We celebrated our 40th anniversary this year, at our conference in Houston, Texas. At that event, we had the opportunity to acknowledge and thank several who were among the 1973 founding members of our original organization, the North American Nursing Diagnosis Association. Nurses who worked at the grassroots level to establish our mission and develop an initial terminology and associated taxonomic structure. Nurses who did this work without any payment or funding, and without the technology we have today.
Since 1973, our terminology has grown to 216 nursing diagnoses, published in NANDA International Nursing Diagnoses: Definitions and Classification, 2012-2014.
DIAGNOSIS SUBMISSION AND APPROVAL PROCESS
Then and Now
Our process of proposed diagnosis submission, review by our Diagnosis Development Committee (DDC) followed by Membership vote has not changed in 40 years – we remain true to our belief that our body of work should be developed, grown and improved by the nurses who use it. We also remain a volunteer organization – those who submit diagnoses and those who serve on the DDC are not compensated for their time or paid for their work.
Our cycle of submission and publication remains basically the same as well: approved diagnoses – and those identified for retirement – are reflected in our book on a 3-year cycle.
A major change to our process took place in 2001 with the implementation of our Level of Evidence Criteria (LOE). Changes to these LOE criteria have occurred twice since that time, with a tightening of requirements for acceptance. Any new diagnosis accepted into our terminology must meet these criteria.
Impact of Changes to Criteria for Development, Evaluation and Inclusion / Exclusion
Nursing science, as with other health care disciplines, continues to evolve – and with that our knowledge of research methodology and design improves. What was considered good science 20 years ago may not have the rigor that would be expected today, and we must continually strive to update our terminology to reflect new scientific knowledge and ways of understanding, explaining and measuring that knowledge. What we were willing to accept as support for a diagnosis prior to the 2001 implementation of the Level of Evidence Criteria would not necessarily meet the level of evidence required today.
Implementing the Level of Evidence Criteria was an essential and appropriate step to take in the evolution of our work. However, that step resulted in three major challenges for our organization and our terminology:
1. Published diagnoses in need of update to meet the new criteria;
2. Volunteer-only resources through which to complete this work; and
3. A publishing cycle which updates only every 3 years.
Our leadership determined the best course of action was to begin the process of a systematic review of older diagnoses, understanding the process would require several years to complete. Optimally, all diagnoses accepted prior to 2008, when the most recent changes to LOE criteria were accepted, should be reviewed to ensure that they are brought current with those criteria, or are retired from the taxonomy, as appropriate. We have retired eight diagnoses in the past two cycles, due to lack of evidence to retain them in the taxonomy; 23 diagnoses have been revised to bring them current with our required levels of evidence.
OPPORTUNITIES FOR ORGANIZATIONAL LEARNING
Good intentions and best efforts can fall short when viewed from the perspective of those using our terminology. As a result, we occasionally receive negative comments. We are open to this feedback, appreciate it and always learn from it.
A recent example has to do with the diagnosis: Disturbed Energy Field (00050), which was accepted into our terminology in 1994 (prior to implementation of the level of evidence criteria). In 2011, we received concerns about this diagnosis from members in Sweden who were concerned about the lack of evidence and the direct linkage to therapeutic touch (TT), which they did not believe met the requirements for evidence-based nursing intervention criteria. These members were encouraged to provide a review of literature with a recommendation for revision or retirement of the diagnosis from the taxonomy. Unfortunately, they were unable to do this, but the DDC itself has begun the process of reviewing older diagnoses in the taxonomy to evaluate the level of evidence and revise/retire them as necessary. Disturbed Energy Field is one of those diagnoses under review.
We recently received an email from James Randi, who in his own words, “has an international reputation as a magician and escape artist, but today he is best known as the world's most tireless investigator and demystifier of paranormal and pseudoscientific claims.” Mr. Randi’s question was this: “Does NANDA-I still officially accept the term "Energy Field Disturbance" - as it is used in the practice of ‘Therapeutic Touch’ - as a diagnostic term for its members to use?”
My response to him was as follows:
"The diagnosis does still stand, and although NANDA-I does not indicate what interventions are most appropriate for its diagnoses, many TT practitioners do use this diagnosis. I should note, however, that this diagnosis is currently under review due to concerns raised regarding the scientific level of evidence available to maintain it within the taxonomy, so it may or may not remain in the next edition (2015-2017), depending on that review. When the diagnosis was accepted, we did not have Level of Evidence Criteria, and we are reviewing all diagnoses that were grandfathered in to the taxonomy at the time that those criteria were adopted. This is a large project, so it takes us a few cycles to get through all of those diagnoses."In our further communications, Mr. Randi commented:
"Be assured that if NANDA-I chooses to change their [sic] opinion on TT, and I'm able to include that before my book goes to press, I will certainly mention that fact. In my opinion, it verges on being a criminal act for nurses to mislead their patients into thinking that they have special powers. NANDA directly contributes to this mis-education of patients and is damaging the nursing profession."
Mr. Randi misquoted NANDA-I in his initial draft of his book chapter, which he shared with us, and despite that, we have tried in good faith to clarify for him what is and what is not the NANDA-I position:
1. NANDA-I does not endorse any particular interventions and holds no “opinion” on TT, nor do we stipulate its use is required with this diagnosis;
2. We are reviewing older diagnoses to ensure that they meet our newer level of evidence criteria and determine whether or not they should remain part of our terminology; and
3. The Disturbed Energy Field diagnosis does not make any claim of a nurse’s “special powers” and can, as with nearly all nursing diagnoses, be based on a patient’s own perception/report.
Rather than await our review of scientific literature for this diagnosis, Mr. Randi’s same criticisms were then posted on our Facebook page. After extended discussion we have removed these Facebook postings, due to concerns of members who have emailed to ask why, and with what authority, an organization outside of nursing (the Museum of Scientifically Proven Supernatural and Paranormal Phenomena) is commenting on nursing science.
We have published this blog post for two primary reasons:
1. To acknowledge that, despite the aggressive approach, we believe Mr. Randi raises a valid concern.
2. To provide clarity and transparency about our strategic direction regarding the older diagnoses in our terminology.
As a science, nursing must determine for itself what is and is not within its own body of knowledge. As a professional organization, NANDA-I must respond to that body of knowledge, and to its members – professional nurses around the world.
However, just as Mr. Randi would, we think, be opposed to us accepting a diagnosis without taking the time to review the current state of the science – we must oppose random retirement of a diagnosis without that same review, despite criticisms from inside or outside of the organization.
Personal opinion aside, we have policies that require that any changes to the terminology must be based on a review of scientific evidence. And so, that is what is occurring – a review of this concept, disturbed energy field, is underway – along with review of a number of our older diagnoses. Recommendations will be made to the DDC members, who will make a determination that will be sent to the Board of Directors and to the organization’s members for their vote, prior to dissemination in the next edition of the text, NANDA International Nursing Diagnoses: Definitions and Classification, 2015-2017.
It is a slow, methodical process – with the intent of ensuring that new diagnoses and diagnosis revisions and retirements are based on the most current level of scientific evidence. It can mean that we do not always keep pace with evidence – an unfortunate reality that is not unique to nursing science.
We would certainly like for such review to happen more rapidly, but without funding for this work, we rely on the dedication and volunteer efforts of those who believe in the importance of an evidence-based terminology to represent the knowledge of nursing.
We encourage all members / professional nurses to each consider choosing one of the older diagnoses to research and review the scientific literature that has been published since the diagnosis was accepted into the taxonomy, and to submit recommended revisions along with the supporting scientific evidence to the DDC. This is how we progress, and we need to continually clarify, revise and/or retire diagnoses as appropriate.