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ICNP® Version 1.0 Book

Table of Contents

CHAPTER 2 - ICNP® Development

What is the ICNP®?

Strategies for Moving from ICNP® Beta 2 to Version 1

CHAPTER 2 – ICNP® DEVELOPMENT

What is the ICNP®?

The definitions of the ICNP® have evolved along with the actual development of the terminology.  When the Alpha Version of the ICNP® was released in 1996, it was stated that the ICNP® provided a vocabulary, a new classification for nursing and a framework into which existing vocabularies and classifications can be cross-mapped to enable comparison of nursing data collected using other recognised nursing vocabularies and classifications.  The ICNP® would be a unified framework that would involve naming, sorting and linking the phenomena that describe nursing practice which include what nurses do relative to certain needs to produce certain outcomes (ICN 1996).

Important to ICNP® development is how the ICNP® relates to existing nursing and health care terminology tools. These relationships are also evolving and continue to be a major focus of the development.  

The ICNP® Beta Version was released in 1999.  It provided an opportunity to expand participation in the ongoing development of the ICNP®. Nurses working with the ICNP® Beta Version recommended many changes.  The review and feedback resulted in the publication of ICNP® Beta 2 Version in 2001.  The key types of changes were grammatical, code corrections or changes, and correcting definitions (ICN 2001).

The December 2000 ICNP® Programme Plan defined the ICNP® as a combinatorial terminology for nursing practice that facilitates cross-mapping of local terms and existing vocabularies and classifications.  The ICNP® served as an informational tool for describing nursing practice and providing data that would represent nursing practice in comprehensive health information systems (ICN 2001) (see Figure 2). The ICNP® was to be used to make nursing practice visible in health information systems.  The ICNP® would also be used to describe and integrate nursing into health care research, education, administration and management, and policy development.

With the introduction of the ICNP® Beta 2 Version in 2001, the ICNP® was operationally defined as a classification of nursing phenomena, nursing actions and nursing outcomes which describe nursing practice (ICN 2001).  Nursing phenomena were defined as aspects of health of relevance to nursing practice.  Within the Beta 2 Version were two classification structures: one for nursing phenomena (to represent nursing diagnoses and outcomes) and one for nursing interventions.  The ICNP® Beta 2 Version was a combinatorial terminology with a multi-axial structure.

In the Beta 2 Version, there were eight axes in the nursing phenomena classification structure and another eight axes in the nursing actions classification structure.  A nursing diagnosis was defined as the label given by a nurse to the decision about a phenomenon, which was the focus of nursing interventions.  Using the ICNP® Beta 2 Version, a nursing diagnosis was formed by composing concepts contained in the nursing phenomena classification structure.  Nursing outcomes were defined as the measure or status of a nursing diagnosis at points in time after a nursing intervention.  The nursing phenomena classification structure was therefore also used to compose nursing outcomes.  Nursing interventions were defined as actions taken in response to a nursing diagnosis in order to produce a nursing outcome.  A nursing intervention was composed of concepts contained in the nursing actions classification structure.

Figure 2:  ICNP® Information Tool

Strategies for Moving from ICNP® Beta 2 to Version 1

ICNP® Research and Dissemination

Following its release, the Beta 2 Version of ICNP® was subjected to extensive use and analysis at sites around the world.  The ICN web site for the ICNP® Programme (http://www.icn.ch/database1.htm) includes a database of ICNP® research and development projects.  The database includes abstracts and contact persons for over 65 projects around the world.  Examples of types of ICNP® projects include: 1) validation studies; 2) computer-based information system demonstration projects; 3) research and evaluation teams; and 4) cross-mapping projects.  In addition, the ICN web site includes a reference list of more than 100 publications about the ICNP® (http://icn.ch/bib-icnp-references.htm).

ICNP® Country Project Funded by the W.K. Kellogg Foundation

In 1994 nurses from nine countries in Africa, North America and South America met in Tlaxcala, Mexico to consider proposals for the development of an informational tool to support community-based nursing programmes and primary health care nursing systems.  The meeting was organised by the International Council of Nurses (ICN) and funded by the W.K. Kellogg Foundation.  This meeting was seen to be an important step in the ICNP® Project.

From this meeting came the ICNP® Country Project, funded by the W.K. Kellogg Foundation.  The project objectives were: 1) to elicit and disseminate model nursing processes in any country that could be used to elucidate the language of nursing in primary health care and community-based systems; 2) to collect and ensure the insertion of primary health care and community-based nursing terms into the ICNP®; 3) to have a mechanism in place at country level that will enable participating countries to continue to contribute primary health care and community-based related nursing terms to ICNP® after the end of the project; and 4) to increase recognition by the nursing profession and health authorities in the countries involved of the need to include data which relates to nursing practice in health information systems.

The countries funded by the W. K. Kellogg Foundation included Botswana, Brazil, Chile, Colombia, Mexico, South Africa, Swaziland and Zimbabwe.  The project resulted in the development of ICNP® networks within each country, as well as across the Latin American and Southern African regions.  These countries conducted research through working groups, setting up methodologies and testing instruments to identify and validate primary health care concepts.  Their work resulted in the addition of many new terms and definitions to the ICNP® Version 1.  ICNP® research and related activities continue in many of these countries today.

ICNP® Translation

An ICNP® Translators and Reviewers Conference, sponsored by Telenurse and ICN, was held in Coimbra, Portugal in 2000.  Participants shared the results of their reviews of translation content and process issues.  The results of this conference were a major contribution to the ICNP® Version 1.0.  

By November 2003, there were over 20 translations of the ICNP® Beta Version.  Countries participating in translation activities included Austria, Bosnia-Herzegovina, Brazil, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Germany, Greece, Hungary, Italy, Japan, Korea, Lithuania, Netherlands, Norway, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Switzerland, Taiwan, and Thailand. Nurses in these countries identified translation as a priority for: 1) the use of ICNP® in care delivery; and 2) ICNP® evaluation in preparation for the release of ICNP® Version 1.0.

ICNP® Evaluation Committee

Simultaneous with the ICNP® related research studies, an ICNP® Evaluation Committee was formed in 2000 to provide formal review, consultation, and recommendations to ICN for the purpose of revising the Beta 2 version in preparation for ICNP® Version 1. The first charge of the ICNP® Evaluation Committee was to establish an ICNP® Review Process (see Figure 3).  In this early stage, approximately 100 nursing practice experts, representing over 25 countries, were tasked with piloting the review process for ICNP® terms and definitions. By November 2003, more than 100 reviews for new terms and definitions were completed.

Some examples of new terms submitted to the ICNP® Programme included: community development (Botswana and Colombia), family crisis (Chile), homelessness (South Africa), informal settlements (South Africa), and literacy rate (Botswana).  Currently, as the ICNP® Version 1 is being published, there are more than 160 nursing practice expert reviewers, representing over 40 countries, participating in the ICNP® Review Process.  More than 300 reviews for terms and definitions have been conducted using this process.

Figure 3:  ICNP® Review Process

ICNP® as a Unified Nursing Language System

As the Beta 2 Version of ICNP® came to be used more widely, and as nurse groups around the world generated translations and reports of analysis, the ICNP® proponents recognised that the goal of a unifying nursing language system that would meet the needs of nurses around the world was not achievable with the current classification structures and strategies.  Some nurses used the Beta 2 Version directly, while others used existing vocabularies other than ICNP®.  Still others were using the Beta 2 Version as a resource for developing new local vocabularies.

However, ICN continued to acknowledge its responsibility for bringing together data from across the world in order to provide consistent and valid information about nursing practice and patient or client outcomes.   The vision for the ICNP® Programme was to have nursing data readily available and used in health care information systems worldwide.  To pursue this vision, the ICNP® would need: 1) to represent existing nursing vocabularies; 2) to continue to support a Beta 2-type axial representation; and 3) to facilitate the development of local vocabularies that would be derived from the ICNP®.  In addition, and importantly for ICN, the ICNP® Version 1 would need to be able to identify similarities and differences between the different representations in order to compare and combine data from different sources.

ICNP® Version 1.0

In 2002, the ICNP® Strategic Advisory Group recommended that ICN commission an investigation of the extent to which information systems software could be used to support the increasingly complex development and maintenance of the ICNP®.  The study canvassed the opinions of world leaders in the field of health care vocabularies. The study was aimed at assuring that the ICNP® Version 1 was consistent with existing de facto and de jure standards for vocabularies.  The major recommendations arising from the study were: 1) to provide a more formal foundation for the ICNP®; and 2) to use software that would be capable of satisfying current, accepted criteria for a fully workable vocabulary.  Examples of these criteria were: 1) to avoid redundancy between terms; 2) to avoid ambiguity of terms; and 3) to ensure that codes associated with terms in a vocabulary do not reflect the hierarchical structure of the vocabulary.  The ICNP® Beta and Beta 2 Versions had not consistently met these accepted criteria.

The ICNP® Version 1 is more than merely a vocabulary.  It is a resource that can accommodate existing vocabularies (through cross-mapping), that can be used to develop new vocabularies (as a compositional terminology), and that can identify relationships among concepts and vocabularies (as a reference terminology).  The ICNP® Version 1 reflects major reformulations aimed at making the classification system technologically more robust while, at the same time, being accessible to the nurse user.  

ICNP® Version 1 moves beyond a simple multi-axial structure by employing a description logic approach.  The ICNP® Version 1 has been developed using Web Ontology Language (OWL) within the ontology development environment, Protégé.  ICN recognises that while such technological complexities are needed to develop and maintain the ICNP® Version 1, they are not relevant to most people.  Thus they will remain hidden to the majority of users.  An excerpt of the ICNP® inferred hierarchy is presented in Appendix 3.

Also in 2002, at the ICNP® Evaluation Committee, based on feedback and repeated recommendations, a new set of axes was proposed that would unify the eight axes from the nursing phenomena classification structure and the eight axes from the nursing actions classification structure.  The new, simplified 7-Axis Model was derived from the ICNP® Version 1.  The intent of the 7-Axis Model is to provide user-friendly access to ICNP® concepts and definitions.  Many of these definitions have been revised through the ICNP® review process.  Relationships between the new 7-Axis Model and the Beta 2 Version are found in Table 1.

Table 1: Relationships between the 7-Axis Model and the Beta 2 Version

ICNP® 7-Axis Model	ICNP® Beta 2 Axes
Focus	Focus of Nursing Practice
Judgement	Judgement; Likelihood
Time	Duration; Frequency; Time; Event from Target
Location	Location; Body Sites; Topology; Body Parts from Target; Infrastructure from Focus
Means	Means; Routes, Artifacts (e.g. Equipment) from Target
Action	Action Type
Client	Bearer; Beneficiary; Human Beings from Target

ICNP® Version 1.0 Catalogues

The 7-Axis Model will be used by nurses to create nursing diagnosis, intervention, and outcome statements for use in practice.  The ICNP® Programme office will collect and code these statements and they will be organised to create ICNP® catalogues.  ICNP® catalogues are defined as purpose-specific subsets of nursing diagnoses, interventions, and outcomes for a select or specialty area of practice.

The catalogues can fill a practical need in building manual or electronic patient record systems, with all of the benefits of being part of a unified language system.  An example of an ICNP® catalogue on Adherence to Treatment is provided in Appendix 4.  Other models and catalogues will be available as ICNP® Version 1 research and development activities continue.

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