NANDA International

Investigating the Diagnostic Language of Nursing Practice

Nursing DiagnosisNursing 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).

NANDA InternationalDevelops 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

Evidence Based Practice

Problem solving approach to clinical practice that integrates the conscientious use of best evidence in combination with a clinician’s expertise as well as patient preferences and values to make decisions about the type of care that is providedMelnyk & Fineout-Overholt (2005)

Best evidence

Expertise

Patient Preferences

Patient

Values

Aims of Evidence Based PracticeStandardize practice

Reduce wide variations in individual clinician’s practices

Maximize good practicesEliminate worst practices

Reduce costsImprove the quality of care

Questioning Clinical PracticeAsk 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?

Questioning Clinical Practice

Adopt a reflective, inquiring approach

“Asking the right questions takes as much skill

as giving the right answers!”Robert Half

Questioning Clinical PracticeConsider research taking place in other

clinical practice settingsLook to the Centers for Evidence-Based

Practice that exist around the worldGermany, New Zealand, Australia, United

Kingdom, United States, CanadaHow does nursing (is nursing) get represented

in those evidence-based practice guidelines?

Practice Outcome Evaluation PointsImproved patient outcomes

Decreased length of stayDecreased readmissionsImproved clinical outcomes measuresBest practice medication usageBest practice self-care education

Decreased practice variationDecreased cost

Developing EBP GuidelinesProtocols 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 topicGuidance on how to implement the practice change, and what parts of that change are based on what level of evidence

Diagnoses – Outcomes - InterventionsLink these three components

Use standardized classification systems and languageIdentify your problem / diagnosisSelect appropriate outcome indicatorsIdentify potential interventions and activities to best reach target outcomes

Nursing Diagnosis: Research Based?Diagnoses in the NANDA-I taxonomy

were developed and/or revised using a variety of research methodsExpert consensusConcept analysisContent, construct and criterion validation

“Ideally, the conceptual base of each diagnostic concept is firmly grounded in studies of the phenomenon.”

(Gordon, 1998 )

Nursing Diagnosis ResearchResearch 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

Concept AnalysisFirst step in developing a new diagnosis and

refining current diagnosesIdentification 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)

Concept AnalysisDistinguish between the defining

characteristics of a concept & its irrelevant attributesRefine ambiguous concepts

Examine published sourcesCompare literature to experience/practiceExamine consistencies between literature

and experience/practice

Content ValidationRefinement of current diagnosesDevelopment of new diagnoses

Studies involving patients who are experiencing the diagnosis are needed

Studies involving nurses caring for those patients

Clinical validation studiesAssess for defining characteristics as patients

are experiencing a particular nursing diagnosisDecrease the number of defining

characteristics to improve diagnostic accuracy

Construct & Criterion Related ValidityMultiple study types are needed to establish validity

Causal analysisShow the relation of diagnoses to theories and the

importance of using standardized nursing diagnoses to achieve high quality nursing care

EpidemiologicIncidence/prevalence of diagnoses in different settings &

populationsShows importance & co-occurrence of diagnosesDemonstrates relationships between NDx – Nursing

Outcomes – Nursing Interventions

Construct & Criterion Related Validity

Generalizability studiesDemonstrate importance of nursing diagnoses across

setting, patient type, institutions and/or medical diagnoses

Outcome / Effectiveness studiesDemonstrate prognoses of diagnosesIdentifies which interventions best lead to desired

outcomesReliability

Establish stability & coherence of diagnose (Parker & Lunney, 1998)

Consensus ValidationUsed to establish connections between NANDA, NOC, NIC and other standardized nursing languages (OMAHA, HHC, etc.)Aids in developing standards of practiceAssists in development of terminology to populate the EHR

Studies of Diagnostic AccuracyAccuracy of nurses’ diagnoses varies widely from low to high

o(Lunney, 2001)Foundation for appropriate outcomes and interventions

Lack of Cultural SensitivityDiagnoses have primarily been developed

and refined by North American nursesNurses from Asia, Europe and South

America are now submitting diagnosesAlso receiving revisions to current diagnoses to

support cultural sensitivity, but need more!

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

The Future of Nursing DiagnosesNANDA-International’s aim is to link with organizations across the world that have as their purpose nursing language developmentIncrease diagnosis submissionIncrease clinical testing of diagnosesEnsure cultural sensitivity of diagnoses