Implementation of Nursing Standardized Languages: NANDA, NIC & NOC
Mary Clarke, MA, RN email@example.com
The use of standardized languages in this 500 bed community hospital dates back to the mid 1970's with the use of the North American Nursing Diagnosis Association (NANDA) classification. Nursing diagnosis, as a concept and a component of the nursing process, was originally introduced in 1974. Following publication of the nursing diagnoses generated from the first (Gebbie & Lavin, 1974) and second conferences (Gebbie, 1975), lists of the diagnostic labels were made available to nurses in all patient care areas. Nurses were requested to use the lists to standardize the language for the documentation of patient's problems, needs, or responses to illness.
Patient Plan of Care
By 1983, the institution computerized the care planning process and included the NANDA classification. Throughout the years the system underwent many enhancements, including the implementation of the Nursing Interventions Classification (NIC).
The Nursing Interventions Classification is a system of standardized language for nursing treatments. NIC identifies both nurse-initiated and physician-initiated interventions that nurses perform to produce certain patient outcomes (McCloskey & Bulechek, 1996).
Three hundred and thirty six direct and indirect care interventions were published in 1992 in the first edition of NIC. Since then, the second edition (McCloskey & Bulechek, 1996) has been published, increasing the number of interventions to 443. Nursing Interventions Classification is an important step in enabling nursing to effectively communicate the work of the profession.
Content development and linkage of appropriate NIC labels to the diagnostic labels was performed by a group of masters prepared Clinical Nurse Specialists (CNSs). The group, with input from the clinical users opted to implement NIC at the label level and not include the discrete NIC activities. The RN users had been suggesting that interventions based on clinical knowledge and judgement not be selectable for care plan inclusion. For example, nurses felt "auscultate lungs" and "monitor lab values" were nursing orders they did not need to see printed in a patient care plan. Therefore, the NIC labels replaced the lengthy descriptions of nursing orders. Instead, staff members were educated to review the NIC text prior to selecting the label.
In 1993, prior to completing the addition of NIC to all of the nursing diagnoses, the organization consolidated with another community hospital. Consolidation brought forth many challenges and changes including the search for a new clinical information system. Until the information system could be replaced a standardized manual system for nursing documentation had to be developed and implemented. The manual system also needed to preserve the data coding and archiving of valuable nursing data that was previously accomplished in the automated system.
Instead of returning to lengthy hand written care plans, a template needed to be developed that utilized preprinted information with use of a check mark to individualize any element of the diagnostic label. A group of staff nurses and CNSs convened to develop the care plan format and the process of implementation.
The manual care plan format uses NANDA diagnoses, including defining characteristics and related factors. In addition, nursing interventions from NIC are included at the label level rather than listing the specific nursing activities.
The most recent nursing standardized language to be added to the patient plan of care is the Nursing Outcomes Classification (NOC). The Nursing Outcome Classification (NOC) is the work of a large research team from the University of Iowa College of Nursing. The classification contains 190 outcomes that are sensitive to interventions performed by the nurse and other health care providers.
A nursing-sensitive patient outcome is defined as "a variable patient or family care giver state, condition, or perception responsive to nursing intervention." The outcomes are conceptualized at various levels of abstraction. Each outcome contains a label, indicators and a measurement scale with descriptors.
The implementation of NOC in a manual system, has been a slower process than the other classifications. The implementation team initially felt that adding NOC label indicators and the measurement scales in a manual system would be too cumbersome. However, after much consideration, NOC is being added to the patient plan of care. The outcome measurement will be applied at the label level and not to each specific indicator. Selected indicators will be listed with each outcome label to be used as a reference when scoring the overall outcome.
Integration into Clinical Pathways
In response to today's health care climate the development of critical pathways has become essential. During the last year, the organization has been in the process of revising several clinical pathways based on high volume DRG patients and entered into a collaborative effort with an affiliated hospital.
The initial step in the development of the clinical pathway was the review of patient records including the historical trends of nursing components from the data repository. High frequency nursing diagnoses for each DRG were identified and included in each path. The theory for including the nursing components (NANDA, NIC and NOC) on the pathways were not only to achieve a true multidisciplinary path but to also eliminate the need for the RN to add the manual patient plan of care. Each selected NANDA diagnosis with its related factor appears on the critical path, along with an area for the RN to individualize the selection of defining characteristics. NIC was added to the pathway in an intervention category. Documentation against an intervention only happens if there is an exception to the patient's plan of care. Specific NOC labels and indicators were identified for each pathway. The measurement scale and description is included for quick reference for the health care provider.
The members of each pathway group determined the measurement intervals for each outcome on the clinical pathway. The outcome is measured at the end of the each phase on the pathway, eliminating the need for each shift to score the patient's outcome. The first group of clinical pathways implemented were Coronary Artery Bypass Graft (CABG), Vaginal Delivery, Cesarean Section, Normal Newborn and Total Knee Arthroplasty (TKA).
NIC Competency Based Orientation
The application of NIC in the development of a competency-based learning plan for nursing has been accomplished by the organizations' shared governance education task force. After careful review of the Joint Commission Standards and nursing literature on competency assessment, the task force opted to utilize the NIC taxonomy as the organizing framework for the selection of competencies for the RN staff nurse.
The method of prioritizing the competency selections included risk, frequency, and essential elements of nursing practice and mandatory requirements. The task force focused on three phase of competency development: 1. Those competencies that would be applicable or "core" for every RN entering the organization; 2. Those competencies that were unit based or specific only to a few PCA's; and 3. The introduction of ongoing or continued developmental new procedures or technologies.
Once a competency was selected, the task force identified the appropriate NIC label. The next step was to compose a statement that defines a broad yet distinguishable area of clinical competence that includes behaviors that can be observed and measured. In most cases the NIC definitions lent themselves to this statement of expected performance.
Once the competency and statement had been identified, the task force selected performance criteria for each competency. Each NIC activity accompanying the selected intervention label was reviewed. Performance criteria were selected based on:
1. Behaviors the orientee must perform.
2. Behaviors that were measurable as well as observable.
3. Performance that is truly essential or critical to competency.
The task force successfully developed twenty-three RN core competencies. The competencies were critiqued by nursing staff and nurse managers and were implemented in the new employee orientation program. In addition to the core competencies, each PCA identified those high-risk, low frequency interventions performed on their PCA and are currently developing the appropriate competency.
The 3 projects described in this article illustrate ways this institution has implemented NANDA, NIC and NOC. Change, evolution, maturation, etc., however you wish to describe it, has always been present with us as we have made our journey along the path of implementing standardized languages for nursing. As we continue this process, we are currently involved in preparing for the future: the implementation of a clinical information system with the inclusion of nursing standardized languages.