Evaluating Research Outcomes
2
Letter to the Editor EVALUATING RESEARCH OUTCOMES After reading the article entitled "Fre- quently Selected Nursing Diagnoses for the Rehabilitation Client with Stroke" (Pierce, et al., 1995), I was left with sev- eral questions and speculations about the meaning of the findings. I believe that re- search measuring actual nursing behav- ior, such as this article reports, is essen- tial to our understanding of nursing practice. The authors reviewed the charts of 100 clients who had been admitted with the diagnosis of stroke to anyone of five rehabilitation units in a large medical center, and they identified the six most frequently selected nursing diagnoses plus 11 other nursing diagnoses found at least once during the chart reviews. The top three nursing diagnoses were im- paired mobility, self-care deficit, and po- tential for injury; for these three, they also reported the most frequently select- ed related factors. What caught my at- tention in these data was the fact that, in a sample in which 49 of the 100 charts represented individuals with left hemi- plegia or paresis (and therefore, right brain damage), the authors did not iden- tify even one nursing diagnosis or relat- ed factor concerning sensory or percep- tual alterations, including unilateral neglect. I find it improbable that none of the persons with right cerebral damage caus- ing left hemiplegia had sensory or per- ceptual alterations.In persons with stroke, difficulties with self-care, mobility, and avoiding injury may be, at least in part, caused by sensory and perceptual alter- ations. In fact, sometimes these difficul- ties may be the first cue that sensory or perceptual deficits may exist. As the re- searchers commented, "Understanding the relationships between nursing diag- noses and various related factors will help nurses implement an appropriate rehabil- itation plan that can...help clients avoid unnecessary complications" (p. 142). Following are some of my specula- tions why sensory and perceptual alter- ations, including unilateral neglect, were not identified: 1. Even though the study data all come from rehabilitation units, the nurses may not have been knowledgeable about the sometimes subtle and sometimes bizarre impact that per- ceptual disturbances can have on an individual's behavior and, therefore, failed to recognize sensory and per- ceptualdisturbances as related fac- tors in some of the diagnoses they did make. 2. The study found no significant change in the nursing diagnoses iden- tified at the time of the clients' ad- mission to the units and their dis- charge from the units. The authors noted that this suggests "little, if any, improvement in the client's well-be- ing during the rehabilitation process" (p. 142). However, it appears to me, and the authors also indicate, that this lack of change in diagnosis may re- flect a lack of ongoing assessment, and as sensory and perceptual alter- ations are often subtle, they may be missed on admission and never picked up if assessment is not a con- tinuing focus. 3. The authors speculate that "some nurses do not believe that this [North American Nursing Diagnosis Asso- ciation (NANDA)] form of [nursing] diagnosis is integral to their [nursing] practice" (p. 143). I believe that nurs- ing diagnosis, especially in the for- malized NANDA format, has the po- tential of limiting the critical thinking necessary to assess and measure changes in clients' status, especially if it is used by nurses in a rote man- ner to fulfill some bureaucratic re- quirement rather than as a tool to help assess and enhance clients' rehabili- tation progress. 4. If standard care plans are used some- what automatically (as, unfortunate- ly, I think they are in some instances), there is a danger that nurses will not systematically screen clients for in- dicators of nursing diagnoses that are not on standard care plans. Therefore, where they are used, it is important that they include one for clients with left hemiplegia and one for clients with right hemiplegia. Although these would have many common elements, they would also include pathophysi- ologically related diagnoses such as sensory and perceptual alterations or unilateral neglect in standard care plans for left hemiplegia and im- paired communication related to lan- guage deficits in standard care plans for right hemiplegia. The authors did not note whether any of the five re- habilitation units in the study used standard care plans, let alone whether, if they did, they used one generic standard plan or two (i.e., one re- flecting common diagnoses for peo- ple with left hemiplegia and another reflecting the common diagnoses for people with right hemiplegia). To the degree that standard care plans cue nurses to assess for a group of fre- quently occurring diagnoses, the more discriminating they can be, the better. 5. Finally, I think that comparisons are useful between studies of actual prac- tice, such as this one, and studies of nurses' retrospective reports of what diagnoses they use, such as the one by Sawin and Heard (1992). In this retrospective self-reported study, nurses were asked to rate how fre- quently they used each of 33 listed di- agnoses. Fifty-seven percent of the respondents said they used the diag- nosis sensory perception alterations very frequently. This study had a large sample of 456 nurses who were either attending an Association of Re- habilitation Nurses (ARN) confer- ence or who were members of ARN, or both. Why did the findings of the practice setting study of nursing di- agnoses recorded on clients' charts differ from the hypothetical reports of nurses about the use of nursing di- agnoses? It is not possible from the information given in these two articles to know whether there are educational or practice 46 Rehabilitation Nursing> Volume 22, Number I • JanlFeb 1997
-
Upload
geraldine-hart -
Category
Documents
-
view
216 -
download
2
Transcript of Evaluating Research Outcomes
Letter to the Editor
EVALUATING RESEARCH OUTCOMES
After reading the article entitled "Frequently Selected Nursing Diagnoses forthe Rehabilitation Client with Stroke"(Pierce, et al., 1995), I was left with several questions and speculations about themeaning of the findings. I believe that research measuring actual nursing behavior, such as this article reports, is essential to our understanding of nursingpractice.
The authors reviewed the charts of100 clients who had been admitted withthe diagnosis of stroke to anyone of fiverehabilitation units in a large medicalcenter, and they identified the six mostfrequently selected nursing diagnosesplus 11 other nursing diagnoses found atleast once during the chart reviews. Thetop three nursing diagnoses were impaired mobility, self-care deficit, and potential for injury; for these three, theyalso reported the most frequently selected related factors. What caught my attention in these data was the fact that, ina sample in which 49 of the 100 chartsrepresented individuals with left hemiplegia or paresis (and therefore, rightbrain damage), the authors did not identify even one nursing diagnosis or related factor concerning sensory or perceptual alterations, including unilateralneglect.
I find it improbable that none of thepersons with right cerebral damage causing left hemiplegia had sensory or perceptual alterations.In persons with stroke,difficulties with self-care, mobility, andavoiding injury may be, at least in part,caused by sensory and perceptual alterations. In fact, sometimes these difficulties may be the first cue that sensory orperceptual deficits may exist. As the researchers commented, "Understandingthe relationships between nursing diagnoses and variousrelated factors will helpnurses implement an appropriate rehabilitation plan that can...help clients avoidunnecessary complications" (p. 142).
Following are some of my speculations why sensory and perceptual alterations, including unilateral neglect, werenot identified:
1. Even though the study data all comefrom rehabilitation units, the nursesmay not have been knowledgeableabout the sometimes subtle andsometimes bizarre impact that perceptual disturbances can have on anindividual's behavior and, therefore,failed to recognize sensory and perceptualdisturbances as related factors in some of the diagnoses they didmake.
2. The study found no significantchange in the nursing diagnoses identified at the time of the clients' admission to the units and their discharge from the units. The authorsnoted that this suggests "little, if any,improvement in the client's well-being during the rehabilitation process"(p. 142). However, it appears to me,and the authors also indicate, that thislack of change in diagnosis may reflect a lack of ongoing assessment,and as sensory and perceptual alterations are often subtle, they may bemissed on admission and neverpicked up if assessment is not a continuing focus.
3. The authors speculate that "somenurses do not believe that this [NorthAmerican Nursing Diagnosis Association (NANDA)] form of [nursing]diagnosis is integral to their [nursing]practice" (p. 143). I believe that nursing diagnosis, especially in the formalized NANDA format, has the potential of limiting the critical thinkingnecessary to assess and measurechanges in clients' status, especiallyif it is used by nurses in a rote manner to fulfill some bureaucratic requirement rather than as a tool to helpassess and enhance clients' rehabilitation progress.
4. If standard care plans are used somewhat automatically (as, unfortunately, I think they are in some instances),there is a danger that nurses will notsystematically screen clients for indicators of nursing diagnoses that arenot on standard care plans. Therefore,where they are used, it is important
that they include one for clients withleft hemiplegia and one for clientswith right hemiplegia. Although thesewould have many common elements,they would also include pathophysiologically related diagnoses such assensory and perceptual alterations orunilateral neglect in standard careplans for left hemiplegia and impaired communication related to language deficits in standard care plansfor right hemiplegia. The authors didnot note whether any of the five rehabilitation units in the study usedstandard care plans, let alone whether,if they did, they used one genericstandard plan or two (i.e., one reflecting common diagnoses for people with left hemiplegia and anotherreflecting the common diagnoses forpeople with right hemiplegia). To thedegree that standard care plans cuenurses to assess for a group of frequently occurring diagnoses, themore discriminating they can be, thebetter.
5. Finally, I think that comparisons areuseful between studies of actual practice, such as this one, and studies ofnurses' retrospective reports of whatdiagnoses they use, such as the oneby Sawin and Heard (1992). In thisretrospective self-reported study,nurses were asked to rate how frequently they used each of 33 listed diagnoses. Fifty-seven percent of therespondents said they used the diagnosis sensory perception alterationsvery frequently. This study had alarge sample of 456 nurses who wereeither attending an Association of Rehabilitation Nurses (ARN) conference or who were members of ARN,or both. Why did the findings of thepractice setting study of nursing diagnoses recorded on clients' chartsdiffer from the hypothetical reportsof nurses about the use of nursing diagnoses?It is not possible from the information
given in these two articles to knowwhether there are educational or practice
46 Rehabilitation Nursing> Volume 22, Number I • JanlFeb 1997
Calendar
differences in the backgrounds of thetwo sample groups that might explainsome of the differences in findings.However, I speculate that when they arecued (as by questionnaires), nurses mayrespond as they believe they do or shouldbehave, but that due to the human needto view and present themselves positively, their responses may not reflect thesame reality that has been found in studies of actual behavior. This is importantto consider when making assumptionsor decisions based on research findings.
Geraldine Hart, MSN RN, AssociateProfessor, School ofNursing, DalhousieUniversity, Halifax, NS, Canada
ReferencesPierce, L., Rodrigues-Fisher, L., Buettner, M.,
Bulcroft, J., Camp, Y., & Bourguignon, C. (1995).Frequently selected nursing diagnoses for the rehabilitation client with stroke. Rehabilitation Nursing, 20, 138-143.
Sawin, K., & Heard, L. (1992). Nursing diagnoses used most frequently in rehabilitation nursing practice. Rehabilitation Nursing, 17,256-262.
Editor's noteThe authors declined to respond to
Ms. Hart's letter.
Rehabilitation Nursing welcomescommentary. Every letter to the editor is read carefully, and your comments, criticisms, and suggestions areconsidered. Address letters to Belinda E. Puetz, PhD RN, Editor, Rehabilitation Nursing, 4700 W.Lake Avenue, Glenview, IL 60025-1485.Please include a telephone number atwhich you can be reached during theday. Rehabilitation Nursing reservesthe right to edit readers' letters tomeet clarity, style, and space requirements.
ARNEvENTS
April 4, 1997Deadline for Submission ofPaperand Poster Abstracts for the Association of Rehabilitation Nurses(ARN) 23rd Annual EducationalConference (October 22-26,1997)Contact: ARN, 4700 W. Lake Avenue,Glenview,IL 60025-1485, 800/229-7530or 847/375-4710, fax 847/375-4777, Email [email protected]
May 16-18Chapter Leadership InstituteSponsor: ARNLocation: Glenview, ILContact: ARN Chapter Leadership Institute, 4700 W.Lake Avenue, Glenview,IL 60025-1485,800/229-7530 or 847/375-4710, fax 847/375-4777, [email protected]
June 9-14, 1997Rehabilitation Nursing: Directionsfor Practice-A Basic RehabilitationNursing CourseSponsor: ARNLocation: San Diego RehabilitationInstitute, San Diego, CAContact: ARN Basic Course, 4700 W.Lake Avenue, Glenview, IL 60025-1485,800/229-7530 or 847/375-4710, fax 847/375-4777, E-mail [email protected]
August 18-23, 1997Rehabilitation Nursing: Directionsfor Practice-A Basic RehabilitationNursing CourseSponsor: ARNLocation: Fletcher Allen HealthcareRehabilitation Center, Burlington, VTContact: ARN Basic Course, 4700 W.Lake Avenue, Glenview, IL 60025-1485,800/229-7530 or 847/375-4710, fax 847/375-4777, E-mail [email protected]
October 22-26, 1997Celebrating Success: ARN 23rdAnnual Educational ConferenceSponsor: ARNLocation: Baltimore, MDContact: ARN 1997 Conference, 4700W. Lake Avenue, Glenview, IL 60025-
1485,800/229-7530 or 847/375-4710,fax 847/375-4777, E-mail info@rehabnurse.org
OTHER EVENTS
February 15-19, 1997CARF Winter National Medical Conference: 1997 Standards and BestPractices in Medical RehabilitationSponsor: CARF. ..The RehabilitationAccreditation CommissionLocation: Doubletree Hotel, Tucson, AZContact: Education and Training Division, CARP, 520/325-1044
March 4-7, 1997Disease Management Congress:Outcomes Management and QualityImprovementSponsor: National Managed HealthCare Congress (NMHCC)Location: Phoenix, AZContact: NMHCC, Inc., PO Box360034, Boston, MA 02241-0634,888/446-6422, fax 617/270-6004, [email protected]
March 15-17, 1997Spirituality and Healing inMedicine IISponsor: Harvard Medical School Department of Continuing Education,Mind/Body Medical Institute, DeaconessHospitalLocation: The Westin BonaventureHotel and Suites, Los Angeles, CAContact: Professional Meeting Planners,5 Central Square, Suite 201, Stoneham,MA 02180, 617/279-9887, fax 617/2799875, E-mail [email protected]
April 9-12, 1997Eighth Annual Educational Conference of the American Association ofLegal Nurse ConsultantsSponsor: American Association of Legal Nurse Consultants (AALNC)Location: The Westin William Penn,Pittsburgh, PAContact: AALNC, 4700 W. Lake Avenue, Glenview, IL 60025-1485,847/375-4713, fax 847/375-4777, [email protected]
Rehabilitation Nursing> Volume 22, Number I • JanlFeb 1997 47
