OUTCOMES

One of the major issues in this course is the importance of outcomes. You can access my lecture notes on outcomes assessment by clicking this link: Outcomes Assessment   

Outcome Evaluation

We have been talking about health education and health promotion, the principal strategies used by nurses in the community. Today’s topic focuses on how to decide whether those strategies, or any nursing interventions have been effective. Although we, as nurses, have always evaluated the effect of interventions, never have nurses been so accountable as they are today. Managed care has focused attention on whether or not the time, money, and other costs for a particular nursing intervention were worthwhile. In earlier times, nurses did the teaching, documented that relevant, appropriate teaching had been accomplished, and considered the job finished. Today, that is not good enough!

The word today is outcomes—it means the same thing as evaluation or quality indicators. Outcomes is an extremely important concept in health care now. We evaluate how well the intervention worked by collecting data. We know what kind of data to collect by the measurable objectives developed earlier to guide the intervention in the first place.

For an example, let’s think about a client who has hypertension, is overweight, and does not take blood pressure medicine as ordered. Relevant measurable objectives might well be:

    2. The client will participate in brisk walking for 30 minutes 3X weekly.  

    3. The client will take medications as ordered 90% of the time.

You already know how to develop these objectives, but if you need some reminders, read Mager’s book on instructional objectives. Well developed objectives not only guide interventions, they also determine decisions about effectiveness of the teaching. The objectives specify the evaluation criteria or what data are collected to evaluate. In today’s terminology, these evaluation criteria are called outcomes. In this case, the outcomes are

    1.  Blood pressure levels at or below 140/90. 

    2.  Participation in brisk walking for 30 minutes 3X weekly.

    3.  Medication compliance as ordered 90% of the time.

Sometimes the data to be collected are the same as the evaluation criteria/outcomes and sometimes a bit different. In this case the data to be collected are: 

    1.  Blood pressure records.

    2.  Verbal reports or logs of walking routine.

Evaluation Outcome Classification Scheme  

In order to provide a framework or “checklist” of types of outcomes or evaluation criteria, I have developed the Evaluation Outcome Classification Scheme in your syllabus. It is based on Donabedian’s famous structure/process/outcome framework for evaluation. This evaluation expert developed three categories used for evaluation— structure, process, and outcome. Look at that page in the syllabus as we talk about a health clinic as an example.

Structure involves the physical plant, the personnel and their particular skills, and the types of clients seen at this clinic. To evaluate the structural characteristics, one would try to decide if the physical aspects of the clinic, and the characteristics of the personnel are appropriate for these particular clients. Maybe the clinic is too small, or located too far from public transportation. Maybe translators are needed.

Process includes the types of services and procedures available at this clinic. Do they screen everyone for tuberculosis because there is a high rate among this population? What types of family planning are available for female clients? For what services do they need to make referrals? Different agencies also use different styles in terms of the degree of self-management of their health that clients are expected to assume. Evaluation of this category asks whether these processes are adequate.

Outcome focuses on the effectiveness of the clinic services. Evaluation of these criteria might include the percentage of those with hypertension who maintain blood pressure at a particular goal. Evaluation of women’s health might include the percentages of term deliveries and the birth weight of the infants. The percentage of fully immunized 2 year olds is often an appropriate outcome criteria for well children.

For our purposes, however, we will not talk about structural evaluation, since it is not relevant to health teaching. However, when you are in charge of a health care agency, you may well evaluate structural criteria to see if the agency is adequate. The rest of this lesson will focus on the process and outcome categories. At this point I will use the term evaluation criteria rather than outcomes, because one of the outcome categories is called outcome, and this creates confusion!

Process evaluation

Process means what the provider does. Examples of process evaluation criteria that focus on how well the provider does are:

Many of these process type evaluation criteria are what have been considered quality control in the past. They ask whether the health care providers are doing the right procedures, doing something the right way, or doing it often enough. Process evaluation is extremely important and relevant. However, it doesn’t say anything about whether or not the client is better. So let’s move now to the outcome evaluation category.

Outcome evaluation

Outcome evaluation criteria describe what the client does. Notice two outcome sections on the Evaluation Outcome Classification Scheme--health status outcome and other outcome. First, let’s look at the health status outcome category.

Health status outcome. The ultimate goal is always for the client to be better as a result of health care interventions. Health status outcomes focus on whether the client is better as a result of what the nurse did. Evaluation criteria that focus on whether the client is better are:

    1.  Blood pressure levels below 140/90.

    2. No substance use during pregnancy

    3. Moderate exercise three times a week.

The previous process criteria of identifying hypertensives and pregnant women using substances are really intended to result in clients who have their hypertension under control and clients with fewer substances used during pregnancy. The process criteria are a means to an end. The health status outcome criteria are the end.

For simplicity the health status outcome evaluation criteria is divided into the familiar physical, social, and psychological categories, as well as a general health category for some criteria that cover more than one category-—such as quality of life. The next page in the syllabus, Health Status Outcome Categories, simply shows this same health status outcome category in an expanded form. This list of health status outcome criteria provide examples that you can use for your clients as you develop objectives and evaluation criteria.

Other outcome.

The second outcome category on the Classification Scheme includes important evaluation criteria about the client, but these criteria don’t necessarily indicate that the client is better. One important reason to use these criteria is that nurses in the community may not be able to collect health status evaluation criteria. If you teach a “safer sex” class to high school students, the improvement in their health status will be difficult to document. It may be years until the benefits are seen. The best evaluation criteria that are realistic might be:

    1.  Number of teens who attended the class (utilization).

    2.  Students’ satisfaction with the class (satisfaction with health care).

    3.  Self-report of intention to use condoms (health behavior)

    4.  Knowledge of STD/HIV transmission (health knowledge).