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50 DRIVEWAY,OTTAWA ON K2P 1E2TEL: (613) 237-2133 1-800-361-8404 FAX: (613) 237-3520 WEB SITE:www.cna-aiic.ca E-MAIL: prr@cna-aiic.ca
tion system using a classificationsystem, a user can retrieve encodeddata – depending on the complete-ness of the data entered and thesoftware product being used.Before things can be classified, how-ever, the concepts have to be devel-oped. In the case of health care deliv-ery, the only concepts available up tothe mid-20
th
century were medicalconcepts. Diseases were classified asearly as the mid 1700s. In 1860,Florence Nightingale herself deliveredapaper urging the classification ofnon-fatal conditions as well as causesof death. By 1893, the
InternationalClassification of Diseases and Causes of Death
was being used and in 1946, the World Health Organization (WHO)assumed responsibility for reviewingand revising this system every10years (Gordon, 1998). The 10
th
revi-sion, adapted for use in Canada, iscalled the
International StatisticalClassification of Diseases and Related HealthProblems – Canada
(ICD-10-CA) and iscurrently being implemented acrossthe country.Nursing theories and philosophiesmatured in the 1950s and interest inclassifying nursing practice increased.National and international nursingorganizations have moved forward theconcept of classifications for nursingpractice.In Canada, the 1993 Nursing MinimumData Set (NMDS) Conference, initiatedby the Canadian Nurses Association(CNA), was the first step in developinganursing minimum data set, nowcalled Health Information: NursingComponents (HI:NC). These includedata on client assessment, nursing
Introduction
In 1859, Florence Nightingalewrote the “very elements of nurs-ing are all but unknown”(Nightingale as cited in Gordon,1998, p. 2). Morethan 140 yearslater, the founder of the nursingprofession might be surprised todiscover that making nursing visi-ble remains a huge challenge!Yes, nurses have made progress,but thereis still not enoughquality information in Canada onwho nurses are, what nurses do,to whom they provide care, whateffect their interventions have onpatient outcomes and how muchthese interventions cost. In orderto plan effective health servicesdelivery, nurses and other deci-sion-makers need better informa-tion on the contribution of nurs-es to health outcomes ofCanadians. The impact of nursingshould be captured in nationalhealth caredatabases throughthe use of effective nursing clas-sification systems.This article will provide a basicoverview of classification systemsdevelopment in nursing andhighlight an international initia-tive designed to establish a com-mon language for describingnursing practice.
Classification Systems: What AreThey?
In order to collect, store, retrieve,analyze and communicate informa-tion about their practice, nursesrequireclassification systems.“Classification is the ordering of enti-ties into groups or classes on thebasis of their similarity” (Gordon,1998, p. 4). We classify things all thetime in our complex world: a dog isclassified under a group called ani-mals; a poodle is further classifiedas a particular breed/type of dog.Imagine trying to find specific infor-mation if the newspaper “classified”ads were not organized into cate-gories! In the field of informatics,classification systems play a criticalrole in systematically arranging dataaccording to similar groups.Classification systems aresome-times referred to as encoding sys-tems, because standardized codesare assigned to each term within aclassification system. If data areentered into a computer informa-
InternationalClassification forNursing Practice:
Documenting Nursing Careand Client Outcomes
NUMBER 14JANUARY 2003
 
CANADIAN NURSES ASSOCIATION, 50 DRIVEWAY, OTTAWA ON K2P 1E2TEL: (613) 237-2133 1-800-361-8404 FAX: (613) 237-3520 www.cna-aiic.ca E-MAIL: prr@cna-aiic.ca
interventions and client outcomes,which are the basic elements –along with nursing resource use andnurse identifier – for classifyingnursing practice. In 2000, CNA pub-lished
Collecting data to reflect nursingimpact: A discussion paper.
This docu-ment provides an overview andcomparison of major nursing classi-fication systems and promotes test-ing the International Classificationof Nursing Practice (ICNP
®
), devel-oped by the International Council ofNurses (ICN), for use in Canada.The American Nurses Association(ANA) has developed criteria forevaluating nursing languages andrecognizes the 12 classificationsystems presented below, manyof which will be familiar toCanadian nurses.teach it or put it into public policy”(ICN, 1993, p. 2).The first step is to clearly identifywhat information is needed andtranslate that into a data set.Connecting with experts throughprovincial/territorial and nationalnursing associations and informat-ics groups is essential to achievingthis step. The next step is to selectappropriate classification systemsthat will make it possible to col-lect the required information.It is important to implement nurs-ing classification systems that arecompatible with health informationsystems already in use in Canada. With the need for integrated infor-mation systems and electronichealth record (EHR) solutions,there is an increasing demand forclassification systems that capturemultidisciplinary as well as disci-pline-specific data. For example,the Canadian Classification ofHealth Interventions (CCI) wasdeveloped by the CanadianInstitute for Health Information(CIHI) to be applicable acrosshealth disciplines and settings, andit is referred to as a discipline andsetting-neutral classification.Likewise, the ability of a classifica-tion system to cross-map to existingnursing terminologies is critical tocomparing information across andwithin provincial/territorial, nationaland international borders.Nursing classification systems alsodiffer in their intended setting onthe continuum of care(acute,home and long-term) and the ele-ments they address: diagnoses(client assessment or status),interventions and outcomes.Given the number of classificationsystems in existence today, wheredo nurses start? Table 1, adaptedfrom
Collecting Data to Reflect NursingImpact: A Discussion Paper 
(CNA,2000), compares several majorclassification systems in use today.
2
 Why Do Nurses NeedClassification Systems?
Classification systems allow nursingdata to be collected consistentlyusing standardized languages toaggregate and compare data acrossand between sites. The inclusion ofnursing data in health informationsystems is essential to support evi-dence-based decision-making byregistered nurses (CNA, 2002). A co-ordinated system to collect, storeand retrieve nursing data in Canadais critical for health human resourceplanning and to expand knowledgeand research on determinants ofquality nursing care (CNA, 2001a).The benefits to nurses of effectivenursing classification systemsinclude those mentioned below.
ImplementationConsiderations In Nursing
In order to achieve the above bene-fits, nurses must give commonnames and definitions to theobjects of their practice and arrangethem in a meaningful way. To quoteICN “If we cannot name it, we can-not control it, finance it, research it,
 What do NursingClassification Systemsdo for Nurses?
•Provide a common language fordescribing nursing practice in orderto communicate effectively to othernurses and health professionals;•Facilitate analysis of patterns in nurs-ing care and resource utilization,trends in the health needs of patientsand outcomes of nursing care;•Facilitate comparisons and thesharing of information on bestpractices between nurses;•Support decisions of policy-makersand health caremanagers throughthe provision of nursing evidenceand knowledge;•Support accountability relation-ships;and•Provide quality data to researchersto investigate key questions relatingto nursing practice.
 ANARecognizedLanguages for Nursing
1.North American NursingDiagnosis Association,Inc.(NANDA)2.Nursing InterventionsClassifications (NIC)3.Home Health CareClassification (HHCC)4.Omaha System5.Nursing Outcomes Classification(NOC)6.Nursing Management MinimumData Set (NMMDS)7.Patient Care Data Set (PCDS)8.PeriOperative Nursing Data Set(PNDS)9.SNOMED RT10.Nursing Minimum Data Set(NMDS)11.International Classification forNursing Practice (ICNP
®
)12.ABC codes developed byAlternativeLink 
Detailed information on each of thesesystems can be found on the NursingInformation and Data Set EvaluationCentre(NIDSECsm) home page atwww.nursingworld.org/nidsec/classlst.htm.
 
SystemDeveloper/Year/CommentsClassification Systems for Each Element
DiagnosisInterventionOutcome
NANDA*(North AmericanNursing DiagnosisAssociation)OMAHAClassification System*HHCC*(Home Health CareClassification)NIC*(Nursing InterventionClassification);IowaIntervention ProjectNOC*(Nursing OutcomesClassification)ICNP*(InternationalClassification forNursing Practice)projectICD-10-CACCISNOMED
®
 –NANDA,1973,all settings –Visiting Nurses Association & U.S.Dept.of Health,1989-93 –Comprehensive system:community,publichealth,school health,home care,communityclinics,institutional settings and acute care. –Virginia Saba et al.,1988-1991 –Home health care,ambulatory-care,long-term care facilities –Large research team at University of Iowa,1987 –Language is comprehensive and can beused bynurses in all settings. –University of Iowa,1997,all settings –International Council of Nurses,Geneva,1993-96,all settings –Mapped the data elements of existingNursing Classification Systems –Nursing outcomes can contribute nursingsensitive information to broader generichealth outcome modules. –Currently being implemented across Canada. –Dates varybyprovince/territory. –Currently being implemented across Canada –dates vary by province/territory –SNOMED
®
International officially launchedthe next generation of its clinical referenceterminology in 2000. –Currently,it is used primarily as a referencein Canada.ProblemClassificationSchemeNursingDiagnosisSystem*Linkedwith NANDAdiagnosesDiagnosis/healthconditionsClinical termsrelated to signs/symptoms/diag-nosis/healthconditions/interventionsInterventionSchemeNursingInterventionSchemeProblemRating Scalefor Outcomes
CANADIAN NURSES ASSOCIATION, 50 DRIVEWAY, OTTAWA ON K2P 1E2TEL: (613) 237-2133 1-800-361-8404 FAX: (613) 237-3520 www.cna-aiic.ca E-MAIL: prr@cna-aiic.ca
vides data representing nursing prac-tice in comprehensive health infor-mation systems. The ICNP
®
can beused to make nursing practice visiblein health information systems.Researchers, educators, managersand policy developers can use datafrom health information systems toidentify nursing’s contribution to
ICNP
®
The International Classification ofNursing Practice (ICNP
®
), devel-oped by ICN and in its Beta 2phase, is a classification systemwith the potential to address manynursing classification issues.The ICNP
®
is an informational tool todescribe nursing practice and pro-
3
health care. The data can be used toassurequality or promote changes innursing practice through education,management, policy and research.For more information visit the ICNP
®
web site at www.icn.ch/icnp.htm.The elements of the ICNP
®
–NursingPhenomena (nursing diagnoses),Nursing Actions (nursing interven-
Table 1.
Comparison of Classification Systems
*Nursing specific 
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