Nursing Outcome Classification

John Mark L. Bocarile, RN

What is the clients response to the nursing intervention?

Nursing Process
y 6-step process (ADOPIE) y ASSESSMENT y DIAGNOSIS y OUTCOME IDENTIFICATION y PLANNING y IMPLEMENTATION y EVALUATION

(ANA, Standards of Clinical Practice, 2008)

Outcome Identification

Outcome Identification
y refers

to formulating and documenting measurable, realistic and client-focused goals that will provide the basis for evaluating nursing diagnosis. y Expected Outcome or the anticipated goal of the identified care interventions and actions needed to treat the patients conditions. y Establish clients goals and outcome criteria

Example of Verbs Used in Goal Setting

y Calculate y Classify y Communicate y Compare y Define y Demonstrate y Describe y Construct y Contrast y Distinguish y Draw y Explain y Express y Identify y List y Name y Maintain y Perform y Particular y Practice y Recall y Recite y Record y State y Use y Verbalize y Ambulates

Example
y Ambulates safely with one-person assistance. y Identifies actual & risk environmental hazards. y Demonstrates signs of sufficient rest before Surgery.

General Qualifiers to Predict Care Outcomes

y To Improve patient's condition y To Stabilize patient's condition y To Support Deterioration or Death of patient's condition

Example
y Goal The client will report a decreased anxiety level regarding

Surgery.

y Possible Criteria

>After client teaching, the client verbalizes decreased anxiety. y The client discusses fears & concern regarding surgical procedure after client teaching. y The client identifies a support system and strategies to use to reduce stress and anxiety related to the surgical experience.

Example
y Goal The client will demonstrate safety habits when

performing activities of daily living.

y Possible Criteria

_____________________________________________ ____________________________________________ ____________________________________________ _____________________________________.

Possible Outcome Criteria

y Immediately after instruction by the nurse, the client uses

call light system for assistance when needs to use the bathroom. y The client demonstrates safety practices when dressing and doing personal hygiene. y The client uses over-the-bed lights, non-skid slippers when transferring to chair or getting out of bed. y The client identifies modification for home safety (removal of throw pillows, installation of hand rails in hallway, better lighting of hallway and stairway), 12 hours after nurses instruction about home safety.

Example
y Goal The client will mobilize lung secretions.

y Possible Outcome Criteria

_____________________________________________ ____________________________________________ ____________________________________________ _______________________.

Possible Outcome Criteria

y After teaching session, the client demonstrates proper

coughing techniques. y The client drinks at least 6 glasses of water per day while in the hospital. y The caregiver or significant other demonstrates proper technique of chest physiotherapy including percussion, vibration and postural drainage before discharge.

Evaluation

Evaluation
y Nurses make decisions all throughout patient (client) care

situations. Within the context of the nursing process, evaluation the sixth phaseis a concurrent and a terminal process. It is concurrent or on-going because the nurse evaluates and makes decision during the implementation phase of the process. y Actual Outcome depicting the outcome of care resulting from the interventions and action types used to treat the patient.

Types of Evaluation
y Structure Evaluation Environment

y Process Evaluation Nurse

y Outcome Evaluation - ???????

Outcome Evaluation
y Outcome evaluation occurs when the client becomes the

focus of evaluation. y Here the nurse is concerned with changes in the client that occur as an effect of the nursing interventions. y Outcome evaluation answers the question To what degree are the client goal and predicted outcomes achieved?

NOC

Situation
y The health care environment in which nurses deliver care is

experiencing constant change characterized by decreased lengths of stay in acute care settings, increased use of technology, increasing emphasis on computerized patient records and care planning options, increasing markets dominated by managed care, and an emphasis on outcomes rather than process. These changes dictate that nursing as a profession ensures that the work of nursing is visible in this health care environment and included in the data used to make health policy decisions (Moorhead et. al., Journal of Nursing Care Quality, 1998)

Nursing Outcome Classification

y It is a comprehensive, standardized system to classify outcomes of

nursing interventions. It is a clinical tool developed by a research team at the University of Iowa that describes and defines the knowledge base for nursing curricula and practice. NOC outcomes have been linked to NANDA diagnoses. At present, NOC includes 385 nursing outcomes for use for individual patients or individual family caregivers in the home. It is considered part of the clinical decision making of the nurse to decide and document the nursing diagnoses, desired outcomes, interventions used, and outcomes achieved. (Mosby's Medical Dictionary, 8th edition. 2009, Elsevier)
y

Outcome Classification
y Health care providers have appreciated the importance of

outcomes as requirements for measuring economic efficiency and system effectiveness in a cost-control environment. In addition to the term "result", eight terms are commonly used in the literature to modify, an outcome: patient, nursesensitive, desired, effective, expected, predicted, projected, and actual outcome. Outcomes may defined as the end results of care, yet when quality of care is being measured outcomes are linked to diagnoses. From this perspective, outcomes are indicators of problem resolution or progress toward resolution (Gordon, The Online Journal of Issues in Nursing, 1998)

Historical Perspective: Outcome Classification

y Aydelotte (1962) was an early pioneer in the measurement of

patient outcomes. She was the first in nursing to use changes in characteristics of patients to evaluate nursing care delivery.
y In 1988 Heater, Becker, and Olson completed a meta-analysis

of studies that suggested a growing interest in nursing goals and outcomes during the previous decade. Outcomes at this time were general, such as "the patient's self care skills" (Hover and Zimmer, 1978).

Historical Perspective: Outcome Classification

y Johnson and Maas summarized the multiple reports of outcome

generation that were characteristic of the 1980s and early 1990s and concluded that identification of outcomes was based mainly on literature reviews and practical experience rather than research or conceptual frameworks" (1997, p.5). These authors also note that nursing outcomes differ in content from medical outcomes. Nursing includes client knowledge and behaviors, safety ,use of resources, home maintenance, and caregiver status (1997, p.5). y In a large, funded project Johnson and Maas (1997) and a team of investigators at the University of Iowa developed a set of outcomes and proposed their linkages to nursing diagnoses. Outcomes and their indicators are the concepts, or elements, to be used in classification.

Nursing Outcome Classification

y The Nursing Outcomes Classification (NOC) describes

patient outcomes sensitive to nursing intervention. NOC evaluates the effects of nursing care as a part of health care. Standardized patient outcomes are essential to ensure that nursing becomes a full participant in clinical evaluation science along with other health disciplines. (Johnson, 1997)

Nursing Outcome Classification

y The Nursing Outcomes Classification (NOC) is a comprehensive

taxonomy of patient outcomes influenced by nursing care. Each outcome is stated as a variable concept measured on a five point Likert scale and includes a definition, indicators, and references. The classification provides outcomes that can be used across the care continuum to assess patient status following nursing interventions. The classification has a number of advantages, including being research based, standardized, comprehensive, and flexible for clinical use. It was developed lay a large research team that included clinical experts and has been subjected to testing (Marion and Meridean, Journal of Nursing Quality, 1998)

y Standardized outcomes are necessary for documentation in

electronic records, for use in clinical information systems, for the development of nursing knowledge and the education of professional nurses. An outcome is a measurable individual, family, or community state, behavior or perception that is measured along a continuum and is responsive to nursing interventions. The outcomes are developed for use in all settings and with all patient populations.

Brief History of NOC

y The Nursing Outcomes Classification contains 190 outcomes

listed alphabetically during the year it was published by Mosby in 1997 (Iowa Outcomes Project, 1997). Since publication, an additional 28 outcomes and the taxonomy have been developed. For this work, an outcome is stated as a variable concept representing a patient or family caregiver state, behavior, or perception that is measurable along a continuum and responsive to nursing interventions. Stating the outcomes as variable concepts, rather than as goals, allows for the identification of positive or negative changes or no change in a patient's status. Each NOC outcome has a definition, a list of indicators that are useful in evaluation of patient status, a measurement scale, and a short list of references used in development of the outcome

Brief History of NOC

y Since August 1991, a research team consisting of 43 nurses

representing service agencies and nursing education has been conducting a study of nursing-sensitive patient outcomes. The purposes of the research are to: y 1) identify, label, validate, and classify nursing-sensitive patient outcomes and indicators y 2) evaluate the validity and usefulness of the classification in clinical field testing y and 3) define and test measurement procedures for the outcomes and indicators.

Brief History
y The research to develop NOC began with the formation of

the outcomes research team in 1991 and has progressed through the following phases. y Phase I - Pilot Work to Test Methodology (1992-1993) Phase II - Construction of the Outcomes (1993-1996) Phase III - Construction of the Taxonomy and Clinical Testing (1996-1997) Phase IV - Evaluation of Measurement Scales (1998-2002) Phase V - Refinement and Clinical Use (1997 - Present)

y Clinical sites used to test the NOC included tertiary care

hospitals, community hospitals, community agencies, nursing centers, and a nursing home. The outcomes are developed for use in all settings and can be used across the care continuum to follow patient outcomes throughout an illness episode or over an extended period of care. Since the outcomes describe patient/client status, other disciplines may find them useful for the evaluation of their interventions.

Nursing Outcome Classification

y The classification contains patient outcome categories and

y y y y y

indicators at four levels of abstraction and empirical measurement scales. The taxonomy of domains and labels can be obtained from the NOC project office at the University of Iowa. Most Abstract Nursing-Sensitive Outcomes Domains High-Middle Level Abstraction Nursing-Sensitive Outcome Classes Middle Level Abstraction Nursing-Sensitive Outcome Labels Low Level Abstraction Nursing-Sensitive Outcome Indicators Empirical Level Measurement Activities for Outcomes

Nursing Outcome Classification

y The outcomes have been linked to NANDA International

diagnoses, to Gordon's functional patterns, to the Taxonomy of Nursing Practice, to Omaha System problems, to resident admission protocols (RAPs) used in nursing homes, to the OASIS System used in home care and to NIC interventions.

THE CENTER FOR NURSING CLASSIFICATION

y Classification research conducted at Iowa is unique and

crucial to the documentation and study of nursing care and to the articulation of nursing care with that of other providers. For nearly a decade the University of Iowa College of Nursing has been a leader in developing standardized languages to describe the work of nursing. The Center for Nursing Classification, established in 1995, facilitates the continued development of this important work.

Benefits
y The Classifications will benefit health care providers, patients, and

third-party payers in many ways.They will:

Provide a standardized language for nursing. Facilitate appropriate selection of nursing interventions. Define and predict outcomes nurses can achieve with patients. Facilitate communication of nursing treatments to other nurses and other providers. Standardize and define the knowledge base for nursing curricula and practice. Facilitate the teaching of clinical decision-making to novice nurses.

Benefits
y Assist administrators in effectively planning for staff and

equipment resources. Enable researchers to examine the effectiveness and cost of nursing care. Assist educators in developing curricula that better conform with clinical practice. Promote the development of a reimbursement system for nursing services. Facilitate the development of computerized information systems. Communicate the nature of nursing to the public.

NOC - Description
y The 330 NOC outcomes in Nursing Outcomes Classification

(NOC) (3rd ed.) are listed in alphabetical order. Each outcome has a definition, a list of indicators that can be used to evaluate patient status in relation to the outcome, a target outcome rating, place to identify the source of data, a five-point Likert scale to measure patient status, and a short list of references used in the development of the outcome. For 76 of the outcomes an additional measurement scale was added to the outcome based on feedback from our research in 10 clinical sites. Examples of scales used with the outcomes are: 1=Extremely compromised to 5= Not compromised and 1=Never demonstrated to 5=Consistently demonstrated.

NOC - Description
y The NOC (3rd ed.) includes 311 individual level outcomes, 10

family and 9 community level outcomes. The NOC outcomes are grouped in a coded taxonomy that organizes the outcomes within a conceptual framework to facilitate locating an outcome. The 330 outcomes are grouped into thirty-one classes and seven domains for ease of use. The seven domains are: Functional Health, Physiologic Health, Psychosocial Health, Health Knowledge & Behavior, Perceived Health, Family Health, and Community Health. Each outcome has a unique code number that facilitates its use in computerized clinical information systems and allows manipulation of data to answer questions about nursing care quality and effectiveness. The classification is continually updated to include new outcomes and to revise older outcomes based on new research or user feedback and is published on a 4 year cycle.

Coding

Strengths
y Comprehensive The NOC contains outcomes for individuals,

caregivers, families, and communities that can be used with all clinical specialties in numerous settings. y Research-based The research, conducted by a large team of University of Iowa College of Nursing faculty and students in conjunction with clinicians from a variety of settings began in 1991. Both qualitative and quantitative strategies were used to develop the classification. y Developed inductively and deductively Research team focus groups reviewed outcomes in eight (8) broad categories that were drawn from the Medical Outcomes Study and nursing literature.

Strengths
y Grounded in clinical practice and research Developed

initially from nursing texts, care plan guides, and clinical information systems, the outcomes were reviewed by clinical experts and many were tested in clinical field sites. Feedback from clinicians and educators is solicited through a defined feedback process. y Uses clear, clinically useful language Throughout the development of the NOC, clarity and usefulness of the language has been emphasized. y Has easy to use organizing structure The taxonomy has five (5) levels: domains, classes, outcomes, indicators and measurement scales. All five levels have been coded for use in practice.

Strengths
y Outcomes can be shared by all disciplines Although the

NOC emphasizes outcomes that are most responsive to nursing interventions, the outcomes describe patient, family, or community states at a conceptual level. y Optimizes information used for the evaluation of effectiveness The outcomes and indicators are variable concepts. They allow for measurement of the patient, family or community outcome at any point on a continuum from most negative to most positive and at different points in time. y Funded by extramural grants To date, the NOC research has received nine (9) years of peer-reviewed grant funding: one (1) year from Sigma Theta Tau International and eight (8) years from the National Institute of Nursing Research (NINR).

Strengths
y Tested in clinical field sites Testing of the NOC has been

conducted in a variety of clinical field sites y Dissemination emphasized Information about the classification, its development, and use is available. y Linked to other nursing languages Linkages have been developed by the NIC and NOC research teams to assist nurses with the use of the classifications and to facilitate use in clinical information systems. Linkages with NANDA-International diagnoses and Gordons Functional Health Care Patterns are included in the book. Linkages among NANDA diagnoses, NOC outcomes, and NIC interventions are available in the book NANDA, NIC, and NOC linkage:

Strengths
y Included in initiatives for electronic clinical record y Developed as companion to the NIC Experience with the NIC at

Iowa has aided the NOC research. y Recipient of national recognition NOC is recognized by the American Nurses Association (ANA), included in the Metathesaurus for a Unified Medical Language at the National Library of Medicine, included in the CINAHL index, and listed as one of the languages that meets the standards set by ANAs Nursing Information and Data Set Evaluation Center (NIDSEC). y Structure for continued development and refinement The classification continues to be evaluated, developed, and refined by the NOC research team. Continued refinement will be facilitated through the Center for Nursing Classification and Clinical Effectiveness, the College of Nursing, and the University of Iowa.

Activity Example

NOC

Indicators
y Have respiratory rate within normal limits, compared with

baseline (14-20/min) y Express relief of (or improvement in) feelings of shortness of breath y Relate causative factors and ways of preventing or managing them. (Carpenito-Moyet, 2008)

Example
y Case Scenario: Medical Diagnosis: CHF

Mr. Art Faylur, 68/M Subjective: The patient verbalized, Madali nga talaga akong mapagod ngayon at di ko magawa yung mga gusto kong gawin Objective: >Conscious, Coherent, Conversant >Weak-looking >Easy fatigability >Experiencing discomfort after an activity as evidenced by facial grimace >Increased in RR 24 to 30cpm and HR 108 to 124bpm every activity >O2 saturation: 95% >Cold Clammy on Peripherals

Nursing Diagnosis: Activity Intolerance related to imbalance of oxygen supply and demand secondary to CHF

Outcome Criteria
y Goal:

y Objectives:

Outcome Criteria
y Goal:Client can perform the activity without complications y After 8 hours to a week of nursing intervention the patient

will maintain activity level within capabilities, as evidenced by normal heart rate and blood pressure during activity, as well as absence of shortness of breath, weakness, and fatigue. y Patient verbalizes and uses energy-conservation techniques.

Which NOC?
A. 1308 Adaptation to Physical Disability: Adaptive response to a significant functional challenge due to a physical disability B. 0005 Activity Tolerance: Physiologic response to energyconsuming movements with daily activities C. 0200 Ambulation: Ability to walk from place to place independently with or without assistive device D. 0400 Cardiac Pump Effectiveness: Adequacy of blood volume ejected from the left ventricle to support systemic perfusion pressure

Correct!
0005 Activity Tolerance: Physiologic response to energyconsuming movements with daily activities

Suggested NOC
y 0005 Activity Tolerance: Physiologic response to energy-

consuming movements with daily activities y 0002 Energy Conservation: Personal actions to manage energy for initiating and sustaining activity y 1813 Knowledge: Treatment Regimen: Extent of understanding conveyed about a specific treatment regimen

Suggested NIC
y Energy Management y Teaching: Prescribed Activity/Exercise

y The use of standardized outcome measures, such as NOC,

offers nursing the opportunity to assume accountability for the effects of nursing interventions on the health of individual patients and the patient populations it serves. The ability to quantify the effects of the care nurses provide is essential for describing the value of nurses to consumers and other providers - (Marion Johnson, 1997, University of IOWA)

End of Report

CHF: A case study

y Name: Mr. EI y Sex: Male y Address: Makati City y Age: 64 years old y Religious Affiliation: Roman Catholic y Civil Status: Married y Room : MICU y Chief Complaint: Difficulty of breathing and chest pain y Medical Diagnosis: CHD y Date of Admission: January 2012

PAST MEDICAL HISTORY

y The past illnesses of the client include colds, cough, fever,

measles, and mumps. He said that he cant remember anything when asked about his immunizations. He has no allergy to any foods, drugs and other things. He has been hospitalized in V. Luna General Hospital on 1990 for a total deep implant of the right hip due to work related accident His second hospitalization was on 1991 in Camp Panophio for a partial implant of the left hip. He discovered his Diabetes Mellitus on 1978 and has been insulin dependent 15 years ago.

HISTORY OF PRESENT ILLNESS

y One day prior to his admission, client experience chest pain

and difficulty of breathing. According to the client, this is not his first time to be confined with this condition. The client said that these were his problems in a day. He has supply of oxygen of 180 liters in his house to be consumed in a day estimated regulation of 7.5 liters per hour. He has maintenance drugs such as Imdur, Metformin and Aspirin.

FAMILY HISTORY
y The patient has a family history of cardiovascular disease and

diabetes. According to the patient, his father died because of the complication of the heart while his mother died of being aspiration because of complications. According to the client, their eldest sibling died of heart disease and three among his living siblings have Diabetes Mellitus also.

SOCIAL HISTORY
y According to the patient he has no vices since then. He

doesnt smoke or even drink alcoholic beverages. He is a retired captain of the Philippine Constabulary (Philippine National Police now). y According to him, he prefers variety of foods, but at the present his diet are mostly fruits, vegetables and fish he seldom eats meat.

NURSING CARE PLAN

Nursing Care Plan

Nursing Care Plan

Nursing Care Plan

Nursing Care Plan

Sample NIC and NOC

y NIC Hemodynamic Regulations y NOC 0400 Cardiac Pump Effectiveness - Adequacy of blood volume ejected from the left ventricle to

support systemic perfusion pressure - Desired Outcomes >Display hemodynamic stability >Report decreased episode of dsypnea, angina, dysrhytmmias >Demonstrate an increase in activity intolerance