Creative Nursing, Volume 15, Number 1, 2009 Work Complexity Assessment, Nursing Interventions Classification, and Nursing Outcomes Classification: Making Connections Cindy A. Scherb, PhD, RN Alice P. Weydt, MS, RN When nurses understand what interventions are needed to achieve desired patient outcomes, they can more easily defi ne their practice. Work Complexity Assessment (WCA) is a process that helps nurses to identify interventions performed on a routine basis for their specifi c patient population. This article describes the WCA process and links it to the Nursing Interventions Classifi cation (NIC) and the Nursing Outcomes Classifi cation (NOC). WCA, NIC, and NOC are all tools that help nurses understand the work they do and the outcomes they achieve, and that thereby acknowledge and validate nursing s contribution to patient care. Cindy A. Scherb, PhD, RN, is a professor in the Graduate Nursing Programs at Winona State University; a clinical nurse researcher at the Mayo Clinic in Rochester, Minnesota; and a fellow in the Center for Nursing Classifi cation and Clinical Effectiveness at the University of Iowa. Her research areas include the effectiveness of nursing interventions and nursing contextual variables on patient outcomes. Alice P. Weydt, MS, RN, is a consultant with Creative Health Care Management. shortage of nurses in the United States has been documented since 1998 A (Ulrich, Buerhaus, Donelan, Norman, & Dittus, 2005). A nursing workforce that is aging (Ulrich et al., 2005), an aging population with increasing needs for health care services (American Association of Colleges of Nursing [AACN], 2008; Ulrich et al., 2005), and the inability of colleges and universities to meet growing nursing enrollment needs (AACN) have been cited as major reasons for this shortage. The shortage has taken on new significance in light of the Institute of Medicine reports on quality and patient safety (Institute of Medicine, n.d.) and descriptions of the work environment (Ulrich et al., 2005). In this time of scarce resources, it is important to address the complexity of the work that nurses do, the outcomes of this work, and the interventions used to achieve these outcomes. Patient satisfaction, the ultimate outcome of care (Donabedian, 1966), is a crucial concern for nurses and, for some health care institutions, is tied to reimbursement (Centers for Medicare and Medicaid, 2008). The nursing profession has developed tools to describe nursing practice and patient outcomes. When nurses understand what interventions are needed to achieve desired patient outcomes, they can more easily define their practice. Work Complexity Assessment (WCA) is a process that helps nurses identify interventions performed on a routine basis for their specific patient population, using the Nursing Interventions Classification (NIC) system described below. Nursing Outcomes Classification (NOC) is a system that measures nursing-sensitive patient outcomes. The purpose of this article is to link the WCA process to NIC and NOC. 16 2009 Springer Publishing Company DOI: 10.1891/1078-4535.15.1.16
WORK COMPLEXITY ASSESSMENT WCA was developed in the 1980s by consultants from Creative Health Care Management to help nurses assess the delegation potential of specific tasks in order to maximize scarce nursing resources during a severe nursing shortage. Infused with professional practice concepts that focus on delegation, WCA addresses the fit between the work and the individuals performing it. WCA helps unit staffs define professional practice and delineate the time, skills, and knowledge needed to perform specific interventions within various categories or domains of care. Nurses identify interventions and activities in each domain that are performed for their particular unit s patient population. This identification process can be specific to nursing or can include the interdisciplinary team that cares for an identified patient population. NURSING INTERVENTIONS CLASSIFICATION The Nursing Interventions Classification (NIC) was developed in 1987 at the University of Iowa College of Nursing to describe nursing interventions performed on behalf of patients/clients. These interventions include direct and indirect care activities, nurse-initiated treatments, and physician-initiated treatments. NIC is comprehensive and thus can be used by all specialty areas in a variety of settings and by all levels of practitioners (Bulechek, Butcher, & Dochterman, 2008). The current NIC contains 542 interventions within a taxonomy of seven domains (physiological: basic, physiological: complex, behavioral, safety, family, health systems, and community) and 30 classes (Bulechek et al., 2008). NIC defines a nursing intervention as any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes (Bulechek et al., 2008, p. 3). Each intervention includes a definition, a list of activities (specific behaviors or actions that need to be completed to implement the intervention), and background readings (Bulechek et al., 2008). In this time of scarce resources, it is important to address the complexity of the work that nurses do, the outcomes of this work, and the interventions used to achieve these outcomes. NURSING OUTCOMES CLASSIFICATION The Nursing Outcomes Classification (NOC) system was developed in 1997 by the University of Iowa College of Nursing to conceptualize, label, define, and classify patient outcomes and indicators sensitive to nursing care (Iowa Outcomes Project, 2000). The current classification system contains 385 nursing-sensitive patient outcomes within a taxonomy of seven domains (functional health, physio logic health, psychosocial health, health knowledge and behavior, perceived health, family health, and community health) and 31 classes (Moorhead, Johnson, Maas, & Swanson, 2008). A nursing-sensitive patient outcome is defined as an individual, family, or community state, behavior, or perception that is measured along a continuum in response to nursing intervention(s) (Moorhead et al., p. 30). Each outcome is defined more specifically by a group of associated indicators (observables needed to measure an outcome). Indicators reflect different dimensions or aspects of the more general outcome label; they are more specific outcomes that are especially useful for tracking responses to treatment during an active provider/ patient relationship (Iowa Outcomes Project, 2000). All outcome labels and indicators have an associated measurement scale or scales. A 5-point Likert scale is used for measurement, with 5 always the most desired state. It is recommended that an Making Connections 17
Infused with professional practice concepts that focus on delegation, WCA addresses the fi t between the work and the individuals performing it. outcome be measured at least on admission and at discharge or transfer to another unit or setting (Moorhead et al., 2008). THE WCA PROCESS WCA begins with the patient care unit or service completing and reviewing the Nursing Management Minimum Data Set (NMMDS) (Delaney & Huber, 1996). The NMMDS gives an overview of patient care unit characteristics (e.g., patient/ client population, nursing care staff demographic profile, average daily census, patient care hours, and ancillary support services). During this process, a discussion of how patient care needs are communicated (e.g., the use of care plans), the relationships within the nursing and the interdisciplinary team, decision-making authority, and a review of the staffing patterns are completed. WCA uses NIC to describe the interventions performed for a unit s patient population in a typical 24-hour period. The members of the patient care staff identify the NIC domains (major care categories), classes (subcategories of the major care categories), and interventions (within the classes of care) typically performed for their patient populations. Once the interventions are identified, the knowledge and skills required to perform the interventions are determined. The activities of the intervention are analyzed and subdivided into tasks or into actions requiring critical thinking. This analysis is needed to determine which pieces of the work can be delegated and how this delegation is supported by the state s Nurse Practice Act. Time spent performing the interventions within each domain is then determined. The two domains in which nurses typically spend the majority of their time are the physiological: complex domain and the health system domain. THE VALUE OF THE WCA PROCESS IN IMPROVING PRACTICE As nurses describe their interventions, they begin to understand how work can be done differently. Many have never questioned the rationale behind the way the work is done. The quality and value of time spent in documentation improves as nurses begin to recognize how this affects their time with patients. Using NIC and NOC in the care planning process can become a framework for documentation and create a clearly defined roadmap for others to follow, thus enhancing communication. When WCA is completed, nurses make recommendations to improve their practice based on what they have learned. Often the nurses want to limit the time spent on documentation, spending it instead on interpersonal interventions that build relationships between the staff, patient, and patient s family. They begin to explore ways to collaborate more effectively with other disciplines that also play an important role in patient care. They also begin to realize how interpersonal relationships among the members of the care teams affect how delegation is done. 18 Scherb and Weydt CONNECTING PROCESS TO OUTCOMES At this time, the WCA process incorporates NIC. We believe that there is an opportunity to take this process one step further and link the NIC interventions to NOC,
which connects nursing practice elements to patient outcomes. Patient satisfaction is a global outcome of care received and is important for nursing to monitor. Hospitals measure patient satisfaction through a variety of methods ranging from individual patient feedback to external surveying processes (Ford, Bach, & Fottler, 1997). Much attention is given to the results, with repeated efforts to raise patient satisfaction scores. Often, staff members do not understand how their individual behavior and their practice norms are perceived by patients and families and how that perception is reflected in satisfaction surveys. Nurses need to be more aware of patient perceptions and of how to meet patients needs (Chang, 1997). Patients and families expect the staff caring for them to be competent (Larrabee & Bolden, 2001), but what is important to them is the staff members interpersonal skills (their ability to interact with patients and families), their attitude, and the caring behavior they exhibit. It is these factors that often determine patients overall satisfaction with their hospitalization and the likelihood that they would recommend the hospital to others (Creative Health Care Management, 2006). NRC Picker, an organization that develops and implements tools to measure the quality of patient care, has identified several health success factors, including an orientation to care that encompasses the mind/body/spirit, a willingness to involve patients and families in determining their care, and the development of a healer/ caregiver relationship (Creative Health Care Management, 2006). If these elements are what patients and families want, then nursing needs to identify how they are reflected in daily practice. NOC includes an overall client satisfaction outcome with 17 specific elements. NOC defines client satisfaction as the extent of positive perception of care provided by the nursing staff (Moorhead et al., 2008, p. 247). The outcome is measured on a scale from 1 (not at all satisfied) to 5 (completely satisfied). We selected this outcome as a tool to evaluate the results of what nurses report that they perform in their practice on a daily basis. The quality and value of time spent in documentation improves as nurses begin to recognize how this affects their time with patients. WCA DATA FROM 17 MEDICAL-SURGICAL UNITS LINKED TO NOC INDICATORS Table 1 represents the time nurses spent in each of the domains with a corresponding NIC class and NIC interventions. These are then linked to the NOC client satisfaction indicators. The first column is based on the average time spent in each NIC domain by each hospital cluster based on the WCA findings. For instance, WCA 1, a cluster of several units within the same organization, spent an average of 3 hours in a 12-hour shift performing interventions in the physiological: basic domain. Column 2 is the NIC class, or major category of interventions, most often performed. Column 3 lists the interventions used most often when working in the corresponding class. Column 4 is the indicator under the client satisfaction outcome that corresponds to the NIC interventions. Every indicator for the NOC client satisfaction outcome is mapped to an NIC intervention. Organizations could link these NOC indicators to their current patient satisfaction tool. This information would be valuable in raising nurses awareness of how their interventions influence patient perceptions. As the nurses in the WCA sessions analyzed the results, they realized that nursing interventions affect patient satisfaction. One nurse commented on the time actually spent on patient education: I can t believe we spend so little time doing this and usually do it as we are doing other Making Connections 19
TABLE 1. Crosswalk of WCA Findings, NIC, and NOC Client Satisfaction Indicators Hours Spent Within NIC Domains in a 24-Hour Period NIC Class NIC Intervention Client Satisfaction Outcome Indicators Physiological: Basic Domain WCA Group 1 6 WCA Group 2 5.4 WCA Group 3 5.18 WCA Group 4 4 WCA Group 5 2.7 WCA Group 6 5.28 WCA Group 7 3.12 WCA Group 8 6.84 Activity and exercise Elimination Physical comfort promotion Self-care facilitation Physiological: Complex Domain WCA Group 1 9.36 WCA Group 2 8.04 WCA Group 3 4.7 WCA Group 4 8.52 WCA Group 5 7.8 WCA Group 6 8.88 WCA Group 7 7.8 WCA Group 8 8.58 Behavioral Domain WCA Group 1 3.76 WCA Group 2 2.88 WCA Group 3 1.74 WCA Group 4 4.56 WCA Group 5 4.2 WCA Group 6 4.08 WCA Group 7 4.8 WCA Group 8 3.78 Drug Perioperative care Tissue perfusion Communication enhancement Coping assistance Patient education Exercise therapy: ambulation Bowel Urinary elimination Nausea/vomiting Pain Self-care assistance Bathing/hygiene Drug administration Preoperative Coordination Surgical assistance Postanesthesia care Bleeding precautions Cardiac care Intravenous insertion Intravenous therapy Complex relationship building Active listening Spiritual support Emotional support Presence Truth telling Teaching: disease process Teaching: individual Assistance to achieve mobility Care to maintain body functions Relief of symptoms of illness Care to control pain Assistance to achieve self care Care to maintain cleanliness Concern for the client by the nursing staff Integration of values into nursing care Assistance with spiritual concerns Assistance with emotional concerns Access to nursing staff Questions answered completely Instructions to improve understanding of illness Instructions to improve participation in care 20 Scherb and Weydt
TABLE 1. (Continued ) Hours Spent Within NIC Domains in a 24-Hour Period NIC Class NIC Intervention Client Satisfaction Outcome Indicators Safety and Health System Domains WCA Group 1 5.88 WCA Group 2 7.22 WCA Group 3 6.62 WCA Group 4 6.4 WCA Group 5 9.3 WCA Group 6 5.76 WCA Group 7 7.2 WCA Group 8 4.8 Family Domain Included in Behavioral Domain Risk Health system Health system mediation Environmental Surveillance: safety Supply Staff development Patient rights protection Cultural brokerage Discharge planning Cleanliness of care environment Care to prevent harm or injury Access to equipment/ supplies for care Competence/knowledge and expertise of nursing staff Protection of legal/ human rights by nursing staff Integrating values and nursing care Coordination of care as the client moves from one setting to another Client/family included in discharge planning Lifespan care Family support Concern for the family by nursing staff things. This might make the patient feel like I am rushed. Another nurse stated, Look at how much time is spent documenting. I need to get comfortable doing this at the bedside instead of leaving the patient s room. A third nurse said, I want to be present and need to think about how I behave when I am with a patient. CONCLUSION Nurses need to look at how they can do things differently. We need to identify the pertinent interventions and activities that registered nurses perform while utilizing their critical thinking skills, as distinct from tasks that can be completed by unlicensed assistive personnel. WCA, NIC, and NOC are all tools that enable nurses to understand the work they do and the outcomes they achieve, thereby acknowledging and validating nursing s contribution to patient care. REFERENCES American Association of Colleges of Nursing. (2008). Nursing shortage fact sheet. Retrieved September 11, 2008, from http://www.aacn.nche.edu/media/factsheets/ NursingShortage.htm We need to identify the pertinent interventions and activities that registered nurses perform while utilizing their critical thinking skills, as distinct from tasks that can be completed by unlicensed assistive personnel. Making Connections 21
Bulechek, G. M., Butcher, H. K., & Dochterman, J. M. (Eds.). (2008). Nursing Interventions Classification (NIC) (5th ed.). St. Louis, MO: Mosby Elsevier. Centers for Medicare and Medicaid. (2008). HCAHPS: Patients perspectives of care survey. Retrieved September 11, 2008, from http://www.cms.hhs.gov/hospitalquality Inits/30_HospitalHCAHPS.asp Chang, K. (1997). Dimensions and indicators of patients perceived nursing care quality in the hospital setting. Journal of Nursing Care Quality, 11 (6), 26 37. Creative Health Care Management. (2006). Relationship- Based Care leader practicum. Minneapolis: Author. Delaney, C., & Huber, D. (1996). A Nursing Management Minimum Data Set (NMMDS): A report of an invitational conference. Chicago: Monograph of the American Organization of Nurse Executives. Donabedian, A. (1966). Evaluating the quality of medical care. Milbank Memorial Fund Quarterly, 44, 166 203. Ford, R. C., Bach, S. A., & Fottler, M. D. (1997). Methods of measuring patient satisfaction in healthcare organizations. Health Care Management Review, 22 (2), 74 89. Institute of Medicine. (n.d.). About the Institute of Medicine: Advising the nation. Improving health. Retrieved September 22, 2008, from http://www.iom.edu/object.file/ Master/36/931/IOM-BROCHURE-FINAL.pdf Iowa Outcomes Project. (2000). Nursing Outcomes Classification (NOC) (2nd ed.). St. Louis, MO: Mosby. Larrabee, J. H., & Bolden, L. V. (2001). Defining patient-perceived quality of nursing care. Journal of Nursing Care Quality, 16 (1), 34 60. Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (Eds.). (2008). Nursing Outcomes Classification (NOC) (4th ed.). St. Louis, MO: Mosby Elsevier. NRC Picker. Retrieved September 22, 2008, from www.nrcpicker.com Ulrich, B. T., Buerhaus, P. I., Donelan, K., Norman, L., & Dittus, R. (2005). How RNs view the work environment: Results of a national survey of registered nurses. Journal of Nursing Administration, 35 (9), 389 396. Correspondence regarding this article should be directed to Cindy A. Scherb, PhD, RN, at cscherb@winona.edu or Alice P. Weydt at aweydt@chcm.com 22 Scherb and Weydt