Dialogue

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To the Editor: Baumann and Deber’s articles, “The Limits of Decision Analysis

for Rapid Decision Making in ICU Nursing” (IMAGE, 21[2]) raises several points which merit further discussion. First, the authors argue that a lack of mutually exclusive nursing interven- tions precludes the use of decision analysis in ICUs. While many nursing decisions lack mutually exclusive alternatives, there are sit- uations where nurses must choose one intervention over another. For example, an acute staffing shortage may require that the nurse quickly determine whether a particular patient requires immediate assessment or whether that time could be better spent with another patient.

Secondly, the authors state that the use of decision analysis is impeded by the less-than-clear relationship between nursing inter- ventions and outcomes. While this may be a valid observation, it is not a limitation of decision analysis. Rather, it points to the paucity of outcome-oriented nursing research and consequent lack of empir- ical nursing data.

Finally, the authors note that the nature of crisis may impede the usefulness of decision analysis. Admittedly, this may be true with respect to manual decision analytic models. However, many critical care decisions can be modeled (e.g. protocols are a type of model) and computerized so that rapid decision making is possible. Once again, this is not a limitation of decision analysis. Rather, it proba- bly reflects the reluctance of clinicians to incorporate decision sup- port or advising systems into everyday practice.

Katharine Kostbade Hughes, R N , PhD Assistant Clinical Professor Arthur Elstein, PhD Professor College of Medicine University of Illinois-Chicago

The Authors respond: We appreciate the comments of Prof . Hughes and Elstein. W e had modeled

our original research design on the seminal contributions of Dr. Elstein ’s group. We are much in agreement: decision analysis involves a certain set of assumptions, and one can apply it more easily if these assumptions are met. T o some extent then, one is arguing about whether a glass is half fu l l or half empty. Better knowledge of relationships between intervention and outcome should greatly improve the possibility of using such techniqlles in a variety of settings.

W e should note, however, that much of current nursing practice does not meet this test. Indeed, one of the vignettes in the study addressed the example they give (having to decide which patient requires immediate attention). The case involved a situation where the nurse had to choose between caring for a man with chest Pain and a head injured patient. Ourfrndings that nurses did not agree on the set of alternatives, or their relative merits, held for this situa- tion. We, along with Hughes and Elstein, hope for improvement, but suspect that the assumptions und&ing decision some nursing situations.

* * To the Editor:

analysis m a y prove a poorjit with

Andrea Baumann Associate Professor School of Nursing McMaster University Hamilton, Ontario, Canada

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The article “Clinical Support for Eliminating the Nursing Diag- nosis of Knowledge Deficit” (IMAGE, 21[3]), by Dennison and Keeling, caught my attention. I use nursing diagnosis as a basis for developing a plan of care and to focus and document visits in my practice as a home care nurse. I use the diagnosis of Knowledge Deficit regularly to document teaching and after reading this article plead guilty to occasional inappropriate use. I agree with the authors that the diagnosis of Knowledge Deficit is open to misuse as a “catch-all,” or a diagnosis used without defining characteristics, or one that limits intervention to the provision of information when more is indicated and needed. However, I believe that this is a legit- imate diagnosis that meets the criteria for clinical validation and do not agree that the diagnosis should be eliminated.

Positive and long term changes in health status are a direct result of medical interventions and the learning process. Medical interven- tions without information show no respect for human dignity, or allow for any options or autonomy in the care of self, to say nothing of the detriment to the health, welfare and safety of an individual. I contend that Knowledge Deficit does have a conceptual focus within the boundaries of nursing and has theoretical validity as a teaching- coaching function, since a certain amount of knowledge would be necessary to facilitate the desired behaviors of coping and recovery. Knowledge Deficit has a diagnostic attribute when it is demon- strated and should be clinically utilized when a real deficit is docu- mented.

As an illustration, take the AM1 patient who has undergone bypass surgery and is being discharged with a referral to home care for wound care. The patient’s cardiac status is stable and he is com- pliant with his medical regimen. His anxiety level is minimal, with a good prognosis and lack of cardiac symptoms, and the patient is motivated and directed toward rehabilitation. During the assess- ment, the patient is asked the purpose and side effects of the medica- tions he is taking and he is unable to recall, although he has been given the information and his memory is not organically impaired. This information is necessary to enable the patient to assume inde- pendent and knowledgable control of his health care. Once assessed and documented, the providing of this information is an interven- tion to resolve the diagnosis of Knowledge Deficit.

Volume 2 2 , Number 1, Spring 1990 61

The areas of demonstrating and documenting a lack of knowledge need to be addressed and use of the diagnosis Knowledge Deficit must be evaluated in care settings less acute than the hospital before a decision is made to eliminate the diagnosis completely.

Kathleen Fleming, RN, BSN Fairfield, C T

To the Editor: Dennison and Keeling’s article (IMAGE, 21 [3]), “Clinical Sup-

port for Eliminating the Nursing Diagnosis of Knowledge Deficit” provided the basis for thought-provoking discussion with RN/BSN students here. The class did not reach a consensus to keep or elimi- nate this diagnosis but as experienced nurses, they had reasons.

First, several nurses disagreed that nurses should not “focus on teaching as an entity in itself’ (p. 143). There are many situations in which client/family teaching is necessary (e.g., glucose finger- sticks, breast exam) before the nurse can detect overt behavioral cues related to lack of information. Indeed, it is possible that if the clients understood their underlying problems, they may not experi- ence anxiety at all; therefore, using the diagnosis of Anxiety or Inef- fective Individual Coping would not be appropriate, or at best would be a potential problem.

Secondly, the misuse of Knowledge Deficit as a catch-all for behavioral response problems is truly a valid concern. But many of the students believed that the inappropriateness stems from lack of education about the NANDA approved taxonomy and diagnostic defining characteristics. Rather than eliminating the diagnosis on the grounds that it is misused, we need to educate nurses about the defining characteristics which can be incorporated in the nursing care plan.

From an educator’s perspective, I believe that we cannot abandon Knowledge Deficit as a nursing diagnosis. Newly accepted diagno- ses such as Health-seeking Behaviors seemed to be more appropriate than Knowledge Deficit to students in this health promotion course. Clinical validation of diagnoses is a slow, difficult process, but I would encourage RN/BSN students in the effort since they are in a unique position to evaluate diagnostic labels in their daily clinical practice.

Kathleen Fox Tennant, RN,C., MSN RN/BSN Class of 1991 Ohio University Athens, OH

The Authors respond: We have received useful and stimulating feedback from colleagues regarding

our proposal to eliminate Knowledge Dejicit as a nursing diagnosis. These responses were not unexpected because Knowledge Dejicit is one of the most fre- quently used diagnoses. However, the feedback has served to reinforce our belief that Knowledge Deficit should be eliminated as it does not accurately reject the disciplinary focus of nursing practice.

In response to Ms. Fleming, the use of Knowledge Deficit in this instance limits the scope of nursing practice. A more inclusive diamosis, one that rejects a holistic approach and focuses on the patient outcome of health maintenance rather than just knowledge acquired, would be “Potential for impaired health maintenance related to insujicient knowledge about self-medication administra- tion. ” In fact, Carpineto (1987) includes as a dejining characteristic and an etiological risk factor the lack of knowledge of health promotion or health main- tenance behaviors. Therefore, not only does Knowledge Dejicit limit the scope of documented nursing practice, it is ojien used as a dejning characteristic for other nursing diagnoses.

In response to the Ohio University RN-BSN class of 1991, we agree that nursing assessment of client and f a m i b needs is necessary before a nursing diagnosis can be made. Historically, nurses have advocated a holistic approach to care. Our taxonomy should reject this holistic approach: we are more con- cerned with measuring outcomes such as the patient’s ability to care for se& than the patient’s ability to regurgitate information.

As to the issue of educating nurses about the dejning characteristics of Knowledge Dejicit, we agree with Jenny (1987) and Pokorny (1985) that there are no defining characteristics for Knowledge Dejicit because that is usu-

ally not the problem. Rather, Knowledge Dejicit or lack of information is either a dejning characteristic or a risk factor for other nursing diagnoses. The use of Knowledge Dejicit as a risk factor rather than a nursing diagnosis enables the educator to describe the more comprehensive nature of nursing practice.

Pamela D. Dennison, RN, M.S.N. Arlene W. Keeling, RN, M.S.N. School of Nursing, University of Virginia

References

Carpineto, L. J. (1987). Nursing Diagnoses. Philadelphia: Lippincott. Jenny, J. L. (1987). Knowledge Deficit: Not a nursing diagnosis. IMAGE, 19, 4,

Pokorny, B. E. (1985). Validating a diagnostic label. Nursing Clinics of North Amer- 184- 185.

ica, 20,4,641-655.

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To the Editor: Nokes’ article, “Rethinking Moral Reasoning Theory”

(IMAGE, Fall, 1989) leaves me caught somewhere between incre- dulity and confusion. Nokes writes: “So long as caring and respon- sibility are perceived as female qualities, society will devaluate them. Thus [emphasis added] a theory of caring that assimilates Kohlberg and Gilligan’s positions needs to be developed” (p. 75). To assimilate the linear concepts of Kohlberg into the dialectic described by Gilligan would produce chaos by destroying the inter- nal consistency of both. Kohlberg’s work has been extremely valu- able, if limited by its inability to describe accurately the moral reasoning process in women, and Gilligan’s work questions its validity for all men.

Gilligan’s work can stand alone in providing a framework for the analysis of moral-ethical dilemmas in nursing. The approach is con- textual and compatible with the ideas of “caring.”

The voices identified by Gilligan as the voices of moral reason are: the voice of the self; the voice of relationships; the voice of jus- tice; and the caring voice. When the listener permits the voices to describe the human dilemma, the psyche embedded (in the male or female person) is freed up to express a perspective which may lean heavily toward caring or justice but usually incorporates both. The female will not express herself in caring terms exclusively, nor the male in justice terms.

Gilligan’s feminist thinking has provided a theoretical picture and method capable of this nature of description. To attempt to combine the theoretical work of Kohlberg and Gilligan would do a serious dissewice to both theorists and undermine the value of women’s thought.

Raphella Sohier, RN, Ph.D. College of Nursing University of Oklahoma, Tulsa

The author responds: In the summary of my article, I point out the need for a synthesis of the good

from both Kohlberg and Gilligan. Although both draw heavilyjiom Piazet and propose developmental models, they are uniquely dijerent. I am not suggesting a combination of the two but rather a new model. Although Gilligan is clearly on the leading edge in exploring the moral domain, she admits that there remains . . . a variety of questions for future research . . . and new research approaches and strategies . . . ’’ (1988, p . ii). I would disagree with Dr. Sohier when she argues that “Gilligan’s work can stand alone . . . ” It is too soon to adopt one theory despite its attractiveness. Moral domain is being examined from a variep of perspectives and nursing theorists need to par- ticipate in the development of this evolving paradigm.

Kathleen M. Nokes Hunter-Bellevue School of Nursing New York City

Reference

Gilligan, C. (1988). Preface. In C. Gilligan, J. Ward, J . Taylor & B. Bardige (Eds.), Mapping the Moral Domain. Cambridge, MA: Harvard University Press.

62 IMAGE: JoumaL of Nursing AkhoLarship