Overview of the Nursing Outcomes Classification (NOC)

Marion Johnson, PhD, RN marion-johnson@uiowa.edu

Description of NOC

The Nursing Outcomes Classification containing 190 outcomes listed alphabetically was published by Mosby in 1997 (Iowa Outcomes Project, 1997). Since publication, an additional 28 outcomes and the taxonomy have been developed. For this work, an outcome is stated as a variable concept representing a patient or family caregiver state, behavior, or perception that is measurable along a continuum and responsive to nursing interventions. Stating the outcomes as variable concepts, rather than as goals, allows for the identification of positive or negative changes or no change in a patient's status. Each NOC outcome has a definition, a list of indicators that are useful in evaluation of patient status, a measurement scale, and a short list of references used in development of the outcome as illustrated in Figure I. Sixteen, 5 point Likert scales have been developed for use with the outcomes to measure patient status in relation to the outcome. The scale for Knowledge: Treatment Regimen in Figure I uses a measurement scale from none to extensive. Examples of other scales are: 1=extremely compromised to 5=not compromised and 1=never demonstrated to 5=consistently demonstrated. All of the scales are developed so that 1 is the least desirable patient state and 5 is the most desirable patient state. One of the 16 scales is used with each outcome to measure patient status for both the outcome and the indicators. For example, in the outcome, Knowledge: Treatment Regimen, 1 = none or no knowledge and represents the least desirable state while 5 = extensive knowledge and represents the most desirable state. It is important to recognize that a 5 rating on the scale may not be achieved by all patients. For example, an aphasic patient may never achieve a 5 on communication ability, but improvement may be measured, for example if they move from a 1 to a 3 on the scale.

Figure 1. Example of NOC Outcome

Knowledge: Treatment Regimen - Extent of understanding and skills conveyed about a specific

treatment regimen

 

Never

Slight

Moderate

Substantial

Extensive

NA

Knowledge: Treatment

Regimen: (Specify disease)

1

2

3

4

5

 

Indicators:

Never

Slightly

Moderately

Substantially

Extensively

NA

Describes prescribed diet

1

2

3

4

5

NA

Describes prescribed medication

1

2

3

4

5

NA

Describes prescribed activity

1

2

3

4

5

NA

Describes prescribed exercise

1

2

3

4

5

NA

Describes prescribed procedures

1

2

3

4

5

NA

Describes rationale for treatment regimen

1

2

3

4

5

NA

Describes self-care responsibilities for ongoing treatment

1

2

3

4

5

NA

Describes self-care responsibilities for emergency situations

1

2

3

4

5

NA

Describes expected effects of treatment

1

2

3

4

5

NA

Demonstrates self-monitoring techniques

1

2

3

4

5

NA

Other __________________
(Specify)

1

2

3

4

5

NA

Used with permission of Mosby-Year Book from Iowa Outcomes Project. M. Johnson & M. Maas (Eds.). (1997). Nursing Outcomes Classification (NOC). St. Louis: Mosby, p. 197.

 

Outcomes in the current classification are developed for use at the individual level and relate to the patient or family caregiver. Outcomes applicable to other social units, such as families and communities, are being developed. The term, patient, is used for conciseness, but refers to any individual receiving nursing care in any setting, for example a nursing home or the patient's home. Outcomes for caregivers are those that apply to any individual who cares for or acts on behalf of the patient, such as a family member, significant other, or personal friend. Caregiver does not apply to professional caregivers paid to provide care. Examples of outcomes for caregivers are: Caregiver Emotional Health and Caregiver Performance: Direct Care.

The outcomes were developed at varied levels within a middle range of abstraction. Thus, some are more general with broader scope than others. For example, Self-Care: Activities of Daily Living (ADL) is defined as the "ability to perform the most basic physical tasks and personal care activities" and has ten indicators that include: eating, dressing, toileting, and bathing. If required, more specific outcomes for each of the dimensions of self-care are available. For example, Self-Care: Eating is defined as the "ability to prepare and ingest food" and the indicators include: handles utensils, picks up cup or glass, and chews food.

 

Description of the Taxonomy

The outcomes are organized in 24 categories referred to as classes. The classes are grouped in the following six broad domains: Functional Health, Physiologic Health, Psychosocial Health, Health Knowledge & Behavior, Perceived Health, and Family Health. Consistent terminology and format were used in the development of domain and class labels and definitions. Each class and domain has a definition that facilitates placement of newly developed outcomes within a particular class. The classes with the number of outcomes in each class for the domain Functional Health are: Energy Maintenance, 4; Growth & Development, 22; Mobility, 11; Self-Care, 11; and Sensory Function, 5.

Each of the domains reflects a dimension of personal or family health and classes represent components of the health dimension. Although NOC is the most inclusive classification of patient and caregiver outcomes currently available to evaluate nursing interventions, it will continually evolve and become more complete. Additional classes may be identified if new outcomes cannot be subsumed in the existing classes and additional domains and classes may be required as outcomes characterizing family and community units are developed.

Each element of the taxonomy has been coded for application in computerized clinical information systems. The code for each outcome places it within a particular class and consequently also within a domain. For example, Figure II illustrates the coding for the outcome Comfort Level and one of the indicators, reported physical well-being. It is important to note that the scale as well as the patient state is also coded.

Figure II: Coding for Outcome Comfort Level

CODE

DIMENSION

Domain 5

Perceived Health

Class V

Symptom Status

Outcome 2100

Comfort Level

Indicator 01

Reported Physical Well-Being

Scale i

None to Extensive

Rating 1 to 5

Individual patient status

5V210001i3

Complete code for a patient evaluated at a 3 on the outcome Comfort Level

 

Issues Related to NOC

Although comprehensive, a number of developmental issues should be considered. Outcomes continue to be identified and developed. Examples of outcomes developed since publication of the book include: Fetal Status: Antepartum; Knowledge: Infant Care; Sensory Function: Hearing; and Risk Control: Cancer. Family outcomes, such as, Family Integrity; Family Communication; Family Safety; and Family Cohesiveness are being developed. The work on community outcomes is underway. Outcomes must also be linked with diagnoses and interventions. The outcomes in NOC have been linked to NANDA diagnoses and NIC interventions and these linkages are being used to develop links between NANDA, NIC, and NOC. The outcomes are also being linked to the Resident Assessment Protocols (RAPS) used in long term care and the Omaha system used in community nursing.

The need for nursing-sensitive outcomes continues to be a topic of debate with the move to develop collaborative outcomes. While collaborative outcomes are important as measures of health care system and organization effects, they do not provide any one discipline with the knowledge necessary to evaluate that discipline’s interventions. Nursing-sensitive outcomes are necessary for the evaluation of nursing practices, nursing interventions, and system and organizational changes that impact the practice of nursing. They are also needed if nursing is to be a collaborative partner in the identification of interdisciplinary outcomes.

The use of measures rather than goals requires a shift in thinking related to the evaluation of nursing care. While the measurement of patient status in relation to selected outcomes allows for the evaluation of change or lack of change following nursing interventions, it may require a more detailed evaluation of patient status when determining the outcome level. The use of NOC, however, does not eliminate setting goals. The outcomes can be converted to goal statements by determining the desired point on the measurement scale for an individual patient or for a specified patient population.

Although selected outcomes have been piloted in three field sites (two hospitals and one nursing home) with favorable results, further evaluation of the outcomes in clinical practice is necessary. The second phase of the research to evaluate the reliability, validity, and sensitivity of the measurement scales is beginning. During this phase of the research, an attempt will be made to isolate risk adjustment factors for the more common nursing-sensitive outcomes. The identification of personal characteristics that contribute to outcome achievement is an important factor when evaluating outcome attainment across organizations and health care systems. The outcomes, use of the outcomes in practice settings and computerized information systems will provide additional information for the evaluation of NOC. Data generated from these sources can be used to determine the frequency with which each outcome is selected, the nursing diagnoses and interventions associated with each outcome, and the characteristics of the patient populations for which specific outcomes are selected.

The use of standardized outcome measures, such as NOC, offers nursing the opportunity to assume accountability for the effects of nursing interventions on the health of individual patients and the patient populations it serves. The ability to quantify the effects of the care nurses provide is essential for describing the value of nurses to consumers and other providers.