Health care providers have appreciated the importance of outcomes as requirements for measuring economic efficiency and system effectiveness in a cost-control environment. The concept of outcome has not been analyzed in nursing resulting in a multiple terms or variations in the basic term. In addition to the term "result", eight terms are commonly used in the literature to modify, an outcome: patient, nurse-sensitive, desired, effective, expected, predicted, projected, and actual outcome (van der Bruggen & Groen, 1995). Outcomes may defined as the end results of care, yet when quality of care is being measured outcomes are linked to diagnoses. From this perspective, outcomes are indicators of problem resolution or progress toward resolution.

Historical Perspective: Outcome Classification

Aydelotte (1962) was an early pioneer in the measurement of patient outcomes. She was the first in nursing to use changes in characteristics of patients to evaluate nursing care delivery. In 1988 Heater, Becker, and Olson completed a meta-analysis of studies that suggested a growing interest in nursing goals and outcomes during the previous decade. Outcomes at this time were general, such as "the patient's self care skills" (Hover and Zimmer, 1978).

Johnson and Maas summarized the multiple reports of outcome generation that were characteristic of the 1980s and early 1990s and concluded that identification of outcomes was based mainly on literature reviews and practical experience rather than research or conceptual frameworks" (1997, p.5). These authors also note that nursing outcomes differ in content from medical outcomes. Nursing includes client knowledge and behaviors, safety, use of resources, home maintenance, and caregiver status (1997, p.5). In a large, funded project Johnson and Maas (1997) and a team of investigators at the University of Iowa developed a set of outcomes and proposed their linkages to nursing diagnoses. Outcomes and their indicators are the concepts, or elements, to be used in classification.

Outcome Concept Development

As previously discussed it is important in classification to clearly define that which is to be classified. Secondly, whether the classification is outcomes, diagnoses or interventions, each category at a particular level in a classification system should be at the same level of abstraction. In the Johnson-Maas study three characteristics of outcomes are identified: a variable state, a consequence, and a level of abstraction.

For the team's research, a nurse-sensitive patient outcome is defined as a variable patient or family caregiver state, behavior or perception that is responsive to a nursing intervention and conceptualized at middle levels of abstraction (e.g., mobility level, nutritional status and health beliefs). Nursing-sensitive outcome indicators are defined as variable patient or family caregiver states, behaviors, or perceptions at a low level of abstraction that are responsive to nursing interventions and used for determining a patient outcome (e.g., for the outcome Mobility Level, indicators include "joint movement, "transfer performance," and "ambulation: walking"(1997, p.21).

This shares some of the characteristics of van der Bruggen and Groen's (1996) definition contained in an interim report of an internafional, Delphi study of nurse-experts.

Further specification of outcome-concepts in the Johnson-Maas report includes measurability on a numerical scale (1997, p.22). This latter characteristic allows

1. measurement on a continuum and evaluation of progress toward resolution of a nursing diagnosis, rather than just resolution-no resolution and
2. a scale for projecting outcomes (e.g., prognosis).

As required in classification development, methods for developing the elements for classification and guidelines for decisions are clearly delineated in the Johnson-Maas report (1997). Methods included review of the literature, information systems and other sources. Concept analysis and graduate student surveys were used to determine the validity of the concepts and their indicators. Field testing is planned in multiple settings which will evaluate "frequency of use and sensitivity to nursing interventions" (1997, p.26).

Outcomes in the Johnson-Maas study were limited to individuals and family-caregivers. Plans exist to expand the nomenclature to include family community, and organization. Also further work on linkages is planned (1997).