Nursing outcomes

Nursing Classifications: Effects in
clinical practice and EHR
requirements
Maria Müller-Staub, RN, MNS, EdN, PhD, (Selzach, Switzerland)
Senior Researcher ZHAW University, Winterthur, Switzerland
Accuracy of nursing diagnoses: Knowledge and knowledge sources Conference Promotion Wolter Paans, Feb. 8, Groningen NL Background / State of research
•  Nursing has a mandate to strive for - quality
- efficiency - measurability (Institute of Medicine, 2004,
•  Unspecific diagnoses, need for accuracy KVG, 2001)
(Lunney, 2001, 2011; Paans 2009)
•  To attain favorable nursing-sensitive patient
outcomes:
nursing diagnoses must be stated accurately,
and linked with effective nursing interventions
(Björwell, 2002; Lavin, 2005, Müller-Staub et. al, 2009; Florin, 2005; Thoroddsen et al.,
2010; Paans et al, 2010)
M. Müller-Staub, PhD, Groningen Feb 2011
2
1
Theoretical framework
Frameworks and definitions
•  Diagoses: NANDA International
•  Interventions: NIC
•  Outcomes: NOC
Transfer of NNN into nursing process: •  Nurse‘s Pocket Guide
(Doenges, Moorhouse, & Murr; 2008; NANDA-I, 2010)
M. Müller-Staub, Promotion Paans, Feb. 2011
Assessment
6-Schritt-Modell
Gordon/NNN
Attained
Outcomes
= Indicators
3
Needs Indicators
(Fiechter & Meier 1987)
1
Informationssammlung
Problemformulierung
385
2
Nursing diagnoses
+ Pflegediagnosen
NANDA-I
stellen
206
Outcomes / Evaluation
Beurteilen
Doenges et. al/NOC
der Angemessen-
6
3
Festlegen
Outcomes / Aims
der
Doenges
Pflegezieleet. al/NOC
heit, Wirkung
und Wirksamkeit
der Pflege
Interventions
Indicators
= Activities
5
585
Durchführen
Planen
der
Interventions
der PflegePflegemassDoenges
et.
al/NIC
massnahmen
nahmen
EBP
07.02.12
Pflege PBS, M. Müller Staub, PhD
desired Outcomes
= Indicators
385
4
2
M. Müller-Staub, Promotion Paans,
Feb. 2011
5
Conceptual Definition of Diagnoses (Top Level Concept)
Domain
Domain
Health
Promotion
Nutrition
Klasse
Class
Class:
Diagnosis Diagnosis
Ineff.
Health
maintenance
07.02.12
Hydration
Hydratation
Health
Manage
ment
Risk for
deficient
fluid volume
Pflege PBS, M. Müller Staub, PhD
3
M. Müller-Staub, Promotion Paans,
Feb. 2011
7
M. Müller-Staub, Promotion Paans,
Feb. 2011
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4
Classifications: WHY?? •  Main question: Are patient outcomes
better after implementing nursing
classifications?
•  Evaluate the implementation of
classifications: nursing diagnoses,
interventions and outcomes
M. Müller-Staub, Promotion Paans,
Feb. 2011
9
Research questions
After staff education in nursing diagnoses,
interventions and outcomes, do nursing records
contain:
§ 
accurate nursing diagnoses?
- including signs/symptoms (def. characteristics) and etiology
(related factors)
§ 
§ 
effective nursing interventions = specific to the
identified etiology? (including planning and implementation)
measurable, achievable nursing outcomes,
describing the improvement in patients?
M. Müller-Staub, Promotion Paans, Feb. 2011
10
5
Implementations and study designs
case meetings on all
• Introductory class and eight
wards – duration of implementation: 1 year.
Pre-post implementation design
• Introductory class and 6 case study sessions for
12 multiplicators (1st year), coaching (2nd year):
Descriptive evaluation study /qualitative interviews
• Guided clinical reasoning v.s. case studies on
wards (3 months): Cluster randomized,
controlled experimental design)
11
Some research results……
•  „Without diagnoses no meaningful care!“
•  „Using classifications (D/I/O) enhanced my
professional role and understanding“
•  „I focus more on individual care needs“
•  „My communication changed: I‘m closer to
patients, know more about their problems and
needs such as anxiety, coping, nutrition, pain....
Nursing became more interesting!“
M. Müller-Staub, Promotion Paans, Feb. 2011
12
6
Results: Diagnoses exemples
Preintervention
Post-intervention
Nursing
problem
Nursing Diagnosis:
Impaired tissue integrity: Pressure ulcer, grade II
“Patient has a
decubitus at
left heel”
Etiology/related factors:
Altered circulation Mechanical (pressure, shear, friction)
Impaired physical mobility Nutritional deficit
Signs/symptoms (def. characteristics)
Distroyed tissue at left heel, 2x3 cm wide, 1mm
deep)
13
Results.... Nursing Outcomes
Pre-intervention
Nursing
outcomes
1) “Skin still
read, small
tissue
damage”.
Post-intervention
Nursing outcomes
1)  „Tissue integrity/observable healing with
epithelized, dry, irritation- and odorless skin, free
of pain
2)  Unimpaired mobility of joint
3)  Improved self-care ability = patient performs skin
observation and care, changes of position, mobility
and constant pressure free positioning of heel 4)  Patient can explain her condition, the etiology
(pressure, immobility, nutritional status and
meaning of risk management). 14
7
Results, other: exemples of diagnoses...
Pre-intervention
Post-intervention
Nursing problem
Nursing Diagnosis
Urinary incontinence, total. includ.signs/symt. + etiol. fact.
Urinary incontinence;
no PES
Hopelessness
includ.signs/symt. + etiol. fact.
•  -----
Anxiety
includ.signs/symt. + etiol. fact.
•  -----
Coping, ineffective includ.signs/symt. + etiol. fact.
•  ----
Confusion, acute includ.signs/symt. + etiol. fact.
•  Confusion, no PES
Sensory Perception, impaired (visuel, kinesthetic)
•  ----
Risk for falling
includ.signs/symt. + etiol. fact.
•  Risk for falling:
sometimes…
15
Nursing interventions and outcomes
4.00
3.00
2.00
A
1.00
0.00
1
2
ZEITPUNKT
Mittelwert Ergebnis
Mittelwert Intervention
4.00
3.00
2.00
A
1.00
A
S
S
0.00
1
2
ZEITPUNKT
T- Tests + Mann Whitney Significance Tests p < 0.0001
8
Results
PreMean (SD)
post-intervention
2.69 (SD = .90)
3.13 (SD = .89)
3.70 (SD = .54) *
2.97 (SD = .80)
Nursing interventions
Intervention group
2.33 (SD = .93)
Control group
2.70 (SD = .88)
3.88 (SD = .35) *
2.46 (SD = .95
Nursing outcomes
Intervention group
Control group
3.77 (SD = .53) *
1.94 (SD = 1.06)
Nursing diagnoses
Intervention group
Control group
1.53 (SD= 1.08)
2.02 (SD = 1.27)
Intervention group: t-Tests p < 0.0001
Nursing outcomes
5
4
110
106
85
108
72
73
47
3
70
2
14
16
11
2
STATION
26
32
CX2
109
Y9
MEANERG
1
402
393
0
400
399
398
-1
N=
37
37
37
37
1
37
37
37
V6
25
Z2
XX2
N2
37
37
37
37
37
2
ZEITPUNK
T-Tests und Mann Whitney Signifikanz Test p < 0.0001 17
9
Classifications = Quality improvement
After implementing nursing diagnoses (NANDA-I):
- Assessments/diagnoses
- Nursing interventions
- Patient outcomes
accurate
effective
enhanced
(Björwell et al, 2002; Curell & Urquart 2003; Daly 2002; Müller-Staub 2007; Müller-Staub et al. 2007, 2008, 2009)
Nurses: Significantly better knowledge
Nurses: Significantly higher satisfaction
- Diagnoses, interventions + - outcomes effective
- Measuring workload and staffing levels
- Grade und Skill-Mix
(Keenan et al, 2008)
EHR requirements
•  Concept oriented (knowledge based) classifications
•  Standardized, research-based language to represent
the unique function of nursing
•  Standardization and coding of concepts
•  Include full NNN into EHRs, PES-Format and
Indicators
•  Apply nursing process based on classifications:
link diagnoses, interventions and outcomes
•  Intelligent expert systems: Decision support
= Individualized, evidence-based care
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10
POC Episode
Hx
Episode of Care Hx
NOC Outcomes
11
NANDA out of Total EOL Episodes (1425)
0.4
0.35
0.3
Percentage
0.25
0.2
0.15
0.1
0.05
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Datenreihe1
0.3586
0.32
0.2996
0.226
0.2077
0.2042
0.1811
0.1733
0.1411
0.1368
0.1319
0.113
0.1088
0.1039
0.0933
NANDA_Label_Name
1. Death Anxiety
Acute Pain
Impaired Gas Exchange
Anticipatory Grieving
Risk For Falls
Deficient Knowledge
Impaired Physical Mobility
Activity Intolerance
Deficient Fluid Volume
Imbalanced Nutrition: Less
Than Body Requirements
Impaired Skin Integrity
Ineffective Health
Maintenance
Ineffective Tissue Perfusion
(Renal, Cerebral,
Cardiopulmonary,
Gastrointestinal,
Peripheral)
Chronic Pain
Risk for Aspiration
12
Including NDx with DRGs
Sample: 123‘241 patients
•  Nursing diagnoses significantly associated
with DRGs (p ≤ 0.0001)
•  By adding nursing diagnoses to DRGs the explanatory power (R2) and model
discrimination (c statistic) improved by 30 % - 146 %
07.02.12
Pflege PBS, M. Müller Staub, PhD
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DRGs & Nursing diagnoses
Variables explained by Nursing Diagnoses
•  Lenght of stay (LOS): 30 %
•  ICU length of stay: 72.5 %
•  Probably of death: 115 % •  Discharge to nursing home: 146.4 %
•  Total charges (costs): 40.3 %
(Welton & Halloran, 2005)
07.02.12
Pflege PBS, M. Müller Staub, PhD
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13
Nursing Related Groups (NRG) explain overall care needs in concordance with DRGs
(Fischer, 2002)
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Bakken, S.; Holzemer, W.L.; Portillo, C.; Grimes, R.; Welch, J.; Wantland, D.: Utility of a standardized nursing terminology to evaluate
dosage and tailoring of an HIV/AIDS adherence intervention. Journal of Nursing Scholarship, 2005, 37: 251-257.
Björvell, C.; Wredling, R.; Thorell-Ekstrand, I.: Long-term increase in quality of nursing documentation: Effects of a comprehensive
intervention. Scandinavian Journal of Caring Sciences, 2002, 16: 34-42.
Boyd, A. D., Funk, E. A., Schwartz, S. M., Kaplan, B., & Keenan, G. M. (2010). Top EHR challenges in light of the stimulus. Enabling
effective interdisciplinary, intradisciplinary and cross-setting communication. Journal of Healthcare Information Management:
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Brokel, J.M.; Nicholson, C.: Care planning with the electronic problem list and care set functions. International Journal of Nursing
Terminologies and Classifications, 2006, 17: 21-22.
Delaney, C.; Herr, K.; Maas, M.; Specht, J.: Reliability of nursing diagnoses documented in a computerized nursing information
system. Nursing Diagnosis, 2000, 11: 121-134.
Doenges, M.E.; Moorhouse, M.F.; Geissler-Murr, A.C.: Pflegediagnosen und Massnahmen. Huber, Bern, 2011.
Gordon, M.; Müller Staub, M.; Georg, J.: Bewusstsein für den pflegediagnostischen Prozess entwickeln. Krankenpflege, 2005, 4:
14-16.
Keenan, G., Tschannen, D., & Wesley, M. L. (2008). Standardized nursing teminologies can transform practice. Jona, 38(3), 103-106.
Lunney, M.: Arbeitsbuch Pflegediagnostik: Pflegerische Entscheidungsfindung, kritisches Denken und diagnostischer Prozess –
Fallstudien und -analysen. Huber, Bern, 2007.
Lunney, M.; Delaney, C.; Duffy, M.; Moorhead, S.; Welton, J.: Advocating for standardized nursing languages in electronic health
records. Journal of Nursing Administration, 2005, 35: 1-3.
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20-23.
Müller-Staub, M.: Evaluation of the implementation of nursing diagnostics: A study on the use of nursing diagnoses, interventions and
outcomes in nursing documentation. Ponsen & Looijen, Wageningen, 2007.
Müller-Staub, M.: Evaluatie van de implementatie van verpleegkundige diagnostiek: Een onderzoek naar het gebruik van
verpleegkundige diagnoses, interventies en uitkomsten in de verpleegkundige verslaglegging. Verpleegkunde, 2008a, 23: 62-68.
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Müller-Staub, M.: Förderung der Pflegediagnostik und ihr Beitrag zu patientenorientierten Kostenmodellen. In: Oggier, W.; Walter, A.;
Reichlin, S.; Egli, M. (Hrsg.): Handbuch Gesundheitswesen Schweiz im Umbruch. Trend Care AG, eHealthCare.ch, Sursee,
2008b, 1-8.
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www.pflege-pbs.ch
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Conclusions/Recommendations
•  Significant quality improvements by using
classifications
•  Implement NNN into EHRs
•  Include linkages: diagnoses, interventions,
outcomes into EHR
•  Interactive, automated nursing assessements and reports
•  Include Nursing Diagnoses to
DRG-based funding models
THANK YOU!
Literature: www.pflege-pbs.ch
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Measurement Instrument Q-DIO
Content validity: Expert validation 100% agreement on key-concepts and items
88.25 % interrater agreement on scores given
Internal consistency: Cronbach’s alpha < 0.83
•  Nursing Diagnoses as Process = 0.83
•  Nursing Diagnoses as Product = 0.97
•  Nursing Interventions = 0.90
•  Nursing Outcomes = 0.98
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4 3
Nursing sensitive patient outcomes
23.
2 1 0
Acute, changing diagnoses are assessed daily or form shift to shift / enduring diagnoses
are assessed every fourth day
24.
The nursing diagnosis is reformulated
25.
The nursing outcome is documented
26.
The nursing outcome is observably /measurably documented according to NOC
27.
The nursing outcome shows
- improvement in patient’s symptoms
- improvement of patient’s knowledge state
- improvement of patient’s coping strategies
- improved self-care abilities
- improvement functional status
28.
There is a relationship between nursing sensitive patient outcomes and nursing interventions
29.
Nursing outcomes and nursing diagnoses are internally related
7 Items, maximus score = 28, mean = 4
Total Items 29
32
16
Measurement Instrument Q-DIO
5-point scale
Nursing diagnoses as product
12.
Nursing problem/nursing diagnosis label is documented
13.
Nursing diagnosis label is formulated according to NANDA and numbered
14.
The etiology (E) is documented
15.
The etiology (E) is correct, related /corresponding to the nursing diagnosis (P)
16.
Signs and symptoms are formulated
17.
Signs and symptoms (S) are correctly related to the nursing diagnosis (P)
18.
The nursing goal relates /corresponds to the nursing diagnosis
19.
The nursing goal is achievable through nursing interventions
4 3
2 1 0
4 3
2 1 0
8 Items, maximum score = 32, mean = 4
Nursing interventions
20.
Concrete, clearly named nursing interventions according to NIC are planned
(what will be done, how, how often, who does it)
21.
The nursing interventions effect the etiology of the nursing diagnosis
22.
Nursing interventions carried out, are documented (what was done, how, how often, who
did it)
3 Items, maximum score = 12, mean = 4
33
17