Theoretical Explanations for the Need to Use NANDA-I, NOC and NIC

Margaret Lunney, RN, PhD

Who Needs Theoretical Explanations?

Nurses & others who:• value the research-theory-practice

relationship• Need an explanation for use of

standardized terms • Are concerned about the

complexity of N/N/N

Explanations Currently Used

1. Need for documentation of nursing diagnoses, interventions, and outcomes

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

serving for nursing3. Improved quality & manageable costs Note: Need additional research support

for this position

Theoretical Explanations for use of N/N/N

• Theoretical perspectives indicate the need for N/N/N

– Linguistic Theory• Hayakawa, S.I., & Hayakawa, A. (1990). Language in

thought and action (5th ed). New York: Harcourt Brace.– Critical thinking theory/concepts

• Scheffer & Rubenfeld (2000). Consensus statement on CT

– Concept of Accuracy• Lunney (2001). Critical thinking and nursing diagnosis

Linguistic theory proposes that:

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

processes• tools for communication with self and

others• sources of cooperative actions with

others• tools to improve human experiences

Linguistic theory proposes that:

• Scientific names are needed because word usage varies by region

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

• There are no “right” names for anything• Definitions tell us nothing about things;

they are statements about linguistic habits

• Definitions are instrumental and historical, not law

Linguistic theory proposes that:

• Naming is classifying• Classifications are developed for specific

purposes • Classifications contribute to 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

Words and phrases are Maps to the Territory

• Many maps are needed to “know” a territory

• No maps “fully” represent the territory

• All maps together do not “equal” the territory

• The goal is to make “good maps” of the territory

Meaning, Context, Experience

• The meanings of words are known through context

• Context is gained through experience

• Experience with use of N/N/N: – depicts interrelationships– reduces complexity

Words ALWAYS have Extensional AND Intensional Meanings

• Extensional– relates to the physical world

• Intensional– relates to individual connotations

• Prejudice occurs from focusing on intensional

How We Know What We Know

• We experience only 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 & Hayakawa, 1990

Abstraction Ladder: Example in 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: Describe, Explain, Predict

• Explain relation of naming to knowing; names as maps to the territory; no ‘right’ names

• Acknowledge reality of naming--names do not fully reflect a phenomenon; names capture similarities not differences

• Describe essential nature of abstraction & levels of abstraction

• Demonstrate connections to the extensional world through case studies: real, computer-based, video-taped, written

Critical Thinking (CT), Accuracy, Discernment

• Complexity of /N/N/N: – ~1000 concepts with related information/knowledge– Ambiguous relationships among concepts

• Complexity of N/N/N affects:– efficiency & effectiveness of thinking– discernment of diagnoses, interventions, and

outcomes

• Reduce complexity of N/N/N by:– Selecting common terms for specific populations– Use literature sources– Conduct consensus validation studies

What is 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

Rubenfeld & Scheffer, 2006

Lunney, 2001, 2009, Ch 1

Why Accuracy of NDx?

• Accuracy is an outcome of CT• Dx choices guide interventions &

outcomes• Client data lead to many possible

dx choices• Research findings show that low

accuracy is a reality

What is Accuracy of NDx?

• Definition“A rater’s judgment of the degree towhich a diagnostic statement matchesthe 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 discernment of outcomes/interventions?

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

• Many possible outcomes & interventions

• Appropriate outcomes & interventions need to be selected through CT & in partnership with consumer

Using N/N/N improves CT for accuracy/discernment

• More efficient and effective:– Analyzing the interrelationships of diagnoses to

interventions, interventions to outcomes, etc.– Discriminating the meaning of data– Information seeking pertaining to diagnoses,

outcomes, interventions & interrelationships– Applying standards for quality-based holistic care– Logical reasoning to determine the rationale for

inferences/conclusions– Predicting a plan of care & quality-based

outcomes of care.

Effects on Quality of Using N/N/N, Lunney, 1999, 2006

Using N/N/N

• Be aware that the labels of N/N/N/ are NOT nursing; nursing is more than this

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

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