1. Nursing Diagnosis in Health Care Organizations: Factors that facilitate – and complicate - implementation

2. Medical Diagnosis
Terminology used by physicians and advanced practice nurses (nurse practitioners) for a clinical judgment that identifies or determines a specific disease, condition, or pathological state

3. Nursing Diagnosis
Terminology used by professional nurses that identifies actual, risk or wellness responses to a health state, problem or condition
Terminology used by professional nurses that identifies a person’s, family’s, or community’s motivation and desire to increase wellbeing and actualize human health potential

4. Comparisons Medical Diagnoses Nursing Diagnoses
Chronic obstructive pulmonary disease
Cerebrovascular attack
Amputation
Nursing Diagnoses
Ineffective breathing pattern
Activity intolerance
Disturbed body image
Readiness for enhanced coping

5. Nursing Diagnosis: Definition
The NANDA definition of a nursing diagnosis was adapted from a national, Delphi study by Dr. Joyce Shoemaker (1984)
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).

6. Suggested Revision to Definition of Nursing Diagnosis (2008)
A nursing diagnosis is a clinical judgment that nurses make about individual, family and community responses to conditions/life processes. Based on that judgment, the nurse is responsible for monitoring of client responses, decision-making culminating in a plan of care, and implementing interventions, including interdisciplinary collaboration and referral as needed.  The nurse is wholly or partially accountable for the achievement of the desired outcomes.

7. The Diagnoses 206 NANDA-approved nursing diagnoses as of 2008
Level of Evidence (LOE) Criteria Established for All New and Revised Diagnoses
Entry into the Taxonomy requires various levels of clinical evidence

8. Diagnosis Requires Assessment
Identifying human responses that are related to medical diagnosis without a complete assessment to determine the presence of defining characteristics
Lack of instruction on clustering assessment data to derive a list of potential diagnoses
Lack of hypothesis testing to determine best diagnoses for each patient

9. “The List”
Automating the electronic record to populate the plan of care with nursing diagnoses when a particular medical diagnosis is used
Becomes a documentation tool rather than an individualized plan of care to direct nursing interventions to meet important patient outcomes
Puts patients at risk / Negligence
May ignore or miss important diagnoses for patients
Plan of care does not address critical outcomes for patients

10. Teaching Methods
Requiring students to develop and detail care plans with “every possible diagnosis” creates resistance that carries into practice
Sets up situation that is not realistic
Cannot address every possible diagnosis in a short hospital stay
Becomes a “thing to do” rather than truly understanding and applying diagnostic reasoning and differential diagnosis
Nurses learn to “just pick a diagnosis” rather than making decisions about the best explanation(s) for patient responses

11. Physician Barriers
Lack of understanding of difference between nursing and medicine
Belief that medicine should direct all nursing care
Lack of collegiality or interdisciplinary collaboration
Nursing may not be seen as an autonomous profession
“Practicing medicine without a license”
Nursing seen as subservient to medicine
Lack of understanding of purpose of nursing diagnosis

12. Organizational Buy-In
Nurse administrator(s) must understand benefits and support the use of standardized languages
Nursing diagnoses articulate phenomena of concern to nurses, and provide a common language for the conditions that nurses treat
Nursing outcomes provide measures of nursing effectiveness
Nursing interventions demonstrate what nurses do
Data can be used to demonstrate when nurses are more effective than unlicensed personnel or when more nurses are needed to achieve desirable outcomes

13. Organizational Buy-In
Nursing staff must understand that diagnosis is more than a “task”
Articulates the critical thinking and clinical judgment of nurses as they care for patients
Consistent education is important
Updating staff on revisions and new diagnoses is critical

14. Provide On-Going Staff Education
Highlight use of standardized nursing language in organizational newsletters
blasts with “diagnosis of the month” and case studies to illustrate proper diagnosis
Peer review / patient grand rounds with actual patient information or use of case studies

15. Nursing Diagnosis Linkages
Cannot stop with identifying the diagnosis
Link to outcomes related to the diagnoses
Identify nursing interventions related to the desired outcomes
Strength is in the combination of all three components of standardized nursing language
Diagnosis outcomes interventions

16. Physician Collaboration
Articulate difference between nursing and medicine
Encourage collegiality and interdisciplinary collaboration
Identify purpose of nursing diagnosis and impact on patient outcomes
Demonstrate local impact of nursing diagnoses on patient outcomes

17. Health Care Today Financial pressures
Early discharges
Fewer hospital admissions
Diminished nurse-to-patient contact
Less time to assess patients and identify accurate diagnoses
Less time to work with patients/families
Patient/family education suffers
Less time to support them in regaining health

18. Clinical Decision Making
Health care professionals face complex decisions daily regarding patient care— and must do so with decreased resources (less staff, less time, less money for equipment and supplies)
What is the area of concern that nurses can treat/prevent/monitor? (Diagnosis)
What is an appropriate goal for this patient? (Outcome)
What treatment is most effective? (Intervention)

19. Quality Nursing Care Accurate Assessment and Diagnosis
Defining characteristics
Related factors
Risk factors
Identify Attainable Patient Outcomes
Efficiency
Utilize Proven Interventions
Effective
Least resource-intensive

20. Standardized Nursing Language
Critical for improving patient care
Lack of standardization leads to:
Inability to identify assessment criteria that are key to diagnostic accuracy
Inability to determine effective interventions that lead to positive outcomes
Inferior patient care

21. Standardized Nursing Language
Provides evidence-based terminology
Describes practice
Drives research
Documents the impact of nursing care on health care quality

22. Implementation Educate staff and other disciplines
Case review to improve diagnostic ability
Reflect diagnostic ability and usage in staff evaluations
Keep it practical – address diagnoses that can actually be treated in your setting
Refer to nurses in other settings for other diagnoses, as needed
Home health care
Hospice
School Nursing

23. Implementation
Teach managers / administrators how to track data to demonstrate what nurses do and how they impact patient outcomes
Routinely share data with staff nurses and other disciplines that demonstrates impact of nursing care on clinical outcomes, through the use of standardized nursing language

24. Implementation Identify gaps in the NANDA-I taxonomy
Revise / develop diagnoses that are needed in your practice
Submit them to NANDA-I electronically for acceptance (

25. Standardized Nursing Language and Evidence-Based Practice
Provide nurses with researched concepts (diagnoses), outcomes for which nurses are accountable and interventions that have been proven to be effective
Why would we use anything else?

26. 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

27. 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