Which domain of the nursing interventions classification taxonomy includes?

Step 1: Assessment

Biopsychosocial data about geriatric patients are collected by means of interviews, record reviews, direct observations and other approaches, as time allows, to build a composite picture of the multiple and often competing needs of the geriatric patient and the informal caregiver. For example, the federally mandated multidisciplinary assessment called the Minimum Data Set (Burke & Walsh 1997) is used in nursing homes by long-term care nurses to record assessment data as part of the team approach to care planning and treatment.

Data from nursing assessments are necessary to identify problems in the order of clinical significance at a specific time and according to the urgent need for nursing interventions. The information may include general and specific data on the presenting problems as defined by the patient and the caregiver, medical diagnoses, prescribed medical treatments, status of physical and mental functions, alternate healthcare resources, patient goals and expectations, safety risks, self-care abilities for recovery, including the ability to perform activities of daily living, and other information that a nurse considers clinically relevant to the case or situation. Identifying nursing diagnoses and prioritizing these problem areas are the major intended process outcomes.

Since 1973, the North American Nursing Diagnosis Association (NANDA) has continued to develop a taxonomy of nursing diagnoses, and currently there are approximately 130 approved classifications of patient care problems in nine categories. In 1987, the Center for Nursing Classification and Clinical Effectiveness at the College of Nursing, University of Iowa, developed taxonomies for classifying and organizing nursing interventions and nursing outcomes through the use of the Nursing Intervention Classification (NIC). This was followed by the development of Nursing Outcomes Classification (NOC) coding systems in 1992. The NIC/NOC codes are linked to the NANDA diagnoses and serve to document the effectiveness of nursing interventions and outcomes (McCloskey et al 2004, Moorhead et al 2004). Refinement of the NIC/NOC classification systems has been ongoing. The use of nursing taxonomies facilitates the capture of nursing data useful for evaluation, quality improvement, and research activities.

It is important for members of healthcare teams to be aware that some problem areas that demand priority nursing interventions may not always be parallel to or target directly the ‘curing’ goals of a medical plan.

Step 2: Planning

The nursing care plan incorporates specific nursing interventions and activities to treat specific nursing diagnoses or deal with problem areas such as changes in food intake, impaired capacity for personal care, risk of accidental injuries due to general weakness and mild dementia, grief unrelated to the health problem, and other needs of the geriatric patient and the caregiver. Included in the plan are nursing actions to insure the continuity of all prescribed medical treatments and other intervention modalities for the geriatric patient. Clinical judgment is an important nursing skill in this process because it enables an accurate identification of the nursing diagnosis.

Step 3: Implementation

The process of implementation utilizes the collective efforts of members of the nursing staff, including auxiliary nursing personnel, and directs them so that the nursing care plan can be carried out. Safe and compassionate approaches that are clinically and technically appropriate are used to achieve the desired clinical outcomes. Nursing actions may include activities such as checking vital signs, changing the position of an immobilized elderly patient, orienting an elder with a memory deficit to time, place, and activity, interviewing a family caregiver prior to homecare, consulting other healthcare professionals, advocating for an elder to obtain a local community resource, and other actions aimed at resolving a nursing problem or reducing the impact of a nursing diagnosis.

Step 4: Evaluation

A patient's physical, verbal and behavioral responses, informal caregivers’ reports and observations by healthcare providers from other disciplines are important aspects of the feedback mechanism that helps the nursing staff to maintain a dynamic, flexible care plan. Critical analysis of information obtained while nursing interventions are in progress may be used to modify nursing interventions, redirect patient and family participation in the overall treatment and management plan, re-examine the healthcare team's understanding of the clinical problem, determine cost benefits, realign leadership and support the standards of quality patient care.

Role of Terminologies in Health Care

A terminology is the body of terms used with a particular technical application in a subject of study, theory, or profession. Terminologies vary in their purposes, scopes, and structures. This is especially true in health care where there is a high degree of specialization. Although there exists a nearly universal terminology for human anatomy that is taught to a variety of health professions, there is a wide array of specialized terminologies used in health-care settings. Nursing, for example, has three major terminologies: NANDA International (NANDA-I), the Nursing Interventions Classification (NIC), and the Nursing Outcomes Classification (NOC). The nursing terminologies provide sets of terms to describe nursing judgments, treatments, and nursing-sensitive patient outcomes.

Terminologies in health-care support the documentation of observations, treatments, and outcomes that clinicians put in the patient chart—which is increasingly performed using electronic health record (EHR) systems. Although there exist a fair number of “major” or standard terminologies like the NIC and NOC, there are many more terminologies developed for specific purposes. A local terminology is one that is created for a specific purpose by a single organization, such as a laboratory, hospital, clinic, or pharmacy. For example, a local terminology may be used by the laboratory supporting a large health system to provide “user friendly” terms to physicians who order the tests.

Although useful to providers in a particular health system, a local terminology may be difficult to interpret by providers in another health system. For example, Health System A might refer to a glycated hemoglobin (HbA1c) test as “Glycohemoglobin,” whereas Health System B may refer to a similar test as “Hemoglobin A1c.” Although a human clinician can use his or her clinical knowledge and expertise to reason that the two tests likely mean the same thing, computers cannot perform such reasoning in isolation. Therefore, to ensure that meaning or semantics are transferred along with the test results during HIE, health information systems should use a reference terminology. A reference terminology is a formal, canonical terminology developed and maintained by a national or international standards development organization (SDO). A reference terminology is often referred to as a standard, terminology standard, or standard terminology. SDOs and the development of standards is described in the chapter “Standardizing and Exchanging Messages”.

Terminologies consist of terms which are also referred to as concepts. A term can represent a clinical observation (eg, weight, blood pressure, response to a question asked of a patient), a laboratory result, or a clinical diagnosis. Most terms, especially those in standard terminologies, are represented by both a code and a description. The code is often a unique, numeric identifier that abstractly represents the concept. A description can be a shorthand name or descriptor that is human-readable. For example, a code 12345 might have a description of “Hemoglobin A1c.” Some standard terminologies often have multiple axes or dimensions for each term to more precisely define them.

3.3 Intervention descriptions

In the following section, a brief overview of the interventions categorised according to the OMAHA nursing intervention classification is given:

Case management (n = 38) (Supplementary Table 2)

Surveillance (n = 27) (Supplementary Table 3)

Teaching, counselling and guidance (n = 131) (Supplementary Table 4)

Treatment and procedures (n = 18) (Supplementary Table 5)

3.3.1 Case management

Thirty-eight studies (57,193 participants) were categorised as case management, most commonly employing a parallel RCT design (n = 26). The sample size varied across studies from 20 to 49,311 participants. Most studies included 101–500 participants (n = 27). Case management studies involved adult (or older adult) participants in 37 studies; only one trial included a mixed population of people with cancer and their carers (Supplementary Table 2).

Over half of the studies in this category included participants with a range of different cancer types (classed as ‘multiple’) (n = 20) (Supplementary Table 2, Fig. 2). The majority of these studies were focused on the active phase of cancer treatment (n = 20) and end-of-life (n = 12) (Fig. 3).

The most common focus of case management interventions was the provision of supportive care or psychosocial and/or psychosexual care. Other common components of these interventions were the management of signs and symptoms, primarily emotional and continuity of care (Supplementary Table 2). Specialist oncology nurses (n = 13) or advanced cancer nurses (n = 12) delivered the majority of interventions (n = 23), however a variety of descriptors were used to document their professional roles, education and training (Supplementary Table 2, Fig. 4).

Fig. 4. Bar graph showing the level of nurse interventionist using the CANO 2016 descriptors.

Key: ADV: advanced, CM: case management intervention category; GEN: general nurse, SPEC: specialist nurse; SURV: surveillance intervention category; TGC: teaching, guidance and counselling intervention category; TP: treatment and procedure intervention category; UNC: unclear; >1 type (more than one type of nurse included in the study).

The number of contacts for delivering case management interventions were clearly reported in 23 studies and ranged from 1 to 18 contacts (face-to-face and telephone), Supplementary Fig. 5a. The length of interventions ranged widely from 1.5 to 260 weeks (Supplementary Fig. 5b). The amount of time attributed to case management interventions delivered by cancer nurses ranged from 120 to 1377 min per participant (Supplementary Table 2).

Standardized Nursing Language as an Organizing Framework

Diagnoses and symptom clusters, as well as interventions and outcomes, were developed using standardized nursing language as the organizing framework for the CPPD practice guideline. No other national clinical guideline development work, using an evidence-based approach, has integrated standard nursing language into the structure and documentation of the guideline.

The work of developing and using standardized language to describe the work of nursing began with the North American Nursing Diagnosis Association in 1975. Researchers at the University of Iowa College of Nursing have conducted classification research since the mid-1980s. The Nursing Interventions Classification (McCloskey & Bulechek, 2000) is now in its third edition, and the Nursing Outcomes Classification (Johnson, Maas, & Moorhead, 2000) is in its second edition.

The organizing framework of standardized nursing language (using the specific standardized nursing languages of the North American Nursing Diagnosis Association, the Nursing Interventions Classification, and the Nursing Outcomes Classification) was chosen by the project team because it

Provides a standardized language for nursing

Facilitates appropriate selection of nursing diagnoses, nursing interventions, and nursing outcomes

Defines and predicts outcomes that are nursing-sensitive; that is, outcomes nurses can achieve with patients

Facilitates communication of nursing treatments to other nurses and other providers

Enables researchers to examine the effectiveness and cost of nursing care

Promotes integration of nursing services into existing reimbursement systems

Facilitates computerized clinical database use across settings

Communicates the nature of nursing to the public

4.3 Types of interventions

Studies that included any modality of service in which APNs could develop their role through different interventions. Interventions were conceptualized as defined by the Nursing Interventions Classifications (Bulechek et al., 2012), as any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient outcomes. These could include specific interventions (assessment, test ordering, prescription, etc.), or more complex interventions (case management, making diagnoses, provision of consultancy for other professionals, referral, etc.). The type of providers included practice nurses, or advanced practice nurses, with or without the participation of physicians. Reimanis et al. (2001) and Manley's (1997) criteria were applied to identify APNs’ role in the studies (Table 2). Other professionals considered were community workers, social workers, occupational therapists, rehabilitation therapists, podiatrists, physiotherapists, and nutritionists. These staff members were included only if they were associated with the intervention of an APN, as members of the team, in order to highlight the APN leadership role in a multidisciplinary team.