Nursing Interventions Classification (NIC) -- Current Status and New Directions
Joanne C. McCloskey, PhD,RN,FAANjoanneemail@example.com
Gloria M. Bulechek, PhD,RN,FAANgloriafirstname.lastname@example.org
(Note: This article is based upon two presentations, one at the NANDA, NIC and NOC conference in St. Charles, IL in November 1997 and one at the NANDA conference in St. Louis in April, 1998. The paper is submitted for inclusion in the NANDA Proceedings of the Thirteenth National Conference and to the On-line Journal of Nursing Informatics.)
The ongoing work at the University of Iowa to name and classify nursing interventions is eleven years old. The impetus for the work on interventions partially evolved from the NANDA work--once a nurse makes a diagnosis, there is an obligation to do something about it. Prior to the development of the Nursing Interventions Classification, the profession of nursing had no language with which to communicate the interventions that nurses perform. In the past decade, the development of this language and its implementation in practice and education has evolved rapidly. The purpose of this paper is to overview NIC and then to discuss some current work and related issues.
Overview of NIC
The Nursing Interventions Classification (NIC) (McCloskey & Bulechek, 1996) names and describes interventions that nurses perform. An intervention is defined as " any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes" (p. xvii). NIC is useful for clinical documentation, communication of care across settings, aggregation of data across systems and settings, effectiveness research, productivity measurement, competency evaluation, reimbursement, and curriculum design.
Each of the 433 interventions in the classification is composed of a naming label, a definition, and a list of activities that describe what a nurse does to carry out the intervention. The label and definition are the standardized language and cannot be changed unless through a formal review process; the activities can be modified somewhat to meet the needs of the situation and to provide for individualized care planning. Each intervention also has a short list of background readings that supports the intervention and a unique four letter code. See one example in Table 1 attached.
The classification includes all treatments that nurses perform, from the most basic (e.g. Body Mechanics Promotion -- facilitating the use of posture and movement in daily activities to prevent fatigue and musculoskeletal strain or injury) to those that are highly complex and specialized (e.g. Anesthesia Administration -- preparation for and administration of anesthetic agents and monitoring of patient responsiveness during administration and Electronic Fetal Monitoring: Intrapartum -- electronic evaluation of fetal heart rate response to uterine contractions during intrapartal care). NIC interventions include both the physiological (e.g. Acid-Base Management--promotion of acid-base balance and prevention of complications resulting from acid-base imbalance) and the psychosocial (e.g. Anxiety Reduction -- minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source of anticipated danger). There are interventions for illness treatment (e.g. Hyperglycemia Management -- preventing and treating above normal blood glucose levels), injury prevention (e.g. Fall Prevention -- instituting special precautions with patient at risk for injury from falling), and health promotion (e.g. Exercise Promotion -- facilitation of regular physical exercise to maintain or advance to a higher level of fitness and health). Interventions are for individuals or for families (e.g. Family Integrity Promotion -- promotion of family cohesion and unity). Indirect care interventions (e.g. Emergency Cart Checking -- systematic review of the contents of an emergency cart at established time intervals) and interventions for communities (e.g. Environmental Management: Community -- monitoring and influencing of the physical, social, cultural, economic, and political conditions that affect the health of groups and communities) are also included.
The interventions are coded in a three level taxonomic structure easy for clinicians to use. At the top, most abstract level, of the taxonomy are 6 domains: Physiological: Basic, Physiological: Complex, Behavioral, Safety, Family, and Health System. At the second level are 27 classes organized within the domains. At the third level are the interventions themselves grouped according to class and domain and all domains, classes, and interventions have definitions. Some (not many) interventions are located in more than one class, but each has a unique code (see Table One below -- unique code number for Cerebral Edema Management is 2540) which identifies the primary class and is not used for any other intervention.
Table 1. 2540 Cerebral Edema Management
Limitation of secondary cerebral injury resulting from swelling of brain tissue
Assess for confusion, changes in mentation, complaints of dizziness, syncope
Establish means of communication: ask yes or no questions; provide magic slate, paper and pencil, picture board, flashcards, vocaid device
Monitor neurologic status closely and compare to baseline
Monitor CSF drainage characteristics: color, clarity, consistency
Record CSF drainage
Decrease stimuli in patient's environment
Give sedation as needed
Note patient's change in response to stimuli
Monitor respiratory status: rate, rhythm, depth of respirations; PaO2, pCO2, pH, bicarbonate
Allow ICP to return to baseline between nursing activities
Screen conversation within patient's hearing
Administer anticonvulsants as appropriate
Avoid neck flexion, or extreme hip/knee flexion
Avoid Valsalva maneuvers
Administer stool softeners
Position with head of bed up 30° or greater
Avoid use of PEEP
Analyze ICP waveform
Plan nursing care to provide rest periods
Monitor patient's ICP and neurologic response to care activities
Administer paralyzing agent
Encourage family/significant other to talk to patient
Avoid hypotonic IV fluids
Adjust ventilator settings to keep PaCO2 at prescribed level
Limit suction passes to less than 15 seconds
Monitor for CSF rhinorrhea/otorrhea
Monitor lab values: serum and urine osmolality, sodium, potassium
Monitor volume pressure indices
Perform passive range of motion
Monitor ICP and CPP
Monitor PAWP and PAP
Monitor P and BP
Monitor intake and output
Drain CSF according to standing orders
Hyperventilate prior to suctioning
Administer loop active or osmotic diuretics
Implement seizure precautions
Titrate barbiturate to achieve suppression or burst-suppression of EEG as ordered
Ackerman, L.L. (1992). Interventions related to neurological care. In G.M. Bulechek & J.C. McCloskey (Eds.), Symposium on Nursing Interventions. Nursing Clinics of North America, 27(2), 325-346.
Alpers, R., & Hertig, V.L. (1990). Cerebral edema management. In M.J. Craft & J.A. Denehy (Eds.), Nursing Interventions for Infants and Children (pp. 345-354). Philadelphia: W.B. Saunders.
American Nurses' Association Council in Medical-Surgical Nursing Practice & American Association of Neuroscience Nurses (1985). Neuroscience nursing practice: Process and outcome for selected diagnoses. Kansas City, MO: ANA.
Cammermeyer, M., & Appledorn, C. (Eds.). (1990). Core curriculum for neuroscience nursing (3rd ed.) (pp. Id1-Id11). Chicago: American Association of Neuroscience Nurses.
Hickey, J.V. (1992). The clinical practice of neurological and neurosurgical nursing (3rd ed.). Philadelphia: J.B. Lippincott.
Johanson, B.C., Wells, S.J., Hoffmeister, D., & Dungca, C.U. (1988). Standards for critical care (3rd ed.). St. Louis: Mosby-Year Book.
Mitchell, P.H., & Ackerman, L.L. (1992). Secondary brain injury reduction. In G.M. Bulechek & J.C. McCloskey (Eds.), Nursing Interventions: Essential Nursing Treatments (2nd ed.) (pp. 558-573). Philadelphia: W.B. Saunders.
Source: McCloskey, J.C. & Bulechek, G. M. (Eds.) Nursing Interventions Classification (NIC), 2nd ed. St. Louis: Mosby Year Book.
NIC can be used in all settings (from acute care intensive care units, to home care, to hospice, to primary care) and specialties (from critical care to ambulatory care and long term care). While the entire classification describes the domain of nursing, some of the interventions in the classification are also done by other providers. NIC can be used by other non-physician providers to describe their treatments.
The classification is continually updated with an ongoing process for feedback and review. In the back of the NIC book, there are instructions for how users can submit suggestions for modifications to existing interventions or propose a new intervention. These submissions are then put through a two level review process, first by selected experts in the area and then by the entire research team. Interventions that need further work are sent back to the author for revision. All contributors whose changes are included in the next edition are acknowledged in the book. The next edition of the classification will be published in fall of 1999 with a 2000 copyright and new editions of the classification are planned for every 4 years. Work between editions and other relevant publications that enhance the use of the classification are available from the Center for Nursing Classification at the University of Iowa, Iowa City, IA.
Several tools are available that assist in the implementation of the Classification. Included in the NIC book are two tools that assist with selecting an intervention: the taxonomic structure and linkage lists with all NANDA diagnoses. In addition, available from the Center for Nursing Classification, there is an implementation manual, an anthology of past publications, linkages with Omaha health problems, a listing of interventions core to 39 clinical specialties, a thesaurus of synonyms and related terms, and linkages with NOC outcomes. A 40 minute video that is useful for implementation in practice and education has been produced by the National League for Nursing and is available from the Center for Nursing Classification. The Center also maintains a listserv for users and a listing of users by state and country.
NIC is recognized by the American Nurses' Association (ANA) and is included as one data set that will meet the uniform guidelines for information system vendors in the ANA's Nursing Information and Data Set Evaluation Center (NIDSEC). NIC is included in the National Library of Medicine's Metathesaurus for a Unified Medical Language. Both the Cumulative Index to Nursing Literature (CINAHL) and Silver Platter have added NIC to their nursing indexes. NIC is included in the Joint Commission on Accreditation for Health Care Organization's (JCAHO) as one nursing classification system that can be used to meet the standard on uniform data. Many health care agencies are adopting NIC for use in standards, care plans, competency evaluation, and nursing information systems; nursing education programs are using NIC to structure curriculum and identify competencies of graduating nurses; authors of major texts are using NIC to discuss nursing treatments; and researchers are using NIC to study the effectiveness of nursing care. Licenses are granted by Mosby Year Book for commercial or institutional use. Licensing fees are determined by the number of users per site and are renewable every two years. Interest in NIC has been demonstrated in several other countries, notably, Canada, Denmark, England, France, Iceland, Japan, Korea, Spain, Switzerland, and The Netherlands
New Directions and Issues
At every stage of major projects there is ongoing work and related issues to be resolved. In this section, we address some of these.
Development of Community Interventions: While the second edition of NIC does include some interventions that can be used with communities (aggregates), this area is still incomplete. Several of the interventions in the classification, including Environmental Management: Community, Environmental Management: Worker Safely, Health Education, Health Screening, Immunization/Vaccination Administration, Risk Identification, and Smoking Cessation, will be used by community health nurses when working with both individuals and groups. However, more interventions aimed at whole populations or communities still need to be developed. Several of the suggestions for interventions on the current "Under Consideration List" which have been submitted by reviewers and users of NIC are community interventions, e.g., Community Advocacy, Community Mobilization, Community Resource Development, Disaster Preparedness, Epidemic Prevention, Environmental Management: Adequate Housing, Environmental Protection: Air Pollution, Environmental Protection: Waste Disposal, Environmental Protection: Water Pollution, and Program Development. This area of intervention is especially important in third world countries where nursing action is often aimed at the entire community. It is also an area of growing importance in the US as health care becomes more prevention and community focused. According to Deal (1994), "As the devastating impact of public health problems such as AIDS, infant mortality, adolescent pregnancy, child abuse, and domestic violence become more evident nationwide, a clear need exists for effective population-based health programs. . . it is imperative that community health nurses define their services and provide evidence supporting the effectiveness of interventions they offer." (p. 315). The American Nurses' Association Division on Community Health Nursing (1980) defines community health nursing as a synthesis of nursing practice and public health practice applied to promoting and preserving the health of populations, with the dominant responsibility to the population as a whole. A population is a collection of individuals who have one or more personal (e.g. gender, age) or environmental (e.g. country, worksite) characteristics in common (Stanhope and Lancaster, 1966). We have tentatively defined a community health intervention as follows: A community (or public health) intervention is targeted to promote and preserve the health of populations. Community interventions emphasize health promotion, health maintenance, and disease prevention of populations and include strategies to address the social and political climate in which the population resides. We hope that in the third edition of NIC we will include many more interventions for the community.
Ongoing Refinement of Existing Interventions and Development of Other New Interventions: In addition to paying special attention to the area of community we are continuing to refine existing interventions and to develop other interventions as user feedback indicates. As the Classification is becoming better known and used, we are receiving increasing amounts of feedback. Sometimes when new interventions are developed, existing related interventions need some modification and this is done as part of the review and revision process. Some of the new interventions that have been developed and will be in the third edition of NIC include: Abuse Protection: Domestic Partner, Anaphylaxis Management, Breast Examination, Case Management, Circulatory Care: Arterial Insufficiency, Circulatory Care: Venous Insufficiency, Community Disaster Preparedness, Cost Containment, Developmental Care, Forgiveness Facilitation, Reminiscence Therapy, Religious Ritual Enhancement, Staff Development, and Triage: Emergency Center.
Need for Effectiveness Research: The essential effectiveness question is "what works best for which patients?" Nursing effectiveness research (also called outcomes research) then, is about studying the effects of nursing interventions. In the future, when nurses systematically document their care with standardized languages (NANDA, NIC, NOC), databases concerning nursing practice information generated from care delivered will become available. Questions concerning which interventions work best for which patients at what cost can readily be studied from the existing sources of data. The progress of nursing science should move more quickly when existing data can be used rather than each researcher having to collect new data each time a research question or hypothesis is proposed. With the help of these databases, we will be able to determine which nursing interventions work best for a given population. We will address research questions such as the following:
1. What intervention works best for the achievement of a specific outcome?
2. What interventions are typically used together?
3. What interventions are typically used in certain areas or specialties?
In order to answer the above questions, we need to collect information about the patient, the providers, and the care environment. We have suggested elsewhere (Iowa Intervention Project, 1997a) that data about the following variables should be collected to confidently answer the previous three questions: the patient's identity number (to allow linking of information), age, sex, race/ethnicity (these three to provide some demographic information), episode admission or encounter date, discharge or termination date, disposition (where the patient went after discharge), and outcomes (both expected and achieved); the physician's diagnoses and interventions; the nurse's diagnoses and interventions, including the specific medications administered (in order to control for the medications' effects in relationship to other nursing interventions); and the work unit's type, staff mix, average patient acuity, and work load (also necessary as controls). Each of these variables needs a standardized definition and measure. (See the chapter by the Iowa Intervention Project, 1997a for the definitions and measures of 24 variables proposed for the basis of a nursing database.)
Our work with the identification and measurement of variables necessary for the conduction of effectiveness research demonstrates that the profession still needs to grapple with several issues related to the collection of standardized data. For example, the collection and coding of medications in easily retrievable form is not yet available in most facilities. While nursing effectiveness research can be done without the knowledge of medications, many of the outcomes that are achieved by nurses are also influenced by certain drugs and so the control for medication effect is desirable. Also, at the present time there is also no unique number that identifies the primary nurse. Consequently, it is not currently possible to attribute clinical interventions or outcomes to particular nurses based upon documentation data. Additionally, health care facilities do not yet collect the unit data in a standardized way. Despite the remaining challenges, we have made enormous progress in our ability to engage in effectiveness research. With the development of standardized language that can be used for documentation of actual clinical practice, we can now add effectiveness methods to our ability to study the impact of our interventions.
Determination of Average Time for Each Intervention: Hand in hand with knowing what works in practice is knowing the cost of what works. Administrators' top concern these days is keeping health care costs affordable (at an acceptable level of quality). As managed care continues to grow, health care and nursing administrators need to be able to know and articulate the cost of nursing care in order to be able to contract for services. The treatment or intervention can be considered the "product" of nursing care and therefore provides an acceptable and explainable item for billing. (That is, the intervention is not everything that nurses do but is a reasonable proxy; other services can be included in the overhead charge or as an add on charge). The steps to determining the costs of nursing interventions can be listed as follows:
• Identify the interventions delivered to the patient.
• Affix a price per intervention taking into account the level of provider and time spent delivering the intervention, as well as supplies and equipment required.
• Determine an overhead or indirect care charge (allocate evenly to all patients) and be able to provide justification.
• Determine the cost of delivering care per patient (direct care interventions plus overhead).
• Determine the charge per patient or use the information to contract for nursing services (Iowa Intervention Project, 1997b).
The first step in determining nursing cost is to identify the interventions that will be delivered to the patient (or patient population). This step is now possible with the use of NIC. The next step of affixing a price per intervention hinges on knowing who needs to deliver the intervention and, on average, how much time it takes. While each agency/managed care group needs to determine these issues for their own practice, some overall guidelines would assist in this process. It is not, in our opinion, desirable to conduct time in motion/work sampling studies for all of the interventions included in NIC. These methods take a good deal of time, are resource intensive and have other problems related to sample size, timing of data collection periods, and the potential influence of the observer on the study subjects (Scherubel & Minnick, 1994). Estimates of time to perform interventions by nurses who do the interventions has been shown to be an accurate and efficient method to determine time values (Albrecht ,1987; McCloskey, Bulechek, Moorhead, and Daly, 1996) While we think it desirable to obtain time estimates for each intervention, at the present time, we do not have plans to conduct this research. While it is a desirable goal, we do not have the resources to do the research without additional funding.
Funding for Ongoing Work: As indicated, funding to continue this work is an ongoing concern. We have been fortunate to have received 7 years of funding (two RO1 grants) from the National Institute of Nursing Research (NINR). We did submit a third grant which was approved but not with a high enough priority score to obtain continued funding. We revised and resubmitted this but the results were similar--the reviewers' comments indicated that while the work was very important, the expectation was that we should now be able to move to the stage of effectiveness research (use of data from information systems using NIC). While many health care institutions are beginning to use NIC and NOC, the implementation takes many years before useful data can be generated. In addition, most institutions do not systematically collect the other variables addressed in the previous section on effectiveness research. In fact, a recent survey of health care executives (Serb, 1998) revealed that only 2 percent of 1,700 respondents indicated that they have a fully operational electronic patient record system. Many health care systems still cannot electronically keep track of patients with no common coding for the same patient. We are, in our opinion, still years away from having good data for effectiveness research in nursing.
We feel that the ongoing refinement and maintenance of NIC is an important contribution to the profession but resources are an ongoing concern. We are fortunate that the College of Nursing is supporting one staff person for three years to assist the investigators of NIC and NOC in the Center for Nursing Classification. The Center was proposed by the investigators three years ago as a structure to keep the work ongoing when grant funding was no longer available. The Center is located in the College of Nursing and provides working and meeting space for staff and investigators. The purposes of the Center are to: a) facilitate the continued development of the Nursing Interventions Classification and the Nursing Outcomes Classification to reflect current nursing practice, b) conduct the review processes and procedures for updating the Classifications, c) publish, sell, and otherwise disseminate materials related to the Classifications, d) provide office support to assist faculty investigators to write grants and obtain funding, and e) offer opportunities for student research assistants' and fellows' education and research experience. In order to have some permanent support for the Center, we are working to raise an endowment. Our goal is to raise $1 million and we need to reach this goal in the next three years when our College support will end. To date we have raised $190,000. We would very much appreciate your donation--without your support, the continued upkeep of these classifications is at risk. Gifts and pledges to the Center for Nursing Classification Endowment Fund should be sent to the University of Iowa Foundation, Iowa City, Iowa. All gifts qualify as charitable contributions.
Copyright and Licensing: NIC is published and copyrighted by Mosby Year Book in St. Louis and they process requests for permissions to use the Classification. We have been asked on several occasions why we decided to allow a publisher to have copyright rather than retain this. There are several reasons. When we first began working on the classification we had little idea of the magnitude of the work or its current widespread use.
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. (We produce and distribute related products form the Center but we do not have the staff or the expertise to do this on a larger scale.) In addition, Mosby has the legal staff and resources to process request for permissions 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 which involves frequent and active participation in permissions requests. We view our relationship as a partnership.
We want to address some of the facts about copyright and licensing as it is our experience that the nursing community has little knowledge in this area. Copyright does not restrict fair use. According to guidelines by the American Library Association (1977), 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 (one 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 should not be Xeroxed and used in syllabi semester after semester--the NIC book should be one of those 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 should be sent to the permissions department of Mosby (see the front of the NIC 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 $2500 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 which are returned to the authors are being reinvested into the endowment fund to be used in the future for further development and refinement of NIC.
Multiple classifications: One additional issue that is of some concern at this crucial stage of dissemination and need for adoption in practice is the confusion that multiple classifications create. The American Nurses Association has recognized five classifications: NANDA nursing diagnoses, Nursing Interventions Classification (NIC), Nursing Outcomes Classification (NOC), the Home Health Care classification (Saba, 1992, and the Omaha system (Martin & Scheet, 1992, Visiting Nurse Association of Omaha, 1986) In addition there are writings and publications about other "classifications" such as the State Board of Nursing's nomenclature developed for their computerized licensure test, Grobe's (1992) lexicon, and Osbolt's database (Osbolt, Fruchtnight, & Hayden, 1994). The International Classification of Nursing Practice (ICNP) (International Council of Nurse, 1996) being produced and disseminated by the International Council of Nurses in collaboration with Randi Mortinson and Gunar Neilson of Denmark also contains different emerging classifications. Some nursing specialty organizations such as the Association of Operating Room nurses are also developing languages for their own specialty. While the profession may be too large for one language, there is still a need to communicate with a common language. The National Library of Medicine which has incorporated the five ANA recognized languages is working to map relationships between these languages but, to date, that work is unavailable to most nurses and has not been evaluated or clinically tested. We believe that the profession is best served by the continued use and development of NANDA, NIC and NOC which are comprehensive across setting and specialty and each of which has an ongoing research effort to continue development of the classification. Linkages based on expert opinion have been established between NANDA and NIC, NANDA and NOC, and NIC and NOC and linkages among all three classifications are in development. Currently each of these classifications has its own taxonomic structure. Another future task is to determine if one taxonomic structure can accommodate all three classifications. While this is highly desirable from a user perspective, it may not be possible from a theoretical perspective.
The work to develop a comprehensive classification of nursing interventions began in 1987 with the formation of a small group of interested individuals at the University of Iowa. The work continues today with the assistance of a large research team and users around the country and in other countries who provide feedback and suggestions for refinement. As the work matures and the use grows, new issues emerge. The challenges with limited funding are enormous but we continue to be gratified by the overwhelming interest.