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

2008• 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 submissions

• The DDC developed rules for evaluating submissions• DDC reviewed and revised the Level of Evidence

Requirements

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 taxonomy.

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 researchers.

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 population.

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

treated)– Factors that are typically associated with the

diagnosis– 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

experience/practice

Development• Where do you start?

– Area of interest– Area that is missing from the taxonomy– Clinical need

Development• 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 (www.nanda.org), 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 languages

• 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

Development• 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)

Development• 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

Development• 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

Development• 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

Development• Each defining characteristic and risk / related factor

must contain a single concept rather than multiple concepts

• Tinnitus

• Hearing impairment

NOT• Tinnitus and/or

hearing impairment

• References are required for each defining characteristic and risk / related factor

Development• Provide examples of appropriate nursing

outcomes and nursing interventions for the diagnosis– 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

Submission• Submit on-line via the www.nanda.org 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

Revision• Where do you start?

– Oldest diagnoses • 1970s – 3• 1980s – 30• 1990s - 79

– Area of interest– Area that is missing from the taxonomy– Clinical need

Refinement• Need to compare changes to the existing

diagnosis

• All revisions must be supported by the literature

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 development– 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).