This literature supporting each diagnosis is available at the Media Center of the Thieme Publishing Company, publishers of Nursing Diagnosis Definitions and Classifications 2018–2020 (see access below under NANDA-I diagnosis resources). Western Journal of Emergency Medicine, 15(4), 541-547. doi:10.5811/westjem.2014.3.19658. Nursing Outcomes Classification (NOC). The act of measurement makes phenomena visible and functions to elevate actual and/or potential quality problems in the consciousness of stakeholders. Bulechek, G. M., Butcher, H. K., Dochterman, J. M., & Wagner, C. M. In response to economic and quality concerns in healthcare, reimbursement policies have shifted from fee for service to value-based purchasing (VBP) (Bodrock & Mion, 2008; Kurtzman, Dawson, & Johnson, 2008). To be endorsed, quality measures must meet established standards in the following areas: importance, scientific acceptability, usability, and feasibility (NQF, 2004). Impact of electronic health records on nurses’ productivity. Purpose NOC provides a standardized classification system of patient outcomes for evaluating the effects of nursing interventions. Specifically, vendors, nurse informaticians, and quality specialists should be directed to design systems that provide reliable and valid information about nursing interventions and patient outcomes related to the following areas: self-care, health promoting behaviors, functional status, symptom management, knowledge of disease and treatment, and health-related quality of life. NURSING OUTCOME CLASSIFICATION( NOC) NOC Format LEVELS OF NOC TAXONOMY NOC Measurement Scales NOC Measurement scale contd. International Journal of Nursing Terminologies and Classifications (21) 166-176. Worldviews on Evidence-Based Nursing, 8(1), 40-50.doi: 10.1111/j.1741-6787.2010.00183x, Jones, T., Hamilton, P., & Murry, N. (2015) Unfinished nursing care, missed care, and implicitly rationed car: State of the science review. The research to develop the Nursing Outcomes Classification (NOC) began with the formation of the outcomes research team in 1991. Journal of Advanced Nursing, 21, 1092-1100. Valid and reliable use of NANDA-I, NOC and NIC depend on skilled implementation of the watching-assessment-recognition and the clinical reasoning and decision-making concepts (see previous PCE pages). VBP policies are predicated on the idiom that what gets measured, gets managed. However, standardization has yet to be achieved and few systems are built to accommodate available nursing taxonomies (Alexander, 2007; Needleman et al., 2007). . New strategies to address the challenges of effective quality assessment and outcome measurement in nursing must be implemented. Nurse staffing and healthcare outcomes. Performance measurement of nursing care. Compared to abstraction of data from paper based documentation systems, retrieval of data from an EHR for quality analysis and reporting is more efficient (Alexander, 2007). Holubowich, E. J. American Health & Drug Benefits, 1(6), 34-42. (1953) The creative approach to nursing. The goal of system redesign is encapsulated in the Institute of Medicine (IOM) six aims for care: safe, effective, timely, equitable, patient-centered, and efficient (IOM, 2001). A systematic review of the international evidence. work toward developing a thorough understanding of the NANDA-I nursing diagnoses commonly used to guide care for the types of patients I care for, . However, the effect of staffing and nursing education on patient outcomes, though statistically significant, is relatively small by scientific and clinical standards. Few would engage in the demanding work of nursing without some degree of belief that their efforts make a difference. Murphy, L. S., Scott, E. S., & Warshawsky, N. E. (2014). Ways to stay focused on your patients, not your EHR. Therefore, assumptions about the nursing contribution to care must be replaced with empirical evidence of the nursing profession’s actual contributions to care. ), Nursing diagnoses definitions and classifications 2018–2020 (pp. The research to develop the Nursing Outcomes Classification (NOC) began with the formation of the outcomesresearch team in 1991. This is a "must read" book. Below the selected outcome indicators is a space for the patient's outcome score on admission to the hospital or when the diagnosis is first made. National Quality Forum. Kurtzman, E. T., & Jennings, B. M. (2008). 8). Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). Researchers cannot establish specific causal chains without capturing the effects of nurse structures on nurse processes and/or the effects of nurse processes on patient outcomes (Needleman et al., 2007). Good watching-assessment-recognition will identify this diagnosis as early as possible in a patient's care process so that its indicators can be systematically evaluated and the best possible health management plan developed. Patient outcomes can be associated with organizational changes. . Electronic documentation systems have not reduced the documentation burden for nurses. Outcomes of care are generally regarded as the most important element of quality assessment because they focus on patients and reflect the social mandate and ultimate goals of healthcare providers (i.e., changes in health status) (Donabedian, 2003). (2005). Nursing Outcomes Classification (NOC) are changes in health status of the patients, according to the NIC that were done (Maas, Johnson, & Moorhead, 1996). Substance Use Disorders and Related Concerns, The 200th Birthday of Florence Nightingale, Addressing Social Determinants of Health: Progress and Opportunities, Translational Research: From Knowledge to Practice, Kavanagh, Comiotti, Abusalem, & Coty, 2012, Klieb, Sales, Doran, Mallette, & White, 2011, Patrician, Loan, McCarthy, Brosch, & Davey, 2010, Kane, Shamliyan, Mueller, Duval, & Wilt, 2007, Cutugno, Hozak, Fitzsimmons, & Ertogan, 2015, Martinez, Battaglis, Start, Mastal, & Matlock, 2015, Association of Women’s Health, Obstetric and Neonatal Nurses [AWHONN], 2014,,, officeofnursingservices-ons_annual_report_2009-web.pdf, Information and Communication Technology: Design, Delivery, and Outcomes from a Nursing Informatics Boot Camp, A Case Review: Integrating Lewin’s Theory with Lean’s System Approach for Change, Potential of Virtual Worlds for Nursing Care: Lessons and Outcomes, A National Comparison of Rural/Urban Pressure Ulcer and Fall Rates, Multigenerational Challenges: Team-Building for Positive Clinical Workforce Outcomes, Why Causal Inference Matters to Nurses: The Case of Nurse Staffing and Patient Outcomes. While adverse events are important, the question remains as to whether or not they should receive a disproportionate share of nursing attention and organizational resources compared to other quality problems. b=California Nursing Outcomes Coalition (Aydin et al., 2004) Measures based on data collection methodologies intrinsic to care processes and captured by existing data systems are highly desirable (Burston, Chaboyer, & Gillespie, 2013; Needleman et al., 2007). Hobbs, J. Fasolino, T., & Verdin, T. (2015). (2010) Core elements of U.S. Nurse Practice Acts and Incorporation of nursing diagnosis language. Introduction of EHRs has indeed changed nursing documentation processes and retrieval of information for analyses. Nurse-Sensitive Indicators Originally Identified by ANA, Assessment and Implementation of Patient Care Requirements, Ratio of RNs to Total Nursing Staff (Skill Mix of RNs, LPNs, & Unlicensed Workers), Total Nursing Care Hours Provided Per Patient (Case Mix, Acuity Adjusted), Table 2 extrapolated from Lewin-VHI (1995). Hospital restructuring: Does it adversely affect care and outcomes? Quality assessment and outcomes research initiatives have historically been hindered by lack of available data related to nursing processes and patient outcomes across these domains of practice. Therefore, outcome measurement is best conceived as one interdependent component of the broader quality management enterprise with intentional selection of measures to drive improvement in outcomes relevant to nursing. State of the science and the current consensus. Farquhar, M., Kurtzman, E. T., & Thomas, K. A. Although nurses may contribute to a broad array of patient outcomes, the expected contribution is variable, and teasing out the unique nursing contribution to patient outcomes is difficult (Needleman et al., 2007). Description NOC outcomes are grouped hierarchically into … However, outcomes offer no guidance for quality improvement unless they are related to modifiable antecedents (e.g., structures and processes of care). (Eds.). The current state of nursing performance measurement, public reporting, and value-based purchasing. Nursing Outcomes Classification Outcomes Now that we have defined a nursing diagnosis and provided some interventions that this patient needed, it is time to discuss the patient outcome. The efficiency gained in information retrieval is potentially offset by a loss of efficiency related to data entry. History demonstrates that when profit margins decrease, healthcare organizations invest fewer resources in services for patients and employees, to include nurses (Aiken, Clarke, & Sloane, 2001; Kavanagh, Comiotti, Abusalem, & Coty, 2012). Careful Nursing uses these NANDA-I, NOC and NIC SNL/Ts because they are evidence-based, the most supported by nursing research, directly applicable in clinical practice and are the most widely used SNL/Ts internationally (Tastan et al. St. Louis, MO: Elsevier. SNL/Ts have developed gradually over time beginning with use of the term nursing diagnosis.In a 1953 issue of the American Journal of Nursing, Fry wrote about use of nursing diagnosis as a creative approach to nursing practice. Over the following 20 years the term nursing diagnosis gradually began to replace the term nursing problem and the nursing process was raised to a higher level of critical thinking, reasoning and decision-making – but not without much debate. Email: Moreover, due to limitations of study designs, the body of evidence produced thus far is still insufficient to support direct causal paths linking nurse structures to patient outcomes. Provide a complete evidence-based model of the intervention of interest. Despite the proliferation of national and regional nursing databases, participation is voluntary and no available databases contain information on all of the 15 nurse-sensitive measures endorsed by the NQF (Kurtzman, Dawson, & Johnson, 2008; Kurtzman & Jennnings, 2008; VanFosson, Jones, & Yoder, 2015). These standards address issues related to the social mandate of nursing (importance), empirical evidence linking practice to outcomes (scientific acceptability and usability), and the pragmatics of data collection (feasibility). These benefits are illustrated in the following NANDA-I nursing diagnoses "before and after" examples constructed by Sinead Murphy, a former Senior Project Manager for a Careful Nursing implementation project. Nursing sensitive databases. However, only 15 of the proposed measures met the consensus standards for endorsement in 2004 (Table 4). Treading water: The no growth investment in health services research. Measures that are too burdensome and costly are less likely to be adopted for quality assessment. Hakes, B., & Whittington, J. The Center for Nursing Classification and Clinical Effectiveness (CNC), an Iowa Board of Regents-approved Center, was established in 1995 to facilitate the ongoing research and development of the Nursing Interventions Classification (NIC) and the Nursing Outcomes Classification (NOC). Setting the bar: Developing quality measures and education programs to define evidence-based patient-centered, high quality care. Efforts to promote a NMDS have continued since the 1980s along with parallel activities to promote a universally accepted taxonomy for nursing diagnoses, interventions, and outcomes (Daly, Maas, & Johnson, 1997; Halloran & Halloran, 2015; Needleman et al., 2007). Journal of Health Care Compliance, 12(1), 36-68. (2018). As with NANDA-I nursing diagnoses and NOC outcomes, patients, caregivers, families and/communities are encouraged to participate in selection of NIC interventions as they are able, according to which interventions they think suite them best. DOI:10.3912/OJIN.Vol21No02Man01 Key Words:Nurse Sensitive Indicators, nursing outcomes, nursing process measures, quality assessment, quality metrics, quality measures, outcomes management, outcomes research, Minimum N… Doran (Ed), Nursing Outcomes State of the Science (2nd ed, 487-508). Griffiths, P. (1995). The NANDA-I, NOC, and NIC SNL/Ts are each comprehensive and complex languages in themselves and can seem very challenging to use together to guide patient care plans, especially to begin with. Evaluating the quality of medical care. . Moreover, data were readily available for only two of the identified outcome measures (mortality and length of stay) and these measures had the weakest theoretical links to nursing care quality (Lewin-VHI, 1995). . Consequently, many colleges and universities have not developed active research programs in this area. To be useful, a measure must provide information that is actionable. Consequently, organizations that fail to meet established performance targets incur penalties and lose revenue (Hines & Yu, 2009). Nursing diagnosis was considered too technical for use by a caring profession and too time-consuming. Although an increase in nurse staffing is associated with an increase in cost, that cost must be weighed against the costs associated with incomplete documentation, nurse overtime, and nurse dissatisfaction. 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, scale(s) to measure patient status, and a short list of references used in the development and refinement of the outcome. An alphabetical listing of 336 interventions was published in a book in May 19 … Patient outcomes reflected in the endorsed measures are important and the act of measurement has without question generated selective attention and resource allocation toward reducing complications. Background: The International Classification for Nursing … Their existence, challenges, and importance. Performance-based payment incentives increase burden and blame for hospital nurses. Each discipline is necessary for recovery of function, yet none is sufficient. Only 10% of diagnoses are health promotion diagnoses, however taken the importance of health promotion and increasing emphasis on provision of health care in communities to reduce the need for acute hospital-based care, health promotion diagnoses will become increasingly important. While these tools may result in more complete documentation, they also may increase documentation burden (Cutugno et al., 2015). Frequent reassessment of patient's fluid balance condition is expected. Therefore, nurses have a social obligation to develop and document the evidence base for the entirety of nursing practice and shift from a task-based practice, which emphasizes what nurses do for patients, to an outcome-based practice that emphasizes what nurses achieve with patients. The American Nurses Association (ANA) social policy statement defines nursing as the “diagnosis and treatment of human responses to actual or potential health problems.”1 The most universally accepted conceptual model of nursing2—the nursing process—delineates a five-stage process of “nursing activity states,” including: assessment of the patients and their environment, definition (diagnosis) o… Expending resources on nursing services with no clear benefit or failing to allocate resources for nursing services with a clear benefit is not good stewardship. Standardized outcomes are essential for documentation in electronic records, for use in clinical information systems, for the development of nursing … McCulloch, G., & Tegethoff, G. (2013). However, this framework is not prescriptive and offers little guidance in the identification of specific quality measures. Moorhead, S., Johnson, M., Swanson, E. & Maas, M.L. Each domain is sub-categorised into a total of 32 classes, for example, the functional health domain has four classes: energy maintenance, growth & development, mobility and self-care (Moorhead et al. VanFosson, C. A., Jones, T. L., & Yoder, L. H. (2015). The American Journal of Nursing, 53, 301-302. & Swanson, E. (2012) NOC and NIC Linkages to NANDA-I and Clinical Conditions (3rd ed.). Other nurses proposed that for professional, political and economic reasons nurses must be able to name what they do clearly, accurately and consistently. 21, No. However, technological advances and healthcare reform legislation provide new opportunities to address some of these challenges. explain and discuss my use of NANDA-I nursing diagnosis, NOC and NIC with other health professionals at least twice a month, . Each outcome is stated as a variable concept measured on a five point Likert scale and includes a definition, indicators, and references. chart abstraction, direct observation) and surveys have been considered less desirable. (2008). Bigbee, J. L., & Issel, L. M. (2012). The Careful Nursing Philosophy and Professional Practice Model©  Progress in measuring nursing outcomes. outcomes are rarely, if ever, the result of a singular process or provider. In 2015, incentive payments related to compliance with meaningful use standards were replaced with penalties for noncompliance. For example, a person's health condition may be a stroke, diagnosed and treated by medicine. In practice settings activities from the list are selected as appropriate to the setting and setting-specific activities are added. Nursing administration research. Cleanliness and quietness of the hospital environment, Fibrinolytic within 30 minutes of arrival, Controlled post-operative blood glucose in cardiac patients, Post-operative urinary catheter removed by day 2, Deep Venous Thrombosis (DVT) prophylaxis within 24 hours of surgery, Central Line Associated Bloodstream Infection (CLABSI), Catheter Associated Urinary Tract Infections (CAUTIs), Surgical Site Infections (abdominal hysterectomy and colon surgery). In addition, the Thieme Publishing Company Media Center offers a range of free resources which may be accessed at When prompted during the registration process enter the following code: XZ88-D7XB-SJK6-QE85. The Department of Health and Human Services (DHHS) supported the development of minimum data sets (MDS) to facilitate these evaluations (Hobbs, 2011). Sometimes surveillance is initiated by one nurse and continued by other nurses throughout an episode of care. If this level is not increased for a given diagnosis within a certain period of time the diagnosis may be removed from the list of approved diagnoses. (2nd ed). (2011). Title: Nursing Diagnosis and Outcome Statements Catalogue Type: Terminology Subset Publication Date: 2008, Updated 2011, 2013, 2015, 2017 Authors: Creation of this catalogue was a group endeavour. Butcher et al. Note: This catalogue provides ICNP concepts to support nurses in assessing, diagnosing, and evaluating outcomes across the continuum of care. Through the process of licensure, the public grants nurses the privilege to practice the art and science of nursing and in exchange, the public expects to receive quality care (ANA, 2010). This first example illustrates what happens when NANDA-I nursing diagnoses are not used: : The second example illustrates what happens when NANDA-I nursing diagnoses are used: Further resources include the key NANDA-I publication, Nursing Diagnoses Definitions and Classifications 2018–2020 (Herdman & Kamitsuru, 2018). Consistent with the SPO framework, an initial measure set was identified and evaluated based on theoretical links to the quality of nursing care (Table 2). The suggested links among the SNL/Ts described by Johnson et al. c=Military Nursing Outcomes Database (Patrician, Loan, McCarthy, Brosch, & Davey, 2010) (Ed.). Evidence suggests that time spent on documentation increases immediately after implementation but eventually returns to baseline (Hakes & Whittington, 2008; Munyisia, Yu, & Hailey, 2011). A. 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