1. Theoretical Explanations for the Importance of Using NANDA/NIC/NOC Margaret Lunney, RN, PhD

2. 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

3. Explanations Currently Used 1.Need for documentation of nursing diagnoses, interventions, and outcomes 2.Visibility of nursing’s contribution Note: 1 & 2 are viewed by critics as self-serving 3.Improved quality & manageable costs

4. 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

5. 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

6. Solution: Theoretical Explanations Theories to describe, explain and predict reasons to use N/N/N: – Linguistic Theory Hayakawa (1990). Language in thought and action. – Critical thinking theory/concepts Scheffer & Rubenfeld (2000). Consensus statement on CT – Concept of Accuracy Lunney (2000). Critical thinking and nursing diagnosis

7. 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

8. 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

9. 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

10. 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”

11. 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

12. Extensional/Intensional Meanings Extensional – relates to the physical world Intensional – relates to individual connotations – focus on intensional = Prejudice N/N/N - extensional & intensional

13. 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

14. 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 of similarities, not differences (Hayakawa, 1990)

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. Using N/N/N Improves CT for Accuracy/Discernment More efficient and effective : Analyzing Discriminating Information seeking Applying standards Logical reasoning Predicting

24. Effects on Quality Words & Critical Accuracy & Phrases + Thinking + Discernment Communication & Cooperation Improved Actions Improved Quality Lunney, 1999, 2001

25. 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 and research that using N/N/N improves quality