The Nursing Outcomes Classification:Validation by Rehabilitation Nurses

Cindy A. Scherb, MS RNCarla Gene Rapp, MNSc RN CRRNMarion Johnson, PhD RNMeridean Maas, PhD RN FAAN

Measuring patient outcomes is im­portant to rehabilitation nurses andthe patients they serve. This article de­scribes researchconducted at the Uni­versity ofIowa College ofNursing todevelop the Nursing Outcomes Clas­sification (NO C) and the validationofthis research by surveys conductedthrough specialty nursing organiza­tions, particularly the Association ofRehabilitation Nurses. Nurses re­sponded to surveys designed to vali­date (a) the importance ofoutcomeindicators to the achievement ofanoutcome and (b) nursing's contribu­tion to the achievement ofthe indica­tors. The results ofthe surveys indi­cated that rehabilitation nursesbelieve that nursing makes a sub­stantial contribution to most outcomesand indicators.

Address correspondence to CindyScherb, 4440 State Highway 22,Kiester, MN 56051.

It is necessary to use standardized language to articulate what nurses do. The devel­opment of standardized language for nursing will allow nurses to communicate moreeffectively with other nurses, nationally and internationally, as well as with members ofother disciplines. Although comprehensive classifications of nursing diagnoses (NorthAmerican Nursing Diagnosis Association [NANDA], 1996) and nursing interventions(Iowa Intervention Project, 1996) have been developed, standardized outcomes that aresensitive to the effects of nursing interventions (i.e., nursing-sensitive outcomes) werenot available until work on the Nursing Outcomes Classification (NOC) began at theUniversity ofIowa College of Nursing in 1991. This article describes the developmentofNOC and the specific results of surveys to assess the content validity of the NOC out­comes. One group of surveys was completed by expert nurses who are members of theAssociation of Rehabilitation Nurses (ARN).

The work of the NOC research team is important to nurses because no comprehen­sive standardized language for nursing outcomes exists (Maas, Johnson, & Moorhead,1996). As healthcare reform issues remain in the national spotlight, standardized lan­guage that identifies and measures nurse-influenced patient outcomes is essential fornursing to compete in the managed care environment (Jennings, 1991; Marek, 1989).Consumers are demanding to know what outcomes they can expect from the dollars theyspend on health care, and they are holding all healthcare professionals accountable forthe achievement of these outcomes (Hegyvary, 1991; Kelly, Huber, Johnson, McCloskey,& Maas, 1994). Because of the pressure on healthcare providers to demonstrate results,nurses must be able to demonstrate and justify their contributions to patient care (Jones,1993).

Rehabilitation nurses have realized the need to identify outcomes pertinent to theirpatient populations. The need for quality rehabilitation services is the driving force be­hind the documentation of outcomes obtained from rehabilitation nursing interventions(McCourt, 1993). The Rehabilitation Nursing Foundation (RNF) published 21 Reha­bilitation Nursing Diagnoses: A Guide to Interventions and Outcomes in 1995, and in1996 RNF set a research agenda for rehabilitation nursing. One of the five priorities RNFidentified was "rehabilitation nurse-sensitive outcomes and costs in the continuum ofcare and interdisciplinary seUing(s)" (Nelson, 1996, p. 3).

BackgroundThe primary purpose of the NOC research, which is ongoing, is to conceptualize, la­

bel, define, and classify patient outcomes and indicators sensitive to nursing care. Oth­er.purposes are to evaluate the validity and usefulness of the classification in field testsand to define and test measurement procedures for the outcomes and indicators (IowaOutcomes Project, 1997).

For purposes of this research, "a nursing-sensitive patient outcome is defined as avariable patient or family caregiver state, behavior, or perception that is responsive tonursing intervention and conceptualized at middle levels of abstraction (e.g., mobility

174 Rehabilitation Nursing' Volume 23, Number 4' Jul/Aug 1998

level, nutritional status, health beliefs)" (Iowa Outcomes Proj­ect, 1997, p. 21). The outcomes are stated as concepts that canbe measured along a continuum, rather than as goals. Most ofthe nursing-sensitive patient outcomes characterize the resolu­tion of nursing diagnoses, but not all outcomes are necessarilynursing diagnosis-specific (Maas et al., 1996). The outcomesincluded in NOC are nursing-sensitive outcomes in that theyare influenced by nursing care; however, nursing is not the onlydiscipline responsible for the outcomes (Johnson et al., 1996).

Rehabilitation nurses have realized theneed to identify outcomes pertinent to

theirpatientpopulations.

Each outcome is defined specifically by a group of associ­ated indicators. An indicator is defined as "variable patient orfamily caregiver states, behaviors, or perceptions at a low lev­el of abstraction that are responsive to nursing intervention andused for determining a patient outcome (e.g., for the outcomeMobility Level, indicators include 'joint movement: 'transferperformance: 'ambulation: walking')" (Iowa Outcomes Proj­ect, 1997, p. 21). Thus, indicators are needed to measure specificoutcomes and to reflect the dimensions or aspects of more gen­eral outcomes.

All outcome labels and indicators are measured on a 5-pointLikert-type scale, with 5 being the most desirable patient state.A 5-point scale allows for demonstration of variability in a pa­tient state, behavior, or perception. The outcomes are designedto be measured over time. Measurements are made, at a mini­mum, on admission or during the initial nurse visit (after nurs­ing diagnoses are established) and upon discharge, transfer, orreferral to another agency or healthcare provider (when the sta­tus of each nursing diagnosis is documented).

The NOC research team includes 17 investigators and addi­tional clinical content experts representing eight focus groups.The focus group categories are based on the Medical OutcomesStudy (MOS) (Tarlov et al., 1989) and on work completed with­in nursing by Lang and Clinton (1984) and Marek (1989). NOCfocus group categories include social and role status; physicalfunctional status; safety status; perceived well-being; family care­giver status; physiological status; psychological and cognitivestatus; and health attitudes, knowledge, and behavior. Outcomelabels for the focus group categories are shown in Figure 1.

Each focus group was responsible for identifying outcomelabels by reviewing nursing and allied health research and oth­er pertinent literature. A concept analysis was completed to re­fine outcome labels, clarify definitions, and develop indicatorsfor each outcome. Each focus group was responsible for re­viewing the literature to identify a recommended method ofmeasuring its outcomes (Johnson et al., 1996).

NOC was published in March 1997 with 190 nursing-sen­sitive outcome labels, definitions, indicators, measurementscales, and corresponding background readings. An example,"Self-Care: Activities of Daily Living (ADL)," is shown in

Table 1. Outcomes continue to be identified and developedthrough literature review and feedback from nurses who are fa­miliar with the classification (Iowa Outcomes Project, 1997).

Another step in the development and validation ofNOC wasa survey of master's degree-prepared nurses who representeddifferent clinical specialties and settings and who provided carefor clients in various age groups. ARN was one of the special­ty groups from which these nurses were drawn. Outcomes per­tinent to rehabilitation were selected for inclusion in the sur­vey. The nurses were asked to rate the importance of eachindicator to its outcome label and each indicator's sensitivityto nursing intervention (Maas et al., 1996).

MethodsSample: Nurses were selected to receive surveys based on

their clinical expertise and their familiarity with research tech­niques and the need for classification systems. The names andaddresses of expert rehabilitation nurses were obtained fromARN, and a random sample of 118 nurses was drawn.

Figure 1. Examples of Outcome Labels by FocusGroup Category

Social and Role Status• Psychosocial Adjustment: Life Change• Social Involvement

Physical Functional Status• Mobility Level• Self-Care: Activities of Daily Living

Safety Status• Infection Status• Safety Behavior: Home Physical• Environment

Perceived Well-Being• Acceptance: Health Status• Quality of Life

Family Caregiver Status• Caregiver Emotional Health• Caregiver-Patient Relationship

Physiological Status• Energy Conservation• Endurance

Psychological and Cognitive Status• Body Image• Self-Esteem

Health Attitudes, Knowledge, and Behavior• Compliance Behavior• Knowledge: Treatment Regimen

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Surveys: The surveys were developed to include outcomesfrom similar specialty areas. Each survey contained between 4and 10 outcome concepts and 6 to 15 nursing-sensitive indica­tors for each outcome. The nurse experts were asked to rate eachindicator as to the importance of the indicator for measuringthe outcome (1 =not at all important, 5 =very important) andthe contribution of nursing to the achievement of the indicator(i.e., nursing sensitivity) (l =no contribution, 5 =contributionis mainly nursing). The nurses were also asked to suggest anyadditional indicators and, if they wished, to modify the indica­tors presented in the survey.

Each nurse received a survey based on his or her area of prac­tice. Fourteen NOC outcome labels were determined to be per­tinent for rehabilitation nurses' practice. Because the surveyswere designed to contain 4 to 10 outcome labels, two differentsurveys were sent to the rehabilitation nurses. Survey A con­tained 4 outcome labels and associated indicators, and SurveyB contained 10 outcome labels and associated indicators.

The nurses were asked to return the completed survey in astamped, addressed envelope within 2 weeks of receiving it. (Apostcard reminder was sent 3 weeks after the survey mailing.)Sixty-eight nurses received Survey A; 31 (45%) completed andreturned it. Fifty nurses received Survey B; 22 (44%) complet­ed and returned it. Fourteen of the nurses who received SurveyB identified rehabilitation as their specialty area of practice.Others identified general adult medicine (1), specialty medi­cine (1), specialty surgery (1), community health (2), and oth­er (2); one person did not indicate a specialty. Fifteen of thenurses who responded to Survey A identified rehabilitation as

Table 1. Example of an NOC Nursing-Sensitive Outcome

their specialty area. Other specialties were general adult med­icine (4), specialty medicine (1), gerontology (6), administration(2), home health (1), education (1), and admissions (1). The av­erage number of years of practice in the identified specialty was11.87 years for those who responded to Survey A and 10.93years for those who responded to Survey B. Forty-three of the53 respondents to the surveys were currently certified by a pro­fessional organization, and 35 of the 43 certified nurses wereCertified Registered Rehabilitation Nurses (CRRNs).

Survey resultsContent validity and sensitivity to nursing interventions were

estimated using a modification of the Fehring (1987) method­ology. Nurse experts were asked to rate each indicator for itsimportance in measuring the nursing-sensitive outcome and forthe contribution of nursing to achievement of the indicator (i.e.,sensitivity). Weighted ratios for each indicator statement werecalculated by adding all the individual responses and dividing thetotal by the total number of responses. The weights suggested byFehring are 5 = 1.00,4 = 0.75,3 = 0.50,2 = 0.25, and 1 = 0.1fthe weighted ratio scores for importance and contribution werehigher than 0.80 for a given indicator, the indicator was con­sidered to be a critical indicator. If the weighted ratio scoreswere higher than 0.60, the indicator was still considered im­portant and was retained. If the weighted ratio scores were low­er than 0.59, the research team evaluated whether the indicatorshould be retained. Most indicators were above the 0.60 level,and many were above the 0.80 level. The overall outcome con­tent validity and outcome sensitivity values were calculated by

Self-Care: Activities of Daily Living (ADL)Definition: Ability to perform the most basic physical tasks and personal care activities

Dependent, Requires assistive Requires assistive Independent with Completelydoes not participate person and device person assistive device independent

Self-Care: ADL 2 3 4 5

IndicatorsEating 2 3 4 5Dressing 2 3 4 5Toileting 2 3 4 5Bathing 2 3 4 5Grooming 2 3 4 5Hygiene 2 3 4 5Oral hygiene 2 3 4 5Ambulation: Walking 2 3 4 5Ambulation: Wheelchair 2 3 4 5Transfer performance 2 3 4 5Other (specify) 2 3 4 5

From Nursing Outcomes Classification (NOC), by Iowa Outcomes Project, M. Johnson and M. Maas (Eds.), 1997, St. Louis:Mosby. Reprinted with permission.

176 Rehabilitation Nursing> Volume 23, Number 4· luI/Aug 1998

averaging the individual indicator importance and contributionscores. Table 2 shows the overall content validity and nursingsensitivity scores for each outcome label.

The research team reviewed the expert nurses' suggestionsand made changes as appropriate. The results of the surveys in­dicated that rehabilitation nurses believe that the indicators areimportant to evaluation of the outcome concepts, that nursing'scontribution to most outcomes and indicators is substantial, andthat no important indicators were missing.

Summary and nursing implicationsARN members assisted in validating outcome labels and in­

dicators pertinent to the rehabilitation specialty.The nurses sub­stantiated that the indicators and outcome labels are sensitiveto nursing intervention and that the indicators are important inmeasuring the outcomes. Survey findings from rehabilitationnurses and members of other nursing specialty groups "provideevidence that the selection, development, and refinement ofnursing-sensitive outcomes and indicators, based on the quali­tative and concept analyses, were valid" (Iowa Outcomes Proj­ect, 1997, p. 39).

Through these survey results, rehabilitation clinicians haveshown that NOC is pertinent to the practice of rehabilitationnursing. However, rehabilitation nurses were surveyed only onselected NOC outcomes, and many more NOC patient outcomescan be used in determining the outcomes of rehabilitation nurs­ing care.

Rehabilitation nurse clinicians have already taken a step to­ward identifying interventions and outcomes pertinent to theirnursing practice through 21 Rehabilitation Nursing Diagnoses:A Guide to Interventions and Outcomes (RNF, 1995). Com­municating these outcomes using standardized language pro­vided by NOC will allow for comparison of nursing practiceacross settings and promote research into the effectiveness ofrehabilitation nursing.

Outcomes or goals often are measured in terms of being metor not met. An advantage of using NOC to measure patient out­comes is the means it uses to measure the status of outcome la­bels and indicators. NOC uses a 5-point Likert-type scale be­cause this type of scale provides "an adequate number ofresponses to demonstrate variability in the patient state, be­havior, or perception depicted in the outcome" (Iowa OutcomesProject, 1997, p. 50).

Rehabilitation nursing is practiced in a variety of roles andsettings. Rehabilitation clinicians may be inpatient or outpa­tient staff nurses, case managers, home health nurses, advancedpractice nurses, managers, or educators. All rehabilitation nurs­es, regardless of their role or practice setting, need to commu­nicate with one another. Additionally, rehabilitation clients areadmitted from and discharged to a variety of settings. Nursesin different settings have an identifiable need for clear com­munication. Using NOC enables nurses to communicate pa­tient outcomes, using standardized language, to all practition­ers across the continuum of care. The use of standardized

Table 2. Outcome Labels Surveyed by ARN Members, with Resulting Content Validityand Nursing Sensitivity Scores

Outcome Label Outcome Definition N* (Content Validity) N* (Nursing Sensitivity)Endurance Extent that energy enables a person's activity 17 (0.79) 17 (0.57)Energy Conservation Extent of active management of energy to 8 (0.79) 8 (0.60)

initiate and sustain activityRest Extent and pattern of diminished activity for 4 (0.86) 4 (0.67)

mental and physical rejuvenationSelf-Care: ADL Ability to perform the most basic physical 9 (0.85) 9 (0.75)

tasks and personal care activitiesSelf-Care: Bathing Ability to cleanse own body 11 (0.72) 11 (0.77)Self-Care: Dressing Ability to dress self 10 (0.71) 10(0.71)Self-Care: Eating Ability to prepare and ingest food 24 (0.74) 24 (0.62)Self-Care: Grooming Ability to maintain kempt appearance 7 (0.72) 7 (0.73)Self-Care: Hygiene Ability to maintain own hygiene 6 (0.80) 6 (0.80)Self-Care: Nonparenteral Ability to administer oral and topical 24 (0.87) 24 (0.92)

medication medications to meet therapeutic goalsSelf-Care: Oral hygiene Ability to care for own mouth and teeth 8 (0.76) 8 (0.69)Self-Care: Parenteral Ability to administer parenteral medications to 27 (0.89) 27 (0.94)

medication meet therapeutic goalsSelf-Care: Toileting Ability to toilet self 10 (0.87) 10 (0.87)Sleep Extent and pattern of sleep for mental and 14 (0.70) 14 (0.56)

physical rejuvenation

·N = Number of indicators per outcome labelIn the original surveys, endurance was called fatigue status; energy conservation was called energy management status; rest wascalled rest status; and sleep was called sleep status.

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language also facilitates effective communication with clientsand their families.

Rehabilitation nurses are familiar with the Functional Inde­pendence Measure (FIMTM), an assessment instrument for gath­ering standardized data on functional ability and interdiscipli­nary rehabilitation outcomes (Uniform Data Set for MedicalRehabilitation, 1996). NOC functions in a similar manner; how­ever, it has a nursing focus rather than an interdisciplinary fo­cus. The use of NOC standardized outcomes involves the mea­surement of status at various intervals; this feature helps thenurse and client define goals and track progress. Communica­tion of NOC status to clients and their families is a way to em­power clients and to facilitate continuity of care across settings.The use ofNOC will allow rehabilitation nurses to create a spe­cialized outcomes database and justify their unique contribu­tion to patient outcomes.

As computer technology advances, the development and useof data sets will accelerate. It is crucial that national data setsrepresent nursing so that nurses do not continue to be unrecog­nized as essential healthcare providers (Johnson & Maas, 1994;Marek, 1989). A fundamental reason for the absence of nurs­ing data in large local and national data sets is the absence of acomprehensive standardized language for nursing. A compre­hensive language must be applicable across all practice settingsand usable by all nursing specialties (Iowa Intervention Proj­ect, 1996). NOC, NANDA, and the Nursing Intervention Clas­sification (NIC) facilitate research related to nursing effective­ness because their classifications comprehensively standardizenursing practice languages and enable collection ofnursing datain large databases (Iowa Intervention Project, 1997).

Communicating outcomes using standardizedlanguage allows comparison across practice

settings andpromotes nursing research.

An important benefit of research related to the effectivenessof nursing is that it provides the ability to compare data acrossinstitutions and settings. A common or standardized languageof measurement is necessary for data to be comparable (Titler& Reiter, 1994). The Omaha Classification System (Martin &Scheet, 1992) and the Home Health Care Classification (Saba,1992) are both well-known classifications, but they are specif­ic to home and community health care (Head, Maas, & John­son, 1997). The only comprehensive standardized classifica­tion systems for nursing diagnoses, nursing interventions, andnursing outcomes are NANDA, NIC, and NOC, respectively.

Through the use of large nursing data sets, the nursing pro­fession will be able to determine what interventions achievecertain desired outcomes, link them to appropriate nursing di­agnoses (Iowa Intervention Project, 1996; Maas et aI., 1996),and identify areas of needed change or improvement in nurs­ing practice (Maas et aI.). McCloskey and Bulechek (1992) stat­ed, "The relationships among diagnosis, interventions, and out-

178 Rehabilitation Nursing> Volume 23, Number 4· Jul/Aug 1998

comes will be determined through the study of actual patientcare using the databases that these classifications generate" (p.65). Rehabilitation nursing can benefit from the developmentof large clinical data sets and subsequent research on effec­tiveness. Data obtained from rehabilitation settings will helpdefine rehabilitation nursing practice.

Nursing will become more visible and influential throughthe use of data gathered using standardized language, and nurs­es will be able to alter their practice based on knowledge gainedfrom the use of standardized language.

All the authors are affiliated with the University ofIowa College ofNursing in Iowa City, fA: Cindy Scherb and Carla Gene Rapp aredoctoral candidates, Marion Johnson is an associate professor, andMeridean Maas is a professor.

ReferencesFehring, R.1. (1987). Methods to validate nursing diagnosis. Heart & Lung,

16,625-629.Head, B., Maas, M., & Johnson, J. (1997). Outcomes for home and com­

munity nursing in integrated delivery systems. Caring Magazine. 16(1),50­56.

Hegyvary, S.T. (1991). Issues in outcomes research. Journal ofNursingQuality Assurance, 5(2), 1-6.

Iowa Intervention Project. (1996). In J.e. McCloskey & G.M. Bulechek(Eds.), Nursing Interventions Classification (NIC) (2nd ed.). St. Louis: Mosby.

Iowa Intervention Project. (1997). Proposal to bring nursing into the in­formation age. Image: Joumal ofNursing Scholarship, 29,275-281.

Iowa Outcomes Project. (1997). In M. Johnson & M. Maas (Eds.), Nurs­ing Outcomes Classification (NOC). St. Louis: Mosby.

Jennings, B.M. (1991). Patient outcomes research: Seizing the opportuni­ty. Advances in Nursing Science, 14(2),59-72.

Johnson, M., & Maas, M. (1994). Nursing-focused patient outcomes: Chal­lenges for the nineties. In J.e. McCloskey & H.K. Grace (Eds.), Current issuesin nursing (4th ed., pp. 136-142). St. Louis: Mosby.

Johnson, S.1.,Brady-Schluttner, K., Ellenbecker, S., Johnson, M., Lassegard,E., Maas, M., Stone, J.L., & Westra, E.L. (1996). Evaluating physical func­tional outcomes: One category of the NOC system. MEDSURG Nursing, 5,157-162.

Jones, K.R. (1993). Outcomes analysis: Methods and issues. Nursing Eco­nomics, 11, 145-152.

Kelly, x.c., Huber, D.G., Johnson, M., McCloskey, i.c., & Maas, M.(1994). The medical outcomes study: A nursing perspective. Journal ofPro­fessional Nursing, 10, 209-216.

Lang, N.M., & Clinton, J.F. (1984). Assessment of quality of nursing care.In H.H. Werley & J.1. Fitzpatrick (Eds.), Annual Review ofNursing Research(pp. 135-163). New York: Springer.

Maas, M.L., Johnson, M., & Moorhead, S. (1996). Classifying nursing­sensitive patient outcomes. Image: Journal ofNursing Scholarship, 28,295­301.

Marek, K.D. (1989). Outcome measurement in nursing. Journal ofNurs­ing Quality Assurance, 4(1), 1-9.

Martin, K.S., & Scheet, NJ. (1992). The Omaha System: Applications forcommunity health nursing. Philadelphia: W.E. Saunders.

McCloskey, J.e., & Bulechek, G.M. (1992). Defining and classifying nurs­ing interventions. In Patient outcomes research: Examining the effectiveness ofnursing practice (NIH Publication No. 93-3411, pp. 63-69). Washington, DC:U.S. Department of Health and Human Services.

McCourt, A.E. (Ed.). (1993). The specialty practice ofrehabilitation nurs-

continued on page 191

Contact [Official publication of the Australian Spina Bifida Association], 1(1),14-19.

Simpson, D., Carney, A., & Creswell, J. (1985). Myelomeningoceles: Va­lidity of early postnatal assessment. Journal of Pediatric Neurosciences, 1,187-202.

Stellman-Ward, G., Bannister, C.M., & Lewis, M. (1993). Assessing theneeds of the adult with spina bifida. European Journal ofPediatric Surgery, 3(Supp!. I), 14-16.

AcknowledgmentsThe authors thank the Minister of Health of South Australia,

the Honorable Dr. Michael Armitage, for his interest in this studyand for providing funds for it under the Commonwealth StateDisability Agreement. The study was coordinated by the Adultswith Physical or Neurological Disabilities Options CoordinationAgency. Dr. Richenda Webb and Ms. Virginia Deegan helped incosting services to spina bifida clients. The authors thank Asso­ciate Professor Peter Reilly, chairman of the adult spina bifidaclinic at Royal Adelaide Hospital, Ms. Joan Beavan, liaison of­ficer at the Spina Bifida Association ofSouth Australia, Inc., andother colleagues at the Royal Adelaide Hospital and Women'sand Children's Hospital for their interest and support. Most im­portantly, the authors thank members of the Spina Bifida Asso­ciation of South Australia, Inc., for making this study possible.

Julie Goodger and Jane Kulas are outreach registered nurses.Annabel Came)' is a coordinator at the Women's and Children '.I'

Hospital'.I'spina bifida clinic. Patrick Dewan is a urologist and"'aschair at the Women '.I' and Children '.I' Hospital's spina bifida clin­ic. Elizabeth Kosmala is the president ofthe Spina Bifida Associa­tion ofSouth Australia, Inc. Donald Simpson is a neurosurgeon atWomen's and Children's Hospital and Royal Adelaide Hospital.He is also a clinical professor at the University ofAdelaide,

ClarificationIn the May/June 1998 issue of Rehabilitation Nursing, the ob­

jectives for the CE feature "Sociodemographic DifferencesAmong Members of Two Ethnic Groups in a Geriatric Reha­bilitation Unit in Israel" (written by Zohar Nir and David Galin­sky, pp. 148-156) were inadvertantly omitted. The CE objec­tives that correspond with the article appear in the box to theright. To apply for CE credit for this article, please refer to theContinuing Education Feature Application Form on page 168ofthe May/June 1998 issue of Rehabilitation Nursing.

Rehabilitation Nursing regrets the omission.

Nursing Outcomes Classificationcontinued from page 178

ing: A core curriculum (3rd ed.). Skokie, IL: Rehabilitation Nursing Founda­tion.

Nelson, A (1996). A research agenda for rehabilitation nursing. ARN News,12(7),3.

North American Nursing Diagnosis Association (NANDA). (1996).NANDA nursing diagnosis: Definitions and classification, 1997-1998. Philadel­phia: Author.

Rehabilitation Nursing Foundation. (1995). 21 Rehabilitation nursing di­agnoses: A guide to interventions and outcomes. Glenview, IL: Author.

Saba, V.K. (1992). The classification of home health nursing: Diagnosisand interventions. Caring Magazine, 11(3),50-57.

Tarlov, AR., Ware, J.E., Greenfield, S., Nelson, E.C., Perrin, E., & Zubkoff,M. (1989). The medical outcomes study: An application of methods for mon­itoring the results of medical care. Journal ofthe American Medical Associa­tion, 262,925-930.

Titler, M.G., & Reiter, R.c. (1994). Outcomes measurement in clinicalpractice. MEDSURG Nursing, 3, 395-398.

Uniform Data Set for Medical Rehabilitation. (1996). Guide for the Uni­form Data Set for Medical Rehabilitation (including the FlM'M instrument),version 5.0. Buffalo, NY 14214: State University of New York at Buffalo.

AcknowledgmentsThe research reported in this article was funded by Sigma

Theta Tau International (1992-1993) and the National Institutefor Nursing Research (Grant ROI NR03437, 1993-1997).

Sociodemographic DifferencesAmong Members of Two EthnicGroups in a Geriatric Rehabilita­tion Unit in Israel (Nir, Galinsky)This continuing education offering (codenumber RNC-131) will provide 1 contact

hour to those who read this article and complete the appli­cation form on page 168 of the May/June 1998 issue ofRe­habilitation Nursing.This independent study offering isappropriate for all re­habilitation nurses. By reading this article, the learner willachieve the following objectives:I. Describe how to implement a plan for nursing interventions

in the first phase of rehabilitation for elderly patients of dif­ferent ethnic backgrounds.

2. Outline the main determining factors that affect attitudes andbehavior of families of elderly patients during the first phaseof rehabilitation.

3. Describe how ethnic background contributes to the under­standing of elderly patients' behavior and to families' attitudesduring their loved one's hospitalization.

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