a conceptual model for nursing information

48 International Journal of Nursing Terminologies and Classifications Volume 19, No. 2, April-June, 2008

doi: 10.1111/j.1744-618X.2008.00081.x

Blackwell Publishing IncMalden, USAIJNTInternational Journal of Nursing Terminologies and Classifications1541-51471744-618XXXX

ORIGINAL ARTICLES

A Conceptual Model for Nursing Information


Rodney Hughes, MSc, RGN, ONC, Dip. Nurs (Lond.), MSocSc, PhD, David Lloyd, MEd, RMN, RNT, and Dame June Clark, DBE, PhD, RN, FRCN

PURPOSE.

This Conceptual Model for Nursing

Information describes the core activities of

nursing, the collection of information about these

activities, and argues that these activities must be

described using standardized nursing languages.

DATA SOURCES.

Relevant literature, both national

and international, was reviewed and summarized.

DATA SYNTHESIS.

A maximum data set for

nursing was developed.

CONCLUSIONS.

In the United Kingdom, a new

and radical approach to the process of nursing is

required; one that demonstrates that nursing is

the decision-making that takes place in all core

activities of nursing.

IMPLICATIONS FOR NURSING PRACTICE.

Unless

nurses have a clear view of what the profession

requires from technological solutions for the

recording of nursing activities, less than optimal

solutions will be forced upon the profession.

Search terms:

Conceptual Model for Nursing

Information, nursing information systems,

standardized nursing languages

Rodney Hughes, MSc, RGN, ONC, Dip. Nurs (Lond.), MSocSc, PhD, is Former Lecturer, and David Lloyd, MEd, RMN, RNT, is Lecturer in the School of Health Care Sciences, University of Wales, Bangor, Gwynedd, Wales, UK; and Dame June Clark, DBE, PhD, RN, FRCN, is Emeritus Professor of Nursing in the School of Health Science, Swansea University, Swansea, Wales, UK.

Introduction

In April 2006, the Royal College of Nursingpublished a document entitled

Putting Information atthe Heart of Nursing Care

(2006), which provided anoverview of “how IT [information technology] is set torevolutionize health care and the NHS [NationalHealth Service].” In the section entitled “The ElectronicPatient Record,” the main features of the record aredescribed together with an outline of the benefits forpatients and for professionals. Most important,however, is the statement, “To be useful for nursing,the electronic patient record must contain the rightnursing information—and that depends on us.” Weagree wholeheartedly with this statement, but wequestion the extent to which nurses, in the UnitedKingdom at least, are able to make this a reality.

This paper describes a conceptual framework thatcould be used to ensure that the electronic patientrecord does contain the right nursing information,and could also help nurses understand the thinkingprocesses that are the core of nursing practice.

Background

In all four countries of the United Kingdom(England, Wales, Scotland, and Northern Ireland) agovernment-sponsored program is in progress tointroduce IT, including an electronic patient record,into the NHS. However, a series of online surveysundertaken by the Royal College of Nursing (2007),which has been monitoring nurses’ responses, showsthat nurses are not being adequately consulted aboutthese developments and are not adequately involved

International Journal of Nursing Terminologies and Classifications Volume 19, No. 2, April-June, 2008 49

in the development of systems. From the nursingperspective, the overall impression in the UnitedKingdom (and perhaps in some other countries) is thatthe nursing profession is not well served by the variousinformation systems currently offered by vendors. Webelieve that this is due to the inability of the professionto articulate clearly its requirements. Furthermore,unless nurses have a clear view of what the professionrequires from technological solutions for the recordingof nursing activity and the collection of nursing data,we will be forced to accept less than optimal solutionssimply because we could not articulate our needsclearly and unambiguously.

The importance of having systems that capturenursing activity and support nursing practice has beenwell argued for many years (Clark & Lang, 1992). Ifnursing activity is to be captured by these systems,then we believe it has to start at the level of theindividual patient, capturing a data set that clearlyidentifies the activities that nurses undertake withindividual patients, for what reason, and with whatresults. It must include what we call the “core activities”of nursing as shown in the model, which must bedescribed in documentation using standardizednursing terminology. Moreover, the record is not just arecord of what the nurse does—it must also capturethe way in which nurses make their decisions,whether consciously or intuitively, in caring forpatients. This means that the challenges for successfulimplementation of the electronic patient record areconceptual as well as technological, and this requiresdevelopment of the cognitive skills that come fromeducation as well as the technical skills that come fromtraining.

Development of the Conceptual Model

The roots of the conceptual model were founded inthe 2003 Association for Common European NursingDiagnoses, Interventions and Outcomes (ACENDIO)Conference on

Naming Nursing

held in Swansea andattended by the authors (Clark, 2003). Following this

conference, the North Wales Nursing TerminologyGroup (NWNTG) was formed to raise awareness ofnursing issues of the electronic patient record (EPR) aswell as to promote the use of nursing terminology.The NWNTG included academics and clinicians drawnfrom across the region, and it was during a meeting toanalyze how nurses could best be convinced of theutility of nursing terminology, critical thinking, andnew technology that the model was developed.

We are aware of the efforts both internationally andwithin particular countries to develop a recognizedminimum data set for nursing (Goosen et al., 1996;International Council of Nurses, 2004; Werley & Lang,1988), and we recognize that ours is not the firstattempt to build a conceptual model of this kind.However, we are working in a context where theseefforts are not widely known and where clinicaldecision-making is not usually taught in basic nursingeducation. We hope that in this context, adoption ofthe conceptual model will help nurses to understandand answer the long-contested question of “What isnursing?” The model shows that nursing is decision-making, and that this decision-making takes place inevery part of the core activities of nursing: in assess-ing, diagnosing, agreeing expected outcomes, selectingand planning nursing interventions, implementing theinterventions, and evaluating the extent to which theoutcomes have been achieved. This is equally truewhether one is providing acute physical care, prevent-ative care, mental health care, learning disability care,or any other nursing specialty. This perspective is inline with the Royal College of Nursing definition ofnursing as “the use of clinical judgement in the provi-sion of care” (2003), but it differs from the concept ofnursing as a collection of tasks, roles, and activitiesthat still prevails in the United Kingdom as in someother countries.

The Nursing Process and Diagnostic Reasoning

The core activities of nursing in the UnitedKingdom are based on an ideology of “individualized



patient care,” using the “nursing process” which wasfirst developed in the United States and later introducedin the United Kingdom in the mid-1970s. It is alsotermed “a problem solving approach to nursing.” In1975, “the nursing process” was incorporated into thesyllabus for basic nursing education by the GeneralNursing Council (the predecessor body to the UnitedKingdom Central Council for Nursing Midwifery andHealth Visiting and the current “Nursing andMidwifery Council”) which, as the regulatory body fornursing in the United Kingdom, sets standards forbasic nursing education. At the same time the govern-ment’s Department of Health directed all NHSorganizations to appoint “nursing process facilitators”

to introduce it into nursing practice. In effect, therefore,the “nursing process” became officially mandatoryfor practice. Its acceptance and use in mainstreamclinical activity, however, was a slow process partlybecause its introduction was seen as a “top down”imposition (Ford & Walsh, 1994; Mead & Bryar, 1992).Moreover, the thinking that underlies the process wasnot well explained, and in many clinical areas thenursing process is still seen as merely a (ratherburdensome) method of documentation. Pesut andHerman (1999) describe three generations of thenursing process: a “first generation,” which began inthe 1950s in the United States, predicated upon a four-stage model of Assessment, Planning, Interventions,

Figure 1. A Conceptual Model for Nursing Information


and Evaluation (APIE); a second generation model,which developed during the 1970s, again in the UnitedStates, which included Nursing diagnosis (the ADPIEmodel); and a third generation model, which is drivenby outcomes (Pesut & Herman). Most British nursingtextbooks use the same four-stage model that Pesutand Herman describe as the “first generation” nursingprocess, and this is the model that prevails in UKnursing practice and documentation. A format withfive stages was promulgated during the late 1980s by afew UK nurse academics: Assessment, Identifyingproblems, Defining expected outcomes, Prescribinginterventions, and Evaluation (Wilson-Barnett & Batehup,1988), and some current documentation systems doinclude provision for identifying problems. The differ-ence between this and the North American secondgeneration model is that the term “Defining problems”is used instead of “Nursing diagnosis.” The differenceis more than semantic: the concept and the language ofnursing diagnosis are still unrecognized, and evenrejected, by most nurses in the United Kingdom.

Diagnostic Reasoning

Pesut and Herman (1999) make the point that thedifference (in the United States) between the first andsecond generations was not just the addition of a fifthstage (the Nursing diagnosis), but is also about changingfrom the stage model of problem solving to one basedon clinical reasoning. We believe that in the UnitedKingdom we have not only failed to adopt the conceptof nursing diagnosis, but we have not moved from thefirst generation model to the second generation modelbased on using clinical reasoning skills as a method ofproblem solving.

Standardized Nursing Languages

The need for categorization and terminology todescribe clinical activity has been recognized inmedicine for more than a century, and was in fact firstdeveloped in Britain (Farr, 1856). British medicine

routinely uses the

International Statistical Classificationof Diseases and Related Health Problems

(10th Revision)and the

Diagnostic and Statistical Manual of MentalDisorders

(4th edition). Such classifications enable theunambiguous communication of medical problems.However, there has been no such recognition in UKnursing: such developments as have been made haveoccurred outside the United Kingdom, mainly in theUnited States.

The United Kingdom does have a few nursingterminology champions. Ten years ago, Hardiker(1997) suggested the following reasons why nursingneeds to develop a standardized vocabulary. These are:

• To formalize and expand knowledge about nursingpractice

• To assist in determining the costs of nursing services• To help target resources more efficiently• To make explicit the role played by nurses in health

care• To provide structure for retrieving and using nursing

data from automated systems• To improve the quality of nursing care by ensuring

a sound basis for clinical decision-making• To assure the quality of nursing practice by con-

tributing to standard setting• To meet the needs of others

These reasons remain valid today, although anyadvance in the acceptance and use of standardizednursing languages in the United Kingdom has beenextremely slow.

Developments in the United States date back to theearly 1970s (Warren, 2003), starting with the work ofAmerican nurses in developing and defining nursingdiagnoses, which led to the establishment of the NorthAmerican Nursing Diagnosis Association (NANDA,now NANDA International). The NANDA Internationalclassification of nursing diagnoses is now translatedinto several languages and is used in many parts ofthe world. In the United Kingdom, the NANDA Inter-national labels have been anglicized by a team at the



Chelsea and Westminster Hospital (Westbrook, 1999);a second edition was published in 2000, and a thirdedition is in preparation.

Of the many definitions of a nursing diagnosis, oneof the earliest, promulgated by Marjory Gordon(1976), is especially useful: “Actual or potential healthproblems which nurses, by virtue of their educationand experience are licensed to treat.” This definitionintroduces several important concepts: firstly, that thenurse is looking for both actual and potential healthproblems; secondly, that these are amenable to nursinginterventions; thirdly, that nurses can treat thembecause their experience and training make themcapable of doing so; and fourthly, because nurses arelicensed to undertake such treatment. The variousdefinitions of the term demonstrate that it has twodistinct meanings: a process, and the label thatemerges from the process. The “process” of formulatinga diagnosis is the same for all professions, that is, it isthe process of diagnostic reasoning. What distinguishesnursing from medicine and all the other professions iswhat is diagnosed: in nursing the diagnosis is thecondition that necessitates nursing care.

Nursing interventions were defined by McCloskeyand Bulechek (1996) more than a decade ago as “anytreatment based upon clinical judgement and knowl-edge, that a nurse performs to enhance patient/clientoutcomes.” Nursing interventions include both directand indirect care: nurse-initiated, physician-initiated,and other provider-initiated treatments (McCloskey &Bulechek).

It is likely that nurses in the United Kingdomwould accept this definition of what they understandby nursing care. The

Nursing Interventions Classification

(NIC), developed as the result of research at theUniversity of Iowa, is described by the authors as the“first comprehensive standardized classification oftreatments that nurses perform.” McCloskey andBulechek (1996) suggest that interventions are selectedin relation to specific nursing diagnoses and that thepatient outcome that is being planned is identifiedbefore the selection of the intervention takes place.

In the United Kingdom, the conceptualization ofnursing outcomes is still contested because, it isargued, they are patient outcomes, and they are notthe result of one discipline alone. However, we arguethat for nursing to monitor and improve its practice, itis important that outcomes that are influenced bynursing care are identified. As Maas, Johnson, andMoorhead (1996) stated:

Outcomes need to be identified that are sensitiveto the interventions of specific disciplines. Ifoutcomes are identified only for the composite ofinterdisciplinary interventions each discipline willbe unable to judge the effects of its specificintervention. Further, no one discipline can be heldaccountable. If interventions do not work, it will bedifficult to determine what needs to be changed inorder to meet the outcome.

To overcome the problem of definition, Maas et al.(1996) have coined the term

nursing sensitive patientoutcomes.

The

Nursing Outcomes Classification

(NOC),developed at the University of Iowa, provides a wayin which patient outcomes can be labeled and defined,and which also provides a tool for measuring patientoutcomes as the result of nursing interventions.

The utility of such tools as NANDA International,NIC, and NOC cannot be overestimated. If nursing isto truly capture those clinical activities that it deemsvaluable, then some system of nomenclature has toexist in order to clearly and unambiguously identifywhat nurses are doing. This clear and unambiguouscommunication of client clinical need is the desire ofall good nurses, but this is not the only benefit of sucha process. In the United Kingdom, as in most othercountries, nurses are required to base their nursingcare on “best practice” related to the current availableevidence. Such best practice can only be gleaned fromthe accumulated wisdom experience and research thatunderpin sound clinical nursing. However, if nursescannot name what it is they are doing, then the oppor-tunity to research best practice is lost. How can we,


therefore, with any degree of confidence, differentiatebetween poor and best practice in the clinical field?

The Conceptual Model

This Conceptual Model for Nursing Informationhas as its foundation the description of the coreactivities of nursing and the collection of informationabout these core activities. These activities of nursingas shown in the model must be described using stand-ardized nursing languages. In the model this producesa data set for nursing that would allow nurses to describecare, manage care, quality assure care, and describe andmeasure outcomes of nursing care. It will also providethe information required to research nursing phenomena.These outputs are essential if we are to be in a positionas a profession to articulate what we do and our reasonsfor doing it. At the center of the model, analogous tothe hub of a wheel, is clinical decision-making. The“spokes” indicate the kinds of decisions that nursesmake. The six core activities of nursing are the following.

Nursing Assessment

Nurses in the United Kingdom use various approachesto assessment, usually based on a model of nursing.In the United Kingdom, the most commonly usedmodel is the Activities of Living Model first developedduring the 1970s by Roper, Logan, and Tierney (1980).Current documents provided for nurses to record theirassessment are usually structured using the 12 Activitiesof Living identified by Roper et al. The reference tothe Unified Assessment is a reference to the proceduresthat have been agreed in Wales for the multidis-ciplinary assessment of older people (Welsh AssemblyGovernment, 2006). Models of assessment are usefulin framing the way the nursing assessment is undertaken,but the model used should be “fit for purpose.” Wequestion whether it is appropriate to use the samemodel, for example, for patients with mental healthproblems as for clients who are expecting a baby.We also note the risk that some nurses may use the

assessment documentation as a series of “tick-boxes”without paying adequate attention to the need forcareful decision-making.

We take it as axiomatic that this assessment has tobe undertaken by a registered (first level) nurse. Thepurpose and the outcome of the assessment, achievedby the application of clinical reasoning, is the identifi-cation of one or more nursing diagnoses. Nursingassessment is not a once-and-for-all matter: it willneed to be regularly revisited and repeated as thepatient’s condition changes.

Nursing Diagnosis

The NANDA International list of

Nursing Diagnoses:Definitions and Classification 2007/8

(2007) provideslabels, definitions, and defining characteristics for 188nursing diagnoses. When diagnoses are defined usingstandardized terms, and coded, they can be capturedby both paper and electronic means. Each diagnosisforms the basis for the selection of nursing interventionsand outcomes, each requires nursing action and thenurse has to make additional decisions, for example,regarding the severity of each, and the urgency andpriority with which they have to be addressed.

Identify Objectives

This is the identification of the desired or expectedoutcome. Such outcomes must clearly be related to thenursing diagnoses. The nurse agrees with the patient(and where relevant with his or her informal carers)the objectives for resolving, controlling, or ameliorat-ing the diagnoses. This negotiation empowers thepatient to be part of the therapeutic team. For thenurse it involves clinical decision-making and clinicalreasoning skills, as well as good interpersonal skills.

In communicating with the patient/family, thenurse will use language that is familiar to the patient,but in documentation shared by the professionalstaff the expected outcome would be expressedusing standardized language. The

Nursing Outcomes



Classification

, 3rd edition (Moorhead, Johnson, & Maas,2004) provides one means.

Selecting the Interventions

Next, the nurse must select the interventions thatwill achieve the outcomes that have been agreed. Thenurse’s education and experience will inform her orhim of the range of interventions that will be appropriateto use to address the diagnosis to achieve the objectivesand will be based on the best evidence available.The

Nursing Interventions Classification

, 4th edition(McCloskey Dochterman & Bulechek, 2004), providesa label and definition for 514 nursing interventionsthat could be incorporated into both paper andelectronic documentation. A good computerizedsystem may include a decision support system thatsuggests appropriate interventions and prescribedprotocols, but selecting the interventions also involvesclinical reasoning skills to decide on the interventionsthat best fit the needs of the particular patient and aretailored to his or her needs. These interventions couldbe a part of a Care Pathway, but it should be notedthat “Care Pathways” tend to be based on medicaldiagnoses, which do not correlate exactly with thenursing diagnoses: patients with the same medicaldiagnosis often have different nursing needs and,therefore, different nursing diagnoses.

Implementation

The interventions must be implemented appropri-ately, to an agreed standard. The nurse must decidewho will undertake them, when they will be under-taken, and how to modify the interventions accordingto the patient’s responses and level of acceptability.

Evaluation

Finally, the nurse must evaluate the effect of theinterventions on the diagnosis. Did the selected inter-vention achieve the predicted result? How do you

measure? What tools do we, as nurses, have to do themeasuring? As well as providing a label and definitionfor outcomes, the

Nursing Outcomes Classification

(Moorhead et al., 2004) also provides a means formeasurement. In this way we can begin to indicate ifthe nursing care has been effective, and to develop theresearch capacity of nursing to find out what works.This is the basis for evidence-based practice.

Although the process has been described as aseries of steps, in practice it is iterative and interactive.Every piece requires clinical decision-making skills andshould also provide an opportunity for knowledgedevelopment. Decision support systems can assist inthis decision-making, but should never replace it.

Scope of the Model

The totality of the data recorded is referred to as aMaximum Data Set for Nursing that will allow nursesto describe care, manage care, quality assure care, andto describe and measure the outcomes of nursing care.When the data about the nursing care provided formany patients is aggregated, it will also provide theinformation required to research nursing phenomena.Such outputs are essential if we are to be in a positionas a profession to articulate what we do and ourreasons for doing it. It will provide evidence by whichpractice improves and quality is maintained, toaccurately reflect the workload of nursing staff, tocomply with legal requirements, and to fulfill theexpectations of an increasingly consumerist public.

The Maximum Data Set for Nursing includeseverything in and around the outer circle. Such a dataset could then be refined electronically to create theNursing Minimum Data Set for inclusion in theelectronic patient record. If that information iscollected for each patient, then we have a tool for care,for teaching, for research, for evidence-based practiceand, at different levels of aggregation, a tool formanaging the service. Of course what we have outlinedcan work with paper but we would see it beingdeveloped electronically.


The model identifies some of the nursing terminologiesin current use. In the United Kingdom, the govern-ment has mandated the use of SNOMED-CT as theterminology to be used for all health information.Fortunately this incorporates the concepts developedby NANDA International, NIC, and NOC, and a nursingteam is constantly reviewing its nursing content.

We have also indicated how the model can beexpanded, for various purposes. For example, inWales we have two languages (Welsh and English)and we believe that in this bilingual environmentstandardized nursing languages need to be availablein Welsh as well as in English. Furthermore, whetherin English or Welsh, there is an opportunity to crossmatch the expressions that patients use for theirconditions (synonyms) with nursing diagnosisclassifications.

Outside the circles we have acknowledged the needfor two-way communication with other professions,especially for assessment and identification of apatient’s needs.

The reference to the Unified Assessment is a refer-ence to the procedures that have been agreed by theNHS and the social services authorities in Wales forthe multidisciplinary assessment of older people(Welsh Assembly Government, 2006).

Adopting and Using the Model

Surveys undertaken by the Royal College ofNursing show that nurses in all four countries are stillgenerally unprepared for these developments, and inparticular need considerable educational preparationfor the introduction of electronic patient records.While the current emphasis is on developing basiccomputer skills, we believe that even more importantis recognizing and developing the underlying cogni-tive skills associated with clinical decision-making. Inorder to move from present nursing to an emphasis onclinical reasoning, nurses will need additional educationif they are to develop top quality clinical reasoningand clinical decision-making skills. In particular, we

believe that nursing in the United Kingdom needs anew and radical approach to what UK nurses call “thenursing process”; this does not imply the abandon-ment of what has gone before, but a new approachthat includes recognition of nursing diagnosis and theneed for standardized language in order to utilizethe opportunities presented by the introduction ofthe electronic patient record.

To make this Conceptual Model a reality in theUnited Kingdom presents huge challenges to nurseeducators, nurse managers, and to clinical nursesthemselves. The good news is that the development ofcomputerized information systems is at last forcingnurses to think about how they structure the documen-tation of their practice. The bad news is that if thisprocess is undertaken without due regard for thethinking and decision-making processes that underpinit, the result will be task-oriented “tick-box” nursing.

It would be wrong to wait for the development ofan appropriate computer system before implementingthe main themes contained in the Conceptual Model.Decisions are being made now that will determine theshape of nursing documentation in the electronicpatient record of the future. The model can beimplemented equally well as a paper-based nursingdocumentation system and in this way the skillsrequired to make it a reality, particularly the clinicalreasoning and clinical decision-making skills, could bedeveloped over time. However, we believe that atechnical solution is the ultimate aim and when we asa profession can agree upon what is needed, we canask someone to build it for us rather than have toaccept what particular vendors want us to have.

Author contact: [email protected]

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