1. Ersek, Mary PhD, RN

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NURSING INTERVENTIONS CLASSIFICATION, 3RD ED NURSING OUTCOMES CLASSIFICATION, 2ND ED NURSING INTERVENTIONS: EFFECTIVE NURSING TREATMENTS, 3RD ED NIC: JC McCloskey and GM Bulechek, eds NOC: M Johnson, M Maas, and S Moorhead, eds Nursing Interventions: GM Bulechek and JC McCloskey, eds Mosby, Inc. 11830 Westline Industrial Dr St. Louis, MO 63146 Phone: 314-872 8370 Fax: 314-432 1380 Web: E-mail:


This trio of books provides the reader with a "state-of-the-art" view of the Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) systems. All 3 volumes are edited by nurse theorists and researchers at the University of Iowa who have been awarded several grants from federal and private sources to develop and refine the classifications. Many of the co-investigators and contributors to each book are leaders in these movements and/or prominent nurse researchers in specific clinical fields, such as pain management or gerontology.


The purposes of the classification systems are clearly articulated in all 3 books. Nursing needs a common language to communicate what nurses do, within both the profession and the larger healthcare community, which includes patients and families, other healthcare providers, and those who direct healthcare policy and reimbursement. Standard nomenclature and theoretical models of practice provide a framework from which to expand nursing knowledge and conduct research on nursing interventions and outcomes. Widely accepted empirically-based nursing diagnoses, interventions, and outcomes facilitate the development of nursing and healthcare information systems. Without standard language to identify nursing contributions to patient care, it is difficult to evaluate care and determine the costs of services provided by nurses. Finally, the classification systems are useful for teaching students the steps of the nursing process and clinical decision making.


These arguments are difficult to refute, because nursing's effect on patient outcomes is largely invisible. These books describe the efforts of a diverse group of nurses to make explicit what nurses do and how they influence healthcare outcomes. Although I'm not an expert or a strong advocate of nursing diagnosis or NIC/NOC, I appreciated the systematic way each was developed and tested. This appreciation came from reading the introductory chapters that describe the historical and theoretical background of the classification systems. The authors also detail the methodologies for constructing the systems and for field-testing the instruments based on NIC and NOC. Also included are discussions of other related systems, such as the Nursing Management Minimum Data Set (NMMDS) and the Nursing Diagnosis Extension Classification (NDEC). How these projects complement and build upon one another is described, and articulations among the systems are included in subsequent chapters, showing links between currently accepted NANDA diagnoses and appropriate interventions (NIC) or outcomes (NOC).


The NIC and NOC books also include discussions of the conceptual and methodologic challenges and controversies surrounding the development and implementation of the classification systems. Both books use a question-and-answer format to explore the reasons behind certain decisions made by the investigators. For example, the NOC book addresses questions such as: "What are nursing-sensitive outcomes?" and "How are these outcomes and indicators validated?" This format effectively draws the reader into a discussion rather than presenting a treatise.


Occasionally, the details are overwhelming and the acronyms confusing, but with effort the reader is rewarded with greater insight regarding these ambitious projects. Both books also contain several useful appendices. Especially valuable were the appendices in the NOC book that contain examples of the actual integration of the nursing diagnoses, interventions, and outcomes schema into care pathways and care plans from a variety of clinical settings.


The most disappointing part of the books was the alphabetical listings of the 486 interventions and the 260 outcomes. I focused on several that are particularly relevant to my work in pain management and end-of-life care. In the NIC listings, it was confusing to read a list of actions that had no discernible conceptual organization or prioritization. I realize that nurses are supposed to choose the most appropriate actions based on assessment, but a simple, seemingly unordered, laundry list without connection to assessment data felt conceptually and heuristically barren. I also had difficulty with the activities listed under "Truth Telling." The tone of the list ignored the cultural variations among patients. Many patients do not want to be fully informed and instead prefer to let family members make decisions. Although this practice runs counter to the ethical and legal precepts guiding western healthcare, there is recognition among many bioethicists and state legislatures that truth should be offered to, not inflicted upon, the patient. These important subtleties are missing from the current NIC conceptualization.


The NOC listings for pain outcomes also deviated from established clinical guidelines. Pain outcomes are grouped under 4 major categories: Pain Control, Pain: Disruptive Effects, Pain Level, and Pain: Psychological Response. The editors identify the need to limit the number of activities included under each outcome; however, conceptually I have a difficult time believing that one could pick and choose pain outcomes-all are necessary, so why separate them? Another difficulty is the lack of differentiation between outcomes for chronic and acute pain. For example, the Pain Level outcome lists several signs of acute pain: changes in respiratory rate, heart rate, and sweating. Autonomic nervous system activation occurs in acute pain, whereas behavioral signs, such as social withdrawal and inactivity, are characteristic of chronic pain. Failing to differentiate between the two seems misguided and confusing.


The result of my perusal of the NIC and NOC listings was that I was left with more questions than answers. Although the criteria for choosing the key literature sources for the NOC system are listed, I wondered why there was such heavy reliance in both books on nursing texts, with much less attention to well-designed research and national clinical guidelines. Another pressing question is whether the prescribed standard format can adequately capture the nuances and complexities of clinical practice and decision making.


After immersing myself in the skeletal listings of the NIC and NOC books, I turned to Bulechek and McCloskey's Nursing Interventions: Effective Nursing Treatments, 3rd edition. This book expands on selected NIC interventions. The book is composed of 43 chapters that are organized according to the NIC categorization scheme: (1) basic physiologic interventions, (2) complex physiologic interventions, (3) behavioral interventions, (4) safety interventions, and (5) health system interventions. In each chapter, the authors review the empirical evidence for each intervention and describe a detailed plan for implementing the intervention. The list of contributors is impressive and includes many recognized experts and experienced nurse researchers. For example, Barbara Braden and Nancy Bergstrom wrote the chapter on pressure ulcer management.


Nursing Interventions fleshes out the details for these interventions. The approach is thorough, scholarly, and well-suited for the intended audience of graduate students and researchers. I agree with the editors that undergraduate students can also use the book, focusing on specific topics that they experience in clinical courses. I also appreciated the critical eye that the authors brought to their work. For example, the chapter on therapeutic touch examines the controversy surrounding this intervention.


Although each of these 3 books alone provides insight about nursing diagnosis, interventions, and outcomes, much is gained by seeing how each complements the others. I wish that the NIC and NOC classifications explicitly incorporated the critical analysis and research base of the Nursing Interventions book. On the other hand, the NIC and NOC books offer a broader, albeit less in-depth, view. One also needs to remember the editors' acknowledgments that these books reflect the state of the science now. We have a long way to go to further test, evaluate, and implement the nursing classification systems. However, these books also demonstrate just how far we've come.