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 contribution Note:1 & 2 are viewed by critics as self serving for nursing 3.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 (5 th 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 of similarities, 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 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

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