3 Country German Conference - Netzwerk Pflegediagnosen Prof_ S... · NANDAINICandNOC 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

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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


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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


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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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


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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-‐[email protected] classifica>on-‐[email protected] 319-‐335-‐7051

The Center for Nursing Classification & Clinical Effectiveness

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