Standardization of Health Care Terminologies

16 © 2009 Springer Publishing Company DOI: 10.1891/1078-4535.15.1.16

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 out- comes, 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.

A shortage of nurses in the United States has been documented since 1998 (Ulrich, Buerhaus, Donelan, Norman, & Ditt us, 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 grow- ing nursing enrollment needs (AACN) have been cited as major reasons for this shortage. The shortage has taken on new signifi cance 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 (Do- nabedian, 1966), is a crucial concern for nurses and, for some health care institu- tions, 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 defi ne their practice. Work Complexity Assessment (WCA) is a process that helps nurses identify interventions performed on a routine basis for their specifi c patient population, using the Nurs- ing Interventions Classifi cation (NIC) system described below. Nursing Outcomes Classifi cation (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.

Cindy A. Scherb, PhD, RN, is a profes- sor in the Graduate Nursing Programs at Winona State Univer- sity; a clinical nurse re- searcher at the Mayo Clinic in Rochester, Minnesota; and a fel- low in the Center for Nursing Classifi cation and Clinical Effective- ness at the University of Iowa. Her research areas include the ef- fectiveness of nurs- ing interventions and nursing contextual variables on patient outcomes.

Alice P. Weydt, MS, RN, is a consultant with Creative Health Care Management.

Making Connections 17

WORK COMPLEXITY ASSESSMENT

WCA was developed in the 1980s by consultants from Creative Health Care Man- agement to help nurses assess the delegation potential of specifi c 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 fi t be- tween the work and the individuals performing it. WCA helps unit staff s defi ne professional practice and delineate the time, skills, and knowledge needed to per- form specifi c 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 identifi cation process can be specifi c to nursing or can include the interdisciplinary team that cares for an identifi ed pa- tient population.

NURSING INTERVENTIONS CLASSIFICATION

The Nursing Interventions Classifi cation (NIC) was developed in 1987 at the Uni- versity 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 sett ings and by all levels of practitioners (Bulechek, Butcher, & Dochterman, 2008). The cur- rent NIC contains 542 interventions within a taxonomy of seven domains (physi- ological: basic, physiological: complex, behavioral, safety, family, health systems, and community) and 30 classes (Bulechek et al., 2008).

NIC defi nes a nursing intervention as “any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client out- comes” (Bulechek et al., 2008, p. 3). Each intervention includes a defi nition, a list of activities (specifi c behaviors or actions that need to be completed to implement the intervention), and background readings (Bulechek et al., 2008).

NURSING OUTCOMES CLASSIFICATION

The Nursing Outcomes Classifi cation (NOC) system was developed in 1997 by the University of Iowa College of Nursing to conceptualize, label, defi ne, and classify patient outcomes and indicators sensitive to nursing care (Iowa Outcomes Proj- ect, 2000). The current classifi cation 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 defi ned as “an individual, family, or community state, behavior, or perception that is measured along a con- tinuum in response to nursing intervention(s)” (Moorhead et al., p. 30).

Each outcome is defi ned more specifi cally by a group of associated indicators (observables needed to measure an outcome). Indicators refl ect diff erent dimensions or aspects of the more general outcome label; they are more specifi c outcomes that are especially useful for tracking responses to treatment during an active provider/ patient relationship (Iowa Outcomes Project, 2000). All outcome labels and indica- tors 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

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.

18 Scherb and Weydt

outcome be measured at least on admission and at discharge or transfer to another unit or sett ing (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 profi le, average daily census, patient care hours, and ancillary support services). During this process, a discus- sion 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 staffi ng patt erns 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 identifi ed, 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 deter- mined. 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 diff erently. 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 aff ects their time with patients. Using NIC and NOC in the care planning process can become a framework for documenta- tion and create a clearly defi ned 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. Oft en 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 eff ectively with other disciplines that also play an important role in patient care. They also begin to realize how interpersonal rela- tionships among the members of the care teams aff ect how delegation is done.

CONNECTING PROCESS TO OUTCOMES

At this time, the WCA process incorporates NIC. We believe that there is an oppor- tunity to take this process one step further and link the NIC interventions to NOC,

Infused with

professional

practice concepts

that focus on

delegation, WCA

addresses the fi t

between the work

and the individuals

performing it.

Making Connections 19

The quality

and value of

time spent in

documentation

improves as

nurses begin

to recognize

how this affects

their time with

patients.

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, & Fott ler, 1997). Much att ention is given to the results, with repeated eff orts to raise patient satisfaction scores. Oft en, staff members do not understand how their in- dividual behavior and their practice norms are perceived by patients and families and how that perception is refl ected 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 (Larra- bee & Bolden, 2001), but what is important to them is the staff members’ interper- sonal skills (their ability to interact with patients and families), their att itude, and the caring behavior they exhibit. It is these factors that oft en 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 identifi ed 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 refl ected in daily practice.

NOC includes an overall client satisfaction outcome with 17 specifi c elements. NOC defi nes client satisfaction as the “extent of positive perception of care pro- vided by the nursing staff ” (Moorhead et al., 2008, p. 247). The outcome is mea- sured on a scale from 1 (not at all satisfi ed) to 5 (completely satisfi ed). We selected this outcome as a tool to evaluate the results of what nurses report that they per- form in their practice on a daily basis.

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 cor- responding NIC class and NIC interventions. These are then linked to the NOC client satisfaction indicators. The fi rst column is based on the average time spent in each NIC domain by each hospital cluster based on the WCA fi ndings. For in- stance, 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 oft en performed. Column 3 lists the interventions used most oft en 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 satisfac- tion tool. This information would be valuable in raising nurses’ awareness of how their interventions infl uence patient perceptions. As the nurses in the WCA sessions analyzed the results, they realized that nursing interventions aff ect patient satisfac- tion. One nurse commented on the time actually spent on patient education: “I can’t believe we spend so litt le time doing this and usually do it as we are doing other

20 Scherb and Weydt

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 management

Exercise therapy: ambulation

Assistance to achieve mobility

Elimination management

Bowel management Urinary elimination

management

Care to maintain body functions

Physical comfort promotion

Nausea/vomiting management

Pain management

Relief of symptoms of illness

Care to control pain Self-care

facilitation Self-care assistance Bathing/hygiene

Assistance to achieve self care

Care to maintain cleanliness

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

Drug management

Perioperative care

Tissue perfusion management

Drug administration

Preoperative Coordination

Surgical assistance Postanesthesia care Bleeding precautions Cardiac care Intravenous

insertion Intravenous therapy

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

Communication enhancement

Complex relationship building

Active listening

Concern for the client by the nursing staff

Integration of values into nursing care

Coping assistance

Spiritual support Emotional support Presence Truth telling

Assistance with spiritual concerns

Assistance with emotional concerns

Access to nursing staff Questions answered

completely Patient

education Teaching: disease

process Teaching:

individual

Instructions to improve understand- ing of illness

Instructions to im- prove participation in care

Making Connections 21

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

Risk management

Environmental management

Surveillance: safety

Cleanliness of care environment

Care to prevent harm or injury

Health system management

Supply management

Staff development

Access to equipment/ supplies for care

Competence/knowl- edge and expertise of nursing staff

Health system me- diation

Patient rights protection

Cultural brokerage Discharge planning

Protection of legal/ human rights by nursing staff

Integrating values and nursing care

Coordination of care as the client moves from one sett ing to another

Client/family included in discharge planning

Family Domain Included in Behavioral Domain

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 diff erently. We need to identify the pertinent interventions and activities that registered nurses perform while utiliz- ing their critical thinking skills, as distinct from tasks that can be completed by un- licensed assistive personnel. WCA, NIC, and NOC are all tools that enable nurses to understand the work they do and the outcomes they achieve, thereby acknowl- edging and validating nursing’s contribution to patient care.

REFERENCES

American Association of Colleges of Nursing. (2008). Nursing shortage fact sheet. Re- trieved September 11, 2008, from htt p://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.

22 Scherb and Weydt

Bulechek, G. M., Butcher, H. K., & Dochterman, J. M. (Eds.). (2008). Nursing Interventions Classifi cation (NIC) (5th ed.). St. Louis, MO: Mosby Elsevier.

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Chang, K. (1997). Dimensions and indicators of patients’ perceived nursing care quality in the hospital sett ing. Journal of Nursing Care Quality, 11 (6), 26–37.

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Donabedian, A. (1966). Evaluating the quality of medical care. Milbank Memorial Fund Quar- terly, 44, 166–203.

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Institute of Medicine. (n.d.). About the Institute of Medicine: Advising the nation. Im- proving health. Retrieved September 22, 2008, from htt p://www.iom.edu/Object.File/ Master/36/931/IOM-BROCHURE-FINAL.pdf

Iowa Outcomes Project. (2000). Nursing Outcomes Classifi cation (NOC) (2nd ed.). St. Louis, MO: Mosby.

Larrabee, J. H., & Bolden, L. V. (2001). Defi ning 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 Classifi cation (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., & Ditt us, 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 [email protected] or Alice P. Weydt at [email protected]