diagnosa nanda nic noc

International Journal of Nursing Terminologies and Classifications Volume 17, No. 3, July-September, 2006 129

Blackwell Publishing IncMalden, USAIJNTInternational Journal of Nursing Terminologies and Classifications1541-5147© 2005 Blackwell Publishing Ltd.73Original ArticleUsing NANDA, NIC, and NOC (NNN) Language for Clinical Reasoning With the Outcome-Present State-Test (OPT) Model

Using NANDA, NIC, and NOC (NNN) Language for Clinical Reasoning With the Outcome-Present State-Test (OPT) Model

Donald D. Kautz, RN, PhD, CNRN, CRRN-A, RuthAnne Kuiper, RN, PhD, CRRN, Daniel J. Pesut, APRN, BC, PhD, FAAN, and Randy L. Williams, RN, MSN/MBA

PURPOSE.

To analyze the degree to which

standardized nursing language was used by

baccalaureate nursing students completing

Outcome-Present State-Test (OPT) model

worksheets in a clinical practicum.

METHODS.

A scoring instrument was developed

and 100 worksheets were retrospectively analyzed.

FINDINGS.

NANDA nursing diagnoses were

correctly stated in 92% of the OPT models. Nursing

Outcomes Classification (NOC) outcomes were

explicitly stated in 22%, and implied in 72%.

Interventions matched appropriate Nursing

Interventions Classification (NIC) activities in 61%.

CONCLUSIONS.

NANDA, NIC, and NOC

(NNN) language was used inconsistently by

students in this sample.

IMPLICATIONS FOR PRACTICE.

If NNN language

is to advance nursing knowledge, its promotion,

representation in curriculum development, and

active use is necessary. Educational research is

needed on the facilitators and barriers to NNN

language use.

Donald D. Kautz, RN, PhD, CNRN, CRRN-A, is Assistant Professor, University of North Carolina at Greensboro, Greensboro, NC; RuthAnne Kuiper, RN, PhD, CRRN, is Associate Professor, University of North Carolina at Wilmington, Wilmington, NC; Daniel J. Pesut, APRN, BC, PhD, FAAN, is Professor and Associate Dean for Graduate Programs, Indiana University School of Nursing, Indianapolis, IN; Randy L. Williams, RN, MSN/MBA, is Staff Nurse, High Point Regional Health Care Systems, High Point, NC.

R

epresentation and classification of nursing knowl-edge is an important professional issue. The evolutionand development of standardized nursing languagehas included a systematic program of research overthe past 32 years, resulting in significant advancementsin nursing knowledge work. The Center for NursingClassification at the University of Iowa has contributedto the creation of standardized nursing languages thatcapture nursing interventions (Nursing InterventionsClassification [NIC], Dochterman & Bulechek, 2004), andnurse-sensitive outcomes (Nursing Outcomes Classifi-cation [NOC], Moorhead, Maas, & Johnson, 2003). Whenthese interventions and outcomes are linked withNANDA diagnoses (NANDA International, 2005), allthe standardized nursing language pieces (NANDA,NOC, and NIC or NNN) exist to represent relationshipsbetween and among nursing diagnoses, interventions,and outcomes (Johnson et al., 2006). When these languagesare used to structure nursing information systems inhospitals and other healthcare organizations, it will bepossible to make nursing care and its associated activ-ities and achievement of nursing-sensitive outcomesevident (Lunney, 2006). As vendors of nursing infor-mation documentation systems adopt the AmericanNurses Association (ANA) Nursing Information andData Set Evaluation Center–approved classificationsystems, NNN will be used more frequently in prac-tice settings. It is imperative that educators anticipatethe adoption and dispersion of standardized nursinglanguage and become more intentional about teaching

130 International Journal of Nursing Terminologies and Classifications Volume 17, No. 3, July-September, 2006


and using NNN language as a clinical vocabulary thatsupports students’ clinical reasoning about patient careneeds, nursing solutions, and nursing interventions.

This article evaluates students’ use of standardizednursing languages with the Outcome-Present State-Test(OPT) model of clinical reasoning. The OPT model has

been described as a third-generation nursing processmodel (Pesut & Herman, 1998). Figures 1 and 2 illustratethe structure of the Clinical Reasoning Web and OPTmodel worksheets completed by a student for a patientwith

decreased cardiac output

related to septic shock. Pesutand Herman (1999) have defined clinical reasoning as

Figure 1. Sample of One Student’s Clinical Reasoning Web.


“reflective, concurrent, creative, critical thinking proc-esses embedded in practice; used to frame, juxtapose, andtest the match between a present state and outcomestate and make judgments about achievement ofdesired outcomes” (p. 4).

The OPT model is unique in that the juxtaposition ofan identified keystone nursing issue is contrasted with

a specified outcome state. The present state is derivedfrom an analysis and synthesis of relationships betweenand among nursing and client nursing care needs.Several teaching learning strategies support the use ofthe OPT model as a concurrent information-processingmodel of clinical reasoning. These strategies includereliance on the patient story, creation of a clinical

Figure 2. Sample of One Student’s OPT Model Worksheet. (This OPT model worksheet corresponds to the Clinical Reasoning Web in Figure 1.)



reasoning web that reveals balancing and reinforcingrelationships between and among nursing diagnoses,and the use of a structured OPT model worksheet toorganize thinking and reflection on client care issues.

The OPT model provides a conceptual structure forthe use of standardized languages. “Present states” inthe nursing model can be defined as NANDA nursingdiagnoses. Outcomes in the OPT model serve asdesired states and can be defined in terms of NOCnursing-sensitive outcomes. NIC interventions arenursing actions that help transition patients fromproblem states to more desirable outcome states.

Teaching learning strategies associated with appli-cation and implementation of the OPT model of clinicalreasoning include attention to the OPT structure;the use of NNN content to represent nursing knowl-edge work; and combining critical, creative, andsystems thinking and reasoning skills. The modelprovides a structure that challenges students tobecome more conscious of the way they frame andattribute meaning to the facts of the client story. Rela-tionships and associations among competing nursingdiagnoses, interventions, and outcomes are empha-sized. The model structures the contrast of nursingproblems with desired outcomes. Nurses implementinterventions and actions to transition clients fromproblem or present states to more desired outcomesstates. Pesut (2006) notes four C’s (contrast, criteria,concurrent considerations, and conclusions) as essen-tial thinking strategies that support clinical judgment.The four C’s in clinical judgment in the model involvereflection about the

contrast

between present anddesired state;

criteria

regarding achievement of thedesired state;

concurrent considerations

of the problem,outcome, and intervention; and

conclusion

s or judg-ments about outcome achievement (Pesut, 2004, 2006;Pesut & Herman, 1999).

Because NNN languages exist and are being incor-porated into nursing information systems, it is impor-tant that educators consider how to promote the use ofstandardized languages and help students think,learn, and reason with these standardized nursing

languages as they learn to provide care in patient set-tings. The authors considered standardized languagerepresented in the NNN classification systems as aclinical vocabulary for clinical reasoning. This researchexamined the degree to which students used NNNlanguage as they developed clinical reasoning skillsusing the OPT model as a guide for thinking and rea-soning about nursing care needs of clients during thestudents clinical practicum.

Research Aims

The research aims of this retrospective analysiswere to evaluate the use of the OPT model as a struc-ture or scaffold for application and learning aboutrelationships between and among standardized nurs-ing language terms as they support clinical reasoningand client care planning. In addition, a second goalwas to determine the extent of students’ use of theNNN language to represent nursing diagnoses, inter-ventions, and outcomes associated with clinical rea-soning about client care stories and situations.

Methods

Setting

The research was conducted in a midsize city in thesoutheastern United States at a school of nursing in ahistorically black college and university. This long-standing nursing program admits a heterogeneouspopulation of students; however, the majority of stu-dents and faculty are African American. Clinical set-tings for students completing their medical surgicalnursing practicums include a Level 1 trauma center(1000 beds) and a nonprofit, tertiary care hospital (850beds). During the study, students had clinical experi-ences on acute care units with cardiac monitored bedsfor 10 weeks in one of these two institutions. At thetime of initial data collection, two of the researcherswere faculty members at the university, at the sametime clinical instructors for the junior level, medical


surgical nursing course in which this sample of stu-dents were enrolled.

Sample

For this study, OPT worksheets from 10 studentswere purposively chosen from a cohort of 23 juniorbaccalaureate nursing students completing their clini-cal practicum for their junior year medical–surgicalcourse. This sample of 10 students all spoke English astheir primary language. The mean age of the samplewas 28 years. One was a male student, six were Afri-can American, and four were Caucasian. Six studentswere single, and five had children. Three had a previ-ous degree and eight were certified nursing assistants.The mean number of hours per week of employmentwas 15 and the mean course load was 12 semester hours.This sample could be considered nontraditional, yettypical of nursing programs throughout the country.The 10 students were chosen to reflect the same demo-graphics as the whole student group and to includesome students who had done well when completingthe OPT model worksheets and some who had donepoorly, as well as some students who had been evalu-ated by clinical faculty members as being strong andsome who had been evaluated as having been weak inclinical preparation and performance.

Procedures

Data for this study was derived from a sample ofstudents who participated in an educational researchproject (Kautz, Kuiper, Pesut, Knight-Brown, &Daneker, 2005). The overall aim of that project was toevaluate the effects of the OPT clinical reasoningmodel on the thinking processes of undergraduatenursing students on acute care units with clients whohad multiple health problems. As a part of the clinicalassignment in the 10-week clinical practicum, the stu-dents completed clinical reasoning webs. A sampleweb is included as Figure 1. A clinical reasoning webis a visual representation of all the potential and actual

nursing diagnoses related to a client’s story. Oncediagnoses are identified, students are asked to drawlines of association linking the diagnoses and explainthe patterns of relationships between and among thediagnoses. For example, if

pain

and

anxiety

were linkedtogether, the student is expected to state how specifi-cally pain and anxiety are related. The teaching-learningintervention behind the use of clinical reasoningwebs is to help students make connections about theinteractive, dynamic, cause–effect, and associationalinteractions among multiple nursing diagnoses andclients’ core needs. The OPT model worksheets reflectthe model structure and provide a way for students toorganize and record this work. A sample OPT modelworksheet corresponding to the sample web isincluded as Figure 2. In order to promote reflectionwhile creating and explaining clinical reasoning websand OPT model worksheets, students kept writtenjournals during the practicum experience. For moreinformation on journaling using OPT model and Self-Regulated Learning–structured prompts with thissample of students, see Kautz et al. The webs and OPTmodel worksheets were rated each week and thestudents received feedback regarding their progressfrom the clinical faculty.

For this study, retrospective descriptive evaluationof OPT model worksheets was done to analyze theextent to which students used NNN language. Thepurpose of the analysis was to determine how oftenNNN language was used for outcomes and interven-tions because the students used clinical resourcessuch as medical-surgical textbooks and a variety ofnursing diagnoses and care plan texts as the source ofnursing language. The medical-surgical texts and nursingdiagnoses texts all incorporated some NNN language.

The first step in the protocol involved the studentcompleting a clinical reasoning web to assist in identi-fying the keystone issue or priority NANDA diagnosisthat would become the focus of the OPT model work-sheet. In the sample web included as Figure 1, the stu-dent identified the NANDA diagnosis of

decreasedcardiac output

as the keystone issue for a client with



sepsis.

Decreased cardiac output

would determine theinput in the “present state” space of the OPT modelworksheet.

Decreased cardiac output

would then be con-trasted with the desired outcome of Effective CardiacOutput. The student then completed the OPT modelworksheet (Figure 2) to develop the outcomes, tests,and interventions related to the priority NANDAdiagnosis.

As a way to measure use of standardized nursinglanguage, the authors developed the NNN scoringinstrument for data collection, which is included asFigure 3. Using the NNN scoring instrument, the stu-dents’ use of NNN language was evaluated eachweek. Since the OPT model emphasizes outcomesinstead of problems, the first step was to document thestudents’ use of NOC language. The Outcome State

portion of the OPT model worksheet was evaluatedand the rater determined if the student had includedeither a “stated” or “implied” NOC for the appropri-ate nursing diagnosis that had been selected as thepriority keystone problem for that client. The ratersthen evaluated the students’ choices of outcomes andtests to see how many matched official NOC indica-tors. The NOC indicators serve as criteria for outcomeachievement as illustrated in Figure 4. The second steprepeated the process to evaluate the use of NIClanguage. The raters chose a NIC category and theaccompanying NIC activities for the keystone issuethat were the best matches for the student’s choice ofinterventions (Figure 5). Using the NNN scoring grid,100 OPT worksheets were evaluated by three inde-pendent raters for frequency and use of NNN language

Figure 3. NNN Scoring Instrument.


on the OPT model worksheets. In the majority ofcases, student outcomes and interventions were notconsistently labeled in NNN language. Thus, raterswere challenged to make a best match of the student’swords to the appropriate NICs and NOCs. A check ofinterrater reliability between the three raters forcoding a random sample of 20 worksheets for NNNlanguage was 65% for NOCs and 45% for NICs. A pos-sible explanation for the low percentages of interraterreliability could be linked to the differing clinical

backgrounds of the raters (e.g., critical care, neurologicrehabilitation, and medical telemetry/intermediatecritical care) and their interpretation of nursing careneeds given this past knowledge and experience.

Results

Students stated the priority keystone problem in theappropriate NANDA format 92% of the time. An out-come stated in NOC language was juxtaposed with a

Figure 4. OPT Model Worksheet/NOC Scoring Grid.



NANDA diagnosis 22% of the time and implied withother language 72% of the time. Students were moreproficient at identifying problems or NANDA diag-noses and less proficient at specifying outcomes. Inter-ventions stated in NIC language corresponded to theNANDA diagnosis 61% of the time. Students includedinterventions that were appropriate for the client’s pri-ority keystone problem but did not correspond to NIClanguage 39% of the time. Students consistently linkednursing interventions activities with NANDA diag-noses rather than NOC outcomes.

Discussion

This research reveals that NNN language was notused consistently by students in completing the OPTmodel worksheets in the clinical area. Because this is aretrospective analysis, the authors speculated regard-ing a few possible explanations for these findings.Either the resources used by the students were notconsistent in the use of NNN language or the studentsdid not choose NNN language from the resourceswhen completing their OPT model worksheets. If

Figure 5. OPT Model Worksheet/NIC Scoring Grid.


consistent use of NNN is an educational goal, ourfindings suggest that clinical instructors need topromote the use of NNN and give consistent feedbackeach time the student turns in clinical assignmentsto encourage students to use NNN language whencompleting their clinical assignments. The need forconsistent feedback each week is based on our researchwith these students in helping them learn the OPTmodel (Kautz et al., 2005). We recommend facultymembers use the OPT tools to give students feedbackon their work. A systematic approach to teachingthe relationships between and among diagnoses,NIC interventions, and NOC outcomes is not possibleunless faculty make these relationships explicit. Despitethe inconsistent use of NNN language, the OPT modelworksheets promoted identification of priority nurs-ing diagnoses that were often associated with impliedoutcomes and a list of appropriate interventions.Evaluation of OPT model worksheets provided thefaculty with guidance about student understandingof patterns and relationships between and among thepriority problems, outcome achievement, and appropri-ate understanding and use of interventions to achievedesired outcomes.

The raters discovered student resources were notas consistent or comprehensive in NNN language asthe NIC (Dochterman & Bulechek, 2004) and NOC(Moorhead, Maas, & Johnson, 2003) and NNN linkage(Johnson et al., 2006) texts. If consistent use of NNN isexpected, students and faculty need NANDA, NIC,NOC, and NNN linkage resources to make the contentavailable. All three raters noted that the students whoconsistently used NNN language with OPT modelswere the students who performed well in the clinicalarea and did better in completing their clinical reason-ing webs and OPT model worksheets. It may be thatlearning standardized nursing language and using theOPT model to frame clinical reasoning activitiesprovides the knowledge driven content for success inprofessional nursing.

Matching the student’s written words to appropriateNICs and NOCs was a challenge. It quickly became

apparent that each rater viewed each student’s narra-tive differently. This is a key finding of this studybecause both faculty members and students believewhat they are reading and writing will be interpretedsimilarly by other students, teachers, and practicingnurses. However, when compared against the preciseNIC and NOC standardized language the researcherssaw that different practice backgrounds led to differentinterpretations of what students recorded. Even thoughthe study sample was small, we suspect that thesedifferences in clinical interpretation and meaningsbetween and among faculty members are significantissues in practice and clinical education.

Implications

The results of this study imply that standardizednursing language was not consistently used by thefaculty or students in this sample. The inconsistent useof NNN language by practicing nurses, students, andclinical instructors creates confusion and impedes thedevelopment and adaptation of standardized languageamong professional nurses. All healthcare institutionswill be required to implement electronic client recordsby 2010 and many will choose NNN as the languageof these records (Lunney, 2006). If educators fail toincorporate the use of standardized nursing languagein nursing curriculum, and hospitals adapt nursinginformation systems that utilize standardized language,then how will students be prepared to practice? Such adisconnect in values and beliefs among the academicand clinical practice settings about the value of stand-ardized language that influences clinical thinking andreasoning needs attention. In conducting this analysisof 100 student worksheets, the authors conclude that itis necessary to use NNN language to see its value forprofessional nursing practice.

One of the authors is practicing full time on a medi-cal telemetry/intermediate care unit and noted whenrating the OPT models with NNN language resourcesthat another value of NNN language would be tofacilitate direct billing for nursing services and show



the value of nursing care. This practice application ofNNN language has been long advocated by NIC andNOC and NANDA authors. Nursing informationsystems that capture patient data with NNN languagewill also support future knowledge work in nursing.While nursing information systems utilizing NNNlanguage have been incorporated in practice settings,clinical instructors need to learn to utilize these sys-tems when teaching nursing students at all levels.

Further research is needed to examine the facets ofclinical reasoning, including content (NNN language),structure (OPT model), process (self-regulated reflec-tion on content and structure), and outcomes (studentOPT model, NNN taxonomies, and self-regulatedreflection). The OPT model and NNN language areeffective tools for documenting students’ progress inlearning clinical reasoning on a weekly basis in theirclinical practicum. Faculty members who teach usingthese tools may find that students are more able to dif-ferentiate between patient needs, prioritize care, andmake more complex patient care decisions. We recom-mend faculty members and students use the NANDA(NANDA International, 2005), NIC (Dochterman &Bulechek, 2004), NOC (Moorhead, Maas, & Johnson,2003), and NNN Linkages (Johnson et al., 2006) refer-ence texts throughout the undergraduate and gradu-ate programs. Faculty can utilize these texts in testconstruction, cite NNN language and linkages incourse syllabi and lectures, and require students to uti-lize NNN language in care planning and class presen-tations. Lunney (2006) gives additional suggestions foreducators and managers for incorporating NNN lan-guage into practice and education.

In summary, the organization of clinical reasoninginto structure, content, and process appears to yieldthe outcomes desired in nursing education and prac-tice. The attention to all these pieces simultaneously isa daunting task and heretofore has been implementedby educators and studied by researchers in isolation ofeach other. We believe that only by bringing structure,

content, and process together in future work will theunderstanding and promotion of clinical reasoningmove forward. Organizing the essence of health careand vast areas of information the nurse has to learnand cope with on a daily basis will advance the profes-sion of nursing into the twenty-first century.

Acknowledgment.

The authors acknowledge the assist-ance of Seth Colaner in developing the figures.

Author contact: [email protected]

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