Successful Clinical Experiences of Using Standardized Nursing Languages

1. Successful Clinical Experiences of Using Standardized Nursing Languages T. Heather Herdman, PhD; RN Executive Director NANDA International

2. Patient Safety • Patient safety is the number one concern in all delivery of health care • Assuring patient safety requires, at a minimum: • Competent, intelligent health care professionals • Expertise in critical thinking and clinical judgment • Holistic approach to care that considers the patient’s priorities, not simply the health care providers’ priorities • Sufficient resources for delivery of care • Patient/family participation in care

3. Quality of Care • Institute of Medicine (2001) identified health outcomes of consumers as the most important indicator of quality health care • Identification of those outcomes is critical for identification, evaluation and prediction of successful interventions • Assumptions underpinning this include: • Effectiveness of interventions varies among providers • Knowledge development of the effectiveness of interventions is the responsibility of health care providers • When effectiveness is compromised, health care consumers may be better off without providers • (Lunney, 2009)

4. Quality of Care • 2008 research on quality of care in 73 hospital systems (1,510 hospitals) demonstrated significant variation in care and outcomes for patients with myocardial infarction, congestive heart failure, pneumonia and surgical infection prevention (Hines & Joshi, 2008) • These are well defined conditions with research-based signs & symptoms • How is this possible? • 80% of all health care worldwide is delivered by nurses (NPR, 2009) • Nurses are professionally accountable for interventions based on diagnoses (nursing and medical)

5. Quality of Care • Evidence-based practice • Decrease variation in care • Improve reliance on research in daily practice • Improve patient outcomes • This approach relies on: • Definitive knowledge base for nursing science and practice • Distinct, research-based conceptual analysis of phenomena of concern to nursing science and practice • Use of this knowledge in clinical judgment • Use of standardized terminology to represent these concepts

6. Evidence-based Practice & Standardized Nursing Languages • NANDA, NOC, NIC developed through research • NANDA-I is continually revised based on latest research • Evidence-based languages require, at a minimum, the following things which must be based on research & clinical literature: • Clear, concise, conceptual label • Standardized definitions of terms • Standardized defining characteristics

7. Lack of Standardization & Evidence-Based Practice • Confusion in clinical practice • Misdiagnosis • Inappropriate outcome determination • Ineffective interventions

8. What’s in a definition?

9. ISO Reference Terminology Model for a Nursing Diagnosis Diagnostic concept (Axis 1) Judgment (Axis 3) Status of diagnosis (Axis 7) Time (Axis 6) Location (Axis 4) Subject of diagnosis (Axis 2) Age (Axis 5)

10. Perils of Clinical Creation of a Nursing Diagnosis • Case study • 78 year old man whose wife has just died • Easily distracted • Paranoid • Unable to keep track of time / forgetful • Loses glasses, keys, medicine frequently • Not sleeping well – wakens frequently • Poor concentration • Jittery • Irritable • Worried

11. Perils of Clinical Creation of a Nursing Diagnosis Acute imbalanced thought process Thought process (Axis 1) Imbalanced (Axis 3) Actual (Axis 7) Actual (Axis 6) N/A (Axis 4) (Individual) (Axis 2) Older adult (Axis 5)

12. Chronic imbalanced thought process • ACUTE • Lasting less than six months • IMPAIRED • Damaged, weakened • THOUGHT PROCESS • Cognitive operations and activities • Defining characteristics • NONE • Related factors • NONE

13. Chronic Pain: What is the definition? • Which is the correct definition – and why should we care??? • Unpleasant sensory & emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe, constant or recurring without an anticipated or predictable end and a duration of greater than 6 months • OR • Unpleasant sensory & emotional experience arising from actual or potential tissue damage or described in terms of such damage; slow onset of any intensity from mild to severe, constant in nature, without an anticipated or predictable end and a duration of greater than 3 months

14. Diagnostic Reasoning in Nursing • Complexity of the phenomena of concern for nursing are “unrivaled” (Webster, 1994) – due to the holistic nature of nursing’s focus: human responses • The mere complexity of the phenomena necessitate that nurses clearly understand and can identify them when they occur in practice • Requires conceptual analysis of these phenomena, including identification of the “signs & symptoms”, or defining characteristics? • How else can we measure diagnostic accuracy?

15. Requisites for successful clinical experiences • Identification and use of a holistic nursing assessment framework that lends itself to the identification of defining characteristics • Nurses must have expertise in: • Assessment and reevaluation of those assessments • Standardized nursing languages and their component parts • Hypothesis generation • Planning of care in conjunction with patients, families and other health care providers • Evaluating and refining of that plan of care

16. Assessment • Many texts teach the nursing process as a subset of medical diagnosis • Ignores importance of nursing assessment • Lacks focus on patient/family individuality • Ignores patient/family priorities • Assumes that all human responses to an actual health problem are the same • Linking the planning of patient care to the nursing and interdisciplinary assessment is more meaningful

17. Successful clinical experiences • Involve staff using evidence-based care • Identify high priority patient segments • Identify high priority human responses (nursing diagnoses) • Identify high frequency human responses (nursing diagnoses) • Determine realistic outcomes for each area of care • Identify critical interventions

18. Successful clinical experiences: Post-operative care • Encourage use of research to guide potential diagnoses • Require link to assessment data to ensure patient-centered • care • Discuss & acknowledge difficulties with languages • Syntax • Translation • Lack of “natural” speech • Contrast Standardized Language – and ability to computerize it – with handwritten, “home grown” terms or terms that are “put together” from a list of standardized terms – but with no accessible standardized definitions or defining characteristics

19. Successful clinical experiences: Electronic health record • Begin with nursing assessment, ensuring that defining characteristics, risk and related factors are present in the assessment screens • Use defining characteristics to suggest a list of potential diagnoses (hypothesis generation) • Use assessment – or reassessment – to refine this list to most appropriate nursing diagnoses • Identify achievable outcomes • Identify interventions most likely to have positive impact at lowest cost

20. Strategies • Top level nurse administrators • Must understand need for standardized languages • Lead drive to incorporate into organization • Appoint committed leaders to implement • Identify how data from languages will be used to: • Improve patient outcomes • Improve effectiveness of nursing care • Identify nurses’ impact on patient outcomes • Validate need for more nurses • Drive cost of care down

21. Strategies • Engage key stakeholders • Formal and informal leaders • Instructors / clinical educators • Informaticists • Quality improvement specialists • Strongest clinical nurses • Set mission and vision for the project • Keep nursing discipline at the center but highlight impact on the patient

22. Strategies • Use consultants or experts to initiate project • Build excitement • Improve buy-in • Shows commitment of organization • Support teams by providing time • Team building • Planning for implementation • “Train the trainer” curriculum design • Roll out slowly – start in areas with key champions to gain small successes • Celebrate success

23. Strategies • Provide ongoing educational updates • Encourage membership in NANDA-I to enable international dialogue and partnership • Consistently review progress • Impact on patient outcome critical • Identify changes in communication among nurses and between disciplines • Engage patients and families to improve satisfaction

24. Successful clinical experiences • Identify lack of appropriate standardized terms • Encourage and support staff to develop new terms or adapt current terms • Submit to NANDA International, NOC and/or NIC to improve the taxonomies • Review training with each new edition of NANDA/NOC/NIC • Emphasize changes, but also provide general overview of use of the languages

25. Contact me at:execdir@nanda.org