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International Journal of Nursing Practice 2014; 20: 636–645
RESEARCH PAPER
Identifying core nursing sensitive outcomes associated with the most frequently used North American Nursing Diagnosis Association— International nursing diagnoses for patients with cerebrovascular disease in Korea Eunjoo Lee PhD RN Professor, Kyungpook National University, College of Nursing, Daegu, South Korea
Hyejin Park PhD RN Assistant Professor, The Florida State University, College of Nursing, Tallahassee, Florida, USA
James Whyte ND PhD ARNP Associate Professor, Florida State University, College of Nursing, Tallahassee, Florida, USA
Youngae Kim MSN RN Registered Nurse, Kyungpook National University Hospital, Daegu, South Korea
Sang Youn Park PhD RN Professor, Kyungpook National University, College of Nursing, Daegu, South Korea
Accepted for publication May 2013 Lee E, Park H, Whyte J, Kim YA, Park SY. International Journal of Nursing Practice 2014; 20: 636–645 Identifying core nursing sensitive outcomes associated with the most frequently used North American Nursing Diagnosis Association—International nursing diagnoses for patients with cerebrovascular disease in Korea
The purpose of this study was to identify the core nursing sensitive outcomes according to the most frequently used five North American Nursing Diagnosis Association—International for patients with cerebrovascular disease using the Nursing Outcomes Classification (NOC). A cross-sectional survey design was used. First, nursing problems were identified through 78 charts review, and then linkages between each of nursing problems and nursing sensitive outcomes were established and validated by an expert group for questionnaires. Second, 80 nurses working in the neurosurgical intensive
Correspondence: Hyejin Park, The Florida State University, College of Nursing, Tallahassee, FL 32306, USA. Email: [email protected] Contributions: Study design: EL, HP, JW; data collection and analysis: EL, YK, SP; and manuscript preparation: EL, HP, JW, YK, SP. Conflict of interest: None. © 2013 Wiley Publishing Asia Pty Ltd
doi:10.1111/ijn.12224
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care unit and neurosurgery departments of five Korean hospitals were asked to evaluate how important each outcome is and how often each outcome used to evaluate patient outcomes using 5-point Likert scale. Although there were some differences in the core outcomes identified for each of the nursing problem, consciousness, cognitive orientation, neurologic status and communication were considered the most critical nursing sensitive outcomes for patients suffering cerebrovascular disease. Core nursing sensitive outcomes of patients suffering cerebrovascular disease using NOC were identified to measure the effectiveness of nursing care. Key words: cerebrovascular disease, effectiveness of nursing care, NOC, nursing sensitive outcomes.
INTRODUCTION For several decades, the need to deliver high quality healthcare while controlling cost has been a concern for healthcare experts, consumers and policymakers alike. As a result, a variety of measurement instruments has been developed to measure health-related outcomes and to ensure the effectiveness and efficiency of health care.1 Current measures are limited in scope and assess nursing’s influence on the quality of care solely in terms of effectiveness.2 With limited measurement of nursing outcomes, the evidence of nursing care effectiveness and unique functions of nurses is unlikely to be demonstrated. To fully represent the contributions of nursing care, measurement tools should be comprehensive and allow for assessments and measurement that characterize nursing care over time within and across settings.3 Following this request, a comprehensive and internationally recognized standardized nursing sensitive patient outcomes classification (Nursing Outcomes Classification (NOC))4 was developed to capture the unique contributions of nursing care to patient outcomes in a more effective way. Currently, the health-care system in Korea is facing concerns regarding the means by which to attain highquality care at reasonable cost. This trend has been seen in many of the world’s health-care systems, not in small part because of worldwide economic trends. Nurse managers in Korea have been increasingly tasked to provide data regarding the effectiveness of nursing care and accountability for patient outcomes. Therefore, the use of NOC with its emphasis on quantifying nursing care effectiveness has increased.5 The use of NOC has been validated in diverse settings in various health-care facilities across Korea.6–8 However, there has been no further research that has identified core NOC outcomes for specific diseases or patient populations to measure nursing care. Thus, it is necessary to identify the core nursing sensitive outcomes according to nursing diagnoses for a specific patient population.
The current study addressed cerebrovascular disease (CVD) patients as a population because the prevalence of CVD in Korea has risen steadily with ever-increasing associated cost and effect of CVD on morbidity and mortality.9 To date, there has been no specific research that captures the unique contribution of nursing on CVD patient outcomes. Therefore, the purposes of this study were to (i) identify the most five frequently used North American Nursing Diagnosis Association—International (NANDA-I) for CVD patients, then (ii) identify the core nursing sensitive outcomes for the identified nursing diagnoses of CVD patients to measure nursing care. This process ultimately improves the quality of nursing care for the CVD patients and provides fundamental line for evidence for the effectiveness of nursing care in multidisciplinary care settings.
BACKGROUND Overview of NOC Identifying nursing outcomes responsive to patients care is a critical work for nursing as we continue to focus on cost and effectiveness in the health-care system. However, in the past, we have been dependent on the use of interdisciplinary outcomes developed primarily for physician practice. In addition, the definition and classification of clinically useful nursing sensitive outcomes were not possible before the NOC was first published in 1997.4 NOC is a comprehensive, standardized classification of patient outcomes that can be used to evaluate the effectiveness of nursing interventions. In the current fifth edition, NOC has 490 outcomes categorized into seven domains and 32 classes for use at the individual, family and community levels. Each NOC outcome consists of a definition, a 5-point measurement scale with five representing the most desirable state. Each outcome also has a list of associated indicators for the outcome concept and measurement scales with codes for use in electronic health-care records. Use of NOC is important because it provides © 2013 Wiley Publishing Asia Pty Ltd
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nurses with a means to evaluate the effects of nursing interventions by comparing the outcomes of nursing interventions for specific populations in a standardized way. Additionally, NOC allows nurses to follow changes in or maintenance of outcome states over time and across settings and facilitates benchmarking with other hospitals regionally, nationally or internationally through retrieving data from nursing information systems.10–13 Many studies show the evidence that NOC is a valid tool to measure nursing interventions in clinical settings.5,14
METHODS Setting and sample The study was based upon a quantitative descriptive research design using a cross-sectional approach. The sample was obtained through convenience sampling. The study setting included neurosurgical intensive care unit (NICU) and neurosurgery departments at three tertiary and two general hospitals located in a metropolitan city in Korea. The hospitals ranged in size from 550 to 900 beds. The study sample included individual nurses who had a minimum of 1 year of practice in a neurological or neurosurgical care setting in order to participate.
Questionnaire The questionnaire was developed in three steps: (i) identifying of the five most prevalent nursing problems (NANDA-I)15 for CVD patients; (ii) developing linkages of the identified NANDA-I with NOC outcomes; (iii) translating of NOC into Korean; and (iv) designing of the questionnaire. Each of four steps was explained in the following sections.
First step: identifying the most prevalent nursing problems (NANDA-I) for CVD patients Identifying the most prevalent nursing problems for CVD patients was the first step in identifying more appropriate NOC outcomes related to the specific nursing problems. Therefore, the researchers used NANDA-I for identifying nursing problems because NANDA-I is the best known standardized nursing languages for nursing problems.16 Chart reviews were undertaken to identify frequently used nursing problems for CVD patients. After permission to access the patient charts was gained from the hospital authorities, 78 records for patients diagnosed with CVD during a 3-month time span were accessed from the participating facilities. Two researchers extracted every nursing problem during the chart review © 2013 Wiley Publishing Asia Pty Ltd
and established a database including the identified nursing problems. A total of 378 narrative descriptions of nursing problems were identified from 78 patient charts. To map the narrative terms of nursing problems with NANDA-I nursing diagnoses, the contexts of nursing problems in the patient records were carefully analysed by each of the researchers. The charts were individually classified and were later compared to ensure consistency and reliability of mapping by each researcher. For example, if there was inconsistency in mapping between the researchers, the narrative nursing descriptions of nursing problems were jointly re-examined with context and made a decision with extensive discussion. Finally, 37 NANDA-I diagnoses were identified from the chart review, with the five most frequently used NANDA-I diagnosis being selected for linking to NOC outcomes because these NANDA-I diagnoses accounted for almost half (44. 8%) of the total NANDA-I diagnoses related to CVD.
Second step: developing the linkage process of NANDA-I with NOC outcomes For developing the linkages, the identification of prevalence of NANDA-I nursing diagnoses for a specific population is the first step. Once NANDA-I nursing diagnoses are determined, nurses can identify the NOC outcomes that are appropriate for the individual patient or patient groups. In the first stage, we identified the prevalence of NANDA-I, and only five NANDA-I were used for this study as these represented half of the total NANDA-I. The five selected NANDA-I were then linked to NOC outcomes based on NANDA-I and NOC linkages from the third edition of NOC.17 Seven highly experienced nurses, including two nursing faculty experts in standardized nursing languages and five clinical nurses who have > 5 years clinical experience with outstanding performance records in the neurosurgery department, reviewed and modified NANDA-I and NOC linkages in order to enhance the construct validity of the linkages. During the reviewing and modification of the NANDA-I and NOC linkages, intensive discussion was undertaken in order to develop classifications that were appropriate to Korean health-care settings. Seventy-two NOC were identified for the five NANDA-I. The result of this review was the selection of the following NOC for each NANDA-I: (i) 14 NOCs for Acute Pain; (ii) 17 NOCs for Risk for disuse syndrome; (iii) 13 NOCs for Decreased intracranial adaptive
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capacity; (iv) 14 NOCs for Ineffective tissue perfusion: cerebral; and (v) 14 NOCs for Acute confusion.
Third step: translating of NOC into Korean The research team included both the Korean translation of NOC outcome labels and English version of the NOC to enhance the understanding for the study participants. The Korean translation was performed by two bilingual researchers. First, each researcher translated the NOC outcomes into Korean, and then, they compared the two translations in terms of meanings and sentence structure. If there was no inconsistency in the compared translations, then the Korean translation was accepted. However, if there were inconsistencies in the compared translations, each researcher retranslated and compared them again. Most of NOC outcomes translated into Korean were accepted the first time. However, 11 NOC outcomes were identified having slightly different in meanings and required revision. After the revision, all 11 Korean NOC outcomes were accepted.
Final step: designing of the questionnaire Finally, the questionnaire was designed to identify the core nursing outcomes for each identified NANDA-I. A 5-point Likert scale was applied to the list of NOC linked to the five NANDA-I in order to facilitate nurse rankings of importance and performance of the individual NOC. The Likert scale included scores ranging from 5 (very important) to 1 (not important). Performance level of NOC also included a 5-point Likert scale from 5 (many times performed a day) to 1 (rarely performed a day). To identify the core set of NOC for each of the identified NANDA-I, the research team adapted the concepts of importance and performance. The reason for adapting the concepts of importance and performance of NOC was that the core set should be implemented in clinical practice very often by nurses to measure the changing patient outcomes and also should be considered critically important to the nurses to measure the outcomes of patients at any time point during the illness. Therefore, the importance level of NOC helps to more adequately characterize the effectiveness of nursing interventions. The performance level of NOC is defined as the frequency of use of various classifications as a means of measuring the effectiveness of nursing interventions in clinical practice. A core nursing outcome was defined as ‘a concise set of outcomes that captures the essence of specialty practice by identifying the outcomes selected most frequently but is
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not comprehensive enough to include all outcomes used by nurses in that specialty’.4 Based on this definition, core outcomes were defined as those have the > 4 point mean score both importance and performance in this study (rating from 1 to 5). The score 4.0 was chosen as a criteria for core elements because it is well above the mean indicating more frequently performed and more importantly perceived NOC.
Data collection Before data collection, consultation regarding the study purpose and data collection method was performed to query the nurse executive at six hospitals regarding participation in the study. Human subject authorization was granted according to each individual facility’s guidelines. A single general hospital declined to participate in the study. After permission was received to perform data collection, the researcher visited the NICU and neurosurgery departments of the participating hospitals and explained the purpose of the study in order to fully inform potential participants regarding the study. Study materials were only distributed to those who agreed to participate in the study, and it was clearly stated in the written consent form that the subjects could freely decide to participate in the study and were not compelled in any way or by anyone to do so. The final sample reflected those who went on to complete the study materials. A total of 100 questionnaires were distributed with returned envelopes, of which 85 questionnaires were returned reflecting a return rate of 85%. Five of the 85 returned questionnaires contained insufficient data to be included in the study, resulting in a total of 80 usable questionnaires for the analysis.
Data analysis Data were analysed using spss version 14.0 (SPSS Inc., Chicago, IL, USA). The top five NANDA-I were analysed related to the frequency and percentages of the occurrence. Nurses’ perception on the importance and performance of NOC outcomes associated with NANDA-I diagnoses was analysed based upon mean and standard deviation (SD) of scored provided.
RESULTS Sample general characteristics The final sample of 80 questionnaires was included in the study. Subjects ranged in age from 21 to 60, with those © 2013 Wiley Publishing Asia Pty Ltd
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Table 1 List of the top five most frequently used NANDA-I mapped from nursing narrative records (n = 78) Nursing diagnosis
n
%
Acute pain Risk for disuse syndrome Decreased intracranial adaptive capacity Ineffective tissue perfusion: cerebral Acute confusion
66 30 29 22 21
17.6 8.0 7.7 5.9 5.6
NANDA-I, North American Nursing Diagnosis Association— International (NANDA-I).
21–30 years of age being the largest group (62.5%). Onehalf of subjects were from a diploma educational background (55%), followed by subjects with a Bachelor of Science in Nursing (40%) and Master of Science in Nursing (5%). Distribution of nurses included neurosurgery ward (60%) and NICU (40%). Nurses assigned to direct patient care comprised the largest proportion of the sample (96.3%) and outnumbered nurses in supervisory roles (3.8%). The average term of clinical experience of nurses in the sample was 7 years with mean experience in neurological care of 3.6 years.
was the most important NOC outcome associated with nursing interventions used in the risk for disuse syndrome. Of the 17 NOC outcomes, the majority involved concerns related to the maintenance of range of motion. Six NOC outcomes were identified as core NOC outcomes in nursing interventions used for CVD with decreased intracranial adaptive capacity. Neurological status: consciousness was perceived as the most important NOC outcome. Four NOC outcomes of the six NOC outcomes were related to the measurement of neurological status, and other NOC outcomes were related to measuring cognition and communication. Nine NOC outcomes were identified as core NOC outcomes for ineffective cerebral tissue perfusion. Of the nine NOC outcomes, neurological status: consciousness was the most important NOC outcome to evaluate CVD patients’ ineffective cerebral tissue perfusion. The most frequently selected NOC was related to communication. Only two NOC outcomes were identified as core NOC outcomes for CVD patients with acute confusion. Cognitive orientation was perceived as the most important NOC outcome to measure nursing interventions used for nursing diagnosis acute confusion followed by neurological status: consciousness.
DISCUSSION The five most frequently used NANDA-I diagnosis Acute pain (17.6%) was the most frequently used NANDA-I followed by risk for disuse syndrome (8.0%), decreased intracranial adaptive capacity (7.7%), ineffective tissue perfusion (cerebral (5.9%)) and acute confusion (5.6%) (Table 1).
Core nursing outcome Seventy-two NOC outcomes identified by level of importance and performance related to the five NANDA-I are described in Table 2. A total of 72 NOC outcomes linked to NANDA-I were rated > 3.0 in both importance and performance. NOC outcomes associated with acute pain are reported in Table 2, with those NOC scoring > 4.0 in bold face to represent core NOC. Three NOC outcomes for acute pain were identified as core outcomes. The single most important NOC outcome linked to acute pain was vital signs (Mean = 4.45, SD = 0.78). One NOC was identified as the core NOC outcome for risk for disuse syndrome. Immobility consequences: physiological © 2013 Wiley Publishing Asia Pty Ltd
The study was performed to identify the core nursing outcomes using NOC outcomes for CVD patients. This study provides the basis for the consideration of more extensive use of the core NOC outcomes in nursing practice because of their ability to effectively characterize key aspects of nursing care quality measures in relation to CVD patients. The most common nursing care problems in terms of NANDA-I diagnoses in persons suffering CVD were identified in this study. This would provide the basis for the selection of NOC which are related to the health problems appropriately. These diagnoses included ‘acute pain’, ‘risk for disuse syndrome’, ‘decreased intracranial adaptive capacity’, ‘ineffective tissue perfusion: cerebral’ and ‘acute confusion’. The identification of these diagnoses provides a focal point for future studies of these diagnoses in persons suffering CVD. The inclusion of the diagnosis of acute pain as the most commonly used is supported by other studies.18,19 Although acute pain was the most commonly identified diagnosis, four other diagnosis were frequently seen (risk for disuse syndrome, decreased intracranial adaptive capacity, ineffective tissue
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Table 2 Importance and performance of NOC outcomes linked to NANDA-I diagnosis (rating from 1 to 5) (n = 80) Nursing diagnosis
Rank
Nursing outcome
Importance Mean ± SD
Performance Mean ± SD
Acute pain
1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1 2 3 4 5 6 7 8 9 10 11 12 13
Vital signs Pain level Pain control Comfort level Symptom severity Sleep Anxiety level Client satisfaction: symptom control Symptom control Stress level Nausea and vomiting severity Rest Fear level Personal well-being Immobility consequences: physiological Joint movement: fingers Joint movement: ankle Joint movement: spine Joint movement: wrist Joint movement: hip Joint movement: neck Joint movement: knee Joint movement: shoulder Joint movement: elbow Transfer performance Immobility consequences: psycho-cognitive Joint movement: passive Pain level Coordinated movement Endurance Mobility Neurological status: consciousness Neurological status Cognitive orientation Communication Neurological status: cranial Sensory/motor function Neurological status: central motor control Tissue perfusion: cerebral Fluid balance Seizure control Electrolyte and acid/base balance Cognition Neurological status: autonomic Neurological status: spinal sensory/motor function
4.45 (0.78) 4.43 (0.63) 4.25 (0.89) 4.14 (0.85) 4.03 (0.89) 3.99 (0.86) 3.98 (0.78) 3.98 (0.76) 3.96 (0.89) 3.78 (0.75) 3.74 (0.88) 3.74 (0.99) 3.54 (0.75) 3.54 (0.81) 4.28 (0.81) 4.14 (0.69) 4.11 (0.75) 4.10 (0.76) 4.10 (0.74) 4.09 (0.75) 4.09 (0.77) 4.08 (0.81) 4.08 (0.74) 4.06 (0.74) 4.04 (0.74) 3.98 (0.89) 3.98 (0.86) 3.98 (0.84) 3.95 (0.97) 3.93 (0.85) 3.91 (0.86) 4.63 (0.56) 4.50 (0.62) 4.48 (0.69) 4.46 (0.69) 4.45 (0.69) 4.41 (0.81) 4.36 (0.68) 4.15 (0.73) 4.08 (0.79) 4.05 (0.81) 4.04 (0.80) 3.94 (0.82) 3.74 (1.00)
4.79 (0.63) 4.26 (0.76) 4.05 (1.02) 3.80 (0.85) 3.90 (0.99) 3.88 (0.92) 3.56 (0.78) 3.64 (0.98) 3.51 (1.17) 3.24 (1.01) 3.74 (0.99) 3.46 (1.01) 3.21 (0.88) 3.23 (0.94) 4.00 (0.86) 3.55 (0.79) 3.51 (0.87) 3.46 (0.83) 3.50 (0.87) 3.38 (0.86) 3.48 (0.89) 3.53 (0.84) 3.56 (0.85) 3.49 (0.89) 3.69 (0.95) 3.33 (0.85) 3.64 (0.92) 4.01 (0.91) 3.96 (1.02) 3.40 (0.91) 3.70 (0.85) 4.50 (0.78) 4.41 (0.84) 4.54 (0.71) 4.49 (0.71) 4.26 (0.81) 4.21 (0.92) 3.59 (0.92) 4.26 (0.67) 3.65 (1.03) 3.99 (0.72) 3.80 (0.95) 3.84 (0.86) 3.49 (1.10)
Risk for disuses syndrome
Decreased intracranial adaptive capacity
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Table 2 Continued Nursing diagnosis
Rank
Nursing outcome
Importance Mean ± SD
Performance Mean ± SD
Ineffective cerebral tissue perfusion
1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Tissue perfusion: cerebral Neurological status: consciousness Communication Cognitive orientation Communication: expressive Neurological status Neurological status: central motor control Communication: receptive Circulation status Coordinated movement Seizure control Swallowing status Cognition Memory Cognitive orientation Neurological status: consciousness Distorted though self-control Sleep Anxiety level Fluid balance Infection severity Respiratory status: gas exchange Electrolyte and acid/base balance Memory Information processing Cognition Thermoregulation Concentration
4.58 (0.69) 4.54 (0.67) 4.49 (0.69) 4.46 (0.69) 4.39 (0.72) 4.38 (0.72) 4.38 (0.83) 4.28 (0.76) 4.24 (0.80) 4.19 (0.81) 4.18 (0.74) 4.05 (0.63) 3.90 (0.65) 3.90 (0.59) 4.58 (0.57) 4.48 (0.66) 4.05 (0.76) 3.93 (0.69) 3.90 (0.63) 3.90 (0.92) 3.89 (1.03) 3.89 (0.87) 3.88 (0.82) 3.84 (0.63) 3.81 (0.73) 3.81 (0.75) 3.80 (1.10) 3.71 (0.72)
3.70 (0.85) 4.44 (0.82) 4.49 (0.75) 4.56 (0.71) 4.33 (0.82) 4.34 (0.78) 4.28 (0.90) 4.30 (0.82) 3.68 (0.98) 4.16 (0.85) 3.71 (0.84) 4.05 (0.76) 3.43 (0.85) 3.85 (0.78) 4.58 (0.71) 4.51 (0.78) 3.36 (1.06) 3.84 (0.75) 3.85 (0.84) 4.08 (0.84) 3.99 (1.04) 3.90 (0.91) 3.81 (0.89) 3.83 (0.71) 3.43 (1.00) 3.48 (0.89) 4.06 (1.12) 3.43 (0.92)
Acute confusion
Boldface items represent core NOC outcomes. Order of rank represents the highest score of importance. NANDA-I, North American Nursing Diagnosis Association—International (NANDA-I); NOC, Nursing Outcomes Classification; SD, standard deviation.
perfusion: cerebral, and acute confusion) and were highly sensitive to the health problems associated with CVD. Identification of these key NANDA-I for specific populations based on the data derived directly from patient records is a key step to assess or evaluate patients’ conditions more accurately using NOC outcomes which are sensitive NANDA-I. The study also sought to explore the core NOC outcomes associated with each NANDA-I diagnosis by the level of importance and performance. From the results of NOC outcomes by the level of importance and performance, 72 NOC outcomes were selected by nurses in © 2013 Wiley Publishing Asia Pty Ltd
neurosurgery departments. Of the 72 NOC outcomes, 21 NOC outcomes were identified as core NOC outcomes. These core NOC outcomes were identified by a mean score > 4.0 in importance and performance levels. Vital Signs was selected the most important NOC outcome for acute pain and followed by pain level and pain control. A study was conducted to identify core NOC outcomes by 33 nursing organizations.17 Similar to this study, Vital signs was also the most frequently identified NOC outcome from 22 specialty areas of the 33 nursing organizations. One of the reasons for this result was that vital signs might be a fundamental and critical outcome
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measure for evaluation of a patient’s condition in a short time. Other NOC outcomes such as pain level and pain control were considered as sensitive NOC outcomes for acute pain to measure nursing interventions performed. Another similar study found the top five nursing outcomes from 230 quality improvement nurses. Vital signs, knowledge of infection control, pain control, safety behaviour: fall prevention, and infection status were identified as useful NOC outcomes in across settings in Korea.5 The findings of the current study revealed two NOC outcomes (vital signs and pain control) as core NOC, which were similar to the findings of Lee’s5 study. In addition, Middleton et al. reported that of the vital signs, temperature measurement is vital and should be well monitored within the first 72 h for acute stroke patients to increase survival and recovery rates.20 Middleton et al. also found that serum glucose level and swallowing dysfunction need to be assessed and managed as well to improve the survival rates of stroke patients. Factors such as these should be integrated into clinical practice and managed by nurses as important nursing sensitive outcomes to improve patient outcomes.20 Moreover, continuing research on identifying new nursing sensitive outcomes as well as new evidences is needed to enhance the nursing contribution to patients’ outcomes. The NANDA-I diagnosis, risk for disuses syndrome, was identified as the second most frequently identified nursing diagnosis for CVD population. The relevant NOC outcomes were primarily associated with measuring joint movement and consequence of immobility. In order to prevent risk for disuse syndrome, assessing or measuring patients’ joint movement in a timely manner is critical and was reflected heavily in the NOC outcomes associated with risk for disuses syndrome. Decreased intracranial adaptive capacity was the third most frequently identified nursing diagnosis for CVD population. Six core NOC outcomes were identified with mean score ranging from 4.21 to 4.63. Of the six NOC outcomes, four NOC outcomes were related to measure neurological status, and others measure cognition and communication. For ineffective cerebral tissue perfusion nursing diagnosis, nine core NOC outcomes were identified. Neurological status, cognitive orientation and communication outcomes were the mostly selected. Finally, acute confusion was the fifth frequently used NANDA-I, and three core NOC outcomes were selected, and the highly sensitive NOC outcome was cognitive orientation.
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Most core NOC outcomes related to the four NANDA-I except acute pain nursing diagnosis were included in neurocognitive class under physiological health domain. This is not surprising because these NOC findings reflect that nurses focus heavily on patient monitoring and diagnostic endeavours on patients suffering from CVD. However, many patients who are suffering stoke need to be provided not only physical care, but also must receive care related to the psychosocial dimension. Kitson et al. explored how stroke survivors described their experience during hospitalization and found the importance of integration of physical (mobility, elimination, eating and drinking, safety and medication, personal cleansing and dressing and comfort, rest and sleep, respiration, temperature control), psychosocial (dignity, communication and education, privacy, and respecting choice) and relational (respectful, personalized, timely care) dimensions of care for stroke patients at each and every point of care during hospitalization.21 They proposed that if these three dimensions are not consistently integrated into the care of stroke patients, they are destined to experience a lack of integrated care for their needs.21 Thus, it is important that nurses provide holistic care to stroke patients and continuously measure outcomes related to these dimensions to improve patient care. In addition, of the core 21 NOC, the top four NOC outcomes such as neurological status: consciousness, cognitive orientation, neurologic status and communication were considered as the most important outcomes to measure nursing effectiveness for CVD population. Of the four NOC, three NOC outcomes except communication were related to evaluation of patients’ consciousness. These results indicated that patients’ consciousness is an important to ensure effectiveness of nursing care in neuroscience unit. One of the previous studies identified core 47 NOC for neuroscience regardless NANDA-I nursing diagnoses.4 The three NOC outcomes (neurological status, cognitive orientation and communication) were matched with the top four core NOC outcomes from this study results. It implies that these three outcomes (neurological status, cognitive orientation and communication) might be more sensitive outcomes for the neuroscience population. Traditionally, studies about nursing sensitive outcomes focused mainly on symptom experience, functional status, self-care, safety (preventable adverse events) and psychological distress of patients, but there was no standardized tool to measure the outcomes of patients regardless of © 2013 Wiley Publishing Asia Pty Ltd
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health-care settings.22 Thus, no comparable data on patient outcomes exit across health-care settings. However, NOC, as a standardized language, can provide comparability of nursing sensitive outcome data as a standard way that enables to compare effectiveness of nursing care provided across the continuum of care settings, nationally and internationally. Although NOC includes comprehensive nursing sensitive outcomes, it must be updated and revised through research to represent all aspects of patient outcomes. Additionally, if outcomes are to be measured across settings, inter-rater reliability (consistency between nurses) should be addressed. Another issues raised by using NOC are validation of each NOC indicator and identifying core outcomes which are sensitive to specific populations for integrating core NOC into electronic health record systems.
CONCLUSIONS AND RELEVANCE TO CLINICAL PRACTICE In the current health-care climate, an interdisciplinary approach to patient care is required to ensure quality patient care. The identification of nursing contribution to patients’ outcomes is important to determine effectiveness of nursing in order to make nursing efforts more visible within health-care organizations. Identifying core NOC outcomes for a specific population makes critical contributions to practice and research. First of all, core NOC outcomes allow nurses to measure and evaluate their interventions to solve the specific health problems more sensitively. As a result, quality care would be offered based on accurate evaluation and measuring patients’ specific conditions or outcomes. Second, using a standardized nursing language such as NOC is feasible for the aggregation of data for effectiveness research that needs a large data set. Therefore, the results of this study enhance utilization of NOC outcomes in practice and provide the useful large dataset for demonstrating effectiveness of nursing care. Third, the identified NOC outcomes related to top five NANDA-I can support novice nurses making decisions. As patient health problems and needs are more complex, novice nurses have difficulties selecting the areas upon which to focus their practice related decision making. Although the current study is an initial work designed to identify core outcomes for specific populations of patients, the results of this study offer a template for future studies aimed at establishing nursing © 2013 Wiley Publishing Asia Pty Ltd
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outcomes measures related to neuroscience unit in other countries and more diverse populations of patients. Based on the results of this study, implementation of the core nursing outcomes from NOC in neurological care settings would positively affect the overall quality of nursing care by providing a framework for outcome-based quality improvement.
ACKNOWLEDGEMENTS This work was supported by the National Research Foundation of Korea Grant funded by the Korean Government (NRF-2013S1A5A2A01014884).
REFERENCES 1 Jennings BM, Staggers N, Brosch LR. A classification schema for outcome indicators. Journal of Nursing Scholarship 1999; 31: 381–388. 2 Naylor MD. Advancing the science in the measurement of health care quality influenced by nurses. Medical Care Research and Review 2007; 64: 144S–169S. 3 Institute of Medicine. Performance Measurement: Accelerating Improvement. Washington, DC: National Academies Press, 2005. 4 Moorhead S, Johnson M, Maas M, Swanson E. Nursing Outcomes Classification (NOC), 4th edn. St. Louis, MO, USA: Mosby, 2008. 5 Lee B. Identifying outcomes from the nursing outcomes classification as indicators of quality of care in Korea: A modified Delphi study. International Journal of Nursing Studies 2007; 44: 1021–1028. 6 Lee EJ. Validation of the nursing outcomes classification (NOC) to nursing in Korea. Korean Community Nurses Academic Society 2002; 13: 523–531. 7 Kwon B. Development of nursing outcomes indicators for stroke patients. Journal of Korean Academy of Adult Nursing 2003; 15: 88–93. 8 Park H. The development of a client health status outcome evaluation instrument in home care. Journal of Korean Academy of Nursing 2004; 34: 552–564. 9 Oh CH, Chung J, Hyun D, Kim E, Park H. Cerebrovascular disease and stroke in Korean male adolescent. Yonsei Medical Journal 2012; 53: 467–476. 11 Huber D, Schumacher L, Delaney C. Nursing Management Minimum Data Set (NMMDS). The Journal of Nursing Administration 1997; 27: 42–48. 10 Ozbolt J, Fruchtnignt JN, Hayden JR. Toward data standards for clinical nursing information. Journal of the American Medical Informatics Association 1994; 1: 175–185. 12 Keenan GM, Tschannen D, Wesley ML. Standardized nursing terminologies can transform practice. The Journal of Nursing Administration 2008; 38: 103–106.
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13 Rutherford M. Standardized nursing languages: What does it mean for nursing practice? OJIN: The Online Journal of Issues in Nursing 2008; 13: 1–11. Available from URL: http://www.nursingworld.org/MainMenu Categories/ThePracticeofProfessionalNursing/Health-IT/ StandardizedNursingLanguage.html. Accessed 13 November 2013. 14 Scherb C, Stevens MS, Busman C. Outcomes related to dehydration in the pediatric population. Journal of Pediatric Nursing 2006; 22: 376–382. 15 NANDA-International (ed.). Nursing Diagnoses: Definition & Classification 2009–2011, 8th edn. Philadelphia, PA, USA: Author, 2009. 16 Thoroddsen A, Thorsteinsson HS. Nursing diagnosis taxonomy across the Atlantic Ocean: Congruence between nurses’ charting and the NANDA taxonomy. Journal of Advanced Nursing 2002; 37: 372–381. 17 Moorhead S, Swanson E, Johnson M, Maas M. Nursing Outcomes Classification (NOC), 3rd edn. St. Louis, MO, USA: Mosby, 2004.
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18 Kim HS. Development and application of a computerized nursing process program for orthopedic surgery inpatients -NANDA, NOC, and NIC linkages. Journal of Korean Academy of Adult Nursing 2005; 35: 979–990. 19 Yoo HS, Chi SA. Construction of linkage database on nursing diagnoses interventions, outcomes in abdominal surgery patients. Journal of Korean Academy of Adult Nursing 2001; 7: 1–13. 20 Middleton S, McElduff P, Ward J et al. Implementation of evidence-based treatment protocols to manage fever, hyperglycemia and swallowing dysfunction in acute storke (ASC): A cluster randomized controlled trial. The Lancet 2011; 378: 1699–1706. 21 Kitson AL, Dow C, Calabrese JD, Locock L, Athlin AM. Stroke survivors’ experiences of the fundamentals of care: A qualitative analysis. International Journal of Nursing Studies 2013; 50: 392–403. 22 Doran D, Harrison M, Lashinger H et al. Nursing-sensitive outcomes data collection in acute care and long term care settings. Nursing Research 2006; 55: S75–S81.
© 2013 Wiley Publishing Asia Pty Ltd
International Journal of Nursing Practice 2014; 20: 636–645
RESEARCH PAPER
Identifying core nursing sensitive outcomes associated with the most frequently used North American Nursing Diagnosis Association— International nursing diagnoses for patients with cerebrovascular disease in Korea Eunjoo Lee PhD RN Professor, Kyungpook National University, College of Nursing, Daegu, South Korea
Hyejin Park PhD RN Assistant Professor, The Florida State University, College of Nursing, Tallahassee, Florida, USA
James Whyte ND PhD ARNP Associate Professor, Florida State University, College of Nursing, Tallahassee, Florida, USA
Youngae Kim MSN RN Registered Nurse, Kyungpook National University Hospital, Daegu, South Korea
Sang Youn Park PhD RN Professor, Kyungpook National University, College of Nursing, Daegu, South Korea
Accepted for publication May 2013 Lee E, Park H, Whyte J, Kim YA, Park SY. International Journal of Nursing Practice 2014; 20: 636–645 Identifying core nursing sensitive outcomes associated with the most frequently used North American Nursing Diagnosis Association—International nursing diagnoses for patients with cerebrovascular disease in Korea
The purpose of this study was to identify the core nursing sensitive outcomes according to the most frequently used five North American Nursing Diagnosis Association—International for patients with cerebrovascular disease using the Nursing Outcomes Classification (NOC). A cross-sectional survey design was used. First, nursing problems were identified through 78 charts review, and then linkages between each of nursing problems and nursing sensitive outcomes were established and validated by an expert group for questionnaires. Second, 80 nurses working in the neurosurgical intensive
Correspondence: Hyejin Park, The Florida State University, College of Nursing, Tallahassee, FL 32306, USA. Email: [email protected] Contributions: Study design: EL, HP, JW; data collection and analysis: EL, YK, SP; and manuscript preparation: EL, HP, JW, YK, SP. Conflict of interest: None. © 2013 Wiley Publishing Asia Pty Ltd
doi:10.1111/ijn.12224
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care unit and neurosurgery departments of five Korean hospitals were asked to evaluate how important each outcome is and how often each outcome used to evaluate patient outcomes using 5-point Likert scale. Although there were some differences in the core outcomes identified for each of the nursing problem, consciousness, cognitive orientation, neurologic status and communication were considered the most critical nursing sensitive outcomes for patients suffering cerebrovascular disease. Core nursing sensitive outcomes of patients suffering cerebrovascular disease using NOC were identified to measure the effectiveness of nursing care. Key words: cerebrovascular disease, effectiveness of nursing care, NOC, nursing sensitive outcomes.
INTRODUCTION For several decades, the need to deliver high quality healthcare while controlling cost has been a concern for healthcare experts, consumers and policymakers alike. As a result, a variety of measurement instruments has been developed to measure health-related outcomes and to ensure the effectiveness and efficiency of health care.1 Current measures are limited in scope and assess nursing’s influence on the quality of care solely in terms of effectiveness.2 With limited measurement of nursing outcomes, the evidence of nursing care effectiveness and unique functions of nurses is unlikely to be demonstrated. To fully represent the contributions of nursing care, measurement tools should be comprehensive and allow for assessments and measurement that characterize nursing care over time within and across settings.3 Following this request, a comprehensive and internationally recognized standardized nursing sensitive patient outcomes classification (Nursing Outcomes Classification (NOC))4 was developed to capture the unique contributions of nursing care to patient outcomes in a more effective way. Currently, the health-care system in Korea is facing concerns regarding the means by which to attain highquality care at reasonable cost. This trend has been seen in many of the world’s health-care systems, not in small part because of worldwide economic trends. Nurse managers in Korea have been increasingly tasked to provide data regarding the effectiveness of nursing care and accountability for patient outcomes. Therefore, the use of NOC with its emphasis on quantifying nursing care effectiveness has increased.5 The use of NOC has been validated in diverse settings in various health-care facilities across Korea.6–8 However, there has been no further research that has identified core NOC outcomes for specific diseases or patient populations to measure nursing care. Thus, it is necessary to identify the core nursing sensitive outcomes according to nursing diagnoses for a specific patient population.
The current study addressed cerebrovascular disease (CVD) patients as a population because the prevalence of CVD in Korea has risen steadily with ever-increasing associated cost and effect of CVD on morbidity and mortality.9 To date, there has been no specific research that captures the unique contribution of nursing on CVD patient outcomes. Therefore, the purposes of this study were to (i) identify the most five frequently used North American Nursing Diagnosis Association—International (NANDA-I) for CVD patients, then (ii) identify the core nursing sensitive outcomes for the identified nursing diagnoses of CVD patients to measure nursing care. This process ultimately improves the quality of nursing care for the CVD patients and provides fundamental line for evidence for the effectiveness of nursing care in multidisciplinary care settings.
BACKGROUND Overview of NOC Identifying nursing outcomes responsive to patients care is a critical work for nursing as we continue to focus on cost and effectiveness in the health-care system. However, in the past, we have been dependent on the use of interdisciplinary outcomes developed primarily for physician practice. In addition, the definition and classification of clinically useful nursing sensitive outcomes were not possible before the NOC was first published in 1997.4 NOC is a comprehensive, standardized classification of patient outcomes that can be used to evaluate the effectiveness of nursing interventions. In the current fifth edition, NOC has 490 outcomes categorized into seven domains and 32 classes for use at the individual, family and community levels. Each NOC outcome consists of a definition, a 5-point measurement scale with five representing the most desirable state. Each outcome also has a list of associated indicators for the outcome concept and measurement scales with codes for use in electronic health-care records. Use of NOC is important because it provides © 2013 Wiley Publishing Asia Pty Ltd
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nurses with a means to evaluate the effects of nursing interventions by comparing the outcomes of nursing interventions for specific populations in a standardized way. Additionally, NOC allows nurses to follow changes in or maintenance of outcome states over time and across settings and facilitates benchmarking with other hospitals regionally, nationally or internationally through retrieving data from nursing information systems.10–13 Many studies show the evidence that NOC is a valid tool to measure nursing interventions in clinical settings.5,14
METHODS Setting and sample The study was based upon a quantitative descriptive research design using a cross-sectional approach. The sample was obtained through convenience sampling. The study setting included neurosurgical intensive care unit (NICU) and neurosurgery departments at three tertiary and two general hospitals located in a metropolitan city in Korea. The hospitals ranged in size from 550 to 900 beds. The study sample included individual nurses who had a minimum of 1 year of practice in a neurological or neurosurgical care setting in order to participate.
Questionnaire The questionnaire was developed in three steps: (i) identifying of the five most prevalent nursing problems (NANDA-I)15 for CVD patients; (ii) developing linkages of the identified NANDA-I with NOC outcomes; (iii) translating of NOC into Korean; and (iv) designing of the questionnaire. Each of four steps was explained in the following sections.
First step: identifying the most prevalent nursing problems (NANDA-I) for CVD patients Identifying the most prevalent nursing problems for CVD patients was the first step in identifying more appropriate NOC outcomes related to the specific nursing problems. Therefore, the researchers used NANDA-I for identifying nursing problems because NANDA-I is the best known standardized nursing languages for nursing problems.16 Chart reviews were undertaken to identify frequently used nursing problems for CVD patients. After permission to access the patient charts was gained from the hospital authorities, 78 records for patients diagnosed with CVD during a 3-month time span were accessed from the participating facilities. Two researchers extracted every nursing problem during the chart review © 2013 Wiley Publishing Asia Pty Ltd
and established a database including the identified nursing problems. A total of 378 narrative descriptions of nursing problems were identified from 78 patient charts. To map the narrative terms of nursing problems with NANDA-I nursing diagnoses, the contexts of nursing problems in the patient records were carefully analysed by each of the researchers. The charts were individually classified and were later compared to ensure consistency and reliability of mapping by each researcher. For example, if there was inconsistency in mapping between the researchers, the narrative nursing descriptions of nursing problems were jointly re-examined with context and made a decision with extensive discussion. Finally, 37 NANDA-I diagnoses were identified from the chart review, with the five most frequently used NANDA-I diagnosis being selected for linking to NOC outcomes because these NANDA-I diagnoses accounted for almost half (44. 8%) of the total NANDA-I diagnoses related to CVD.
Second step: developing the linkage process of NANDA-I with NOC outcomes For developing the linkages, the identification of prevalence of NANDA-I nursing diagnoses for a specific population is the first step. Once NANDA-I nursing diagnoses are determined, nurses can identify the NOC outcomes that are appropriate for the individual patient or patient groups. In the first stage, we identified the prevalence of NANDA-I, and only five NANDA-I were used for this study as these represented half of the total NANDA-I. The five selected NANDA-I were then linked to NOC outcomes based on NANDA-I and NOC linkages from the third edition of NOC.17 Seven highly experienced nurses, including two nursing faculty experts in standardized nursing languages and five clinical nurses who have > 5 years clinical experience with outstanding performance records in the neurosurgery department, reviewed and modified NANDA-I and NOC linkages in order to enhance the construct validity of the linkages. During the reviewing and modification of the NANDA-I and NOC linkages, intensive discussion was undertaken in order to develop classifications that were appropriate to Korean health-care settings. Seventy-two NOC were identified for the five NANDA-I. The result of this review was the selection of the following NOC for each NANDA-I: (i) 14 NOCs for Acute Pain; (ii) 17 NOCs for Risk for disuse syndrome; (iii) 13 NOCs for Decreased intracranial adaptive
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capacity; (iv) 14 NOCs for Ineffective tissue perfusion: cerebral; and (v) 14 NOCs for Acute confusion.
Third step: translating of NOC into Korean The research team included both the Korean translation of NOC outcome labels and English version of the NOC to enhance the understanding for the study participants. The Korean translation was performed by two bilingual researchers. First, each researcher translated the NOC outcomes into Korean, and then, they compared the two translations in terms of meanings and sentence structure. If there was no inconsistency in the compared translations, then the Korean translation was accepted. However, if there were inconsistencies in the compared translations, each researcher retranslated and compared them again. Most of NOC outcomes translated into Korean were accepted the first time. However, 11 NOC outcomes were identified having slightly different in meanings and required revision. After the revision, all 11 Korean NOC outcomes were accepted.
Final step: designing of the questionnaire Finally, the questionnaire was designed to identify the core nursing outcomes for each identified NANDA-I. A 5-point Likert scale was applied to the list of NOC linked to the five NANDA-I in order to facilitate nurse rankings of importance and performance of the individual NOC. The Likert scale included scores ranging from 5 (very important) to 1 (not important). Performance level of NOC also included a 5-point Likert scale from 5 (many times performed a day) to 1 (rarely performed a day). To identify the core set of NOC for each of the identified NANDA-I, the research team adapted the concepts of importance and performance. The reason for adapting the concepts of importance and performance of NOC was that the core set should be implemented in clinical practice very often by nurses to measure the changing patient outcomes and also should be considered critically important to the nurses to measure the outcomes of patients at any time point during the illness. Therefore, the importance level of NOC helps to more adequately characterize the effectiveness of nursing interventions. The performance level of NOC is defined as the frequency of use of various classifications as a means of measuring the effectiveness of nursing interventions in clinical practice. A core nursing outcome was defined as ‘a concise set of outcomes that captures the essence of specialty practice by identifying the outcomes selected most frequently but is
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not comprehensive enough to include all outcomes used by nurses in that specialty’.4 Based on this definition, core outcomes were defined as those have the > 4 point mean score both importance and performance in this study (rating from 1 to 5). The score 4.0 was chosen as a criteria for core elements because it is well above the mean indicating more frequently performed and more importantly perceived NOC.
Data collection Before data collection, consultation regarding the study purpose and data collection method was performed to query the nurse executive at six hospitals regarding participation in the study. Human subject authorization was granted according to each individual facility’s guidelines. A single general hospital declined to participate in the study. After permission was received to perform data collection, the researcher visited the NICU and neurosurgery departments of the participating hospitals and explained the purpose of the study in order to fully inform potential participants regarding the study. Study materials were only distributed to those who agreed to participate in the study, and it was clearly stated in the written consent form that the subjects could freely decide to participate in the study and were not compelled in any way or by anyone to do so. The final sample reflected those who went on to complete the study materials. A total of 100 questionnaires were distributed with returned envelopes, of which 85 questionnaires were returned reflecting a return rate of 85%. Five of the 85 returned questionnaires contained insufficient data to be included in the study, resulting in a total of 80 usable questionnaires for the analysis.
Data analysis Data were analysed using spss version 14.0 (SPSS Inc., Chicago, IL, USA). The top five NANDA-I were analysed related to the frequency and percentages of the occurrence. Nurses’ perception on the importance and performance of NOC outcomes associated with NANDA-I diagnoses was analysed based upon mean and standard deviation (SD) of scored provided.
RESULTS Sample general characteristics The final sample of 80 questionnaires was included in the study. Subjects ranged in age from 21 to 60, with those © 2013 Wiley Publishing Asia Pty Ltd
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Table 1 List of the top five most frequently used NANDA-I mapped from nursing narrative records (n = 78) Nursing diagnosis
n
%
Acute pain Risk for disuse syndrome Decreased intracranial adaptive capacity Ineffective tissue perfusion: cerebral Acute confusion
66 30 29 22 21
17.6 8.0 7.7 5.9 5.6
NANDA-I, North American Nursing Diagnosis Association— International (NANDA-I).
21–30 years of age being the largest group (62.5%). Onehalf of subjects were from a diploma educational background (55%), followed by subjects with a Bachelor of Science in Nursing (40%) and Master of Science in Nursing (5%). Distribution of nurses included neurosurgery ward (60%) and NICU (40%). Nurses assigned to direct patient care comprised the largest proportion of the sample (96.3%) and outnumbered nurses in supervisory roles (3.8%). The average term of clinical experience of nurses in the sample was 7 years with mean experience in neurological care of 3.6 years.
was the most important NOC outcome associated with nursing interventions used in the risk for disuse syndrome. Of the 17 NOC outcomes, the majority involved concerns related to the maintenance of range of motion. Six NOC outcomes were identified as core NOC outcomes in nursing interventions used for CVD with decreased intracranial adaptive capacity. Neurological status: consciousness was perceived as the most important NOC outcome. Four NOC outcomes of the six NOC outcomes were related to the measurement of neurological status, and other NOC outcomes were related to measuring cognition and communication. Nine NOC outcomes were identified as core NOC outcomes for ineffective cerebral tissue perfusion. Of the nine NOC outcomes, neurological status: consciousness was the most important NOC outcome to evaluate CVD patients’ ineffective cerebral tissue perfusion. The most frequently selected NOC was related to communication. Only two NOC outcomes were identified as core NOC outcomes for CVD patients with acute confusion. Cognitive orientation was perceived as the most important NOC outcome to measure nursing interventions used for nursing diagnosis acute confusion followed by neurological status: consciousness.
DISCUSSION The five most frequently used NANDA-I diagnosis Acute pain (17.6%) was the most frequently used NANDA-I followed by risk for disuse syndrome (8.0%), decreased intracranial adaptive capacity (7.7%), ineffective tissue perfusion (cerebral (5.9%)) and acute confusion (5.6%) (Table 1).
Core nursing outcome Seventy-two NOC outcomes identified by level of importance and performance related to the five NANDA-I are described in Table 2. A total of 72 NOC outcomes linked to NANDA-I were rated > 3.0 in both importance and performance. NOC outcomes associated with acute pain are reported in Table 2, with those NOC scoring > 4.0 in bold face to represent core NOC. Three NOC outcomes for acute pain were identified as core outcomes. The single most important NOC outcome linked to acute pain was vital signs (Mean = 4.45, SD = 0.78). One NOC was identified as the core NOC outcome for risk for disuse syndrome. Immobility consequences: physiological © 2013 Wiley Publishing Asia Pty Ltd
The study was performed to identify the core nursing outcomes using NOC outcomes for CVD patients. This study provides the basis for the consideration of more extensive use of the core NOC outcomes in nursing practice because of their ability to effectively characterize key aspects of nursing care quality measures in relation to CVD patients. The most common nursing care problems in terms of NANDA-I diagnoses in persons suffering CVD were identified in this study. This would provide the basis for the selection of NOC which are related to the health problems appropriately. These diagnoses included ‘acute pain’, ‘risk for disuse syndrome’, ‘decreased intracranial adaptive capacity’, ‘ineffective tissue perfusion: cerebral’ and ‘acute confusion’. The identification of these diagnoses provides a focal point for future studies of these diagnoses in persons suffering CVD. The inclusion of the diagnosis of acute pain as the most commonly used is supported by other studies.18,19 Although acute pain was the most commonly identified diagnosis, four other diagnosis were frequently seen (risk for disuse syndrome, decreased intracranial adaptive capacity, ineffective tissue
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Table 2 Importance and performance of NOC outcomes linked to NANDA-I diagnosis (rating from 1 to 5) (n = 80) Nursing diagnosis
Rank
Nursing outcome
Importance Mean ± SD
Performance Mean ± SD
Acute pain
1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1 2 3 4 5 6 7 8 9 10 11 12 13
Vital signs Pain level Pain control Comfort level Symptom severity Sleep Anxiety level Client satisfaction: symptom control Symptom control Stress level Nausea and vomiting severity Rest Fear level Personal well-being Immobility consequences: physiological Joint movement: fingers Joint movement: ankle Joint movement: spine Joint movement: wrist Joint movement: hip Joint movement: neck Joint movement: knee Joint movement: shoulder Joint movement: elbow Transfer performance Immobility consequences: psycho-cognitive Joint movement: passive Pain level Coordinated movement Endurance Mobility Neurological status: consciousness Neurological status Cognitive orientation Communication Neurological status: cranial Sensory/motor function Neurological status: central motor control Tissue perfusion: cerebral Fluid balance Seizure control Electrolyte and acid/base balance Cognition Neurological status: autonomic Neurological status: spinal sensory/motor function
4.45 (0.78) 4.43 (0.63) 4.25 (0.89) 4.14 (0.85) 4.03 (0.89) 3.99 (0.86) 3.98 (0.78) 3.98 (0.76) 3.96 (0.89) 3.78 (0.75) 3.74 (0.88) 3.74 (0.99) 3.54 (0.75) 3.54 (0.81) 4.28 (0.81) 4.14 (0.69) 4.11 (0.75) 4.10 (0.76) 4.10 (0.74) 4.09 (0.75) 4.09 (0.77) 4.08 (0.81) 4.08 (0.74) 4.06 (0.74) 4.04 (0.74) 3.98 (0.89) 3.98 (0.86) 3.98 (0.84) 3.95 (0.97) 3.93 (0.85) 3.91 (0.86) 4.63 (0.56) 4.50 (0.62) 4.48 (0.69) 4.46 (0.69) 4.45 (0.69) 4.41 (0.81) 4.36 (0.68) 4.15 (0.73) 4.08 (0.79) 4.05 (0.81) 4.04 (0.80) 3.94 (0.82) 3.74 (1.00)
4.79 (0.63) 4.26 (0.76) 4.05 (1.02) 3.80 (0.85) 3.90 (0.99) 3.88 (0.92) 3.56 (0.78) 3.64 (0.98) 3.51 (1.17) 3.24 (1.01) 3.74 (0.99) 3.46 (1.01) 3.21 (0.88) 3.23 (0.94) 4.00 (0.86) 3.55 (0.79) 3.51 (0.87) 3.46 (0.83) 3.50 (0.87) 3.38 (0.86) 3.48 (0.89) 3.53 (0.84) 3.56 (0.85) 3.49 (0.89) 3.69 (0.95) 3.33 (0.85) 3.64 (0.92) 4.01 (0.91) 3.96 (1.02) 3.40 (0.91) 3.70 (0.85) 4.50 (0.78) 4.41 (0.84) 4.54 (0.71) 4.49 (0.71) 4.26 (0.81) 4.21 (0.92) 3.59 (0.92) 4.26 (0.67) 3.65 (1.03) 3.99 (0.72) 3.80 (0.95) 3.84 (0.86) 3.49 (1.10)
Risk for disuses syndrome
Decreased intracranial adaptive capacity
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Table 2 Continued Nursing diagnosis
Rank
Nursing outcome
Importance Mean ± SD
Performance Mean ± SD
Ineffective cerebral tissue perfusion
1 2 3 4 5 6 7 8 9 10 11 12 13 14 1 2 3 4 5 6 7 8 9 10 11 12 13 14
Tissue perfusion: cerebral Neurological status: consciousness Communication Cognitive orientation Communication: expressive Neurological status Neurological status: central motor control Communication: receptive Circulation status Coordinated movement Seizure control Swallowing status Cognition Memory Cognitive orientation Neurological status: consciousness Distorted though self-control Sleep Anxiety level Fluid balance Infection severity Respiratory status: gas exchange Electrolyte and acid/base balance Memory Information processing Cognition Thermoregulation Concentration
4.58 (0.69) 4.54 (0.67) 4.49 (0.69) 4.46 (0.69) 4.39 (0.72) 4.38 (0.72) 4.38 (0.83) 4.28 (0.76) 4.24 (0.80) 4.19 (0.81) 4.18 (0.74) 4.05 (0.63) 3.90 (0.65) 3.90 (0.59) 4.58 (0.57) 4.48 (0.66) 4.05 (0.76) 3.93 (0.69) 3.90 (0.63) 3.90 (0.92) 3.89 (1.03) 3.89 (0.87) 3.88 (0.82) 3.84 (0.63) 3.81 (0.73) 3.81 (0.75) 3.80 (1.10) 3.71 (0.72)
3.70 (0.85) 4.44 (0.82) 4.49 (0.75) 4.56 (0.71) 4.33 (0.82) 4.34 (0.78) 4.28 (0.90) 4.30 (0.82) 3.68 (0.98) 4.16 (0.85) 3.71 (0.84) 4.05 (0.76) 3.43 (0.85) 3.85 (0.78) 4.58 (0.71) 4.51 (0.78) 3.36 (1.06) 3.84 (0.75) 3.85 (0.84) 4.08 (0.84) 3.99 (1.04) 3.90 (0.91) 3.81 (0.89) 3.83 (0.71) 3.43 (1.00) 3.48 (0.89) 4.06 (1.12) 3.43 (0.92)
Acute confusion
Boldface items represent core NOC outcomes. Order of rank represents the highest score of importance. NANDA-I, North American Nursing Diagnosis Association—International (NANDA-I); NOC, Nursing Outcomes Classification; SD, standard deviation.
perfusion: cerebral, and acute confusion) and were highly sensitive to the health problems associated with CVD. Identification of these key NANDA-I for specific populations based on the data derived directly from patient records is a key step to assess or evaluate patients’ conditions more accurately using NOC outcomes which are sensitive NANDA-I. The study also sought to explore the core NOC outcomes associated with each NANDA-I diagnosis by the level of importance and performance. From the results of NOC outcomes by the level of importance and performance, 72 NOC outcomes were selected by nurses in © 2013 Wiley Publishing Asia Pty Ltd
neurosurgery departments. Of the 72 NOC outcomes, 21 NOC outcomes were identified as core NOC outcomes. These core NOC outcomes were identified by a mean score > 4.0 in importance and performance levels. Vital Signs was selected the most important NOC outcome for acute pain and followed by pain level and pain control. A study was conducted to identify core NOC outcomes by 33 nursing organizations.17 Similar to this study, Vital signs was also the most frequently identified NOC outcome from 22 specialty areas of the 33 nursing organizations. One of the reasons for this result was that vital signs might be a fundamental and critical outcome
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measure for evaluation of a patient’s condition in a short time. Other NOC outcomes such as pain level and pain control were considered as sensitive NOC outcomes for acute pain to measure nursing interventions performed. Another similar study found the top five nursing outcomes from 230 quality improvement nurses. Vital signs, knowledge of infection control, pain control, safety behaviour: fall prevention, and infection status were identified as useful NOC outcomes in across settings in Korea.5 The findings of the current study revealed two NOC outcomes (vital signs and pain control) as core NOC, which were similar to the findings of Lee’s5 study. In addition, Middleton et al. reported that of the vital signs, temperature measurement is vital and should be well monitored within the first 72 h for acute stroke patients to increase survival and recovery rates.20 Middleton et al. also found that serum glucose level and swallowing dysfunction need to be assessed and managed as well to improve the survival rates of stroke patients. Factors such as these should be integrated into clinical practice and managed by nurses as important nursing sensitive outcomes to improve patient outcomes.20 Moreover, continuing research on identifying new nursing sensitive outcomes as well as new evidences is needed to enhance the nursing contribution to patients’ outcomes. The NANDA-I diagnosis, risk for disuses syndrome, was identified as the second most frequently identified nursing diagnosis for CVD population. The relevant NOC outcomes were primarily associated with measuring joint movement and consequence of immobility. In order to prevent risk for disuse syndrome, assessing or measuring patients’ joint movement in a timely manner is critical and was reflected heavily in the NOC outcomes associated with risk for disuses syndrome. Decreased intracranial adaptive capacity was the third most frequently identified nursing diagnosis for CVD population. Six core NOC outcomes were identified with mean score ranging from 4.21 to 4.63. Of the six NOC outcomes, four NOC outcomes were related to measure neurological status, and others measure cognition and communication. For ineffective cerebral tissue perfusion nursing diagnosis, nine core NOC outcomes were identified. Neurological status, cognitive orientation and communication outcomes were the mostly selected. Finally, acute confusion was the fifth frequently used NANDA-I, and three core NOC outcomes were selected, and the highly sensitive NOC outcome was cognitive orientation.
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Most core NOC outcomes related to the four NANDA-I except acute pain nursing diagnosis were included in neurocognitive class under physiological health domain. This is not surprising because these NOC findings reflect that nurses focus heavily on patient monitoring and diagnostic endeavours on patients suffering from CVD. However, many patients who are suffering stoke need to be provided not only physical care, but also must receive care related to the psychosocial dimension. Kitson et al. explored how stroke survivors described their experience during hospitalization and found the importance of integration of physical (mobility, elimination, eating and drinking, safety and medication, personal cleansing and dressing and comfort, rest and sleep, respiration, temperature control), psychosocial (dignity, communication and education, privacy, and respecting choice) and relational (respectful, personalized, timely care) dimensions of care for stroke patients at each and every point of care during hospitalization.21 They proposed that if these three dimensions are not consistently integrated into the care of stroke patients, they are destined to experience a lack of integrated care for their needs.21 Thus, it is important that nurses provide holistic care to stroke patients and continuously measure outcomes related to these dimensions to improve patient care. In addition, of the core 21 NOC, the top four NOC outcomes such as neurological status: consciousness, cognitive orientation, neurologic status and communication were considered as the most important outcomes to measure nursing effectiveness for CVD population. Of the four NOC, three NOC outcomes except communication were related to evaluation of patients’ consciousness. These results indicated that patients’ consciousness is an important to ensure effectiveness of nursing care in neuroscience unit. One of the previous studies identified core 47 NOC for neuroscience regardless NANDA-I nursing diagnoses.4 The three NOC outcomes (neurological status, cognitive orientation and communication) were matched with the top four core NOC outcomes from this study results. It implies that these three outcomes (neurological status, cognitive orientation and communication) might be more sensitive outcomes for the neuroscience population. Traditionally, studies about nursing sensitive outcomes focused mainly on symptom experience, functional status, self-care, safety (preventable adverse events) and psychological distress of patients, but there was no standardized tool to measure the outcomes of patients regardless of © 2013 Wiley Publishing Asia Pty Ltd
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health-care settings.22 Thus, no comparable data on patient outcomes exit across health-care settings. However, NOC, as a standardized language, can provide comparability of nursing sensitive outcome data as a standard way that enables to compare effectiveness of nursing care provided across the continuum of care settings, nationally and internationally. Although NOC includes comprehensive nursing sensitive outcomes, it must be updated and revised through research to represent all aspects of patient outcomes. Additionally, if outcomes are to be measured across settings, inter-rater reliability (consistency between nurses) should be addressed. Another issues raised by using NOC are validation of each NOC indicator and identifying core outcomes which are sensitive to specific populations for integrating core NOC into electronic health record systems.
CONCLUSIONS AND RELEVANCE TO CLINICAL PRACTICE In the current health-care climate, an interdisciplinary approach to patient care is required to ensure quality patient care. The identification of nursing contribution to patients’ outcomes is important to determine effectiveness of nursing in order to make nursing efforts more visible within health-care organizations. Identifying core NOC outcomes for a specific population makes critical contributions to practice and research. First of all, core NOC outcomes allow nurses to measure and evaluate their interventions to solve the specific health problems more sensitively. As a result, quality care would be offered based on accurate evaluation and measuring patients’ specific conditions or outcomes. Second, using a standardized nursing language such as NOC is feasible for the aggregation of data for effectiveness research that needs a large data set. Therefore, the results of this study enhance utilization of NOC outcomes in practice and provide the useful large dataset for demonstrating effectiveness of nursing care. Third, the identified NOC outcomes related to top five NANDA-I can support novice nurses making decisions. As patient health problems and needs are more complex, novice nurses have difficulties selecting the areas upon which to focus their practice related decision making. Although the current study is an initial work designed to identify core outcomes for specific populations of patients, the results of this study offer a template for future studies aimed at establishing nursing © 2013 Wiley Publishing Asia Pty Ltd
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outcomes measures related to neuroscience unit in other countries and more diverse populations of patients. Based on the results of this study, implementation of the core nursing outcomes from NOC in neurological care settings would positively affect the overall quality of nursing care by providing a framework for outcome-based quality improvement.
ACKNOWLEDGEMENTS This work was supported by the National Research Foundation of Korea Grant funded by the Korean Government (NRF-2013S1A5A2A01014884).
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