This second edition of the Nursing Outcomes Classification (NOC) contains 260 outcomes

Each outcome includes a

v label name
va definition
v a set of indicators that describe specific patient,caregiver,family, or community states related to the outcome
va 5 –point likert-type measurement scale
v selected references used in the development of the outcome.

Definition: “ outcomes are the changes ,either favorable or adverse, in the actual or potential health status of persons,groups,or communities that can be attributed to prior or concurrent care

Strengths of the Nursing – sensitive outcomes classification

vComprehensive
vResearch-based
vDeveloped inductively and deductively
vGrounded in clinical practice and research

vUses clear, clinically useful language
vOutcomes can be shared by all disciplines
vOptimizes information for the evaluation of effectiveness
vTested in clinical field sites
vDissemination emphasized
vLinked to NANADA nursing diagnoses and NIC interventions

Reasons for Standardized Outcomes for Nursing

ØCreation of a common nursing language
ØComputerized nursing information systems
ØUniform nursing data sets
ØNational data sets
ØEvaluation of nursing care quality
ØEvaluation of nursing effectiveness
ØEvaluation of nursing innovations
ØParticipation in interdisciplinary care
ØContribution to knowledge development

Outcome development in health care

Florence nightingale ; (crimean war) : systematic use of pt’s outcomes to evaluate health care . Recording and analyzing healthcare conditions and pt’s outcomes.

Ernest codman(1900s) ; a boston surgeon:

Proposed the use of outcome-based measures as indicators of medical care quality. Precursor of modern outcome research.

Outcome development in health care (cont’d)

Donabedian ( mid1960s) : a model for assessing the quality of physician practice.

vemphasized structure , process and outcome
v adopted by other health care disciplines
vwide use as the preferred method of evaluating the quality of health care services.

 however, there were complexities and problems inherent in identifying and measuring pt’s outcomes.

*Until mid-1980s , mortality , morbidity and clinical signs served as traditional outcome measures.
*With the emphasis on effectiveness in the mid- 1980s, fueled by political pressure and the availability of large data sets resulting from advances in IT, attention again turned to measures of pt’s outcomes as a means to evaluate physician practice.
*MOS= medical outcomes study:

 this study used a conceptual framework based on structure , process, and outcome.

Outcome measures in the MOS were defined and placed in the following broad categories:

*Clinical end points including signs & symptoms
*Laboratory values
*Death
*Functional status including physical, mental , social and role statuses
*General wellbeing : health perceptions , energy/fatigue, pain, and life satisfaction.
*Satisfaction with care : access, convenience, financial coverage, quality and general satisfaction.

Accrediting organizations have assumed a major role in fostering the use of outcomes to evaluate organizational effectiveness and care quality. The joint commission on the accreditation of healthcare organizations (JCAHO) initiated a requirement that all hospitals and long-term care organizations seeking JCAHO accreditation use a performance measurement system to provide data about patient outcomes and other indicators of care( effective January 1 , 1998).

 organizations can select the Joint commission’s indicator measurement system (IM system) or one of the commercial systems approved by the commission , or they can develop their own system for approval. 

      

The IM system contains 31 measures for perioperative, obstetric, trauma, oncologic and cardiovascular patients, as well as 11 measures of medication use and infection control. It is anticipated that other organizations such as home care will be required to implement similar requirements for JCAHO accreditation.

The national committee on quality assurance (NCQA) monitors outcomes as part of their evaluation and accreditation of managed care plans.

The federal government has assumed an active role in outcomes research and management , primarily through the agency for health care policy and research (AHCPR) and health care financing administration.

Nursing- Sensitive Patient Outcomes Research: Phases I and II

Preliminary work to develop and classify nursing intervention laid the foundation for the NOC research, specifically the conceptualization of outcomes representative to nursing interventions and the qualitative and quantitative methods used to develop the outcomes and to assess the content validity of the outcomes and indicators.

Nursing- Sensitive Patient Outcomes Research: Phases I and II (cont’d)

In phase I of the research, conceptual and methodological issues were identified and resolved and outcome statements used by nurses were gathered , organized into common referent clusters, and assigned conceptual outcome labels. Phase II included the refinement and content validation of each outcome through concept analysis and surveys of nurse experts.

Nursing- Sensitive Patient Outcomes Research: Phases I and II (cont’d)

Preliminary field testing of the outcomes was completed and the outcomes and indicators were organized into a classification structure, supported by hierarchical analysis, with defined rules and principles being used to determine the structure.

phase III is now underway , and it features 4 years of National Institute of Nursing Research funding( RO1-NR03437) for the testing of the psychometric integrity and practicality of measurement scales and procedures with clinical data from eight field sites representing the continuum of care settings . Phase III also will assess the validity of the NOC classification structure , and clinical field data will be used to describe the use of the outcomes and linkages between nursing diagnoses, interventions and outcomes in specific populations and health care settings.    

Purposes and significance of the research:

1)Identify , label ,validate and classify nursing –sensitive patient outcomes
2)Field test and validate the classification
3)Define and test measurement procedures for the outcomes and indicators using clinical data

Preliminary

A) pilot studies of patient satisfaction outcomes:

Two pilot studies were conducted to test the methodology of validating the content of nursing –sensitive patient outcomes and indicators. The fehring method was used to assess content validity. The identified outcomes based on a review of literature were as follows:

*Physical environment
*Availability and access to care
*Protection of patient rights
*Caring
*Technical aspects of care
*Meeting the physical needs
*Continuity of care
*Functional status assistance
*Teaching and counseling
*Communication
*Symptom control
*Costs
*safety

Development of the NOC Team

The team formed in august 1991 at the University of Iowa . The team consisted of

 17 investigators including one biostatistician ,

 7 graduate students ( 4 doctoral students)

2 post doctoral fellows

4 consultants

The current team includes:

v 18 investigators( both faculty and clinicians )
v one biostatistician

v 3 doctoral students
v2 post doctoral fellows
v5 consultants
v 15 clinicians

  since the inception of research , a total of 22 faculty and clinical investigators , 13 graduate students ( 8 masters and 5 doctoral) , 5 post doctoral fellows , 9 consultants and 30 clinician team members have participated.

Nine masters and doctoral theses have been completed as part of the NOC research .

Resolution of Conceptual and Methodological Issues

To prepare for the identification and resolution of conceptual and methodological issues , the team reviewed the literature on patient outcomes , information systems , the science of taxonomic classification , effectiveness research and relevant qualitative and quantitative methods.

Team members reviewed several sources of patient outcomes used by nurses( e.g. textbooks, nursing information systems , critical pathways and care plans , outcome studies and standards of practice) , conceptual frameworks and outcome classifications.   

Identification of seven conceptual questions:

*Who is the patient?( clients , residents, patient groups , organizations , communities)
*What do outcomes describe?
*At what levels of abstraction should outcomes be developed?
*How should the outcomes be stated?
*What are nursing – sensitive outcomes?
*Are nursing – sensitive outcomes the resolution of nursing diagnoses?
*When should outcomes be measured?

Methodological issues and strategies

The NOC team identified and resolved the following five methodologic issues to develop and validate the initial list of nursing –sensitive patient outcomes:

1)What strategies are used( inductive or deductive ; qualitative or quantitative)?
2)What sources are used to sample outcome statements?
3)What criteria are used to select the sources from which outcome statements are extracted?
4)How are nursing-sensitive outcomes and indicators validated?
5)What methods will be used to develop the classification structure?

Definition of Terms

Classification of Nursing –sensitive patient/family outcomes:

The ordering or arranging of nursing-sensitive patient outcomes and indicators into groups or sets on the basis of their relationships and the assigning of labels and definitions to these groups.

Nursing-sensitive patient outcomes:

A measurable patient or family state ,behavior, or perception , conceptualized as a variable, largely influenced by and sensitive to nursing interventions. A nursing –sensitive patient outcome is at the conceptual level. In order to be measured , the outcome requires identification of a series of more specific indicators. N-SPOs define the general patient state, behavior or perception resulting from nursing interventions. 

Nursing – sensitive patient outcome indicator:

A specific variable referent of a N-SPO that is sensitive to nursing intervention. An indicator is an observable patient state, behavior or self reported perceptions or evaluation. N-SPO indicators characterize a patient’s state at the concrete level. Ex. “ Describes reasons why medication must be taken according to prescribed dose and schedule”.

Nursing –sensitive outcome measures:

The operations or activities that describe precisely what outcome indicator is to be measured , how is to be measured , and how it will be quantified. Quantification will reflect a continuum , such as 1= toilets self independently ; 2= requires some assistance with clothing for toileting; 3=requires assistance with transfer for toileting; 4 = requires total assistance for toileting.    

Caregiver Emotional Health-2506

Domain-Family Health (VI)

Class- Family Member Health Status (Z)

Scale- Extremely Compromised to Not Compromised ( a )

Definition: feelings , attitudes and emotions of a family care provider while caring for a family member or significant other over an extended period of time

                                 Extremely      substantially   Moderately          Mildly            Not

                                       compromised   compromised  compromised  compromised compromised