Classifying Nursing Work

Introduction

In this paper, we take the example of the Nursing Interventions Classification (NIC) to study the tensions that arise when developing and applying a "working memory" or record of nursing interventions. On one hand, such a record helps to build a knowledge base for the development of scientific nursing and for teaching. In addition, by documenting and representing nursing work in the form of atomic, indivisible units, it allows both the integration of nursing informatics into medical informatics and the recognition of heretofore invisible nursing work by hospital information systems, accounting information systems, and the electronic medical record (Berg and Bowker, 1997). Only work that is visible can truly be identified as valuable.

On the other hand, visibility has inherent dangers. Many nurses feel that the classification does not properly reflect the process-oriented -- and indeed "invisible"-- nature of their work. Further, such a representation risks exposing nursing to process re-engineering which could result in the reassignment of the "unskilled" portions of nursing work. We show how NIC (see LaDuke, 2000, for a concise, readily accessible overview of the NIC and for practice-based examples of its use) has developed a rich strategy for dealing with the central tension between the desire for--and the dangers of--visibility. Managing the tension between visibility and discretion has necessitated that the definition of nursing intervention must itself map the shifting boundaries among direct, indirect, and administrative care, depending on ever-changing concerns surrounding the need for increased legitimacy versus the fear of undermining surveillance. Moreover, to protect local autonomy and legitimize local differences NIC architects have decided to specify only down to the level of interventions, leaving the subactivities of care activities indeterminate and opaque. As Bowker and Star (1999) state: "Common practice, contingency, and legitimacy temper visibility" (p. 248).

What is NIC

The Nursing Intervention Classification (NIC) aims to depict the range of activities that nurses carry out in their daily routines. Their original system consisted of a list of some 336 interventions; each comprised of a label, a definition, a set of activities, and a short list of background readings. Each of those interventions is in turn classified within a taxonomy of six domains and 26 classes. For example, one of the tasks nurses commonly perform is preparing and monitoring intravenous medication. The nursing intervention Epidural Analgesia Administration is defined as: "preparation and delivery of narcotic analgesics into the epidural space"; another common one, Cough Enhancement, groups activities designed to help respiration. Caring work such as calming and educating patients, usually done by nurses, often cuts across specific medical diagnostic categories. The NIC investigators use their list of interventions in order to make visible and legitimate the work that nurses do. The idea is that it will be used to compare work across hospitals, specialties and geographical areas, and to build objective research measures for the outcomes. NIC, although still relatively young, promises to be a major rallying point for nurses in the decades to come. More information can be found at: http://coninfo.nursing.uiowa.edu/nic/index.htm.

This paper represents a portion of a larger project discussing the nature and developing of medical classification systems (Bowker and Star, 1999). In addition, this paper should be considered complementary to other work in nursing classification, such as McCormick and Jones (1998). In their paper, the authors discuss the implications of new technologies for linking classifications at local, network, and universal levels. Particularly relevant to the tone of the present work is their use of the Rosetta Stone as an evocative, resonant metaphor for evolving classifications and nomenclatures.

The Erasure of Nursing

Nursing work has traditionally been invisible, and its traces have been expunged at the earliest opportunity from the medical record. This has been accomplished both externally, by hospital administrations, and internally, by nurses themselves.

External Erasure

Historically, the selective erasure of nursing records within hospital information systems has been drastic. Nursing records are the first destroyed when a patient is released. The hospital administration does not require them (in accounting, the cost of nursing is frequently lumped in with the price of the room); doctors consider them irrelevant to medical research; and nursing theorists are not well enough entrenched to demand their collection. Nursing has been seen as an intermediary profession that does not need to leave a trace; in accord with traditional gender expectations, nurses are "on call" (Star and Strauss, 1999).]

Huffman (1990: 319), in a standard textbook on medical records management writes:

As nurses' notes are primarily a means of communication between the physicians and nurses, they have served their most important function during the episode of care. Therefore, to reduce the bulk and make medical records less cumbersome to handle, some hospitals remove the nurses' notes from records of adult patients when medical record personnel assemble and check the medical record after discharge of the patient. The nurses' notes are then filed in chronological order in some place less accessible than the current files until the statute of limitations has expired, and they are destroyed.

Traditionally, nurses have been facilitated out of the equation: though they may not have an official trace of their own past, their duty is to remember for others. In one of those vague but useful generalizations that characterize information statistics, it was asserted, in a book on next-generation nursing information systems, that 24 percent of total hospital operating costs were devoted to information handling. Nursing, it is stated, "accounted for most of the information handling costs (28 percent to 34 percent of nurses' time)"; and what is worse, "in recent years, external regulatory factors, plus increasing organizational and health care complexity, have augmented the central position of information in the health care environment" (Zielstorff, Hudgings, & Grobe, 1993, p. 5).

The nursing profession acts as a distributed memory system for doctors and hospital administrators. Ironically, in so doing, it is denied its own official memory.

Internal Erasure

Even when the erasure is not mandated, it has been voluntary. One text on a nursing classification system cites as a motif of the profession an observation that: "The subject of record-keeping has probably never been discussed at a convention without some agitated nurse arising to ask if she is expected to neglect her patients in order to write down information about them..." (Martin and Scheet, 1992, p. 21 - echoing a 1917 source). And Joanne McCloskey, one of the two principal architects of NIC notes that: "...the most convincing argument against nursing service or Kardex care plans is the absence of them. Although written care plans are a requirement by the Joint Commission for Hospital Accreditation and a condition for participation in Medicare, few plans are, in fact, written" (McCloskey, 1981, p. 120).

In her study of the International Classification of Diseases, Ann Fagot-Largeault (1989) notes the same reluctance on the part of doctors to spend time accurately filling in a death certificate (itself a central tool for epidemiologists) when they might be helping live patients. Because accurately representing the activities that comprise nurses' work takes time, systems are designed to favor summary (e.g., forms) over complex, but more faithful, representations. In the case of a computerized NIC, nurses are sometimes suspected by the NIC implementation team of using the choices that appear before them on a screen (which they can elect with a light pen) rather than searching through the system for the apt descriptor (IIP 6/8/95; unpublished field notes)¹.

One of the main problems that the nurses have is that they are trying to situate their activity visibly within an informational world that has factored them out of the equation. It has furthermore maintained that they should be so excluded, since what nurses do can be defined precisely as that which is not measurable, finite, packaged, accountable. In nursing theorist Jenkins' terms: "Nurses have functioned in the post-World War II era as the humanistic counterbalance to an increasingly technology-driven medical profession" (Jenkins, 1988, p. 92). Nursing informaticians face a formidable task. They have tried to define nursing as something that fits naturally into a world partly defined by the erasure of nursing and other modes of invisible articulation work.

Sometimes the nurses are driven for these reasons by their own logic to impeach medical truth. At other times, they challenge orthodoxy in organization science; or they seek to restructure nursing so that these challenges will not be necessary. At the end of the day there will be an information infrastructure for medical work that contains an account of nursing activity. The move to informational panopticons is overwhelming in this profession as in many others. With projects like NIC, which offer new classification systems to embed in databases, tools, and reports we get to see what is at stake in making invisible work visible.

Clearance: The Importance of Classification

The very establishment of NIC necessitated a wiping clean of the slate, which we call clearance. The nurses involved believed that, up to then, there had been no nursing science and therefore there was no nursing knowledge to preserve. For example, there was no standard (i.e., universally accepted) terminology to record nursing diagnoses, interventions, or outcomes. One nursing informatician ruefully noted:

It is recognized that in nursing, overshadowed as it is by the rubrics of medicine and religion, no nurse since Nightingale has had the recognized authority to establish nomenclature or procedure by fiat. There are no universally accepted theories in nursing on which to base diagnoses, and, in fact, independent nursing functions have not yet gained universal acceptance by nurses or by members of other health professions. (Castles, 1981, p. 40)

Nursing, it was argued, had until then been a profession without form. There was no way of codifying past knowledge and linking it to current practice. A conference was held to establish a standardized nursing minimum data set (information about nursing practice that would be collected from every care facility). It found that: "The lists of interventions for any one condition are long partially because nursing has a brief history as a profession in the choosing of interventions and lacks information for decision-making. As a profession, nursing has failed to set priorities among interventions; nurses are taught and believe they should do everything possible." (McCloskey and Bulechek, 1992: p. 79)

In the face of the view of the nurse as doing everything that nobody else does should all previous nursing knowledge be abandoned? William Cody, in an open letter to the Iowa Intervention Team, who produced NIC and published it in Nursing Outlook in 1995, charged that this was precisely what would follow from widespread adoption of NIC:

It would appear that the nursing theorists who gave nursing its first academic leg to stand on, as it were, are deliberately being frozen out. I would like to ask Drs. McCloskey and Bulechek, Why is there no substantive discussion of nursing theory in your article? How can you advocate standardizing "the language of nursing" by adopting the language of only one paradigm? (Cody, 1995, p. 93).

The Project team responded that indeed clearance was an issue:

The Iowa group contends that taxonomic development represents a radical shift in theory construction in which the grand conceptual models are not debated, but transcended. We believe that, as a scientific community, nursing has moved to the point of abandoning the conceptual models of nursing theorists as forming the science base of the discipline (McCloskey, Bulechek and Tripp-Reimer, 1995, p. 95).

It is not just at the level of nursing theory that this act of clearance is seen as unsettling. Practicing nurses implementing NIC at one of four test bed sites had several complaints. They stated that learning to use NIC, together with the new computer system of which it was a part, was like going to a foreign country where you had to speak the language; to make matters worse, you had to go to a new country every day. More prosaically, they said that they felt they were going from being experts to novices.

The argument was made in response that quite simply there has been no foundational work done in the past: "The discipline of nursing has not yet constructed a cohesive body of scientific knowledge" (Tripp-Reimer et al, 1996, p. 2). However, this issue often arises in connection with the strategy of clearance. The desire to be able to say that nurses now do something that is valuable and adaptable to scientific principles coexists with the belief that nurses have not yet (until the development of the classification system) been able to develop any nursing theory and thence any systematic, scientific improvement in practice.

This difficulty is common when new classification schemes are introduced. While the new scheme effectively invalidates much previous knowledge by creating new sets of categories, it seeks to draw on the authority of the outdated knowledge while simultaneously supplanting it.

New classifications reflect a bootstrapping between what practicing nurses already know and what the science of nursing will tell them. Thus, in order to get the category of culture brokerage in NIC, Tripp-Reimer had to get it into the research literature as something which was already being done by nurses (and indexed in databases!). The NIC team in general claims both that nursing is already a science and that it is a science that has not yet been formulated. They need both points for their project. That is, they need to maintain the former in order to justify the profession against current attacks, and the latter in order to justify their classification system, which when in place will protect it from future attacks.

We are not of course here accepting the position that such clearance leads to the creation of some sort of truer science - the issue of the validity of nursing knowledge is entirely independent of our purpose. We are producing an account of what it has meant in the case of nursing work to create such a science. This is not an accidental byproduct of their work, but can be seen as a core strategy over the centuries in the creation of sciences through the establishment of stable classification schemes. The strategy itself provides a way of managing a past that threatens to grow out of control. One can declare by fiat that the past is irrelevant to nursing science (while, in Tripp-Reimer's case validating the past as embodied in current best practice). The development of a classification scheme will provide for a good ordering of memory in the future - so that nothing henceforth deemed vital will be lost.

This claim that nothing vital will be lost is strategically important but largely unverifiable for two reasons. First, the classification scheme itself forms a relatively closed system with respect to the knowledge that it enfolds. It is difficult to stand outside of it and demonstrate that something is being selectively deleted or overlooked from the archive it supports. Second, you can only make a case that something has been overlooked if you have records to make the case with -- all the records tell you about is what is already in the classification scheme!

Erasure vs. Clearance

Erasure is employed (primarily) externally on the profession of nursing as a tool for rendering nursing a transparent distributed memory system. Clearance is a strategy employed internally within the nursing profession as a tool for defining the origin of the science of nursing. The logic of the relationship between clearance and erasure has been that nurses perform a clearance of their own past in order to combat the erasure of their present in the records of medical organizations. Medical information systems, they argue, should represent the profession of nursing as if it just began yesterday. Otherwise, these systems will copy the transparency of nursing activity from one representational space (the hospital floor and paper archives) to another (the electronic record). This poses, then, the question of what happens when a new ecology of attention (what can be forgotten and what should be remembered) is inaugurated with the development of a new information infrastructure.

The development of a new information infrastructure for nursing, at least part of which the NIC represents, will make nursing more memorable. And if the infrastructure is designed so that nursing information must be present as an independent, well-defined category, then nursing itself as a profession will have a better chance of surviving through rounds of business process reengineering and nursing science as a discipline will have a firm foundation. The fate of nursing, as both profession and discipline, is inextricably intertwined with those of infrastructural projects like NIC: "Having ensured that all nursing acts are potentially remembered by any medical organization, the NIC team will have gone a long way to ensuring the future of nursing" (Bowker and Star, 1999, p. 275).

Conclusion

A key feature of the ongoing integration of information systems into vast federated systems (be these in government, industry, or the medical professions) is that work which is not represented in those systems is at a huge disadvantage: it cannot be evaluated, accounted for, and/or rewarded. The kind of accounting that goes on frequently involves quantification; in John King's phrase, in general nowadays "numbers beats no numbers every time", even if the numbers one produces are inherently problematic. You need to produce numbers, even if you don't believe in the numbers that you are producing.

We have been struck in our analysis of the NIC intervention team by the subtlety of the Iowa Intervention Team's response to the need to produce a scientific classification of nursing work. They have recognized in discussions and publications that nursing work is not easily quantifiable and divisible; and they have developed a classification system which retains a judicious level of ambiguity; they do not try to overspecify the parts of a particular intervention.

The attempt to produce a scientific classification of nursing work represents one important direction for building up robust nursing knowledge. It also, at the same time, represents a significant strategy for defending the profession of nursing. Nursing is in this way no different from any other profession. Andrew Abbott (1988) in his The System of Professions demonstrates how many modern professions (drawing on the medical model) seek to demarcate for themselves an autonomous territory of scientific knowledge. The resulting visibility of nursing work is unavoidable; the price of the visibility is as yet uncertain. The recognition that the act of making nursing work visible is both scientific and strategical work is vital to the future development of the nursing profession.

Authors

Geoffrey C. Bowker, Ph.D.
bowker@ucsd.edu
http://weber.ucsd.edu/~gbowker

Geoffrey C. Bowker is Professor of the Department of Communication, University of California at San Diego. His PhD was in the history and philosophy of science (University of Melbourne). He is author, with Susan Leigh Star of Sorting Things Out: Classification and its Consequences (Cambridge, MA: MIT Press, 1999) and co-editor of a book on integrating social research and information systems design (Social Science, Technical Systems and Cooperative Work: Beyond the Great Divide, Mahwah, NJ: LEA Press, 1997). He is currently working on a book on memory practices in the sciences.

Susan Leigh Star, Ph.D.
lstar@ucsd.edu

Susan Leigh Star is Professor of the Department of Communication, University of California at San Diego. Her PhD was in medical sociology at the University of California, San Francisco, where she was a student of Anselm Strauss. As well as writing Sorting Things Out with Geoffrey Bowker, she has edited a collection on Ecologies of Knowledge (Albany, NY: SUNY, 1995). Her current project is studying the ethics of online research.

Mark A. Spasser, PhD, AHIP
mas1200@bjc.org

Mark A. Spasser is Associate Professor at the Jewish Hospital College of Nursing and Allied Health. He is actively engaged in social informatics research and has an active interest in the organization of nursing knowledge. Prior to joining the Jewish Hospital College, Dr. Spasser was a researcher at the Center for Botanical Informatics at the Missouri Botanical Garden where he helped develop the information infrastructure supporting the distributed publication of the Flora of North America. He received his PhD from the University of Illinois at Urbana-Champaign in 1998 and attained membership in the Academy of Health Information Professionals in 2000.