Feasibility of Studying the Effects of Using NANDA, NIC and NOC on Health Outcomes

Margaret Lunney, RN, PhD

&

Laurence Parker, PhD

Acknowledgements

Co-Investigators:– Sylvia Contessa, RN, MA & Linda Fiore, RN,

MA (NYC Dept. of Health)– Roberta Cavendish, RN, PhD, CPN (College

of Staten Island/CUNY)– Margaret Grey, DrPH, CPNP, CDE, FAAN

(Yale University)– Joyce Pulcini, RN, PhD, CPNP (Boston

College)

Acknowledgements

Agency Facilitators & Nurses

– NYC DOH School Health Program

– NYC Board of Education

– Public Health Nurses• 5 nurses from District 22 (Brooklyn)• 7 nurses from District 31 (Staten Island)

– BS degree nurses from CSI

Partially Funded By:

AREA grant, National Institutes of Health, National Institute of Nursing Research, # 41355-00-01, $107,700

Marlene Springer, President, College of Staten Island (CSI); CSI Foundation

Professional Software for Nurses, Inc., Sharon and Peter Redes

Need for Research

Objections to & avoidance of using SNLs:– Standardization – High cost– Time & effort for teaching/learning

National concern re: children’s healthNursing care elements NOT

communicatedUse of NNN improves communication communication may improve actions

Conceptual Framework

Three theories: 1) The nursing process;

2) Barrett’s theory of power;

3) Hayakawa’s theory of language

NNN = Pooled nursing knowledgeUse of language, knowledge, & power has

positive effects on thinking and actions (Hayakawa & Hayakawa, 1990)

Aims of the Study

Investigate the effects of using NNN on: 1) nurses power to participate knowingly in

changes for children’s health;

2) children’s effectiveness of coping;

3) children’s health self concept;

4) children’s health behaviors.

Methods: Design

Quasi-experimental, two group designControl group- SNAP without NNNIntervention group- SNAP with NNN4 hypotheses predicting positive effects Pre & Posttests: Nurses and children Same protocols for each groupField study, limitations expected

Methods: Sample

14 nurses/schools enrolled in Bklyn & SIMinimum needed: 10 nurses, 100 childrenTwo groups of schools matched on:

– Race/ethnicity– SES– Attendance rate– Reading– Total registration

Random assignment to two groups

Methods: Sample

Nurses-Two withdrawalsSample = 12 nurses in 12 schools (6 per gp)(450-1590 children registered, 12-24 enrolled in study)

Children-Attrition r.t. relocation, absences– 236 parents gave permission– 232 children (4th and 5th grades) signed assents– 220 children completed pre and posttests;

103 control; 117 intervention– Total numbers vary based on missing tools/items

Methods: Instruments

Barrett’s PKPCT, vII • 52 semantic differential items, 4 subscales: Awareness,

Choices, Freedom to Act Intentionally, & Involvement in Creating Change, alpha = .98 (pre) & .99 (post)

Coping Strategies (CS) Inventory• 26 CSs, Effectiveness subscale: How much does it help? 0=

never do it to 3 = helps a lot, alpha = .78 & .72 Child Health Self Concept Scale

• 45 items; two alternatives; child decides which describes him or her, 1 = worst CHSC to 4 = best CHSC, alpha = .88 & .88

How Often Do You? (Health Behaviors)• 36 appropriate health behaviors, 0 = never, 1= not very

often, 2 = sometimes, 3 = very often, alpha = .80 & .79

Methods: Procedures

Informed consent– Reviewed by four IRBs

– Informed consent of nurses and parents

– Written assent of children

7 BS degree students conducted pre-testing of children, 6 conducted post-testing– Successful completion of research course

– Trained by PI and co-investigator in procedures

Methods: Procedures

Education of nurses (3days), e.g.,– Documentation issues (paper vs computer)– Community-based care & Healthy People 2010– Strategies for health promotion and health protection– Intervention group: NNN and critical thinking– Control group: Nursing process and critical thinking– How computers work– How to use SNAP with and without NNN

Computer equipment purchased & installed– 14 computers, printers, & security systems

Methods: Procedures

Pre-testing: – Nurses pre-tested on Day 1 of education, June 00– Children pre-tested in Nov & Dec 00

Nurses met with children-12/00 to 06/014 – 8 sessions with each child– Individuals and/or small groups– Nurses selected topics: Needs assessment & other– Unable to use computers every day as planned

Post-testing of nurses & children-June 01

Data Analysis

Data entered in ExcelData cleaningData converted to SAS and SPSSExamination of frequency distributionsDescriptive analysesReliability analysesPaired T test

Findings: Nurses

Pretest (m, sd, n)– Control 262, ± 40.59 (6)– Intervention 290, ± 17.6 (6)

Change, Post-Pre, groups compared:– Control 17.2, ± 22.5 (6)– Intervention 12.8, ± 22.5 (6)– T-test: N.S.

Overall change, Post-Pre:15.2 ± 21.6 (12)T-test: t = 2.43 (p = .03)

Findings: Children’s Effectiveness of Coping

Pretest (Item m, sd, n)– Control 1.62, .40 (102) – Intervention 1.60, .45 (117)

Change, Post-Pre, groups compared– Control -0.02, .45 (96)– Intervention 0.008, .49 (94)– T-test: N.S.

Overall change, Post-Pre-0.008, .47 (190)T-Test: N.S.

Findings: Health Self Concept

Pretest (Item m, sd, n)– Control 2.98, 0.36 (95)– Intervention 2.94, 0.4 (116)

Change, Post-Pre, groups compared– Control -.03, .35 (83)– Intervention 0.009, .38 (98) – T-test: N.S.

Overall change, Post-Pre– -0.007, .37 (181)– T-Test: N.S.

Findings: Health Behaviors

Pretest (Item m, sd, n)– Control 2.18, 0.29 (103)– Intervention 2.14, 0.33 (117)

Change, Posttest-Pretest, groups compared– Control 0.08, .31 (98)– Intervention -0.01, ± .36 (92)– T-test: N.S.

Overall change, Post-Pre– .03 ± .34 (190)– T-test: t = 3.03 (p = .003)

Findings: Use of NNN

High percentages of NNN labels usedUse of NNN illustrated comprehensive and

complex SN servicesVisit logs showed logical relations of

NDxs, NRxs, & NOC Outcomes (validity & reliability implied)

NOC outcome measures were not optimally used

Findings: Use of NNN

Agency paper record requirements limited the use of computer systems to only the health visits of these children

Nurses’ workload responsibilities limited the use of NNN

Positive reports from children & parents:– Children were enthusiastic

– Parents & children reported positive effects

Discussion: Nurses

Higher power scores than other staff nurses:– Community–based practice?– Ongoing opportunities to work with children?– Socially desirable responses?

Hypothesis not supported:– Insufficient use of NNN?– Small effects & sample not large enough?

Increase in power from pre to posttests: – Study effects?– Naturally occurring in one year time period?

Discussion: Children

Matching of groups achieved its purposesHypotheses not supported:

– Small effects & larger sample size needed?– Insufficient use of NNN?– Instruments not sensitive enough?

Means on health variables were comparable to means from other studies

Improvement in freq. of health behaviors:– Exposure to health promotion activities?– Naturally occurring in 7 month time period?

Conclusions/Implications

Experimental field studies are probably not feasible

Evaluation studies are critically important to demonstrate effectiveness

NNN are useful to communicate SN services

Once computerized, school-wide data collection & aggregation are feasible

Study was published in CIN

Lunney, M., Parker, L., Fiore, L., Cavendish, R., Pulcini, J. (2004). Feasibility of studying the effects of using NANDA, NIC and NOC on children’s health outcomes. CIN:

Computers, Informatics, Nursing, 22(6), 316-325.