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Standardized language can boost outcomes research
Acute care nurses in Iowa say they have found a way to properly classify and describe virtually the entire range of what bedside nurses do for hospitalized patients. Now, they say, they can measure with greater certainty the effectiveness of nursing care on patients.
The system, Nursing Interventions Classifi-cation (NIC), has been in existence for more than seven years. Yet, relatively few critical care nurses outside the state have ever worked with it.
Proponents of NIC argue the system has a variety of valuable applications for ICU nurses. For example, as a standardized tool it can help create reliable patient outcomes studies and be utilized to conduct intelligent nurse competency testing.
NIC can also serve as the basis for creating well-defined patient care plans and total quality management programs within a unit, or across patient-care departments, a hospital, or an entire integrated system.
As a standardized language for nursing care, nurses in unrelated specialties can refer to the system for virtually any nursing procedure in acute care and can communicate the same language consistently across several departments.
Best of all, it answers a call for a clear, standardized language that for once properly communicates what acute, critical care, and other nurses do for patients.
Before NIC, nursing from a standardized language standpoint was a big empty box. No one knew exactly what nurses were doing or were supposed to do, says Joanne McCloskey-Dochterman, RN, a professor of nursing at the University of Iowa College of Nursing, and one of NIC’s co-authors. It’s opened up doors that were previously closed for all nurses, she adds.
Roughly similar to a coded index of patient care procedures, somewhat like the Physicians’ Current Procedural Terminology coding system but with an emphasis on nursing, NIC defines an entire range of bedside practices.
It breaks them down into categories going from the broadly general to the specific.
Presented in an indexed form, NIC classifies some 486 nursing interventions by label names into seven distinct domains. Interventions range from alkaline acid base management (NIC 1914) to hemodynamic regulation (NIC 4150). (See a section of one of the domains, inserted in this issue.)
The domains form categories from basic and complex physiological to behavioral, patient safety, and communitywide public health domains. There is even one on family support issues.
Once defined by their domain, the interventions fall into one of 27 distinct classes, including electrolyte and acid base management, perioperative care, and thermoregulation.
In turn, each intervention lists between 10 and 30 activities that involve nurses at the bedside. Each intervention is introduced by an alphanumeric code, such as 2G (domain 2, Class G) followed by a unique four-digit numeric code such as 1200. The combination identifies the domain, its corresponding class, and the intervention itself. For example, total parenteral nutrition is classified as 2G 1200.
Well-suited for critical care
The heart of the system is composed of the definitions and nursing activities that explain each intervention. Between 10 and 30 related activities define each intervention. For example, the activities that describe intervention 2590: intracranial pressure (ICP) monitoring include:
• assist with ICP monitoring device insertion;
• provide information to family or significant other;
• calibrate and level the transducer;
• irrigate flush system;
• set alarms;
• obtain cerebrospinal fluid drainage samples, as appropriate.
NIC can be quite useful in acute and critical care because so much of what goes on in the ICU is concrete and well-defined, compared to other nursing activities, says Ellen Cram, RN, MA, associate director of nursing for intensive and surgical services at University of Iowa Healthcare (UIH). The teaching hospital operates seven ICUs with more than 62 beds.
For managers, business and financial concerns are classified under a separate domain described as "Health System," and include discharge planning, fiscal management, staff development, documentation, and staff supervision.
According to the Center for Nursing Classifica-tion at the University of Iowa, where NIC was developed in the early 1990s, some 250 health care organizations nationwide currently use NIC.
However, the system has yet to become a household term among nurses, especially in critical care, a problem that has stumped NIC’s developers. We don’t really know why it hasn’t taken on wider appeal among ICUs, acknowledges McCloskey-Dochterman.
At UIH, the critical care department, among others, uses NIC to support its nursing care plan and to track patient data and help with documentation, says Cram.
By using the interventions as a standard reference tool, the nursing staff has been able to achieve two important tasks. Nurses are able to tailor the care uniformly throughout the department.
Everyone is working on the same page, says Cram. But individual nurses can also differentiate the care according to individual patient needs without straying too far from sound nursing practice.
The reference tool works quite well, particularly with the hospital’s post-operative cardiac patients and those undergoing mechanical ventilator weaning. Because the patients need careful monitoring to watch their progress, nurses resort to the NIC activities when documenting each of their interventions.
The activities are carefully recorded in the patients’ records, where even subtle nuances in the care plan are properly recorded, Cram notes.
Before NIC, no one was certain what nurses were actually doing and to what extent they were being effective, says Cram. NIC has taken nursing out of the realm of invisibility, she adds.
Administrators are planning to take NIC one step further. Soon, the hospital will be using the system to track a large body of patient data hospitalwide.
The information will be analyzed using the NIC coding system to determine differences in nursing care that have resulted in improved patient outcomes. The language will be invaluable in aiding the data analysis, adds Cram.
At 220-bed Kern Medical Center in Bakersfield, CA, nursing officials have also integrated NIC into their nursing care plans.
In the past, our care plan descriptions ran 200 words long and were vague, says Linda O’Hotto, RN, Kern’s nursing information systems coordinator.
The standardized language, O’Hotto says, has enabled nurses to identify a patient problem. For example, a blood gas exchange impairment in the patient, and set an expected outcome.
Using NIC, nurses can implement a care plan that employs the published interventions and increase the likelihood of achieving predictable results based on the knowledge that it’s been done that way in the past.
The difficulty with the system lies in its universal acceptance. People have to buy into it for it to work properly, admits McCloskey-Dochterman.
NIC has worked best in a committed, interdisciplinary environment in which there is administration support and a commitment to engage large numbers of clinicians and allied professionals.
Another problem to date has been in its implementation. At present, the system exists in book form. A word processing version of it exists among a handful of software vendors.
But the tool isn’t downloadable for seamless integration into a hospital’s existing software or database systems. That process is now in the works, McCloskey-Dochterman says.
For more information, contact: Barbara Head, RN, PhD, project manager/ research associate, Center for Nursing Classification, University of Iowa, College of Nursing, 492 Nursing Building, Iowa City, IA 52242. Telephone: (319) 335-7051. Web site: www.nursing. uiowa.edu/cnc.