Nursing outcomes classification (NOC) is the standardized terminology nursing uses to name, define, and measure patient, caregiver, family, and community outcomes that are responsive to nursing interventions. Developed at the University of Iowa College of Nursing beginning in 1991 and first published in 1997 by Marion Johnson, Meridean Maas, and Sue Moorhead, NOC reached its 7th edition in 2024 under Moorhead, Swanson, Johnson, and Maas. Each NOC outcome carries a unique label, a numeric code, a definition, a list of measurable indicators, and a 5-point Likert scale on which baseline, target, and change scores are recorded. NOC sits beside NIC and NANDA-I as the third corner of the standardized nursing language triad and is recognized by the American Nurses Association.
Why the Iowa Outcomes Project began in 1991
The Iowa Outcomes Project was launched in 1991 at the University of Iowa College of Nursing to answer a question the profession had largely avoided: when a nurse intervenes, what changes for the patient, and how would anyone know? Marion Johnson and Meridean Maas led the early work, with Sue Moorhead joining as the project matured into what is now nursing outcomes classification. The motivation was not academic. Hospitals were beginning to capture electronic data, payers were beginning to ask for evidence of value, and nurses had no shared vocabulary to describe what their care produced.
Before NOC, an outcome statement in a student care plan template typically read like a wish: "Patient will tolerate activity." There was no scale, no definition, and no way to compare one shift to the next. The Iowa team set out to fix that by treating outcomes the way physiology treats blood pressure, as variables with definitions and measurable values. The first edition of NOC appeared in 1997 with 190 outcomes and was housed in the Center for Nursing Classification and Clinical Effectiveness, the same center that maintains NIC. By the 7th edition in 2024 the count had grown past 600 outcomes covering individuals, families, and communities. Understanding why nursing outcomes classification exists, that it is a deliberate response to invisibility, helps students stop treating it as paperwork and start treating it as the discipline's measurement language.
The 1991 founding context also explains a quirk students often complain about: NOC overlaps with NANDA-I and NIC in vocabulary but has its own governance. The Iowa group deliberately chose not to fold outcomes into NANDA's diagnostic system because diagnoses describe present states and outcomes describe future states, and confusing the two had already produced years of muddled documentation. By holding outcomes in their own taxonomy, the Iowa team preserved the conceptual difference between problem identification and goal-directed measurement. That separation, awkward as it can feel during a sleepless clinical night, is the structural foundation that makes nursing outcomes classification able to function in research, in nurse-sensitive quality reporting, and in interdisciplinary care planning where physicians and pharmacists need to see exactly what nursing aims to change without translating from prose.
The seven NOC domains: from functional health to community health
NOC organizes its hundreds of outcomes into seven domains, and the domains are the first level of the taxonomy a student should memorize. They are: Functional Health, Physiologic Health, Psychosocial Health, Health Knowledge and Behavior, Perceived Health, Family Health, and Community Health. Each domain represents a different lens on what nursing influences. Functional Health captures energy, mobility, and self-care. Physiologic Health covers cardiopulmonary, fluid and electrolyte, immune, metabolic, neurocognitive, and tissue integrity outcomes. Psychosocial Health spans psychological well-being, psychosocial adaptation, self-control, and social interaction.
Health Knowledge and Behavior contains outcomes about what patients understand and what they do, the territory most relevant to discharge teaching plans. Perceived Health includes self-rated health, satisfaction with care, and quality of life, recognizing that the patient's view is itself an outcome. Family Health holds outcomes about caregiver performance, family integrity, and parenting. Community Health, the last and least familiar domain, covers community competence, community health protection, and community well-being, and is where public health nursing students will spend most of their time. When you write a care plan and reach for a NOC outcome, the discipline of nursing outcomes classification begins with picking the correct domain, because a domain mismatch almost guarantees an indicator mismatch downstream.
The seven-domain structure also reflects a deliberate epistemological choice. Nursing has historically wrestled with whether its proper subject is the body, the mind, the family, or the community, and each ideological camp tended to dismiss the others. The Iowa team resolved the dispute by including all four levels in the same taxonomy, signaling that nursing outcomes classification regards every level as legitimate and measurable. For a graduate student writing a theoretical paper, this is a useful talking point: NOC operationalizes the metaparadigm of person, environment, health, and nursing without forcing an ideological commitment to any single nursing theorist. For an undergraduate writing fundamentals papers, the practical takeaway is simpler. Read the patient scenario, decide whether the case is primarily about function, physiology, psychology, behavior, perception, family, or community, and let that decision pick your domain before you scroll the outcome list.
The 31 NOC classes that organize each domain
Below the seven domains, NOC subdivides into 31 classes. Classes are mid-level groupings that make the taxonomy navigable in print and in electronic health records. Functional Health, for example, contains the classes Energy Maintenance, Growth and Development, Mobility, and Self-Care. Physiologic Health holds Cardiopulmonary, Elimination, Fluid and Electrolytes, Immune Response, Metabolic Regulation, Neurocognitive, Sensory Function, Therapeutic Response, and Tissue Integrity. Psychosocial Health is split into Psychological Well-Being, Psychosocial Adaptation, Self-Control, and Social Interaction. The remaining four domains carry their own classes following the same logic.
Students often skip the class layer because faculty rarely test it directly. That is a mistake. Classes are how clinicians find an outcome quickly when they know the domain but not the exact label, and they are how the EHR builds drop-down menus. If you are looking for an outcome about a patient's ability to feed himself after a stroke, the path is Functional Health domain, then Self-Care class, then the specific outcome label. Treat classes as the table of contents of nursing outcomes classification rather than memorization material, and you will use the book, the database, and the EHR with much less friction.
| Domain | Representative classes | Example outcome focus |
|---|---|---|
| Functional Health | Energy Maintenance, Mobility, Self-Care | Activities of daily living, ambulation |
| Physiologic Health | Cardiopulmonary, Tissue Integrity, Metabolic Regulation | Wound healing, glucose control |
| Psychosocial Health | Psychological Well-Being, Self-Control, Social Interaction | Anxiety self-control, hope |
| Health Knowledge and Behavior | Health Behavior, Health Knowledge, Risk Control | Medication adherence, fall prevention behavior |
| Perceived Health | Health and Life Quality, Symptom Status, Satisfaction with Care | Pain level, comfort status |
| Family Health | Family Caregiver Performance, Family Member Health Status, Parenting | Caregiver emotional health |
| Community Health | Community Health Protection, Community Well-Being | Community immunity, community violence level |
Anatomy of a single NOC outcome label, definition, and indicators
A NOC outcome is not a sentence; it is a structured object with five fixed parts. Take "Self-Care: Activities of Daily Living" with code 0300, one of the most cited examples in nursing curricula. The label is the proper-noun phrase used everywhere it appears. The code is a four-digit identifier that allows the outcome to travel between paper, EHR, and research database without ambiguity. The definition reads, in essence, ability to perform the most basic physical tasks and personal care activities independently with or without assistive device. That definition is the contract: if a documented outcome does not match it, the outcome chosen was wrong.
Below the definition sits the indicator list, the operational behaviors that make the outcome measurable. For 0300 the indicators include eats, dresses, toilets, bathes, grooms, performs oral hygiene, walks, transfers, and uses adaptive devices. Each indicator is also coded. Finally each indicator carries a 5-point Likert scale, in this case "severely compromised" through "not compromised." A care plan does not score the entire outcome; it scores selected indicators that match the patient's actual deficits, then aggregates. Once a student internalizes this anatomy, the rest of nursing outcomes classification stops feeling like vocabulary and starts feeling like a measurement instrument, which is what it was always designed to be.
The structural symmetry across all 600-plus outcomes is part of the design's elegance. Whether the outcome is Pain Level, Family Coping, Community Disaster Readiness, or Knowledge: Diabetes Management, the same five-part anatomy applies: label, code, definition, indicators, scale. A student who memorizes the structure of one outcome has effectively memorized the structure of every outcome. This means revision time before a fundamentals exam should focus not on cramming individual outcomes but on rehearsing the anatomy until it becomes automatic. Faculty test items frequently present a clinical vignette and ask which component of nursing outcomes classification is missing from a flawed care plan. The answer is almost always either an absent indicator selection, a missing baseline score, an incorrect Likert scale paired with the indicator, or an invented label that does not exist in the published taxonomy.
The 5-point Likert measurement scales
Every NOC indicator is paired with one of several 5-point Likert scales, and learning the scale names is the fastest way to read NOC fluently. The most common is Scale a: severely compromised, substantially compromised, moderately compromised, mildly compromised, not compromised. Scale b runs from never demonstrated to consistently demonstrated and is used for behavioral outcomes such as medication adherence. Scale c moves from severe to none, used for symptom outcomes like nausea or pain level. Scale m runs from no knowledge to extensive knowledge for knowledge outcomes. There are roughly fourteen scales in total, but four or five cover most clinical situations a student will document.
The scales are deliberately direction-consistent: 1 is always the worst clinical state and 5 is always the best. This is the opposite convention from many pain scales students see at the bedside, and the inversion is a frequent source of charting errors during clinical rotations. NOC scoring is also explicitly ordinal, not interval, which means a change from 2 to 3 is not necessarily equal in magnitude to a change from 4 to 5. Faculty grading a scholarly paper will sometimes ask students to comment on this property when defending their evidence-based practice approach. The 5-point scale is what allows nursing outcomes classification to function as a measurement tool rather than a wish list, and the scale is the part most often lost in copy-paste student care plans.
One subtlety worth flagging early is the relationship between the Likert anchor and the patient's lived experience. A score of 3 on Scale a, "moderately compromised," is not a neutral midpoint; it is a clinical state that requires continued nursing attention. Students sometimes treat the middle score as acceptable and stop intervening once a patient reaches it. NOC's design instead expects movement from baseline toward the target, and the target is rarely 5. A realistic target for an elderly post-stroke patient on Self-Care: Activities of Daily Living might be 3 by discharge, with home health follow-up to push toward 4 over weeks. Treating the Likert as ordinal evidence of trajectory rather than a pass-fail line is one of the maturity signals graders look for. Anchoring scores to documented assessment data rather than to nurse impression is the other, and it is what separates competent nursing outcomes classification from cosmetic charting.
How baseline, target, and change scores work in care plans
NOC documentation in a care plan follows a three-score pattern: baseline, target, and current or change. The baseline score is captured at the moment care is initiated, using the appropriate Likert scale for each selected indicator. The target score is the realistic level the team and the patient agree to aim for within a stated timeframe, often discharge or a defined number of days. The current score is then re-rated at each evaluation point, producing a change score that demonstrates whether the intervention worked.
Consider a postoperative patient with the diagnosis Acute Pain. The chosen NOC is Pain Level 2102, the indicators selected are reported pain, length of pain episodes, facial expressions of pain, and restlessness, all on Scale c (severe to none). Baseline at admission shows reported pain at 1, length at 2, facial expressions at 2, restlessness at 1. The target after 24 hours is reported pain 4, length 4, facial expressions 4, restlessness 4. At 24 hours the actual scores are 3, 3, 4, 3, indicating partial achievement. That partial achievement is the data point. It justifies continuing the nursing process iteration and refining the intervention plan rather than declaring victory or failure. This baseline-target-change architecture is the operational heart of nursing outcomes classification, and faculty graders look for it explicitly.
The NIC-NOC-NANDA triad: how the three terminologies link
NOC was never designed to stand alone. It is one corner of the standardized nursing language triad with NANDA-I (the diagnoses) and NIC (the interventions). The logic flows in a clinical sequence. NANDA-I supplies the labeled nursing diagnosis homework help, which names the human response the nurse is treating. NOC supplies the outcome, which names what should change as a result of nursing care. NIC supplies the intervention, the action plan that produces the change. Together they answer three questions: what is wrong, what should improve, and what will I do.
The Center for Nursing Classification publishes formal NNN linkages, books and tables that map each NANDA-I diagnosis to the NOC outcomes most often paired with it and the NIC interventions most often used to achieve those outcomes. These linkages are not prescriptions; they are evidence-informed defaults a student can deviate from with justification. A diagnosis of Risk for Falls links commonly to NOC outcomes Fall Prevention Behavior 1909 and Falls Occurrence 1912, and to NIC interventions Fall Prevention 6490 and Surveillance: Safety 6654. Memorizing the triad as a workflow rather than three separate vocabularies is the single largest leap in clinical writing maturity, and it is also what makes nursing outcomes classification usable rather than ornamental.
How NOC fits inside SNOMED CT and the LOINC reference architecture
Beyond nursing's own house, NOC has been mapped into the broader health terminology stack. SNOMED CT, the international clinical terminology, has incorporated mappings to NOC outcomes so that a nursing-documented outcome can travel into interdisciplinary records and be queried alongside medical findings. LOINC, which standardizes observations and assessments, supports NOC indicators as observable entities, allowing NOC scores to behave like other lab or assessment values for analytics. ANA recognition of NOC since the 1990s and continued endorsement underwrite this interoperability work.
For students this matters in two ways. First, it explains why the EHR you use in clinical may surface NOC labels through a SNOMED-coded picker rather than a NOC-branded drop-down: the underlying terminology is NOC, but the user interface displays the SNOMED concept. Second, it gives a defensible answer when classmates ask why anyone bothers with standardized nursing language in an era of shared EHRs. The answer is that without standardized labels with codes, nursing data cannot be aggregated for research, quality measurement, or staffing models. Nursing outcomes classification is what allows nursing-sensitive outcomes to be counted and compared across hospitals, and that is impossible with free-text goals in nursing informatics architectures.
Examples of NOC outcomes paired with common NANDA-I diagnoses
A small set of NANDA-NOC pairings appear in nearly every fundamentals course. Knowing them by heart shortens care-plan writing dramatically. The table below shows the most frequently cited pairings, with selected indicators and the appropriate Likert scale for each.
| NANDA-I diagnosis | Linked NOC outcome (code) | Selected indicators | Scale |
|---|---|---|---|
| Acute Pain | Pain Level (2102) | Reported pain, length of pain episodes, facial expressions, restlessness | Severe to none |
| Acute Pain | Pain Control (1605) | Recognizes onset of pain, uses non-analgesic relief, reports controlled pain | Never to consistently demonstrated |
| Risk for Falls | Fall Prevention Behavior (1909) | Asks for assistance, uses assistive devices correctly, removes hazards | Never to consistently demonstrated |
| Risk for Falls | Falls Occurrence (1912) | Falls while standing, falls while transferring, falls while walking | 10+ to none |
| Impaired Skin Integrity | Tissue Integrity: Skin and Mucous Membranes (1101) | Skin temperature, sensation, hydration, lesion-free skin | Severely to not compromised |
| Anxiety | Anxiety Self-Control (1402) | Monitors intensity, uses relaxation techniques, controls anxiety response | Never to consistently demonstrated |
| Deficient Knowledge | Knowledge: Disease Process (1803) | Familiar disease name, signs and symptoms, complications, self-care strategies | No to extensive knowledge |
| Ineffective Airway Clearance | Respiratory Status: Airway Patency (0410) | Respiratory rate, rhythm, ability to clear secretions, breath sounds | Severely to not compromised |
These pairings are starting points, not commandments. A patient with Acute Pain after orthopedic surgery may need Pain Level alone; a patient with chronic cancer pain may need Pain Level plus Pain Control plus Comfort Status. Using nursing outcomes classification well means selecting outcomes that match the patient, not pasting a default block.
Evidence base: validation studies and the Center for Nursing Classification
NOC is not a consensus document; each outcome has been developed and refined through Fehring-style content validation studies, expert reviews, and clinical testing across hospitals, long-term care facilities, and community settings. The Center for Nursing Classification and Clinical Effectiveness at the University of Iowa coordinates this work, including translations into more than ten languages and ongoing revision cycles that have produced editions roughly every four years since 1997. Each edition retires outcomes that no longer perform, revises definitions that proved unreliable, and adds outcomes for clinical territory the previous edition missed.
The validation evidence is where students writing literature reviews about nursing outcomes classification can find substantive material. Studies have examined inter-rater reliability of NOC scoring, sensitivity of NOC outcomes to nursing interventions versus medical interventions, and the use of NOC change scores as nurse-sensitive quality indicators. Critiques exist as well. Some researchers argue that the Likert scaling underdetects clinically meaningful change in stable populations, others note that selection of indicators by individual nurses introduces variability that complicates aggregation. A balanced review paper acknowledges both the maturity of the validation program and the open methodological questions, and that balance is what graders want to see in a scholarly assignment.
For students unfamiliar with how content validation works, the Fehring methodology used by Iowa rates each indicator on its degree of relatedness to the target outcome by panels of expert nurses, computes weighted ratios, and retains indicators above a defined threshold. This is the same approach used to validate NANDA-I diagnostic indicators, which is why the two systems share methodological vocabulary. The Iowa team supplements Fehring with clinical field testing, where nurses use the outcome in real care and report on its usability and discriminating power. The combination of expert content review plus practitioner field test is what makes nursing outcomes classification defensible as a measurement system rather than a curated word list, and it is the thread to follow when a research paper asks for the psychometric basis of standardized nursing language. A capstone literature review that traces three or four representative outcomes through their original validation papers usually scores higher than a generic overview that stays at the level of the textbook chapter.
How NOC appears in EHRs: implementation, drop-down menus, and the documentation burden critique
Most contemporary electronic health records expose NOC through structured documentation modules tied to the care plan or assessment workflow. A nurse opens the care plan, selects a NANDA-I diagnosis, and the system suggests linked NOC outcomes from the published NNN linkages. The nurse picks outcomes, picks indicators, and enters baseline scores. At each shift the indicators reappear and the nurse re-scores. The change is calculated automatically and rolls up into nurse-sensitive quality dashboards.
This implementation is also the source of NOC's most persistent critique. Drop-down menus encourage selection of default indicator sets that do not match the patient. Time pressure encourages copying yesterday's scores forward. Scoring fatigue across a 24-bed unit dilutes the precision the methodology assumes. Several studies have documented that nurses who appreciate NOC in principle still find its EHR implementation a contributor to documentation burden. The honest answer is that the tool is sound and the implementation is where the work remains. A student writing about nursing outcomes classification in a health informatics course should engage both the validity of the terminology and the usability of its workflow, often referencing parallel concerns about narrative documentation in SOAP format and structured assessment templates.
How nursing students should write NOC outcomes in care plans and concept maps
The structure that earns full marks in a student care plan is consistent across most US nursing programs. Each outcome is written as the NOC label, the code in parentheses, the selected indicators numbered or bulleted, the appropriate Likert scale named, and baseline plus target scores entered for each indicator. A timeframe accompanies the target. Below the outcome statement, a brief rationale connects the outcome to the diagnosis and to evidence supporting why this outcome will respond to nursing intervention rather than to medical or pharmacologic action alone.
For concept maps, NOC outcomes attach to the diagnosis node with a labeled arrow indicating expected direction of change, and indicators may be listed in a satellite box. Avoid the temptation to write outcomes as full sentences in patient-narrative form; that style belongs in the older "Patient will..." goal tradition that nursing outcomes classification was designed to replace. Pair every NOC outcome with at least one NIC intervention and one NANDA-I diagnosis so the triad is visible. When the assignment includes a head-to-toe assessment write-up, place baseline NOC scores immediately after the relevant body-system findings so the connection between assessment data and outcome scoring is obvious to the grader.
Common student errors with NOC
Three errors dominate first-year care plans, and recognizing them is faster than relearning the system after losing points. The first is writing nursing-task outcomes instead of patient-state outcomes. "Nurse will ambulate patient three times per shift" is an intervention, not an outcome. The patient-state version is "Ambulation 0200, indicator: walks short distance, baseline 2, target 4 by discharge." Outcomes describe what changes for the patient, not what the nurse does.
The second error is inventing labels. Students often write "Improved Pain Management" because it sounds clinical, then attach NOC formatting to it. Improved Pain Management is not a NOC label. The exact label is Pain Level 2102 or Pain Control 1605, and one of those must be used verbatim. Faculty check the codes. The third error is copying without selecting indicators. Each NOC outcome carries a long indicator list, and the student is expected to select the indicators that match the patient and ignore the rest. Copying the full list inflates the care plan, dilutes the scoring, and signals that the writer did not engage with the outcome. Avoiding these three errors raises a typical care-plan grade by a full letter, and it is the fastest leverage point in mastering nursing outcomes classification.
Two more recurring errors deserve mention because they show up in higher-stakes assignments. The fourth is mismatched scale selection: pairing an indicator that requires Scale c (severe to none) with the wrong anchor language, for example writing "1 = never demonstrated, 5 = consistently demonstrated" next to a pain indicator. The label of the scale must match the published pairing for that indicator, not whichever scale the student remembers. The fifth is failing to revise targets when the patient's trajectory changes. A target set on admission may become unrealistic by day three, or may have already been exceeded. NOC documentation expects targets to be revisited at evaluation, not held fixed for chart neatness. Graduate-level capstones and DNP projects that integrate nursing outcomes classification into quality-improvement designs are routinely critiqued on this point, because static targets undermine the change-score logic that gives NOC its analytic value in the first place.
How EssayFount writing experts help with care-plan and concept-map assignments using NOC
Care-plan assignments are deceptive. They look like worksheets and grade like research papers, with rubrics that score taxonomic accuracy, evidence linkage, scoring discipline, and writing clarity all at once. EssayFount writing experts pair nursing students with named leads who have built care plans, concept maps, and NNN-linkage essays from program-specific rubrics. We work from your assigned diagnosis or scenario, build NOC outcomes that match the patient state and the rubric weighting, defend each indicator selection in the rationale, and integrate NIC interventions and NANDA-I diagnoses so the triad is visible to the grader.
For longer scholarly papers about nursing outcomes classification, the workflow extends to literature review, validation evidence synthesis, EHR-implementation critique, and APA-formatted citation of Iowa Outcomes Project sources. Students working on capstones, evidence-based practice projects, and informatics theses receive draft chapters with embedded NOC analysis rather than generic nursing prose. Health-sciences review is led by writing experts who have coached learners through fundamentals, medical-surgical, community health, and graduate informatics courses, so the level of NOC depth is calibrated to the assignment rather than treated as a one-size template. Start with a free quote, share the rubric, and a writing expert who has worked the same assignment shape before will reply within hours.
Reader questions about the Nursing Outcomes Classification
What are the 5 levels of proficiency in nursing?
Patricia Benner's 1984 framework names five levels of clinical-skill proficiency: novice, advanced beginner, competent, proficient, and expert. The novice follows context-free rules; the advanced beginner recognises recurring features; the competent nurse plans care two to three years into practice; the proficient nurse perceives the situation as a whole; the expert relies on intuition built from deep pattern recognition. The framework is the basis of most clinical-ladder programmes in United States hospitals and is referenced in nursing-outcomes scholarship as the developmental backdrop for outcome measurement.
What are outcomes in nursing?
Nursing outcomes are measurable patient states, behaviours, or perceptions that respond to nursing intervention. The Nursing Outcomes Classification (Sue Moorhead and colleagues, sixth edition 2018) catalogues 540 standardised outcomes organised into seven domains: functional health, physiological health, psychosocial health, health knowledge and behaviour, perceived health, family health, and community health. Each outcome is rated on a five-point Likert scale, allowing the same patient to be measured before and after intervention. Outcomes are written into care plans during the planning phase of the nursing process.
What are the 4 categories of nursing?
When the question refers to NANDA-I, the four categories are problem-focused, risk, health-promotion, and syndrome diagnoses. When the question refers to nursing practice levels, the four are licensed practical nurse, registered nurse, advanced practice registered nurse, and doctorate-prepared roles such as the Doctor of Nursing Practice. The Nursing Outcomes Classification overlaps both: NOC outcomes are written for any patient regardless of practice category, but the level of clinical reasoning that selects them increases with each practice tier.
What is standard 3 outcomes identification?
Standard 3 of the American Nurses Association Standards of Practice (third edition, 2021) names Outcomes Identification as a free-standing step in the nursing process, separate from Planning. The standard requires the registered nurse to identify expected outcomes for a plan individualised to the patient. Outcomes must be derived from the diagnosis, mutually formulated with the patient where possible, culturally appropriate, and measurable. The Nursing Outcomes Classification supplies the standardised vocabulary that Standard 3 expects, and the six-step ADOPIE version of the nursing process incorporates Standard 3 explicitly.
What are the 5 levels of nurses?
The five levels in the United States nursing workforce are nursing assistant or certified nurse aide, licensed practical or vocational nurse, registered nurse, advanced practice registered nurse (nurse practitioner, certified registered nurse anaesthetist, certified nurse midwife, clinical nurse specialist), and doctorally prepared nurse (Doctor of Nursing Practice or PhD). Each level has its own scope of practice defined by the state Nurse Practice Act. The Nursing Outcomes Classification is used across the upper four levels because all of them are responsible for patient outcomes, although the ownership and prescriptive authority differ by level.
What are the 4 levels of competency?
Four-level competency frameworks vary by source. Benner's adapted version names novice, competent, proficient, and expert when the advanced-beginner stage is folded into novice. The Dreyfus brothers' original framework, which Benner adapted, also has five but is sometimes summarised as four. The American Nurses Credentialing Center clinical-ladder template names beginner, competent, proficient, and expert as the four steps that drive promotion within a clinical-ladder programme. The Nursing Outcomes Classification is taught at the competent level and above, where outcome measurement is the standard of practice.