We were delighted to see a review of three of our books related to interventions and outcomes in the September/October issue of CIN. We appreciate Dr. Ersek taking the time to review the books and writing up her report. It is good to see a clinical nurse researcher appreciate the value of standardized nursing language and the efforts that have gone into the preparation of the NIC and NOC languages.
While Dr. Ersek was very positive in her review, she did raise some questions and concerns that we would like to address. First, she was disappointed in the alphabetical listing of the interventions and outcomes, but she failed to note that both the interventions and outcomes are, in addition to the alphabetical presentation, located in a taxonomic structure and linked to NANDA diagnoses. All three methods (alphabetical, taxonomy, and linkage with NANDA) can be used for different purposes to help locate the desired intervention or outcome. In addition, our most recent book [Johnson et al. Nursing Diagnoses, Outcomes, and Interventions: NANDA, NOC and NIC Linkages, St. Louis: Mosby; 2001] provides linkages between these three classifications to assist in clinical decision making.
Related to her questions about NIC, the activity lists of the NIC interventions are not "seemingly unordered" but, as explained in the book, are arranged from logical order of what a nurse would do first to what she/he would do last. The activities can and should be modified (revised, added to, or deleted) to fit the needs of the patient and the situation. Since NIC is comprehensive and is designed to address all specialties and settings and all levels of nurse providers including students, the activity lists are fairly comprehensive. Dr. Ersek also remarked that the activities under the intervention of "Truth Telling" ignored the cultural variations of patients, some who do not want to be fully informed. We agree that not all patients want or should have this intervention; the activities only address what one would do if one decided, based on good clinical decision making, that the patient should have the intervention. All of the interventions in NIC require clinical judgments by nurses of what is needed in the situation for the patient. Although NIC is not a clinical decision-making book, we do include on pages 40-42 the 6 factors that should be considered in selecting an intervention.
Dr. Ersek's comments about the pain-related outcomes in NOC illustrate the issues that arose when developing outcome measures for multifaceted concepts. Although the team initially began development of the pain outcomes along the recognized division of chronic and acute pain, it became evident that a number of the indices (indicators) were the same for both, and that the defining difference was the length of time the pain existed. For example, while behavioral signs such as disruptive and psychological effects of pain are less common in acute pain, they can occur with severe acute pain of a few weeks' duration. The team made the decision to differentiate the outcomes along the various dimensions of pain and let the clinician select the outcome(s) and the indicators most relevant to a particular patient. This was consistent with how other complex concepts were developed in the classification in an attempt to keep the number of indicators reasonable, while including those pertinent to patients with a variety of conditions in care settings across the continuum. Feedback such as this and from clinical users is extremely important because it allows us to determine if more general outcomes, such as chronic and acute pain and cardiopulmonary status, should be developed in the future and added to the list of outcomes from which nurses can select. Research evaluating the use of the outcomes in a number of clinical settings has just been completed and the findings have influenced a number of changes in the outcomes that will appear in the next edition. It is through feedback from users of the outcomes that the outcomes will evolve to be most useful for nurses in clinical care, research, and education.
From her perspective of research scientist, we understand Dr. Ersek's enthusiasm for the third book that details the research for 43 of the 486 NIC interventions. Books like this provide excellent support for the interventions and outcomes in NIC and NOC. (Readers might also want to see Craft-Rosenberg M, Denehy J, eds, Nursing Interventions for Infants, Children, and Families, Thousand Oaks, CA: Sage Publications, Inc; 2001; and Maas ML, Buckwalter KC, Hardy MD, Tripp-Reimer T, Titler MG, Specht JP. Nursing Care of Older Adults: Diagnoses, Outcomes and Interventions, St. Louis: Mosby; 2001.) We would encourage more nurse researchers to study the impact of interventions on patient outcomes. The references in the NIC and NOC books do include the clinical practice guidelines developed under the auspices of the AHCPR and some of the research articles about the specific concepts but are limited to those research articles that were most helpful in identifying the specific activities or indicators-these are sometimes more clinical in nature. NIC and NOC are based on practice as well as research and were developed for the specific purpose of conceptualizing the knowledge of the profession- What is it that nurses do? What patient outcomes do nursing interventions influence? Prior to NIC and NOC we could identify lists of discrete actions and patient changes, but we could not name in a few words the intervention or the desired outcomes.
We agree with Dr. Ersek that the naming and describing of interventions and outcomes in NIC and NOC assist the profession to identify future research. The classifications also provide a language to communicate the nature of nursing that can be taught to students and used in nursing information systems to document and study the impact of nursing care.
Joanne McCloskey Dochterman
Marion Johnson