Teaching NANDA-I NIC and NOC: Novice to Exper t Chapter Three.

Teaching NANDA-I NIC and NOC: Novice to Expert

Chapter Three

Teaching NANDA-I NIC and NOC: Novice to Expert

ContributorMargaret Lunney

• Explain Three Propositions Related to Teaching NNN

• Set Expectations for Students at Novice to Expert Stages of Development

• Implement Teaching Strategies

• Integrate NNN With Nursing Curricula (Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Learning Objectives

• Use of NNN Requires Intellectual, Interpersonal, and Technical Competencies, Tolerance of Ambiguity and Reflection

• Accurate Diagnoses are the Basis for Use of NIC and NOC

• Use of NNN Differs from the Traditional Nursing Process(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Objective 1: Explain Propositions

•Intellectual

•Knowledge Related to:•Diagnoses•Interventions•Outcomes

•Thinking Processes

•Research Findings:•Human Beings Vary in Thinking Process Abilities•Thinking Process Abilities can be Improved

Proposition #1: Skills/Competencies

N = 86 (Lunney 1992)

Basic Thinking Abilities Mean SD Range

DMU-Fluency 21.3 7.2 6–41.5

DMC-Flexibility 10.8 6.5 0–27.5

DMI-Elaboration 17.8 4.9 7–30.5

Variation in Nurses’ Thinking Abilities

Research Findings related to Women•Thinking Processes of Women Develop Through Relationships•Women’s Perspectives on Thinking (Belenkey et al. 1986)

•Silence•Received Knowledge•Subjective Knowledge•Procedural Knowledge•Constructed Knowledge

•Nursing Students and Nurses may have Lower Level Perspectives

Intellectual Skills

•Critical Thinking (CT) Processes can be Improved•Stimulate to Use•Expect Use•Validate Appropriate Use•Demonstrate Support and Confidence in Abilities

•CT Abilities - Essential for Accuracy of Diagnoses and Use of NOC and NIC(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Intellectual Skills: Critical Thinking

•Delphi Study of 55 Nurse Experts (Scheffer and Rubenfeld 2000)

•Purpose: Identify the Components of CT that Relate to Nursing

•Results - Definition for Nursing:•7 Cognitive Skills•10 Habits of Mind

Intellectual Skills: What is CT in Nursing?

•Analyzing

•Applying Standards

•Discriminating

•Information Seeking

•Logical Reasoning

•Predicting

•Transforming Knowledge

Cognitive Skills

•Confidence•Contextual Perspective•Creativity•Flexibility•Inquisitiveness

•Intellectual Integrity•Intuition•Open-Mindedness•Perseverance•Reflection

Habits of Mind

•CT Involves Continuous Processing of Data and Inferences

•In Any Situation, Two or More Cognitive Skills are Probably Being Used

•Habits of Mind Support Cognitive Skills

•The Combination of CT Abilities Needed is Unique to the Situation

Intellectual Skills: CT Process

•Exquisite Communication

•Promote Trust

•Work n Partnership, Share Power

•Validate Perceptions

•Accept That We Do Not “Know” Others

Proposition #1: Interpersonal Skills

•Obtain Valid and Reliable Data

•Health Histories: Comprehensive

•Physical Exams: Focused

•Perform Nursing Interventions

•Technical Aspects of Using NNN

Proposition #1: Technical Skills

•Tolerate Ambiguity

•Decisions are Relative to Context and Specific Nature of Individuals

•Multiple Factors Influence Clinical Situations

•Human Beings are Complex and Diverse

•Ambiguity is the Norm

Proposition #1: Personal Strengths

•Reflect on Practice Experiences •Accept Possible Flaws

•Thinking

•Interpersonal

•Technical

•Aim - Develop and Grow

Proposition #1: Personal Strengths

Foundational•Cues/Data may be Incorrect

•Examples

Objective Data: •Diagnostic Tests

Subjective Data:•Patients•Families

Proposition #2: Accurate Interpretations

•Use of NNN Requires Many Decisions•All Decisions are Based on Patient Data•Data Amounts are Overwhelming•Short-Term Memory = 7 ± 2 Bits of Data•Data are Converted to Interpretations(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Foundational


•Interpretations Determine Actions•Additional Data Collection•Subsequent Decisions•Possible Outcomes to Consider•Choices of Interventions

•High Potential for Inaccuracy•Diagnosis and Etiology

Foundational


Case Study: Marian Hughes(1) Marian Hughes is a 16-year-old girl with a medical diagnosis of diabetes mellitus. (2) She was admitted 3days ago for treatment of an acute episode of diabetic ketoacidosis. (3) When Marian discussed with you how she managed the therapeutic regimen before hospitalization, she states that she was not adhering to her prescribed diet. (4) You decide that Marian needs assistance to improve her management of the therapeutic regimen, especially the types of foods she eats. (5) Marian's stay in the hospital unit is uneventful in that medical treatments are successfully resolving the crisis. (6) Marian's daily habits include getting up for school about 7.00 a.m. and rushing to get the bus by 7.30. (7) She says that she should get up about 6.30 but she likes to sleep. (8) She states that she does not want her mother to help her get up earlier. (9) The meal that she eats at school is consistent with her prescribed diet while the two meals at home are not. (10) In the morning she grabs whatever is quick and easy, usually toast and butter. (11) In the evening, her mother makes meals that comply with the diabetic diet but Marian states that she does not like them so she only eats part of her supper and then snacks on other foods later. (12) Marian is able to explain to you what she should be eating and she can adjust her diet to her lifestyle. (13) The knowledge of what foods are on her diet that she likes was not discussed with her mother because she doesn't want to sit down and talk with her. (14) In general, Marian and her mother argue over many of Marian's behaviors, such as school grades, smoking, and coming in late at night.

High Potential for Inaccuracy

•16-Year-Old Diabetic (#1)

•Hospitalized, DKA (#2)

•“Did Not Follow Prescribed Diet” (#3)

•NDx: Ineffective Management of Therapeutic Regimen, Related to _______ (Fill in the Blank)

Case Study: Marian Hughes


•Knowledge Deficit

•Disconfirming Cues: •Meals Eaten at School are Consistent with Diet (#9)•Able to Explain What She Should be Eating (#12)•She can Adjust Her Diet to Her Lifestyle (#13)

•Conclusion: Low Accuracy Diagnosis

•Teaching is Waste of Time, Effort, and Money

Case Study: Marian HughesPossible Interpretation/Diagnosis


(Herdman 2012)

•Ineffective Self-Health Management, Related to Communication Difficulties Between Marian and Her Mother

•Patient Outcome (NOC): •Communication = 3 (Moderately Compromised), Increase to 5 (Not Compromised)

•Nursing Intervention•Communication Enhancement(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Case Study: Marian HughesHighest Accuracy Diagnosis


Examples•Communication Difficulties Mother/Daughter•Stressful Mother/Child Relationship•Altered Family Dynamics•Ineffective Coping•Ineffective Time Management•Adolescent Image•Low Self-Esteem•Denial•Deficient Knowledge

44 Diagnoses by 80 Nurses

+5 Highest Level of Accuracy

+4 Close to the Highest Level But Not Quite

+3 General Idea But Not Specific Enough

+2 Not Enough Highly Relevant Cues or Not

the Highest Priority

+1 Suggested by Only One or a Few Cues

0 Not Indicated by Data

-1 Should be Rejected, Disconfirming Cues

Seven Levels of Accuracy

•Communication Difficulties Between Mother and Daughter +5•Stressful Mother/Child Relationship +4•Altered Family Dynamics +3•Ineffective Coping +2•Ineffective Time Management +2•Adolescent Image +1•Low Self-Esteem +1•Denial 0•Deficient Knowledge -1

Diagnostic Accuracy Scores

•Studies: 1966 to Present •Conclusions: Interpretations Vary Widely•All Interpretations are Not High Accuracy•Influencing Factors (Carnevali 1983; Gordon 1982)

•Nurse Diagnostician•Diagnostic Task•Situational Context

Research Findings

•Diagnostic Task

•Lesser Amounts and Complexity of Data

•Nurse Diagnostician

•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

Research: Positive Influences

Puzzle: What is the Diagnosis?

Challenge: Achieving Accuracy

Is It This? Or This? Or This?

Solving the Puzzle

•Supporting Factors:•Acknowledge that Data Interpretations are Probabilistic; Question Accuracy

•Use CT, Interpersonal and Technical Skills

•Develop Tolerance ofAmbiguity•It’s OK Not to Have an Answer•Accept that We Might Make Mistakes

•Develop Reflective Practice

Foundational


Traditional•Limited # of Concepts•Collect Comprehensive Data•No Accountability for Diagnoses•Intervene Based on Data•Behavioral Outcomes•Disorganized Follow-Up

Use of NNN•Currently 1147 Concepts•Cue-Based and Hypothesis-Driven Data Collection•Fully Accountable for Diagnoses•Intervene Based on Data Interpretations•Neutral Terms with Scale•Systematic Follow-Up

Proposition #2: New Perspectives on Nursing Process

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

•Acknowledge Difficulty Level: Simple to Complex

•Influencing Factors:•Similarity of Terms in Three Systems•Structure of Classifications•Resources (Books, Pamphlets, Other)•Complexity of Clinical Situations•Nurses Perspective/Model for Practice•Experience With NNN

Changing from Traditional to Use of NNN


NANDA-I NOC NICAnxiety:Vague uneasy feeling; autonomic response; feeling of apprehension; altering signal warning of impending danger

Anxiety Control:Personal actions to eliminate or reduce feelings of apprehension and tension from an unidentifiable source

Anxiety Reduction:Minimizing apprehension, dread, foreboding or uneasiness related to unidentified source of anticipated danger

Risk ofInfection:Increased risk ofbeing invaded by pathogens

Infection Status:Presence and extent of infection

Infection Protection:Prevention and early detection of infection in a patient at risk

Examples: User-Friendly Simplicity


•Use Theoretical Perspective•Change Theory

•Diffusion of Innovations (Rogers 2003)

•S-Shaped Diffusion Curve •Perceived Characteristics:•Relative Advantage (+)•Compatibility (+)•Complexity (-)•Trial Ability (+)•Observability (+)



•Be a Champion•Sell First to Opinion Leaders•Goal: Create a Critical Mass•Share Demonstration Projects (For Example, Protocols and Journals)•Faculty Development Program•Adoption by System •Adoption by Individuals



Novice to Expert

•Novices and Advanced Beginners (ABS) Learn to Use NNN as Well as Experienced Nurses

•Novices and ABS may be Easier to Teach than Nurses at Competent, Proficient and Expert (Expert) Stages

•Expert Nurses must be “Sold” on New Way to Think and Document

Objective 2: Set Expectations

(Benner 1984; Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

•EHR is Imminent•NNN = File Names for EHR •NNN Describes What Nurses Bring to the Table•NNN Makes Knowledge Available at Bedside•Aggregated Data = Knowledge•Measurement of Care = Improved Quality•Linguistics Theory Supports SNLS •Fits with Nursing Theories

Selling NNN to Experts

•Expect (At All Levels of Expertise):•Correct Use of the Three Systems:

•Nursing Diagnoses are used to Guide Interventions, Not for Labeling per se •Intervention Label is the Intervention, Not the Activities•Outcome Label is the Outcome, Not the Indicators

•Correct Use of Concepts:•NANDA-I: Social Isolation•NIC: Coping Enhancement •NOC: Knowledge (Specify)

Set Expectations


•Do Not Underestimate Nursing Students or Nurses:• “…Nursing and Nursing Knowledge must be Presented in All Its Complexity …

• Help Students and Nurses to “… Experience the Complex and Messy

World of Nursing … and Learn How to Navigate Through It …” (Doane and Varcoe 2005, p.xi)

Set Expectations

•All Levels:•Self-Evaluation

•Integrate with New Theories, for Example:•Pender’s Health Promotion Model

•Integrate with Strategies for Evidence-Based Nursing

Set Expectations

(Pender et al. 2010)

•Encourage Experts to:•Integrate with Previous Knowledge

•Use NNN in:•Communicating Scope of Practice •Developing Standards of Care•Evidence-Based Nursing Projects•Research Projects

•Evaluate Clinical Applications of NNN

•Teach CE Programs to Nursing Personnel

Set Expectations


Intellectual•Assume that Thinking Is Human, Imperfect, Attainable

•Encourage Thinking in Class and Clinical:•Ask Questions Instead of Giving Answers•Provide Opportunities for Problem Solving

Objective 3: Teaching Strategies

Intellectual: Deflate Authority


Intellectual

•Think Out Loud with Students

•Act as Midwife or Coach

•Help them Think About Thinking: •Ask: What Kind of Thinking is Needed? •Use the 17 CT Terms and Definitions

•Evaluate Thinking Processes

•Expect Self-Evaluation of Thinking


•Share Paradigm Cases (e.g. Marian Hughes)

•Simplify Representations, Identify High Relevance Cues

•Conduct Iterative Hypothesis Testing


•Seminars Instead of Lectures: Why?•Groups Represent Wide Variations in Thinking Abilities

•Promotes “In-Class” Thinking

•Recognizes Students’ Abilities to Think and Learn without Authority/Experts

•Supports Future Work in Groups to Describe, Analyze and Synthesize Information, Solve Problems (e.g. What is the diagnosis?)

Intellectual


•Seminars: How?•Assign Readings, Provide Discussion Questions•Lead the Group, Ask the Discussion Questions•Be Respectful; Protect Students’ Self-Esteem

•Address:•What is the Author Saying?•What is the Fit with Previous Knowledge?•How Does This Information Apply to Practice?

•25-30% of Grade for Discussion of Readings

Intellectual


•Expect Self Evaluation•Ask Questions, Instead of Giving Answers•Discussion in Class•Discussion Online•Journal Writing (Degazon and Lunney 1996)

Intellectual


•Expect Accountability For Patient Relationships

•Demonstrate:•Good Interviewing•Validation of Diagnoses•Partnership Processes to Select Outcomes and Interventions

•Reward Power Sharing

•Teach and Support Assertiveness

Interpersonal


•Expect Accountability For Using Standardized Methods

•Demonstrate Use of Diagnostic Reasoning

•Show Technical Use of NNN Using Case Studies

Interpersonal



•Demonstrate Correct Use of NNN

•Provide Incentives for Correct Use of NNN, e.g. Percentage of Grade

•Integrate with Theories of Nursing

General



•30-Year-Old Woman in Good Health

•Smokes 1-1.5 Packs Per Day for >12 years

•Asked for assistance to quit

•Stated “I know it’s not good for me and I want to stay healthy”

With Permission of Dr Arlene Farren

Case Study

•Readiness for Enhanced Self-Health ManagementDefinition: A Pattern of Regulating and Integrating Into Daily Living a Therapeutic Regime for Treatment of Illness and Its Sequelae that is Sufficient for Meeting Health-Related Goals and can be Strengthened

What is the Diagnosis?

(Herdman 2012)

Smoking Cessation Behavior•Personal Actions to Eliminate Tobacco Use

•Rarely Demonstrated (3), Goal = 5

•Indicators:•Expresses Willingness to Stop Smoking (3)•Identifies Benefits of Smoking Cessation (3)•Adjusts Tobacco Elimination Strategies as Needed (3)•Uses Strategies to Cope with Withdrawal Symptoms (2)•Develops Effective Strategies to Eliminate Tobacco Use (2)

What is the Outcome?

(Moorhead et al. 2008)

•Smoking Cessation Assistance •Teaching: Medication, Nicotine Replacement Therapy

What are the Interventions?

(Bulecheck et al. 2008)

Helping Another to Stop Smoking

•Activities:•Give Laura Clear, Consistent Advice to Quit•Assist Laura in Choosing Strategies•Motivate Her to Set a Quit Date•Refer to Group Programs/Individual Therapy•Inform Laura of Possible Symptoms•Help Plan Coping Strategies and Problem Resolution

NIC: Smoking Cessation Assistance


Smoking Cessation Behavior

•After 6 Weeks, Nurse and Laura Rate Outcome as 5•Laura Consistently Monitors Her Environment and Personal Behaviors for Factors that Affect Her Tobacco Use•Laura Developed Effective Strategies and Remains Consistently Committed to Controlling Her Use•Laura Uses Friends and Group for Help•Laura Has Not Smoked for 6 Weeks

Evaluation of Outcomes


•49 Years Old; Single, Italian-American Woman•Type 2 Diabetes Mellitus (DM) with Adequate Control•Overweight•Head of Household; 80-Year-Old Dependent Mother•Works Full Time, Provides Care for Self and Mother •Accepts Care of Mother But has Many Frustrations•Attempts to Reduce Her Workload have Failed•Mother Thinks Stella “Can Do It All”•Mother Discourages Son’s Involvement•Stella Expresses Conflicting Emotions, Stress, Lack of Control

With Permission of Coleen Kumar

Case Study

•The Diagnostic Process:•Which are Important Cues?•What are Possible Diagnoses?•Which Diagnoses Have the Best Support?

•Are the Diagnoses Consistent with the Situational Context?

•Can the Nurse Help Stella with the Diagnoses?

What are the Diagnoses?

•NANDA-I Diagnoses:•Risk of Caregiver Role Strain•Readiness for Enhanced Family Coping

•Checking for Accuracy:•Are There a Sufficient Number of Confirming Cues?•Are There Any Disconfirming Cues?•Did Stella Validate the Diagnosis?•Should Other Providers be Consulted?

What are the Diagnoses?

(Herdman 2012)

Caregiver Well-Being •Caregiver Satisfaction with Health and Lifestyle Circumstances•Moderately Compromised (3), Goal = 4 or 5•Indicators:•Satisfaction with Physical Health (3)•Satisfaction with Emotional Health (2)•Satisfaction with Usual Lifestyle (3)•Satisfaction with Instrumental Support (2)•Satisfaction with Social Relationships (3)

What are the Outcomes?


Family Coping •Family Actions to Manage Stressors that Tax Family Resources•Moderately Compromised (3); Goal = 4 or 5•Indicators:•Demonstrates Role Flexibility (3)•Family Enables Member Role Flexibility (3)•Expresses Feelings and Emotions Freely (2)•Arranges for Respite Care (2)•Seeks Assistance When Appropriate (3)•Uses Social Support (3)

What are the Outcomes?


•Assertiveness Training •Self-Esteem Enhancement•Emotional Support•Caregiver Support •Role Enhancement •Family Involvement Promotion •Respite Care

What are the Interventions?


Assertiveness Training•Assistance with the Effective Expression of Feelings, Needs, and Ideas While Respecting the Rights of Others

•Activities:•Determine Barriers to Assertiveness (for Example, Family Roles)•Help Stella Recognize and Reduce Cognitive Distortions•Instruct Stella in Different Ways to Act Assertively•Facilitate Practice Opportunities Using Discussion, Modeling and Role Playing•Help Stella Practice Conversational Skills

NIC Example


Caregiver Well-BeingAfter 4 Weeks, Nurse and Stella Rate Outcome as 4

•Stella’s Physical Health has Improved; Satisfaction with Physical Health (4)•Stella Uses Assertiveness Skills to Make Time for Herself After Work and to Plan Recreation; Satisfaction with Emotional Health (4)•Stella Continues to Need Help in The Performance of Caregiver Roles; Satisfaction with Performance of Usual Roles (4)•Stella Feels n Control of Her Caregiver Routines; Satisfaction with Caregiver Role (4)



Family Coping After 4 Weeks, Nurse and Stella Rate Outcome as 4

•Stella’s Assertiveness Behaviors Work Well to Accomplish Goals; Demonstrates Role Flexibility (4)•Stella’s Mother Agrees with the Plan to Relieve Her of Some of the Workload; Family Enables Member Role Flexibility (4)•Stella’s Brother Stays with Her Mother So Stella can Go Away for Short Periods; Arranges For Respite Care (4)•Family Exhibits a Wider Repertoire of Coping Behaviors (4)



•Case Studies Help Students to Practice Thinking and Clinical Judgment in a Safe Environment

•Standardized: Everyone Uses the Same Clinical Data •Additional Case Studies, and Their Interpretations, can be Found in Lunney (2009)

Use Case Studies

Observe Students Grow in Abilities through Encouragement, Trust, and Respect

Teaching Strategies: Summary

•Prepare Faculty •Diffusion of Innovations (Rogers 2003)•Talking Points:

•Electronic Health Record•Quality-Based Nursing Care•Ability to Develop Information and Knowledge

•Involve Clinical Faculty

•Evaluation/Peer Observation

Objective 4: Integrate with Curricula

•Simplify Complexity-Map of Diagnoses, Interventions and Outcomes for Courses

•All Faculty Evaluate Students’:•Correct Use of NNN•Partnership Processes, Use of “We”•Technical Skills•Individualize NNN Content with Patients



•Fundamentals of Nursing•NNN - Framework for Skills Learning•Thinking - High Priority Diagnoses, Include in Testing•Expect Students to Use CT Terms and Definitions (for Example, in Journal Writing and Discussion)•Develop Case Studies (Lunney 1992)

•Iterative Hypothesis Testing



•Educators and Practice-Based Leaders: Spread the Word to Nurses in Other Agencies

•Meet with Leaders; Use Marketing Strategies

•Demonstrate Advantages of NNN

•Provide CE Programs

•Disseminate Your Success in Using NNN to Others



•“Teamwork is the Fuel that Allows Common People to Attain Uncommon Results” (Unknown)

• “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)

Questions/Discussion

Benner PA. (1984) Novice to Expert: Promoting Excellence and Power in Professional Nursing Practice. Menlo Park, CA: Addison Wesley.Bulechek GM, Butcher H, Dochterman JC. (2008) Nursing Interventions Classification (NIC), 5th edn. St Louis, MO: Mosby.Carnevali DL. (1983) Nursing Care Planning: Diagnosis and Management. Philadelphia: Lippincott Williams and Wilkins.Degazon CE, Lunney M. (1995) Clinical journal: a tool to foster critical thinking for advanced levels of competence. Clinical Nurse Specialist 9(5): 270-274. Doane GH, Varcoe C. (2005) Family Nursing as Relational Inquiry: Developing Health Promoting Behavior. Philadelphia: Lippincott.Gordon M. (1982) Nursing Diagnosis: Process and Application. New York: McGraw- Hill.Herdman TH. (ed). (2012) NANDA International Nursing Diagnoses: Definitions and Classification, 20122014. Oxford: Wiley-Blackwell.Lunney M. (1992) Divergent productive thinking and accuracy of nursing diagnoses. Research in Nursing and Health 15: 303-311.Lunney M. (2009) Critical thinking to achieve positive health outcomes: nursing case studies and analyses. Ames, IA: Wiley-Blackwell.Moorhead S, Johnson M, Maas M, Swanson E. (2008) Nursing Outcomes Classification (NOC). 4th edn. St Louis, MO: Mosby. Pender NJ, Murdaugh C, Parsons MA. Health Promotion in Nursing Practice, 6th edn. Upper Saddle River, NJ: Pearson/Prentice-Hall, 2010.Rogers M. (2003) Diffusion of Innovations, 5th edn. New York: Free Press.Scheffer BK, Rubenfeld MG. (2000) A consensus statement on critical thinking. Journal of Nursing Education 39: 352-359.

References

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Teaching NANDA-I NIC and NOC: Novice to Exper t Chapter Three.

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