Results of the Nursing Outcomes Classification / NOC for patients with obsessive-compulsive disorder

Rev Bras Enferm. 2020;73(1): e20180209 http://dx.doi.org/10.1590/0034-7167-2018-0209 8 of ABSTRACT Objective: To analyze the application of nursing outcomes and indicators selected from the Nursing Outcomes Classification (NOC) to evaluate patients with obsessivecompulsive disorder (OCD) in outpatient follow-up. Method: Outcome-based research. First, a consensus was achieved between nurses specialized in mental health (MH) and in the nursing process to select NOC-related outcomes and indicators, followed by the elaboration of their conceptual and operational definitions. Then, an instrument was created with these, which was tested in a pilot group of six patients treated at a MH outpatient clinic. The instrument was applied to patients with OCD undergoing Group Cognitive Behavioral Therapy (GCBT). The study was approved by the Research Ethics Committee of the institution. Results: Four NOC outcomes and 17 indicators were selected. There was a significant change in the scores of nine indicators after CBGT. Conclusion: The study showed feasibility for evaluating symptoms of patients with OCD through NOC outcomes and indicators in an outpatient situation. Descriptors: Obsessive-compulsive Disorder; Nursing Process; Nursing Care; Evaluation of Outcomes (Health Care); Mental Health.


INTRODUCTION
Obsessive-compulsive Disorder (OCD) is a chronic mental disorder, characterized by the unadapted response of psychic functions of thought regarding obsessions and behavior, which are compulsions (1) . OCD affects about 1.6% to 3.1% of the population at some point in life, and its symptoms cause a negative impact on quality of life (2)(3) .
Currently, there is evidence of effective treatment for OCD such as Exposure Response Prevention (ERP), Cognitive Behavioral Therapy (CBT), and medications (3) . CBT for OCD can be performed within a group (GCBT), with evidence of efficacy for reducing the intensity of symptoms (4) .
The Hospital de Clínicas de Porto Alegre [Outpatient Clinic of Porto Alegre] (HCPA) uses the GCBT for the treatment of patients with OCD, and such is coordinated by a nurse. For the indication of the intervention, patients are individually evaluated in an outpatient nursing consultation, which is structured according to the stages of the Nursing Process (NP) (5) . During the appointment, patients are evaluated through the Mental State Examination (MSE) to define nursing diagnoses and interventions based on the NANDA-International (NANDA-I) and the Nursing Interventions Classification (NIC) taxonomies (6)(7) .
Currently, the response to the GCBT intervention is evaluated by instruments, such as the Yale Brown Obsessive-Compulsive Scale (Y-BOCS) and the Obsessive Compulsive Inventory Revised (OCI-R) (4,8) , and not by a standardized nursing evaluation system. In this sense, the Nursing Outcomes Classification (NOC) has a list of clinical indicators for each of its proposed outcomes to assess patients' status and response to interventions in health care. The indicators can be selected by the nurse according to clinical status, and can be continuously measured by the five-point Likert scale, being 1 the worst possible score and 5 the best expected outcome. Patients should be evaluated at least twice to allow the comparison of results before and after a nursing intervention (9)(10) .
In this context, considering the need for a system to assess outcomes of the health care provided by nurses in outpatient care, and due to the scarcity of studies in this area, our motivation to conduct this study emerged in order to improve the knowledge of NOC within the clinical practice of mental health in the outpatient situation. We aim to select the most appropriate NOC outcomes and indicators for the evaluation of patients with OCD and to analyze their application into a group of patients undergoing the GCBT intervention.

OBJECTIVE
To analyze the application of nursing outcomes and indicators selected from the NOC to evaluate patients with OCD in outpatient follow-up.

Ethical aspects
The study was approved by the Research Ethics Committee of the HCPA. Participants signed an informed consent form specific to each research step.

Study design, location, and period
This is an outcome-based research (11) , carried out in the Mental Health Nursing Outpatient Clinic of the HCPA, and developed in two stages. The first was performed through a consensus-validation study of specialists, who selected NOC-related outcomes and indicators to be applied to the real healthcare scenario of patients with OCD. In the second stage, an instrument with the selected outcomes and indicators was applied in order to evaluate patients with OCD in outpatient follow-up and attending GCBT sessions, comparing the initial and final health status.
The used intervention protocol of 12 GCBT sessions was based on a previous study whose authors evidenced positive response in patients with OCD (4) . The group was coordinated by a nurse and a physician co-therapist resident in psychiatry. The meetings occurred weekly and lasted for 120 minutes each. During the sessions, different themes were approached, and in the initial sessions (from the 1 st to the 3 rd ), techniques of psychoeducation and ERP were used. Patients were gradually exposed to the tasks performed in the session, at home, or in the work environment, considering the anxiety level for each exercise, in such a way they could be habituated. In intermediate sessions (from the 4 th to the 9 th ), cognitive techniques were used to correct dysfunctional beliefs (cognitive distortions). After the 10 th session, relapse prevention was approached. The family was invited to participate in the 1 st and the 8 th session for psychoeducation about OCD and about how relatives can assist in the treatment (4) .

Population: inclusion and exclusion criteria
In the first stage of the study, there were three researchers, who were nurses specialists in mental health, and one specialist in NP. As inclusion criterion, we considered the clinical nursing experience in mental health and in research on NP in the outpatient situation. Patients were chosen by convenience and the established criteria were in accordance with a previous study (12) .
In the second stage, patients attended in the Nursing Program in Mental Health (Programa de Enfermagem em Saúde Mental -PESM) and selected for the GCBT participated in the pilot group. The inclusion criteria for attending the GCBT, according to a previous study (4) , were: adult individuals (aging 18 to 65 years) with diagnosis of OCD, literate, and using medications or not. For patients who were undergoing pharmacological treatment, those with a stable dose of medication for at least four months were included. Exclusion criteria (4) were: patients with psychotic symptoms, risk of suicide, severe depression, or those who had previously undergone treatment with GCBT.
Admission of patients to attend GCBT consecutively occurred, to the extent that they were referred through an individual consultation conducted by the nurse coordinating the group, in which scales for assessing the severity of OCD were applied.

Study protocol
In the first stage, a meeting was held to discuss and select the NOC-related outcomes and indicators. At the meeting were present the nurse coordinator of the GCBT, a nurse and teacher specialist in NP, a nurse and professor specialist in Mental Health, and a nurse researcher. Prior to the meeting, the researcher made a previous selection of the nursing diagnoses (ND) most frequently listed for patients with OCD, according to NANDA-I, a diagnostic classification system used in the research field (7) . The ND were Anxiety (00146), Fear (00148), Ineffective coping (00069), and Ineffective activity planning (00199). After the selection, the researcher considered the chapter on NOC and NANDA-I relations (10) , in which are described the suggested and additional results associated with the ND, considering its application into the clinical practice for evaluating patients. Then, specialists achieved a consensus for the selection of the most appropriate outcomes and indicators for the patients in question.
The second stage consisted of the evaluation of patients with OCD attending GCBT using the instrument that contained the NOC-related outcomes and indicators previously selected by consensus. The evaluation was performed by the researcher by observation during the sessions and in individual appointments that occurred at three different times: in the first, the sixth, and the last session of the group (equivalent to the 12 th session). According to the literature, the interval between assessments is decided by the nurse, but the minimum of assessments required to measure a NOC outcome are two times, one at the beginning and the other at the end of the intervention (10) . Clinical and sociodemographic data were also collected in the initial evaluation consultation.
Instruments used to verify the severity of OCD were Y-BOCS (4) and the OCI-R (8) , both validated for Portuguese language. They indicate that the higher the score, the more severe the OCD.

Analysis of results and statistics
For the selection of indicators and outcomes of NOC suggested in the first stage of the study, we selected those who obtained 100% of agreement among the specialists.
We used descriptive analysis to present sociodemographic and clinical characteristics. Continuous variables are expressed as mean and standard deviation or median and interquartile range, according to data distribution. Categorical variables were expressed as percentages and absolute numbers. To compare the scores of the NOC indicators identified in the patients under follow-up, we used the Generalized Estimating Equations (GEE).
Data were analyzed using the Statistical Package for the Social Sciences (SPSS) program, version 18.0. The adopted significance level adopted was 5% (p< 0.05), and confidence interval (CI) of 95%.

RESULTS
After the specialists' consensus, we selected 4 nursing outcomes and 17 NOC-related indicators. The selected outcomes were: Anxiety self-control (1402) For each of these outcomes, the respective indicators were selected, which had established conceptual and operational definitions based on the literature, in order to make the evaluation of the patient as reliable as possible (1,13) . In a second meeting for the consensus of specialists, definitions and operational magnitude of each indicator according to the Likert scale were finalized. We show the conceptual and operational definitions of each outcome indicator in Chart 1. In order to verify the potential use in the clinical practice, the 4 NOC-related outcomes and the respective 17 indicators were applied to a pilot group of patients with OCD who attended GCBT.

Pilot group: Nursing Outcomes Classification/NOC characteristics and outcomes
The pilot group of our study was attended by six patients. Regarding sociodemographic characteristics, 5 patients (83%) were women, with mean (standard deviation) age of 40.8 (SD = 13.7) years, and 5 (83%) self-reported being of white ethnicity. Regarding occupation and marital status, 3 (50%) had formal job and 3 (50%) were married. The education found was 4 (66%) with high school degree and 2 (33%) with higher education degree. During the initial consultation, the severity of the patients' symptoms was assessed by the nurse coordinator of the group with the Y-BOCS and OCI-R scales, and the mean was 30 (SD = 10.8) and 37.8 (SD = 14.9), respectively.
The nursing outcomes Anxiety self-control (1402), Fear level (1210), Anxiety level (1211), and Personal time management (1635) totaled 17 assessments for each indicator, considering that 6 patients participated in the first and second evaluation, and 5 participated in the third due to the withdrawal of one of them in the 7 th session (Table 1).
We observed that there was a significant change after the GCBT in the indicator "Uses effective coping strategies" (p< 0.001) concerning the Anxiety self-control outcome (1402). The remaining four indicators related to this outcome were not significant when compared with the evaluations during the intervention.
Plan activities by the week Conceptual definition: Succeeds in making schedule of commitments/activities for the following week and perform it, without interruptions or changes of time due to rituals/ obsessions/compulsions.

1.
Never succeeds in planning activities for the next week 2. Rarely succeeds in planning activities for the next week 3. Succeeds in planning activities for the next week one week a month 4. Succeeds in planning activities for the next week almost every weeks a month 5. Usually succeeds in planning activities for the next week

Minimizes interruptions
Conceptual definition: Decrease the number of ritualrelated interruptions (e.g., checking, repeating) during daily or exceptional tasks.

Usually interrupts tasks 2.
Interrupts tasks several times a week 3. Interrupts tasks several times a month 4. Rarely interrupts tasks 5. Never interrupts tasks Uses strategies to reduce anxiety Conceptual definition: Uses personal or learned strategies aimed at reducing anxiety in moments of crisis, without confusing strategies with "masked" rituals. Examples of strategies: The STOP technique, seeking to be distracted to cut the flow of invasive thoughts, doing another activity etc.  Regarding the Fear level outcome (1210), four out of six indicators had significant changes in their scores after the intervention, namely: "Distress" (p < 0.001), "Restlessness" (p = 0.028), "Difficulty concentrating" (p < 0.001), and "Exaggerated concern about life events" (p = 0.040).
In the Anxiety level outcome (1211), both indicators "Indecisiveness" (p = 0.004) and "Decreased productivity" (p < 0.001) had significant differences in the evaluation, among the three evaluated.
In the indicators "Sets time for completion of commitments" (p = 0.019) and "Minimizes interruptions" (p = 0.040), regarding the Personal time management outcome (1635), we observed a significant change before and after the intervention, among the four evaluated.
During the sessions and in the course of the progress of the GCBT pilot group, we could establish a bond with patients and notice a feeling of confidence and expectation concerning the evaluations with the constructed instrument. To the extent the ERP exercises proposed by the therapy were more complex, and the patients were willing to make them, their advances were more perceptible during the evaluations, measured by the indicators of evaluation of the NOC-related outcomes and the researcher's perception.
At the end of the last evaluation, we exposed to the patients, individually, the evaluation instrument containing the scores of each indicator, together with an explanation of the significance of the evolution of the scores throughout the therapy, as well as what each indicator represented to their treatment.

DISCUSSION
Our study was based on the stages of the NP as a guideline, starting from the selection of the ND most frequently listed for OCD patients, followed by the consensus of specialists to establish the expected outcomes for these patients and the application of an instrument based on the NOC for evaluating the intervention in the outpatient practice scenario.
According to the ND that sought to comprise the different dimensions of OCD, this represents a combination between Anxiety (00146) and Fear (00148), which results in Ineffective coping (00069) of everyday situations and consequently can cause an Ineffective activity planning (00199), impairing social and family relationships-related issues and directly affecting the lifestyle of patients with the disease (1,7) .

Consensus of specialists
In the consensus among specialists, based on the composition between the knowledge about mental health and NP, we could list nursing outcomes that encompass important issues to be considered about the different dimensions of OCD and, at the same time, indispensable factors for the correct evaluation of these patients in the clinical practice; focusing on the interventions performed during the GCBT, from the psychoeducation provided to the patients, and the access to knowledge and selfmonitoring of their symptoms.
During the consensus we addressed the need to balance the amount of outcomes that could be evaluated by the evaluator's observation, and those that could be assessed by the patient's information, since information provided by patients is rarely compatible with the reality, making the nurse the main evaluator of the evolution of the expected outcomes.
Authors of recent studies (9,14) have used the specialists' consensus method to establish the nursing outcomes based on the most appropriate NOC taxonomy for patients' evaluation, in addition to concluding that conceptual and operational definitions of indicators enable the use of this taxonomy in the clinical practice.

Result of the pilot group
The sample characteristics of our study showed similarity regarding previous studies, since there are patients categorized as severe and according to the scores obtained by the evaluation scales Y-BOCS and OCI-R (4) .
Themes and exercises related to the ERP therapy mostly comprise techniques to cope with fears and beliefs deemed as real on the part of the patients, associated with the prevention of rituals for decreasing anxiety (4) . Therefore, we could observe a significant improvement in relation to coping strategies addressed in the Anxiety self-control outcome (1402).
Distress and restlessness are considered physical and psychic symptoms related to peaks of anxiety that may be caused by the performance of the ERP exercises (4,7) . From the habituation of the exposures, the progressive improvement of these symptoms is expected, as we observed through the Fear level outcome (1210). Moreover, concerning the difficulty concentrating and exaggerated concern about everyday situations, such as those that are addressed during therapy, the improvement of the insight throughout the treatment is expected from the understanding of the cognitive therapy, as observed in this study (1) .
The Anxiety level outcome (1211) comprises issues such as indecisiveness and decreased productivity in daily activities. Both are closely related to the anxiety generated due to the obsessions of doubts and the consequent accomplishment of compulsions (4,15) . According to the progressive cessation of rituals and the understanding of the uncertainty present and inherent in daily activities, the reduction of these symptoms was observed throughout the treatment.
The Personal time management outcome (1635) covers issues related to the time demanded by the accomplishment of compulsions. During the GCBT, the establishment of exact periods of time for the accomplishment of daily tasks is suggested, aiming to minimize interruptions due to rituals, in order to improve productivity (15) . Through the indicators "Sets time for completion of commitments" and "Minimizes interruptions, " a significant change was observed between the assessments.
Based on the scores obtained from the evaluation of the selected indicators, we could observe the oscillation of symptoms throughout the therapy: before the treatment scores were higher, during the treatment, they fell, and in the end the scores increased. These alterations are opposed to the process of awareness and understanding of patients throughout the therapy about their symptoms and the functioning mechanisms of the OCD cycle. Before the beginning of therapy, there is no knowledge about the disease yet, and the insight can be considered as low, (most of the time) leading the patients to higher scores; throughout the treatment, some ERP exercises could already be performed (there were some failures), and there is a greater understanding of the symptoms and functioning of the OCD, leading the patients to become aware of the situation and to lower scores; at the end of therapy, the improvement of symptoms, quality of life, and social relationships is expected, with consequent higher scores in those evaluated (4,15) .

Study limitations
Among the limitations of this study, firstly we mention the number of patients in the sample, since this is a pilot study and there was a loss in the final evaluation. There should be more time for evaluating new patients with OCD through the created instrument in other CBT groups. It is worth highlighting that information was collected by the same evaluator at all stages and based on the patients' reports about their healthcare status at a given time.

Contributions to the field of nursing
This study contributes to the improvement of the evaluation of patients with OCD from the use of instruments to measure nursing outcomes, reflecting the expansion of knowledge about the application of NOC to the mental health outpatient scenario .
The prepared conceptual and operational definitions of the indicators selected for these patients contribute to the more accurate identification of signs and symptoms presented by them throughout the established treatment (GCBT), favoring the diagnostic accuracy and the consequent process of critical reasoning of the nurse, focused on decision-making about the expected results, thus providing safer evidence-based health care and increasing the quality of the provided care.

CONCLUSION
The consensus of specialists allowed the selection of the four NOC-related nursing outcomes, with 17 indicators more appropriate for the evaluation of patients with OCD attending GCBT. The instrument created with conceptual and operational definitions of each indicator for evaluating the patients in the pilot group confirmed the possibility of detecting differences in their scores, especially regarding questions addressed during the GCBT.
From the measurement of indicators selected during the GCBT, we can observe the improvement of symptoms related to anxiety, restlessness, concentration, indecisiveness, productivity, and excess of responsibility related to exaggerated concern. We also observed a decrease in the performance of rituals, the establishment of periods determined to perform tasks, and the use of coping strategies.
The created instrument containing nursing outcomes and indicators proved to be sensitive to survey the alteration of symptoms throughout the treatment, being suitable for the evaluation of the expected outcomes for patients with OCD attending GCBT.
We suggest the performance of future studies with the application by different evaluators of the created instrument and to a larger sample of patients, in order to corroborate the findings found in the pilot study.