The International Classification for Nursing Practice (ICNP^®) Programme: Advancing a Unifying Framework for Nursing

Special Section: Nursing Classifications

This is an article in the Special Section for the topic "Nursing Classifications".  Articles on this subject will continue to be posted. We invite submission of other manuscripts that further this continued discussion of Nursing Classifications Worldwide.

What is the ICNP^®?

The International Classification for Nursing Practice (ICNP^®) is a programme of the International Council of Nurses (ICN), a federation of national nurses associations, which currently has more than 120 country members (For more information on ICN see www.icn.ch).

The International Classification for Nursing Practice (ICNP®) is defined as a classification of nursing phenomena, nursing actions, and nursing outcomes that describes nursing practice...The vision of the ICNP® Programme is to have nursing data readily available and used in health care information systems worldwide. font>

The original objectives of the ICNP^®, published in 1996 (ICN) were reviewed by ICN in 2000. Although minor revisions in the objectives were made, they still reflect the original aim that has guided development of the ICNP^® since its inception. The objectives are:

• Describe the nursing care of people (individuals, families and communities) in a variety of settings both institutional and non-institutional.
• Enable comparison of nursing data across clinical populations, settings, geographic areas and time.
• Demonstrate or project trends in the provision of nursing treatments and care and the allocation of resources to patients according to their needs based on nursing diagnoses.
• Stimulate nursing research through links to data available in nursing information systems and health information systems.
• Provide data about nursing practice in order to influence health policy making (ICN, 2001).

The ICNP^® is defined as a classification of nursing phenomena, nursing actions, and nursing outcomes that describes nursing practice. The ICNP^® focuses on nursing practice, with the acknowledgement that practice is changing and dynamic. The ICNP^® reflects the ICN definition of nursing:

Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles (ICN, 2002).

Although the core aspects of nursing practice are shared across countries, its dynamic quality is noted in its variation, for example the similarities and differences of practice by locality and specialty. Therefore, the ICNP^® must be broad enough to represent the dynamic nature of nursing and the cultural variation in practice globally.

The ICNP^® is a combinatorial terminology and provides a unifying framework into which local language and existing nursing vocabularies and classifications can be cross-mapped to enable comparison of nursing data across organizations, across sectors within health care systems, and among countries.

The ICNP® is a combinatorial terminology for nursing practice and provides a unifying framework into which local language and existing nursing vocabularies and classifications can be cross-mapped...

One of the first steps in the development of the ICNP^® was to collect and compare all the nursing concepts in existing nursing terminologies (Wake,et.al, 1993; Wake & Coenen, 1998). The aim was to build on and unify the existing work in nursing classifications, rather than to create something that would not be complementary to efforts already underway in nursing. In addition to promoting comparable nursing data, the ICNP^® is intended to facilitate comparison of nursing data with data from other health disciplines.

The ICNP^® Beta Version uses a multi-axial structure to support the idea of a unifying framework.

The ICNP® Beta Version uses a multi-axial structure to support the idea of a unifying framework... terms from different axes are combined to create a concept.

In a multi-axial or combinatorial terminology, terms from different axes are combined to create a concept. For example, the term "pain" (from the ICNP^® Focus of Nursing Practice Axis) can be combined with "chronic" (from the ICNP^® Duration Axis) to create the diagnosis "chronic pain." Another example of a nursing diagnosis could be "intermittent acute pain" (see Figure 1). Other examples of using the ICNP^® can be applied to composing nursing interventions such as: "Teaching relaxation techniques" and "Supporting family during hospitalization." These interventions were composed using terms from select ICNP^® Axes as displayed in Figure 1.

Figure 1. Examples of composing nursing diagnoses and interventions using ICNP^®.

Using ICNP^® axes from the Nursing Phenomena Classification to compose nursing diagnoses:

• "Chronic pain," "Chronic pain in the lower back," "Moderated pain in the lower back."
• "Acute pain," "Intermittent acute pain," "Intermittent acute pain in the right knee"

Phenomena AXES	A Focus	B Judgement	C Frequency	D Duration	F Body site	G Likelihood	H Bearer
Examples of Terms	Pain	Moderate		Chronic	Lower	Back
	Pain	[Yes]	Intermittent	Acute	Right	Knee

Using ICNP^® axes from the Nursing Actions Classification to compose nursing interventions:

"Teaching relaxation techniques," "Teaching relaxation techniques using instructional materials," "Supporting family during hospitalization"

Action AXES	A Action type	B Target	C Means	D Time	E Topology	F Location	G Routes	H Beneficiary
Examples of Terms	Teaching	Relax- ation tech niques	Instruc- tional materials
	Supporting			During Hospital- ization				Family

Through the use of a multi-axial design, the ICNP^® facilitates the creation of relevant and useful concepts that were not previously identified in the existing classification systems (Nielsen & Mortensen, 1996; Nielsen & Mortensen, 1997). The multi-axial approach facilitates addition of new terms and representation of local expressions. More examples and further information on the ICNP^® is available on the Internet from ICN at www.icn.ch/icnp.htm.

History and Development of ICNP^®

In 1989, the ICN passed a resolution that encourages member National Nurses Associations (NNAs) to become involved in developing classification systems for nursing care that nurses in all countries could use to identify nursing practice and describe nursing and its contributions to health. There is rarely one cause or simple explanation for any professional, international initiative. Similarly, there were a number of converging forces influencing the starting point of the International Classification for Nursing Practice (ICNP^®). Clark (1998) discussed how the context was ready to support the development of such an idea, identifying the scientific, linguistic, and political roots for an international initiative to establish a common language for nursing (nursingworld.org/ojin/).

Since the 1989 resolution, ICN has taken on the work to develop the ICNP^®. The ICNP^® Alpha Version was published in 1996, as a first draft and was intended to promote participation of NNAs and others in the project (ICN, 1996). In 1999, the ICNP^® Beta Version was published for evaluation and testing (ICN, 1999).

The ICNP^® Beta Version has been translated into more than 20 languages.

The ICNP® Beta Version has been translated into more than 20 languages.

In 2000 ICN and TelenurseID; a research and development project supported by the European Union to facilitate dissemination, translation, and testing of the ICNP^® in Europe (Mortensen, 1999), sponsored an ICNP^® translators’ and reviewers’ workshop. Translators and peer reviewers from 26 countries including Brazil, Croatia, Czech Republic, Denmark, England, Estonia, France, Germany, Greece, Hungary, Italy, Japan, Korea, Lithuania, Madeira, Netherlands, Norway, Poland, Portugal, Romania, Switzerland, Slovakia, Slovenia, Sweden, Taiwan, and Thailand were represented at the workshop held in Coimba Portugal. In response to the workshop, ICN released the ICNP^® Beta 2 Version (ICN, 2001), providing editorial corrections and minor revisions to the original Beta Version. With continued testing and evaluation of ICNP^® Beta 2 Version, the goal is to release ICNP^® Version 1.0 in 2005.

Overview of the ICNP^®Programme

After beginning as an ICN project in 1990, the ICN officially established the ICNP^® Programme in 2000. The ICNP^® Programme plan identified three major aims for 2001-2005:

• Maintain up-to-date ICNP^® content.
• Ensure that ICNP^® is compatible with the current state of nursing science, classification and informatics science, and other health care developments.
• Co-ordinate international dissemination, utilization and promotion of the ICNP^® and related activities.

To achieve the above aims, a new position of ICNP^® Programme Director was established with dedicated ICN staff for administrative and technical support. Similar to other ICN Programmes, the ICNP^® Programme is funded by ICN, grants, and other contributions. Funding from W. K. Kellogg Foundation supported six country projects (Brazil, Chile, Colombia, Mexico, Botswana, Swaziland, South Africa, and Zimbabwe) that focused on expanding the representation of primary care and community-based nursing concepts in the ICNP^®. ICN member associations have supported many projects and continue to support ongoing work with the ICNP^®. For example the Taiwan Nurses Association has sponsored two ICNP^® conferences for the Asian Pacific region, the Nurses Association of Thailand has held various meetings and a national conference, and the Japanese Nurses Association provides a dedicated staff as well as consultation and meetings on ICNP^®. A research group in Sweden has had support from the Swedish Society of Nursing and the Swedish Association of Health Professionals.

The development and ongoing evaluation of the ICNP^® has benefited from the contributions of many researchers and experts in nursing and health informatics. Many of the ICNP^® translations were complete with assistance, including funding from the European Union Telematics for Health Care Programme for the Telenurse Projects (Mortensen, 1999) and the International Committee of the Red Cross support for translation in Bosnia-Herzegovina. Many of the ICN member national nurses associations have supported translation efforts in their countries.

The ICNP^® is owned and copyrighted by ICN. All those wanting to use ICNP^® for any purpose need permission from ICN. There is no fee for non-commercial use, such as the use of ICNP^® in research and education. If the use is commercial and involves distribution of a product for-profit (e.g. software products or publications) there is a small licensing (or royalty) fee. Other uses, such as government use within a national health information system are negotiated on a case-by-case basis. ICN anticipates that it will provide discounted pricing to developing countries. Besides protection of copyright, ICN is most concerned about facilitating access to ICNP^® for use by nurses.

Following the establishment of the ICNP^® Programme, the Programme Director developed a plan that organized ICNP^® Programme activities into three clusters:

• communication and dissemination,
• research and development, and
• coordination and programme management.

Select examples of programme activities within each of these three clusters are presented to demonstrate the growth of this ICN initiative in its first two years (see Figure 2).

Figure 2. ICNP^® Programme.

Communication and Dissemination

The ICNP^® Programme uses many avenues to facilitate communicate including: conference presentations, meetings, printed materials and other publications (hardcopy, electronic via Internet and CD/ROM). One example of a communication strategy is a bi-annual ICN publication, the ICNP^® Bulletin. The ICNP^® Bulletin is an outcome of the ICNP^® W.K. Kellogg Foundation Country Projects, www.icn.ch/icnpkellogg.htm. These country-based projects included select NNAs; Botswana, Brazil, Chile, Colombia, Mexico, South Africa, Swaziland and Zimbabwe. The purpose of these country projects was to promote the inclusion of primary health care and community-oriented nursing terms in the development of the ICNP^®. The ICNP^® Bulletin was developed as a means to communicate among the project participants. The Bulletin has expanded as a communication strategy and is disseminated in mailings to all ICN member associations, as well as available on the Internet at: www.icn.ch/icnpbulletin.htm.

Additional ICNP^® resources are available at the Internet site, such as a list of ICNP^® related references (http://icn.ch/bib-icnp-references.htm) and other updates on the ICNP^® Programme (www.icn.ch/icnp.htm). The majority of ICN publications are available in the three official ICN languages English, French, and Spanish.

In addition to disseminating information from ICN, communication processes must be multidirectional to promote the exchange of information and ideas among ICN, NNAs, and the many stakeholders involved or interested in the ICNP^® Programme. Mechanisms to facilitate ongoing exchange of information continue to evolve. For example a recent ICN publication, The ICNP^® Review Process: How to Participate (ICN, 2001), provided an overview of processes for submitting recommendations (including new terms and definitions) to the ICNP^® Programme and how recommendations are reviewed by ICN. Open, transparent processes for input and decision-making will facilitate communication and participation in the programme. By promoting participation, the ICNP^® review processes will expand the breath of coverage in order to better represent international nursing. In the past year alone, hundreds of new terms have been submitted for review and consideration for inclusion in the ICNP^® . For example, a Korean project in cross-mapping ICNP^® with other nursing classifications led to the suggested addition of 76 new terms to the ICNP^® phenomena classification alone (Coenen, Marin, Park, & Bakken, 2001).

Networking is another strategy to promote communication. Networking efforts are aimed at engaging the participation of a wider audience, both within and beyond the profession, especially in the areas of research and development.

Research and Development Activities

A major emphasis of the ICNP^® Programme is to facilitate and coordinate ICNP^® research and development projects.

A major emphasis of the ICNP® Programme is to facilitate and coordinate ICNP® research and development projects.

Nursing, informatics, and terminology experts from around the world have been leading and partnering with ICN in research and development projects. For a listing of ICNP^® research and development projects, including a short abstract and contact information for each project, see www.icn.ch/database1.htm.

With the publication of the ICNP^® Beta Version, in 1999, research priorities have shifted from development to evaluation. A number of ICNP^® programme mechanisms have been developed to support research and evaluation. Examples of these mechanisms in the Research and Development cluster are discussed below including (a) informatics expert reviewers, (b) nursing practice expert reviewers, (c) ICNP^® Evaluation Committee, (d) ICNP^® Development Centres, and (e) Partnerships.

ICNP^® Informatics Expert Reviewers. A number of informatics experts have agreed to share their expertise with ICN through the review of select issues regarding the ICNP^® structure and other technical concerns. Informatics reviewers include nurses and others with expertise in informatics and health care terminology. These experts have reviewed recommendations and critique (a) sent to ICN for review, (b) gathered from the literature, (c) reported on ICNP^® projects and (d) based on concerns identified at conferences or meetings.

...the ICN definitions include the phrase "is a type of"...

An example of an issue sent out to informatics experts for review was the recommendation to change the phrasing of words used in all of the ICNP^® definitions. Currently, the ICN definitions include the phrase "is a type of" for example "Pain is a type of sensation." The systematic use of this phase in all of the ICNP^® definitions was intended to identify the nearest broader concept (genus) in relation to each term (ICN, 1999). Experts have provided feedback regarding the use of this phrase within definition, resulting in the need for more evaluation and revisions.

ICNP^® Nursing Practice Expert Reviewers. ICN has established a bank of clinical experts to provide reviews of recommendations for modification, addition, and deletion of terms and definitions in the ICNP^® . These reviewers provide their expertise in nursing practice, representing multiple specialty areas. Currently, there are over 80 nursing practice expert reviewers, from more than 30 countries. Over the past 2 years, these experts have reviewed over 100 terms and definitions submitted to ICNP^®. Examples of new terms submitted to the ICNP^® are provided in Figure 3.

Figure 3. Examples of terms and definitions submitted to the ICNP^® review process.

Country	Term	ICNP® Classification (Axis)
Botswana	Water Storage	Phenomena (Focus of Nursing Practice)
Chile	Family Crisis	Phenomena (Focus of Nursing Practice)
Korea	Stress	Phenomena (Focus of Nursing Practice)
Mexico	Work-related Stress	Phenomena (Focus of Nursing Practice)
Portugal	During the Day	Actions (Time)
Portugal	Central Venous Pressure	Action (Target)
South Africa	Homelessness	Phenomena (Focus of Nursing Practice)
Swaziland	Gender Violence	Phenomena (Focus of Nursing Practice)
Zimbabwe	Relapse	Phenomena (Focus of Nursing Practice)

The ICNP^® review process (www.icn.ch/icnp_review.htm) provides opportunities for individuals and groups to review terms and concepts, as well as exchange information and ideas about the ICNP^® generally. For example, one of the criteria that reviewers use to examine new terms submitted to the ICNP^® is, "placement in the classification is appropriate." Use of this criterion often results in evaluation and critique related to the existing terms, as well as structure and organization of concepts in the ICNP^®. Nursing practice experts have provided a tremendous amount of feedback with their reviews. Their input is further reviewed by the members of the ICNP^® Evaluation Committee.

The ICNP^® Evaluation Committee. The ICNP^® Evaluation Committee was established in 2000. This committee is charged to:

• Assist ICN in establishing evaluation and review processes for ongoing development and maintenance of the ICNP^® .
• Provide periodic review of the ICNP^®.
• Provide consultation and recommendations for the purpose of revising the ICNP^® using reviews, feedback, critique and research on the Beta Versions.

A major task of the ICNP^® Evaluation Committee members is to critique the reviews from the nursing practice expert reviewers on new and revised terms and definitions. Since the committee was established early in the ICNP^® Programme, the members were charged with facilitating the development and testing of the ICNP^® Review Process. Their work has resulted in the ICN publication mentioned earlier, The ICNP^® Review Process: How to Participate (ICN, 2001).

Mechanisms such as an Internet discussion forum and email have been used to facilitate the work of this group between meetings. Even with these distance-work processes, the face-to-face meeting have been essential to support the operations of this committee, especially in this early stage of the ICNP^® Programme.

ICNP^® Centres. A new initiative to support ICNP^® research and development is the establishment of ICNP^® Centres.

A new initiative to support ICNP® research and development is the establishment of ICNP® Centres...organized or supported at a number of levels, including but not limited to country, intercountry, regional, interregional and global levels.

The ICNP^® Programme plan targets 2002-2003 for designating ICNP^® Development Centres. These centres will be designated by ICN in accordance with established criteria and review via a formal application process. ICN envisages that these centres can become the core of an ICNP^® consortium and thus advance the work of each individual centre, while extending ICN’s and each individual centre’s access to expertise beyond that available at present.

The ICNP^® Centres may be organized or supported at a number of levels, including but not limited to country, intercountry, regional, interregional and global levels. Centres may be organized by categorization that is meaningful to the work of the ICNP^® , for example language, area of nursing specialization, or research expertise. The Centres ICNP^® may provide resources in terms of research, services, and education.

ICNP^® Centres will collaborate as part of a consortium set up by ICN to support the ICNP^® Programme, including establishing links with respective NNAs. Through the network, Centres are able to strengthen nursing and health from local to global development.

The implementation plans for ICNP^® Centres are currently in development. Initial plans include the development of criteria and an application process, with use of a pilot site to evaluate these procedures. The ICNP^® Users Group from German-speaking countries will participate as the pilot site for the first Centre.

Establishing Partnerships. In addition to designating ICNP^® Centres, ICN has emphasized the importance of developing and promoting partnerships with other associations and organizations who have a stake in health care terminology.

ICN has emphasized the importance of developing and promoting partnerships with other associations and organizations who have a stake in health care terminology...a move toward collaboration and convergence

While early nursing terminology work primarily occurred in isolation and resulted in some duplicative efforts, more recent activities demonstrate a move toward collaboration and convergence not only within the discipline of nursing, but with multi-disciplinary standards initiatives (Coenen, et al., 2001). The ICNP^® has a distinct advantage as a programme within ICN. As an ICN Programme, there is an established, direct relationship between the ICNP^® Programme and all of the 124 ICN members or NNAs. The work of ICN is often carried out in collaboration and coordination with member associations. ICN has provided leadership in programme priorities, as well as support for collaboration and networking among NNAs. By providing an international voice for the profession, ICN has been able to strengthen nursing initiatives such as the ICNP^® Programme. In parallel, the member associations strengthen their countries resources, by extending the work of ICN at the local level. Participation of ICN member associations provides an important advantage in assuring worldwide representation for ICNP^® as an international nursing initiative.

Another example of partnership is ICN’s association with the International Medical Informatics - Nursing Informatics Special Interest Group (IMIA-NI). The ICN and IMIA-NI have partnered on two projects: (a) developing a standard for a reference terminology model for nursing, and (b) testing an International Nursing Minimum Data Set. One project is aimed at developing an International Standards Organization (ISO) standard for a reference terminology model for nursing concepts (ISO, 1999). The intent is that the model will not only support representation of nursing concepts and mediation among representations, but that it will integrate with other ISO models for health care concepts. Although the ICNP^® was not initially conceptualised as a concept representation model, the axes were used as a source for categories and semantic links in development of a terminology model to represent nursing diagnosis and activity concepts (Bakken, Parker, Konicek, & Campbell, 2000).

Since the pioneering work of Werley and Lang (1988), there has been ongoing discussion of a Nursing Minimum Data Set (NMDS). The conceptualisation of the NMDS by Werley and Lang strongly influenced the development of the ICNP^® to include classification of nursing diagnoses, nursing interventions, and nursing outcome. Research has identified many commonalities, as well as differences in existing NMDSs across countries (Goossen, et.al., 1998). IMIA-NI and ICN have supported an initiative to further explore the issue of NMDS with an international approach toward development and testing.

Coordination and Programme Management

The third activity cluster in the ICNP^® Programme is management and ongoing coordination. Although this is often thought of as the day-to-day work of any programme, it also includes short and long term strategic planning.

A major focus in the management of the ICNP^® Programme is the maintenance of the ICNP^® itself. Maintaining all the data and information related to the ongoing development and evolution of the ICNP^® is a major task. Maintenance includes for example: tracking recommendations and suggestions, expert reviews, and revisions to the ICNP^®; as well as organizing committee meetings, conference presentations, and ad hoc groups.

In addition to the day-to-day operations of any programme, organizational support and strategic planning are essential. Ongoing evaluation is needed to assure a realistic and strategic plan to advance the ICNP^® Programme.

Moving Forward

Through the establishment of a formal ICNP^® Programme, ICN has demonstrated its commitment to the ICNP^®. With the establishment and realization of specific programme activities and objectives, the ICNP^® Programme has taken hold. Specific organizational supports for such a large-scale effort have been realized, with the ICNP^® Programme as part of the ICN. In order to assure that the ICNP^® Programme continues to be informed on the current state of the science in health care terminology and has a focus on the future, the ICNP^® Strategic Advisory Group was established.

Strategic Advisory Group

In 2002, ICN established the ICNP^® Strategic Advisory Group. This group is advisory to the ICN Chief Executive Officer on strategic development and planning of the ICNP^® and the ICNP^® Programme.

The terms of reference for this group include:

• Provide consultation and feedback regarding the ICNP^® and the ICNP^® Programme, including evaluation of the Programme plan.
• Consider and recommend ideas to advance the ICNP^® and the ICNP^® Programme

Members were chosen to reflect geographic distribution of ICN membership as well as for their expertise in strategic capability, knowledge of ICNP^® , and informatics expertise. Determining and prioritizing objectives for the ICNP^® will assist ICN in strategic development of this programme.

The Strategic Advisory Group held their first meeting in October 2002 and identified a number of important issues and opportunities for the ICNP^® Programme. Future programme planning will focus on each of the three programme areas, with an emphasis on research and development. Ongoing research will continue to promote open partnerships and the use of ICNP^® as a unifying framework. Small demonstration projects are already underway that use ICNP^® in health care information systems. Some studies map local terminology presented at the interface to the ICNP^® (Hyun & Park, 2002) and others use the ICNP^® to pre-coordinate or compose diagnoses, interventions, and outcomes used at the interface (Šušteršic, et.al., 2002). In both types of studies, ICNP^® is used to collect comparable nursing data, at the point-of-care. The data can then be stored in a matter in which it can be retrieved for reuse in research. The Strategic Advisory Group encouraged continuing and disseminating this type of research, which demonstrated the use of the ICNP^® in health information systems.

Summary

To achieve the vision of the ICNP^® , to have nursing data readily available and used in health care information systems world wide, the ICNP^® Programme was established. The ICNP^® has evolved and the ICNP^® Programme will support the ongoing development of this resource to represent nursing practice concepts internationally. Through the ICNP^® Programme, ICN is investing in nursing’s future by capturing the contributions of nursing, with all its diversity; and promoting evidenced-based, quality nursing practice.

Author

Amy Coenen, PhD, RN, FAAN
Email: amy.coenen@marquette.edu

Amy Coenen, PhD, RN, FAAN is the Director of the International Classification for Nursing Practice (ICNP®) Programme at the International Council of Nurses in Geneva Switzerland. She is an Associate Professor at the Marquette University College of Nursing in Milwaukee Wisconsin, USA.

Amy Coenen, PhD, RN, FAAN began her research program with a focus on the Nursing Minimum Data Set (NMDS) in the United States. Her research provided the foundation for participation with the International Council of Nurses in the development and testing of the ICNP®. Through this programme, she has had the opportunity to work with nurses on every continent of the world and in many countries. Dr. Coenen has served on American Nurses Association Committee on Nursing Practice Information Infrastructure. She teaches health care informatics in the graduate program at Marquette University College of Nursing.