“To better understand a work is advisable to get informed about the author and his / her context .”

Note : The text reproduced below was published as an appendix to the author’s doctoral thesis in 2012.

” The reasons that led the author to the construction of the interface terminology have been made explicit along different sections of this thesis; reasons that have evolved over time, scientific and disciplinary advances but also, with the researcher’s own personal and professional history. In this sense, there are different events that significantly influenced the development of this work.

Shortly after that Mr. Joan Antoni Samaranch uttered the words that open this appendix (… a la Ville de Barcelona), I enrolled the Nursing studies at the University of Barcelona (1987). Among other scholars and lectures, nurses and physicians, who guided our theoretical and practical learning at this nursing school, I was fortunate to learn from a young but experienced registered nurse, María Teresa Luis Rodrigo. I think  that it was by the end of the 4th semester, Maite suggested me to collaborate with her in a project, an initiative of the Manresa University School of Nursing, to translate a classification of nursing diagnoses: NANDA Taxonomy I. The document, whose main author was María Teresa Luis, entitled NANDA Diagnostics d’ infermeria segons la revisió de la taxonomia I-1989, was the first translation in Spain of the North American Nursing Diagnosis Association works .

I remember translating in my room, in our family home, with a “big” computer that one of my uncles (Jordi Udina ) had gifted to me, using Word Star and a floppy disk system that no longer exists. It was my first written work entirely done on a computer (until then written works used to be presented hand or typewritten).

At that time, I already knew the works of this association because Maite and some other professors taught them to us in class, the meaning and use of the methodology in Nursing, the application of the nursing process, and because fortunately, during my childhood and adolescence my parents insisted on the need to get certain degree of fluency in English, which I learned with one of my aunts (Maria Cinta Comas) and by listening and singing songs from Frank Sinatra, Ella Fitzgerald , Billie Holiday or Tina Turner. This allowed me to locate and get some British and American Nursing books during my university years, such as Nancy Holloway’s works on standardized care plans , which already contained NANDA diagnoses and differentiated them from interdependent problems.

For a couple of years, already working  as a staff registered nurse, I subscribed a NANDA membership, study in depth the content of their diagnoses, the aspects related to its application within the framework of the nursing process and I participate multiple courses organized by the Spanish Association of Nursing Education (AEED) in Barcelona and Madrid, with prominent U.S. nursing scholars such as Rosalinda Alfaro or Linda Juall Carpenito .

At that time I started working as a registered nurse in clinical hematology in Duran i Reynals Oncology Hospital which was close to the Ciutat Sanitaria i Univeristaria de Bellvitge (a high-tech metropolitan hospital facility) and in early 1992, I had the opportunity to train for a few months at the Royal Marsden Hospital in Sutton (Surrey, UK) to expand my knowledge and skills on  the care for patients requiring bone marrow transplantation. Direct contact with the daily reality and the weight of history of British Nurses amazed me . I was impressed not only by their professionalism and their discipline, but above all by their outstanding role in the community, the actual social recognition they already  had and the responsibility with which they hold their power. It was there that I fully understood the influence of Florence Nightingale on the scientific and professional development of Nursing in Commonwealth countries and the difference that this marked in the social conception of our discipline, as well as the divergence, in the form and the content, of nursing scope of practice in my country, in whose history, forty years of dictatorial regime weighed, a strong Catholic and military tradition that imbue the way of learning and practicing healthcare disciplines and the weight of too many years of nursing training programs as Sanitary Technical Assistants. More than twenty years later I believe that the distance has not been reduced as I expected.

While in the Marsden I subscribed to several North American Oncology Nursing Journals, I loaded my bags back home with countless books on cancer patient care but also other works on chronic patient care and other topics in vogue today in our country, which I “devoured” in the following months, most of them I kept as reference books for many years to support my professional practice. In the Marsden, I observed, not only procedures and attitudes towards patients but the way in which they care of words in their oral and written expression. In this hospital, nurses paper records were very complete, at my then young view, and it caught my attention they did not use the NANDA taxonomy. It was there, I discovered the strong positioning of English nurses in relation to a vocabulary that in their critical opinion did not suit their patient record needs at all, which was subsequently the reason for various publications in journals such as the Journal of Advanced Nursing . This fact, made me reflect on something that I had already observed in the healthcare practice in the hospitals where I had worked in Barcelona: the “veteran” nurses (many of whom were really proficient and expert nurses), who were my mentors and guided my first years in clinical practice, they objected that the NANDA diagnoses did not allow to properly  identify many of the situations and problems that hospitalized patients experienced. The history of the dichotomization debate on diagnoses and the for and against positions on the implementation and usefulness of the nursing methodology in our country is known; the results to date are obvious.

When I got back home,  I return to work as staff registered nurse, trying to bring into practice methodology and language classifications, published a couple of papers in the journal Enfermería clínica related to oncology patient care in which I used concepts from the NANDA taxonomy and Marjory Gordon’s functional health patterns, and in 1996 I published a book on the care of oncohematological patients in which I included elements of the terminology however all that time, I kept on capturing a gap between the academic world and healthcare practice. I felt that perhaps the problem was not only the method and the language, but mostly the socialization processes that surrounded our practice, and I understood that I had to do several things: establish strategies to promote a progressive approach between the nurses’ natural language and disciplinary academic languages, learn research methodology, further progress in the study of theoretical foundations of Nursing and optimize my skills in the use of systems information.

As initial approaching strategies, I observed for months how registered nurses with whom I worked or kept contact for diverse issues, expressed their observations and reasoning. I identified natural language they used  to express themselves in practice included an infinity of verbs, mostly in first and third person singular, in all verb tenses, with a surprisingly intensive use of the imperative form to identify what they did, what they should indicate and what they observed in patients (“ How are you feeling today?”, “I’m going to talk with … “,” I must prepare … “,” he was not moving “,” he is crying “,” Stop the pump “,”Discontinue the administration “,” call the doctor “,” Take a look at the dressing “) and also, occasionally with forms that in a certain way “ alienated ” the patient or abducted him into the nurse-patient dyad (“let’s calm down”, “for now we shouldn’t worry”, “we’ll start with a drug that ….” , “We have surgery  delayed ”). I think some professionals understand this type of statements as a form of empathy , proximity or complicity with the patient. Personally, I have always tried to make very limited use of this resource. In any case, this observation match with a very generalized traditional idea in my country: “Nurses DO things”, which was reflected in the old popular saying  “Nurses are the doctor’s hands “, as if thought and reasoning were a medical domain and the solicitous execution, the reason of being a nurse. I understand that these statements are parts of the historical influence that Medicine has exerted on Nursing practice but I always rebelled against them, because one cannot do without observing, thinking and making decisions, Cogito ergo sum, but to them I owe my interest and my subsequent studies on the relationship between nursing professional autonomy, decision-making and nursing expertise and also , the opportunity to discover the work of Patricia Benner on nursing competence and from the model form Hubert and Stuart Dreyfus, on decision- making, skill acquisition and artificial intelligence.

Nursing natural language also contains an infinity of conditions, conditional verbs and doubtful adverbs (“probably”, “it is possible”, “if everything goes well”, “if it does not improve”, ” should “), almost always related to management of uncertainty that characterized being ill, life change or transitions in vital situations, as well as a way of showing respect to the person with conventions such as “ would you be so kind as to you raise your arm a little more ” or “would you mind holding this towel for a moment ”, while only occasionally as a reflection of the professional’s indecision when facing a new situation that generates insecurity.

Nursing natural language is rich in adjectives (” pale “, “sad”, “moderate”, “extensive”, “serous”, “localized”, “passive”, “stable”, “inactive”, “clear”, ” solitary ”), which contribute to enrich the descriptions of the observations and findings, being in most cases a subjective interpretation but with huge clinical value, and also abound in adverbs (“ extremely intense ”,“ progressively decreasing ”,“ near of the area ”,“ during the night ”), which allow adding circumstantial information in its natural or superlative way and ease the evaluation of the evolution of the patients’ situation and the identification of the achievement of expected outcomes.

The lexical elements, verbs, adjectives, pronouns, adverbs were used so frequently, but what about nouns? … Over those years, I realized that naming of nursing phenomena had been one of the main reasons for the disciplinary theoretical development of recent decades, initially linked to the attempt to build the identity and professional autonomy of the Nursing profession and differentiate it mainly from Medicine. Language is one of the cornerstones on which the social construction of a discipline is based and not only has the practical effect of facilitating the identification of phenomena and inter-professional communication, but it also has important connotations at an ethical, political and economic level. It is a double-edged sword since it is the formal representation of knowledge and, at the other extreme, the lack of its knowledge places the individual (or the group) in ignorance. In addition, disciplinary language has the socio – political function of presenting what is important, what is ethically correct in practice and consequently, of making visible what one is, does and achieve.

For years , different sectors of nursing have fiercely advocated avoiding the use of medical concepts in nursing language. Professionally and personally I have never shared this view  The history of modern medicine has been nurtured and greatly enriched with concepts from other branches of knowledge such as chemistry, mathematics, economy, law, biology, physics or psychology, and this has not detracted any value. On the contrary, it has allowed Medicine to grow and advance enormously. If nurses can, and as Nightingale asserted, “we must” incorporate statistical knowledge and language , why should not we be able to incorporate (or recover) aspects of medical language, as part that contributes to development of our knowledge? Phenomena are not an exclusive property of any discipline. They are human or environmental elements and each discipline focuses on them, studies them and develops them from its perspective and with its methods, in some cases sharing a same name or label, in others attributing a specific term. Or is it that nurses do not use terms and concepts from mathematics or physics when regulating an I.V. infusion; from chemistry, when considering the prescription of the most appropriate diet for the patient; or from philosophy, sociology and theology when we assist a sick person to express his spiritual suffering?

One of the first things I learned about nursing diagnoses, which was also clearly stated in the works on the subject, was that the nursing diagnosis should not be used to describe or attempt to substitute a medical diagnosis. The nursing literature of recent years is full of examples of an incorrect use of the nursing diagnosis in this sense. One will never replace the other. There are two complementary judgments, one aimed at the precise identification of the disease from the field of medical knowledge , the other aimed at determining the different health states and their consequences from the wealth of nursing knowledge. And it is from this symmetry of both knowledges, despite the historical disadvantages of Nursing , that people we intend to help, both nurses and physicians, can really benefit in terms of health outcomes and autonomy. I do not share the warlike positions of some physicians and nurses. There are many lexical elements that Medicine offers to human knowledge and also many concepts that Nursing has developed and contribute to the growth of other disciplines, as seen for instance in the current language used by social workers; the jargon of social and health well-being is full of constructs that the nursing discipline generated almost a century ago: autonomy , self-care, responsibility for the health and well-being of people and the community are constructs that already appear in the works of Bertha Harmer from 1922. Likewise, the origin of some of these concepts is previously linked to other humanistic disciplines such as philosophy, ethics or law.

The observation of nursing natural language and the study of controlled vocabularies were, for some years, the sources of inspiration for many terminological works I made and that contributed to progressively introduce small changes in the nursing records and the interprofessional communication and that finally, would allow the creation of this interface language . I was not really aware of its potential as ian interface terminology until some time later, when the then Nursing Director of the Ciutat Sanitaria i Universitaria de Bellvitge (Montserrat Artigas) proposed me to work in a project of  “Computerization of nursing care plans”. This was 1994. I must admit that I failed several  times in developing and implementing information systems for nurses based on care plans between the years 1997 and 2001 and meanwhile, the lack of understanding I perceived on the value of developing this interface vocabulary, in front to the hegemony of the doctrine of the American nursing vocabularies, somehow slowed down its progress. Sometimes I thought that only few people understood what I was doing and where were the boundary between my work in the hospital and my personal out-of-work dedication developing this standardized vocabulary. Between 1994 and 2001,  without receiving any acknowledgment of my own work, many parts of the ATIC terminology and its data model were used as the basis of several projects to computerize care plans, first linked to an application prototype developed by the company Andersen Consulting; after for the development of electronic health record system by the company Centrisa and finally, between 1998 and 2001, for the inclusion of nursing care in a software for electronic patient records named OMI-AH from the company STACKS-CIS. I finally landed to publish the structure of part of this data model, based on the theory of complexity, in the Spanish edition of Nursing in 2005.  A couple of years later, as proposed by an external task force, I would have the opportunity to share the use of the ATIC terminology and knowledge tools  for the development of the ARES program on nursing care standards and the implementation of  electronic health records of the Institut Català de la Salut

Since the publication of this appendix, a decade has passed in which I have kept on evolving terminology developments, updated all axes, strengthened the system of management indicators and the data model, published multiple research papers, introduced a new classification of diagnostic typologies ,  developed new ontologies to further ease the use of the language in practice and the circular and iterative representation of the nursing care process, developed algorithms of screening and early detection of acute deterioration and designed and validated a patient classification system that predicts required intensity of nursing care based on the main nursing diagnosis.

To be continued.