The development and refinement of nursing diagnoses by vpo20543


									  The development
   and refinement
of nursing diagnoses
        NANDA International
Develops terminology (Nursing Diagnoses)
to describe clinical judgments made by nurses as
they provide care for individuals, families, groups
and communities.
             The Diagnoses
• 206 NANDA-approved nursing diagnoses as of
• Level of Evidence (LOE) Criteria Established
  for All New and Revised Diagnoses
  – Entry into the Taxonomy requires various levels of
    clinical evidence
Diagnosis Development Committee
• Responded to concerns from the membership that the
  concept analysis requirement for acceptance of a
  diagnosis into the taxonomy may be a barrier to
• The DDC developed rules for evaluating submissions
• DDC reviewed and revised the Level of Evidence
     Level of Evidence Criteria
• 2.1 Label, Definition, Defining Characteristics or Risk
  Factors (for risk diagnoses), Related Factors (for
  actual diagnoses) and References
   – At 2.1, references are cited for the definition, each defining
     characteristic or risk factor, and each related factor. In addition,
     it is recommended that the submitter provide examples of
     nursing interventions (NIC or other nursing intervention) and
     nursing outcomes (NOC or other nursing outcome).
   – Acceptance at this level is required for entrance into the
   Level of Evidence Criteria
• 2.2 Concept Analysis
  – The criteria in 2.1 are met. In addition, a narrative review of
    relevant literature, culminating in a written concept analysis, is
    required to demonstrate the existence of a substantive body of
    knowledge underlying the diagnosis.
  – The literature review/concept analysis supports the label and
    definition, and includes discussion and support of the defining
    characteristics or risk factors (for risk diagnoses) and related
    factors (for actual diagnoses).
   Level of Evidence Criteria
• 2.3 Consensus Studies Related to Diagnosis
  Using Experts
  – The criteria in 2.2 are met. Studies include those
    soliciting expert opinion, Delphi, and similar studies of
    diagnostic components in which nurses are subjects.
   Level of Evidence Criteria
• 3.1 Literature Synthesis
  – The criteria in 2.2 are met. The synthesis is in
    the form of an integrated review of the
    literature. Search terms/MESH terms used in
    the review are provided to assist future
    Level of Evidence Criteria
• 3.2 Clinical Studies Related to Diagnosis, But Not
  Generalizable to the Population
   – The criteria in 2.2 are met. The narrative includes a description
     of studies related to the diagnosis, which includes defining
     characteristics or risk factors, and related factors.
   – Studies may be qualitative in nature, or quantitative studies
     using nonrandom samples in which patients are subjects.
   Level of Evidence Criteria
• 3.3 Well-Designed Clinical Studies with Small
  Sample Sizes
  – The criteria in 2.2 are met. The narrative includes a
    description of studies related to the diagnosis, which
    includes defining characteristics or risk factors.
  – Random sampling is used in these studies, but the
    sample size is limited.
    Level of Evidence Criteria
• 3.4 Well-Designed Clinical Studies with Random
  Samples of Sufficient Size to Allow for
  Generalizability to the Overall Population
   – The criteria in 2.2 are met. The narrative includes a description
     of studies related to the diagnosis, which includes defining
     characteristics or risk factors, and related factors.
   – Random sampling is used in these studies and the sample size
     is sufficient to allow for generalizability of results to the overall
Defining Characteristics (DCs)
• Reflect assessment data, including subjective and
  objective data:
   –   Client verbalizations
   –   Provider observations
   –   Patient, family or community perceptions, behaviors and attributes
   –   Client report
   –   Physical and/or behavioral data
• Outcome indicators are the obverse of DCs
• Nursing Diagnoses and related factors are inferred
  from DCs
                 Risk Factors
• Increase the vulnerability of the individual,
  family or community to an unhealthful event:
  –   Environmental factors
  –   Physiological elements
  –   Psychological elements
  –   Genetic elements
  –   Chemical elements
            Related Factors
• The part of the diagnostic statement that
  guides the specific nursing intervention
  – The etiology (cause) of the diagnosis (problem to be
  – Factors that are typically associated with the
  – The focus for interventions
Coding of Nursing Diagnostic Language
• Barriers to the Coding of Nursing Diagnostic Language
  have been identified
   – Multiple concepts within a single defining characteristic, risk
     factor or related factor
       • Self-Care Deficit: Bathing/Hygiene
           – ―Inability to wash body or body parts, obtain or get to water
             source, regulate temperature or flow of bath water, get bath
             supplies, dry body, get in and out of bathroom‖
       • Delayed Growth and Development
           – ―Listlessness, decreased response time‖
           – ―Inability to perform self-care or self-control activities
             appropriate for age‖
Coding of Nursing Diagnostic Language
• Diagnoses which include “specify”
  – Health-Seeking Behaviors (specify)
  – Deficient Knowledge (specify)
  – Readiness for Enhanced Knowledge (specify)
• Labels with primary concept as descriptor
  rather than as a noun
  – Self Care Deficit
          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
  – Any of the diagnoses in the book that do not show a
    LOE need to be reviewed and evidence provided
           Concept Analysis
• 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
• Where do you start?
  – Area of interest
  – Area that is missing from the taxonomy
  – Clinical need
• Obtain the most recent edition of NANDA-I’s Nursing
  Diagnoses: Definitions & Classification and review
  related diagnoses, if these exist
• Find the Diagnosis Submission Guidelines
  (, following the ―Diagnostic Review‖ link
• Follow the guidelines on the web in case they have
  been updated since publication of the most recent
  Nursing Diagnoses: Definitions & Classification book
         Steps in Development
• Review the literature
  – Nursing discipline
     • If none exists, identify this in your submission
  – Other disciplines
     •   Concept analysis
     •   Literature reviews/syntheses
     •   Qualitative research
     •   Quantitative research
        Literature Review Tips
• Look for information on the phenomenon or outcomes
  related to it, but NOT intervention studies or information
  on how to teach the use of standardized nursing
• Articles, NOT books (unless ―classics‖)
• Research-based articles, not editorials or quality
  improvement projects / unit-based implementation
  articles that are not based on research studies
   – If the research does not exist, indicate this on your submission
• Review ―Glossary of Terms‖ in the most recent
  edition of the NANDA-I Nursing Diagnoses:
  Definitions & Classification text
• Determine whether your diagnosis is an actual,
  risk, wellness or health-promotion diagnosis (or
  whether the concept can cross multiple facets)
• Develop the label for your diagnosis
• Provide a definition for the diagnosis that
  is supported by references
  – Identify those references in your submission
• Keep the language clear and concise
• Identify themes that arise in your literature review
   – Appearance of a particular defining characteristic / related / risk
     factor in one study does not mean it is a critical characteristic
   – Look for consensus in the defining characteristics / related / risk
     factors across the majority of your literature
   – Less IS more!
       • Assists with diagnostic accuracy if we can focus in on the major
         defining characteristics / related / risk factor
   – Consider the continuum of care if appropriate for your concept
• Defining Characteristics are required for:
  – Actual diagnoses
  – Wellness diagnoses
  – Health-promotion diagnoses
• Risk Factors are required for:
  – Risk diagnoses
• Related Factors are required for:
  – Actual diagnoses
• Each defining characteristic and risk / related factor
  must contain a single concept rather than multiple
    • Tinnitus                    • Tinnitus and/or
                     NOT            hearing
    • Hearing                       impairment
• References are required for each defining characteristic
  and risk / related factor
• Provide examples of appropriate nursing
  outcomes and nursing interventions for the
  – Assists DDC members in understanding the intent of
    the diagnosis
  – May be critical in differentiating this diagnosis from
    another that is already in the taxonomy
• Submit on-line via the website
• PLEASE use the prepared forms for diagnosis
  submission when sending your work in to NANDA-I for
  review if you are not submitting via our on-line website
• Where do you start?
  – Oldest diagnoses
     • 1970s – 3
     • 1980s – 30
     • 1990s - 79
  – Area of interest
  – Area that is missing from the taxonomy
  – Clinical need
• Need to compare changes to the existing
• All revisions must be supported by the
 Non-English Language Submission
• IF submitting in English, but English is not your primary
  language, try if possible to have another English-
  speaker review your translation prior to submission
   – IF NOT, submit it anyway!!!
• DDC will work with you to find someone to translate your
  work into English if you do not have a contact to do this
  for you
   – This will increase the review cycle
   – We want your work—we will work with you!
          Content Validation
• Refinement of current diagnoses
• Development of new diagnoses
   – Studies involving patients who are experiencing the
     diagnosis are needed
• 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
               The Future
• NANDA-International’s aim is to link with
  organizations across the world that have
  as their purpose nursing language
  – Increase diagnosis submission
  – Increase clinical testing of diagnoses
  – Ensure cultural sensitivity of diagnoses
 "If we cannot name it, we
 cannot control it, finance it,
research it, teach it, or put it
      into public policy."
        (Lang, 1993).

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