NCVHS Hearings on Medical Terminology and Code Development
May 18, 1999
Rockville, Maryland
Health Care Terminology: Nursing Interventions
Classification (NIC)
Center for Nursing Classification, The University of Iowa
Joanne McCloskey, PhD, RN, FAAN
Distinguished Professor and Principal Investigator, NIC
Director of Center for Nursing Classification
Chairperson, Organizations, Systems, and Community Area of Study (Department)
College of Nursing
University of Iowa
Iowa City, Iowa 52440
There are 2.6 million registered nurses in the US and approximately half that number of nursing assistants. Nurses are the largest group of health care providers and spend the most time with patients, yet the nature and impact of nursing services are virtually unknown and invisible. Nursing data must be included in the patient’s health care record in order to be able to study the cost and effectiveness of nursing care as well as determine the relationship of specific nursing interventions to the interventions of other health providers.
The Nursing Interventions Classification (NIC) is a comprehensive standardized classification of interventions that nurses perform. It is useful for clinical documentation, communication of care across settings, integration of data across systems and settings, effectiveness research, productivity measurement, competency evaluation, reimbursement, and curricular design. The Classification includes all interventions that nurses do on behalf of patients. An intervention is defined as “ any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes.” While an individual nurse will have expertise in only a limited number of interventions reflecting her or his specialty, the entire classification captures the expertise of all nurses. NIC can be used in all settings (from acute care intensive care units, to home care, to hospice, to primary care) and all 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 providers to describe their treatments.
NIC interventions include both the physiological (e.g. Acid-Base Management) and the psychosocial (e.g. Anxiety Reduction). Interventions are included for illness treatment (e.g. Hyperglycemia Management), illness prevention (e.g. Fall Prevention), and health promotion (e.g. Exercise Promotion). Most of the interventions are for use with individuals but many are for use with families (e.g. Family Integrity Promotion,), and some are for use with entire communities (e.g. Environmental Management: Community). Indirect care interventions (e.g. Supply Management) are also included.
Each intervention as it appears in the classification is listed with a label name, a definition, a set of activities to carry out the intervention, and background readings.
The classification was first published in 1992, the second edition in 1996, and the third edition will be published in 2000. New editions of the classification are planned for every 4 years. The 3rd edition will contain 486 interventions grouped into 7 domains and 30 classes. The 7 domains are: Physiological: Basic, Physiological: Complex, Behavioral, Safety, Family, Health System, and Community. Each intervention has a unique number (code). NIC interventions have been linked with NANDA nursing diagnoses, Omaha System problems, and NOC nurse-sensitive outcomes. The classification is continually updated with an ongoing process for feedback and review. In the back of the 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 individuals and then by the entire research team. Interventions that need more work are sent back to the author for revision. All contributors whose changes are included in the next edition are acknowledged in the book. Work that is done between editions and other relevant publications that enhance the use of the classification are available from the Center for Nursing Classification at the College of Nursing, the University of Iowa.
The research to develop NIC began in 1987 and has progressed through four phases each with some overlap in time:
Phase I - Construction of the Classification (1987-1992)
Phase II - Construction of the Taxonomy (1990-1995)
Phase III - Clinical Testing and Refinement (1993-1997)
Phase IV- Use and Maintenance (1996- ongoing)
The ongoing research, conducted by a large research team at Iowa, has received seven years of funding from the National Institutes of Health, National Institute of Nursing. Multiple research methods have been used in the development of NIC. An inductive approach was used in Phase I to build the classification based on existing practice. Original sources were current textbooks, care planning guides, and nursing information systems. Content analysis, focus group review and questionnaires to experts in specialty areas of practice were used to augment the clinical practice expertise of team members. Phase II was characterized by deductive methods. Methods to construct the taxonomy included similarity analysis, hierarchical clustering and multidimensional scaling. Through clinical field testing, steps for implementation were developed and tested and the need for linkages between NANDA, NIC and NOC were identified. Over time, more than 1,000 nurses have completed questionnaires and approximately fifty professional associations have provided input about the classification.
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) manual as one nursing classification system that can be used to meet the standard on uniform data. The National League for Nursing has made a 40-minute video about NIC to facilitate teaching of NIC to nursing students and practicing nurses. Alternative Link has included NIC in its ABC codes used for reimbursement for alternative providers.
The Center for Nursing Classification maintains a list of users of NIC in practice and education by state in the US and by other countries. It is estimated that over 300 clinical agencies located in 46 states and 20 countries are using NIC for communicating the care provided by nurses. In addition over 150 schools of nursing across the US are using NIC in their curriculums. Mosby processes requests for licenses for vendors and those users who put NIC in information systems. To date, 3 vendors and approximately 15 clinical institutions have signed licensing agreements. Several dozen others vendors and agencies have indicated interest.
Interest in NIC has been demonstrated in several other countries, notably, Brazil, Canada, Denmark, England, France, Iceland, Japan, Korea, Spain, Switzerland, and The Netherlands. NIC has been translated into Dutch (De Tijdstroom, 1997) and Korean (Hyun Moon Sa, 1998) and several other translations are in progress, including French (Masson), Japanese (Nankodo), Chinese (Farseeing), and German (Ullstein Medical).
It’s my pleasure to state, without any exaggeration, that there is continuing widespread interest in NIC. Users report that it is a clinically meaningful language that clearly communicates the work of nurses and simplifies the documentation of nursing care.
Nursing Interventions Classification (NIC), 2nd edition 1996, 3rd edition forthcoming 2000
Nursing Interventions Classification (NIC), second edition, 1996
McCloskey, J. C. & Bulechek, G. M. (Eds.) Nursing Interventions Classification (NIC). St. Louis: Mosby Year Book.
Center for Nursing Classification, University of Iowa, Iowa City, Iowa.
ANSI accreditation not applied for.
A. Purpose or objective
NIC is a comprehensive classification that names and describes treatments that nurses perform. It includes interventions delivered by all nurses in all settings. An intervention is defined as “ any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes.” It is useful for clinical documentation, communication of care across settings, integration of data across systems and settings, effectiveness research, productivity measurement, competency evaluation, reimbursement, and curricular design.
B. Type of code set
This is a classification that names, describes, and organizes 433 interventions (3rd edition will contain 486 interventions). Each intervention has a label, a definition, and a list of activities that describe what a nurse does to carry out the intervention. Each intervention also has a short list of background readings that support the intervention and a unique 4 letter code. See one example in Table 1 attached.
C. Clinical topics addressed
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.
D. Domain focus
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.
E. How often is this code set updated or enhanced?
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 which 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 third 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.
F. How are these updates or enhancements distributed?
The new editions are published by Mosby Year Book in St. Louis. (Mosby is the largest publishing company of nursing books and has branches in several other countries with world wide distribution.) 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.
G. What is the source of funding for these updates or enhancements?
The Center is supported by the College of Nursing, University of Iowa and by revenue from publications and products. The research for the development and implementation of NIC has been supported by 7 years of funding from the National Institute of Nursing Research, National Institutes of Health (1RO1NR02079, 2RO1NR02079) and by a fellowship from the Rockefeller Foundation. The updates for the publications are supported by grants from the publisher, Mosby Year Book.
H. Are there regular user group meetings? If so, how frequently do they meet?
A large research team led by two University of Iowa professors (McCloskey and Bulechek) has met regularly (at least 2 times per semester) for the past 10 years. This team developed NIC and is responsible for the ongoing research. In addition to the large team meetings, the Principal Investigators, McCloskey and Bulechek, meet with project staff every two weeks. During the initial implementation phase, we had regular user group meetings (via teleconferencing) with the five agencies who were the pilot sites. We maintain an active listserv for users and publish a newsletter that is distributed to over 1100 individuals three times a year. The Center has also co-sponsored with the North American Nursing Diagnosis Association (NANDA) two conferences (in Chicago in October 1997 and in New Orleans in April 1999) which focused on the implementation and use of NANDA, NIC, and NOC (see other description). We are planning to have a third conference in two years. We also offer a speaker and consultant service whereby a member of the research team can be hired to do a presentation or consultation for a particular group.
I. Is the code set/vocabulary copyrighted?
NIC is published and copyrighted by Mosby Year Book, St. Louis, MO.
J. Does the license allow derivative works, such as the creation of a database?
The license allows the user to input, store and use NIC in its information system for use at its own facilities only in providing health services and not for resale. The user may create a database or other derivative work using NIC for use as an internal management and research tool.
K. Other relevant characteristics such as, are terms coded in a fixed structure, does it support synonyms, is it concept-oriented ?
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. 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--unique code number for Cerebral Edema Management is 2540) which identifies the primary class and is not used for any other intervention. All of the interventions are concepts and each of them has a definition. A thesaurus is available, whereby, for each intervention, we have identified synonyms and related terms that clinicians might use to identify the intervention as well as other similar interventions in the NIC taxonomy. The third edition of NIC will contain 486 interventions located in 7 domains and 30 classes. The new domain consists of two classes of community interventions (targeted at the aggregate or population level). In addition, a new class has been added to the family domain.
L. How is this code set different from or superior to others that it may compete with?
NIC is the only comprehensive classification of nursing interventions. Only two other classifications (Omaha System and the Home Health Care Classification) contain nursing interventions but each of these classifications is limited in scope and specificity. For example, the Omaha system contains 62 “targets” and the Home Health Care Classification contains 160 interventions whereas the Nursing Interventions Classification contains 433 interventions (486 interventions in the 3rd edition). Both of these other classifications were developed for community settings and do not contain the interventions needed in other settings. Research studies have demonstrated that NIC can account for all interventions documented by nurses in practice. Research has also compared NIC with the CPT and demonstrated that whereas NIC can capture 100% of the interventions that nurses perform, the CPT can only capture up to 16%.
A. What portions of the code set are complete and implementable now?
All parts of the code set are complete and implementable.
B. What portions or versions are under development?
Current work is around the development of a complete linkage structure (NANDA diagnoses, NIC interventions , and NOC outcomes). We plan to have a monograph and a software program with linkages between NANDA, NIC, and NOC by March of 2000. We are also working on linkages with Oasis assessment/outcomes categories. In addition we are always responding to suggestions for new and revised interventions as clinicians in the field submit these.
C. When will these new portions or versions be available?
The third edition of NIC which will include new and revised interventions will be available in the fall of 1999 with a 2000 copyright date. This will be published as part of a companion set with the second edition of NOC published at the same time by the same publisher. The linkages of NANDA, NIC, and NOC will be published in 2000 in both printed and electronic form.
D. How do users obtain the code set?
The Classification is available in book form from Mosby Year Book. If the user wishes to put this in an information system or use in a software package a licensing agreement can be purchased and comes with an electronic format.
E. What tools are available?
Several tools are available that assist in the implementation of the Classification. Included in the NIC book are linkages with all NANDA diagnoses to facilitate decision support and the taxonomic structure. 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 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 now available from the Center for Nursing Classification). The Center for Nursing Classification at the University of Iowa also maintains a listserv for users and a listing of users by state and country.
F. What organizations develop and maintain each of these tools?
The materials are developed and maintained by the Center for Nursing Classification at the University of Iowa.
G. Which of these tools are provided with the code set?
The Classification contains the 433 interventions, the complete taxonomic structure, all of the interventions linked with NANDA diagnoses, a description of the feedback and review process and instructions on how to submit suggestions, and three chapters that describe the research done to develop and test the Classification and guidelines on how to use the Classification.
H. What tools are required that are not provided with the code set?
None
I. If the tool is not provided, how is it acquired?
Additional tools listed in E above may be obtained from the Center for Nursing Classification at the University of Iowa.
J. Is a user guide available?
Yes, a user guide is available and was developed with the initial agencies who pilot tested use of NIC. In NIC, there are Steps for Implementing NIC in a Clinical Practice Agency and Steps for Implementing NIC in an Educational Setting. A detailed implementation manual, that contains more help with the organizational change process and implementation materials developed by 14 agencies who have implemented NIC, is available from the Center for Nursing Classification. In the 3rd edition, one of the chapters will focus on implementation, and multiple forms from various practice and educational agencies that have implemented NIC will be included.
K. Is the user guide approved by the development organization?
Yes, the user guide was prepared by the researchers and clinicians who developed NIC.
L. Are there any other indicators of readiness that may be appropriate?
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. The National League for Nursing has made a 40 minute video about NIC to facilitate teaching of NIC to nursing students and practicing nurses. Alternative Link has included NIC in its ABC codes for reimbursement for alternative providers. Many health care agencies have/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. Interest in NIC has been demonstrated in several other countries, notably, Brazil, Canada, Denmark, England, France, Iceland, Japan, Korea, Spain, Switzerland, and The Netherlands. NIC is a prominent part of the International Council of Nurses, International Classification of Nursing Practice
A. What number or percentage of relevant vendors have adopted it?
NIC has been licensed by three vendors, with one more signing in the next month (McKesson/HBOC) and numerous other vendors that have inquired about licensure.
B. What number or percentage of healthcare institutions use it?
Based upon contacts received by the Center, it is estimated that there are approximately 250 health agencies and 150 educational institutions in the United States that are using NIC. In addition 45 users have been identified in 18 countries outside the US.
C. What number or percentage of health professional societies refer to it?
As noted in V.(L.) above, NIC is recognized by the American Nurses Association and the National League for Nursing has made a 40 minute video about NIC to facilitate its use in practice and education. NIC is also suggested by the Joint Commission on Accreditation for Health Care Organization (JCAHO) as a nursing classification system that can be used to meet the JCAHO uniform data standard. Three state nurses associations (Iowa, Michigan, and Minnesota) have passed resolutions encouraging the implementation of NIC and other standardized nursing languages. Thirty nine of nursing’s clinical specialty organizations have identified their core interventions using NIC. The Board of the American Academy of Ambulatory Care Nursing passed a resolution in November 1998 to promote the teaching and implementation of standardized nursing languages, including NIC. Information about NIC has been sent to the developers of SNOMED. NIC has been included in Alternative Link’s ABC Codes, a billing system for complementary and alternative providers.
D. What number or percentage of government agencies use it or refer to it?
NIC is included in the National Library of Medicine’s Metathesaurus for a Unified Medical Language. The National Institute of Nursing Research at the National Institutes of Health has provided 7 years of research funding. The Pennsylvania Department of Health is considering the use of NIC in revising its school nursing standards. Several of the Veterans’ Administration hospitals use NIC.
E. Is the code set being used on other countries?
Yes, in several other countries, notably, Australia, Brazil, Canada, Denmark, England, France, Iceland, Japan, Korea, Spain, Switzerland, and The Netherlands . The first edition of NIC (1992) was translated into French (Canadian). The second edition (1996) has been translated into Dutch by Elsevier/Tijidstroom and Korean by Hyun Moon Sa. In addition, translations are underway in French, Japanese, Chinese, German, Spanish, and Icelandic. A recent request for a translation in Portuguese has just been received. The National League for Nursing video has been translated into Japanese, and two articles have been translated and published in Dutch.
F. Are there any other relevant indicators of market acceptance?
The Center for Nursing Classification’s listserv, maintained to provide information and opportunities for discussion of NIC and NOC and other nursing classifications, currently has 350 subscribers. Subscribers represent 33 states in the US and 10 other countries. (Australia, Canada, England, Germany, Hong Kong, Iceland, Netherlands, Saudi Arabia, Spain, and Switzerland).
A. Describe its clinical specificity and/or granularity
The Nursing Interventions Classification has a four level taxonomy structure. The top level (2nd edition) contains 6 domains: Physiological: Basic, Physiological: Complex, Behavioral, Safety, Family, and Health System. The second level is made up of 27 classes of interventions which are placed in the appropriate domain. An example of classes from each domain includes: Immobility Management, Respiratory Management, Patient Education, Crisis Management, Child Bearing Care, and Information Management. These top two levels assist the user to locate the interventions. The third level of the taxonomy contains 433 interventions and definitions that are used for care planning and documentation. Examples include Positioning, Feeding, Pain Management, Seizure Precautions, Smoking Cessation Assistance, Reminiscence Therapy, Anticipatory Guidance, Abuse Protection, Code Management, Infant Care, Patient Rights Protection, and Telephone Consultation. This is the part of the standardized language that enhances communication among providers and continuity of care across settings, and makes possible the aggregation of data about nursing treatments in local, regional, and national databases. The fourth level of the classification is made up of the activities that are done to carry out each intervention. From a listing of 10-30 activities per intervention, the provider selects the activities that are appropriate for the specific individual or family and then can add new activities if desired. This permits individualization of care while retaining the benefits of standardized language. This specificity can be even more detailed when combined with provider and time data elements. There are more than 11,500 activity statements in NIC. Examples of activities are seen in Table 1.
B. Does it reference or assume other code sets?
NIC is not dependent on other code sets. It can be used by itself or with other code sets of nursing diagnoses or patient outcomes. NIC has been linked with NANDA nursing diagnoses, Omaha health problems, and NOC outcomes. Linkages with Oasis assessment/outcome categories are currently being done. In the NIC book, comparisons are made between NIC and ICD-10, ICD-9-CM, CPT-4, DSM-IV, SNOMED, HCPCS, and NANDA ICD Code (see pages 10, 11, 12 in the NIC book,2nd edition).
C. If so, what are they? Why are they being referenced?
Linkages with other nursing classifications have been done to facilitate use. Comparisons are made with the above mentioned code sets to demonstrate the need for NIC and to show the similarities and differences.
A. Describe the relationships
NIC names, describes, codes, and categorizes the treatments carried out by nurses. Nursing treatments are not adequately represented by the CPT or ICD-9-CM. Studies have shown that nursing care is captured by NIC but only to a small extent by the CPT. A clinical nursing information system should also include nursing diagnoses and patient outcomes. We recommend that the diagnoses developed by the North American Nursing Diagnosis Association (NANDA) and the Nursing Outcomes Classification (NOC) developed by the Iowa Outcomes Project be used in concert with NIC. We have developed linkages between the terms in these classifications to help the user make the clinical decision as to which intervention is likely to resolve the diagnosis and achieve the desired outcome. Linkages between NANDA and NIC, NANDA and NOC, and NOC and NIC have been completed. Vendors are building software which incorporate these linkages. NIC can also be used with Omaha system problems and these linkages have also been completed.
B. Describe any coordination or reconciliation activities
The developers of NANDA, NIC, and NOC have a working relationship, so there is coordination as the classifications evolve. NIC and NOC are based in the Center for Nursing Classification at the University of Iowa. The PIs meet regularly to plan the coordination of efforts. Several team members are NANDA board and committee chairs so there is regular communication between the Iowa and NANDA groups. The premier conference on utilization of NANDA/NIC/NOC was held in Chicago in November 1997, with a follow-up conference in New Orleans in April 1999. The first conference was attended by 350 persons representing 8 countries; the second by 250 persons representing 11 countries. All major publishers were in attendance as well as several vendors.
C. What portion of the code set is affected by this coordination?
The NIC terms are independent of the other code sets. While NIC interventions have been linked to NANDA, to NOC, and to Omaha in print format, the NIC classification is not constrained by these other classifications and can be used alone.
D. What conditions are assumed in order for this coordination to be effective?
Because NIC and NOC are new and practicing nurses who graduated from education programs in the past did not learn about these in school, inservice education is needed for nurses to implement the classifications in practice.
E. What gaps exist among related code sets that should be addressed?
NANDA is in need of expansion to be more inclusive of the client conditions which nurses identify; NOC needs to include community/group outcomes. Both of these are happening.
F. Describe what is being done to address these gaps.
NANDA has contracted with a research team to expand and refine the diagnostic terminology. NOC has received funding for development of community/group outcomes.
A. Are your codes or terms used within specific message formats standards? If so, which ones?
NIC codes are consistent with HL7 standards. NIC has also been coded to meet the requirements for the universal bill, which allows up to five characters. The coding structure is similar to HCPCS National Level II Medicare Codes. The NIC taxonomy was coded for several reasons: 1) to facilitate computer use, 2) to facilitate ease of data manipulation, 3) to enhance articulation with other coded systems and 4) to allow for use in reimbursement. The codes for the six domains are 1-6; the codes for the 27 classes are A-Y plus a and b. Each intervention has a unique number consisting of four spaces. Activities are coded after the decimal using two digits. An example of a complete code is 4U-6140.01. Each class has been allocated 300 numbers to allow for future additions of interventions without recoding as the classification expands.
B. If your code sets or terms are used, are they specified as required, preferred, or optional by the message format standard?
Our code set is preferred as it allows for a standardized coding system which would facilitate aggregation and comparison of data across settings. NIC could be included in HCPCS by placing a letter (e.g. N for Nursing) in front of each 4 digit intervention identifier (e.g. N0140).
C. Has this code set been adopted for use within a vendor or end-user system? If so, which ones?
NIC has been licensed and incorporated into the nursing information systems of several agencies. These include but are not limited to: Arkansas Children’s Hospital, Little Rock, AR; Lutheran General Hospital, Park Ridge, IL; University of Kentucky Hospital, Lexington, KY; Mayo Foundation, Rochester, MN; St. Michael’s Hospital, Stevens Point, WI; UT Bowld Hospital, Memphis TN, University of Iowa Hospital, Iowa City, IA. Licenses are in process with nine new institutions at this time. NIC is licensed and in the software of three vendors (Ergo Partners in Mission KS, Fasttrack in Laguna Niguel, CA, and LCI in Madison, WI). In addition, McKesson/ HBOC in Atlanta, GA will sign a license this next month. Pending agreements are in process with several other vendors.
D. How are the links between your code set and specific message formats maintained?
The NIC is compatible with HL7 standards.
E. In which message format standards organizations do you regularly participate?
We are individual members of the American Nurses Association. the North American Nursing Association, and the American Medical Informatics Association.
A.Cost of licensure
Licenses are granted for commercial or institutional use. Licensing fees are determined by the number of users per site and are renewable every 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.
B. Cost of acquisition (if different from licensure)
NIC is available in book form to individuals for a single fee, which in January 1998 was $36.95.
C.Cost of tools
The cost of the tools ranges from $10 for the monograph of NIC Interventions Linked to Omaha Problems to $45 for the NIC Implementation Manual.
D. Cost/time frames for education and training
NIC is easy to learn and easy to use but one does have to have some exposure. Nurses need to read the book and some related articles, and perhaps see the video and attend an educational session.
E.Cost/time frames for implementation
The time and cost for implementation of NIC into a nursing information system in a clinical practice agency depends on the agency’s selection and use of a nursing information system, the computer competency of nurses, and their previous use and understanding of standardized nursing language. The change to use of nursing standardized language using a computer represents a major change in the way in which nurses have traditionally documented and effective change strategies need to be used. Complete implementation of NIC throughout an agency may take 12 months to several years; the agency does need to devote resources for computer programming, education and training. As major vendors complete clinical nursing information systems which include NIC, implementation will be easier.
F. Any other cost considerations
To ensure the most complete data set of NIC interventions, the user needs to purchase a new edition of the Classification every 4 years. For those using NIC in information systems, the license must be renewed every 2 years. Maintenance of NIC is done by the Center for Nursing Classification at the University of Iowa. Fund raising to establish an endowment of $1 million to support the Center is underway.
Center for Nursing Classification , University of Iowa (classification-center@uiowa.edu), phone 319-335-7051, fax 319-335-5129.
or Joanne McCloskey, Director, Center for Nursing Classification,
joanne-mccloskey@uiowa.edu, 319-335-7120 (phone) or 319-335-7129 (fax)
A web site is available at http://www.nursing.uiowa.edu/cnc.
Table 1. Example of NIC intervention
2540 Cerebral Edema Management
DEFINITION: Limitation of secondary cerebral injury resulting from swelling of brain tissue
ACTIVITIES:
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
Hyperventilate patient
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
Restrict fluids
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 CVP
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
Maintain normothermia
Administer loop active or osmotic diuretics
Implement seizure precautions
Titrate barbiturate to achieve suppression or burst-suppression of EEG as ordered
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