The Omaha System

Latar Belakang

Sistem Omaha (OS) adalah salah satu yang tertua dari Asosiasi Perawat Amerika
yang diakui terminologi standar yang menggambarkan dan mengukur dampak layanan
perawatan kesehatan. Tinjauan sistematis ini menyajikan keadaan sains tentang penggunaan
OS dalam praktik, penelitian, dan pendidikan.

Bertujuan

(1) Untuk mengidentifikasi, mendeskripsikan dan mengevaluasi publikasi pada OS

antara tahun 2004 dan 2011, (2) untuk mengidentifikasi tren utama dalam penggunaan OS
dalam penelitian, praktik, dan pendidikan, dan (3) untuk menyarankan area untuk penelitian
masa depan .

Metode

Pencarian sistematis dalam database perawatan kesehatan online terbesar (PUBMED,

CINAHL, Scopus, PsycINFO, Ovid) dari 2004 hingga 2011. Kualitas metodologi dari studi
penelitian yang ditinjau dievaluasi.

Hasil

56 publikasi pada OS diidentifikasi dan dianalisis. Kualitas metodologis dari studi

penelitian yang ditinjau relatif tinggi. Seiring waktu, fokus publikasi bergeser dari
mendeskripsikan masalah klien ke hasil penelitian. Ada peningkatan penerapan metode
statistik tingkat lanjut dan sebagian besar penulis yang berfokus pada penelitian klasifikasi
dan interoperabilitas. Ada banyak literatur internasional tentang OS. Penelitian kecil berfokus
pada aspek teoritis OS, penggunaan OS yang efektif dalam pendidikan, atau adaptasi budaya
dari OS di luar Amerika Serikat.

Kesimpulan

OS memiliki potensi tinggi untuk memberikan informasi yang berarti dan berkualitas
tinggi mengenai layanan perawatan kesehatan yang rumit. Penelitian lebih lanjut tentang OS
harus fokus pada penerapannya dalam pendidikan kesehatan, dasar-dasar teoritis dan validitas
internasional. Para peneliti yang menganalisis data OS harus membahas bagaimana mereka
berusaha untuk mengurangi dampak dari data yang hilang dalam menganalisis hasil mereka
dan dengan jelas menyajikan keterbatasan studi mereka.

Pengantar Sejarah

Selama lebih dari empat dekade, Sistem Omaha (OS) melayani penyedia layanan
kesehatan di berbagai pengaturan sebagai terminologi standar untuk dokumentasi informasi
klinis dan untuk mendukung penelitian perawatan kesehatan. Pertama kali dikembangkan
pada awal 1970-an oleh para praktisi di Visiting Nurse Association (VNA) Omaha sebagai
sistem untuk dokumentasi dan manajemen layanan perawatan rumah, penerapan dan validitas
OS meningkat terus selama beberapa dekade. Saat ini, OS-salah satu yang tertua dari
American Nurses Association diakui terminologi standar keperawatan-secara luas diterapkan
di seluruh disiplin ilmu kesehatan dan pengaturan di Amerika Serikat dan internasional.

Tujuan dari makalah ini adalah untuk melaporkan tinjauan sistematis dari publikasi
terbaru pada OS. Sebuah tinjauan sebelumnya tentang topik ini dipublikasikan 8 tahun yang
lalu. 2 Dengan kesibukan baru-baru ini kemajuan dalam catatan kesehatan elektronik (EHRs)
dan penelitian informatika, ada kebutuhan penting untuk mengidentifikasi bukti yang
diterbitkan sejak saat itu. Publikasi terbaru pada OS harus ditinjau dan dianalisis untuk
mengidentifikasi cara-cara di mana data klinis yang dihasilkan oleh perawat dan profesional
kesehatan lainnya mungkin digunakan secara bermakna dari EHRs. Presentasi yang tepat dari
informasi ini dapat memungkinkan penyedia layanan kesehatan, peneliti, dan pemangku
kepentingan lainnya untuk lebih memahami bagaimana data EHR standar dapat mengarah
pada peningkatan kualitas perawatan dan penurunan biaya.

Pengembangan historis OS

Pada awal tahun 1970-an, praktisi, manajer, dan administrator VNA of Omaha
mengenali kebutuhan yang berkembang untuk mengukur praktek perawatan kesehatan
profesional. VNA mengembangkan visi membangun sistem yang akan menggunakan
terminologi standar untuk menggambarkan dan mengoperasionalkan proses keperawatan.
Visi ini dan upaya gabungan dari VNA dan beberapa lembaga akademis menghasilkan
penciptaan OS. Antara tahun 1970-an dan akhir 1990-an, para peneliti, pendidik, dan manajer
dari berbagai disiplin ilmu kesehatan menerima beberapa hibah federal untuk
mengembangkan lebih lanjut dan memperluas kegunaan, validitas, dan keandalan OS.1 Saat
ini, OS adalah terminologi standar yang komprehensif yang dirancang untuk menghasilkan
data komprehensif untuk deskripsi dan evaluasi perawatan klien.

Metode

Tinjauan literatur sebelumnya pada OS termasuk artikel yang diterbitkan antara tahun
1983 dan 2003.2 Untuk membangun pekerjaan ini dan menciptakan keadaan saat ini dari
ilmu pengetahuan, ulasan ini termasuk artikel yang diterbitkan antara 1 Januari 2004 dan 31
Desember 2011. Kami memutuskan untuk meninjau artikel yang diterbitkan dalam bahasa
Inggris untuk memungkinkan pemahaman menyeluruh atas naskah yang disertakan. Untuk
menemukan literatur yang relevan, kata kunci 'OS' digunakan untuk melakukan pencarian
yang terkomputerisasi dalam database biomedis dan perilaku utama, yaitu PUBMED,
CINAHL, Scopus, PsycINFO, dan Ovid. Pencarian dilakukan dengan teks bebas dan
menggunakan istilah utama, bila berlaku (misalnya, kategori MeSH di PUBMED). Selain itu,
daftar referensi artikel yang relevan dan situs web OS ditinjau untuk mengidentifikasi
publikasi tambahan.
 Artikel dimasukkan dalam ulasan ini jika mereka membahas, mempresentasikan, atau
menganalisis OS dan ditulis dalam bahasa Inggris antara 2004 dan 2011.

NANDA International
(dulunya Asosiasi Keperawatan Diagnosis Amerika Utara) adalah organisasi
profesional terminologi keperawatan yang disembuhkan yang secara resmi didirikan pada
tahun 1982 dan mengembangkan, penelitian, menyebarluaskan dan memurnikan
nomenklatur, kriteria, dan taksonomi diagnosis keperawatan. Pada tahun 2002, NANDA
diluncurkan kembali sebagai NANDA International sebagai tanggapan atas perluasan
cakupan keanggotaannya. NANDA International menerbitkan Diagnosis Keperawatan setiap
tiga bulan, yang menjadi Jurnal Pengetahuan Keperawatan Internasional pada tahun 2002.
Asosiasi internasional terkait lainnya adalah ACENDIO (Eropa), AENTDE (bahasa
Spanyol), AFEDI (bahasa Perancis) dan JSND (Jepang). Keanggotaan Grup Jaringan
mendorong kolaborasi di antara anggota NANDA-I di negara-negara (Brasil, Kolombia,
Ekuador, México, dan Nigeria-Ghana) dan untuk bahasa: Grup Bahasa Jerman (Jerman,
Austria, Swiss) dan Kelompok Bahasa Belanda (Belanda dan Belgia ).

Mendefinisikan Pengetahuan tentang Keperawatan

Kata-kata itu sangat kuat. Mereka memungkinkan kita untuk mengkomunikasikan ide
dan pengalaman kepada orang lain sehingga mereka dapat berbagi pemahaman kita.

Tentang NANDA International

Diagnosis keperawatan mengkomunikasikan penilaian profesional yang dibuat

perawat setiap hari kepada pasien, kolega, anggota disiplin lain, dan masyarakat umum.
Diagnosis keperawatan menentukan apa yang kita ketahui - mereka adalah kata-kata kita.

Tujuan kita

Pelaksanaan diagnosis keperawatan meningkatkan setiap aspek praktik keperawatan,

dari mengumpulkan penghargaan profesional untuk memastikan dokumentasi konsisten yang
mewakili penilaian klinis profesional perawat, dan dokumentasi akurat untuk memungkinkan
penggantian. NANDA International hadir untuk mengembangkan, memperbaiki dan
mempromosikan terminologi yang secara akurat mencerminkan penilaian klinis perawat.
 Visi kami

NANDA International akan menjadi kekuatan global untuk pengembangan dan

penggunaan terminologi standar keperawatan untuk memastikan keselamatan pasien melalui
perawatan berbasis bukti, dengan demikian meningkatkan perawatan kesehatan semua orang.

Misi kita

Untuk memfasilitasi pengembangan, penyempurnaan, diseminasi dan penggunaan

diagnostik keperawatan standar

terminologi:

• Kami menyediakan diagnosis keperawatan berbasis bukti terkemuka di dunia untuk

digunakan dalam praktik dan untuk menentukan intervensi dan hasil;

• Kami berkontribusi untuk keselamatan pasien melalui integrasi terminologi berbasis

bukti ke dalam praktek klinis dan pengambilan keputusan klinis;

• Kami mendanai penelitian melalui NANDA-I Foundation;

• Kami adalah jaringan global perawat yang mendukung dan energik, yang
berkomitmen untuk meningkatkan kualitas asuhan keperawatan dan peningkatan keselamatan
pasien melalui praktik berbasis bukti.

SEJARAH

Pada tahun 1973, Kristine Gebbie dan Mary Ann Lavin menyebut Konferensi
Nasional Pertama tentang Klasifikasi Diagnosis Keperawatan. Itu diadakan di St. Louis,
Missouri. Para peserta menghasilkan klasifikasi awal, daftar diagnosis keperawatan
berdasarkan abjad. Konferensi ini juga menciptakan tiga struktur: A National Clearinghouse
for Nursing Diagnoses, yang terletak di Saint Louis University dan dipimpin oleh Ann
Becker; Newsletter Diagnosis Keperawatan, diedit oleh Anne Perry; dan Kelompok
Konferensi Nasional untuk membakukan terminologi keperawatan dan dipimpin oleh
Marjory Gordon. Pada tahun 1982 NANDA dibentuk. Ini termasuk anggota dari Amerika
Serikat dan Kanada.

NANDA mengembangkan klasifikasi keperawatan untuk mengatur diagnosa

keperawatan ke dalam berbagai kategori. Meskipun taksonomi direvisi untuk
mengakomodasi diagnosis baru, pada tahun 1994 menjadi jelas bahwa diperlukan perbaikan.
Pada tahun 2002 Taksonomi II, yang merupakan versi revisi dari pola kesehatan fungsional
Gordon, dilepaskan.
 Pada tahun 2002, NANDA menjadi NANDA International sebagai tanggapan atas
permintaan dari basis keanggotaannya yang berkembang dari luar Amerika Utara. Akronim
NANDA dipertahankan dalam nama karena pengakuan nama, tetapi tidak lagi hanya
"Amerika Utara", dan bahkan membanggakan anggota dari 32 negara pada 2010.

PRESIDEN

• 1982-1988 Dr Marjory Gordon

• 1988-1993 Jane Lancour

• 1993-1997 Dr. Lois Hoskins

• 1997-2001 Dr. Judith Warren

• 2001-2005 Dr. Dorothy A. Jones

• 2005-2006 Kay Avant

• 2006-2007 Mary Ann Lavin

• 2007-2008 Martha Craft-Rosenberg

• 2008-2009 Dr. Heather Herdman

• 2009-2012 Prof. Dickon Weir-Hughes

• 2012-2016 Dr. Jane Brokel

• 2016- Dr. Shigemi Kamitsuru

Diagnosis, Intervensi, dan Klasifikasi Hasil telah dibangun di berbagai negara sejak
tahun tujuh puluhan, dan telah diubah dan diperbaiki melalui penelitian.

Konferensi Amerika Utara pertama untuk diskusi diagnosis keperawatan terjadi pada
tahun 1973, di Universitas St. Louis (2). Konferensi terus terjadi, ketika pada tahun 1980
istilah diagnosis dihasilkan, disempurnakan, dan diklasifikasikan. Karena proses ini, pada
tahun 1982, Asosiasi Diagnosis Keperawatan Amerika Utara (NANDA) diciptakan (3).
NANDA, sampai 2000, digunakan untuk mengklasifikasikan diagnosis keperawatan menurut
Taksonomi I, yang disusun oleh sembilan kategori, sebagai model konseptual dari Standar
Respon Manusia (untuk bertukar, untuk berkomunikasi, untuk berhubungan, untuk menilai,
untuk memilih, untuk bergerak, untuk merasakan, mengetahui, merasakan).
 NIC Overview

The use of NIC to plan and document care will facilitate the collection of large databases that
will allow us to study the effectiveness and cost of nursing treatments. The use of
standardized language provides for the continuity of care and enhances communication
between nurses and other providers. NIC provides nursing with the treatment language that is
essential for the computerized health care record. The domains and classes provide a
description of the essence of nursing. NIC is helpful in representing nursing to the public and
in socializing students to the profession. The coded interventions can be used in
documentation and in reimbursement. For the first time in the history of nursing, nurses have
a language which can be used to describe their treatments. The language is comprehensive
and can be used by nurses in all settings and in all specialties. poster, giving an overview of
the development of NIC, will be accompanied by a display of books and publications about
NIC and its use.

The Nursing Interventions Classification (NIC)

is a comprehensive, research-based, 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 the interventions that nurses do on behalf of patients, both
independent and collaborative interventions, both direct and indirect care. An intervention is
defined as “any treatment, based upon clinical judgment and knowledge, that a nurse
performs to enhance patient/client outcomes” (Butcher, Bulechek, Docterman, & Wagner,
2018, p.xii). While an individual nurse will have expertise in only a limited number of
interventions reflecting on 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
non-physician 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 565 interventions in NIC (7th ed.)

are grouped into thirty classes and seven domains for ease of use. The 7 domains are:
Physiological: Basic, Physiological: Complex, Behavioral, Safety, Family, Health System,
and Community. Each intervention has a unique number (code). 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. All contributors whose changes are
included in the next edition are acknowledged in the book. New editions of the classification
are planned for approximately every 5 years. The classification was first published in 1992,
the second edition in 1996, the third edition in 2000, the fourth edition in 2004, the fifth
edition in 2008, and the sixth edition in 2013, and the seventh edition in 2018.

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 Medial Language and the cumulative index of
nursing Literature (CINAHL). NIC is also included in The Joint Commission as one nursing
classification system that can be used to meet the standard on uniform data. NIC is mapped
into SNOMED Clinical Term (SNOMED CT).

Hundreds of health care agencies

have adopted 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, Germany, Iceland, Japan, Korea, Spain, Switzerland, and The
Netherlands. NIC has been translated into Simplified Chinese, Traditional Chinese, Dutch,
French, German, Italian, Indonesian, Japanese, Korean, Norwegian, Portuguese, Spanish, and
Turkish; other translations are in progress.

Source: Butcher, H. K., Bulechek, G. M., Dochterman, J. M., & Wagner, C. M. (Eds.).
(2018). Nursing interventions classification (NIC) (7th ed.). St. Louis, MO: Elsevier.
 NOC Overview

The Nursing Outcomes Classification (NOC) is a classification system which

describes patient outcomes sensitive to nursing intervention. The NOC is a system to evaluate
the effects of nursing care as a part of the nursing process. The NOC contains 330 outcomes,
and each with a label, a definition, and a set of indicators and measures to determine
achievement of the nursing outcome and are included The terminology is an American
Nurses' Association-recognized terminology, is included in the UMLS, and is HL7registered.
With the development of advanced nursing practice and the need to demonstrate effectiveness
in patient care, academics and advanced practitioners have started researching and identifying
nursing-sensitive outcome. These are defined as defined as an individual’s, family or
community state, behaviour or perception that is measured along a continuum in response to
nursing intervention. Nursing sensitive outcomes have been identifying in rheumatology
nursing, paediatric nursing and in intensive care.

The Nursing Outcomes Classification (NOC)

is a comprehensive, standardized classification of patient, family and community outcomes
developed to evaluate the impact of interventions provided by nurses or other health care
professionals. Standardized outcomes are essential for documentation in electronic records,
for use in clinical information systems, for the development of nursing knowledge and the
education of professional nurses and students. An outcome is defined as a measurable
individual, family, or community state, behavior or perception that is measured along a
continuum in response to nursing interventions. The outcomes are developed for use in all
clinical settings and with all patient populations. NOC outcomes can be used across the care
continuum to follow patient outcomes throughout an illness episode or over an extended
period of time. Nurses in tertiary care hospitals, community hospitals, community agencies,
nursing centers, and nursing homes evaluated the use of NOC outcomes in their practice as
part of a federally funded NIH grant. Since the outcomes describe patient, family or
community status, other disciplines may find them useful for the evaluation of the
interventions they provide to patients.

The 540 outcomes

in Nursing Outcomes Classification (NOC) (6th ed.) are listed in alphabetical order in the
classification. Each outcome has a definition, a list of indicators that can be used to evaluate
patient status in relation to the outcome, a target outcome rating, a measurement scale(s) to
measure patient status, and a short list of references used in the development and refinement
of the outcome. A five-point Likert scale is used with all outcomes and indicators. A rating
of a '5' is always the best possible score and '1' is always the worst possible score. Examples
of measurement scales used with the outcomes are: 1= Extremely compromised to 5= Not
compromised and 1= Never demonstrated to 5= Consistently demonstrated. The NOC
outcomes are grouped in a coded taxonomy that organizes the outcomes within a conceptual
framework to facilitate nurses identifying an outcome for use with a patient, family or
community. The outcomes are grouped into thirty-four classes and seven domains for ease of
use. The seven domains are: Functional Health, Physiologic Health, Psychosocial Health,
Health Knowledge & Behavior, Perceived Health, Family Health, and Community Health.
Each outcome has a unique code number that facilitates its use in computerized clinical
information systems and allows manipulation of data to answer questions about nursing care
quality and effectiveness. The classification is continually updated to include new outcomes
and to revise outcomes based on new research or user feedback.

The outcomes have been linked

to NANDA International diagnoses, to Gordon's functional patterns, to the Taxonomy of
Nursing Practice, to Omaha System problems, to resident admission protocols (RAPs) used in
nursing homes, to the OASIS System used in home care and to NIC interventions. In
addition linkages have been developed between the International Classification of
Functioning, Disability and Health (ICF) and NOC in an attempt to explore the components
of ICF and its international and interdisciplinary use. A more in depth look at the linkage
between NOC, NIC, and NANDA-I is available in a separate book NOC and NIC Linkages to
NANDA-I and Clinical Conditions: Supporting Critical Reasoning and Quality Care.

NOC is one of the standardized languages recognized

by the American Nurses' Association (ANA). As a recognized language it meets the
language guideline standards set by ANA's Nursing Information and Data Set Evaluation
Center (NIDSEC) for information system vendors. NOC is included in the National Library
of Medicine's Metathesaurus for a Unified Medical Language and in The Cumulative Index
to Nursing Literature (CINAHL). NOC is currently being mapped into SNOMED Clinical
Term (SNOMED CT). The use of NOC in practice, nursing education, and research is the
most accurate indicator of the classification’s usefulness. NOC has been adopted in a number
of clinical sites for the evaluation of nursing practice and is being used in educational settings
to structure curricula and teach students clinical evaluation. Interest in NOC has been
demonstrated in other countries. NOC has been translated into Chinese (simplified and
traditional), Dutch, French, German, Indonesian, Italian, Japanese, Korean, Norwegian,
Portuguese, and Spanish and several other translations are in progress.

Source: Moorhead, S., Swanson, E., Johnson, M., & Maas, M., (Eds.). (2018). Nursing
outcomes classification (NOC): Measurement of Health Outcomes (6th ed.). St. Louis, MO:
Elsevier.
 Home Health Care Classification System (HHCC)
Abstract
This paper provides an overview of the Home Health Care Classification (HHCC) System
focusing on its two interrelated taxonomies: HHCC of Nursing Diagnoses and HHCC of
Nursing Interventions both of which are classified by 20 Care Components. It highlights the
major events that influenced its development, current status, and future uses. The two HHCC
taxonomies and their 20 Care Components are used as a standardized framework to code,
index, and classify home health clinical nursing practice. Further, they are used to document,
electronically track, evaluate outcomes and analyze home health care over time, across
settings, population groups, and geographic locations.

Introduction

This section provides the background on the Home Health Care Classification (HHCC)
System. It highlights why and how the HHCC System including its two taxonomies were
developed. It describes changes with the introduction of the Medicare legislation in 1966 in
the home health industry, clinical nursing practice, information technology, classification
systems, and federal reporting requirements.

The Home Health Care Classification (HHCC) System was developed by Saba and
colleagues from research conducted at the Georgetown University School of Nursing (Saba,
1991) called the Home Care Project research (1988-1991). It was funded through a
cooperative agreement (# 17C - 98983/3) by the Health Care Financing Agency (HCFA),
now named the Center for Medicare and Medicaid Services (CMS). The purpose of the
research was to meet a needed problem in home health which was to develop a means for
predicting resource needs and measuring outcomes. The specific goal of the research was to
develop a method to assess and classify home health Medicare patients in order to predict
their need for nursing and other home care services (resource requirements) as well as to
evaluate (measure) their outcomes of care. To accomplish this goal, data on actual resource
use, which could objectively be measured, were collected and used to predict resource
requirements.

The research team consisted of home health nursing experts, a statistician, a systems analyst,
and a national advisory committee. They believed that by collecting a large volume of data
(national sample) on Medicare patients and resources used for their home health care, a
system could be designed to predict care requirements. They conducted a pilot study,
designed a framework, established a methodology, and developed an abstract form consisting
of 73 pre-coded variables. They then applied the methodology to a national sample of home
health agencies (HHAs) that provided all services and products used to restore, maintain, and
promote physical, mental, and emotional health to patients in their homes (Spradley &
Dorsey, 1985)

Retrospective research data were collected from 8,967 patient records from a sample of 646
HHAs randomly stratified by staff size, type of ownership, and geographic location. The
HHAs represented every state in the nation including Puerto Rico and the District of
Columbia. Approximately 5 to 50 recently discharged Medicare patient records for an entire
episode of care were abstracted from each of the sample HHAs providing data on the 8,967
patients (Saba, 1991).
The data consisted of all relevant variables considered to be possible predictors of home
health care resource requirements. They were collected and analyzed to determine the
statistical significance of alternative classification methods. Data were collected consisting of
two sets of narrative textual statements focusing on (a) patient problems and/or nursing
diagnoses and (b) nursing services, treatments, actions, and/or interventions. Approximately
40,000 narrative statements about patient problems and 72,000 narrative statements
representing nursing services provided during their episodes of care were collected from the
sample patients.

Nursing Classifications

Nursing classifications emerged as critical to the advancement of the profession and were
created to name nursing phenomena. They emerged as data sets, taxonomies, or classification
systems that could be used to document clinical nursing practice in CPR systems. They were
viewed as the foundation for a unified nursing language system (UNLS) and proposed as the
basis for the CPR. Nursing data had to be identified to measure patient care. Data had to be
processed into nursing information and ultimately into nursing knowledge to advance the
science of nursing.

HHCC System’s Two Taxonomies

This section describes the HHCC System focusing on its two taxonomies and classification
framework. It provides a description of the two taxonomies and care component classes,
highlights their definitions, coding structure, current status, educational uses, and research
and evaluation studies

Overview

The HHCC System is specifically designed for the documentation of patient care using a
CPRS. It consists of two standardized interrelated taxonomies: HHCC of Nursing Diagnoses
and the HHCC of Nursing Interventions. These two taxonomies are classified by 20 Care
Components that serve as the standardized framework for documenting home health clinical
nursing practice. They are used not only to code, index, and classify home health care; but,
also, to document, track, and analyze the care over time, across settings, population groups,
and geographic locations (Saba, 1994a). (See web site http://www.sabacare.com/ - Tables 1-
8).

HHCC of Nursing Diagnoses

The HHCC of Nursing Diagnoses consists of 145 categories (50 two-digit major categories
and 95 three digit subcategories) that depict nursing diagnoses and/or patient problems. The
terms in this taxonomy include over 50 unique home health nursing diagnostic terms as well
as several of the 104 NANDA terms derived from the Taxonomy I Revised (1991). Further,
the NANDA terms were transcribed from verb phrases to noun clauses to conform to the
structure of the HHCC terms. A Nursing Diagnosis is defined as:

A clinical judgement about an individual, family, or community response to actual and

potential health problems/life processes. Nursing Diagnoses provide the basis for the
selection of nursing interventions to achieve outcomes which the nurse is accountable
(NANDA, 1992, p. 5).
This taxonomy is expanded by using three qualifiers (improve, stabilize, deteriorate). These
qualifiers expand by modifying each diagnostic term to code the expected outcomes and the
same qualifiers (improved, stabilized, deteriorated) are used to code actual outcomes.

HHCC of Nursing Interventions

The HHCC of Nursing Interventions consists of 160 categories (60 two digit major categories
and 100 three digit subcategories) that depicts nursing interventions, procedures, treatments,
activities, and/or services. A single nursing action is designed to achieve an outcome for a
diagnosis (medical/nursing) for which the nurse is accountable. This taxonomy is expanded
by four qualifiers (assess/monitor, care/perform, teach/supervise, manage/refer) that represent
a specific type of intervention action. These qualifiers enhance and expand by modifying
each intervention to code the specific action making a total of 640 terms that comprise the
HHCC of Nursing Interventions.

HHCC System taxonomies are being used to develop HHCC Clinical Pathways for the
electronic documentation of clinical nursing practice for CPRSs. The HHCC Pathways use
the 20 Care Components as its framework and the two standardized HHCC System
taxonomies to (a) assess and diagnose care needs on admission, (b) document and track care
during and between visits/encounters, and (c) evaluate and measure care outcomes on
discharge for an episode of illness.

Pathway definition. An electronic pathway is a method such as a summarized worksheet that

can be computerized. The electronic pathway format makes it possible to track interventions
and actions as well as to facilitate for flexibility and individualized care, while monitoring
actions to see if expected outcomes are being met. An electronic pathway can assist in the
case management of patient care by providing comprehensive, coordinated, and cost-effective
care (Zander, 1988; Spath, 1993).

Clinical pathway uses. The Clinical HHCC Pathways are used on admission to link the
OASIS Instrument, the PPS Instrument, and the HCFA Forms to the patient assessment. The
HHCC Pathways are used to identify clinical actions and events for the entire episode and
specifically for each visit to determine the patient, family, and resources needed for the care
process. The pathway events and actions are planned based on the admission assessment of
the patient by component and then tracked during the individual home visits.

The HHCC Pathways are used to measure quality, provide evidence for the evidence-based
practice, decision making, bench marking, and standards of cost effective care. Further, they
are used to summarize the episode to provide clinical, financial, and research information as
well as manage the care provided, determine resources required, and measure the outcome of
home health care.
 International Classification for Nursing Practice.

Abstract
An International Classification of Nursing Practice (ICNP) is needed to support the processes
of nursing practice and advance the knowledge necessary for cost-effective delivery of
quality nursing care. Below, the authors present their case for developing such a system that
will provide nursing with a nomenclature, a language and a classification that can be used to
describe and organize nursing data. It is their belief that this landmark project is achievable
and that ICN should lead the work in collaboration with its member associations, the World
Health Organization and key national, international, governmental and nongovernmental
groups. But to ensure that the system will be adaptable across borders, nurses and
organizations are being encouraged to share their ideas and research on such a system.

A resolution of the ICN's Council of National Representatives in 1989 asked that ICN
encourage member National Nurses Associations (NNA's) to become involved in developing
classification systems for nursing care, nursing information management systems and nursing
data sets, and to provide tools that nurses in all countries could use to identify nursing
practice and describe nursing and its contributions to health.

The International Classification for Nursing Practice Project, begun in 1990 by the
International Council of Nurses, aims to develop a standardised vocabulary and classification
of nursing phenomena (nursing diagnoses), nursing interventions, and nursing outcomes
which can be used in both electronic and paper records to describe and compare nursing
practice across clinical settings. An Alpha Version of the Classification of Nursing
Phenomenon and Nursing Interventions was released for further development and field
testing in 1996 and an outline for a classification of Nursing Outcomes in 1997. Nurses
around the world, and other classification experts, have been invited to participate in the
development of the Beta Version which it is hoped will be ready for release in 1999.

The goals of the project, which were set out in the initial proposal to the ICN Board of
Directors' are:

1. To develop an ICNP with specified process and product components.

2. To achieve recognition by the national and international nursing communities.
3. To ensure that the ICNP is compatible with and complementary to the WHO Family
of Classifications, and the work of other standardisation groups such as the
International Organisation for Standardisation (ISO) and related groups including the
ComiteEuropean de Normalisation (CEN), and to secure inclusion of ICNP in
relevant classifications.
4. To achieve utilisation of ICNP by nurses at country level for the development of
national databases.
5. To establish an international data set and a framework that incorporates the ICNP, the
nursing minimum data set, a nursing resource data set, and regulatory data.

These goals continue to provide the mission and the framework for the project.
Testing the Alpha Version

The Alpha Version is currently being tested in various ways and further participation is
welcomed. All member National Nurses Associations have been asked for feedback, and
documentation for submission of new terms and changes to existing terms is available. A
process for managing feedback is being developed.

In Europe the TELENURSE project has enabled the Alpha Version to be translated into
several languages and is testing aspects of the use of ICNP in electronic patient records.
Validation studies are being undertaken at Marquette University and by individual
researchers in several countries.

The ICNP Country Project, funded for 3 years by the W K Kellogg Foundation, will assist
ICN to focus particularly on describing nursing practice in community-based practice and
primary health care. Country work groups in several countries of Africa and Latin America
will explore and develop new processes and look critically at the nature and structure of
ICNP as well as contributing new terms. The project also includes publication of a Newsletter
to disseminate information and ideas.

Meerabeau et al (1997) point out that nurses already use different languages for different
purposes. They note that the US National Center for Nursing Research (1993), distinguishes
between clinical terms (the language of practice) and definitional terms (the language of
nursing knowledge — theory and research). Hoy (1995) sets out a continuum of steps
between "informal language" which nurses use to communicate information about patients
whose care they share, and the "formal language" which is necessary for remote
communication such as anonymised aggregated data for research or statistical purposes. It
has been suggested that as nurses learn to articulate more precisely their phenomena of
concern, the gap between the two extremes of Hoy's continuum will narrow, but it is unlikely
that they will ever merge.

Classification brings even greater problems. The existing nursing classifications, like the
ICD, are first-generation mono-axial classifications, and have usually been inductively
developed. The ICNP Alpha Version classification of nursing phenomena was also mono-
axial, but it differs from the other nursing classifications in that it is built according to strict
rules of classification based on generic relations — that is, the concepts are arranged in a
strict hierarchy in which each subordinate term is related to each superordinate term (the
genus) by a principle of division, and distinguished from other terms on the same level by its
special characteristics (the characteristic of the species).

The meaning of the concept is, therefore, defined by its place in the classification as well as
by any other definition it may be given. The ICNP Beta version will use multi-axial
classification in which each complex concept (eg impaired mobility) is broken down into
separate axes, (eg mobility : impaired). This kind of classification increases richness and
flexibility because it allows the terms in different axes to be combined in various ways, but
the penalty is that the increased complexity limits use to computerised systems, to which
nurses in many countries have no access.