NANDA International

DEFINING THE KNOWLEDGE OF NURSING: Priorities for Terminology Development in Our 40th Year and Forward

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.

TERMINOLOGY EVOLUTION
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
An Example
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.

OUR COMMITMENT
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.

Speaking the Same Language: Go beyond the label!!

Imagine your mom has been admitted to the emergency room for shortness of breath and chest pain. She has her tests done, is assessed by her nurse and her doctor, and they come in to tell both of you what they think is happening. You tell them both you and your mom are nurses, thinking that will help them to explain things more completely.

The doctor says to you, “well, your mom has an alteration in cardiac rhythm” and the nurse says, “we also have assessed that you are suffering from altered anxiety management." Would you have any idea what they were saying? Or you might wonder, “What kind of alteration in cardiac rhythm? What do you mean by altered anxiety management???”

Sound ridiculous? Possibly….but isn’t that exactly what happens when we decide it is okay to create labels for nursing diagnoses/patient problems for ourselves – with no literature support, no basis in research, no consensus around the terms? If one nurse calls a patient’s problem “Pain," the second nurse stipulates “Acute Pain” and the third nurse chooses “Chronic Pain” – do we really have any idea what the patient is experiencing, or why the nurse chose to use the label that she did?

How frustrated would we be as patients or nurses if each doctor who saw a patient changed the medical diagnosis – how would we know what was going on with the patient? How would we know how to intervene or to set appropriate outcomes? And yet, we are often content to do just that with nursing diagnoses.

The primary problem with this is patient safety – if we do not have nursing diagnoses with clear definitions, and with diagnostic indicators (assessment data – the things NANDA-I calls defining characteristics, related factors or risk factors), then how do we know that we are making the correct diagnosis in the first place? And how do we know the interventions we choose are going to be effective? Chronic pain and acute pain, for example, require very different interventions and have different underlying etiologies. If we do not know how the diagnosis was made (by referring to the indicators used to make the diagnosis), and we do not have a clear definition, then we do not have a way to ensure that we are providing the best care to our patients.

Nursing is so much more than following doctor’s orders, isn’t it? Then don’t we need to have one terminology that allows us to identify and communicate our knowledge about our clinical judgment – to one another, our health care partners, and our patients?

Is the terminology within NANDA-I perfect? Absolutely not! Does it need clarification, revision, expansion? Most definitely! But if we do not have it, we either have to go back to the days that we wrote paragraphs in our patient charts – which meant very little of what we knew (our judgments) about our patients was ever seen by other care givers – or we will be relegated to showing the things we do (the tasks of nursing) in an electronic record, which could lead administrators / financial leadership to determine that “we don’t need nurses because non-licensed personnel can be taught to do these tasks."

Is that really in the best interest of our patients?

Clinical nursing assignments: are we teaching the most important skills?

One of the most interesting things about my role as Executive Director of NANDA International, is that I get a lot of questions from nurses and students who are working with NANDA-I nursing diagnoses. Many of the questions seem to revolve around the same general theme: the students are given a brief history of the patient they are to see the next day in clinical, with the assignment: develop a plan of care based on that data for the following day's clinical unit.

This is common practice in many universities – I know I had to do this same exercise as a student, and I had to assign such exercises as a clinical instructor in a variety of settings. I understand the intent of the exercise: get students thinking about what they need to do in clinical the next day. But – get ready – is it really as important for them to think about what they need to do, as it is for them to think about what they need to know?

If we focus our students on what they need to do, based on the “Care Plan," but don’t really help them tie in the assessment, the data from the patient history, from progress notes of their colleagues in nursing and other disciplines – is it really any wonder that the Care Plan becomes a thing to check off a list, without having any real tie-in to the “real world” of nursing?

Here is the real kicker for me, though - often, the data students are given is too vague to really select nursing diagnoses on which to base a plan of care. At best, they might be able to walk in to clinical with a list of potential diagnoses, and ideas about what additional data they need to collect to rule out, validate and/or prioritize diagnoses once they assess the patient. If that were the assignment, I would applaud it – it would get students thinking about potential nursing diagnoses, and they would need to review them, think about what data is missing in order for them to validate (or not) the diagnoses on their list, and think about how these human responses might be impacting their patients.  HOWEVER, when students are asked to come to clinical with a plan of care developed – based on as little information as the medical diagnosis, list of medications and diagnostic test results – what are we really teaching our students?

Based on the inquiries I receive, the following is what many of our students are perceiving from this clinical exercise:
1. Medical diagnoses determine the nursing diagnoses,
2. Medical conditions, medications and diagnostic tests are the main things they need in terms of assessment data, and
3. Nursing diagnosis doesn't really require clinical judgment, because you just pick something off a list based on the medical diagnosis.

Is this really what we want our students to think? Is it any wonder we hear nurses say to them, “don’t worry – you won’t have to do this once you get out of school?” If the exercises we give our students in clinical practice settings fail to develop their clinical reasoning skills, what is the point? If we are teaching them to rely primarily on medical diagnoses, diagnostic tests and pharmaceutical agents as the key points for determining appropriate nursing care….well….didn’t we lose nursing in there, somewhere?

Yes, we need to know all of those things to provide nursing care – but we could know all of those things and provide care without being a nurse, because the essence of our discipline doesn’t reside in those things, does it?

If we do not support our students in developing clinical reasoning abilities, and support them in considering, validating and prioritizing their clinical judgments that reflect their own domain of practice – nursing diagnoses – do we really need nurses at all?

T. Heather Herdman, PhD, RN, FNI
Executive Director
NANDA International

Consensus on Language Translations: Some thoughts and lessons learned.

A meeting was held in June, in Kassel, Germany, to discuss and resolve issues related to the German translation of the NANDA-I book Nursing Diagnoses: Definitions and Classification 2012-2014.

I have had the opportunity to participate in translation consensus meetings for German-speaking countries for the last two editions of  This might seem quite strange, because unfortunately, I have no German-language skill. (Thankfully, my German-speaking colleagues have a much greater mastery of English than I have of German!) However, I have found that these meetings provide a very important and helpful opportunity that could impact all language versions of our book – including the original English version!

As with any translation, the first issue is that of conceptual versus literal “word-for-word” translation. Literal translation is fairly straightforward and it is possible quite quickly to get all to agree that the need for conceptual clarity is most important.

For example the nursing diagnosis Disorganized infant behavior (00116) does not mean that the infant is “disorganized” (e.g., messy, confused, cluttered), but rather that his physiological and neurobehavioral responses are not well integrated. Therefore the translation of the diagnostic label must represent that diagnostic concept (infant behavior) and the nursing judgment (disorganized); it should not merely translate the three individual words, “disorganized” + “infant” + “behavior”. It is also critical that translation reviewers are aware of the nursing literature, to ensure use of terms that are already established in the nursing literature rather than developing new terms.

It is also quickly realized that words that are quite obvious in meaning to a native English speaker, are not so obvious to those for whom English is a second language. Even those for whom English is a strong second language find difficulties in the vagaries of some of our common English words. Take a simple example: what is the meaning of the phrase “lack of?" Does this mean "nonexistent" or does it mean "insufficient?" Unfortunately, in English it can mean either of these things. However, I learned that in the German language, the phrase "lack of" cannot be translated in the same way for both of those concepts – so we really need to specify "absence of" when we mean “nonexistent," and "insufficient" when we mean “not enough." This not only helps with the German translation - it clarifies the English meaning as well! These lessons learned have helped to institute the beginning of a list of standards, which we can use to clarify terms used in all of our diagnoses.

There are also grammatical inconsistencies that may not catch the attention of those of us who are English speaking, but which make a significant difference when trying to translate accurately. When a term is used in the singular in one place in a diagnosis, but in the plural in another, this is confusing and can, in some instances, lead to different words being used.

Finally, there are terms which may have apparently clear meanings, but which change across culture, or as knowledge and common use evolve over time. For example, how does NANDA-I define substance abuse? Does this relate to addictive chemical substances only, or could addiction to food be an example? When we say “addiction”, does this mean any addiction (e.g., gambling) or are we really meaning addictions to a chemical substance? Issues such as these need clarified to help with translation, but they will also help all clinicians to clearly understand the intent of the diagnoses.

Ultimately, clarification of what we mean when we say something translates to safer patient care, as a result of standardizing terms that can therefore support more accurate diagnosis – and isn’t that the point?

What is Nursing Diagnosis - And Why Should I Care?

One of the most frequent questions we get goes something like this….”My patient has Congestive Heart Failure. What is the highest priority/most likely nursing diagnosis?”

There is no right answer, because it’s the wrong question! Assigning a nursing diagnosis based on a medical diagnosis skips several steps essential to optimal and safe patient care. A medical diagnosis is only one piece of the puzzle; it does not by itself, provide the depth of information necessary to make an accurate nursing diagnosis.

WHAT IS A NURSING DIAGNOSIS?
Maybe the easiest thing is to start with what a nursing diagnosis is NOT.

A nursing diagnosis is NOT:

• Merely a label that you make up that “sounds like” it explains what you are seeing in your patient.
• Another way of explaining the medical diagnosis, or of renaming a medical condition.
• Something that “goes with a particular medical diagnosis”.

Nursing diagnosis is defined as “a clinical judgment about individual, family, or community experiences/responses to actual or potential health problems/life processes. A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.” (Herdman, 2012, p. 515). 

In other words, a nursing diagnosis is a judgment based on a comprehensive nursing assessment. The medical diagnosis provides one important piece of data, but it does not provide anywhere near the depth of information necessary for making an accurate nursing diagnosis.

WHY SHOULD YOU CARE?
Because an accurate nursing diagnosis based on a thorough assessment results in more effective and safer patient care. Period.

Let’s take a look at an example:

A man is admitted through the Emergency Department with a medical diagnosis of Viral Pneumonia with the following profile:

• Age 78;
• Dyspneic and demonstrating very shallow breathing;
• Pulse oximeter is showing 90% on 4L of O2;
• History of COPD.

What is the primary nursing diagnosis? Did you think of impaired gas exchange? Seems obvious, doesn’t it, considering the data and medical diagnosis? However, the question the nurse should ask is this: “What is causing the low SpO2?”

After completing a thorough assessment, the nurse discusses her findings with the patient, including the very shallow breathing. She learns the patient is breathing shallowly because he’s in pain. He’s suffering from posthepatic neuralgia as a result of a very painful course of shingles. In this example, the assessment-based, primary nursing diagnosis is chronic pain.

Consider these two scenarios:

Nursing Diagnosis Linked to the Medical Diagnosis
A care plan is developed to address the nursing diagnosis of impaired gas exchange, based on the medical diagnosis of Viral Pneumonia. The posthepatic neuralgia as a cause for shallow breathing is not identified and overlooked in treatment.

OR

Nursing Diagnosis Linked to Nursing Assessment and Critical Thinking
A care plan is developed to address the nursing diagnosis of chronic pain, with treatment designed to resolve this as the primary cause of the shallow breathing, and to prevent recurrence.

Which scenario provides the best patient care and outcome? What do you think the relationship is – or is not – between medical diagnosis and nursing diagnosis?

LEARN MORE
NANDA-I 2012 Conference: May 23-26, 2012
NANDA-I Nursing Diagnoses: Definitions and Classifcation 2012-2014
NANDA-I Frequently-Asked Questions
NANDA-I Fact Sheet