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Using NANDA, NIC, and NOC (NNN) Languagefor Clinical Reasoning With the Outcome-PresentState-Test (OPT) ageClinical Reasoning With the Outcome-PresentBlackwellMalden,InternationalIJNT giesandforClassificationsDonald D. Kautz, RN, PhD, CNRN, CRRN-A, RuthAnne Kuiper, RN, PhD, CRRN, Daniel J. Pesut, APRN,BC, PhD, FAAN, and Randy L. Williams, RN, MSN/MBAPURPOSE.To analyze the degree to whichstandardized nursing language was used bybaccalaureate nursing students completingOutcome-Present State-Test (OPT) modelworksheets in a clinical practicum.METHODS.A scoring instrument was developedand 100 worksheets were retrospectively analyzed.FINDINGS.NANDA nursing diagnoses werecorrectly stated in 92% of the OPT models. NursingOutcomes Classification (NOC) outcomes wereexplicitly stated in 22%, and implied in 72%.Interventions matched appropriate NursingInterventions Classification (NIC) activities in 61%.CONCLUSIONS.NANDA, NIC, and NOC(NNN) language was used inconsistently bystudents in this sample.IMPLICATIONS FOR PRACTICE.If NNN languageis to advance nursing knowledge, its promotion,representation in curriculum development, andactive use is necessary. Educational research isneeded on the facilitators and barriers to NNNlanguage use.Donald D. Kautz, RN, PhD, CNRN, CRRN-A, isAssistant Professor, University of North Carolina atGreensboro, Greensboro, NC; RuthAnne Kuiper, RN, PhD,CRRN, is Associate Professor, University of NorthCarolina at Wilmington, Wilmington, NC; Daniel J. Pesut,APRN, BC, PhD, FAAN, is Professor and Associate Deanfor Graduate Programs, Indiana University School ofNursing, Indianapolis, IN; Randy L. Williams, RN,MSN/MBA, is Staff Nurse, High Point Regional HealthCare Systems, High Point, NC.Representation and classification of nursing knowledge is an important professional issue. The evolutionand development of standardized nursing languagehas included a systematic program of research overthe past 32 years, resulting in significant advancementsin nursing knowledge work. The Center for NursingClassification at the University of Iowa has contributedto the creation of standardized nursing languages thatcapture nursing interventions (Nursing InterventionsClassification [NIC], Dochterman & Bulechek, 2004), andnurse-sensitive outcomes (Nursing Outcomes Classification [NOC], Moorhead, Maas, & Johnson, 2003). Whenthese interventions and outcomes are linked withNANDA diagnoses (NANDA International, 2005), allthe standardized nursing language pieces (NANDA,NOC, and NIC or NNN) exist to represent relationshipsbetween and among nursing diagnoses, interventions,and outcomes (Johnson et al., 2006). When these languagesare used to structure nursing information systems inhospitals and other healthcare organizations, it will bepossible to make nursing care and its associated activities and achievement of nursing-sensitive outcomesevident (Lunney, 2006). As vendors of nursing information documentation systems adopt the AmericanNurses Association (ANA) Nursing Information andData Set Evaluation Center–approved classificationsystems, NNN will be used more frequently in practice settings. It is imperative that educators anticipatethe adoption and dispersion of standardized nursinglanguage and become more intentional about teachingInternational Journal of Nursing Terminologies and Classifications Volume 17, No. 3, July-September, 2006129
Using NANDA, NIC, and NOC (NNN) Language for Clinical Reasoning With the OutcomePresent State-Test (OPT) ModelFigure 1. Sample of One Student’s Clinical Reasoning Web.and using NNN language as a clinical vocabulary thatsupports students’ clinical reasoning about patient careneeds, nursing solutions, and nursing interventions.This article evaluates students’ use of standardizednursing languages with the Outcome-Present State-Test(OPT) model of clinical reasoning. The OPT model has130been described as a third-generation nursing processmodel (Pesut & Herman, 1998). Figures 1 and 2 illustratethe structure of the Clinical Reasoning Web and OPTmodel worksheets completed by a student for a patientwith decreased cardiac output related to septic shock. Pesutand Herman (1999) have defined clinical reasoning asInternational Journal of Nursing Terminologies and Classifications Volume 17, No. 3, July-September, 2006
Figure 2. Sample of One Student’s OPT Model Worksheet. (This OPT model worksheet corresponds to theClinical Reasoning Web in Figure 1.)“reflective, concurrent, creative, critical thinking processes embedded in practice; used to frame, juxtapose, andtest the match between a present state and outcomestate and make judgments about achievement ofdesired outcomes” (p. 4).The OPT model is unique in that the juxtaposition ofan identified keystone nursing issue is contrasted witha specified outcome state. The present state is derivedfrom an analysis and synthesis of relationships betweenand among nursing and client nursing care needs.Several teaching learning strategies support the use ofthe OPT model as a concurrent information-processingmodel of clinical reasoning. These strategies includereliance on the patient story, creation of a clinicalInternational Journal of Nursing Terminologies and Classifications Volume 17, No. 3, July-September, 2006131
Using NANDA, NIC, and NOC (NNN) Language for Clinical Reasoning With the OutcomePresent State-Test (OPT) Modelreasoning web that reveals balancing and reinforcingrelationships between and among nursing diagnoses,and the use of a structured OPT model worksheet toorganize thinking and reflection on client care issues.The OPT model provides a conceptual structure forthe use of standardized languages. “Present states” inthe nursing model can be defined as NANDA nursingdiagnoses. Outcomes in the OPT model serve asdesired states and can be defined in terms of NOCnursing-sensitive outcomes. NIC interventions arenursing actions that help transition patients fromproblem states to more desirable outcome states.Teaching learning strategies associated with application and implementation of the OPT model of clinicalreasoning include attention to the OPT structure;the use of NNN content to represent nursing knowledge work; and combining critical, creative, andsystems thinking and reasoning skills. The modelprovides a structure that challenges students tobecome more conscious of the way they frame andattribute meaning to the facts of the client story. Relationships and associations among competing nursingdiagnoses, interventions, and outcomes are emphasized. The model structures the contrast of nursingproblems with desired outcomes. Nurses implementinterventions and actions to transition clients fromproblem or present states to more desired outcomesstates. Pesut (2006) notes four C’s (contrast, criteria,concurrent considerations, and conclusions) as essential thinking strategies that support clinical judgment.The four C’s in clinical judgment in the model involvereflection about the contrast between present anddesired state; criteria regarding achievement of thedesired state; concurrent considerations of the problem,outcome, and intervention; and conclusions or judgments about outcome achievement (Pesut, 2004, 2006;Pesut & Herman, 1999).Because NNN languages exist and are being incorporated into nursing information systems, it is important that educators consider how to promote the use ofstandardized languages and help students think,learn, and reason with these standardized nursing132languages as they learn to provide care in patient settings. The authors considered standardized languagerepresented in the NNN classification systems as aclinical vocabulary for clinical reasoning. This researchexamined the degree to which students used NNNlanguage as they developed clinical reasoning skillsusing the OPT model as a guide for thinking and reasoning about nursing care needs of clients during thestudents clinical practicum.Research AimsThe research aims of this retrospective analysiswere to evaluate the use of the OPT model as a structure or scaffold for application and learning aboutrelationships between and among standardized nursing language terms as they support clinical reasoningand client care planning. In addition, a second goalwas to determine the extent of students’ use of theNNN language to represent nursing diagnoses, interventions, and outcomes associated with clinical reasoning about client care stories and situations.MethodsSettingThe research was conducted in a midsize city in thesoutheastern United States at a school of nursing in ahistorically black college and university. This longstanding nursing program admits a heterogeneouspopulation of students; however, the majority of students and faculty are African American. Clinical settings for students completing their medical surgicalnursing practicums include a Level 1 trauma center(1000 beds) and a nonprofit, tertiary care hospital (850beds). During the study, students had clinical experiences on acute care units with cardiac monitored bedsfor 10 weeks in one of these two institutions. At thetime of initial data collection, two of the researcherswere faculty members at the university, at the sametime clinical instructors for the junior level, medicalInternational Journal of Nursing Terminologies and Classifications Volume 17, No. 3, July-September, 2006
surgical nursing course in which this sample of students were enrolled.SampleFor this study, OPT worksheets from 10 studentswere purposively chosen from a cohort of 23 juniorbaccalaureate nursing students completing their clinical practicum for their junior year medical–surgicalcourse. This sample of 10 students all spoke English astheir primary language. The mean age of the samplewas 28 years. One was a male student, six were African American, and four were Caucasian. Six studentswere single, and five had children. Three had a previous degree and eight were certified nursing assistants.The mean number of hours per week of employmentwas 15 and the mean course load was 12 semester hours.This sample could be considered nontraditional, yettypical of nursing programs throughout the country.The 10 students were chosen to reflect the same demographics as the whole student group and to includesome students who had done well when completingthe OPT model worksheets and some who had donepoorly, as well as some students who had been evaluated by clinical faculty members as being strong andsome who had been evaluated as having been weak inclinical preparation and performance.ProceduresData for this study was derived from a sample ofstudents who participated in an educational researchproject (Kautz, Kuiper, Pesut, Knight-Brown, &Daneker, 2005). The overall aim of that project was toevaluate the effects of the OPT clinical reasoningmodel on the thinking processes of undergraduatenursing students on acute care units with clients whohad multiple health problems. As a part of the clinicalassignment in the 10-week clinical practicum, the students completed clinical reasoning webs. A sampleweb is included as Figure 1. A clinical reasoning webis a visual representation of all the potential and actualnursing diagnoses related to a client’s story. Oncediagnoses are identified, students are asked to drawlines of association linking the diagnoses and explainthe patterns of relationships between and among thediagnoses. For example, if pain and anxiety were linkedtogether, the student is expected to state how specifically pain and anxiety are related. The teaching-learningintervention behind the use of clinical reasoningwebs is to help students make connections about theinteractive, dynamic, cause–effect, and associationalinteractions among multiple nursing diagnoses andclients’ core needs. The OPT model worksheets reflectthe model structure and provide a way for students toorganize and record this work. A sample OPT modelworksheet corresponding to the sample web isincluded as Figure 2. In order to promote reflectionwhile creating and explaining clinical reasoning websand OPT model worksheets, students kept writtenjournals during the practicum experience. For moreinformation on journaling using OPT model and SelfRegulated Learning–structured prompts with thissample of students, see Kautz et al. The webs and OPTmodel worksheets were rated each week and thestudents received feedback regarding their progressfrom the clinical faculty.For this study, retrospective descriptive evaluationof OPT model worksheets was done to analyze theextent to which students used NNN language. Thepurpose of the analysis was to determine how oftenNNN language was used for outcomes and interventions because the students used clinical resourcessuch as medical-surgical textbooks and a variety ofnursing diagnoses and care plan texts as the source ofnursing language. The medical-surgical texts and nursingdiagnoses texts all incorporated some NNN language.The first step in the protocol involved the studentcompleting a clinical reasoning web to assist in identifying the keystone issue or priority NANDA diagnosisthat would become the focus of the OPT model worksheet. In the sample web included as Figure 1, the student identified the NANDA diagnosis of decreasedcardiac output as the keystone issue for a client withInternational Journal of Nursing Terminologies and Classifications Volume 17, No. 3, July-September, 2006133
Using NANDA, NIC, and NOC (NNN) Language for Clinical Reasoning With the OutcomePresent State-Test (OPT) ModelFigure 3. NNN Scoring Instrument.sepsis. Decreased cardiac output would determine theinput in the “present state” space of the OPT modelworksheet. Decreased cardiac output would then be contrasted with the desired outcome of Effective CardiacOutput. The student then completed the OPT modelworksheet (Figure 2) to develop the outcomes, tests,and interventions related to the priority NANDAdiagnosis.As a way to measure use of standardized nursinglanguage, the authors developed the NNN scoringinstrument for data collection, which is included asFigure 3. Using the NNN scoring instrument, the students’ use of NNN language was evaluated eachweek. Since the OPT model emphasizes outcomesinstead of problems, the first step was to document thestudents’ use of NOC language. The Outcome State134portion of the OPT model worksheet was evaluatedand the rater determined if the student had includedeither a “stated” or “implied” NOC for the appropriate nursing diagnosis that had been selected as thepriority keystone problem for that client. The ratersthen evaluated the students’ choices of outcomes andtests to see how many matched official NOC indicators. The NOC indicators serve as criteria for outcomeachievement as illustrated in Figure 4. The second steprepeated the process to evaluate the use of NIClanguage. The raters chose a NIC category and theaccompanying NIC activities for the keystone issuethat were the best matches for the student’s choice ofinterventions (Figure 5). Using the NNN scoring grid,100 OPT worksheets were evaluated by three independent raters for frequency and use of NNN languageInternational Journal of Nursing Terminologies and Classifications Volume 17, No. 3, July-September, 2006
Figure 4. OPT Model Worksheet/NOC Scoring Grid.on the OPT model worksheets. In the majority ofcases, student outcomes and interventions were notconsistently labeled in NNN language. Thus, raterswere challenged to make a best match of the student’swords to the appropriate NICs and NOCs. A check ofinterrater reliability between the three raters forcoding a random sample of 20 worksheets for NNNlanguage was 65% for NOCs and 45% for NICs. A possible explanation for the low percentages of interraterreliability could be linked to the differing clinicalbackgrounds of the raters (e.g., critical care, neurologicrehabilitation, and medical telemetry/intermediatecritical care) and their interpretation of nursing careneeds given this past knowledge and experience.ResultsStudents stated the priority keystone problem in theappropriate NANDA format 92% of the time. An outcome stated in NOC language was juxtaposed with aInternational Journal of Nursing Terminologies and Classifications Volume 17, No. 3, July-September, 2006135
Using NANDA, NIC, and NOC (NNN) Language for Clinical Reasoning With the OutcomePresent State-Test (OPT) ModelFigure 5. OPT Model Worksheet/NIC Scoring Grid.NANDA diagnosis 22% of the time and implied withother language 72% of the time. Students were moreproficient at identifying problems or NANDA diagnoses and less proficient at specifying outcomes. Interventions stated in NIC language corresponded to theNANDA diagnosis 61% of the time. Students includedinterventions that were appropriate for the client’s priority keystone problem but did not correspond to NIClanguage 39% of the time. Students consistently linkednursing interventions activities with NANDA diagnoses rather than NOC outcomes.136DiscussionThis research reveals that NNN language was notused consistently by students in completing the OPTmodel worksheets in the clinical area. Because this is aretrospective analysis, the authors speculated regarding a few possible explanations for these findings.Either the resources used by the students were notconsistent in the use of NNN language or the studentsdid not choose NNN language from the resourceswhen completing their OPT model worksheets. IfInternational Journal of Nursing Terminologies and Classifications Volume 17, No. 3, July-September, 2006
consistent use of NNN is an educational goal, ourfindings suggest that clinical instructors need topromote the use of NNN and give consistent feedbackeach time the student turns in clinical assignmentsto encourage students to use NNN language whencompleting their clinical assignments. The need forconsistent feedback each week is based on our researchwith these students in helping them learn the OPTmodel (Kautz et al., 2005). We recommend facultymembers use the OPT tools to give students feedbackon their work. A systematic approach to teachingthe relationships between and among diagnoses,NIC interventions, and NOC outcomes is not possibleunless faculty make these relationships explicit. Despitethe inconsistent use of NNN language, the OPT modelworksheets promoted identification of priority nursing diagnoses that were often associated with impliedoutcomes and a list of appropriate interventions.Evaluation of OPT model worksheets provided thefaculty with guidance about student understandingof patterns and relationships between and among thepriority problems, outcome achievement, and appropriate understanding and use of interventions to achievedesired outcomes.The raters discovered student resources were notas consistent or comprehensive in NNN language asthe NIC (Dochterman & Bulechek, 2004) and NOC(Moorhead, Maas, & Johnson, 2003) and NNN linkage(Johnson et al., 2006) texts. If consistent use of NNN isexpected, students and faculty need NANDA, NIC,NOC, and NNN linkage resources to make the contentavailable. All three raters noted that the students whoconsistently used NNN language with OPT modelswere the students who performed well in the clinicalarea and did better in completing their clinical reasoning webs and OPT model worksheets. It may be thatlearning standardized nursing language and using theOPT model to frame clinical reasoning activitiesprovides the knowledge driven content for success inprofessional nursing.Matching the student’s written words to appropriateNICs and NOCs was a challenge. It quickly becameapparent that each rater viewed each student’s narrative differently. This is a key finding of this studybecause both faculty members and students believewhat they are reading and writing will be interpretedsimilarly by other students, teachers, and practicingnurses. H
International Journal of Nursing Terminologies and Classifications Volume 17, No. 3, July-September, 2006 129 Blackwell Publishing IncMalden, USAIJNTInternational Journal of Nursing Terminologies and Classifications1541-5147 2005 Blackwell Publishing Ltd.73Original ArticleUsing NANDA, NIC, and NOC (NNN) Language for Clinical
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