Tips for Teaching Nursing Diagnosis and the Use of NANDA International Terminology

Nursing Diagnosis: Definition The NANDA-I 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).

The Diagnoses 206 NANDA-approved nursing diagnoses will be present in the Definitions & Classifications book for 2009 - 2011 Level of Evidence (LOE) Criteria Established for All New and Revised Diagnoses Entry into the Taxonomy requires various levels of clinical evidence

Clinical Decision Making Health care professionals face complex decisions daily regarding patient care— and must do so with decreased resources 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)

Critical Thinking Nurses need knowledge of diagnoses, definitions and defining characteristics, especially those common to the populations with which they work and the diagnostic processes that are used to interpret patient data Skills of analyzing, logical reasoning, and applying standards are thinking processes required for accurate diagnosis in nursing These skills are developed through: Discussions of how data should be clustered to generate accurate diagnoses Relation of data clusters to diagnoses Comparisons of existing data to expected data based on research findings. Lunney (2009)

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

Nurses Are Diagnosticians Diagnosticians interpret data within their fields of expertise in order to provide needed services A key element of data interpretations is that they are subject to error. A good diagnostician must realize that there are always risks to the accuracy of data interpretations Becoming a nurse diagnostician requires development of professional and personal skills and characteristics Competencies in intellectual, interpersonal, and technical domains Personal strengths of tolerance for ambiguity and use of reflective practice

Teaching Methods Review proper method to complete patient assessment to determine the presence of defining characteristics Clustering of defining characteristics is often misunderstood : presence of one defining characteristic does not necessarily require a diagnosis All nursing interventions do not require a nursing diagnosis Medication administration for a condition that is not a primary focus of nursing care is related more to a medical diagnosis Need to test hypotheses Need to evaluate success of plan of care and reassess continually

Diagnostic Process Assessment Cluster cues / defining characteristics Collect additional data to narrow list of potential diagnoses Generate list of potential diagnoses Implement plan of care based on identified diagnoses Evaluate success of plan of care Determine diagnosis/diagnoses to be treated

Cue Generation and Nursing Diagnosis Cues are analyzed in relation to possible diagnoses Existing cues are matched with the expected cues for the diagnoses being considered During the evaluation of cues and related diagnoses, nurses may decide that there are not enough data to make a diagnostic decision or that there is enough evidence for one or more likely diagnoses If there are not enough data to make a diagnosis, then the next step involves a focused search for additional cues If there is enough supporting evidence, a diagnosis is made and then validated

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

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

Incorrect Diagnostic Process Cluster cues / defining characteristics Collect additional data to narrow list of potential diagnoses Generate list of potential diagnoses Implement plan of care based on identified diagnoses Evaluate success of plan of care Assessment OR Identify Medical Diagnosis Determine nursing diagnosis/diagnoses to be treated

Teaching Methods Requiring students to develop and detail care plans with “every possible diagnosis” creates resistance 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 Students learn to “just pick a diagnosis” rather than making decisions about the best explanation(s) for patient responses

Teaching Methods Use of case studies can assist students in identifying cues in patient situations that may be defining characteristics of one or more nursing diagnoses Hypothesis generation and differential diagnosis skills can be developed through case studies, clinical conference discussions and in skills lab scenarios

“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

Reportable Quality Measures: Where is Nursing? Management of diabetes: Percent of adults with diabetes who had a foot examination in past year Percent of adults with diabetes who had an influenza immunization in past year Percent of adults with diagnosed diabetes with HbA1c level > 9.0% (poor control); < 7.0% (optimal) Hospital admissions for short-term complications of diabetes per 100,000 population Nursing diagnoses represent the phenomena of concern to the nursing profession. The consistent utilization of standardized nursing terminologies such as NANDA-I’s nursing diagnoses within electronic health records is necessary to enable collection and analysis of nursing data and nurse-sensitive outcomes. Without this ability, nursing remains relatively invisible to patients, and hospital administrators are more likely to consider nurses solely as the single largest line item in terms of hospital expenses. A true analysis of nursing’s impact, enabled by the accurate and consistent use of standardized nursing languages, will enable linkage of nursing care to patient outcomes – demonstrating the invaluable impact of nurses on patient/family/community well-being.

The Role of Nursing in Patient Quality Percent of adults with diagnosed diabetes with HbA1c < 7.0% (optimal) Readiness for enhanced family coping Health-seeking behaviors Readiness for Enhanced Self Health Management

The Role of Nursing in Patient Quality Management of diabetes: Hospital admissions for short-term complications of diabetes per 100,000 population Anxiety Ineffective coping Ineffective health maintenance Risk for injury Deficient knowledge Ineffective Self Health Management

Diagnostic Difficulties Significant overlap of cues (Defining Characteristics) to diagnoses Contextual factors such as culture can change the perspective on diagnosis Many studies have verified that interpretations of clinical cases have the potential to be less accurate than indicated by the data (Lunney, 2007).