Skip to main content
PMC home page
Journal of the American Medical Informatics Association : JAMIA logoLink to Journal of the American Medical Informatics Association : JAMIA
. 2001 May-Jun;8(3):202–211. doi: 10.1136/jamia.2001.0080202

Collaborative Efforts for Representing Nursing Concepts in Computer-based Systems

International Perspectives

Amy Coenen 1, Heimar F Marin 1, Hyeoun-Ae Park 1, Suzanne Bakken 1
PMCID: PMC131028  PMID: 11320065

Abstract

Current nursing terminology efforts have converged toward meeting the demand for a reference terminology for nursing concepts by building on the foundation of existing interface and administrative terminologies and by collaborating with terminology efforts across the spectrum of health care. In this article, the authors illustrate how collaboration is promoting convergence toward a reference terminology for nursing by briefly summarizing a wide range of exemplary activities. These include: 1) the International Classification of Nursing Practice (ICNP) activities of the International Council of Nurses (ICN), 2) work in Brazil and Korea that has contributed to, and been stimulated by, ICNP developments, 3) efforts in the United States to improve understanding of the different types of terminologies needed in nursing and to promote harmonization and linking among them, and 4) current nursing participation in major multi-disciplinary standards initiatives. Although early nursing terminology work occurred primarily in isolation and resulted in some duplicative efforts, the activities summarized in this article demonstrate a tremendous level of collaboration and convergence not only in the discipline of nursing but in multi-disciplinary standards initiatives. These efforts are an important prerequisite for ensuring that nursing concepts are represented in computer-based systems in a manner that facilitates multi-purpose use at local, national, regional, and international levels.

Standardized terminologies exist for nursing diagnoses, nursing interventions, nursing-sensitive outcomes of care, and patient goals.1–8 Most were developed in the English language in the United States and have subsequently been translated into other languages and, in some cases, modified by nursing experts in other countries. Historically, the primary motivation for developing nursing terminologies was to identify, name, and classify the major concepts of the domain for multiple purposes. These purposes include 1) implementation of computer-based systems in clinical settings, 2) the quest for reimbursement for nursing services delivered, 3) the education of students, 4) documentation of nursing contributions to patient care outcomes, and 5) development of nursing knowledge. Recently, however, expectations of standardized terminologies have become more stringent in response to increased demands for health care information at local, national, regional, and international levels; constrained health care resources; multi-disciplinary models of care; and the evolution of information science methods and tools (see, for example, Cimino,9 Campbell et al.,10 and the Danish Institute of Health and Nursing Research11 ).

To address current and future demands, terminologies must be incorporated into computer-based systems in a manner that supports rich descriptions of clinical encounters, data re-use, and comparisons of data captured in different systems and even in different languages.12–14 To achieve these more ambitious objectives requires a different kind of terminology from those previously developed in nursing. Such representations of terms have been referred to by various authors as concept-oriented terminologies,14 reference terminologies,15 formal terminologies,16 or third-generation language systems,17 and are designed to complement and support terminologies optimized for other purposes, e.g., statistical classification (administrative terminology) or end-user data entry (interface terminology). For consistency, “reference terminology” will be used throughout this article.

Standardized nursing terminologies have typically been designed to function as both administrative and interface terminologies and do not possess the characteristics and associated functionality of reference terminologies.18,19 In addition to sets of terms (which may come from existing interface and administrative terminologies) for the concepts of interest, a reference terminology includes a terminology model that defines the manner in which atomic concepts are linked to create molecular expressions, and a knowledge formalism (i.e., representation language) supported by software tools for the management and manipulation of the terminology.

Functionally, a reference terminology facilitates mapping among standardized terminologies with terms at differing levels of granularity (e.g., interventions represented using the Omaha System and the Patient Care Data Set); decreases the maintenance burden of mappings for pairs of terminologies because each terminology need be mapped only to the reference terminology; and supports the transformation of interface terms into administrative terminologies for comparative statistical analyses. Recent studies in the medical domain have also demonstrated the effects of reference terminologies that support data sharing and re-use on significant aspects of care such as improving understanding of patient care data, accessing information resources relevant to specific patient care problems, applying expert systems to the care of patients, and improving the quality of the information retrieval of clinical findings.20,21

Current nursing terminology efforts have converged toward meeting the demand for a reference terminology for nursing concepts by building on the foundation of existing interface and administrative terminologies and by collaborating with terminology efforts across the spectrum of health care. In this article, we illustrate how collaboration is promoting convergence toward a reference terminology for nursing by briefly summarizing a wide range of exemplary activities. These include 1) the International Classification of Nursing Practice (ICNP*) activities of the International Council of Nurses (ICN), 2) work in Brazil and Korea that has contributed to, and been stimulated by, ICNP developments, 3) efforts in the United States to improve understanding of the different types of terminologies needed in nursing and to promote harmonization and linking among them, and 4) current nursing participation in major multi-disciplinary standards initiatives, including work occurring in the Clinical LOINC (Logical Observation Names, Identifiers, and Codes) Committee, European Committee on Standardization (CEN), Health Level 7 (HL7), snomed International, and the International Standards Organization (ISO).

International Classification of Nursing Practice

The International Classification of Nursing Practice (ICNP) is a product and a program of the International Council of Nurses (ICN), a federation of national nurses associations, which currently has more than 120 country members. The recently reaffirmed objectives of the ICNP program are to:

  • Establish a common language for describing nursing practice in order to improve communication among nurses, and between nurses and others

  • Describe the nursing care of people (individual patients, families, and communities) in a variety of settings, both institutional and non-institutional

  • Enable comparison of nursing data across clinical populations, settings, geographic areas, and time

  • Demonstrate or project trends in the provision of nursing treatments and care and the allocation of resources to patients according to their needs, on the basis of nursing diagnoses

  • Stimulate nursing research through links to data that are available in nursing information and health information systems

  • Provide data about nursing practice to influence health policy making22

The ICNP product is defined as a classification of nursing phenomena, nursing actions, and nursing outcomes that describes nursing practice. Consistent with the ICN core values of inclusiveness and flexibility, ICNP development is based on the concept of a unifying framework. As a unifying framework, the ICNP builds on existing nursing interface and administrative terminologies, provides a structure into which existing terms in these terminologies can be cross-mapped, and supports continued use and development of the existing nursing terminologies.22

The development of the ICNP product is part of a larger program with three clusters of activities: 1) communication and marketing; 2) research and development; and 3) co-ordination and project management. Examples of these activities are provided in Table 1▶. Partnership is a core value of ICN, and thus formal partnerships as well as related country and regional projects play a key role in the ICNP Program. Although a list of all the ICNP partnerships and projects across the world is beyond the scope of this paper, selected examples are provided in Table 2▶.

Table 1.

Examples of Activities Related to Clusters of the ICNP Program

Communication and marketing:
ICNP Bulletin
ICN Web site
Clearinghouse for ICNP-related publications
CD-ROM of ICNP beta version
Educational materials
Research and development:
Formal ICNP evaluation program
Database of ICNP research and evaluation projects
ICNP Evaluation Committee
Coordination and project management:
ICNP Users Agreement
Policy on ICNP translation, publication, reproduction, and distribution
Open in a new tab

abbreviations: ICNP indicates International Classification of Nursing Practice; ICN, International Council of Nurses.

Table 2.

Examples of ICNP Partnerships and Projects

Collaborator Focus
Formal partnerships:
Telenurse and TelenurseID Dissemination, development and testing of ICNP
W.K. Kellogg Foundation, four African countries (Botswana, South Africa, Swaziland, and Zimbabwe), and four Latin American countries (Brazil, Chile, Columbia, and Mexico) Expansion of ICNP in its representation of nursing concepts from primary health care and community-based practice; testing and establishing mechanisms that will keep the ICNP responsive to changes in nursing knowledge and practice
International Medical Informatics Association Special Interest Group—Nursing Informatics (IMIA-NI) Development of International Standards Organization (ISO) standards for a reference terminology model for integration of nursing concepts
Projects:
Taiwan Nurses Association Testing of ICNP and dissemination
Norwegian Nurses Association Relationship of ICNP to nursing documentation
Thailand Nurses Association and the Nursing Division of the Ministry of Public Health Development of a nursing data set as integral part of health information system
Swiss Nursing Data Project Development of a Swiss nursing minimum data set in partner- ship with the Swiss government, National Nurses Association, health care providers (private and public hospitals), and industry (software developers)
Korean Nurses Association Cross-mapping terms from existing nursing classification systems to ICNP
Open in a new tab

abbreviations: ICNP indicates International Classification of Nursing Practice.

The Telenurse projects (Telenurse and Telenurse ID) and the W. K. Kellogg Foundation are two major partnerships. The current Telenurse project, Telenurse ID (1998–2000), is a large European Union effort that is focused on use of the ICNP as a unifying framework for electronic documentation of nursing care in Europe.8 Use of ICNP is promoted through dissemination activities23,24 and demonstration projects related to electronic health records.25,26 The ICNP country projects in the Latin American and Southern African regions that are funded by the W. K. Kellogg Foundation are listed in Table 2▶.

An alpha version of the ICNP was released in 1996 to stimulate research, feedback, and participation in the project.27 In 1999, the substantially revised ICNP beta version was published and has subsequently been translated into more than 20 languages.22 Work in Brazil, funded by the Kellogg Foundation and Telenurse partnerships, and in the Republic of Korea illustrates the range of research and testing that contributed to the development of the ICNP alpha and beta versions and will continue to feed into subsequent versions. This work is described in the following two sections.

Efforts in the United States to clarify the different types of terminologies needed in nursing and to promote harmonization among different nursing terminologies (described later in this paper) have also contributed to the evolution of ICNP. Although ICNP was originally conceptualized as a terminology that would primarily meet the purposes served by interface and administrative terminologies, the beta version incorporates some characteristics of a reference terminology. For instance, atomic terms from multiple axes can be combined to form a specific molecular expression based on a terminology model for defining that type of expression.8 The nursing intervention “Assess adherence behavior after discharge,” for example, would be formed with terms from four of eight ICNP axes relevant to nursing actions—specifically, 1) Action type: Assessing; 2) Target: Adherence behavior; 3) Beneficiary: Individual; and 4) Time: After discharge.22

The ICNP was initiated as an endeavor to collect all nursing concepts, to cover and complete the description of the nursing domain.28,29 Several additional benefits have been realized through related research and development efforts. For example, through its multi-axial design, the ICNP has facilitated the creation of relevant and useful concepts that were not present in existing classification systems.8,30,31 Moreover, although the ICNP was not initially conceptualized as a concept representation model, recent reports document the utility of the axes as a source of categories and semantic links in a terminology model to represent nursing activity concepts.32,33

As the ICNP evolves, the goal remains unchanged—to make the ICNP an information tool that will assist with communication about nursing practice and capture data representing nursing practice in comprehensive health information systems, thus providing a means to make the contribution of nursing clearly visible in health care systems worldwide.22

Nursing Terminology Work in Brazil

As in other countries, nursing terminology activities in Brazil first centered on translation of North American terminologies developed primarily for interface or administrative purposes. In 1990, the North American Nursing Diagnosis Association (NANDA) taxonomy was translated into Portuguese and introduced into Brazil. The Home Health Care Classification (HHCC) has been translated more recently. Brazil has also moved on to collaborative activities contributing to the development of ICNP and, under the aegis of the Pan American Health Organization (PAHO), to broader issues associated with developing standards-based nursing information systems. Table 3▶ summarizes Brazilian nursing terminology projects that illustrate the significant progress of Brazilian nurses in promoting implementation of standardized terminologies in nursing practice in national, regional, and international nursing contexts and in addressing the relationship between terminologies and information models in nursing information systems. Projects involving the ICN and PAHO are described here.

Table 3.

Brazilian Activities Related to Standardized Terminologies

Year Project Focus
1990 NANDA Introduction of NANDA nursing diagnoses into clinical practice
1995 Classification for Nursing Practice in Collective Care Development of community health nursing terms for incorporation into ICNP
1996 Telenurse Translation, field testing, and implementation of alpha version of ICNP into an electronic patient record
2000 HHCC Translation and testing of HHCC in the Brazilian home care setting
2001 Standards-based Nursing Information Systems PAHO-sponsored publication directed to promotion of data standards in nursing information and management in Latin America and the Caribbean
Open in a new tab

abbreviations: NANDA indicates North American Nursing Diagnosis Association; HHCC, Home Health Care Classification; PAHO, Pan American Health Organization.

Stimulated by the ICN, several national nursing associations in Latin America and Southern Africa initiated a collaborative research project to expand the primary health care and community nursing terms in the ICNP. Since 1996, Brazil has participated in this ICN project, supported by the W. K. Kellogg Foundation. Specific aims of the ICNP country projects include 1) to elicit and disseminate model processes that can be used by nurses in any country to elucidate the language of nursing in primary health care and community-based systems, 2) to collect and ensure the insertion of primary health care and community-based nursing terms into the ICNP, 3) to have a mechanism in place at the country level that will enable participating countries to continue to contribute terms and recommendations to the ICNP after the end of the project, and 4) to increase recognition by the nursing profession and health authorities in the countries involved of the need to include data that relate to nursing practice in health information systems. As a consequence of the Brazilian project, Classification for Nursing Practice in Collective Health, new terms and recommendations for revision and refinement of the ICNP have been submitted.

In a second ICNP-related activity, the Nursing Informatics Center of the Federal University of Sao Paulo (NIEn/UNIFESP) is a sponsored partner in the Telenurse consortium. The responsibilities of NIEn/UNIFESP are to 1) translate the alpha version of ICNP into the Brazilian Portuguese language, 2) field-test the alpha version of ICNP to identify possible matches with the local terms in the patient record, and 3) implement the ICNP in an electronic patient record.34 The first two activities have been completed. The Brazilian translation of the ICNP is available on the Web (www.epm.br/enf/nien/cipe). The field test, conducted at the Sao Paulo Hospital, a teaching hospital of the Universidade Federal de São Paulo, found that the nurses were using only a small number of ICNP terms in clinical documentation.34

Brazilian nurses have also played a leadership role in a project organized by PAHO which has three goals—to characterize how nursing informatics and the use of standards can improve nursing practice and management; to take advantage of information technology resources to improve nursing care; and to produce a guidebook describing how nursing informatics and standards can improve nursing care practice and management. The role of different types of standardized terminologies in both paper-based and computer-based systems is a major component of the guidebook, which is being developed by an international group of experts in nursing, informatics, and standards. In addition, in the context of standards-based nursing information systems, the guidebook addresses the relationships between various types of nursing terminologies and other standards of relevance to representing nursing concepts in computer-based systems.

Nursing Terminology Work in the Republic of Korea

In 1997, the Health Technology Planning and Evaluation Board, Korean Ministry of Health and Welfare, Republic of Korea, funded a research team from Seoul National University and the Korean Nurses Association to address the need for a standardized nursing terminology, to support data compatibility, clinical documentation, and outcome research. Activities supported by this three-year grant include Korean translation and cross-validation of standardized nursing terminologies developed in North America; translation, validation, and cross-mapping activities related to alpha and beta versions of the ICNP; and standardization of documentation forms and related interface terminology. These activities illustrate collaboration toward the development of interface, administrative, and reference terminologies for use in Korea and internationally, as well as the linkage between documentation forms and terminologies.

In the first year of the three-year project, HHCC, NANDA, the Nursing Intervention Classification (NIC), the Nursing Outcomes Classification (NOC), the Omaha System, and the ICNP alpha version were translated and subsequently validated by an expert panel. The validity of each term was tested using a five-point Likert-like scale ranging from 1 (very inappropriate) to 5 (very appropriate). Almost 99 percent of terms from the North American standardized terminologies received a rating of 3.5 or higher. Of the total 294 nursing phenomena analyzed in the ICNP alpha version, all had a score higher than 3.5. For nursing actions, a total of 1,002 terms were analyzed. Only two actions had a score lower than 3.5. The Korean translation of the terms was modified on the basis of rater suggestions.35

The beta version of the ICNP was subsequently translated and validated. No terms received a score of less than 3.5. The Korean translation of the ICNP beta version is available on the Web at http://nis.snu.ac.kr

In a related activity, alpha and beta versions of ICNP were cross-mapped with selected standardized nursing terminologies developed in North America. The cross-mapping of ICNP beta version with HHCC, NANDA, and the Omaha System led to the suggested addition of 76 new terms to the ICNP phenomena classification. To cross-map the interventions from NIC, HHCC, and Omaha to ICNP, 166 new terms were required. Recommendations for additions or modifications to the ICNP were submitted to ICN.

Standardization of nursing documentation forms and related terminology was another significant area addressed in the three-year project. The motivation for this aspect of the project was the variation in nursing documentation across settings and within a single setting. For example, documentation forms with the same title were being used for different purposes with different data elements, and both English and Korean languages were used in the documentation forms. In addition, the manner in which each item was recorded differed even within a single hospital. To address these issues, nursing documentation forms were collected and analyzed. On the basis of the analysis, prototype forms with standardized data elements (e.g., interface terms) were developed along with instruction manuals for completing the forms. Nurses in clinical settings tested the validity of forms and manuals through their use with actual patients. Subsequently, forms and guidelines were modified and a public hearing was held. Following the public hearing, forms and manuals were again modified, and the final results were disseminated via the Web (http://nis.snu.ac.kr.).

A number of new activities that build on these achievements are currently under way in the Republic of Korea, including the development of a Korean Unified Nursing Language System using the ICNP framework, categorization of ICNP terms into existing semantic types from the Unified Medical Language System (UMLS), and cross-mapping of ICNP with nursing terminology used in nursing records in a cardiology unit and an intensive care unit at a tertiary hospital in Seoul. Testing the use of ICNP in electronic patient records that support nursing practice is a priority for the future.

U.S. Work to Define Nursing Terminology Requirements and Promote Harmonization

In addition to work on the development of administrative and interface terminologies that informed the creation of the ICNP and collaboration with other countries wishing to translate these terminologies, U.S. nurses are playing leading roles in efforts to define the range of needed nursing terminologies and promote harmonization among existing nursing terminologies. Groups in the United States that are working on these goals include the American Nurses Association (ANA), the Nursing Working Group of AMIA, and the Nursing Vocabulary Summit Conference. There is considerable cross-representation and synergy among the participants in these groups.

For more than a decade, the ANA has promoted the notion of a unified nursing language system based on standardized nursing terminologies that meet the criteria for ANA recognition.36 Recently, the recognition criteria were revised and expanded to reflect the development of standardized terminologies (e.g., reference terminologies) that differ in structure and content from the nursing classification systems (typically designed as interface and administrative terminologies) recognized with the original criteria; the revised criteria also reflect improvements in the methods and tools for computable concept representations and harmonization with the efforts of recognized standards bodies.37 To date, 12 systems have been recognized—the Complete Complementary Alternative Medicine Billing and Coding Reference, HHCC, ICNP, NANDA, NIC, NOC, Nursing Management Minimum Data Set (NMMDS), Nursing Minimum Data Set (NMDS), Omaha System, Patient Care Data Set (PCDS), Perioperative Nursing Data Set (PNDS), and snomed-rt.1–7,15,22,38–40

In addition to representation of the profession of nursing in standards groups such as HL7 and the snomed International Editorial Board, the ANA has served as a voice for nursing terminology developers as a group in U.S. government activities such as the development of the UMLS41 and implementation of the standards-related provisions of the Health Insurance Portability and Accountability Act of 1996.42

Since 1997, the AMIA Nursing Working Group has sponsored activities to facilitate communication between those with nursing terminology expertise and those with informatics expertise, including software developers and system implementers. Activities have included tutorials, workshops, and panels at the AMIA Annual Symposium and the publication of a series of articles in JAMIA.18,43–45 Systematic efforts have been made to ensure that both introductory and advanced content (e.g., concept representation methods, Unified Modeling Language) are presented at each symposium, to inform those with a general interest and to increase the knowledge and skill levels of those working with aspects of nursing concept representation.

The 1999 Nursing Vocabulary Summit Conference brought together stakeholders with expertise in different areas, such as terminology development, concept representation, software development and implementation, and standards.46,47 Participation in the 2000 Summit was expanded to include additional international representatives from the ICNP, Telenurse, CEN, and the International Medical Informatics Association Special Interest Group—Nursing Informatics (IMIA-NI). Consistent with the aims of consensus development, convergence among nursing terminologies, and congruence with national and international efforts to develop clinical terminology standards, the conference participants initiated work items related to the development and evaluation of reference information models and reference terminology models for nursing diagnoses, nursing interventions, standardized assessments, and goals.46–50 Such activities are an essential step toward the development of a reference terminology that supports nursing concepts. In addition, the Summit is the primary venue in which the relationship between the attributes of the HL7 Reference Information Model (RIM) and standardized nursing terminologies is being critically examined.

Nursing Participation in Multi-disciplinary Standards Initiatives

The collaborative, discipline-specific activities described thus far are necessary, but not sufficient, to meet the demand for a reference terminology for nursing concepts that is consistent with evolving standards for health care information models and reference terminologies. This demand requires nursing participation in integrative health care standards initiatives. The Clinical LOINC Committee, HL7, snomed International, CEN, and ISO are illustrative examples of such initiatives.

LOINC

Development of LOINC originally focused on a public use set of codes and names for electronic reporting of laboratory test results.51,52 With minor extensions to the original definitions, but not to the elements of the semantic structure, LOINC content continues to expand, especially in the area of direct patient measurements and clinical observations (e.g., blood pressure, symptoms). This expansion is commonly known as Clinical LOINC. Support for the utility of the semantic categories of Clinical LOINC as a terminology model for standardized assessments including those specifically designated as sensitive to nursing care was recently documented.48 Subsequently, nursing assessment terms from two nursing terminologies in the public domain (i.e., HHCC and the Omaha System) and three research-based standardized assessments were incorporated into the LOINC database. The Clinical LOINC Committee will determine priorities for inclusion of additional standardized assessment terms on the basis of perceived utility and availability for inclusion in the LOINC database.

Health Level 7

Health Level 7 is a not-for-profit, ANSI-accredited standards development organization whose mission is to provide standards for the exchange, management, and integration of data that support clinical patient care and the management, delivery, and evaluation of health care services. Activities of the HL7 Patient Care and Vocabulary technical committees (TCs) are particularly relevant to the topic of standardized terminologies for nursing concepts. Consequently, participation in HL7 by nursing terminology developers and the ANA liaison has focused on these two TCs. For example, the HL7 Reference Information Model (RIM),53,54 requires that specific terminologies be designated as the source of allowable values for any coded attributes for RIM classes. The primary focus for Patient Care TC activities in the near future is to select the terminologies that may be used for assessments (e.g., goals, outcome evaluations). These are elements of the patient care process that are well-represented in nursing terminologies; therefore, terms from nursing systems have the potential to be specified as the allowable values.

Although each domain committee (e.g., Patient Care, Patient Administration/Financial Management) is responsible for terminology selection for the HL7 RIM classes for which it serves as steward, the Vocabulary TC has overall responsibility for the development of a process and database for registering terminologies for use in HL7.55 The ANA liaison to HL7 and other nursing representatives participated in the development of this process, including the definition of principles for HL7-compliant terminologies and HL7-sanctioned terminology integration efforts. Moreover, four ANA-recognized nursing terminologies (HHCC, NIC, NOC, and snomed) were among the initial terminologies registered.

SNOMED-RT

snomed-rt is a reference terminology designed to represent a broad array of health care concepts. The Convergent Terminology Group for Nursing (CTGFN) is a subgroup of the snomed International Editorial Board and was originally charged with the task of developing principles, processes, and strategies for enhancing the nursing content in snomed rt. The charge has been extended to include the new collaborative work of snomed International and National Health Service Clinical Terms Version 3, snomed Clinical Terms (CT).56 Core members of CTGFN include representatives from the ANA, Royal College of Nursing in the United Kingdom, and Convergent Medical Terminology Project, snomed staff, and the nursing consultant to the snomed International Editorial Board. Toward the goal of integration of nursing concepts into snomed-rt and snomed-ct (a terminology with both reference and interface characteristics), CTGFN activities have focused on two areas. First, a series of studies have evaluated terminology models to support representation of nursing concepts in snomed-rt and snomed-ct. 32,57 Second, CTGFN has facilitated collaborative agreements between the developers of nursing terminologies and the snomed-rt and snomed-ct developers.32,58

European Committee on Standardization (CEN)

Work by CEN related to the development of a system of concepts for nursing59 has built on the significant accomplishments of the Telenurse,8,60 ICNP,30 and Galen-in-Use (now OpenGALEN)61,62 projects. In 1999, CEN undertook a short strategic study to develop a strategy for progress toward a system of concepts for nursing.59 Current efforts are intended to develop a European pre-standard and to provide a foundation for the scope of work for an ISO standard related to integration of a reference terminology model for nursing as described in the next section.49

International Standards Organization

The ICN and IMIA-NI are co-leading a project to develop an ISO standard related to a reference terminology model for nursing concepts.63 This scope of work will proceed in collaboration with CEN under the Vienna Agreement, with ISO as the designated lead, and will also build on the existing work of other groups that did not directly participate in the creation of the CEN pre-standard (e.g., HL7, snomed-rt). The intent is that the model will not only support representation of nursing concepts and mediation among representations but also integrate with other ISO models for health care concepts.

Conclusions

Although early nursing terminology work occurred primarily in isolation and resulted in some duplicative efforts, the activities summarized in this article demonstrate a tremendous level of collaboration and convergence not only within the discipline of nursing but with multi-disciplinary standards initiatives. These efforts are an important prerequisite to ensuring that nursing concepts are represented in computer-based systems in a manner that facilitates multi-purpose use at local, national, regional, and international levels. However, there are additional prerequisites.

A larger cadre of nurses with specialized knowledge in concept representation is necessary for both discipline-specific and multi-disciplinary purposes. Given the importance of collaboration and convergence of nursing concept representation efforts with multi-disciplinary standards initiatives, it is essential that more nurses are prepared with the relevant knowledge and skills to effectively communicate the needs of the nursing discipline to others and are supported for participation in standards activities.

Additional research related to nursing concept representation is needed. Studies evaluating the utility of reference terminology models and reference terminologies for nursing concepts (see, for example, the article by Hardiker and Rector in this issue64) must be conducted and disseminated in the peer-reviewed literature. The relationships among clinical document architecture, information models, and reference terminologies for nursing concepts also warrant further examination.

For decades, authors of papers appearing in the nursing literature have purported that standardized nursing data are essential to support the delivery of nursing services, to build nursing knowledge, to apply knowledge to nursing practice, and to document the effects of nursing on care outcomes. Activities such as those reviewed in this article represent another step toward achievement of those goals.

This manuscript was adapted from papers and other material presented by the authors at the IMIA Nursing Informatics Postconference, May 2000, in Rotorua, New Zealand. This work was supported in part by grant P-33751-ICN from The W. K. Kellogg Foundation; grant HMP-97-1-1-0001 from Telenurse ID, the Health Technology Planning and Evaluation Board, Ministry of Health and Welfare, Republic of Korea; and grant NR04423 from the National Institutes of Health.

References

  • 1.Kleinbeck SVM. In search of perioperative nursing data elements. AORN J. 1996;63(5):926–31. [DOI] [PubMed] [Google Scholar]
  • 2.Martin KS, Scheet NJ. The Omaha System: Applications for Community Health Nursing. Philadelphia, Pa: Saunders, 1992.
  • 3.McCloskey JC, Bulechek GM. Nursing Interventions Classification. 3rd ed. St. Louis, Mo: Mosby, 2000.
  • 4.Johnson M, Maas M, Moorhead S (eds). Nursing Outcomes Classification (NOC). 2nd ed. St. Louis, Mo: Mosby, 2000.
  • 5.Ozbolt JG. From minimum data to maximum impact: using clinical data to strengthen patient care. Adv Pract Nurs Q. 1996;1(4):62–9. [PubMed] [Google Scholar]
  • 6.Saba VK, Zuckerman AE. A new home health classification method. Caring Mag. 1992;11(9):27–34. [PubMed] [Google Scholar]
  • 7.North American Nursing Diagnosis Association. Nursing Diagnoses: Definitions and Classification 1999–2000. Philadelphia, Pa: NANDA, 1999.
  • 8.Mortensen RA (ed). ICNP and Telematic Applications for Nurses in Europe: The Telenurse Experience. Amsterdam, The Netherlands: IOS Press, 1999. [PubMed]
  • 9.Cimino JJ. Terminology tools: state of the art and practical lessons. Presented at: IMIA Working Group 6 Triennial Conference on Natural Language and Medical Concept Representation; Dec 16–19, 1999; Phoenix, Arizona.
  • 10.Campbell KE, Cohn SP, Chute CG, Shortliffe EH, Rennels G. Scalable methodologies for distributed development of logic-based convergent medical terminology. Methods Inf Med. 1998;37(4–5):426–39. [PubMed] [Google Scholar]
  • 11.Danish Institute of Health and Nursing Research. Telenurse continues to the year 2000 as TelenurseID-entity: Integration and Dissemination of European Nursing Terminology in Information Technology. WHO Collaborating Centers for Nursing/Midwifery Development Newsletter. 1998;13:5–6. [Google Scholar]
  • 12.Campbell J, Carpenter P, Sneiderman C, Cohn S, Chute C, Warren J. Phase II evaluation of clinical coding schemes: completeness, taxonomy, mapping, definitions, and clarity. J Am Med Inform Assoc. 1997;4(3):238–51. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Chute CG, Cohn SP, Campbell JR. A framework for comprehensive terminology systems in the United States: development guidelines, criteria for selection, and public policy implications. ANSI Healthcare Informatics Standards Board Vocabulary Working Group and the Computer-based Patient Records Institute Working Group on Codes and Structures. J Am Med Inform Assoc. 1998;5(6):503–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Cimino JJ. Desiderata for controlled medical vocabularies in the twenty-first century. Methods Inf Med. 1998;37(4–5):394–403. [PMC free article] [PubMed] [Google Scholar]
  • 15.Spackman KA, Campbell KE, Cote RA. snomed-rt: a reference terminology for health care. Proc AMIA Annu Fall Symp. 1997:640–4. [PMC free article] [PubMed]
  • 16.Ingenerf J. Taxonomic vocabularies in medicine: the intention of usage determines different established structures. MedInfo. 1995;8(Pt 1):136–9. [PubMed] [Google Scholar]
  • 17.Rossi Mori A, Consorti F, Galeazzi E. Standards to support development of terminological systems for healthcare telematics. Methods Inf Med. 1998;37(4–5):551–63. [PubMed] [Google Scholar]
  • 18.Henry SB, Warren J, Lange L, Button P. A review of the major nursing vocabularies and the extent to which they meet the characteristics required for implementation in computer-based systems. J Am Med Inform Assoc. 1998;5(4):321–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Henry SB, Mead CN. Nursing classification systems: necessary but not sufficient for representing “what nurses do” for inclusion in computer-based patient record systems. J Am Med Inform Assoc. 1997;4(3):222–32. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Brown PJB, Sonksen P. Evaluation of the quality of information retrieval of clinical findings from a computerized patient database using a semantic terminological model. J Am Med Inform Assoc. 2000;7(4):392–403. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Cimino JJ. From data to knowledge through concept-oriented terminologies: experience with the MED. J Am Med Inform Assoc. 2000;7(3):288–97. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.International Council of Nurses. ICNP Update: Beta 1 Version. Geneva, Switzerland: ICN, May 1999.
  • 23.Slajmer-Japelj M, Filej B, Kersnic P. Slovenia efforts. In: Mortensen RA (ed). ICNP and Telematic Applications for Nurses in Europe: The Telenurse Experience. Amsterdam, The Netherlands: IOS Press,1999:241–2.
  • 24.Tackenberg P. Consensus building out of many German translations: coming to an agreement about nursing phenomena and interventions. In: Mortensen RA (ed). ICNP and Telematic Applications for Nurses in Europe: The Telenurse Experience. Amsterdam, The Netherlands: IOS Press,1999:185–90.
  • 25.Magalini FI, Mencuccini B, Pertoldi F. Use and usability of the ICNP in a mediguard structured electronic nursing report. In: Mortensen RA (ed). ICNP and Telematic Applications for Nurses in Europe: The Telenurse Experience. Amsterdam, The Netherlands: IOS Press,1999:128–36.
  • 26.Thoroddsen A. Primary health care and ICNP: data from clinical nursing practice through SAGA. In: Mortensen RA (ed). ICNP and Telematic Applications for Nurses in Europe: The Telenurse Experience. Amsterdam, The Netherlands: IOS Press,1999:144–52.
  • 27.International Council of Nurses. The International Classification for Nursing Practice: A Unifying Framework. Geneva, Switzerland: ICN, 1996.
  • 28.Wake MM, Murphy M, Affara FA, Lang NM, Clark J, Mortensen R. Toward an international classification for nursing practice: a literature review and survey. Int Nurs Rev. 1993;40(3):77–80. [PubMed] [Google Scholar]
  • 29.Wake MM, Coenen A. Nursing diagnosis in the International Classification for Nursing Practice (ICNP). Nurs Diag. 1998;9(3):111–8. [PubMed] [Google Scholar]
  • 30.Nielsen GH, Mortensen RA. The architecture for an International Classification of Nursing Practice (ICNP). Int Nurs Re.v 1996;43(6):175–82. [PubMed] [Google Scholar]
  • 31.Nielsen GH, Mortensen RA. The architecture of ICNP: a time of outcomes, part 2. Int Nurs Rev. 1997;45(1):27–31. [DOI] [PubMed] [Google Scholar]
  • 32.Bakken S, Parker J, Konicek D, Campbell K. An evaluation of ICNP intervention axes as terminology model components. Proc AMIA Annu Symp. 2000:42–6. [PMC free article] [PubMed]
  • 33.Nielsen GH. A categorical structure for ICNP as core categorial structure for systems of concepts for nursing: a contribution to the CEN short strategic study “Systems of Concepts for Nursing.” Copenhagen, Denmark: Danish Institute for Health and Nursing Research, 1998.
  • 34.Marin HF. Translating and testing ICNP in Brazil. In: Mortensen RA (ed). ICNP and Telematic Applications for Nurses in Europe: The Telenurse Experience. Amsterdam, The Netherlands: IOS Press,1999:254–7.
  • 35.Park H-A, Cho IS. Standardisation of nursing classification systems in Korea. In: Saba V, Carr R, Sermeus W, Rocha P (eds). Nursing Informatics 2000: One Step Beyond—The Evolution of Technology and Nursing. Proceedings of the 7th IMIA International Conference on Nursing Use of Computers and Information Science. Auckland, New Zealand: Adis International, 2000:277–82.
  • 36.McCormick K, Lang N, Zielstorff R, Milholland DK, Saba V, Jacox A. Toward standard classification schemes for nursing language: recommendations of the American Nurses Association Steering Committee on Databases to Support Nursing Practice. J Am Med Inform Assoc. 1994;1:421–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Coenen A, McNeil B, Bakken S, Bickford C, Warren JJ. Toward comparable nursing data: American Nurses Association criteria for data sets, classification systems, and nomenclatures and related dissemination activities [under review]. [PubMed]
  • 38.Alternative Billing Concepts. Las Cruces, New Mexico: Alternative Link, 1998.
  • 39.Huber D, Delaney C, Crossley J, Mehmert M, Ellerbe S. Nursing Management Minimum Data Set. J Nurs Admin. 1992;22(7–8):35–40. [DOI] [PubMed] [Google Scholar]
  • 40.Werley HH, Lang NM (eds). Identification of the Nursing Minimum Data Set. New York: Springer, 1988.
  • 41.Humphreys BL, Lindberg DAB, Schoolman HM, Barnett GO. The Unified Medical Language System: an informatics research collaboration. J Am Med Inform Assoc. 1998;5(1):1–11. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Braithwaite W. HIPAA and the Administration Simplification Law. MD Comput. 1999;16(5):13–6. [PubMed] [Google Scholar]
  • 43.Button P, Androwich I, Hibben L, et al. Challenges and issues related to implementation of nursing vocabularies in computer-based systems. J Am Med Inform Assoc. 1998;5:332–4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Forsythe D. An anthropologist's viewpoint: observations and commentary regarding implementation of nursing vocabularies in computer-based systems. J Am Med Inform Assoc. 1998;5(4):329–31. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Gassert C. A focus on implementing nursing vocabularies [editorial]. J Am Med Inform Assoc. 1998;5:390. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Ozbolt J. Toward a reference terminology model for nursing: The 1999 Nursing Vocabulary Summit Conference. In: Saba V, Carr R, Sermeus W, Rocha P (eds). Nursing Informatics 2000: One Step Beyond—The Evolution of Technology and Nursing. Proceedings of the 7th IMIA International Conference on Nursing Use of Computers and Information Science. Auckland, New Zealand: Adis International, 2000:267–76.
  • 47.Ozbolt J. Terminology standards for nursing: collaboration at the summit. J Am Med Inform Assoc. 2000;7:517–22. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 48.Bakken S, Cimino JJ, Haskell R, et al. Evaluation of the Clinical LOINC specification as a terminology model for standardized assessments. J Am Med Inform Assoc. 2000;7:529–38. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Hardiker NR, Hoy D, Casey A. Standards for nursing terminology. J Am Med Inform Assoc. 2000;7(6):523–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.Harris MR, Graves JR, Solbrig HR, Elkin PL, Chute CG. Embedded structures and representation of nursing knowledge. J Am Med Inform Assoc. 2000;7(6):539–49. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 51.Forrey AW, McDonald CJ, DeMoor G, et al. Logical Observation Identifiers, Names and Codes (LOINC) database: a public use set of codes and names for electronic reporting of clinical laboratory results. Clin Chem. 1996;42:81–90. [PubMed] [Google Scholar]
  • 52.Huff SM, Rocha RA, McDonald CJ, et al. Development of the LOINC (Logical Observation Identifiers Names and Codes) Vocabulary. J Am Med Inform Assoc. 1998;5(3):276–92. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53.Beeler GW. Taking HL7 to the next level. MD Comput. 1999:21–4. [PubMed]
  • 54.Russler DC, Schadow G, Mead C, et al. Influences of the Unified Service action model on the HL7 reference information model. Proc AMIA Annu Symp. 1999:930–4. [PMC free article] [PubMed]
  • 55.Bakken S, Campbell KE, Cimino JJ, Huff SM, Hammond WE. Toward vocabulary domain specification for HL7 coded data elements. J Am Med Inform Assoc. 2000;7(4):333–42. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 56.Spackman KA. Presentation to snomed Users Group. 1999.
  • 57.Bakken S, Cashen MS, Mendonca E, O'Brien A, Zieniewicz J. Representing nursing activities within a concept-based terminologic system: evaluation of a type definition. J Am Med Inform Assoc. 2000;7(1):81–90. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 58.Zingo CA, Abilla AJ, Correia CM, Konicek DJ, Lundberg CB. Future vision for developing and implementing nursing content: an enterprise-wide approach. In: Saba V, Carr R, Sermeus W, Rocha P (eds). Nursing Informatics 2000: One Step Beyond—The Evolution of Technology and Nursing. Proceedings of the 7th IMIA International Conference on Nursing Use of Computers and Information Science. Auckland, New Zealand: Adis International, 2000:357–63.
  • 59.Ehnfors M, Hardiker N, Hoy D, et al. European Committee for Standardization (CEN) Technical Committee 251 (TC251) Short Strategic Study: Systems of Concepts for Nursing—A Strategy for Progress. Final Report. Brussels, Belgium: CEN TC251, 1999.
  • 60.Mortensen RA, Nielsen GH. Concerted action telenursing. In: Henry SB, Holzemer WL, Tallberg M, Grobe SJ (eds). Informatics: The Infrastructure for Quality Assessment and Improvement in Nursing. Proceedings of the 5th International Nursing Informatics Symposium Post-Conference. San Francisco, Calif: UC Nursing Press, 1994: 36–45.
  • 61.Rector AL, Glowinski AJ, Nowlan WA, Rossi-Mori A. Medical concept models and medical records: an approach based on GALEN and PEN&PAD. J Am Med Inform Assoc. 1995;2(1):19–35. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 62.Hardiker N, Kirby J. A compositional approach to nursing terminology. In: Gerdin U, Tallberg M, Wainwright P (eds). Nursing Informatics: The Impact of Nursing Knowledge on Health Care Informatics. Stockholm, Sweden: IOS Press, 1997:3–7. [PubMed]
  • 63.International Standards Organization. Proposed Scope of Work: Integration of a Reference Terminology Model for Nursing. Geneva, Switzerland: ISO, 1999.
  • 64.Hardiker NR, Rector AL. Structural validation of nursing terminologies. J Am Med Inform Assoc. 2001;8:212–21. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from Journal of the American Medical Informatics Association : JAMIA are provided here courtesy of Oxford University Press

RESOURCES