms which includes nursing terms integrated with those contributed by medicine, physiotherapy and other disciplines (Casey 1995). The Read terms are already widely used in primary health care and will soon become mandatory for all parts of the British National Health Service.
In almost every country of the world nurses experience problems of "powerlessness" due to the "invisibility" of nursing in the information systems which are used for making decisions about health policy and resource allocation.
Yet many of the political problems which have driven the work in the USA are universal. In almost every country of the world nurses experience problems of "powerlessness" due to the "invisibility" of nursing in the information systems which are used for making decisions about health policy and resource allocation. As nursing education becomes more sophisticated and nursing research activity develops and spreads, nurse managers and policy makers want to be able to compare nursing activities and performance across time and place, and nurse researchers are increasingly frustrated by their inability to compare their results.
At the clinical level, increasing pressure on individual nurses to accept accountability and demonstrate their effectiveness are forcing ordinary clinical nurses to recognise the need to develop ways of recording their practice which give a more comprehensive and accurate picture of what they do. The development and use of standardised terminology and classification systems are an essential pre-requisite for achieving these aims.
Yet, as often happens, the trigger for action was political. Driven by the need to ensure nursing visibility within the information systems which were used in the USA for reimbursement and other purposes, the American Nurses Association approached WHO with a proposal to include the specially adapted version of the NANDA taxonomy in the (then) forthcoming 10th edition of the International Classification of Diseases. The proposal was rejected — not because the proposed content was poor, but because WHO considered it inappropriate to include in the International Classification content which had been developed within and for a single country. In other words, the real reason for an International Classification was the need to avoid cultural imperialism. The ANA, wisely, approached the International Council of Nurses, which is the federation of National Nurses Associations around the world, and the idea of the International Classification for Nursing Practice (ICNP) was born.
The International Classification for Nursing Practice Project
A resolution of the ICN's Council of National Representatives in 1989 asked that ICN encourage member National Nurses Associations (NNA's) to become involved in developing classification systems for nursing care, nursing information management systems and nursing data sets, and to provide tools that nurses in all countries could use to identify nursing practice and describe nursing and its contributions to health.
The International Classification for Nursing Practice Project, begun in 1990 by the International Council of Nurses, aims to develop a standardised vocabulary and classification of nursing phenomena (nursing diagnoses), nursing interventions, and nursing outcomes which can be used in both electronic and paper records to describe and compare nursing practice across clinical settings. An Alpha Version of the Classification of Nursing Phenomenon and Nursing Interventions was released for further development and field testing in 1996 and an outline for a classification of Nursing Outcomes in 1997. Nurses around the world, and other classification experts, have been invited to participate in the development of the Beta Version which it is hoped will be ready for release in 1999.
The goals of the project, which were set out in the initial proposal to the ICN Board of Directors' are:
- To develop an ICNP with specified process and product components.
- To achieve recognition by the national and international nursing communities.
- To ensure that the ICNP is compatible with and complementary to the WHO Family of Classifications, and the work of other standardisation groups such as the International Organisation for Standardisation (ISO) and related groups including the ComiteEuropean de Normalisation (CEN), and to secure inclusion of ICNP in relevant classifications.
- To achieve utilisation of ICNP by nurses at country level for the development of national databases.
- To establish an international data set and a framework that incorporates the ICNP, the nursing minimum data set, a nursing resource data set, and regulatory data.
These goals continue to provide the mission and the framework for the project.
Testing the Alpha Version
The Alpha Version is currently being tested in various ways and further participation is welcomed. All member National Nurses Associations have been asked for feedback, and documentation for submission of new terms and changes to existing terms is available. A process for managing feedback is being developed.
In Europe the TELENURSE project has enabled the Alpha Version to be translated into several languages and is testing aspects of the use of ICNP in electronic patient records. Validation studies are being undertaken at Marquette University and by individual researchers in several countries.
The ICNP Country Project, funded for 3 years by the W K Kellogg Foundation, will assist ICN to focus particularly on describing nursing practice in community-based practice and primary health care. Country work groups in several countries of Africa and Latin America will explore and develop new processes and look critically at the nature and structure of ICNP as well as contributing new terms. The project also includes publication of a Newsletter to disseminate information and ideas.
What Kind of Classification?
The form and content of any classification reflects its purpose, and it is recognised that no one classification can meet all needs. The World Health Organisation has developed the concept of a "family of classifications" built around the core of the ICD itself (1992). The "peripheral" members of the family would include specially based adaptations of ICD, (eg for psychiatry, oncology, dentistry and stomatology), the International Nomenclature of Diseases (the purpose of which is to provide a single recommended name for every disease entity), and other health-related classifications such as the International Classification of Impairments, Disabilities and Handicaps (ICIDH). It is an explicit goal of the ICNP project that ICNP should join the "family", probably among the "Other Health Related Classifications".
It is already clear that the ICNP cannot serve all the purposes that all nurses in every country would like.
It is already clear that the ICNP cannot serve all the purposes that all nurses in every country would like. Its explicit purpose, as stated in the Alpha Version (ICN 1996), is to "provide a vocabulary, a new classification for nursing, and a framework into which existing vocabularies and classifications can be cross-mapped to enable comparison of nursing data collected using other recognised nursing vocabularies and classifications". Even these three purposes are difficult to achieve by means of a single tool.
Meerabeau et al (1997) point out that nurses already use different languages for different purposes. They note that the US National Center for Nursing Research (1993), distinguishes between clinical terms (the language of practice) and definitional terms (the language of nursing knowledge — theory and research). Hoy (1995) sets out a continuum of steps between "informal language" which nurses use to communicate information about patients whose care they share, and the "formal language" which is necessary for remote communication such as anonymised aggregated data for research or statistical purposes. It has been suggested that as nurses learn to articulate more precisely their phenomena of concern, the gap between the two extremes of Hoy's continuum will narrow, but it is unlikely that they will ever merge.
Classification brings even greater problems. The existing nursing classifications, like the ICD, are first-generation mono-axial classifications, and have usually been inductively developed. The ICNP Alpha Version classification of nursing phenomena was also mono-axial, but it differs from the other nursing classifications in that it is built according to strict rules of classification based on generic relations — that is, the concepts are arranged in a strict hierarchy in which each subordinate term is related to each superordinate term (the genus) by a principle of division, and distinguished from other terms on the same level by its special characteristics (the characteristic of the species).
The meaning of the concept is, therefore, defined by its place in the classification as well as by any other definition it may be given. The ICNP Beta version will use multi-axial classification in which each complex concept (eg impaired mobility) is broken down into separate axes, (eg mobility : impaired). This kind of classification increases richness and flexibility because it allows the terms in different axes to be combined in various ways, but the penalty is that the increased complexity limits use to computerised systems, to which nurses in many countries have no access.
Is It Feasible?
Problems such as these raise the challenge that even if an international classification is desirable, it may not be feasible. Such a view is, however, unduly pessimistic.
One cause for optimism is the integration of a Unified Nursing Language System (UNLS) within the Unified Medical Language System (UMLS) which is being developed by the National Library of Medicine (Lindberg, Humphreys & McCray, 1993). The UMLS includes concepts, terms, strings and semantic relationships which enables terms from different vocabularies to be mapped from one language to another. The UMLS already includes the ANA recognised languages, the UK Read terms (which include nursing terms), and the vocabularies used in some non-English speaking countries.
The most important step, however — a pre-requisite for the successful international use of any standardised language or classification — would be the international adoption of an agreed nursing minimum data set. Until countries agree on the data elements to be described, the availability of standardised terminology and classification is irrelevant. It is 10 years since Werley and Lang (1988) identified as essential the four nursing elements of nursing diagnosis, nursing interventions, nursing outcomes and nursing intensity. Goosen (1998) has recently reviewed the minimum data sets developed in several countries. Nurses in most countries record nursing interventions in some form, but the concept of nursing diagnoses is not widely used in Europe and the only "problems" which nurses record are usually medical diagnoses. The recording of outcomes is rare in all countries, and although some system of predicting nursing workload is common, there is no agreed measure for nursing intensity.
Criteria for an International Classification
The ICNP project set criteria for its own classification as follows:
- Broad enough to serve the multiple purposes required by different countries.
- Single enough to be seen by the ordinary practitioner of nursing as a meaningful description of practice and a useful means of structuring practice.
- Consistent with clearly defined conceptual frameworks but not dependent upon a particular theoretical framework or model of nursing.
- Based on a central core to which additions can be made through a continuing process of development and refinement.
- Sensitive to cultural variability.
- Reflective of the common value system of nursing across the world as expressed in the ICN Code for Nurses.
- Usable in a complementary or integrated way with the family of disease and health related classifications developed within WHO.
These criteria describe the challenge for any classification for nursing practice. They are not easy to meet, and success will not be quick. The ICNP has been described as "the kind of project that never ends but for which the need is urgent". It is certainly a goal worth aiming for.
June Clark, DBE, PhD, RN, RHV, FRCN
June Clark DBE, PhD, RN, RHV, FRCN is a Professor of Community Nursing, University of Wales Swansea, Wales, UK. Dr. Clark is responsible for the development of a program of research in community health nursing and primary health care at the University of Wales, Swansea. Her special interest is the development and use of standardized nomenclatures to describe nursing practice, in particular in primary health care. Since 1990 she has been consultant to the International Council of Nurses' project to develop an International Classification of Nursing Practice.
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© 1998 Online Journal of Issues in Nursing
Article published September 30, 1998
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