Chapter Two

TEACHING NANDA-I NIC AND NOC: NOVICE TO EXPERT

Nursing Assessment, Clinical Judgmentand Nursing Diagnoses:

How to Determine Accuracy

Teaching NANDA-I NIC and NOC: Novice to Expert

ContributorMargaret Lunney

Learning Objectives• Explain 3 Propositions Related to Teaching NNN

• Set Expectations for Students at Novice to Expert Stages of Development

• Implement Teaching Strategies

• Integrate NNN With Nursing Curricula

Objective 1: Explain Propositions• Use of NNN Requires Intellectual, Interpersonal,

And Technical Competencies, Tolerance for Ambiguity And Reflection

• Accurate Diagnoses are the Basis for Use of NIC and NOC

• Use of NNN Differs from the Traditional Nursing Process

Proposition # 1: Skills/Competencies• Intellectual

• Knowledge Related to: Diagnoses, Interventions and Outcomes

• Thinking Processes• Research Findings:

• Human Beings Vary in Thinking Process Abilities

• Thinking Process Abilities can be Improved

Variation in Nurses’ Thinking Abilities N = 86 (Lunney 1992)

Basic Thinking Abilities Mean SD RangeDMU-Fluency 21.3 7.2 6-41.5

DMC-Flexibility 10.8 6.5 0-27.5

DMI-Elaboration 17.8 4.9 7-30.5

Intellectual Skills: Research Findings Related to Women• Thinking Processes of Women Develop Through Relationships• Women’s Perspectives on Thinking (Belenkey et al. 1986)

• Silence• Received Knowledge• Subjective Knowledge• Procedural Knowledge• Constructed Knowledge

• Nursing Students and Nurses may have Lower Level Perspectives

Intellectual Skills: Critical Thinking (CT)

• Thinking (CT) Processes can be Improved• Stimulate to Use• Expect Use• Validate Appropriate Use• Demonstrate Support and Confidence in Abilities

• CT Abilities - Essential for Accuracy of Diagnoses and Use of NOC and NIC

Intellectual Skills: What is CT in Nursing?• Delphi Study of 55 Nurse Experts

(Scheffer and Rubenfeld 2000)

• Purpose: Identify the Components of CT that Relate to Nursing

• Results - Definition for Nursing• 7 Cognitive Skills• 10 Habits of Mind

Cognitive Skills• Analyzing

• Applying Standards

• Discriminating

• Information Seeking

• Logical Reasoning

• Predicting

• Transforming Knowledge

Habits of Mind• Confidence• Contextual Perspective• Creativity• Flexibility• Inquisitiveness

• Intellectual Integrity• Intuition• Open-Mindedness• Perseverance• Reflection

Intellectual Skills: CT Processes• CT Involves Continuous Processing of Data and

Inferences

• In Any Situation, Two or More Cognitive Skills are Probably Being Used

• Habits of Mind Support Cognitive Skills

• The Combination of CT Abilities Needed is Unique to the Situation

Proposition # 1: Interpersonal Skills (continued)

• Exquisite Communication

• Promote Trust

• Work in Partnership, Share Power

• Validate Perceptions

• Accept that We Do Not “Know” Others

• Obtain Valid and Reliable Data

• Health Histories: Comprehensive

• Physical Exams: Focused

• Perform Nursing Interventions

• Technical Aspects of Using NNN

Proposition # 1: Technical Skills (continued)

• Tolerate Ambiguity

• Decisions are Relative to Context and Specific Nature of Individuals

• Multiple Factors Influence Clinical Situations

• Human Beings are Complex and Diverse

• Ambiguity is the Norm

Proposition # 1: Personal Strengths(continued)

• Reflect on Practice Experiences

• Accept Possible Flaws:

• Thinking

• Interpersonal

• Technical

• Aim - Develop and Grow

Proposition # 1: Personal Strengths(continued)

Proposition # 2: Accurate Interpretations -Foundational• Cues/Data may be Incorrect• Examples:

• Objective Data: Diagnostic Tests

• Subjective Data• Patients• Families

• Use of NNN Requires Many Decisions• All Decisions are Based on Patient Data• Data Amounts are Overwhelming• Short-Term Memory = 7 ± 2 Bits of Data• Data are Converted into Interpretations

Proposition # 2: Accurate Interpretations -Foundational

• Interpretations Determine Actions• Additional Data Collection

• Subsequent Decisions

• Possible Outcomes to Consider

• Choices of Interventions

• High Potential for Inaccuracy• Diagnosis and Etiology

Proposition # 2: Accurate Interpretations -Foundational

High Potential for Inaccuracy, e.g. Marian Hughes – A Case Study(1) Marian Hughes is a 16-year-old female with a medical diagnosis of diabetes

mellitus.(2) She was admitted 3 days ago for treatment of an acute episode of diabetic

ketoacidosis. (3) When Marian discussed with you how she managed the therapeutic regimen

before hospitalization, she states that she was not adhering to her prescribed diet.

(4) You decide that Marian needs assistance to improve her management of the therapeutic regimen, especially the types of foods she eats.

(5) Marian's stay in the hospital unit is uneventful in that medical treatments are successfully resolving the crisis.

(6) Marian's daily habits include getting up for school about 7.00 a.m. and rushing to get the bus by 7.30.

(7) She says that she should get up about 6.30 but she likes to sleep. (8) She states that she does not want her mother to help her get up earlier.  

Marian Hughes (continued)

(9) The meal that she eats at school is consistent with her prescribed diet while the two meals at home are not.

(10) In the morning she grabs whatever is quick and easy, usually toast and butter. (11) In the evening, her mother makes meals that comply with the diabetic diet, but

Marian states that she does not like them so she only eats part of her supper and then snacks on other foods later.

(12) Marian is able to explain to you what she should be eating and she can adjust her diet to her lifestyle.

(13) The knowledge of what foods are on her diet that she likes was not discussed with her mother because Marian doesn't want to sit down and talk with her.

(14) In general, Marian and her mother argue over many of Marian's behaviors, such as school grades, smoking, and coming in late at night.

 

High Potential for Inaccuracy, e.g. Marian Hughes• 16 Year Old Diabetic (#1)

• Hospitalized, DKA (#2)

• “Did Not Follow Prescribed Diet” (#3)

• NDX: Ineffective Management of Therapeutic Regimen, Related to _______ (Fill in the Blank)

Possible Interpretation/Diagnosis• Knowledge Deficit

• Disconfirming Cues: • Meals eaten at school are consistent with diet (#9)• Able to explain what she should be eating (#12)• She can adjust her diet to her lifestyle (#13)

• Conclusion: Low Accuracy Diagnosis

• Teaching is Waste of Time, Effort, and Money

Highest Accuracy Diagnosis• Ineffective Self-Health Management Related to

Communication Difficulties Between Marian and Her Mother

• Patient Outcome (NOC): • Communication = 3 (moderately compromised), Increase to 5 (not

compromised)

• Nursing Intervention• Communication Enhancement

44 Diagnoses by 80 Nurses•Examples:

•Communication Difficulties Between Mother/Daughter•Stressful Mother/Child Relationship•Altered Family Dynamics•Ineffective Coping•Ineffective Time Management•Adolescent Image•Low Self-Esteem•Denial•Knowledge Deficit

Seven Levels of Accuracy

+5 Highest Level of Accuracy

+4 Close to the Highest Level But Not Quite

+3 General Idea But Not Specific Enough

+2 Not Enough Highly Relevant Cues or Not the Highest Priority

+1 Suggested by Only One or a Few Cues

0 Not Indicated by Data

-1 Should Be Rejected, Disconfirming Cues

Diagnostic Accuracy Scores•Communication Difficulties Between Mother and Daughter +5•Stressful Mother/Child Relationship +4•Altered Family Dynamics +3•Ineffective Coping +2•Ineffective Time Management +2•Adolescent Image +1•Low Self-Esteem +1•Denial 0•Knowledge Deficit -1

Research Findings•Studies: 1966 to Present •Conclusions: Interpretations Vary Widely•All Interpretations are Not High Accuracy•Influencing Factors (Carnevali 1983; Gordon 1982):

•Nurse Diagnostician•Diagnostic Task•Situational Context

Research: Positive Influences•Diagnostic Task

•Lesser Amounts and Complexity of Data

•Nurse Diagnostician•Education Related to Nursing Diagnoses

•Knowledge of Diagnostic Process and Concepts

•Teaching Aids for Diagnostic Reasoning

•Variety of Thinking Processes

•Experience Specific to Diagnostic Task

Challenge: Achieving AccuracyPuzzle: What is the Diagnosis?

Solving the Puzzle

Is It This? Or This? Or This?

Supporting Factors:•Acknowledge That Data Interpretations Are Probabilistic; Question Accuracy

•Use CT, Interpersonal and Technical Skills

•Develop Tolerance for Ambiguity•It’s OK Not to Have an Answer•Accept that We Might Make Mistakes

•Develop Reflective Practice

Proposition # 2: Accurate Interpretations -Foundational

Proposition # 3: New Perspective on Nursing ProcessTraditional•Limited # Concepts•Collect Comprehensive Data•No Accountability for Diagnoses•Intervene Based on Data•Behavioral Outcomes•Disorganized Follow-up

Use of NNN•Currently 1147 Concepts•Cue-based and Hypothesis-Driven Data Collection•Fully Accountable for Diagnoses•Intervene Based on Data Interpretations•Neutral Terms with Scale•Systematic Follow-up

Changing from Traditional to Use of NNN•Acknowledge Difficulty Level: Simple to Complex

•Influencing Factors:•Similarity of Terms in Three Systems•Structure of Classifications•Resources (Books, Pamphlets, Other)•Complexity of Clinical Situations•Nurses’ Perspective/Model For Practice•Experience with NNN

Examples: User-Friendly SimplicityNANDA-I NOC NIC

Anxiety:Vague uneasy feeling; autonomic response; feeling of apprehension; altering signal warning of impending danger

Anxiety Control:Personal actions to eliminate or reduce feelings of apprehension and tension from an unidentifiable source

Anxiety Reduction:Minimizing apprehension, dread, foreboding, or uneasiness related to unidentified source of anticipated danger

Risk for Infection:Increased risk of being invaded by pathogens

Infection Status:Presence and extent of infection

Infection Protection:Prevention and early detection of infection in a patient at risk

•Use Theoretical Perspective:•Change theory

•Diffusion of Innovations (Rogers 2003)

•S-Shaped Diffusion Curve •Perceived Characteristics:•Relative Advantage (+)

•Compatibility (+)

•Complexity (-)

•Trial Ability (+)

•Observability (+)

Changing from Traditional to Use of NNN

•Be a Champion

•Sell First to Opinion Leaders

•Goal: Create a Critical Mass

•Share Demonstration Projects, e.g. Protocols, Journals

•Faculty Development Program; Adoption by System, Adoption by Individuals

Changing from Traditional to Use of NNN

Objective # 2: Set Expectations, Novice to Expert •Novices and Advanced Beginners (ABS) Learn to Use NNN as Well as Experienced Nurses

•Novices and ABS may be Easier to Teach Than Nurses at Competent, Proficient and Expert (Expert) Stages

•Expert Nurses must be “Sold” on New Way to Think and Document

Selling NNN to Experts•HER is Imminent•NNN = File Names for EHR •NNN Describes What Nurses Bring to the Table•NNN Makes Knowledge Available at Bedside•Aggregated Data = Knowledge•Measurement of Care = Improved Quality•Linguistics Theory Supports SNLS •Fits with Nursing theories

Set Expectations•Expect (At All Levels of Expertise)

•Correct Use of the Three Systems, e.g.:•Nursing Diagnoses are Used to Guide Interventions, Not for Labeling Per Se •Intervention Label is the Intervention, Not the Activities•Outcome Label is Outcome, Not Indicators

•Correct Use of Concepts, e.g.:•NANDA-I: Social Isolation•NIC: Coping Enhancement •NOC: Knowledge (Specify)

Set Expectations•Do Not Underestimate Nursing Students or Nurses:

•“…Nursing and Nursing Knowledge must be Presented in All Its Complexity …”

• Help Students and Nurses to “… Experience the Complex and Messy World of Nursing … and Learn How to Navigate Through It …”

(Doane and Varcoe 2005, p.xi)

Set Expectations•All Levels:

•Self-Evaluation

•Integrate With New Theories, e.g. Pender’s Health Promotion Model

•Integrate with Strategies for Evidence-Based Nursing

•Set Expectations•Encourage Experts to:

•Integrate with Previous Knowledge

•Use NNN in:•Communicating Scope of Practice •Developing Standards of Care•Evidence-Based Nursing Projects•Research Projects

•Evaluate Clinical Applications of NNN

•Teach CE Programs to Nursing Personnel

Objective 3:Teaching Strategies, Intellectual

•Assume that Thinking Is Human, Imperfect, Attainable

•Encourage Thinking in Class and Clinical:•Ask Questions Instead of Giving Answers•Provide Opportunities for Problem Solving

Teaching Strategies: Intellectual•Deflate Authority

Teaching Strategies: Intellectual•Think Out Loud with Students

•Act as Midwife or Coach

•Help Them Think About Thinking: •Ask: What Kind of Thinking is Needed? •Use the 17 CT Terms and Definitions

•Evaluate Thinking Processes

•Expect Self-Evaluation of Thinking

•Share Paradigm Cases (e.g. Marian Hughes)

•Simplify Representations, Identify High Relevance Cues

•Conduct Iterative Hypothesis Testing

Teaching Strategies: Intellectual

•Seminars Instead of Lectures: Why?•Groups Represent Wide Variations in Thinking Abilities

•Promotes “In-Class” Thinking

•Recognizes Students’ Abilities to Think and Learn without Authority/Experts

•Supports Future Work in Groups to Describe, Analyze and Synthesize Information, Solve Problems (e.g. What is the diagnosis?)

Teaching Strategies: Intellectual

•Seminars: How?•Assign Readings, Provide Discussion Questions•Lead the Group, Ask the Discussion Questions•Be Respectful; Protect Students’ Self-Esteem

•Address:•What is the Author Saying?•What is the Fit with Previous Knowledge?•How Does This Information Apply to Practice?

•25-30% of Grade for Discussion of Readings

Teaching Strategies: Intellectual

•Expect Self-Evaluation•Ask Questions, Instead of Giving Answers•Discussion in Class•Discussion Online•Journal Writing (Degazon and Lunney 1995)

Teaching Strategies: Intellectual

•Expect Accountability for Patient Relationships

•Demonstrate:•Good Interviewing•Validation of Diagnoses•Partnership Processes to Select Outcomes and Interventions

•Reward Power Sharing

•Teach and Support Assertiveness

Teaching Strategies: Interpersonal

•Expect Accountability for Using Standardized Methods

•Demonstrate Use of Diagnostic Reasoning

•Show Technical Use of NNN Using Case Studies

Teaching Strategies: Interpersonal

•Demonstrate Correct Use of NNN

•Provide Incentives for Correct Use of NNN, e.g. Percentage of Grade

•Integrate with Theories of Nursing, e.g.:•Neuman’s Systems Model•Roger’s Science of Unitary Human Beings•Leininger’s Sunrise Model•AACN Synergy Model of Patient Care

Teaching Strategies: General

Case Study: Laura (with permission from Dr Arlene Farren)

•30-Year-Old Woman in Good Health

•Has Smoked 1-1.5 Packs Per Day for >12 Years

•Asked for Assistance to Quit

•Stated “I Know It’s Not Good for Me and I Want to Stay Healthy”

What is the Diagnosis?•Readiness for Enhanced Self-Health ManagementDefinition: A Pattern of Regulating and Integrating into Daily Living a Therapeutic Regime for Treatment of Illness and Its Sequelae that is Sufficient for Meeting Health-Related Goals and can be Strengthened

What is the Outcome?Smoking Cessation Behavior

•Personal Actions to Eliminate Tobacco Use

•Rarely Demonstrated (3), Goal = 5

•Indicators:•Expresses Willingness to Stop Smoking (3)•Identifies Benefits of Smoking Cessation (3)•Adjusts Tobacco Elimination Strategies as Needed (3)•Uses Strategies to Cope with Withdrawal Symptoms (2)•Develops Effective Strategies to Eliminate Tobacco Use (2)

What are the Interventions?•Smoking Cessation Assistance •Teaching: Medication, Nicotine Replacement Therapy

NIC: Smoking Cessation Assistance•Helping Another to Stop Smoking

•Activities:•Give Laura Clear, Consistent Advice to Quit•Assist Laura in Choosing Strategies•Motivate Her to Set a Quit Date•Refer to Group Programs/Individual Therapy•Inform Laura of Possible Symptoms•Help Plan Coping Strategies and Resolve Problems

Evaluation of Outcomes•Smoking Cessation Behavior

•After 6 Weeks, Nurse and Laura Rate Outcome as 5•Laura Consistently Monitors Her Environment and Personal Behaviors for Factors that Affect Her tobacco Use•Laura Developed Effective Strategies and Remains Consistently Committed to Controlling Her Use•Laura Uses Friends and Group for Help•Laura has not Smoked For 6 Weeks

Case Study: Stella C (with permission of Coleen Kumar)

•49-Year-Old Single, Italian-American Woman•Type 2 DM with Adequate Control•Overweight•Head of Household; 80-Year-Old Dependent Mother•Works Full Time, Provides Care for Self and Mother •Accepts Care of Mother But has Many Frustrations•Attempts to Reduce Her Workload Have Failed•Mother Thinks Stella “Can Do It All”•Mother Discourages Son’s Involvement•Stella Expresses Conflicting Emotions, Stress, Lack of Control

What are the Diagnoses?•The Diagnostic Process:

•Which are Important Cues?•What are Possible Diagnoses?•Which Diagnoses Have the Best Support?

•Are the Diagnoses Consistent with the Situational Context?

•Can the Nurse Help Stella with the Diagnoses?

What are the Diagnoses?•NANDA-I Diagnoses:

•Risk of Caregiver Role Strain•Readiness for Enhanced Family Coping

•Checking for Accuracy:•Are There a Sufficient Number of Confirming Cues?•Are There Any Disconfirming Cues?•Did Stella C Validate the Diagnosis?•Should Other Providers be Consulted?

What are the Outcomes?•Caregiver Well-Being

•Caregiver Satisfaction with Health and Lifestyle Circumstances•Moderately Compromised (3), Goal = 4 or 5•Indicators:•Satisfaction with Physical Health (3)•Satisfaction with Emotional Health (2)•Satisfaction with Usual Lifestyle (3)•Satisfaction with Instrumental Support (2)

•Satisfaction with Social Relationships (3) (Moorhead et al. 2008)

What are the Outcomes?•Family Coping

•Family Actions to Manage Stressors that Tax Family Resources•Moderately Compromised (3); Goal = 4 or 5•Indicators:

•Demonstrates Role Flexibility (3)

•Family Enables Member Role Flexibility (3)

•Expresses Feelings and Emotions Freely (2)

•Arranges for Respite Care (2)

•Seeks Assistance When Appropriate (3)

•Uses Social Support (3) (Moorhead et al. 2008)

What are the Interventions?•Assertiveness Training •Self-Esteem Enhancement•Emotional Support•Caregiver Support •Role Enhancement •Family Involvement Promotion •Respite Care(Bulecheck et al. 2008)

NIC Example: Assertiveness Training•Assistance With the Effective Expression of Feelings, Needs, and Ideas While Respecting the Rights of Others

•Activities:•Determine Barriers to Assertiveness, e.g. Family Roles•Help Stella Recognize and Reduce Cognitive Distortions•Instruct Stella in Different Ways to Act Assertively•Facilitate Practice Opportunities Using Discussion, Modeling and Role Playing•Help Stella Practice Conversational Skills(Bulecheck et al. 2008)

Evaluation of Outcomes•Caregiver Well-Being

•After 4 Weeks, Nurse and Stella Rate Outcome as 4•Stella’s Physical Health has Improved; Satisfaction with Physical Health (4)•Stella Uses Assertiveness Skills to Make Time for Herself After Work and to Plan Recreation; Satisfaction with Emotional Health (4)•Stella Continues to Need Help in the Performance of Caregiver Roles; Satisfaction with Performance of Usual Roles (4)•Stella Feels in Control of Her Caregiver Routines; Satisfaction with Caregiver Role (4)

Evaluation of Outcomes•Family Coping

•After 4 Weeks, Nurse and Stella Rate Outcome as 4•Stella’s Assertiveness Behaviors Work Well to Accomplish Goals; Demonstrates Role Flexibility (4)•Stella’s Mother Agrees with the Plan to Relieve Her of Some of the Workload; Family Enables Member Role Flexibility (4)•Stella’s Brother Stays with Her Mother So Stella can Go Away for Short Periods; Arranges for Respite Care (4)•Family Exhibits a Wider Repertoire of Coping Behaviors (4)

Use Case Studies•Case Studies Help Students to Practice Thinking and Clinical Judgment in a Safe Environment

•Standardized: Everyone Uses the Same Clinical Data

(Lunney 2009)

Teaching Strategies: Summary•Observe Students Grow in Abilities Through Encouragement, Trust, Respect

Objective 4: Integrate with Curricula •Prepare Faculty

•Diffusion of Innovations (Rogers 2003)

•Talking Points:•Electronic Health Record•Quality-Based Nursing Care•Ability to Develop Information and Knowledge

•Involve Clinical Faculty

•Evaluation/Peer Observation

Integrate with Curricula•Simplify Complexity: Map Diagnoses, Interventions and Outcomes for Courses

•All Faculty Evaluate Students’:•Correct Use of NNN•Partnership Processes, Use of “We”•Technical Skills•Individualize NNN Content with Patients

Integrate with Curricula•Fundamentals of Nursing

•NNN - Framework for Skills Learning•Thinking - High Priority, Include in Testing•Expect Students to Use CT Terms and Definitions, e.g. Journal Writing, Discussion•Develop Case Studies (Lunney,1992)

•Iterative Hypothesis Testing

Integrate with Curricula•Educators and Practice-Based Leaders: Spread the Word to Nurses in Other Agencies

•Meet with Leaders; Use Marketing Strategies

•Demonstrate Advantages of NNN

•Provide CE Programs

•Disseminate Your Success in Using NNN to Others

Questions/Discussion?“Teamwork is the Fuel that Allows Common People to Attain Uncommon Results” (Unknown)

“The Illiterate of the 21st Century will Not be Those Who Cannot Read and Write, But Those Who Cannot Learn, Unlearn and Relearn” (AlvinToffler)

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