3 Country German Conference - Netzwerk Pflegediagnosen Prof_ S... · NANDAI*NIC*and*NOC* Patient Pressure Management (NIC) 3500 Pressure Ulcer Care (NIC) 3520 Impaired Skin Integrity

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Measuring  Outcomes  of  Nursing  Care  Using  the  NOC              

Sue  Moorhead  PhD  RN  Associate  Professor  &  Director  Center  for  

Nursing  Classifica>on    &  Clinical  Effec>veness  University  of  Iowa,  Iowa  City,  IA  

Nursing  is  More  than  Tasks  

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Making  Sense  of  Concepts  

Critical Thinking

Clinical Reasoning

+

=  

Antecedents  of  Clinical  Reasoning  •  Cogni>ve  percep>on  •  Tacit  or  explicit  knowledge  •  Cues  •  Perceived  need  for  ac>on  •  Discipline  specific  knowledge  •  Experience  •  Short  and  long  term  memory  •  Formal  and  informal  educa>on    Simmons,  B.  (2010).  Clinical  reasoning:  Concept  analysis.  Journal  of  Advanced  Nursing,  66(5),  p.  1151-­‐1158.  

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Clinical    Reasoning  

•  A  process  that  enables  one  to  collect  data,  solve  problems,  and  make  decisions  and  judgments  to  provide  quality  nursing  care.  

•  Requires  knowledge  skills  and  abili>es  grounded  in  reflec>ons  and  supported  by  the  individual’s  capacity  for  self  regula>on  and  the  development  of  exper>se.  

 Kuiper,  R.,  Pesut,  D.  &  Krautz,  D.  (2009).  Promo>ng  the  self-­‐regula>on  of  clinical  reasoning  skills  in  nursing  students.  The  Open  Nursing  Journal,  3,  76-­‐85.  

Consequences  of  Clinical  Reasoning  

•  Choice  •  Cogni>ve  awareness  of  addi>onal  cues  •  Evalua>on  of  alterna>ves  •  Decision  •  Implied  ac>on  •  Judgment  •  Inference    Simmons,  B.  (2010).  Clinical  reasoning:  Concept  analysis.  Journal  of  Advanced  Nursing,  66(5),  p.  1151-­‐1158.  

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Delphi  Study  on  Cri>cal  Thinking  

•  Purpose:  to  define  cri>cal  thinking  in  nursing  using  an  interna>onal  panel  

•  A  five  round  Delphi  technique  was  used  •  Developed  a  consensus  defini>on  •  Iden>fied:    

– 10  habits  of  the  mind  (affec>ve  component)  – 7  skills  (cogni>ve  component)  

Scheffer,  B.K.  &  Rubenfeld,  M.  G.  (2000).  A  consensus  statement  on  cri>cal  thinking  in  nursing.  Journal  of  Nursing  Educa;on,  39(8),  352-­‐359.  

Cri>cal  Reasoning:  Habits  of  the  Mind  

•  Confidence  •  Crea>vity  •  Flexibility  •  Inquisi>veness  •  Intellectual  Integrity  •  Open-­‐mindedness  •  Perseverance  •  Reflec>on  

Scheffer,  B.K.  &  Rubenfeld,  M.  G.  (2000).  A  consensus  statement  on  cri>cal  thinking  in  nursing.  Journal  of  Nursing  Educa;on,  39(8),  352-­‐359.  

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Cri>cal  Reasoning:  Skills  

•  Informa>on  seeking  •  Discrimina>ng  •  Analyzing  •  Transforming  knowledge  •  Predic>ng  •  Applying  standards  •  Logical  reasoning  

Thinking  Like  a  Nurse:  Key  Ideas  from  a  Review  of  200  Studies  

•  Clinical  judgments  are  influenced  by:  – What    the  nurse  brings  to  the  situa>on  more  than  the  objec>ve  data  

– Knowing  the  pa>ent  and  typical  behaviors  – Context  of  the  situa>on  and  the  unit  culture  – A  variety  of  reasoning  pagerns  or  combina>ons  – Reflec>on  on  prac>ce  triggered  by  a  breakdown  in  judgment  (cri>cal  for  development  of  clinical  knowledge  &  improved  reasoning)  

 Tanner,  C.  (2006).  Thinking  like  a  nurse:  A  research-­‐based  model  of  clinical  judgment  in  nursing.  Journal  of  Nursing  Educa;on,  45(6),    204-­‐211.  

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Nursing  Process  Genera>ons    

v 1950-­‐1970:    Problems  to  process  v 1970-­‐1990:    Diagnosis  and  reasoning  v 1990-­‐2010:    Outcome  specifica>on  &  tes>ng  v 2010-­‐2025:    Knowledge  building    v 2025-­‐2035:    Models  of  care  (archetypes)  v 2035-­‐2050:    Predic>ve  care       Pesut,  D.  J.  &  Herman,  J.  (1999).  Clinical  Reasoning:  The  Art  &  Science  of  Cri;cal  &  Crea;ve  Thinking.  Albany:  Delmar  Publishers.  

How  are  Standardized  Languages  Used  by  Nurses?  

•  Describes  the  phenomenon  of  interest  •  To  share  observa>ons  &  knowledge  with  other  members  of  the  profession  

•  To  make  the  work  of  the  profession  visible  •  To  bring  order  to  the  domain  of  prac>ce  •  To  evaluate  quality  of  care  &  conduct  research  

•  To  build  evidence  for  expert  prac>ce  

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Nursing Knowledge　

Diagnoses Classification　　　　　

Interventions Classification

Outcomes Classification 　　　　

Choice Choice Choice Clinical Decision-Making　

Modified  from  Iowa  Interven>on  Project.  (1996).    Nursing  Interven>ons  Classifica>on  (NIC).    2nd    ed.,  St.  Louis:  Mosby,  p.  6.  

• 216  diagnoses  

NANDA  Interna>onal  

• Components  – Label  Name  – Defini>on  – Defining  Characteris>cs  

– Risk  Factors  – Related  Factors  

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Nursing  Interven>ons  Classifica>on  

•  554  interven>ons    

•  Structure  –  Label  name    – Defini>on  –  Set  of  ac>vi>es  –  References  

Nursing  Outcomes  Classifica>on  

• 490  outcomes  

• Structure  • Label  name  • Defini>on  • Measurement  scale(s)  • List  of  Indicators  • References  

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NOC  and  NIC  Linkages  to    NANDA-­‐I  &  Clinical  Condi>ons  

• Demonstrate  rela>onships  among  NANDA-­‐I,  NOC,  and  NIC  

– Prac>ce  – Educa>on  – Research  

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Clinical  Condi>ons  

• Asthma  • Colon  and  Rectal  Cancer  • Chronic  Obstruc>ve  Pulmonary  Disease  • Depression  • Diabetes  Mellitus  • Heart  Failure  • Hypertension  • Pneumonia  •  Stroke  •  Total  Joint  Replacement:  Hip/Knee    

Harris, M., Graves, J. R., Solbrig, H.R., Elkin, P.L., Chute, C.G. (2000). Embedded structures and nursing knowledge representation. Journal of the American Medical Informatics Association. 7(6)

NANDA-­‐I  NIC  and  NOC  

Patient

Pressure Management (NIC)

3500

Pressure Ulcer Care (NIC)

3520

Impaired Skin Integrity (NANDA)

1.6.2.1.2.1

Pressure Ulcer Prevention (NIC) 3540

Tissue Integrity: Skin and Mucous (NOC) 1101

• Extremely Compromised to

• Not compromised

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Describe  The  Nursing  Outcomes  Classifica>on  

Nursing  Outcome  Defini>on  

•  An  individual,  caregiver,  family,  or  community  state,  behavior  or  percep>on  measured  along  a  con>nuum  in  response  to  a  nursing  interven>on(s).    

   •  Each  outcome  has  an  associated  group  of  indicators  that  are  used  to  determine  current  status  in  rela>on  to  the  outcome.    

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NOC  Format  

•  Label  name  •  Defini>on  •  Measurement  scale(s)  •  Indicators  •  References  

NOC  Levels  of  Outcomes  

•  Individual  &  Family  Caregiver  •   Family  •  Community  

Focus  of  measurement  changes  across  these  levels    

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NOC  Outcomes  for  Individuals  

Ac>vity  Tolerance  Aspira>on  Preven>on  Body  Image  Gastrointes>nal  Func>on  Kidney  Func>on    Pain  Control  Symptom  Severity  Knowledge:  Depression  Management  Weight  Loss  Behavior  

NOC  Outcomes  for  Families  

Family  Integrity  Family  Coping  Family  Func>oning  Family  Normaliza>on  Family  Social  Climate  Family  Par>cipa>on  in  Professional  Care  Family  Resiliency  Family  Health  Status  

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NOC  Outcomes  for  Communi>es  

Community  Risk  Control:  Chronic  Disease  

Community  Risk  Control:  Communicable  Disease  

Community  Risk  Control:    Lead  Exposure  

Community  Health  Status  

Community  Competence  

NOC  Example  

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NOC  Domains  in  the  Taxonomy  

•  Func>onal  Health  •  Physiological  Health  •  Psychological  Health  •  Health  Knowledge  Behavior  •  Perceived  Health  •  Family  Health    •  Community  Health  

NOC  Classes  v  Energy  Maintenance  v  Growth  &  Development  v  Mobility  v  Self-­‐Care  v  Cardiopulmonary  v  Elimina>on  v  Fluid  &  Electrolytes  v  Immune  Response  v  Metabolic  Regula>on  v  Neurocogni>ve  v  Diges>on  &  Nutri>on  v  Therapeu>c  Response  v  Tissue  Integrity  v  Sensory  Func>on  v  Psychological  Well-­‐Being  v  Psychosocial  Adapta>on  

v  Self-­‐Control  v  Social  Interac>on  v  Health  Behavior  v  Health  Beliefs  v  Health  Knowledge  v  Risk  Control  &  Safety  v  Health  &  Life  Quality  v  Symptom  Status  v  Sa>sfac>on  with  Care  v  Family  Caregiver  Performance  v  Family  Member  Health  Status  v  Family  Well-­‐Being  v  Paren>ng  v  Community  Well-­‐  Being  v  Community  Health  Protec>on  v  Health    Management  

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Taxonomy  of  Nursing  Outcomes:    Domains  &  Classes  Physiologic  Health  

Func>onal    Health   Psychosocial  Health  

Health  Knowledge  &  Behavior  

Perceived    Health   Family  Health   Community  Health  

Energy    Maintenance  

Growth  &  Development  

Mobility  

Self-­‐Care  

Psychological          Well-­‐Being  

Psychosocial  Adapta>on  

Self-­‐Control  

Social  Interac>on  

Cardiopulmonary  

 Fluid  &  Electrolytes  

Immune  Response  

Elimina>on  

Metabolic  Regula>on  

Diges>on  &  Nutri>on  

Therapeu>c  Response  

Neurocogi>ve  

Sensory  Func>on  

Tissue  Integrity  

Health  Behavior  

Health  Beliefs  

Health  Knowledge  

Health  Management  

Health  &  Life  Quality  

Symptom  Status  

Family  Caregiver  Performance  

Family  Member  Health  Status  

Family        Well-­‐Being  

Community              Well-­‐Being  

Community  Health  Protec>on  

Sa>sfac>on  with  Care  

Paren>ng  

Risk  Control      &  Safety  

 New  Class:    Health  Management  (n=16)    Defini>on:  Outcomes  that  describe  an  

individual’s  ac>ons  to  manage  an  acute  or  chronic  condi>on  

A  few  examples:    Self-­‐Management:  Acute  Illness    Self-­‐Management:  Hypertension    Self-­‐Management:  Lipid  Disorder    Self-­‐Management:  Kidney  Disease    Self-­‐Management:  Peripheral  Artery  Disease  

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A  five-­‐point  Likert  type  scale  that  quan>fies  a  pa>ent  outcome  or  indicator  status  on  a  con>nuum  from  least  to  most  desirable  and  provides  a  ra>ng  at  a  point  in  >me    

1  =  Least  Desirable  State  

5  =  Most  Desirable  State    

NOC  Measurement  Scales  

Very  weak  to  Very  strong  

Never  to  Consistently  Demonstrated  

Severe  to  None  

Poor  to  Excellent  

Not  at  all  to  Completely  Sa>sfied    

No  Knowledge  to  Extensive  Knowledge  

NOC  Measurement  Scales  

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Severely  to  Not  Compromised  

Severe  to  No  Devia>on  from  Normal  Range  

Not  Adequate  to  Totally  Adequate  

10  and  over  to  None  

None  to  Extensive  

Never  Posi>ve  to  Consistently  Posi>ve  

NOC  Measurement  Scales  

Evalua>on  of  NOC  Measures  

CRITERION  STANDARD  

•  Inter-­‐rater  Reliability      %  

• Criterion  Validity                      r    >  .60  

• Change          t-­‐test                

• Prac>cality,  Time,  Cost,  Ease  of  Use  

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Select  Outcome  

•  Problem/Diagnoses  

•  Pa>ent  Preferences  

•  Pa>ent  Characteris>cs  

•  Nursing  Treatment  

Compare  to  Reference  Person  

•  Healthy  individual  •  Same  sex  •  Same  age  •  Implies  that  all  pa>ents  do  not  have  the  poten>al  to  be  a  “5”  

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Comparison    

•  Dependent  on  exper>se  of  nurse  •  Experience  builds  range  of  cases  by  age  group  or  condi>on  

•  Need  to  iden>fy  differences  in  health  status  among  pa>ents  

•  Provide  cases  that  match  1  to  5  ra>ngs  on  an  outcome  for  novice  nurses  

Rate  Pa>ent  Status  

• Select  indicators  • Evaluate  pa>ent  on  selected  indicators  • Determine  overall  outcome  ra>ng  

• Set  target  ra>ng-­‐  goal  • Determine  focus  of  each  discipline  involved  in  care  

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Target  Outcome  Ra>ng  

Allows  for  seqng  goal  for  pa>ent  related  to  a  NOC  outcome  score  using  2  op>ons:  

   Maintain  at  _____    Increase  to  _____  

The  difference  between  a  baseline  ra>ng  and  the  post  interven>on  ra>ng(s)  of  the  outcome.  This  change  score  can  be:    

Change  in  Ra>ng  Score  

• Posi>ve,        • Nega>ve,    • No  change    

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Change  in  Ra>ng  Score    

The  difference  between  a  baseline  ra>ng  of  the  outcome  and  the  post  interven>on  ra>ng(s)  of  the  outcome.  This  change  score  can  be:  

Posi>ve  (ra>ng  increased)        Nega>ve  (ra>ng  decreased)  No  change  (ra>ng  stayed  the  same)  

The  change  in  ra>ng  score  represents  the  outcome  achieved  following  a  health  care  interven>on  or  set  of  interven>ons.    

Range  -­‐4  to  +4  

Examples:  

+3                -­‐2                    0                    +1                      -­‐3  

Change  in  Ra>ng  Score  

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Change  Scores  Post  Interven>on-­‐    Early  Research  on  NOC  

Outcome N Average Average Average Base Follow Change

Self-Mutilation Restraint 06 2.17 4.33 2.17 Respiratory Status: Gas Exchange 31 2.94 4.13 1.19 Mobility Level 53 2.47 3.62 1.15

Nursing Knowledge　

Diagnosis

Classification　　　　

Interventions

Classification

Outcomes

Classification

Choice Choice Choice Clinical Reasoning

Linkages  

• Systematic assessment • Diagnostic accuracy • Patient priorities

• Measurement accuracy • Longitudinal data • Patient involvement

• Evidence base & Cost •  Patient preferences • Competencies

Models of Care for Populations Predictive Care based on Practice Evidence

Future Knowledge  

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Transla>ons:  NIC  &  NOC  

Chinese  (simplified  and  tradi>onal)  Dutch  French  German  

Italian  Japanese  Korean  Norwegian  Portuguese  Spanish  

The  Key  to  the  Future  

• Our  efforts  in  language  development  have  placed  nursing  in  a  key  posi>on  to  provide  important  key  concepts  for  the  electronic  health  record    

• Opportuni>es  exist  to  use  actual  nursing  data  to  conduct  outcome  evalua>on,  quality  improvement,  and  effec>veness  research  

• Nursing  is  poised  to  be  a  leader  in  this  endeavor!      

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References  

•  Bulechek,  G.,  Butcher,  H.,  Dochterman,  J.,  &  Wagner,  C.  (Eds.).  (2013).  Nursing  interven;ons  classifica;on  (NIC).  St.  Louis:  Elsevier.  

•  Herdman,  T.  H.  (Ed.).  (2012).  NANDA  Interna;onal  nursing  diagnoses:  Defini;ons  and  classifica;on  2012-­‐2014.  Oxford,  UK:  Wiley-­‐Blackwell.  

•  Johnson,  M.,  Moorhead,  S.,  Bulechek,  G.,  Butcher,  H.,  Maas,  M.,  &  Swanson,  E.  (Eds.).  (2012).  NOC  and  NIC  linkages  to  NANDA-­‐I  and  clinical  condi;ons:  Suppor;ng  cri;cal  reasoning  and  quality  care  (3rd  ed.).  Maryland  Heights,  MO:  Elsevier  Mosby.    

•  Moorhead,  S.,  Johnson,  M.,  Maas,  M.,  &  Swanson,  E.  (Eds.).  (2013).  Nursing  outcomes  classifica;on  (NOC):  Measurement  of  health  outcomes.  St.  Louis:  Elsevier.  

References  •  Pesut,  D.  &  Herman,  J.  (1999).    Clinical  reasoning:  The  art  &  science  of  cri;cal  &  crea;ve  thinking.  Albany:  Delmar.  

•  The  Future  of  Nursing:  Leading  Change,  Advancing  Health.  Washington,  DC:  The  Na>onal  Academies  Press,  2011.  

•  Simmons,  B.  (2010).  Clinical  reasoning:  Concept  analysis.  Journal  of  Advanced  Nursing,  66(5),  p.  1151-­‐1158.  

•  Kuiper,  R.,  Pesut,  D.  &  Krautz,  D.  (2009).  Promo>ng  the  self-­‐regula>on  of  clinical  reasoning  skills  in  nursing  students.  The  Open  Nursing  Journal,  3,  76-­‐85.  

•  Scheffer,  B.K.  &  Rubenfeld,  M.  G.  (2000).  A  consensus  statement  on  cri>cal  thinking  in  nursing.  Journal  of  Nursing  Educa;on,  39(8),  352-­‐359.  

•  Tanner,  C.  (2006).  Thinking  like  a  nurse:  A  research-­‐based  model  of  clinical  judgment  in  nursing.  Journal  of  Nursing  Educa;on,  45(6),    204-­‐211.  

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Sue  Moorhead,  RN,  PhD,  FNI  Associate  Professor  &  Director  Center  for  Nursing  Classifica>on  &  Clinical  Effec>veness  

The  University  of  Iowa    College  of  Nursing  Iowa  City,  Iowa  52242  USA  sue-­‐moorhead@uiowa.edu  classifica>on-­‐center@uiowa.edu  319-­‐335-­‐7051    

The Center for Nursing Classification & Clinical Effectiveness

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