Theoretical Explanations for the Importance of Using

NANDA/NIC/NOC

Margaret Lunney, RN, PhD

Who Needs Theoretical Explanations?

Nurses and others who:• value research-theory-practice

relationship• reject standardization • reject the complexity of N/N/N• feel the “power of nursing” without

N/N/N

Explanations Currently Used1. Need for documentation of nursing

diagnoses, interventions, and outcomes

2. Visibility of nursing’s contributionNote: 1 & 2 are viewed by critics as self-serving

3. Improved quality & manageable costs

Problem: Pervasive Criticisms

• Covert response (most common)– N/N/N are ignored & avoided

• Overt responses:– Articles: Shamansky & Yanni (1983);

Hagey & McDonough (1984); Leininger (1990); Mitchell (1991);

– Negative comments on listservs; negative reviews of manuscripts & research

Effects of Criticisms • N/N/N not included in education • N/N/N not required for

documentation• N/N/N not in HIS/EHR • Research proposals & manuscripts

not approved for funding/publication

Solution: Theoretical Explanations Theories to describe, explain and predict reasons touse N/N/N:

– Linguistic TheoryHayakawa (1990). Language in thought and action.

– Critical thinking theory/conceptsScheffer & Rubenfeld (2000). Consensus statementon CT

– Concept of AccuracyLunney (2000). Critical thinking and nursing diagnosis

Linguistic Theory Languages are:• fundamental mechanism of survival• most highly developed symbolic

processes• tools for communication with self & others• sources of cooperative actions with others• tools to improve human experiences

Linguistic Theory

• Scientific names are needed because word usage varies

• Naming is a “great” step forward; it makes discussion possible

• There are no “right” names for anything

• Definitions are statements of linguistic habits; not law

Linguistic Theory• Naming is classifying• Classifications are developed for specific

purposes • Classifications =pooled knowledge• Pooled knowledge helps us to deal with

the physical world• Science seeks generally useful

classifications, ones that produce results• Results in nursing = quality of nursing

care

Maps to the Territory

• Many maps needed to “know” a territory

• No maps “fully” represent the territory• All maps do not “equal” the territory • Goal- Make “good maps” of the

territory • NANDA, NIC and NOC are the “good

maps”

Meaning, Context, Experience• Meanings known through context• Context gained through experience• Using N/N/N increases experience

by: – depicting interrelationships– reducing complexity– available in one source

Extensional/Intensional Meanings• Extensional

– relates to the physical world• Intensional

– relates to individual connotations– focus on intensional = Prejudice

• N/N/N - extensional & intensional

How We Know What We Know• We experience a small fraction of

phenomena• We abstract the objects of our experiences • It makes no sense to distrust abstractions• We need to be AWARE of abstracting• Words always need to be connected with

what they stand for.Avoid this:

words defining words

Abstraction Ladder (read from bottom) 8. Wealth

7. Asset 6. Farm asset 5. Livestock

4. Cow 3. Bessie 2. Perception 1. Process_______________________Words are abstractions ofsimilarities, not differences (Hayakawa, 1990)

Abstraction Ladder: Nursing 8. Human-Environment Interaction

7. Nurse-Client Partnership 6. Functional Health Patterns 5. Cognitive-Perceptual Pattern 4. Decision Making

3. Decisional Conflict re: infant feeding choice

2. Cheryl’s Breastfeeding 1. Experience of breastfeeding____________________________ Gigliotti & Lunney, 1998

Application to N/N/N• Explain relation of naming to

knowing • Acknowledge reality of naming• Describe essential nature of

abstraction & levels of abstraction• Demonstrate connections to the

extensional world through case studies

Complexity of NNN and Theory• Indicators of Complexity:

– ~1000 concepts with related information/knowledge

– Ambiguous relationships among concepts– Extreme # of choices

• Reducing complexity of N/N/N improves:– Efficiency and effectiveness of thinking– Accuracy of diagnoses– Discernment of best interventions and outcomes

What is Critical thinking (CT)? Consensus of 57 Nurse Experts:• Cognitive Skills (7)

– Analyzing– Applying Standards– Discriminating– Information Seeking– Logical Reasoning– Predicting

• Habits of mind (10) Scheffer & Rubenfeld, 2000 Lunney, 2001, Ch 1

Why Critical Thinking?• Thinking abilities of adults vary from

low to high• The thinking processes needed for

the nursing process are complex• Each clinical case requires specific

types of thinking abilities• Thinking affects choices of

diagnoses, interventions and outcomes

What is Accuracy of NDx?• Definition

“A rater’s judgment of the degree to which a diagnostic statement matches the cues in a client situation.” (Lunney, 1990)

• Characteristics– Ranges from high to low– Relative to interactive elements– Simple to complex according to # of cues, types

of cues, characteristics of cues– Includes supporting and conflicting cues– Relative to the whole situation

Why Accuracy of NDx?• Accuracy is an outcome of CT• Client data lead to many possible

dx choices, including etiologies• Research findings show that low

accuracy is a reality• Diagnoses are the foundation of

interventions and outcomes

Why discernment of outcomes/interventions?

• Clinical situations differ based on contextual factors (e.g., culture, age, history)

• Many outcomes and interventions are possible

• The most appropriate outcomes and interventions need to be selected through CT

Using N/N/N Improves CT for Accuracy/Discernment

• More efficient and effective:Analyzing DiscriminatingInformation seeking Applying standards Logical reasoningPredicting

Effects on Quality Words & Critical Accuracy & Phrases + Thinking + Discernment

Communication & Cooperation

Improved Actions

Improved Quality Lunney, 1999, 2001

Using N/N/N• Mitigate criticisms, e.g.,

– Be conscious that the labels of N/N/N/ are NOT nursing

• Show connections of N/N/N to thinking & actions through case studies

• Demonstrate through theories andresearch that using N/N/N improves quality