Nursing-Sensitive Patient Outcomes - Description and Framework

Authored by the ONS Outcomes Project Team:
Barbara Given, PhD, RN, FAAN, Team Leader, Susan Beck, PhD, APRN, AOCN®, Caroline Etland, MSN, AOCN®, Barbara Holmes Gobel, RN, MS, AOCN®, Luana Lamkin, RN, MPH, and Vicki D. Marsee, RN, MBA, CNAA

ONS Nursing-Sensitive Outcomes

With the rapid changes within the health care system, the demand for professional accountability becomes paramount. Nurses are challenged to articulate and document the quality of their contributions to the health outcomes of the patient. Thus far in the literature, quality indicators have been discussed within a conceptual framework that includes structure of care, process of care, and outcomes of care (ANA, 2002; Donabedian, 1980; Johnson & Maas, 1999; Jennings, 1995; Doran, 2003). Structure and process have become common areas to examine; concern for outcomes is more recent.

ONS has, as its mission, the promotion of excellence in oncology nursing and quality cancer care. A strategic goal is to drive quality care through education, research, leadership, and advocacy. Excellence is to be fostered in practice, research, education, and administration. The strategic plan for 2003-2005 speaks to assuming leadership for quality oncology care in the United States. Specifically, ONS mentions generating public awareness of the specific contributions that nursing research makes to patient outcomes. The strategic plan additionally indicates the need to generate and disseminate new knowledge to identify key oncology nursing-sensitive outcomes for practice, research, educational programming, and policy.

Outcomes, which focus on how patients and their health care problems are affected by nursing interventions, have been identified and are described as Nursing-Sensitive Outcomes. Nursing-sensitive outcomes are those outcomes arrived at, or significantly impacted, by nursing interventions. The interventions must be within the scope of nursing practice and integral to the processes of nursing care; an empirical link must exist. Nursing-Sensitive Outcomes represent the consequences or effects of nursing interventions and result in changes in patients' symptom experience, functional status, safety, psychological distress, and/or costs.

Given the status of health care, the need for articulation of nursing's contribution to quality care and ONS' commitment for quality, a strategic plan for defining, measuring and educating about nursing-sensitive outcomes is essential. It is within that context that the Nursing-Sensitive Outcomes definition is offered.
Nursing-Sensitive Outcomes are outcomes that are sensitive to nursing care or care rendered in collaboration with other healthcare providers.

Important Considerations

Evaluation of quality of care, and effectiveness of treatment, for patients with cancer and their families is measured in outcomes. Nurses are accountable for promoting and upholding standards of care and practice, and being able to track the results of their care to achieve quality outcomes. Major outcomes of concern for patients with cancer include symptom control from the cancer or cancer treatment, functional status, or performance status. Healthcare systems, however, evaluate outcomes by measuring system resources; that is, healthcare resource utilization - that is related to the patients' symptoms and performance status. The selection of outcome(s) to measure depends on multiple considerations, including level of nursing practice (Staff Nurse or Advanced Practice Nurse); setting (hospital, clinic, office, home care, etc.); clinical context (episode of care, continuum of care, etc.); population or type (cancer site, cancer stage); and the intervention of interest (Carroll & Fay, 1997; Patrick & Chiang, 2000). In addition, in measuring the effectiveness of nursing care across multicultural populations, nurses must take into consideration the values and health practices that influence a patient's experience with the cancer diagnosis and evaluate which outcomes are valued or desired.

To be meaningful, outcomes must be evaluated across the care continuum: short, intermediate, and long-term outcomes should all be addressed. The time of measurement becomes important when interventions are evaluated. Measurement must take place at the time(s) consistent with the expected effects of the intervention (outcome). When time of expected effects is unclear or not supported by evidence, measurement may take place close to the intervention so that confounding variables that can affect the outcome(s) can be eliminated, and thus the outcome(s) can be attributed to the oncology nursing care.

Rationale for Concern with Nursing-Sensitive Outcomes

Treatment and care outcomes/evaluations are important to legislators, purchasers, regulators, insurers, providers, and consumers due to the concern for cost and quality of care. All want to know whether the care being considered has any "value". The desire of the constituents is to know to what extent does the intervention actually bring about improvement in health - in other words, did the patient achieve the desired outcome? It is important then to validate the effectiveness of the care in achieving outcomes. Due to the chronic and often life-threatening nature of cancer, as well as the cost of curative and palliative therapies, it becomes even more urgent to examine outcomes that describe quality of life, performance status, patient satisfaction, and cost. Extensive resources are utilized in the care of the cancer patient and nurses have a tremendous impact on preventing or minimizing symptoms and complications.

Framework for Classifying Outcomes

Jennings, Staggers, and Brosch (1999) provide a framework for classifying outcome indicators using a literature review from medicine, nursing, and health services research. Several other researchers have also described similar indicators which fall within that framework.

Jennings, et al. divided outcome categories into patient focused indicators (e.g. disease specific and holistic) and provider focused indicators. For the patient set of indicators, they use diagnostic (disease-specific) outcomes, which are comparable to clinical status outcomes described by Urden (1999). These clinical outcomes are related to physiological functioning or processes and indicate whether illness, disease, or injuries are improving, unchanged, or deteriorating. Physiological response to interventions may result in changes in vital signs such as blood pressure, heart rate, white blood counts, weight, serum glucose, and wound healing (Urden, 1999).

Jennings, et al. include a category of holistic indicators that goes beyond the disease boundaries. The indicators include functional health status, mental health, patient and family satisfaction, and symptom management. Additional clinical outcomes include nutritional status, sleep maintenance, and other symptoms common to patients with cancer such as pain, fatigue, insomnia, nausea, vomiting, anorexia, diarrhea, constipation, and mucositis. Cleeland describes symptom burden as a summative indicator of the severity of symptoms, and a summary of the patient's perception of the impact of the symptom on daily living (Cleeland, 2002). Psychosocial outcomes refer to outcomes that are related to behavioral, emotional status, mood (family and other), relationships, or communication. Examples are spiritual distress, role functioning, quality of life, depression, anxiety, caregiver strain and burden, and sexual functioning (Urden, 1999). Functional outcomes relate to activities of daily living and general daily functions and performance. Examples of functional outcomes are physical mobility, role, self-care ability, activity tolerance, and return to normal daily activities (Urden, 1999). Social role functioning can be included in this category. These indicators do not relate to the disease, but the person's response to that disease.

For Jennings, provider focused outcomes relate to provider proficiency, knowledge and skill, self-confidence, turnover, priority satisfaction, and caregiver demands. Provider practice activities affect patient outcomes. This includes complications and provider effectiveness. The family caregiver activities are included in this category for Jennings. Most other authors do not mention this.

The organizational focus is more global and focuses on measures of the organization or system effectiveness of which nursing is a part, including adverse events such as infections, nosocomial ulcers, falls, and other safety issues. Access to care and appropriateness of care can also be included in this category. As such, cost and length of stay are outcomes of importance to the organization. Economic outcomes can be defined as any outcome that can be quantified to reflect the costs of healthcare. Examples of economic outcomes are length of stay, readmission to hospital or home care, clinic and home care utilization, hospice use, emergency visits, healthcare services utilization, out of pocket costs, referrals, consultations, cost per patient day/episode of care, morbidity, and mortality (Urden, 1999).

The following classification merges concepts from several models in order to propose a classification schema that is meaningful for oncology nurses. Oncology Nursing-Sensitive Outcomes are classified as symptom experience, functional status, safety (preventable adverse events), psychological distress, and costs/economics (incorporated in all categories). Examples of specific outcomes are provided.

Oncology Nursing-Sensitive Outcomes: A Classification with Exemplars

Symptom Experience
Pain
Fatigue
Insomnia
Nausea
Constipation
Anorexia
Breathlessness
Diarrhea
Altered Skin/mucous membranes
Neutropenia

Functional Status
ADL (activities of daily living)
IADL (instrumental activities of daily living)
Role functioning
Activity tolerance
Ability to carry out usual activities
Nutritional status

Safety (Preventable adverse events)
Infections
Falls
Skin ulcers
Extravasation incidents
Hypersensitive reactions

Psychological Distress
Anxiety
Depression
Spiritual distress

Economic (incorporate this category into all categories)
Length of stay
Unexpected re-admissions
Emergency visits
Out-of-pocket costs (family)
Cost per patient day
Cost per episode of care

Summary

Health care has entered the era of accountability. Oncology nurses have a mandate to measure the end results of their care and to improve the results over time. This document serves as a foundation for advancing knowledge and action related to oncology nursing-sensitive outcomes. It provides a rationale for the importance of measuring outcomes, provides a useful definition, and proposes a classification schema building on the work of other nursing colleagues. The schema includes outcomes of importance to patients, caregivers, and organizations and provides examples of outcomes that are relevant to oncology nursing practice. This foundational document provides a context for beginning a needed educational process and provides a context for ONS to develop a plan to move forward-to take the lead in helping oncology nurses to provide the highest quality and most cost-effective care.

References

  • American Nurse Association (2002). Nursing-sensitive quality indicators for community based non-acute care settings and ANA's safety & quality initiative.
    Carroll, T.L, Fay, V.P. (1997). Measuring the impact of advanced practice nursing on achieving cost-quality outcomes: Issues and challenges. Nursing Administration Quarterly, 2(14), 32-40.
  • Cleeland, C., Reyes-Gibby, C. (2002). When is it justified to treat symptoms? Measuring symptom burden. Oncology (Huntingt), 16, 64-70.
  • Donabedian, A. (1980). The definition of quality and approaches to its assessment. Health Administration Press: Ann Arbor, MI.
  • Doran, Diane. (2003). Nursing-sensitive outcomes: state of the science, Jones and Bartlett.
  • Jennings, B. (1995). Outcomes: two directions - research and management. AACN Clin Issues, 6, 79-88.
  • Jennings, B., Staggers, N., & Brosch, L. (1999). A classification scheme for outcome indicators. Image: Journal of Nursing Scholarship, 31(4), 381-388.
  • Johnson, M. & Maas, M. (1999). Implementing the nursing outcomes classification in a practice setting. Outcomes Management for Nursing Practice Practice, 2(3): 99-104.
  • Patrick, D.L. & Chiang, Y. (2000). Measurement of health outcomes in treatment effectiveness evaluations: Conceptual and methodological challenges. Medical Care, 38(9), II-14 -II 25.
  • Urden, L. (1999). Outcome evaluation: An essential component for CNS practice. Clinical Specialist, 15(6), 260-268.

July, 2004
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