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

1. Feasibility of Studying the Effects of Using NANDA, NIC and NOC on Health Outcomes Margaret Lunney, RN, PhD & Laurence Parker, PhD

2. 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)

3. 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

4. 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

5. Need for Research • Objections to & avoidance of using SNLs: • Standardization • High cost • Time & effort for teaching/learning • National concern re: children’s health • Nursing care elements NOT communicated • Use of NNN improves communication • communication may improve actions

6. Conceptual Framework • Three theories: 1) The nursing process; 2) Barrett’s theory of power; 3) Hayakawa’s theory of language • NNN = Pooled nursing knowledge • Use of language, knowledge, & power has positive effects on thinking and actions (Hayakawa & Hayakawa, 1990)

7. Aims of the Study • Investigate the effects of using NNN on: • nurses power to participate knowingly in changes for children’s health; • children’s effectiveness of coping; • children’s health self concept; • children’s health behaviors.

8. Methods: Design • Quasi-experimental, two group design • Control group- SNAP without NNN • Intervention group- SNAP with NNN • 4 hypotheses predicting positive effects • Pre & Posttests: Nurses and children • Same protocols for each group • Field study, limitations expected

9. Methods: Sample • 14 nurses/schools enrolled in Bklyn & SI • Minimum needed: 10 nurses, 100 children • Two groups of schools matched on: • Race/ethnicity • SES • Attendance rate • Reading • Total registration • Random assignment to two groups

10. Methods: Sample • Nurses-Two withdrawals Sample = 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

11. 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

12. 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

13. 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

14. 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 06/01 4 – 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

15. Data Analysis • Data entered in Excel • Data cleaning • Data converted to SAS and SPSS • Examination of frequency distributions • Descriptive analyses • Reliability analyses • Paired T test

16. 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)

17. 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.

18. 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.

19. 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)

20. Findings: Use of NNN • High percentages of NNN labels used • Use of NNN illustrated comprehensive and complex SN services • Visit logs showed logical relations of NDxs, NRxs, & NOC Outcomes (validity & reliability implied) • NOC outcome measures were not optimally used

21. 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

22. 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?

23. Discussion: Children • Matching of groups achieved its purposes • Hypotheses 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?

24. 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

25. 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.