Mercedes Donahue, Adunola Henry, & Jessica Fischer
Historically, nurses haven't used a consistent language to document interventions that were performed. Nursing Intervention Classification (NIC) provides classifications for both direct and non-direct care. Overall, NIC meets Cimino's Desiderata criteria of domain completeness, lack of ambiguity, lack of redundancy, synonymy, multiple classifications, a consistency of views, and multiple relationships. Implementation of NIC on an orthopedic surgical unit in an acute care setting would allow for more standardized care with improved consistency in documentation among the nursing staff. The stakeholders involved in implementation include a multidisciplinary team of nurses, healthcare providers, and ancillary staff. Technology, such as electronic medical records, can facilitate the use of standardized language, consistent documentation, and improved ability to recall the data for purposes such as billing. Keywords: Nursing Intervention Classification, Desiderata criteria, orthopedic surgical unit, electronic medical record Historically, nurses documented to meet individual or unit-based needs, leading to poorly defined terms and no standard language among nurses (Rutherford, 2008). Implementation of electronic medical records (EMR) may have standardized documentation in a hospital or network, however, the standardization has sometimes been vendor specific and not nursing specific (Stolee, Steeves, Glenny, & Filsinger, (2010). A standardized language allows for “better communication among nurses and other health care providers, increased visibility of nursing interventions, improved patient care, enhanced data collection to evaluate nursing care outcomes, greater adherence to standards of care, and facilitated assessment of nursing competency” (Rutherford, 2008, Benefits section para 1).
Nursing Intervention Classification Nursing Intervention Classification (NIC) was first published in 1992 and alphabetically listed 336 nursing interventions (Bulecheck & McCloskey, 1995). The nursing interventions are classified as the physiological, the psychosocial, illness treatment, illness prevention, health promotion, family, and community. Interventions involve both direction and indirect care interventions. Since 1992, NIC has undergone several revisions and interventions have been added (Scherb & Weydt, 2009). At the time, this NIC was groundbreaking for the nursing profession as this was the first time in the history of nursing that nurses had a common language to describe their treatments (Bulecheck & McCloskey, 1995). “NIC defines a nursing intervention as any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes” (Scherb & Weydt, 2009, p.17). According to Rutherford (2008), nurses often rely on informal means to communicate patient care that was provided such as verbal report. This means these nursing interventions remain invisible, not captured in the documentation or research. NIC provides nurses with a standardized language to describe the nursing interventions, as well as the necessary activities. Documenting interventions close to the bedside will allow for more consistent and accurate documentation of nursing interventions performed for patients (Rutherford, 2008). “The use of a standardized language to record nursing care can provide the consistency necessary to compare the quality of outcomes for various nursing interventions across settings (Rutherford, 2008, Enhanced data para 1).
Desiderata Criteria In 1989 J.J. Cimino, a researcher specializing in biomedical communication, with assistance from associate’s developed what is known as “Cimino’s desiderata” as an evaluative tool for medical vocabularies (Columbia University, n.d.). This desiderata, or criteria, consist of a vocabulary having