Nursing Diagnosis in Health Care Organizations:

Factors that facilitate – and complicate - implementation

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

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 person’s, family’s, or community’s motivation and desire to increase wellbeing and actualize human health potential

Comparisons• Medical Diagnoses

– Chronic obstructive pulmonary disease

– Cerebrovascular attack

– Amputation

• Nursing Diagnoses– Ineffective breathing

pattern

– Activity intolerance

– Disturbed body image– Readiness for enhanced

coping

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).

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.

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

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

“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

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

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

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

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

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

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

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

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

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)

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

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

Standardized Nursing Language • Provides evidence-based terminology

– Describes practice– Drives research– Documents the impact of nursing care on health care

quality

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

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

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)

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?

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

The Future of Nursing Diagnoses

• NANDA-International’s 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