Standard 3. Outcomes Identification
Margaret G. Williams PhD, RN, CNE
Kathleen M. White PhD, RN, NEA-BC, FAAN
Standard 3. Outcomes Identification. The registered nurse identifies expected outcomes for a plan individualized to the healthcare consumer or the situation.
Definition and Explanation of the Standard
The nursing community has defined an outcome as an individual’s, family’s, or community’s state, behavior, or perception that can be measured along a continuum and is responsive to nursing interventions (University of Iowa, 2012). Discussions in today’s healthcare environment expand that definition and identify the terms outcome, expected outcome, desired outcome, goal, and objective as interchangeable terms to describe a desired change in the healthcare consumer’s health status or functioning. The nurse, using clinical knowledge and experience, determines outcomes in collaboration with the healthcare team and the healthcare consumer to provide individualized care and to delineate what is to be accomplished and when. This determination promotes the healthcare consumer’s involvement in the care and enables measurement of the effectiveness of the plan.
Much as diagnoses are identified and prioritized from assessment data, outcomes identification refers to the formulation of specific, measurable, achievable, realistic, and time-framed (SMART) outcomes:
Specific: The outcome must be clearly defined and understandable to all team members.
Measureable: The team must be able to determine if the outcome is attainable and what improvement or movement must be accomplished (increase, decrease, size, and number).
Achievable: All team members determine what the outcome should be.
Realistic: The team agrees that the outcomes can be achieved with the current clinical condition and resources available.
Time-framed: The team identifies the time needed to achieve the outcome.
Those outcomes are the statement of the healthcare consumer’s status or progress that would demonstrate reduction, resolution, or prevention of a problem that was identified in the assessment and diagnosis steps of the nursing process, and they serve as criteria to evaluate the plan of care. Examples of SMART outcome statements are as follows:
The healthcare consumer’s temperature will decrease to normal or to baseline within four hours after administration of antipyretic medication.
The healthcare consumer will reduce smoking to less than one pack per day within one month following daily administration of “the patch.”
The outcomes identified in the plan may be either short-term or long-term. Short-term outcomes are those that can be achieved fairly quickly, within hours or days; that show progress toward resolution of a problem; and that are often a stepping stone toward reaching a long-term goal. A long-term goal often requires weeks or months to be achieved and usually reflects resolution or prevention of a problem.
In the past, healthcare outcomes that were determined to be nursing sensitive were those that were influenced by and improved by a greater quantity or quality of nursing care. In 1994, the American Nurses Association (ANA) launched the Patient Safety and Quality Initiative that funded a series of pilot studies to evaluate links between nurse staffing and quality of care (ANA, 1995). Several quality indicators were identified from those pilots, and a final set of 10 nursing-sensitive indicators to use in evaluating patient-care quality was adopted (Gallagher & Rowell, 2003).
The ANA established the National Database of Nursing Quality Indicators® (NDNQI®) in 1998 with the goals of (1) providing acute care hospitals with comparative information on nursing indicators that could be used in quality
improvement projects and (2) developing a database that could be used to examine the relationship between aspects of the nursing workforce and nursing-sensitive patient outcomes (Dunton, Gajewski, Klaus, & Pierson, 2007; Montalvo, 2007). Outcome measures in the database that hospitals are collecting and reporting include but are not limited to the following:
improvement projects and (2) developing a database that could be used to examine the relationship between aspects of the nursing workforce and nursing-sensitive patient outcomes (Dunton, Gajewski, Klaus, & Pierson, 2007; Montalvo, 2007). Outcome measures in the database that hospitals are collecting and reporting include but are not limited to the following:
Patient fall rate.
Injury from fall rate.
Hospital-acquired pressure ulcer rate.
Psychiatric patient injury assault rate.
Prevalence of pediatric IV infiltration.
Completeness of the pain assessment cycle for pediatric patients.
Restraint prevalence.
Urinary catheter-associated urinary tract infection for intensive care unit (ICU) patients.
Central line catheter-associated blood stream infection rate for ICU and high-risk nursery (HRN) patients.
Ventilator-associated pneumonia for ICU and HRN patients.
ANA has collaborated with The Joint Commission to include NDNQI as a recognized reporting mechanism for nursing outcomes, and several NDNQI outcome indicators have been endorsed by the National Quality Forum (NQF) through its voluntary consensus measurement identification process.
The nurse is also involved in identifying outcomes to design plans for improvement in direct and indirect nursing work, such as with groups, communities, populations, organizations, and systems. Examples of those outcomes may include the healthcare needs of an at-risk vulnerable population in a community or insurance plan, identification and planning for human capital needs in an organization, educational needs of a department or facility, or program planning quality and safety improvement for an organization or system. Outcomes for this nursing work, beyond the healthcare consumer and family, must also be based on comprehensive assessment and diagnosis and on using the SMART framework for outcomes identification to serve as a basis for planning, implementation, and evaluation.
Although it is generally recognized that outcomes should be individualized to the healthcare consumer or group, the use of standardized outcomes
is necessary for the evaluation of nursing interventions, documentation in electronic records, use in clinical information systems, development of nursing knowledge, and education of professional nurses. Various tools are available to help the nurse identify approved and standardized outcomes.
is necessary for the evaluation of nursing interventions, documentation in electronic records, use in clinical information systems, development of nursing knowledge, and education of professional nurses. Various tools are available to help the nurse identify approved and standardized outcomes.
Structure, Process, and Outcomes Model
Historically, the model of quality evaluation in health care proposed by Donabedian (1966/2005) identified three dimensions that are still useful for outcomes identification in health care and can be used in both direct and indirect nursing. The three dimensions are structure, process, and outcomes. Structure refers to the setting where care is provided, including equipment, staff, and programs, and assesses if the right things are in place to provide or access health care or alleviate the issue. Process determines the effectiveness, appropriateness, efficiency, and competency of care provided and assesses if the right things are being done to provide or access health care or alleviate the issue. Outcomes refer to the end points of care and ask if the right things are happening because of the actions of the providers.
Nursing Outcomes Classification
Another tool is the Nursing Outcomes Classification (NOC) developed and maintained by the University of Iowa’s College of Nursing. The NOC is a comprehensive, standardized classification of patient and client outcomes that are sensitive or responsive to the effects of nursing interventions (University of Iowa, 2012). The NOC has identified 385 outcomes that can be used with all populations, in all settings, and across the care continuum to follow patient outcomes throughout an illness episode or over an extended period of care. The NOC is complementary to the Nursing Intervention Classification (NIC) system and has been linked to North American Nursing Diagnosis Association International (NANDA-I) diagnoses, to Marjorie Gordon’s functional patterns, to the Taxonomy of Nursing Practice, to Omaha System problems, to resident admission protocols (RAPs) used in nursing homes, and to the Center for Medicare and Medicaid Services’ Outcome and Assessment Information Set (OASIS) used in home care. NOC is recognized by the ANA, is included in the Metathesaurus for a Unified Medical Language at the National Library of Medicine, and is listed in the Cumulative Index to Nursing and Allied Health Literature (CINAHL*) index.
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