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Standardizing the Language of Public Health Nursing:

Integrating the Nursing Interventions Classification System (NIC)

 and the Core Public Health Functions  

 

Mary Lober Aquilino, PhD, RN, FNP  mary-aquilino@uiowa.edu

Eleanor McClelland, PhD, MPH, RN

Mary Tarbox, EdD, RN

 

Introduction

Public health nurses have provided care to individuals, families and communities for over a century. Their work is population focused and includes not only direct services but also indirect interventions that affect the health system or the context of care. Emphasis is placed on health promotion and disease prevention with consideration of the interface between the health status of the population and the community environment. The goal of public health nursing is to promote healthy communities by identifying at-risk groups within a community and targeting these groups for nursing interventions that improve health and prevent disease (Stanhope & Lancaster, 1992, 1996). The core public health functions summarize the practice of public health and serve as a guide to public health nursing practice. The purpose of this article is to demonstrate how public health nursing interventions that reflect the core public health functions are described using a standardized language. Standardizing the language of public health nursing will make the work of public health nurses more visible and improve communication within the specialty and with other disciplines.

Classification and Standardized Languages

Classifications, which have existed since early times, help to promote the knowledge base of a field of study by identifying the underlying principles of what is known about the field. Classifications also identify gaps in knowledge, which can then be addressed by research, and help to achieve economy of memory and facilitate communications (McCloskey & Bulechek, 1992). There are several existing classification systems for nursing including: the Omaha System (Martin & Scheet, 1992), a client focused taxonomy of nursing diagnoses related to community health nursing; an intervention taxonomy by Saba and colleagues (Saba, 1992) for home health care; a system of outcome measures of service quality related to home care by Shaughnessy and colleagues (1995); Henderson’s components of basic nursing (Henderson, 1961); Verran’s (Verran, 1981) ambulatory care nursing taxonomy; the eight domains of nursing described by Benner (1984); and Sigma Theta Tau’s International Classification of Nursing Knowledge (1987).

Language standardization involves assignment of a single term or phrase to a phenomenon that can be described by several different words or phrases. In standardizing nursing interventions, the phenomena being classified are the nurse behaviors or activities that are directed toward maintaining or improving the client’s health status. Labeling discrete sets of activities and defining the assigned label improves communication and understanding among nurses and between nurses and other professionals. It allows nurses to communicate both the unique and complementary functions of nursing. In addition to improving communication, language standardization can foster the expansion of nursing knowledge, enhance development of health information systems, facilitate determining the cost of nursing services, plan for resource needs, and improve nursing education. When multiple labels exist that describe similar interventions, documenting and comparing nursing treatments becomes very complex requiring enormous investments of time and resources.  Standardization increases comparability when observing or measuring phenomena across individuals or groups, or across different settings. This is particularly useful in public health where there are a variety of care providers and care settings.

The Nursing Interventions Classification

The development of a standardized language used to describe activities performed by nurses is outlined in the first edition of a comprehensive publication, Nursing Interventions Classification (NIC) (McCloskey & Bulechek, 1992), a book that documents the development of a standardized language for nursing interventions. The NIC work initiated and continued by McCloskey and Bulechek represents the first major effort to describe and standardize systematically the treatments performed by nurses (McCloskey & Bulechek, 1992). The 2^nd edition of the Nursing Interventions Classification (McCloskey & Bulechek, 1996) contains 433 interventions, each with a definition and a detailed set of activities that describe what it is a nurse does to implement the intervention. Each intervention is coded with a unique number. The interventions are organized in 27 classes and 6 domains.

The Nursing Intervention Classification (NIC) was developed using a multidimensional research approach including content analysis, expert survey, focus group review, similarity analysis, hierarchical clustering, multidimensional scaling and clinical field testing.  Research teams of faculty and clinicians used inductive methods to developed nursing interventions and activities based on current practice as reflected in textbooks, journal articles, care planning guides, and clinical documentation systems.  More than 1000 nurses and 50 professional organizations have provided input on the classification.

Of particular interest to nurses whose practice encompasses the community beyond institutional walls is the current NIC teamwork which has resulted in the development of community interventions. The third edition of NIC (McCloskey & Bulechek, 2000) includes a new domain in the taxonomy called Community having two classes: Community Health Promotion and Community Risk Management. This edition includes 16 new community interventions. Overall, the third edition of NIC has 58 new interventions, 10 label name changes, 32 substantive intervention changes and 58 minor intervention changes. Five interventions included in the second edition have been deleted for the third edition by replacement or in combination to form new interventions.

Standardized Language in Public Health Nursing

Public health nurses have been recognized for their accomplishments for over a century and have consistently been identified with the struggles of communities to meet the needs of particularly vulnerable populations (Erickson, 1996; Jossens & Ferjancsik, 1996; Reverby, 1993; Salmon, 1993; Zerwekh, 1992). Their services, although effective when measured, were and may still be invisible to the public and even to other care providers. The current changes in health care delivery which focus on cost containment, managed care and home-based service have caused public health nurses to once again focus on their unique contributions to the care of communities. Clarification of that care is essential to recognizing the work of public health nurses and to assuring that their work will continue and will be recognized as effective.

The public health core functions of assessment, policy development and assurance reflect the practice of all public health professionals including public health nurses (IOM, 1988). These functions are evident in public health interventions and are broad enough to meet individual, population, community and system needs (MDH/CHS, 1997). Assessment includes activities associated with community diagnosis; policy development includes the process by which society makes decisions about problems and their solutions; and assurance involves the necessary services to reach agreed upon goals based on the specified level of services (IOM, 1988).

As authors explore the roles and functions of public health nurses, it is evident that their efforts cover a wide range of concerns associated with the naming, describing and evaluating what it is that public health nurses do. There also continues to be an on-going discussion to differentiate the roles of community health nurses and public health nurses (Baldwin, Conger, Abegglan & Hill, 1998, Kuehnert, 1995; Kuss, Proulx-Girouard, Levitt, Katz & Kennelly, 1997). Such a distinction focuses on the nurse’s educational preparation, location of practice and individual versus population focused care. Although there is clearly an attempt in the literature to make a distinction between community and public health nurses, the task of naming what it is that these nurses do is not dependent on whether they are called community health or public health nurses. The distinction between roles is more at the level of care to be provided. In other words, care focused at the individual or family levels versus care focused at the community or health system levels.

These levels at which public health nurses provide care are the focus of additional literature describing their scope of practice. Some authors identify the work of public health nurses, which is focused on the individual client or family unit as one level, to be part of the role but not that which distinguishes the public health nurse’s specialty. The distinctive role of the public health nurse is at the level of interacting with populations or communities and with health systems or the context of care (Keller, Strotschein, Hoagberg & Schaffer, 1998; Neufeld & Harrison, 1995; Salmon, 1993; Zerwekh, 1993).

Public health nurses are also recognized for their expertise in well-defined specialty areas working with vulnerable populations. Although their efforts may be focused on individual clients or families with vulnerabilities such as AIDS, drug abuse, adolescent pregnancy or chronic disease (Kane & Mahony, 1997; Twohy & Reif, 1997; Weise, Mathers & Schank, 1997), the distinctive practice of public health nurses is again at the population, community and systems levels. The language for care provided to individuals and families is well developed. The language, which refers to care of vulnerable populations in communities and through systems, is the current work of the NIC team.

Along with efforts to name what it is that public health nurses do, there is an urgent need to identify the effectiveness of such efforts. Many authors have attempted to measure the effectiveness of the nurses’ interventions, primarily at the individual/family level; however, such efforts are inconsistent and may not lend themselves to generalization across levels or populations (Coenen, Marek & Lundeen, 1996; Deal, 1994). The early efforts of the Nursing Sensitive Outcomes Classification (NOC) team (Head, Maas & Johnson, 1997; Johnson, Maas & Moorhead, 2000) have started to clarify the language and process of measuring outcomes applicable to all health care settings. Knowing that interest is building for developing a language to describe and evaluate the unique interventions of public health nurses prompted these authors to propose a new domain, Community, in NIC which can be clearly integrated with the Core Public Health Functions. This integration will enhance the language of interventions and outcomes to better define the scope of public health nursing practice.

Relating Nursing Interventions to the Core Public Health Functions

The Community Intervention and Public Health Core Functions Matrix depicts the relationship between the core public health functions and NIC community health interventions (see Table 1).  The matrix also shows the relationship of selected interventions in the NIC classification to the level of care provided and how the three core functions of assessment, policy development and assurance are represented by NIC.

Core Public Health Functions

The core public health functions are the underpinnings of public health nursing practice, serving as a framework for nursing interventions in the community.  The current functions include assessment, policy development, and assurance.  First defined in the Institute of Medicine report (IOM, 1988), the core functions characterize the major phases of public problem solving including problem identification, mobilization of necessary effort and resources, and assurance that vital conditions are in place and that crucial services are received. Assessment includes activities such as surveillance, needs identification, case finding, monitoring, and forecasting.  This function facilitates decision-making in both the private and public sectors (IOM, 1988, p. 44).  Examples of policy development are policy leadership, advocacy; convening, negotiating, brokering; mobilizing resources; training, constituency building and provision of public information (IOM, 1988, p. 44-45).  The assurance function in public health involves insuring the implementation of legislative mandates as well as maintaining statutory responsibilities.  This function is carried out through developing adequate responses to crises, supporting crucial services, regulating services and products in both the public and private sector, and maintaining accountability to the people by setting objectives and reporting on progress (IOM, 1988, p. 45).  The current core functions represent a broader view of public health activities than has existed in the past (Turnock, 1997, p. 178).

Community Health Interventions Defined

“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” (McCloskey & Bulechek, 2000). In the 3^rd edition of NIC, there is a separate community domain that contains interventions reflecting “care that supports the health of the community”. This new domain has two classes, community health promotion, interventions that promote the health of the whole community, and community risk management, interventions that assist in detecting or preventing health risks to the whole community. Figure 1 presents an example of the community intervention, "program development."  

Nursing Interventions and Levels of Care

Community health nurses provide care to individuals, families, aggregates, and communities. They also impact community health status by indirect services that affect the health system or the context in which health care is delivered. Currently, there are several community level interventions in NIC including environmental management: community, environmental management: worker safety, health education, health policy monitoring, health screening, risk identification, and teaching: group. There are also interventions that can be used in community nursing practice at the individual and family levels of care. Examples of interventions for individuals in the community include abuse protection: child, patient rights protection and immunization/vaccination administration. Additional interventions such as developmental enhancement, caregiver support and parent education: adolescent are examples of family-level interventions that could be used in community health practice.  Further work of the NIC team will be to develop additional interventions at the health system level such as collaboration enhancement.

The NIC team has developed several additional community and health system level interventions which are included in the current edition of the classification (McCloskey & Bulechek, 2000). They are case management, communicable disease management, community disaster preparedness, community health development, consultation, cost containment, environmental risk protection, financial resource assistance, fiscal resource management, program development, surveillance: community, and vehicle safety promotion. Additional community-level interventions, including advocacy, collaboration, health promotion and staff/provider education are being developed.

Conclusion

The efforts of the NIC team to incorporate community health interventions are necessary and helpful as one examines the context and content of the professional work of community/public health nurses. Integrating these interventions with those of the IOM’s Public Health Core Functions illustrates the unique work of public health professionals and the ability of the standardized language of NIC to address the specific activities of public health nurses.  As public health professionals strive to clarify their roles and functions in the rapidly changing health care arena, with emphasis on health promotion, disease prevention and community-based or system level care, a standardized language will describe the mission of public health nurses more clearly and make it more visible to consumers and providers.  Evaluating the outcomes of public health nursing interventions remains an essential element of determining effectiveness and will continue to be the work of the NOC team as they develop and apply meaningful measures of the interventions of nurses in all settings.

Acknowledgments

The research reported in this article was assisted by a grant from the National Institute of Nursing Research, NIH (NR02079). The authors wish to thank Joanne McCloskey, Gloria Bulechek and the members of the Iowa Intervention Team for assistance in intervention development.