Investigating the Diagnostic Language of Nursing Practice

1. Investigating the Diagnostic Language of Nursing Practice NANDA International

2. Nursing Diagnosis • Nursing diagnosis is a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable (NANDA, 1997).

3. NANDA International • Develops terminology (Nursing Diagnoses) to describe the clinical judgments made by nurses as they provide care for individuals, families, groups and communities • Nursing diagnoses are the basis for selection of outcomes, & interventions needed to reach those outcomes

4. Evidence Based Practice • Problem solving approach to clinical practice that integrates the conscientious use of best evidencein combination with a clinician’s expertiseas well as patient preferences and valuesto make decisions about the type of care that is provided • Melnyk & Fineout-Overholt (2005) Expertise Best evidence Patient Preferences Patient Values

5. Aims of Evidence Based Practice • Standardize practice • Reduce wide variations in individual clinician’s practices • Maximize good practices • Eliminate worst practices • Reduce costs • Improve the quality of care

6. Questioning Clinical Practice • Ask questions about your clinical practice • What are the conditions nurses treat most frequently in neonates? • How does the parent of a child hospitalized in an intensive care unit respond? • What phenomena that you see are most often linked to increased length of stay in your patient populations?

7. Questioning Clinical Practice • Adopt a reflective, inquiring approach “Asking the right questions takes as much skill as giving the right answers!” Robert Half

8. Questioning Clinical Practice • Consider research taking place in other clinical practice settings • Look to the Centers for Evidence-Based Practice that exist around the world • Germany, New Zealand, Australia, United Kingdom, United States, Canada • How does nursing (is nursing) get represented in those evidence-based practice guidelines?

9. Practice Outcome Evaluation Points • Improved patient outcomes • Decreased length of stay • Decreased readmissions • Improved clinical outcomes measures • Best practice medication usage • Best practice self-care education • Decreased practice variation • Decreased cost

10. Developing EBP Guidelines • Protocols or Guidelines provide: • Comfort for practitioners that the practice changes are based on evidence versus opinion or cost factors • The level of evidence available on the topic • Guidance on how to implement the practice change, and what parts of that change are based on what level of evidence

11. Diagnoses – Outcomes - Interventions • Link these three components • Use standardized classification systems and language • Identify your problem / diagnosis • Select appropriate outcome indicators • Identify potential interventions and activities to best reach target outcomes

12. Nursing Diagnosis: Research Based? • Diagnoses in the NANDA-I taxonomy were developed and/or revised using a variety of research methods • Expert consensus • Concept analysis • Content, construct and criterion validation “Ideally, the conceptual base of each diagnostic concept is firmly grounded in studies of the phenomenon.” (Gordon, 1998 )

13. Nursing Diagnosis Research • Research on the validity and reliability of diagnostic categories has increased, but remains insufficient • Large scale funding for basic research is needed to identify, develop, and validate diagnostic • Leaders in nursing research have not always supported the need for a language and classification system that differs from medicine • Informatics is an impetus for this work

14. Concept Analysis • First step in developing a new diagnosis and refining current diagnoses • Identification and exploration of phenomena of concern to nursing remains critical today in order to fill in the gaps in our taxonomy "I use the word nursing for want of a better... I believe...that the very elements of nursing are all but unknown." (Nightingale, 1860)

15. Concept Analysis • Distinguish between the defining characteristics of a concept & its irrelevant attributes • Refine ambiguous concepts • Examine published sources • Compare literature to experience/practice • Examine consistencies between literature and experience/practice

16. Content Validation • Refinement of current diagnoses • Development of new diagnoses • Studies involving patients who are experiencing the diagnosis are needed • Studies involving nurses caring for those patients • Clinical validation studies • Assess for defining characteristics as patients are experiencing a particular nursing diagnosis • Decrease the number of defining characteristics to improve diagnostic accuracy

17. Construct & Criterion Related Validity • Multiple study types are needed to establish validity • Causal analysis • Show the relation of diagnoses to theories and the importance of using standardized nursing diagnoses to achieve high quality nursing care • Epidemiologic • Incidence/prevalence of diagnoses in different settings & populations • Shows importance & co-occurrence of diagnoses • Demonstrates relationships between NDx – Nursing Outcomes – Nursing Interventions

18. Construct & Criterion Related Validity • Generalizability studies • Demonstrate importance of nursing diagnoses across setting, patient type, institutions and/or medical diagnoses • Outcome / Effectiveness studies • Demonstrate prognoses of diagnoses • Identifies which interventions best lead to desired outcomes • Reliability • Establish stability & coherence of diagnose (Parker & Lunney, 1998)

19. Consensus Validation • Used to establish connections between NANDA, NOC, NIC and other standardized nursing languages (OMAHA, HHC, etc.) • Aids in developing standards of practice • Assists in development of terminology to populate the EHR

20. Studies of Diagnostic Accuracy • Accuracy of nurses’ diagnoses varies widely from low to high • (Lunney, 2001) • Foundation for appropriate outcomes and interventions

21. Lack of Cultural Sensitivity • Diagnoses have primarily been developed and refined by North American nurses • Nurses from Asia, Europe and South America are now submitting diagnoses • Also receiving revisions to current diagnoses to support cultural sensitivity, but need more!

22. What do we need? • Emphasis on development, testing and validation of new diagnostic concepts • Revision of current diagnoses that lack sufficient evidence-based defining characteristics, risk factors or related factors

23. The Future of Nursing Diagnoses • NANDA-International’s aim is to link with organizations across the world that have as their purpose nursing language development • Increase diagnosis submission • Increase clinical testing of diagnoses • Ensure cultural sensitivity of diagnoses