2.1 The nursing outcomes classification (NOC)

Standardized nursing terminologies (SNTs) are commonly understood as sets of terms used to support nurses' clinical judgement when assessing patients to determine nursing diagnoses, select interventions and choose relevant patient outcomes in the documentation of nursing care (NANDA International [NANDA-I], 2022). NOC is a comprehensive terminology of patient, caregiver, family and community outcomes influenced by nursing care (Moorhead et al., 2018). Each outcome represents a concept that can be used to measure a state of a patient, caregiver, family or community before and after a nursing intervention (Moorhead et al., 2018). The impact of nursing care provided for patients and families can be evaluated using 5-point Likert-type scales (Gencbas et al., 2018).

The sixth edition of NOC contains 540 research-based outcomes for measuring health outcomes of individuals, family and community (Moorhead et al., 2018). The taxonomic structure of the classification has seven domains and 34 classes. For this study, the classes of Knowledge Health Condition, Knowledge Health Promotion and Health Management from the Health Knowledge and Behaviour Domains are considered most relevant to patients with chronic conditions (Table 1). In addition, there are 40 outcomes (e.g. Knowledge: Chronic Disease Management) focused on knowledge of clinical conditions such as cardiac disease and depression, 34 outcomes (e.g. Knowledge: Weight Management) focused on evaluation of knowledge of health promotion, and 29 outcomes (e.g. Self-Management: Chronic Disease) addressing self-management of clinical conditions. Also relevant to the SFMF are outcomes that focused on the family as a unit, that is, family functioning, and specific outcomes for the roles of family and caregivers (Moorhead et al., 2018). There are 51 outcomes directly focused on family and/or caregivers (e.g. Family Coping, Caregiver Emotional Health).

2.2 The self- and family management framework (SFMF)

The SFMF is a theoretical framework that can be used to organize research that advances self- and family management science and to guide nursing care (Grey et al., 2006). The SFMF was originally developed by a group of faculty at the Yale School of Nursing in 2006 (Grey et al., 2006) and was revised in 2015 (Grey et al., 2015). Schulman-Green and colleagues have continued to refine the SFMF (Schulman-Green et al., 2012; Schulman-Green et al., 2016; Schulman-Green, Feder, Dionne-Odom, et al., 2021; Schulman-Green, Feder, Montano, et al., 2021). The SFMF has been used to guide research and practice on self- and family management of chronic diseases such as diabetes, cancer, heart failure and HIV/AIDS internationally (Schulman-Green, Feder, Montano, et al., 2021).

The 2015 version of the SFMF (Grey et al., 2015) depicts relationships among four components: Facilitators and barriers; processes; proximal outcomes; and distal outcomes of self- and family management (Grey et al., 2015). Facilitators and barriers influence self- and family management across chronic disease trajectories and is comprised of four categories—personal/lifestyle, health status, resources and health care system—with a total of 19 sub-categories. The processes component includes three categories—focusing on illness needs, activating resources and living with a chronic condition—with a total of 12 sub-categories. Proximal outcomes has four categories—behaviours, cognition, biomarkers and symptom management—with 13 sub-categories. Distal outcomes also have four categories—health status, individual outcomes, family outcomes and health care—with 12 sub-categories (Figure 1).

2.3 Selection of the SFMF for linkage with the NOC

The SFMF was chosen to link to NOC due to its comprehensiveness in articulating facilitators and barriers to the adoption of self- and family management behaviours along with potential outcomes. Additionally, the framework supports the application of knowledge in real-life situations that matter to patients and families. As noted, NOC includes many outcomes for chronic conditions, self-management and family management which have the potential to measure numerous aspects of self- and family management. The SFMF components are evidence based and sufficiently complete to evaluate patient and family/caregiver outcomes of self- and family management. There is a need to develop linkages between standardized nursing terminologies and elements of the SFMF to facilitate research and practice in this area. This article focuses on the nursing outcomes relevant to the sub-categories of the SFMF.

2.4 The value of the SFMF-NOC linkage

Nursing classification systems not only provide information about nursing care, but also offer the opportunity for critical thinking to aggregate nursing knowledge. A linkage can be defined as that which directs the relationship or association of concepts (Johnson et al., 2011). The use of NOC linkages for planning care has been developed for specific populations, such as elderly women with incontinence living in a nursing home (Gencbas et al., 2018), cancer patients requiring acute or chronic pain control in palliative care (Mello et al., 2016) and patients with COVID-19 (Moorhead et al., 2021; Swanson et al., 2021; Wagner et al., 2022). The linkage of NOC outcomes to the elements of the SFMF enables nurses to evaluate nursing outcomes in patients with chronic diseases to support clinical reasoning, quality and consistency of care.

3.1 Aim

The purpose of this study was to establish linkages between components of the SFMF and outcomes of the NOC to evaluate the comprehensiveness of outcomes addressing self- and family management.

3.2 Design

A descriptive study was carried out in six steps from July 2020 to July 2021: (1) preliminary mapping of all relevant NOC outcomes to the SFMF based on team expertise; (2) development of checklists for team members serving as ‘identifiers’ and ‘reviewers’; (3) mapping all relevant NOC outcomes to the SFMF; (4) final agreement on the results of the mapping process; (5) establishment of inter-rater reliability; and (6) discussion of findings and conclusions with authors of the SFMF. An iterative consensus-based approach has been used by previous researchers to implement the agreement-reaching process in group decision-making for this type of descriptive linkage study (Lucena et al., 2020; Moorhead et al., 2021; Swanson et al., 2021; Wagner et al., 2022).

We formed a team composed of five nurse experts with a range of 7 to 30 years of experience working with SNT as practicing nurses, researchers or developers of standardized terminologies. According to the Delphi technique used in the health sciences, a minimum of three experts should be invited to participate in this kind of study (Niederberger & Spranger, 2020), but the selection of qualified experts was considered more important for this study. It was essential that the reviewers for this project had a deep understanding of the taxonomy and extensive list of NOC outcomes. The team was formed based on the judgement of selected members of the NOC research team who are editors of the NOC (SM and ES) at the University of Iowa. All members of the team were involved in developing and validating NOC outcomes, including editors of the NOC (SM and ES) and former PhD students of the NOC (SC, HO and NCFO) at the University of Iowa.

Experts had one of two roles: identifier or reviewer. Identifiers were responsible for the identification of appropriate NOC outcomes aligned with the categories and sub-categories of the SFMF. To facilitate this process, we established conceptual definitions for each category and sub-category of the SFMF in preparation for linking NOC outcomes with the SFMF. The conceptual definitions of 16 categories and 54 sub-categories of the SFMF were specified (Oh et al., unpublished manuscript). To identify appropriate linkages between SFMF and NOC, identifiers read the conceptual definitions for the SFMF categories and sub-categories as well as the definitions of the NOC outcomes per the sixth edition of the NOC (Moorhead et al., 2018) and selected the NOC outcomes that aligned with the conceptual definitions of the SFMF.

Each reviewer's task was to evaluate whether the NOC outcomes chosen by identifiers for representation in a SFMF category were relevant to measuring the effectiveness of nursing interventions to improve self- and family management of chronic conditions. Reviewers also made suggestions for additional or new NOC outcomes if they perceived a better match than originally identified. For the identification and revision of linked NOC outcomes to the SFMF, we only considered NOC outcomes pertinent for the measurement of nursing interventions for the self-management of chronic diseases; we excluded NOC outcomes for acute conditions (e.g. Blood Loss Severity (0413)). The six steps undertaken by identifiers and reviewers are described below.

5.1 Advantages of linkage work for clinical nursing practice

From this study, a total of 363 unique nursing outcomes across the four components of the SFMF were identified as appropriate to evaluate interventions for patients with chronic diseases and their family caregivers. Nurses play important roles at the frontline of health care for patients with chronic diseases in a wide variety of settings, including health promotion and preventive care. They work with interdisciplinary teams who are responsible for understanding and addressing complex issues for patients with chronic diseases and for providing person-centred care. NOC outcomes linked with the SFMF can be used across the care continuum to follow patient outcomes throughout a chronic disease episode or over an extended period as the teams and family caregivers provide support.

When nurses create the care plan for patients with chronic disease, they can choose which outcomes will be evaluated based on nursing diagnoses and interventions with the perspective of the SFMF. As nurses assess facilitators and barriers and processes and select appropriate proximal and distal outcomes, they can better guide patients and plan more effectively with them and their families to provide care that addresses all components of chronic illness management. Moreover, these linkages allow nurses to evaluate nursing outcomes in a more accurate and measurable way. This evaluation involves the measurement of an individual (e.g. personal health status), family (e.g. family support during treatment) or community state (e.g., community risk control: chronic disease), behaviour (e.g. compliance behaviour) or perception (e.g. self-awareness). This is a critical step in the nursing process because the interpretation of the collected data enables nurses to evaluate the impact of interventions provided by nurses or other health care professionals.

One of the benefits of linkages of SNT and theoretical frameworks is the strengthening the comprehensiveness of the plan of care for patients with chronic diseases and retrieving standardized nursing practice data in a computerized information system (Chae et al., 2020; Johnson et al., 2011). There is fast-growing demand for the reuse of clinical data and electronic health interventions for high-quality health care and population health management (Meystre et al., 2017; Schulman-Green, Feder, Montano, et al., 2021). If NOC is used with the SFMF and coded in electronic health records (EHRs), nursing data can be included in national EHR datasets and can be analysed to determine the value of nursing care to improve practice (Chae et al., 2020; Johnson et al., 2011; Macieira et al., 2019).

5.2 Advantages of linkage work for nursing research

We note many benefits of using the SFMF and the linked NOC outcomes. A potential challenge that researchers and practitioners may face while using this approach is a lack of expertise in the use of NOC. Continuous education of SNTs, expanding collaborative research opportunities using NOC, and operationalization of NOC outcomes are essential for the application of theories and models into nursing practice. These efforts help improve the quality of nursing care because they allow nurses to evaluate what they do for patients with chronic diseases for self-management in tertiary care hospitals, community hospitals, community agencies, nursing centres and nursing homes. The results of this study may contribute to developing NOC outcomes that consider self-management processes, improving self-management for patients with chronic conditions using measurable and quantifiable NOC.

5.3 Methodological issues

The team confronted several methodological issues during this work. One was the question of whether NOC outcomes could be assigned to multiple components of the SFMF (e.g. Motivation (1209), Pain Control (1605) and Caregiver-Patient Relationship (2204)). If team members thought an outcome could only be listed in one part of the framework, the team had to decide which component was the best fit with the outcome. However, for Caregiver-Patient Relationship (2204), effective communication can be placed in several different components of the framework across facilitators and barriers, process or outcomes, therefore, we linked this outcome as well as others to multiple sub-categories. We also dealt with another question as to whether adaptation or adjustment are in the Processes or Outcomes components. We included emotions under facilitators and barriers, enabling us to link Personal Resiliency (1309) and Family Resiliency (2608) during the first linkage review. However, the definition of Family Resiliency (2608) is the capacity of a family to adapt and function following a crisis or adversity (dealing with a chronic illness of a family member). The definition could also fit into a broader category of distal outcomes as this series of outcomes had multiple sub-categories. Therefore, Family Resiliency (2608) was placed under the facilitators and barriers and distal outcomes components. Finally, the definitions of several sub-categories (e.g., Co-morbidity under Health Status category, Financial under Resources category, Work under Environment category, Stress under Biomarkers category) in the framework did not connect with titles, definitions or indicators of any NOC outcomes. This finding suggests the need for development of additional outcomes related to these sub-categories in the NOC.

5.4 Future work

In this study, we linked NOC outcomes to the SFMF, which strengthens the SFMF by creating clearer references to practice-based outcomes in the framework. In a future study, we suggest establishing NANDA-I or Nursing Interventions Classification (NIC) linkages to guide nursing practice for specific illness and conditions based on theoretical perspectives. It may be useful for the phases of the nursing process, NANDA-I, NIC and NOC classifications to be mapped with the SFMF, as these phases describe the elements of nursing care in different steps, including the specificities related to patients with chronic diseases and their caregivers. Future editions of NOC will provide additional opportunities to link new outcomes to the SFMF to better support the care of patients and families with the challenges of managing chronic illnesses.

5.5 Limitations

Limitations of our study pertain to the SFMF and to the review team. About the SFMF, the framework captures adult self-management. Thus, applied NOC outcomes reflect adult versus paediatric populations. Additionally, while NOC outcomes related to family caregivers were applied, the 2015 version of the SFMF does not explicitly include family caregiver components. Facilitators and barriers to family management and family caregivers' management processes have been delineated by the SFMF team elsewhere (Schulman-Green, Feder, Dionne-Odom, et al., 2021). Family-related NOC outcomes were matched to SFMF sub-categories based on expert team members' opinion and review with the SFMF team.

About the review team, a potential limitation is that linkages were developed using a consensus process based on team members' expertise, and experiences and were not validated by other subject matter experts. In future validation of these linkages, we would include external reviewers to check their face validity. Another limitation is that the NOC experts might have had biases and pre-conceived ideas in defining terms of chronic diseases and how to manage chronic disease. Another consideration is the changing extent of illness in defining terms of chronic illness and managing chronic diseases (Walker, 2001).