During the 1980s, I was the sole author or co-author of a trilogy of papers about what I referred to as Hallmarks of Success. The first paper was Hallmarks of Success in Nursing Theory Development (Fawcett, 1983). The second paper was Hallmarks of Success in Nursing Research (Fawcett, 1984a, 1984b). The third paper was Hallmarks of Success in Nursing Practice (Fawcett & Carino, 1989). Each of the papers emphasized the importance of knowledge development and the use of that knowledge within our discipline. In 1999, I had an opportunity to review what had been accomplished since the publication of the 1980s papers (Fawcett, 1999).
The purpose of this blog is to review the evolution of the hallmarks since 1983 and offer my understanding of the status of these hallmarks in 2023. Note that I now regard nursology as the most appropriate word for our discipline (see Fawcett et al., 2015). I ask for the indulgence of readers for what is my lack of modesty in writing about my own papers and referring to them as Notable Works.
Nursology Theory Development-Evolution from 1983 to 2023
The four hallmarks identified in my 1983 paper and then discussed in my 1999 paper are: “specification of a metaparadigm for nursing, explication of conceptual models of nursing, explication of unique nursing theories, and theories shared with other disciplines” (Fawcett, 1999, p. 311).
In the four decades since the publication of the theory development hallmarks, the concepts of our disciplinary metaparadigm have evolved from person, environment, health, and nursing to human beings, global environment, culture, planetary health, and nursologists’ activities (Fawcett, 2023a, 2023b, in press). The most recent version of the metaparadigm concepts takes into account nursology’s growing awareness of the importance of worldwide changes in environment and the equally important emphasis on the health of not only human beings but also of our planet, as one way to articulate a concern for the effects of worldwide climate change, both on the surface and within the and the deep oceans (the abyss) of Planet Earth. Perhaps the next iteration of the metaparadigm concepts will include consideration the health of the universe.
Substantial progress is evident in the development of many more nursology-specific conceptual models and theories, with the relatively recent addition of situation-specific theories. See https://nursology.net/nurse-theories/ for summaries of many nursology conceptual models, middle-range theories, and situation-specific theories. Noteworthy is that the arguably most widely recognized nursology conceptual models in 1983 remain as such in 2023—Johnson’s Behavioral System Model, King’s Conceptual System, Levine’s Conservation Model, Neuman’s Systems Model, Orem’s Self-Care Framework, Rogers’ Science of Unitary Human Beings, and Roy’s Adaptation Model (see Fawcett, 2017), although additions to or revisions of some content over the years have been made by the theorist and/or those of us who use these conceptual models.
Nursologists continue to use theories developed by members of other disciplines although there is little if any discussion of whether these theories could be considered as shared (see Barnum, 1979, 1998), that is, equally relevant for nursology situations. See Gazarian et al. (2022) for an example of discussion of non-nursology theories used to guide nursology PhD dissertations that were focused only on health policy.
Nursology Research- Evolution from 1984 to 2023
The three hallmarks identified in my 1984a and 1984b papers and then discussed in my 1999 paper are: “specification of the boundaries of nursing research, explication of the types of research needed by the professional discipline of nursing, and delineation of research activities appropriate for nurses according to educational preparation” (Fawcett, 1999, p. 311).
Some progress has been made for these hallmarks. However, as of 2023, there is no explicit consensus about what the boundaries of nursology discipline-specific research should be, not even at the level of nursology’s metaparadigm (Fawcett, 2023, in press). There also is no consensus about the types of research needed by our discipline, although there has been increased recognition and approval of quantitative, qualitative, and mixed method approaches, which indicates an advance from the earlier emphasis on quantitative research. Furthermore, there is some acceptance of the need for research or other types of inquiry needed to develop empirical, aesthetic, ethical, spiritual, personal knowing, sociopolitical, and emancipatory theories.
There is a modest advancement in understanding and acceptance of nursologists’ research activities based on different academic degrees (American Association of Colleges of Nursing [AACN], 2021). For example, there is some recognition that baccalaureate degree prepared nursologists are prepared to engage in application of the findings of nursing research as the evidence needed for practice. Master’s degree prepared nursologists may be expected to focus on identifying and evaluating the evidence for practice activities and then advocating for application of practice activities for which strong evidence exists. Nursologists holding the Doctor of Nursing Practice degree typically are expected to conduct quality improvement (QI) projects and apply the results in practice, particularly as recommendations for revision of existing health policies or development of new health policies in a clinical setting. There is some indication of recognition that these QI projects and health policy recommendations center on clinical practice guidelines that may be within a specific clinical facility or may be guidelines promulgated by a national or international task force (see Fawcett, 2022). Nursologists holding a PhD or other research-focused doctoral degree are prepared “to create, translate, and communicate new knowledge as leaders within institutions of higher education and outside of academia” (https://www.aacnnursing.org/news-data/position-statements-white-papers/research-focused-pathways-to-excellence). New knowledge is created by means of original empirical and other types of research and other forms of scholarship, such as historical research and philosophic inquiry.
Nursology Practice-Evolution from 1989 to 2023
The four hallmarks identified in the 1989 Fawcett and Carino paper and then discussed in my 1999 paper are: “use of conceptual models of nursing to guide nursing practice, development of classification systems, establishment of formal partnerships between nursing education and nursing service, and recognition of clinical scholars and clinical scholarship” (Fawcett, 1999, p. 312).
Some progress for these hallmarks is evident. There was a substantial increase in use of nursology conceptual models to guide nursology practice throughout the 1980s and into the early 1990s (Fawcett & DeSanto-Madeya, 2013). Since that time, however, relatively few publications focus on this topic. One can only assume that interest in the use of explicit nursology conceptual models as guides for practice has waned. However, inasmuch as it is impossible to think atheoretically (Fawcett, 2019), it may be that whatever frame of reference nursologists now use to guide their practice is more implicit than explicit. Alternatively, it may be that nursologists do not clearly distinguish between practice delivery models, such as team nursing or primary nursing, that guide how nursology practice is organized and how services are implemented, from nursology conceptual models that provide an overall frame of reference for the why of practice (Fawcett, 2021a, 2021b). It also may be that the inclusion of the knowledge domain in the recent AACN Essentials (2021) will sensitize nursology educators to explicitly identify the conceptual basis for practice. However, I am very concerned that the AACN (2021) Essentials have emphasized competencies, described as
a process whereby students are held accountable to the mastery of competencies deemed critical for an area of study. Competency-based education is inherently anchored to the outputs of an educational experience versus the inputs of the educational environment and system. Students are the center of the learning experience, and performance expectations are clearly delineated along all pathways of education and practice. Across the health professions, curriculum, course work, and practice experiences are designed to promote responsible learning and assure the development of competencies that are reliably demonstrated and transferable across settings. By consistently assessing their own performance, students develop the ability to reflect on their own progress towards the achievement of learning goals and the ongoing attainment of competencies required for practice. (AACN, 2021, p. 4)
Note that this description does not include explicit mention of application of knowledge (or the knowledge identified in the knowledge domain). Thus, this emphasis could, I fear, overshadow a focus on practice as application of knowledge by focusing on the skills of nursology practice.
The so-called professional practice models required for Magnet® recognition could be considered use of a conceptual model to guide practice. However, these professional practice models tend to be very specific to a clinical facility and are not widely known, at least through publications or in descriptions of the nursing focus in advertisements about Magnet® designated clinical facilities, such as those found in the American Nurse Journal.
Development of a classification system for nursology has progressed through the substantial work of NANDA International (previously known as the North American Nursing Diagnosis Association; https://nanda.org/who-we-are/our-story/). Inasmuch as the conceptual frame of reference for NANDA-I diagnoses is not evident in the website materials, it is impossible to determine the conceptual basis for each diagnosis. A few of the widely known nursology conceptual models (e.g., the Roy adaptation model, Roy, 2009) have adopted some nursing diagnoses from the NANDA list although these conceptual models have not yet developed distinctive classification systems. The one exception is a Neuman Systems Model-based classification system development by Ziegler (1982). However, there are no publications indicating the use of this classification system to date.
The use of the term, diagnosis is, I believe, inappropriate when applied to judgements about the results of a nursologist’s assessment of a person’s behaviors, as diagnosis means knowledge of disease. Levine (1966) offered trophicognosis—knowledge of nursing judgement–as the more appropriate term.
Other classification systems are the Nursing Intervention Classification ([NIC] https://nursing.uiowa.edu/cncce/nursing-interventions-classification-overview) and the Nursing Outcomes Classification (NOC). No mention of a conceptual framework for NIC is mentioned in the website materials. In contrast, although “[t]he 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 content of this conceptual framework is not evident (https://nursing.uiowa.edu/cncce/nursing-outcomes-classification-overview). Noteworthy is that the website materials for NIC and NOC do not mention any association of NIC or NOC with NANDA diagnoses nor any connection between NIC and NOC.
There is growing recognition of clinical scholars and clinical scholarship, especially since the implementation of Doctor of Nursing Practice (DNP) programs. Nursologists holding a DNP degree are considered clinical scholars and their scholarly work focuses on quality improvement projects, which are considered clinical scholarship, at least at some universities and clinical agencies.
Formal partnerships between nursing education and programs and nursing services are evident. Examples of such partnerships, which are based on use of the Neuman Systems Model (Neuman & Fawcett, 2011), are given in Beckman and Fawcett’s (2017) book.
References
American Association of Colleges of Nursing. (2021). The essentials: Core competencies for professional nursing practice.
Barnum, B. S. (1979). Nursing theory: Analysis, application, evaluation. Little, Brown. Barnum, B. S. (1998). Nursing theory: Analysis, application, evaluation (5th ed.). Lippincott.
Beckman, S., & Fawcett, J. (Eds.). (2017). The Neuman systems model: Celebrating academic-practice partnerships. Fort Wayne, IN: Neuman Systems Model Trustees Group.
Fawcett, J. (1983). Hallmarks of success in nursing theory development. In P. L. Chinn (Ed.), Advances in nursing theory development (pp. 3 17). Aspen.
Fawcett, J. (1984a). Hallmarks of success in nursing research. Advances in Nursing Science, 7(1), 1 11. doi: 10.1097/00012272-198410000-00002
Fawcett, J. (1984b). Hallmarks of nursing research: Past, present, future. In Research: The basis for nursing in the eighties (Monograph series 1984: One, pp. 1 21). Sigma Theta Tau. (Keynote address presented at Third Annual Research Conference, University of South Florida College of Nursing, Tampa, FL. May 18, 1984.)
Fawcett, J. (1999). The state of nursing science: Hallmarks of the 20th and 21st centuries. Nursing Science Quarterly, 12 (4), 311-.315. doi: 10.1177/089431849901200411. [Reprinted in Kenny, J. W. (2002). Philosophical and theoretical perspectives for advanced nursing practice (3rd ed., pp. 207-213). Jones and Bartlett. Reprinted in Cody, W. K. (2006). Philosophical and theoretical perspectives for advanced nursing practice (4th ed., pp. 51-57). Jones and Bartlett. Reprinted in Cody, W. K. (Ed.). (2013). Philosophical and theoretical perspectives for advanced nursing practice (5th ed., pp. 35-42). Jones and Bartlett. ]
Fawcett, J. (2017). Applying conceptual models of nursing: Quality improvement, research, and practice. Springer.
Fawcett, J. (2019, January 22) The Impossibility of Thinking “Atheoretically.” nursology.net. https://nursology.net/2019/01/22/the-impossibility-of-thinking-atheoretically/
Fawcett, J. (2021a). Thoughts about nursing practice delivery models. Nursing Science Quarterly, 34(3), 328-330. doi: 10.1177/08943184211010460
Fawcett, J. (2021b). More thoughts about nursing practice delivery models. Nursing Science Quarterly, 34(4), 458-461. doi:10.1177/08943184211031584
Fawcett, J. (2022). Thoughts about health policies. Nursing Science Quarterly, 35(3), 378-382. https://doi.org/10.1177/08943184221092444
Fawcett, J. (2023a, January 17). Evolution of One Version of Our Disciplinary Metaparadigm. nursology.net. https://nursology.net/2023/01/17/evolution-of-one-version-of-our-disciplinary-metaparadigm/
Fawcett, J. (2023b). Thoughts about the metaparadigm of nursing: Contemporary status and recommendations for evolution. Nursing Science Quarterly 36(3), 303-305. doi: 10.1177/08943184231169770
Fawcett, J. (in press). More thoughts about the evolution of the metaparadigm of nursing: Addition of culture as another metaparadigm concept and definitions of all the concepts. Nursing Science Quarterly
Fawcett, J., Aronowitz, T., AbuFannouneh, A., Al Usta, M., Fraley, H. E., Howlett, M. S. L., Mtengezo, J. T., Muchira, J. M., Nava, A., Thapa, S., & Zhang, Y. (2015). Thoughts about the name of our discipline. Nursing Science Quarterly, 28(4), 330-333. doi: 10.1177/0894318415599224
Fawcett, J., & Carino, C. (1989). Hallmarks of success in nursing practice. Advances in Nursing Science, 11(4), 1-8. https://doi.org/10.1097/00012272-198907000-00004
Fawcett, J., & DeSanto-Madeya, S. (2013). Contemporary nursing knowledge: Analysis and evaluation of nursing models and theories (3rd ed.). F.A. Davis
Gazarian, P., Ballout, S., Heelan-Fancher, L., & Sundean, L. J. (2022). Theories, models, and frameworks used in nursing health policy dissertations: A scoping review. Applied Nursing Research, 67, 8 pages. doi: 10.1016/j.apnr.2020.151234
Levine, M.E. (1966). Trophicognosis: An alternative to nursing diagnosis. In American Nurses’ Association Regional Clinical Conference (Vol. 2, pp. 55–70). American Nurses’ Association.
Neuman, B., & Fawcett, J. (Eds.). (2011). The Neuman systems model (5th ed.). Pearson Roy, C. (2009). The Roy adaptation model (3rd ed.).
Pearson. Ziegler, S.M. (1982). Taxonomy for nursing diagnosis derived from the Neuman systems model. In B. Neuman, The Neuman systems model: Application to nursing education and practice (pp. 55–68). Appleton-Century Crofts.
Greetings Dr. Fawcett
And many thanks for a very interesting and enlightening article! I do enjoy reading your publications! As first editor of the Nursing Interventions Classification (NIC) I feel compelled, however, to correct and augment some of the information that you have noted about the NIC, the Nursing Outcomes Classification (NOC) and a little about the NANDA-I, too.
First, I must apologize that the website information you chose to use for your source for NIC and NOC is not up to date, a problem we are currently rectifying. More importantly, in this time of electronic health records (EHRs) and the need to electronify everything related to nursing documentation, I should correct some of your comments and add additional useful information about standardized nursing languages (SNLs) so that your readers are well-informed.
“NIC, like all classifications, accomplishes its goals first by reflecting the work that nurses perform and second by carefully organizing and categorizing that work. In other words, NIC is useful when the interventions reflect and are connected to the real world of nursing practice” (Wagner et al., 2024, p. 2). Although the classification itself is a taxonomy which (by definition) is a modeling of nomenclature into recognizable levels or classes, I realize that you are lamenting the lack of a nursing conceptual model in the NIC. Notwithstanding the obvious connection of the NIC to the nursing conceptual practice model of Assess, Plan, Intervene, Evaluate (or APIE as it was commonly known) in the care planning process, we also depict the usefulness and interconnectivity of the NIC to nursing care and clinical decision making in the Outcome Present State Test (OPT) model of reflective clinical reasoning, first developed by Pesut and Herman (1999) and applied by Kautz et al. (2006) incorporating the NIC, NOC and NANDA-I. Within the OPT model, NIC can be used in conjunction with NANDA-I diagnoses and NOC to assist students in developing the skills necessary for clinical decision making. Kautz et al. conducted extensive research into the teaching of clinical reasoning using SNLs with the OPT model, noting that “students who consistently used NNN language with OPT models were the students who performed well in the clinical area” (2006, p. 137). We have included the model in our NIC textbooks since 2013 (Bulechek et al., 2013; Butcher et al., 2018; Wagner et al., 2024) and provide more detail as to the application of NIC and NOC to the model in the opening chapters of the books (Bulechek et al., 2013; Butcher et al., 2018; Wagner et al., 2024).
That information aside, the point I would most like to make concerns the usefulness of SNLs in accurately depicting nursing practice and the provision of nursing care. I need to emphasize the urgent need for a change in our current documentation practices, not only because what nurses do is woefully underrepresented and inaccurately portrayed, but also because when well-developed SNLs are used to document the work of nurses in practice, we can determine the impact of nursing care on health outcomes. Unfortunately, with the movement toward computerized health care using EHRs in the US, the knowledge of nursing informaticists with expertise in SNLs is not always pursued. In addition, unlike many European countries (e.g., Italy, Spain, Estonia, Finland), the U.S. has not enacted federal policies for the use of SNLs. This has resulted in nursing documentation in EHR systems that focuses on flowsheets with check-boxing tasks and assessments and an overarching control of that documentation by vendors who build individualized systems for each organization. Not only does this result in a lack of interoperability of the data (Keenan, 2014), but also renders invisible the intellectual and critical thinking work of nurses to identify patient problems, plan interventions and measure outcomes of those interventions (Wagner et al., 2023).
This is a VERY important point to make in the world of electronic health records (EHRs) and sadly, something about which most nursing leaders and nursing professionals are woefully uninformed. Currently, EHRs are harmful to us as a profession since we have little to no ability to track the outcomes of our work in providing nursing care, and frequently have no control over what and how we document in those EHRs.
I would be remiss if I did not point out that research conducted in the few but enlightened health care organizations using these languages produces meaningful data that are valid representations of nursing care and amenable to efficient processing and analysis (Khokhar et al., 2017), demonstrate relationships between nursing care plan components and patient outcomes (Sanson et al., 2019; Bertocchi et al., 2023), and assist the care provider in targeting areas of need (Herrero et al., 2018). Since NANDA-I, NIC and NOC (collectively known as NNN) have been used most often in research and secondary data analysis worldwide (Tastan et al, 2014; Fennelly et al, 2021, Macieira et al., 2019) are suitable for use in secondary analysis of EHR data (Macieira et al., 2019), and have sound taxonomic nursing structures (including definitions on all classification levels), they are extraordinarily useful for inclusion in nursing documentation systems.
Finally, I must note that we do have multiple linkage books that connect NNN (Johnson et al., 2012) and we have recently published three articles containing useful linkages for COVID-19 conditions (Moorhead et al., 2020; Swanson et al., 2020, Wagner et al., 2021), so linkages are there and these linkage articles are available on the website you mentioned. We are currently negotiating for a fourth linkage book, so stay tuned!
Again, I thank you for your kind mention of NNN in your article, but felt it best to augment your information to depict NIC and NOC more accurately, give information about our linkage materials, and provide a brief expose about the current state of nursing documentation. I hope your collective readership can benefit from my small contribution.
References
Bertocchi, L., Dante, A., La Cerra, C., Masotta, V., Marcotullio, A., Jones, D., Petrucci, C., & Lancia, L. (2023). Impact of standardized nursing terminologies on patient and organizational outcomes: A systematic review and meta-analysis. Journal of Nursing Scholarship: An Official Publication of Sigma Theta Tau International Honor Society of Nursing, 10.1111/jnu.12894. Advance online publication. https://nam10.safelinks.protection.outlook.com/?url=https%3A%2F%2Fdoi.org%2F10.1111%2Fjnu.12894&data=05%7C01%7Cjacqueline.fawcett%40umb.edu%7C894f7a45424542e69c0908dbd65ee3f0%7Cb97188711ee94425953c1ace1373eb38%7C0%7C0%7C638339475270979366%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=aAz46xrl7%2BXl5RzjpK8awGtVnSZAWGDsF%2FmlwkLkXK0%3D&reserved=0
Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C.M. (2018). Nursing Interventions Classification (NIC). 7th edition. St. Louis, MO: Mosby Elsevier.
Bulechek, G., Butcher, H., Dochterman, J., & Wagner, C.M. (2013). Nursing Interventions Classification (NIC). 6th edition. St. Louis, MO: Mosby Elsevier.
Fennelly, O., Grogan, L., Reed, A., & Hardaker, N. R. (2021). Use of standardized terminologies in clinical practice: A scoping review. International Journal of Medical Informatics, 149, 104431. https://nam10.safelinks.protection.outlook.com/?url=https%3A%2F%2Fdoi.org%2F10.1016%2Fj.ijmedinf.2021.104431&data=05%7C01%7Cjacqueline.fawcett%40umb.edu%7C894f7a45424542e69c0908dbd65ee3f0%7Cb97188711ee94425953c1ace1373eb38%7C0%7C0%7C638339475270979366%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=eqw6JqHNvi5SeG8ufPBTHHCBHx5170Vkb2FDOqstF2E%3D&reserved=0
Herrero Jaén, S., Madariaga Casquero, L. (2018). Las variables de salud y su aplicación en el cálculo del estado de salud de las personas. ENE Revista de Enfermeria, 12(3):1-20.
Kautz, D. D., Kuiper, R., Pesut, D. J., & Williams, R. L. (2006). Using NANDA, NIC, and NOC (NNN) language for clinical reasoning with the Outcome-Present State-Test (OPT) model. International Journal of Nursing Terminologies and Classifications: The Official Journal of NANDA International, 17(3), 129–138. https://nam10.safelinks.protection.outlook.com/?url=https%3A%2F%2Fdoi.org%2F10.1111%2Fj.1744-618X.2006.00033.x&data=05%7C01%7Cjacqueline.fawcett%40umb.edu%7C894f7a45424542e69c0908dbd65ee3f0%7Cb97188711ee94425953c1ace1373eb38%7C0%7C0%7C638339475270979366%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=OYKgPsVWpseQ4YG15coLMGPc0QqUbhVhG3Gnzq03ADY%3D&reserved=0
Keenan, G. (2014). Big Data in health care: An urgent mandate to CHANGE nursing EHRs! Online Journal of Nursing Informatics (OJNI), 18(1), 46-49. Available at https://nam10.safelinks.protection.outlook.com/?url=https%3A%2F%2Fojni.org%2Farchive.html&data=05%7C01%7Cjacqueline.fawcett%40umb.edu%7C894f7a45424542e69c0908dbd65ee3f0%7Cb97188711ee94425953c1ace1373eb38%7C0%7C0%7C638339475270979366%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=EPm3SFX%2BlR6K3kC8ZbYMJ6x%2BhJMCjWCFeTAmvb31BGU%3D&reserved=0
Khokhar, A., Lodhi, M. K., Yao, Y., Ansari, R., Keenan, G., & Wilkie, D. J. (2017). Framework for mining and analysis of standardized nursing care plan data. Western Journal of Nursing Research, 39(1), 20–41. https://nam10.safelinks.protection.outlook.com/?url=https%3A%2F%2Fdoi.org%2F10.1177%2F0193945916672828&data=05%7C01%7Cjacqueline.fawcett%40umb.edu%7C894f7a45424542e69c0908dbd65ee3f0%7Cb97188711ee94425953c1ace1373eb38%7C0%7C0%7C638339475270979366%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=Ke3%2FED9UX45pFgXWU8PgBjT2uHLA%2FZ4iCzQEDdzwLmY%3D&reserved=0
Macieira, T. G. R., Chianca, T. C. M., Smith, M. B., Yao, Y., Bian, J., Wilkie, D. J., Dunn Lopez, K., & Keenan, G. M. (2019). Secondary use of standardized nursing care data for advancing nursing science and practice: A systematic review. Journal of the American Medical Informatics Association: JAMIA, 26(11), 1401–1411. https://nam10.safelinks.protection.outlook.com/?url=https%3A%2F%2Fdoi.org%2F10.1093%2Fjamia%2Focz086&data=05%7C01%7Cjacqueline.fawcett%40umb.edu%7C894f7a45424542e69c0908dbd65ee3f0%7Cb97188711ee94425953c1ace1373eb38%7C0%7C0%7C638339475270979366%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=61YMFlbOccIkWyznjwoVcK6MWr3k3IvB1Gtt0xI4Ago%3D&reserved=0
Moorhead, S., Macieira, T. G. R., Dunn Lopez, K., Mantovani, V. M., Swanson, E., Wagner, C., & Abe, N. (2021). NANDA-I, NOC and NIC linkages to SARS-COV-2 (COVID-19): Part 1. Community response. International Journal of Nursing Knowledge, 32(1), 59-67.
Pesut, D., & Herman, J. (1999). Clinical reasoning: The art and science of critical and creative thinking. Delmar.
Sanson, G., Welton, J., Vellone, E., Cocchieri, A., Maurici, M., Zega, M., Alvaro, R., & D’Agostino, F. (2019). Enhancing the performance of predictive models for hospital mortality by adding nursing data. International Journal of Medical Informatics, 125, 79–85. https://nam10.safelinks.protection.outlook.com/?url=https%3A%2F%2Fdoi.org%2F10.1016%2Fj.ijmedinf.2019.02.009&data=05%7C01%7Cjacqueline.fawcett%40umb.edu%7C894f7a45424542e69c0908dbd65ee3f0%7Cb97188711ee94425953c1ace1373eb38%7C0%7C0%7C638339475270979366%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=a4Nq6ntwoOmqRoj8QUXlweRh26eWNZcz0o5VBWCmnVQ%3D&reserved=0
Swanson, E., Mantovani, V. M., Wagner, C., Moorhead, S., Macieira, T. G. R., Dunn Lopez, K., & Abe, N. (2021). NANDA-I, NOC and NIC linkages to SARS-COV-2 (COVID-19): Part 2. Individual response. International Journal of Nursing Knowledge, 32(1), 68-83.
Tastan, S., Linch, G. C., Keenan, G. M., Stifter, J., McKinney, D., Fahey, L., Lopez, K. D., Yao, Y., & Wilkie, D. J. (2014). Evidence for the existing American Nurses Association-recognized standardized nursing terminologies: A systematic review. International Journal of Nursing Studies, 51(8), 1160–1170. https://nam10.safelinks.protection.outlook.com/?url=https%3A%2F%2Fdoi.org%2F10.1016%2Fj.ijnurstu.2013.12.004&data=05%7C01%7Cjacqueline.fawcett%40umb.edu%7C894f7a45424542e69c0908dbd65ee3f0%7Cb97188711ee94425953c1ace1373eb38%7C0%7C0%7C638339475270979366%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=3KoDozT6fHhzePnRaO2oyksZAr6NnokwM0lusgXpkUA%3D&reserved=0
Wagner, C.M., Butcher, H., & Clarke, M.F. (2024). Nursing Interventions Classification (NIC). 8th edition. Mosby Elsevier.
Wagner, C.M., Lopes, C.T., Jensen, G.A., Moreno, E.A.M., DeBoer, E., & Dunn Lopez, K. (2023). Removing the roadblocks to promoting health equity: Finding the social determinants of health addressed in nursing standardized classifications. JAMIA: Journal of the American Medical Informatics Association, 1-10, https://nam10.safelinks.protection.outlook.com/?url=https%3A%2F%2Fdoi.org%2F10.1093%2Fjamia%2Focad098&data=05%7C01%7Cjacqueline.fawcett%40umb.edu%7C894f7a45424542e69c0908dbd65ee3f0%7Cb97188711ee94425953c1ace1373eb38%7C0%7C0%7C638339475270979366%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=9SfV8mxmFST1h7WQepG6h7AGgrokp3TInURlC8TJv7E%3D&reserved=0
Wagner, C.M., Swanson, E., Moorhead, S., Mantovani, V. M., Dunn Lopez, K., Macieira, T. G. R., Breitenstein, S., & Abe, N. (2021). NANDA-I, NOC and NIC linkages to SARS-COV-2 (COVID-19): Part 3. Family response. International Journal of Nursing Knowledge, 32(2), 1-13.
Greetings Dr. Fawcett!
And many thanks for a very interesting and enlightening article! I do enjoy reading your publications! As first editor of the Nursing Interventions Classification (NIC) I feel compelled, however, to correct and augment some of the information that you have noted about the NIC, the Nursing Outcomes Classification (NOC) and a little about the NANDA-I, too.
First, I must apologize that the website information you chose to use for your source for NIC and NOC is not up to date, a problem we are currently rectifying. More importantly, in this time of electronic health records (EHRs) and the need to electronify everything related to nursing documentation, I should correct some of your comments and add additional useful information about standardized nursing languages (SNLs) so that your readers are well-informed.
“NIC, like all classifications, accomplishes its goals first by reflecting the work that nurses perform and second by carefully organizing and categorizing that work. In other words, NIC is useful when the interventions reflect and are connected to the real world of nursing practice” (Wagner et al., 2024, p. 2). Although the classification itself is a taxonomy which (by definition) is a modeling of nomenclature into recognizable levels or classes, I realize that you are lamenting the lack of a nursing conceptual model in the NIC. Notwithstanding the obvious connection of the NIC to the nursing conceptual practice model of Assess, Plan, Intervene, Evaluate (or APIE as it was commonly known) in the care planning process, we also depict the usefulness and interconnectivity of the NIC to nursing care and clinical decision making in the Outcome Present State Test (OPT) model of reflective clinical reasoning, first developed by Pesut and Herman (1999) and applied by Kautz et al. (2006) incorporating the NIC, NOC and NANDA-I. Within the OPT model, NIC can be used in conjunction with NANDA-I diagnoses and NOC to assist students in developing the skills necessary for clinical decision making. Kautz et al. conducted extensive research into the teaching of clinical reasoning using SNLs with the OPT model, noting that “students who consistently used NNN language with OPT models were the students who performed well in the clinical area” (2006, p. 137). We have included the model in our NIC textbooks since 2013 (Bulechek et al., 2013; Butcher et al., 2018; Wagner et al., 2024) and provide more detail as to the application of NIC and NOC to the model in the opening chapters of the books (Bulechek et al., 2013; Butcher et al., 2018; Wagner et al., 2024).
That information aside, the point I would most like to make concerns the usefulness of SNLs in accurately depicting nursing practice and the provision of nursing care. I need to emphasize the urgent need for a change in our current documentation practices, not only because what nurses do is woefully underrepresented and inaccurately portrayed, but also because when well-developed SNLs are used to document the work of nurses in practice, we can determine the impact of nursing care on health outcomes. Unfortunately, with the movement toward computerized health care using EHRs in the US, the knowledge of nursing informaticists with expertise in SNLs is not always pursued. In addition, unlike many European countries (e.g., Italy, Spain, Estonia, Finland), the U.S. has not enacted federal policies for the use of SNLs. This has resulted in nursing documentation in EHR systems that focuses on flowsheets with check-boxing tasks and assessments and an overarching control of that documentation by vendors who build individualized systems for each organization. Not only does this result in a lack of interoperability of the data (Keenan, 2014), but also renders invisible the intellectual and critical thinking work of nurses to identify patient problems, plan interventions and measure outcomes of those interventions (Wagner et al., 2023).
This is a VERY important point to make in the world of electronic health records (EHRs) and sadly, something about which most nursing leaders and nursing professionals are woefully uninformed. Currently, EHRs are harmful to us as a profession since we have little to no ability to track the outcomes of our work in providing nursing care, and frequently have no control over what and how we document in those EHRs.
I would be remiss if I did not point out that research conducted in the few but enlightened health care organizations using these languages produces meaningful data that are valid representations of nursing care and amenable to efficient processing and analysis (Khokhar et al., 2017), demonstrate relationships between nursing care plan components and patient outcomes (Sanson et al., 2019; Bertocchi et al., 2023), and assist the care provider in targeting areas of need (Herrero et al., 2018). Since NANDA-I, NIC and NOC (collectively known as NNN) have been used most often in research and secondary data analysis worldwide (Tastan et al, 2014; Fennelly et al, 2021, Macieira et al., 2019) are suitable for use in secondary analysis of EHR data (Macieira et al., 2019), and have sound taxonomic nursing structures (including definitions on all classification levels), they are extraordinarily useful for inclusion in nursing documentation systems.
Finally, I must note that we do have multiple linkage books that connect NNN (Johnson et al., 2012) and we have recently published three articles containing useful linkages for COVID-19 conditions (Moorhead et al., 2020; Swanson et al., 2020, Wagner et al., 2021), so linkages are there and these linkage articles are available on the website you mentioned. We are currently negotiating for a fourth linkage book, so stay tuned!
Again, I thank you for your kind mention of NNN in your article, but felt it best to augment your information to depict NIC and NOC more accurately, give information about our linkage materials, and provide a brief expose about the current state of nursing documentation. I hope your collective readership can benefit from my small contribution.
References
Bertocchi, L., Dante, A., La Cerra, C., Masotta, V., Marcotullio, A., Jones, D., Petrucci, C., & Lancia, L. (2023). Impact of standardized nursing terminologies on patient and organizational outcomes: A systematic review and meta-analysis. Journal of Nursing Scholarship: An Official Publication of Sigma Theta Tau International Honor Society of Nursing, 10.1111/jnu.12894. Advance online publication. https://doi.org/10.1111/jnu.12894
Butcher, H., Bulechek, G., Dochterman, J., & Wagner, C.M. (2018). Nursing Interventions Classification (NIC). 7th edition. St. Louis, MO: Mosby Elsevier.
Bulechek, G., Butcher, H., Dochterman, J., & Wagner, C.M. (2013). Nursing Interventions Classification (NIC). 6th edition. St. Louis, MO: Mosby Elsevier.
Fennelly, O., Grogan, L., Reed, A., & Hardaker, N. R. (2021). Use of standardized terminologies in clinical practice: A scoping review. International Journal of Medical Informatics, 149, 104431. https://doi.org/10.1016/j.ijmedinf.2021.104431
Herrero Jaén, S., Madariaga Casquero, L. (2018). Las variables de salud y su aplicación en el cálculo del estado de salud de las personas. ENE Revista de Enfermeria, 12(3):1-20.
Kautz, D. D., Kuiper, R., Pesut, D. J., & Williams, R. L. (2006). Using NANDA, NIC, and NOC (NNN) language for clinical reasoning with the Outcome-Present State-Test (OPT) model. International Journal of Nursing Terminologies and Classifications: The Official Journal of NANDA International, 17(3), 129–138. https://doi.org/10.1111/j.1744-618X.2006.00033.x
Keenan, G. (2014). Big Data in health care: An urgent mandate to CHANGE nursing EHRs! Online Journal of Nursing Informatics (OJNI), 18(1), 46-49. Available at https://ojni.org/archive.html
Khokhar, A., Lodhi, M. K., Yao, Y., Ansari, R., Keenan, G., & Wilkie, D. J. (2017). Framework for mining and analysis of standardized nursing care plan data. Western Journal of Nursing Research, 39(1), 20–41. https://doi.org/10.1177/0193945916672828
Macieira, T. G. R., Chianca, T. C. M., Smith, M. B., Yao, Y., Bian, J., Wilkie, D. J., Dunn Lopez, K., & Keenan, G. M. (2019). Secondary use of standardized nursing care data for advancing nursing science and practice: A systematic review. Journal of the American Medical Informatics Association: JAMIA, 26(11), 1401–1411. https://doi.org/10.1093/jamia/ocz086
Moorhead, S., Macieira, T. G. R., Dunn Lopez, K., Mantovani, V. M., Swanson, E., Wagner, C., & Abe, N. (2021). NANDA-I, NOC and NIC linkages to SARS-COV-2 (COVID-19): Part 1. Community response. International Journal of Nursing Knowledge, 32(1), 59-67.
Pesut, D., & Herman, J. (1999). Clinical reasoning: The art and science of critical and creative thinking. Delmar.
Sanson, G., Welton, J., Vellone, E., Cocchieri, A., Maurici, M., Zega, M., Alvaro, R., & D’Agostino, F. (2019). Enhancing the performance of predictive models for hospital mortality by adding nursing data. International Journal of Medical Informatics, 125, 79–85. https://doi.org/10.1016/j.ijmedinf.2019.02.009
Swanson, E., Mantovani, V. M., Wagner, C., Moorhead, S., Macieira, T. G. R., Dunn Lopez, K., & Abe, N. (2021). NANDA-I, NOC and NIC linkages to SARS-COV-2 (COVID-19): Part 2. Individual response. International Journal of Nursing Knowledge, 32(1), 68-83.
Tastan, S., Linch, G. C., Keenan, G. M., Stifter, J., McKinney, D., Fahey, L., Lopez, K. D., Yao, Y., & Wilkie, D. J. (2014). Evidence for the existing American Nurses Association-recognized standardized nursing terminologies: A systematic review. International Journal of Nursing Studies, 51(8), 1160–1170. https://doi.org/10.1016/j.ijnurstu.2013.12.004
Wagner, C.M., Butcher, H., & Clarke, M.F. (2024). Nursing Interventions Classification (NIC). 8th edition. Mosby Elsevier.
Wagner, C.M., Lopes, C.T., Jensen, G.A., Moreno, E.A.M., DeBoer, E., & Dunn Lopez, K. (2023). Removing the roadblocks to promoting health equity: Finding the social determinants of health addressed in nursing standardized classifications. JAMIA: Journal of the American Medical Informatics Association, 1-10, https://doi.org/10.1093/jamia/ocad098
Wagner, C.M., Swanson, E., Moorhead, S., Mantovani, V. M., Dunn Lopez, K., Macieira, T. G. R., Breitenstein, S., & Abe, N. (2021). NANDA-I, NOC and NIC linkages to SARS-COV-2 (COVID-19): Part 3. Family response. International Journal of Nursing Knowledge, 32(2), 1-13.
Greetings again Dr. Fawcett,
I was trying to post a response but am having some difficulties. Hopefully my latest submission works!
Thanks!
Dr. Cheryl Wagner
Dear Dr. Fawcett
Thank you for your article updating the progress made toward meeting the hallmarks of nursing scholarship. I have long valued the hallmarks and have referenced this work. I do, however, need to address two concerns specifically about the use of nursing standardized languages, specifically NIC and NOC. My first concern is the comment about the lack of integrating theory with nursing classification systems, specifically NIC and NOC. In the NIC textbook, ever since the 5th edition published in 2008, we present the Outcome Present State Test (OPT) model of reflective clinical reasoning and clinical decision-making viewed as the next generation of the nursing process, first developed by Pesut and Herman (1999) and applied by Kuiper et al. (2017). The NIC and NOC editors have incorporated NIC, NOC and NANDA-I (NNN) into the OPT model in all published editions since 2008. Framing is one of the components of the OPT model, and in the text, we describe and show how a nursing conceptual model/theory serves as the “frame” of the entire decision-making process in the OPT model (see Wagner, et. al., 2024, p. 18). In addition, for nurses using the traditional nursing process (APIE) in the care planning process, the selection of a nursing theory would drive the entire decision-making process, including selecting the appropriate NICs for intervention and NOC or evaluation. Thus, in the texts, we have made explicit connections between NIC and NOC to nursing theories in both the use of the OPT model and the nursing process.
Secondly, you may not be aware of the mass of published articles that link NNN. There are literally 1000s of published articles addressing NANDA-NIC-NOC linkages in both research and clinical practice contexts in virtually all patient populations and setting. Many of these published articles are referenced in the textbook. Furthermore, there were three editions a “linkages” textbook (Johnson et al., 2006, 2012), as well as sections in various editions of book NIC and NOC texts providing linkages to NIC and NOC to all NANDA diagnoses and to a range of clinical situations. In addition, NNN has been implemented in a multitude of electronic healthcare documentation systems. At last count, more than 1800 health care agencies use NNN in their EHR globally. Thus, in all these systems, there are clear linkages between NNN. NIC has been translated into 13 different languages and is nursing to teach the nursing process globally, which would naturally include linking NANDA, NOC, and NOC.
Thus, I am happy to say, much progress in making links between NNN in research, practice, and the EHR globally, and there is a model for conceptualizing NNN within various nursing conceptual models, especially clinical decision-making models such as the OPT. Of course, there is much, much more work to be done in getting this work fully integrated into standards of practice, accrediting bodies, all educational and practice settings, and all electronic health care systems. The foundation is there in all these works, now is the time to infuse all of nursing with nursing theories conceptualizing the NNN linkages. I want to thank all Nursology does toward this effort.
Howard K. Butcher, RN; PhD, FAAN
Professor
Florida Atlantic University
Cheryl and Howard
Thank you very much for your comments and the much more comprehensive information about NANDA, NIC, and NOC than I had provided in the blog. I had searched only the website, so did not know about the books and journal articles addressing many of my concerns about NANDA, NIC, and NOC. Hopefully, the website will be updated soon so that many others will have comprehensive information from that resource (Cheryl mentioned that the website is not up to date.)
A concern that lingers for me is how, given that NANDA, NIC, and NOC are based in the OPT model, incorporating content from NANDA, NIC, or NOC into some other nursology conceptual model would be logically compatible–it is likely that philosophic assumptions differ.
Best regards, Jacqui (Jacqueline Fawcett)