NCVHS Hearings on Medical Terminology and Code Development
May 18, 1999
Rockville, Maryland
Health care providers no matter their specialty are struggling to maintain quality patient care while holding down or decreasing the costs of health care. This environment has made outcomes of care a key concern and a focus for individuals and organizations that provide health care to individuals, families, and communities. To date no reliable, comprehensive system for measuring outcomes has been developed that captures the variety of nursing specialties and allows information about patients to cross different health care settings. To measure outcomes effectively a classification system that is useful across settings is needed so that the outcome can be followed over time regardless of the location of the patient.
The Nursing Outcomes Classification (NOC) is a comprehensive, standardized classification of patient/client outcomes developed to evaluate the effects of nursing interventions. Standardized outcomes are necessary for documentation in electronic records, for use in clinical information systems, and for the development of nursing knowledge and the education of professional nurses. In this classification an outcome is stated as a variable concept representing an individual, family, or community condition that is measurable along a continuum and responsive to nursing interventions. The outcomes are developed for use in all settings and with all patient populations. Since the outcomes describe patient/client status, other disciplines may find them useful for the evaluation of their interventions.
NOC, first published in 1997, contains 190 outcomes listed in alphabetical order. Each outcome has a definition, a list of indicators that can be used to evaluate patient status in relation to the outcome, a five-point Likert scale to measure patient status, and a short list of references used in the development of the outcome. Examples of scales used with the outcomes are: 1=extremely compromised to 5=not compromised and 1=never demonstrated to 5=consistently demonstrated. The outcomes are developed for use across the care continuum and therefore can be used to follow patient outcomes throughout an illness episode or over an extended period of care.
A second edition of the NOC, currently in press, has 260 outcomes including individual, family, and community level outcomes as well as the taxonomy developed for this classification. The 260 outcomes are grouped into twenty-nine classes and seven domains for ease of use. The seven domains are: Functional Health, Physiologic Health, Psychosocial Health, Health Knowledge & Behavior, Perceived Health, Family Health, and Community Health. Each outcome has a unique code number that facilitates the use of the outcomes in computerized clinical information systems and the manipulation of data to answer questions about health care quality and effectiveness. The classification is continually updated to include new outcomes and to revise older outcomes based on new research or user feedback.
The research to develop NOC began with the formation of the outcomes research team in 1991and has progressed in phases.
Phase I - Pilot Work to Test Methodology (1992-1993)
Phase II -Construction of the Outcomes (1993-1996)
Phase III- Construction of the Taxonomy and Clinical Testing (1996-1997)
Phase IV- Refinement and Clinical Use (1997-2000)
Phase V - Evaluation of Measurement Scales (1998-2002)
Funding for Phase I was received from Sigma Theta Tau International and funding for Phases II through V from the National Institutes of Health, National Institute of Nursing Research. Multiple research methods have been used in the development of NOC. An inductive approach was used to develop the outcomes based on current practice and research. Concept analysis and research team review were used in the construction of the outcomes. Questionnaire surveys of expert nurses were used to assess the content validity and nursing sensitivity of the outcomes. The taxonomy was constructed using similarity/dis-similarity analysis and hierarchical clustering techniques. Feedback from clinical test sites and other sites implementing NOC have been used to identify new outcomes for development and refine current outcomes. Currently, a number of methods are being used to evaluate the reliability, validity, and sensitivity of the outcome measures in clinical sites. Clinical sites used in the study include tertiary care hospitals, community hospitals, community agencies, and a nursing home. Several tools are available to assist in the implementation of NOC. The outcomes have been linked to North American Nursing Diagnosis Association (NANDA) diagnoses, to Omaha System problems, to resident admission protocols (RAPs) used in nursing homes, and to NIC interventions.
NOC is one of the standardized languages recognized by the American Nurses’ Association (ANA). As a recognized language it meets the language guideline standards set by ANA’s Nursing Information and Data Set Evaluation Center (NIDSEC) for nursing information system vendors. NOC is included in the National Library of Medicine’s Metathesaurus for a Unified Medical Language. The Cumulative Index to Nursing Literature (CINAHL) is adding NOC to their nursing index. The use of NOC in practice, nursing education, and research is the most accurate indicator of NOC’s usefulness. NOC is being adopted in a number of clinical sites for the evaluation of nursing practice and is being used in educational settings to structure curricula and teach students clinical evaluation. Interest in NOC has been demonstrated in other countries. NOC is being translated in Dutch, French, Japanese and Spanish with other translations pending (China, Germany and Korea).
Since the publication of NOC just two years ago interest in measuring the effectiveness of nursing interventions on specific outcomes has become a key concern for nurses in all settings. Nurses are excited about measuring accurately the outcomes of the care they provide. The NOC is the only classification system to date that provides a standard vocabulary and measures for use across settings and specialties and offers nurses a key tool for making their contribution to health care visible. Our current research focuses on validating the measurement scales for 190 outcomes through implementation of NOC in 9 clinical sites across 5 states. Validation of the measures within the NOC will strengthen this classification and allow for the collection of data about the effectiveness of nursing care across settings in the future. This will allow health care providers to truly evaluate the quality of health care provided to individuals, families, and communities.
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The Nursing Outcomes Classification vocabulary is published in Johnson, M. & Maas, M. (Eds.) Nursing Outcomes Classification (NOC) published by Mosby Year Book, St. Louis. The code set for the vocabulary is available through the Center for Nursing Classification, College of Nursing, The University of Iowa, Iowa City, IA. The code set will be published in the second edition of the book Nursing Outcomes Classification (NOC) due out in the fall of 1999.
Center for Nursing Classification, College of Nursing, The University of Iowa, Iowa City, IA 52242.
Not applied for.
A. Purpose or objective.
The purpose of the Nursing Outcomes Classification (NOC) is to provide a standard language and associated measures for patient outcomes influenced by nursing practice. It is useful for clinical documentation of patient care, integration of data across the care continuum and across systems, aggregation and analysis of patient outcomes, and research that measures the outcomes of clinical practice and/or the effects of changes in system or organizational structures. The published classification contains outcomes measured at the individual level of the patient or the primary family care provider in the home. The revised edition (in press) will contain some family unit and community level outcomes.
B. Type of code set.
NOC is a classification that organizes over 190 (260 outcomes, 2nd Edition) patient outcomes and associated measures of client states, behaviors, and perceptions. Each outcome has a standardized name, definition, indicators, and measures. Each element is coded for inclusion in computerized or paper data bases. See the following example:
Knowledge: Treatment Regimen--1813
Domain-Health Knowledge & Behavior (IV)
Class-Health Knowledge (S)
Scale-None to Extensive (i)
Definition: Extent of understanding conveyed about a specific treatment regimen
| Knowledge: Treatment Regimen | None 1 | Limited 2 | Moderate 3 | Substantial 4 | Extensive 5 | |
|---|---|---|---|---|---|---|
| 181301 | Description of rationale for treatment regimen | 1 | 2 | 3 | 4 | 5 |
| 181302 | Description of self-care responsibilities for ongoing treatment | 1 | 2 | 3 | 4 | 5 |
| 181303 | Description of self-care responsibilities for emergency situations | 1 | 2 | 3 | 4 | 5 |
| 181304 | Description of expected effects of treatment | 1 | 2 | 3 | 4 | 5 |
| 181305 | Description of prescribed diet | 1 | 2 | 3 | 4 | 5 |
| 181306 | Description of prescribed medication | 1 | 2 | 3 | 4 | 5 |
| 181307 | Description of prescribed activity | 1 | 2 | 3 | 4 | 5 |
| 181308 | Description of prescribed exercise | 1 | 2 | 3 | 4 | 5 |
| 181309 | Description of prescribed procedures | 1 | 2 | 3 | 4 | 5 |
| 181310 | Description of disease process | 1 | 2 | 3 | 4 | 5 |
| 181311 | Performance of self-monitoring techniques | 1 | 2 | 3 | 4 | 5 |
| 181312 | Performance of treatment procedure | 1 | 2 | 3 | 4 | 5 |
| 181313 | Selection of foods recommended in diet | 1 | 2 | 3 | 4 | 5 |
| 181314 | Other __________________ (Specify) |
1 | 2 | 3 | 4 | 5 |
________________________________________________________________________
Iowa Outcomes Project. M. Johnson & M. Maas (Eds.). (1997). Nursing Outcomes Classification (NOC). St. Louis: Mosby.
C. Clinical topics addressed.
The clinical topic addressed is patient outcomes. The classification contains outcomes that measure aspects of: functional health (eg. mobility level, endurance), physiologic health (eg. urinary continence, tissue integrity), psychosocial health (eg. body image, aggression control), health knowledge and behavior (eg. symptom control behavior, knowledge: treatment regimen), perceived health (eg. well-being, comfort level), family health (eg. parenting, family functioning) and community health (eg. community health status, community risk control: communicable disease).
D. Domain focus.
The classification can be used in all settings and specialties in which nurses practice. Although the classification was developed for use by nurses, the outcomes measure client states, behaviors, and perceptions and therefore could be used by other disciplines.
E. How often is this code set updated or enhanced?
The classification is continually updated by the research team that developed the initial classification. The need for additional outcomes is identified through literature review, by users of the classification, and by members of the research team. The process for the development of new outcomes includes the identification of the concept describing the outcome, concept analysis to define the outcome and identify the outcome indicators, and review by clinical experts. Approximately 70 additional outcomes have been defined and developed since the classification containing 190 outcomes was published. All new outcomes will be included in the second volume of the book.
F. How are these updates or enhancements distributed?
The classification is published by Mosby Year Book in St. Louis, a second edition of the classification will be published late in 1999 or early 2000. Work completed between publications is available through the Center for Nursing Classification at Iowa. The Center maintains a list-serve with 205 subscribers where new outcomes available from the Center are periodically posted on the list-serve.
G. What is the source of funding for these updates or enhancements?
The Center for Nursing Classification is supported by the College of Nursing and by a small revenue stream from publications and products. For example, 40% of the book royalties go to the Center (for the first six months this was $3,339.87 less indexing charges and honorariums paid) as does income from a licensing agreement with Ergo, a software company using NOC in it’s software. Money from this has totaled $2,000. In the future, 40% of the money from licenses sold by Mosby will come to the Center. The National Institute of Nursing Research, NIH supported four years of funding for the development and testing of the language and is currently supporting four years of a continuation grant to further validate the outcome measures in clinical settings.
H. Are there regular user group meetings? If so, how frequently do they meet?
During the development and pilot testing of NOC regular user group meetings were held with the four agencies participating in the testing of NOC. Regular user group meetings are held with the nine agencies participating in further testing of the measures. NOC is being used in three software products, by various service organizations, and in educational settings. Approximately 22 service organizations and 5 educational institutions have contacted the Center for information about licensing NOC. Seven organizations have obtained a license for use of NOC in their information systems from Mosby. Others may be using the language without having contacted the Center. Since NOC is published, it is impossible to identify all possible users. It is not possible to have regular user group meetings due to the variety of users and financial constraints. The listserv serves as a medium of exchange among users and the Center publishes a newsletter three times a year. Information is also disseminated through conferences and workshops. Members of the research team have presented at 70 conferences and/or workshops. The Center maintains a speakers bureau whereby a member of the research team can be contracted to do a presentation for a particular group.
I. Is the code set/vocabulary copyrighted?
NOC is published and copyrighted by Mosby Year Book, St. Louis, MO. A license to use the work can be purchased through Mosby at a minimal price. See question X.
J. Does the license allow derivative works, such as the creation of a database?
The license allows organizational users to input, store, and use NOC in its information system for use at its own facilities. The user can create a database/data warehouse or other derivative work using NOC as an internal management and research tool; work derived from this use can be published. Software companies that wish to use NOC in their software can also purchase a license from Mosby that allows the inclusion of NOC in software that will be marketed and sold to healthcare organizations and systems.
K. Other relevant characteristics such as, are terms coded in a fixed structure, does it support synonyms, is it concept-oriented (that is, do codes correspond to meanings), does it include multiple hierarchies, and so forth).
The classification is a hierarchical structure that contains seven broad domains, 29 classes, 260 outcomes each with four to 20 indicators, and 16 measurement scales each with a 5-point Likert-type scale (see attached). Each of these elements is coded for inclusion in clinical information systems. The codes correspond to both concepts, (eg. the concepts in the outcomes and classes) and the location of the concepts within the classification. For example, the code for the outcome can be used without the code for the domain and class since the outcome code locates the outcome in a specific class and domain. A fixed structure is used for the codes, but it is flexible to allow for the inclusion of additional outcomes and further expansion of the classification. The fixed structure allows the user to differentiate the outcome, indicator, measurement scale used, and the patient status on the measurement scale.
L. How is this code set different from or superior to others that it may compete with?
NOC is currently the only classification of nursing-sensitive patient outcomes that contains a standard vocabulary and measures for use across settings and specialties. There is currently no direct competition for NOC. Although the first edition containing NOC wasn’t published until 1997 it’s dissemination has been rapid, partially because it provides a comprehensive vocabulary of patient outcomes for nursing practice. Although developed for use by nurses, the outcomes measure client states, behaviors, and perceptions and therefore could be used by other disciplines.
A. What portions of the code set are complete and implementable now?
The NOC is completely coded. There are codes for domain, class, outcome, indicator, and measure (See VII narrative). Thus the complete NOC is currently implementable and will continue to be so as content is added to the taxonomy.
B. What portions or versions are under development?
The classification is constantly being updated as the need for new outcomes are identified. Outcomes and indicators that characterize family and community units will be included in the NOC 2nd edition. When completed and content validated, outcomes are added to the taxonomy and coded.
C. When will these new portions or versions be published or available?
All new outcomes will be available in the second edition of Nursing Outcomes Classification, (Johnson, M., Maas, M., & Moorhead, S., Eds.) to be published by Mosby, Fall, 1999 (copyright 2000).
D. How do users obtain the code set?
Currently, the code set is obtained from the Nursing Classification Center office (Attn: Lori Penaluna, Room 407 NB, College of Nursing, The University of Iowa, Iowa City, Iowa, 52242; e-mail, lori-penaluna@uiowa.edu; telephone, 319-353-5414). The code set will be in the second edition.
E. What tools are available?
Several tools are available from the Nursing Classification Center Office, College of Nursing, The University of Iowa, Iowa City, IA.
Linkages among NANDA & OMAHA diagnoses, NIC interventions, and NOC outcomes have been developed and are available to users. Linkages of NANDA, NIC, & NOC with the Long Term Care Minimum Dataset (MDS) and Resident Assessment Protocols (RAPs) also have been developed. The linkages are not at this point research-based, but are developed by experts and are helpful to users in developing computerized nursing clinical planning and documentation systems. The results of Use Surveys will be available in the near future. These surveys will document the NOC outcomes that are most frequently used and most relevant for specific nursing specialties and practice settings. The NOC research is funded for 4 additional years of research to test the reliability and validity of the NOC measures in clinical field sites. These research sites will have NOC implemented in computerized clinical planning and documentation systems, enabling psychometric evaluation of the measures with actual clinical data. Nursing Outcomes Classification (1997, Johnson, M. & Maas, M. Eds.), is available for purchase from Mosby Book Company, St. Louis, and contains the original 190 NOC outcomes, indicators, and measurement scales.
Several software companies have or are implementing NOC, along with other nursing classifications, in care planning and documentation products (e.g., ERGO, 5700 Broadmoor, suite 800, Mission, KS 66202). Other electronic versions of NOC linked with nursing diagnosis and nursing interventions classifications are under development and will be available soon.
F. What organizations develop and maintain each of these tools?
Software products are developed and maintained by the software companies. Tools available through the Nursing Classification Center are developed, maintained, and updated by the Center investigators and staff.
G. Which of these tools are provided with the code set?
The taxonomy with domains, classes, outcomes, indicators and scales are provided with the code set. Other tools are obtained from the Nursing Classification Center or software vendors.
H. What tools are required that are not provided with the code set?
No tools other than the NOC and code set are required.
I. If the tool is not provided, how is it acquired?
NANDA & OMAHA, NIC, NOC linkages and use survey results are acquired from the Nursing Classification Center office (see address above in section describing acquisition of the code set). These tools will be included in the 2nd edition of Nursing Outcomes Classification (Johnson, M., Maas, M., & Moorhead, S., Eds.) to be published Fall, 1999. The 1st edition of Nursing Outcomes Classification is available from Mosby Book Company.
J. Is a user guide available?
The NOC 2nd edition will contain several examples of implementation both in education and practice. Guidelines for implementation are included in the 1st edition of Nursing Outcomes Classification (1997, Johnson, M. & Maas, M., Eds.) available from Mosby.
K. Is the user guide approved by the development organization?
The NOC 2nd edition includes the implementation examples mentioned above and was developed by external NOC contributors in practice and approved by the NOC research team, the development organization.
L. Are there any other indicators of readiness that may be appropriate?
NOC is recognized by the American Nurses' Association (ANA) and is included as one data set that will meet the uniform guidelines for information system vendors in the ANA's Nursing Information and Data Set Evaluation Center (NIDSEC). NOC is included in the National Library of Medicine's Metathesaurus for a Unified Medical Language. The Cumulative Index to Nursing Literature (CINAHL) has also added NOC to their nursing index.
Several software companies and provider organizations have implemented NOC in clinical planning and documentation systems. NOC also is included in a number of provider generated clinical pathways, patient teaching plans, and care plans, both manual and computerized systems. Referrals to these companies and organizations can be obtained by contacting the Center for Nursing Classification Office, College of Nursing, The University of Iowa. Mosby Year-Book also maintains a list of companies, organizations, and individuals who have applied for or who have obtained licensure to use the NOC nomenclature and taxonomy. Mosby also maintains a list of textbooks and other book publications that have incorporated NOC.
A. What number or percentage of relevant vendors have adopted it?
Six licensing agreements are pending with vendors and one vendor has completed the licensing process. Recently 3 additional vendors have requested NOC licensing information from the publisher. The American Nurses Association (ANA) established the Nursing Information and Data Set Evaluation Center (NIDSEC) to develop and disseminate standards pertaining to information systems that support the documentation of nursing practice, and to evaluate voluntarily submitted information systems against these standards. NOC, as a recognized ANA classification is included in the NIDSEC standards.
B. What number or percentage of healthcare institutions use it?
While it is difficult to accurately estimate the number of healthcare institutions using NOC, the list of health care providers who have contacted the office for information or materials is growing and represents approximately 250. This includes many international providers in British of Columbia, Canada, Korea, Japan, The Netherlands, Iceland, Brazil, United Kingdom, Hong Kong, Saudi Arabia, and Australia.
C. What number or percentage of health professional societies refer to it?
NOC is recognized by the American Nurses’ Association as a classification system useful for the practice of nursing. NOC is also recognized by the Iowa Nurses’ Association for inclusion in the Nursing Minimum Data Set (NMDS) and complementary to the Nursing Management Minimum Data Set (NMMDS) as essential nursing data that need to be collected across all healthcare delivery settings. The Michigan Nurses Association also recognized NOC as a standardized language that should be included in all data collection systems across healthcare settings. The Michigan Nurses Association Task Force version statement is as follows: Nurses will work together to ensure that NANDA, NIC, and NOC are incorporated into communication, the nursing process, and computerized documentation systems in the State of Michigan by 2003 for purposes of refining these languages and demonstrating the effectiveness of nursing practice.
D. What number or percentage of government agencies use it or refer to it?
CINAHL, the premier index to the nursing and allied health professional literature, has included NOC in the CINAHL Thesaurus. The National Library of Medicine’s Metathesaurus for a Unified Medical Language includes NOC. NINR, National Institute of Nursing Research has supported the NOC research for eight years (Grant No. 1 R01 NR03437).
E. Is the code set being used in other countries? If so, which ones?
NOC is translated into Dutch, and current translation rights are held for Japanese, French and Spanish. Three additional countries (China, Germany and Korea) have pending translation contracts. Over 110 international nurses receive the Center for Nursing Classification Newsletter (NIC & NOC) which supports education and use of NOC. The International Council of Nurses (ICN) is working to develop an international classification of nursing practice. The council has expressed an interest in reviewing NOC for inclusion in this international work.
F. Are there any other relevant indicators of market acceptance?
The listserv maintained to provide information and opportunities for discussion of NOC and other nursing classifications currently has over 250 subscribers representing 50 states plus Washington, DC, Guam and 15 foreign countries. The Center for Nursing Classification Newsletter (NIC & NOC) has a mailing list of over 1,095 which includes 127 foreign recipients. The newsletter is mailed to 49 states and 22 countries: Netherlands, Switzerland, Brazil, France, Canada, Denmark, Japan, Belgium, United Kingdom, Germany, New Zealand, Sweden, Korea, Spain, Saudi Arabia, Hong Kong, Taiwan, Norway, Australia, Austria, South Africa and Iceland. These individuals have explicitly expressed an interest in NOC and NIC.
A. Describe its clinical specificity and/or granularity.
Nursing Outcomes Classification (NOC) outcomes are organized by a 4 level taxonomic structure; domains, classes, outcomes, and indicators. Also included is an empirical level of measurement scales, one scale for each outcome and its indicators. At the most abstract level are 7 domains of outcomes: Functional Health, Physiological Health, Psychological Health, Health Knowledge and Behavior, Perceived Health, Family Health and Community Health. The next level includes 24 classes within the 6 domains. Examples of classes for the domain, Functional Health, are Energy Maintenance & Self Care; for the domain, Health Knowledge and Behavior, Health Beliefs and Risk Control & Safety; and for the domain, Family Health, Family Caregiver Status and Maltreatment Resolution. Currently, 260 outcomes are classified within the 29 classes along with the indicators for each of the outcomes. As stated, each outcome and its indicators have an associated measurement scale.
B. Does it reference or assume other code sets?
Currently, the more than 200 NOC outcomes characterize individuals. Outcomes that characterize family units and communities will be included in the NOC 2nd edition. The NOC is comprehensive of outcomes for individuals, families and community that are responsive to nursing interventions in all nursing specialties and practice settings. From 5 to 25 indicators are associated with each outcome and are designed so that those most relevant to specific clinical specialties and practice settings can be selected for specifying an outcome. The measurement scales enable standardized measurement of patient status over time and across clinical settings. The linkages of NOC with other nursing classifications enhance the use and measurement of the outcomes because the effectiveness of nursing interventions to treat specific problems can be documented, quantified, and compared for different patient populations and across settings. All elements of the NOC taxonomy are coded, including the indicators and measurement scales and require a 9 character field to code domain, class, outcome, indicator, & measurement scale. The coding is alphanumeric which enables easy identification of domain, class, outcome, indicator(s), and measurement scale.
C. If so, what are they? Why are they being referenced?
NOC does not currently reference other code sets. However, many of the outcomes, used as aggregate measures, are similar to several report card approaches to outcome measurement. This is especially true for a number of the variables included in the American Nurses Association Report Card for acute care outcome evaluation. Although NOC outcomes are developed based on an assessment of patient states that are most responsive to nursing interventions, many can be used by other disciplines and are therefore consistent with an interdisciplinary database structure. Because there are currently no other comprehensive classifications of standardized patient outcomes that detail the number of outcomes that are included in the NOC, no other code sets are referenced.
A. Describe the relationships, such as inclusion, dependency, interface, overlap, conflict, or coordination.
Inclusion.
NOC is a standardized coded vocabulary of patient outcomes that are influenced by nursing interventions in all settings and by all nursing specialties. NOC includes outcomes, associated indicators, and suggested measurement scales for specific patient states, behaviors, or perceptions. While all of the outcomes included have been established by literature/ clinical nursing information system review and other validation methods as influenced by nursing, NOC developers recognize that the outcomes are not exclusive to the nursing domain. The NOC research used The Medical Outcomes Study categories along with outcome categories that had been used to organize nursing outcomes as a framework for identifying outcomes for development. Therefore, the NOC includes a number of outcome concepts that have also been identified as outcomes of medical care.
NOC outcome development has also been guided in part by the content of other nursing classification systems, especially the classifications that are similar in comprehensiveness of scope. The nursing diagnoses published by the North American Nursing Diagnosis Association (NANDA) and being extended by the Nursing Diagnosis Extension Classification (NDEC) research and the nursing interventions included in the Nursing Interventions Classification (NIC) have been linked to NOC outcomes. A publication with these linkages will be forthcoming in 1999.
Dependency. The NOC is not dependent on any other code set/vocabulary, although changes in clinical terminology in other health care vocabularies may necessitate review of NOC to assure standardization.
Interface. No formal interfaces exist between NOC and other code sets/vocabularies. However, ongoing coordination efforts (described below) make a number of interfaces possible with other nursing and health care vocabularies.
Overlap. As noted above, NOC includes a few outcome concepts that are also used in other health care vocabularies. The indicators associated with outcomes are likely to be most unique for the discipline of nursing. Some degree of conceptual overlap has been noted between the NOC outcomes and indicators and the specific OASIS home health outcome measures.
Conflict. The NOC can be used without regard to the vocabularies selected to document nursing diagnoses and nursing interventions. It is the most specific of the current proposals for outcome documentation in nursing with the exception of the OASIS system. Further analysis of compatibility between NOC and the OASIS is planned.
Coordination. Linkages have been developed between NANDA diagnoses and NOC outcomes; and between NOC outcomes and NIC interventions. A document was recently completed to link the NOC outcomes with NANDA and NIC for common long-term care problems using the framework required by the nursing home minimum data set. General outcome terms proposed for use in community and home health care by the Omaha System and Saba’s Home Healthcare Classification have also been reviewed. Linkages have been developed between the Omaha System problems and NOC outcomes. An analysis is underway to determine the relationship between the NOC and the OASIS system that HCFA will soon require for quality assessment in Medicare-certified home health agencies.
B. Describe any coordination or reconciliation activities.
Developers of NANDA, NIC, and NOC have a working relationship that facilitates ongoing coordination among the classifications. Both NOC and NIC are based in the Center for Nursing Classification at the University of Iowa, and principal investigators for these research teams meet regularly to plan coordination of efforts. Several team members are members of the NANDA board of directors and chair NANDA committees, so there is regular communication among NANDA, NIC, and NOC representatives. The premier conference on utilization of NANDA/ NIC/NOC was held in Chicago in November 1997 with 350 persons from 8 countries in attendance. The 2nd conference on utilization of NANDA/NIC/NOC was held in New Orleans in April 1999 with over 250 persons from 9 countries in attendance. All major publishers and several information system vendors also attended the conference.
Preliminary conversations indicate that additional coordination between the NOC and the Saba Home Healthcare Classification may be possible but no work has yet taken place.
C. What portion of the code set is affected by this coordination?
All NOC terms have been linked to NANDA, NIC, and Omaha System terms. Only NOC outcomes determined relevant for long term care have been linked to NANDA and NIC using the nursing home Minimum Data Set (MDS) framework.
D. What conditions are assumed in order for this coordination to be effective?
Coordination of the vocabularies will require the education of nurses in practice, education, and research. Planned educational efforts include: dissemination of written linkage materials through the Center for Nursing Classification; participation of experts in the standardized nursing languages in professional meetings, conferences and other educational endeavors to enhance the learning experience.
E. What gaps exist among related code sets that should be addressed?
NOC and other outcomes code sets identified above focus primarily on individual-level patient outcomes rather than family-level or community-level outcomes.. NANDA and NIC both presently include family-level phenomena.
F. Describe what is being done to address these gaps.
NOC includes a number of family caregiver outcomes and family- and community-level nursing-sensitive outcomes. NANDA and NIC are also working to develop community-level nursing diagnoses and interventions.
A. Are your codes or terms used within specific message formats standards? If so, which ones?
Codes or terms are not used within specific message formats; no coding would inhibit meeting HL7 standards.
B. If your code sets or terms are used, are they specified as required, preferred, or optional by the message format standard?
Not applicable since not used.
C. Has this code set been adopted for use within a vendor or end-user system? If so, which ones?
Yes, the language is used in one operational clinical information system produced by Ergo out of Mission, Kansas and in two other products in which it provides the vocabulary, one being produced by LCI of Wisconsin and one by Pace Health Management Systems of Des Moines. In addition, license agreements are currently being negotiated with four other software vendors who produce clinical information systems, one of which has a national market.
D. How are the links between your code set and specific message formats maintained?
Links can be bridged between the NOC code set and any specific message formats. A coding table can be used to indicate the links.
E. In which message format standards organizations do you regularly participate?
Do not participate in any message format standards organizations.
A. Cost of licensure.
Licenses are granted for commercial or institutional use. Licensing fees are determined by the number of users (e.g. patient care person) per site and are renewable every two years. There is a $2500 flat fee for incorporating NOC into a vendor’s database and then a sublicense fee for each sublicense (additional fee for additional client sites) undertaken based on the number of users. The NOC sublicense fee structure is as follows: 0-56 users $300, 57-99 users $5.30 per user, 100-199 users $5.00 per user, 200-499 users $4.70 per user and 500 or more users $4.40 per user.
B. Cost of acquisition.
NOC is available in book form to individuals for a single fee, which in January 1998 was $37.95.
C. Cost of tools.
The Nursing Outcomes Classification (NOC) Taxonomy is an 8 page booklet containing a three-level organizing structure for the 195 outcomes contained in the Nursing Outcomes Classification (NOC). This NOC Taxonomy is sold for $8.00. The NOC Use Survey is a 20 page questionnaire to identify unit specific outcomes that should be available in information systems. The questionnaire could also be used by faculty to determine which outcomes should be taught in academic programs. The NOC Use Survey sold with a 3.5” disk at a cost of $12.50.
D. Cost/time frames for education and training.
The time and cost for education and training to implement NOC into a nursing information system in a clinical practice agency depends on the agency’s selection and use of a nursing information system, the computer competency of nurses, and their previous use and understanding of standardized nursing language.
E. Cost/time frames for implementation.
The time and cost for implementation of NOC depends on the software capabilities and the amount of programming necessary to incorporate the language. It is possible to purchase software with NOC language incorporated, reducing the cost and time of implementation. However, time reports from one NOC test site indicate that the nurses’ documentation time has been reduced significantly with the use of computerized documentation systems using standardized language.
F. Any other cost considerations, such as annual or usage fees, updates, maintenance, and so forth.
The user needs to purchase a new edition of the Classification every 4 years, and for those using NOC in information systems need renew the license fee every 2 years.
Contact: Dr. Marion Johnson
Principal Investigator for Nursing Outcomes Classification (NOC)
Phone: 319-335-7125
FAX: 319-335-7119
E-Mail:marion-johnson@uiowa.edu