Evaluating the Outcomes of Nursing Care for Older Adults Diagnosed with Elder Frailty Syndrome (NANDA-I): A Six-Step Nursing Process Using NANDA-I, NOC, and NIC

Introduction Frailty among older adults is a critical issue in Japan's super-aged society. Although potentially reversible, frailty may progress to disability if left unaddressed. Home-visit nursing plays a key role, yet outcome evaluation remains limited. This study examined the effectiveness of care for older adults with frailty using a six-step nursing process based on standardized nursing terminologies NANDA-I, NOC, and NIC. Methods Nine older adults diagnosed with Elder frailty syndrome received individualized home-visit nursing a six-step NNN process over three months. NOC indicators were defined as each participant's “best possible state” and were evaluated monthly. Data were recorded in Excel and analyzed using EZR. Ethical approval was obtained, and informed consent was independently managed. Results All nine participants completed the study. Most showed improvement in NOC indicators, and some demonstrated resolution of frailty-related symptoms. One participant showed improvement in the initially selected NOC indicators, but new nursing diagnoses emerged and other frailty-related indicators worsened, resulting in no overall improvement in frailty status. Six NOC outcomes showed statistically significant improvement (p < .05), with several demonstrating large effect sizes (Cohen's d > 0.8). Nurses reported that using NNN helped clarify care focus and promoted team collaboration. In some cases, reassessment shifted the diagnostic framework from Elder frailty syndrome to Readiness for Enhanced Healthy Aging. Conclusion The NNN-based six-step nursing process may support frailty improvement by visualizing individualized outcomes and guiding targeted care. It may also support collaboration and structured evaluation in home-visit nursing. Practical Implications Although preliminary, NNN-based care shows potential for addressing frailty through individualized assessment. Defining NOC outcomes as the “best possible state” may reflect diverse aging trajectories. Visualizing care transitions may promote team knowledge sharing. Future implementation requires standardized documentation and practitioner training.