CNC - NOC: Frequently Asked Questions
What are some suggestions for the implementation of NOC?
To assist with the use and implementation of NOC you might find the following helpful.
Selecting The Outcome
You will select the outcome appropriate for an individual patient or patient group as you normally do. That is, after assessing the patient and determining the pertinent nursing diagnoses and patient problems you will determine the outcome you want to achieve. If you have a patient with the nursing diagnosis "breathing pattern: ineffective", you would probably select "respiratory status: gas exchange" as one of your outcomes. You should then rate the patient on the scale extremely compromised to not compromised. You will reevaluate the patient on the scale at the intervals you determine is appropriate, but at least at the time of discharge from your care. Changes in patient status or lack of change will be immediately recognized by the patient ratings. For example, a patient may be admitted to your care with "respiratory status: gas exchange" extremely compromised and leave your care with "respiratory status: gas exchange" moderately compromised or not compromised.
The portions of the outcome that are to remain standardized (e.g. no changes in terminology) are the outcome label and the definition. We would also like to see the scale retained, but since we do not have the measurement work done in relation to scale reliability and validity at this time we recognize that you may wish to select other terminology such as decreased, maintained, increased to measure patient status in relation to the outcome. If you wish to use the scale with the anchor points but cannot do so in the suggested format, we suggest the following format:
Ambulation: Walking--Ability to walk from place to place
1. Dependent, does not participate 2. Requires assistive person & device 3. Requires assistive person 4. Independent with assistive device 5. Completely independent
If you want to use the outcome to identify a specific goal for an individual patient or a group of patients, for example in a critical path, you can indicate where the patient is expected to be.(e.g. On day 3, for ambulation: walking, you expect the patient to have a 5 rating/be completely independent).
The language of the indicators should remain standardized as much as possible. However, you may wish to add some indicators which are pertinent to your area of practice or to make the indicator more specific. For example, you may want to substitute specific ranges for your patient population when we use the abbreviations IER (in expected range) or WNL (within normal limits). If you identify major problems with the indicators for any outcome, we would appreciate feedback from you.
The indicators are less abstract than the outcome and are provided to assist you in determining patient status in relation to the outcome. You may choose all of the indicators, only those pertinent to an individual patient or a group of patients, or none of the indicators to determine patient status. You may want to use the scales provided with the indicators to determine the mean score on the selected indicators as a guide to the score for the outcome. You may also identify other indicators that are more pertinent to the patient population you are serving The indicators may serve as intermediate outcomes in care plans or critical paths.
Why are the outcomes not stated as goals for the patient?
The research team developed the outcomes as variable concepts so that patient status in response to nursing interventions could be documented and monitored over time and across settings and yield more information than just whether a goal was met. For clinical and research purposes, either\or type data provide a very limited amount of information and will not allow nurses to adequately evaluate the effectiveness of their interventions. If goals are not met, it is important to know whether any progress was made or the extent that the patient's status deteriorated, if at all. It is important to note, however, that the NOC outcomes can be used to state a goal for the patient.
How are the outcomes different from nursing diagnoses?
NOC outcomes describe a variable patient or family state, behavior or perception, responsive to nursing intervention and conceptualized at middle levels of abstraction. The outcome state for a particular patient at a particular time can be at any point on a negative to positive continuum. Nursing diagnoses, on the other hand, describe patient states that are in some way less positive than what is desired. Nursing diagnoses describe patient problems, actual or potential, that the nurse seeks to resolve through intervention.
At what intervals should the outcomes be assessed and documented?
Research is needed to definitively answer this question. At present, the nurse will determine the intervals for measurement and documentation of the outcome based on clinical judgment as to when the effect of interventions need to be assessed. However, at minimum, the outcomes should be assessed and documented (1) when a patient is admitted to a care setting or makes an initial visit to a nurse for care, and (2) when the patient is discharged, transferred, or referred to another setting or clinician for care.
How are the outcomes used in critical paths?
NOC outcomes are very useful in clinical pathways because they allow quantification of the patient or family state, behavior, or perception that is expected to occur at specific points in time during an episode of care. A major advantage of their use is the ability to monitor and compare the achievement of specific states across settings and providers. Use of the standardized outcomes will greatly facilitate the development of large data bases across settings and providers, rather than the more limited, unique setting or provider data bases that result when setting or provider specific outcomes are used in critical pathways.
Why is it necessary for nurses to have their own list of outcomes?
NOC outcomes are patient outcomes that are responsive to nursing interventions. They are not intended to be unique to nursing. Clearly most, if not all, patient outcomes are influenced by multiple health care providers. However, it is important for nurses to measure the effects of their interventions on patient outcomes. The NOC provides indicators for each outcome that are more sensitive to nursing interventions. Thus whereas the team expected all disciplines to use the majority of the outcomes, different indicators will be of most use to different health care disciplines. Without discipline-specific indicators for shared outcomes, it will be impossible to monitor the accountability of each discipline for its contribution to outcome improvement or deterioration.
Why is it important to assess outcomes across care settings?
Continuity of care always has been an important value for the nursing profession. Yet, communication between settings and nurse providers has been constrained. A major obstacle has been the lack of standardized nomenclatures to describe the patient problems nurses treat, the interventions used, and the resulting patient outcomes. The inability to optimize continuity of care is costly to the patient and to the health care system. In the current resource-constrained environment, more emphasis is placed on continuity of care to reduce costs. Further, providers are developing networks that include providers and settings across the continuum of care to enhance continuity and reduce costs. There also is an emphasis on the demonstration of outcomes effectiveness. NOC outcomes provide a standardized language for outcomes that can be measured across the entire continuum of care, providing essential information that clinicians need to achieve continuity and to assess the cost-effectiveness of care.
Why is it necessary to use the outcome labels when the indicators may be more useful?
Along with medicine, the nursing profession is a key member of the interdisciplinary health care team. The profession's contribution to interdisciplinary patient outcomes must be documented and the effectiveness of nursing interventions must be evaluated. Large, standardized data bases will contain NOC outcomes, but likely not discipline-specific indicators in all cases because of space limitations. Therefore, it is essential that the nursing profession use the standardized outcome labels that are included in large data bases so that the profession's influence on outcomes will be assessed to affect health policy.
Why is the standardization of outcomes advocated when each patient is an individual?
Standardizing the language used to describe patient outcomes in no way interferes with assessing each patient as an individual. Rather, use of the NOC outcomes will enable nurses to measure each outcome state for each individual and will provide more information for monitoring the progress of each patient as an individual. Further, specific quantified goals can be set for each individual, and the extent that goals are or are not met can be documented over time and across settings.