In 2019, DxR Development Group incorporated the Clinical Care Classification nursing taxonomy as an option into its nursing education software, DxR Nursing SELECT. We were privileged to meet the originator of this system, Dr. Virginia Saba at a gathering of CCC users. As part of Nurses Week and International Nurses’ Day, we interviewed her about her eventful career and the CCC nursing terminology.
Nursing as Art and Science
When Virginia Saba enrolled in Skidmore College in New York, young women who wanted to pursue a bachelor’s degree chose from two predominant career paths open to them: education or nursing. Her keen interest in science led Saba to pursue a bachelor of nursing science degree. With a 40-plus year career that encompasses community and public health nursing, research, education, advocacy, and informatics, she’s ‘Dr. Saba’ (EdD, Honorary PhD, DS, RN, FAAN, FACMI, LL), nursing legend. Understandably, she says she has no regrets about choosing nursing. The career that she originally viewed as the ‘next best’ thing to being a physician has been broad-based, rewarding, fruitful, and varied.
Saba started practice as a community or home health nurse, serving with the Visiting Nurse Association in New England, but she soon moved on to roles broadening her personal career and altering the future of nursing and nursing education. In what she calls the most important part of her nursing career, Saba spent 20 years conducting nursing research at the federal government level. She served as the Nurse Officer for the U.S. Health Service, the medical branch of the U.S. Coast Guard. Her work would prove pivotal in the professional training of nurses. “The major focus of the division was the distribution of federal funds for the advancement of nursing education at all levels. This is what changed nursing education … the funding from the Division to hospitals so their nurses could become academicians. As a result, nursing changed from primarily a diploma program to a baccalaureate program.”
Researching for the Computer Age
As part of her federal government work, Saba focused on gathering and reporting statistical data about nurses and nursing care in the U.S. Making sense of that data required coding it, something that had never been done before. It required collaboration with state public health officials. “We would decide how to code the count and the skills of nursing so we could get an accurate count of who was doing what where. The reason we needed that was not only for the industry or the profession, but also for the government. Congress needed to know, ‘How many nurses are we talking about? How much money needs to be allocated so that the nurses can get their education?’”
Along the line, Saba realized that because the data were being coded, she needed to understand coding and computers. She immersed herself in the only available computer training courses at the time, so she could effectively work with programmers who were writing code. “I started taking those courses to learn ‘what is a computer and what does is do?’ Of course, my next question [was] what does it do for nursing? That has been the answer and the question I have had for the last 30 years.”
Getting to the Source
When she retired from the federal government, Saba accepted a teaching position at Georgetown University. She continued her research, through a federal government grant to quantify the scope of home healthcare. “We were going to collect 10-thousand cases…we only got 6-thousand cases covering home health, community health, public health, and also got at hospital care, as well. With all of this mixture, we came up with the best and the biggest description of nursing health care in the country.”
The next step was a revelation. “I asked every agency to list not only the problems nurses faced on each patient in their case load, but also, what did they do for the patient? Well, what a surprise. We got 40-thousand statements about what were the problems and we got 80-thousand statements about what they did. These were in the words of the nurses.” The results may have marked the first time researchers had hard evidence of what nurses contribute toward patient care.
Naming and Claiming It: Nursing informatics
A standardized language or nomenclature is supposed to reflect what happens in professional practice. Nursing educators teach students the nursing process (Assessment, Diagnosis, Planning, Implementation, and Evaluation) to describe the ‘steps’ nurses follow, but the process doesn’t provide names and labels to nursing decisions. As the healthcare system computerized its record-keeping and documentation, various professionals — including physicians —adopted ‘coded’ terminologies. “They had ICD (International Classifications of Diseases), we [nurses] didn’t have anything. So that became the second focus of the study: to categorize, code, and analyze all this data. That’s how the Clinical Care Classification system came about.”
Saba and her research team developed the Clinical Care Classification system as a coded standard that nurses could use to document patient problems (using nursing diagnosis labels) and the interventions they identified to address those problems. The CCC system also includes codes for patient outcomes. Saba insisted that all nursing diagnoses in the CCC system must have at least one potential intervention that a nurse could perform to address that patient need. Saba’s CCC system was developed at the same time other nursing diagnosis systems were under development, and all compete for a following. Other systems, including the NANDA-I taxonomy, are copyrighted and are subject to licensing fees. Saba turned over management of the CCC system to Healthcare Corporation of America late last year, stipulating that it must remain available, free of charge. The CCC system is used internationally, with translations in Chinese, Korean, Norwegian, Persian/Farsi, Spanish, Portuguese, Slovene, Turkish, and Italian.
Saba says while it may cost money for hospitals to institute a unified nursing language system, the lack of one for nursing care is costly. In-patient nursing care is reimbursed as part of the ‘room-rate’ — the nightly charge for a hospital room. Nursing activities are not reimbursed for the time and effort they require or for their effectiveness. Saba says if there’s a single nursing language, it becomes impossible for government and insurers to ignore the value and the effects of nursing care. “This data is so crucial. It helps change the role of nursing. It makes them visible, valuable and critical to what I call, ‘the care of the patients.’”
Cooperation for the future
Dr. Saba says for the nursing profession to advance to its potential, all players in government, research, academia, and the industry need to come together. “So it requires not only our work and our demand for research and our own research but also, once we get our research, for the government to recognize it, and for the nursing profession to support it.”
During this year of the nurse and midwife, the spotlight is on the ‘caring’ element of nursing. Dr. Saba agrees excellent nurses must be caring. But she maintains the scientific element is equally important. “What I want to see is not only a caring nurse, but also a caring technology nurse, or a technology-caring nursing, or however you want to put it. That for me is nursing informatics. It’s not only caring, it is the science of what we do that makes patients well.”