Nursing Dx

We will look at the process and progress of describing the work of nursing. At first glance, it seems a simple task. However, over many years, the profession has struggled with it. The struggle, in part, is a result of changes in healthcare delivery and financing, the expansion of nursing’s role, and the dawning of the computer age. Gordon reminds us that classification system development parallels knowledge development in a discipline. As
theory development and research have begun to define nursing, it has become necessary for nursing to find a common language to describe what nursing is, what nursing does, and how to codify it. Thus, the terms “classification systems” and “standardized language” were born, and the work continues.

Changes in the healthcare system occur at an ever-increasing rate. One of these changes is the movement toward a paperless (computerized or electronic) client record. The use of electronic healthcare information systems is rapidly expanding, and the focus has shifted from its original uses—financial and personnel management functions—to the efficient documentation of the client encounter, whether that is a single office visit or a lengthy hospitalization. The move to electronic documentation is being fueled by changes in healthcare delivery and reimbursement as well as the advent of alternative healthcare settings (outpatient surgeries, home health, rehabilitation or subacute units, extended or long-term care facilities, etc.), all of which
increase the need for a commonality of communication to ensure continuity of care for the client, who moves from one setting or level of care to another.

These changes in the business and documentation of healthcare require the industry to generate data about its operations and outcomes. Evaluation and improvement of provided services are important to the delivery of cost-effective client care. Therefore, providers and consumers interested in outcomes of care benefit from accurate documentation of the care provided and the client’s response. With the use of language or terminology that can be coded, healthcare information can be recorded in terms that are universal and easily entered into an electronic database and that can generate meaningful reporting data about its operation and outcomes. In short, standardized language is required.

A standardized language contains formalized terms that have definitions and guidelines for use. For example, if the impact of nursing care on financial and clinical outcomes is to be analyzed, coding of this information is essential. While it has been relatively easy to code medical procedures, nursing is more of an enigma, because its work has not been so clearly defined.

Since the 1970s, nursing leaders have been working to define the profession of nursing and to develop a commonality of words describing practice (a framework of communication and ocumentation) so that nursing’s contribution to healthcare is captured, is visible in healthcare databases, and is thereby recognized as essential. Therefore, the focus of the profession has been on the effort to classify tasks and to develop standardized nursing languages (SNLs) to better demonstrate what nursing is and what nursing does.

Around the world, nursing researchers continue their efforts to identify and label people’s experiences with (and responses to) health and illness as they relate to the scope of nursing practice. The use of universal nursing terminology directs our focus to the central content and process of nursing care by identifying, naming, and standardizing the “what” and “how” of the work of nursing—including both direct and indirect activities. This wider application for a standardized language has spurred its development.

A recognized pioneer in SNL is NANDA International’s (formerly North American Nursing Diagnosis Association) “nursing diagnosis.” Simply stated, a nursing diagnosis is defined as a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable. NANDA-I nursing diagnoses currently include 188 labels with definitions, defining characteristics, and related or risk factors used to define a client need or problem. Once the client’s need is defined, outcomes can be developed and nursing interventions chosen to achieve the desired outcomes.

The linkage of client problems or nursing diagnoses to specific nursing interventions and client outcomes has led to the development of several other SNLs, including Home Health Care Classification (HHCC; now Clinical Care Classification), Nursing Interventions Classification (NIC), 5 Nursing Outcomes Classification NOC), Omaha System-Community Health Classification System (OS), Patient Care Data Set (PCDS),  and Perioperative Nursing Data Set (PNDS).

Whereas some of these languages (e.g., OS, PCDS, and PNDS) are designed for a specific client population, the NANDA, NIC, and NOC languages are comprehensively designed for use across systems and settings and at individual, family, and community or population levels.

NIC is a comprehensive standardized language providing 514 direct and indirect intervention labels with definitions. A list of activities a nurse might choose to carry out each intervention is also provided and can be modified as necessary to meet the specific needs of the client. These research-based interventions address general practice and specialty areas.

NOC is also a comprehensive standardized language providing 330 outcome labels with definitions; a set of indicators describing specific client, caregiver, family, or community states related to the outcome; and a 5-point Likert-type measurement scale that facilitates tracking clients across care settings and that can demonstrate client progress even when outcomes are not fully met. The outcomes are research-based and are applicable in all care settings and clinical specialties.

In addition, NIC and NOC have been linked to the Omaha System problems, to resident assessment protocols (RAPs) used in extended/long-term care settings, and to NANDA-I. This last linkage created the NANDA, NIC, NOC (NNN) Taxonomy of Nursing Practice. The combination of NANDA-I nursing diagnoses, NOC outcomes, and NIC interventions in a common unifying structure provides a comprehensive nursing language recognized by the American Nurses Association (ANA) and is coded in the Systematized Nomenclature of Medicine (SNOMED) in support of the electronic client record.

Having an SNL entered into international coded terminology allows nursing to describe the care received by the client and to document the effects of that care on client outcomes, and it facilitates the comparison of nursing care across worldwide settings and diverse databases. In addition, it supports research by comparing client care delivered by nurses with that delivered by other providers, which is essential if nursing’s contribution is to be recognized and nurses are to be reimbursed for the care they provide.

Today, 13 versions of SNLs are recognized by the ANA and have been submitted to the National Library of Medicine for inclusion in the Unified Medical Language System Metathesaurus. The Metathesaurus provides a uniform, integrated distribution format from over 100 biomedical vocabularies and classifications (the majority in English and some in multiple languages), and it links many different names for the same concepts, establishing new relationships between terms from different source vocabularies.

Indexing of the entire medical record supports disease management activities (including decision support systems), research, and analysis of outcomes for quality improvement for all healthcare disciplines. Coding also supports telehealth (the use of telecommunications technology to provide medical information and healthcare services over distance) and facilitates access to healthcare data across care settings and different computer systems.