NANDA International Investigating the Diagnostic Language of Nursing Practice

Nursing Diagnosis Nursing 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 International Develops 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 provided Melnyk & Fineout-Overholt (2005) Best evidence Expertise Patient Preferences Patient Values

Aims of Evidence Based Practice Standardize practice Reduce wide variations in individual clinician’s practices Maximize good practices Eliminate worst practices Reduce costs Improve the quality of care

Questioning Clinical Practice Ask 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 Practice Consider research taking place in other clinical practice settings Look to the Centers for Evidence-Based Practice that exist around the world Germany, New Zealand, Australia, United Kingdom, United States, Canada How does nursing (is nursing) get represented in those evidence- based practice guidelines?

Practice Outcome Evaluation Points Improved patient outcomes Decreased length of stay Decreased readmissions Improved clinical outcomes measures Best practice medication usage Best practice self-care education Decreased practice variation Decreased cost

Developing EBP Guidelines Protocols 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 topic Guidance on how to implement the practice change, and what parts of that change are based on what level of evidence

Diagnoses – Outcomes - Interventions Link these three components Use standardized classification systems and language Identify your problem / diagnosis Select appropriate outcome indicators Identify 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 methods Expert consensus Concept analysis Content, construct and criterion validation “Ideally, the conceptual base of each diagnostic concept is firmly grounded in studies of the phenomenon.” ( Gordon, 1998 )

Nursing Diagnosis Research Research 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 Analysis First step in developing a new diagnosis and refining current diagnoses Identification 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 Analysis Distinguish between the defining characteristics of a concept & its irrelevant attributes Refine ambiguous concepts Examine published sources Compare literature to experience/practice Examine consistencies between literature and experience/practice

Content Validation Refinement of current diagnoses Development of new diagnoses Studies involving patients who are experiencing the diagnosis are needed Studies involving nurses caring for those patients Clinical validation studies Assess for defining characteristics as patients are experiencing a particular nursing diagnosis Decrease the number of defining characteristics to improve diagnostic accuracy

Construct & Criterion Related Validity Multiple study types are needed to establish validity Causal analysis Show the relation of diagnoses to theories and the importance of using standardized nursing diagnoses to achieve high quality nursing care Epidemiologic Incidence/prevalence of diagnoses in different settings & populations Shows importance & co-occurrence of diagnoses Demonstrates relationships between NDx – Nursing Outcomes – Nursing Interventions

Construct & Criterion Related Validity Generalizability studies Demonstrate importance of nursing diagnoses across setting, patient type, institutions and/or medical diagnoses Outcome / Effectiveness studies Demonstrate prognoses of diagnoses Identifies which interventions best lead to desired outcomes Reliability Establish stability & coherence of diagnose (Parker & Lunney, 1998)

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

Studies of Diagnostic Accuracy Accuracy of nurses’ diagnoses varies widely from low to high o(Lunney, 2001) Foundation for appropriate outcomes and interventions

Lack of Cultural Sensitivity Diagnoses have primarily been developed and refined by North American nurses Nurses from Asia, Europe and South America are now submitting diagnoses Also 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 Diagnoses NANDA-International’s aim is to link with organizations across the world that have as their purpose nursing language development Increase diagnosis submission Increase clinical testing of diagnoses Ensure cultural sensitivity of diagnoses