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Evidence Based Nursing (EBN) & Diagnostic Accuracy

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Evidence Based Nursing (EBN) & Diagnostic Accuracy. Rona F. Levin, PhD, RN (New York, USA) Margaret Lunney, PhD, RN (New York, USA) Barbara Krainovich Miller, EdD, RN (New York, USA) Diná Monteiro da Cruz, PhD, RN (Sao Paulo, Brazil) Cibele de Mattos Pimenta, PhD, RN (Sao Paulo, Brazil). - PowerPoint PPT Presentation
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Evidence Based Nursing (EBN) & Diagnostic Accuracy Rona F. Levin, PhD, RN (New York, USA) Margaret Lunney, PhD, RN (New York, USA) Barbara Krainovich Miller, EdD, RN (New York, USA) Diná Monteiro da Cruz, PhD, RN (Sao Paulo, Brazil) Cibele de Mattos Pimenta, PhD, RN (Sao Paulo, Brazil)
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Page 1: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Evidence Based Nursing (EBN)& Diagnostic Accuracy

Rona F. Levin, PhD, RN (New York, USA)Margaret Lunney, PhD, RN (New York, USA)

Barbara Krainovich Miller, EdD, RN (New York, USA)Diná Monteiro da Cruz, PhD, RN (Sao Paulo, Brazil)

Cibele de Mattos Pimenta, PhD, RN (Sao Paulo, Brazil)

Page 2: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Objectives

• Explain accuracy of diagnosis as the foundation of EBN-M. Lunney

• Describe an evidenced-based model (PCD) for use by nurses-R. Levin

• Apply the PCD format to diagnose anxiety-B. K. Miller

• Apply the PCD format to teach EBN- D. M. da Cruz & C.M. Pimenta

Page 3: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Foundation of Evidence-Based PX: Accurate Interpretation of Data

• Interpretations determine actions

• Additional data to be collected• Subsequent interpretations• Possible outcomes to consider• Choices of interventions

Page 4: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Foundation of Evidence-Based PX: Accurate Interpretation of Data

• High potential for inaccuracies• Human beings are complex and diverse• We do not “know” other people

(Munhall, 1993)• Knowledge of nursing concepts varies • Critical thinking abilities vary

Page 5: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Foundation of Evidence-Based PX: Accurate Interpretation of Data

• What is diagnostic accuracy?Accuracy is a rater’s judgment of the degree to which a diagnostic statement matches the cues in a patient situation (Lunney, 1990).

Page 6: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Challenge of Achieving Accuracy:

Puzzle: What is the Diagnosis?

Page 7: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Research Findings

• Studies: 1966 to present

• Conclusions: Interpretations vary widely

• Influencing factors:• Diagnostic Tasks

• Situational contexts

• Nurse Diagnosticians

Page 8: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Diagnostic Tasks

• Factors studied:• Task complexity

• Amount of data

• Relevance of data

Page 9: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Situational Contexts

• Factors studied:• Time constraints

• Role in healthcare system

• Factors still to be studied:• Policies

• Procedures

• Philosophy and theories

Page 10: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Nurse Diagnosticians

• Factors studied:• Education

• Use of teaching aids

• Nursing experience

• Cognitive strategies

• Cognitive abilities

• Personality

Page 11: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Summary of Research Findings: Positive Influences on Accuracy

• Education related to nursing diagnoses

• Knowledge of diagnostic process and concepts

• Teaching aids for diagnostic reasoning

• Variety of thinking processes

• Experience specific to diagnostic task

• Lesser amounts and complexity of data

Page 12: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Conclusions from Knowledge Development

• Problem: Diagnostic Accuracy varies from high to low.

• Solution: Use an evidence-based practice approach to facilitate the formulation of accurate diagnoses.

Page 13: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Evidence-Based Practice

Best Evidence

Clinician’s Experience

PatientPreference

Page 14: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Solving the PuzzleIs it this? Or This? Or This?

Page 15: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Evidence-Based Practice to Solve the Puzzle

• Evidence from Literature• Which diagnosis are indicated by the cues?

• What differentiates similar diagnoses?

• Which of the possible diagnoses is the best match?

• Clinician perspective

• Patient perspective

Page 16: Evidence Based Nursing (EBN) & Diagnostic Accuracy

EBM Model

• Asking answerable questions

• Finding the best evidence

• Appraising validity of evidence

• Integrating evidence with clinician expertise and patient preferences

• Evaluating one’s effectiveness in above steps

• Sackett, Straus, Richardson, Rosenberg, & Haynes (2000)

Page 17: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Asking Answerable Diagnostic Questions in Nursing

• PCD format

• P = Patient population

• C = Comparison cue or cue cluster

• D = Differential diagnosis

• developed by Levin, Miller & Lunney (2004)

Page 18: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Asking Answerable Diagnostic Questions in Nursing

• Example of PCD question:

• In adult critical care patients (population) who exhibit angry outbursts, complaints about treatments that interfere with sleep/rest, and irritable behavior (cue cluster) what are the possible nursing diagnoses to consider (differential diagnosis)?

Page 19: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Asking Answerable Diagnostic Questions in Nursing

• Possible diagnoses to consider• sleep pattern disturbance

• ineffective coping

• hopelessness

• powerlessness

• fear and/or anxiety

• cognitive impairment

• other?

Page 20: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Asking Answerable Diagnostic Questions in Nursing

• Based on evidence, what is the strength of the cues in relation to the possible diagnoses?

• Based on evidence, which of the possible diagnoses represents the best match with the cues?

• Does the patient validate the clinician’s interpretation?

Page 21: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Finding the Evidence

• Knowledge of possible diagnoses

• Research evidence associated with specific diagnoses

• Knowledge of useful data bases

• Access to data bases and sources

Page 22: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Appraising the Evidence

• Assess validity of the research-based evidence• Type of study

• survey of nurses?

• Observation of patients?

• Sample size and selection

• Applicability to your practice

Page 23: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Integrating Evidence

• With clinician’s expertise• knowledge of diagnoses and diagnostic task

• specialty focus

• frequency of caring for patients’ with specific responses (cue clusters)

• knowledge of related interventions

Page 24: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Integrating Evidence

• Patient’s Perspective• Uniqueness of individual

• Context of human response

• Values and preferences

• Validation of nurse’s interpretation

Page 25: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Evaluating Effectiveness

• Am I looking for the research evidence about human responses?

• Am I considering the highly relevant diagnoses associated with observed cue clusters?

• Am I considering the individual patient and the specific context when applying research-based evidence?

Page 26: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Evidence-Based Nursing Diagnosis: Anxiety

• NANDA Nursing Diagnoses: Definitions & Classification 2003-2004

• Refined based on research submitted to DRC

• 1973, 1982, 1998

Page 27: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Refinement: Nursing Research Validation Studies

• Whitley (1994, 1992, 1989)• Levin, Krainovich-Miller et al. (1989)\• Krainovich (1988) • Fadden, Fehring & Kendel-Rossi (1987)• Lopez & Risey (1986) • Jones & Jakob (1984)• Jones & Jakob (1981)• Haag & Adamski (1978)• Graham & Conley (1971)

Page 28: Evidence Based Nursing (EBN) & Diagnostic Accuracy

NDx Normal Anxiety

• Nursing Research Clinical & Content Validation Studies

• Interdisciplinary Case Studies & Research Findings

Page 29: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Differential Diagnoses

• Anxiety

• Fear

• Ineffective Coping

• Disturbed Thought Processes

Page 30: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Diagnostic Reasoning Process

• Definition

• Defining Characteristics

• Related Factors

Page 31: Evidence Based Nursing (EBN) & Diagnostic Accuracy

P-Population:Pre-Op Pt’s

C-Cues: Presenting Objective &Subjective Data

D-Differential NDxs Definition Defining Characteristics Related Factors

Evidence-basedNDx: Pre-Op Anxiety

COMPARE

DERIVE

PCD

Page 32: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Patient Perspective

• Critical to Diagnostic Accuracy

• Compare to Clinician Perspective

• Results: NDx statement that best fits the patient’s cues in context

Page 33: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Interpreting Human Responsesis a Complex Task

Principles of EvidenceBased Practice

Inaccuracy

Accuracy

Page 34: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Evidence-Based Nursing

.

PatientPreference

BestEvidence

Clinician’sexperience

• Asking Answerable Questions

• Finding the Best Evidence

• Appraising Validity of Evidence

• Integrating Evidence (clinician/patient)

• Evaluating Effectiveness Sackett et al (2000)

Applied to diagnosis, interventions (treatments), and outcomes

Page 35: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Case Study

• “Cases are stories with a message. They are not

simply narratives for entertainment. They are stories

to educate.”

• “... the role of students and instructor vary as will the

case material itself.”

(Herreid CF, 2004)

Page 36: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Case Study

“Case methods or studies provide a process of

participatory learning that facilitates active and

reflective learning and results in the development of

critical thinking and effective problem-solving skills.

This develops self-directed lifelong learners.”(Tomey AM,2003)

Page 37: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Case Study

• A Patient in Respiratory Critical Care*A Patient in Respiratory Critical Care*

“Mrs. H, 70 years old, was admitted to a

respiratory medical unit because she

presented with increasing shortness of

breath over....” (Handout p.1)

* Perry, K. A patient in respiratory critical care. In: Lunney M. (2002).

Critical thinking & nursing diagnosis (pp. 74-75, 140-142).

Philadelphia: NANDA International.

Page 38: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Case Study

• Objective:Participants will apply the PCD format to interpret patient data

• Directions:• Use groups of 5 to 7

• Assign leader & recorder

- Leader: Help group to stay focused; conduct discussions in a nurturing environment

- Recorder: Document relevant aspects of the discussion and report group conclusions

Page 39: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Case Study

• Directions

• Read the text carefully (Handout p.1)

• Imagine you are the nurse of the patient

• Task- state NDxs that best explain the patient’s situation

• Apply the PCD format* to ask answerable questions to make accurate NDXs

*developed by Levin, Miller & Lunney (2004)

Page 40: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Case Study

PCD formatPCD format**

• P = Patient population

• C = Comparison

• D = Differential diagnosis

*Developed by Levin, Miller & Lunney (2004)

Asking answerable questions

Searching evidence

Appraising evidence

Page 41: Evidence Based Nursing (EBN) & Diagnostic Accuracy

P-Population

• Asking Answerable Questions

• What are the most common nursing

diagnoses (NDxs) in the population that this

patient represents (critical care patients)?

• Searching the Evidence• CINAHL• Medline

Page 42: Evidence Based Nursing (EBN) & Diagnostic Accuracy

P-PopulationSearching the Evidence

Subject Search CINAHL MEDLINE

S1: Nursing Diagnosis 2537 1661

S2: Critical Care 2574 7252

S3: Intensive Care - 6371

S4: Critically Ill Patient / Critical Illness 2054 4825

S5: S1 and S2 4 64

S6: S1 and S3 - 15

S7: S1 and S4 / Limit: research 10 / 3 4 / NA

Page 43: Evidence Based Nursing (EBN) & Diagnostic Accuracy

P-PopulationSearching the Evidence

• CINAHL

Wang LT, Lee C. (2002)

Asencio JMM. (1997) [Spanish]

Roberts BL et al. (1996)

Logan J; Jenny J. (1991)

Page 44: Evidence Based Nursing (EBN) & Diagnostic Accuracy

P-PopulationSearching the Evidence

• MEDLINE

Gordon M, Hiltunen E. (1995)

Wieseke A et al. (1994)

Pasini DA et al. (1996) [Portuguese]

Alorda C et al. (1996) [Spanish]

Page 45: Evidence Based Nursing (EBN) & Diagnostic Accuracy

P-PopulationAppraising the Validity of Evidence

Question:

What are the most common nursing diagnoses

(NDxs) in the population that this patient

represents (critical care patients)?

Page 46: Evidence Based Nursing (EBN) & Diagnostic Accuracy

P-PopulationAppraising the Validity of Evidence

Prevalence studies (cross-sectional)

• Population & Sample

• Is the population similar to the population

of the case study patient?

• How was the sample drawn?

Page 47: Evidence Based Nursing (EBN) & Diagnostic Accuracy

P-PopulationAppraising the Validity of Evidence

Prevalence studies (cross-sectional)

• Data collection• Cover different domains?

• Who were the diagnosticians?

• How was accuracy of NDxs assured?

• Results• Valid and reliable?

• Applicable to this case study?

Page 48: Evidence Based Nursing (EBN) & Diagnostic Accuracy

C-Comparison

• Asking Answerable Questions

• Which data are cues to possible NDxs (human responses)?

• Which data are highly relevant to explain the human responses?

Page 49: Evidence Based Nursing (EBN) & Diagnostic Accuracy

C-Comparison

• Asking Answerable Questions• Which data are cues to possible NDxs (human

responses)?

- participation in care

- use of the call bell

- interest in providers’ actions

- sleep

- communication with daughter (who used to read Bible to her)

- What else?

Page 50: Evidence Based Nursing (EBN) & Diagnostic Accuracy

C-Comparison

• Asking Answerable Questions

• Which NDx (human response) best explains the current situation?

Relevant data

participation in care

use of the call bell

interest in providers’ actions

sleep

communication with daughter (who used to read Bible to her)

Possible Explanations

Fear?

Powerlessness?

Hopelessness?

Spiritual Distress?

What else?

Page 51: Evidence Based Nursing (EBN) & Diagnostic Accuracy

C-Comparison

• Asking Answerable Questions

• Based on evidence, what is the strength of the cues in relation to possible diagnoses?

• Searching Evidence• CINAHL• Medline• NANDA International

Page 52: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Subject Search CINAHL MEDLINE

S1: Fear (* and Validation Studies) 1202 (*15) 4736 (*0)

S2: Hopelessness (* and Validation Studies) 175 (*0) (*0)

S3: Hope (*and Validation Studies) 870(*12) (*0)

S4: Powerlessness (* and Validation Studies) 251 (*3) (*0)

S5: Spiritual distress NANDA (*and Validation Studies)

25 (*7) (*0)

S6: Validation Studies 4340 (*0)

C-ComparisonSearching the Evidence

Page 53: Evidence Based Nursing (EBN) & Diagnostic Accuracy

C-ComparisonSearching the Evidence

• CINAHL Fear

Whitley GG. (1997)

PowerlessnessBufe GM & Abdul-Hamid M. (1995)

HopelessnessBeyea SC & Peters DD. (1987)

Spiritual DistressTwibell RS et al. (1996) Hensley LD. (1994)

Page 54: Evidence Based Nursing (EBN) & Diagnostic Accuracy

C-ComparisonSearching the Evidence

• Nursing Diagnosis Classification (NANDA International, Handout, p.2)

Fear

Powerlessness

Hopelessness

Spiritual Distress

Page 55: Evidence Based Nursing (EBN) & Diagnostic Accuracy

C-ComparisonAppraising Validity of the Evidence

Question:

Based on evidence, what is the strength of the

cues in relation to possible NDxs?

Page 56: Evidence Based Nursing (EBN) & Diagnostic Accuracy

C-ComparisonAppraising Validity of the Evidence

• Validation studies

• Design- Clinical? Control group (with x without the NDx)?

- Content validation by experts?

• Sample- Similar to the patient’s population?

- Sampling methods?

Page 57: Evidence Based Nursing (EBN) & Diagnostic Accuracy

C-ComparisonAppraising Validity of the Evidence

• Validation studies• Data collection

• InstrumentsWide search for defining characteristics?Based on operational definitions of the defining

characteristics?Validity and reliability?

• Results• Valid and reliable?

• Applicable to the patient?

Page 58: Evidence Based Nursing (EBN) & Diagnostic Accuracy

C-ComparisonAppraising Validity of the Evidence

• Concept analysis/development studies• Purpose

- Identification?- Development?- Clarification?

• Method- Consistent?

• Results- Valid and reliable?- Applicable to the patient?

Page 59: Evidence Based Nursing (EBN) & Diagnostic Accuracy

D-Differential Diagnosis

• Asking Answerable Questions

• Which of the possible NDxs represent the

best match with the cues?

• Searching Evidence• CINAHL• Medline• NANDA International’s Classification

Literature data basewill be the same

selected forCOMPARISON

Page 60: Evidence Based Nursing (EBN) & Diagnostic Accuracy

D-Differential DiagnosisAppraising Validity of the Evidence

• Validation studies• Design

- Compare nursing diagnoses?

- Clinical? Control group (with x without the ND)?

- Content validation by experts?

• Sample, Data collection, and Results- Apply the same criteria of Comparison

Page 61: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Summary

PCD FormatLevin, Miller & Lunney (2004)

Population Comparison Differential Diagnosis

What are the most commom NDxs in this situation?

Based on evidence, what is the strength of the cues in relation to the possible diagnoses?

Which of the possible NDxs represent the best match with the cues?

AnswerableQuestion

SearchingEvidence

AppraisingEvidence

Epidemiologicalstudies

Criteria of validityapplied to epidemiological studies

Validation studies comparingnursing diagnosis

Validation studiesConcept analysis / developmentstudies

Criteria of validityapplied to nursing diagnosis validation studies

Criteria of validityapplied to nursing diagnosis validation studies

Page 62: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Challenges

• Clinical research-based literature• Epidemiological studies

• Validation studies

• Criteria to appraise evidence

• Data base frameworks

• Measurement tools for specific NDxs

• Skills for searching evidence

• Accessibility of data bases

Page 63: Evidence Based Nursing (EBN) & Diagnostic Accuracy

Conclusion

The illiterate of the 21st century will not be

those who cannot read and write, but those

who cannot learn, unlearn and relearn.

Alvin Toffler


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