Nursing Diagnosis in Health Care Organizations: Factors that

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Nursing Diagnosis in Health Care
Organizations Factors that facilitate and
complicate - implementation
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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

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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 persons, familys, or communitys
  motivation and desire to increase wellbeing and
  actualize human health potential

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Comparisons

• Medical Diagnoses
• Chronic obstructive pulmonary disease
• Cerebrovascular attack
• Amputation

• Nursing Diagnoses
• Ineffective breathing pattern
• Activity intolerance
• Disturbed body image
• Readiness for enhanced coping

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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).

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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.

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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

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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

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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

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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

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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

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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

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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

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Provide On-Going Staff Education

• Highlight use of standardized nursing language in
  organizational newsletters
• Email 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

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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

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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

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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

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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)

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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

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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

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Standardized Nursing Language

• Provides evidence-based terminology
• Describes practice
• Drives research
• Documents the impact of nursing care on health
  care quality

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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

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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

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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 (www.nanda.org)

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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?

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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

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The Future of Nursing Diagnoses

• NANDA-Internationals 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