Theoretical Explanations for the Importance of Using NANDA/NIC/NOC

1. Theoretical Explanations for the Importance of Using NANDA/NIC/NOC Margaret Lunney, RN, PhD

2. Who Needs Theoretical Explanations? Nurses and others who: • value research-theory-practice relationship • reject standardization • reject the complexity of N/N/N • feel the “power of nursing” without N/N/N

3. Explanations Currently Used • Need for documentation of nursing diagnoses, interventions, and outcomes • Visibility of nursing’s contribution Note: 1 & 2 are viewed by critics as self-serving • Improved quality & manageable costs

4. Problem: Pervasive Criticisms • Covert response (most common) • N/N/N are ignored & avoided • Overt responses: • Articles: Shamansky & Yanni (1983); Hagey & McDonough (1984); Leininger (1990); Mitchell (1991); • Negative comments on listservs; negative reviews of manuscripts & research

5. Effects of Criticisms • N/N/N not included in education • N/N/N not required for documentation • N/N/N not in HIS/EHR • Research proposals & manuscripts not approved for funding/publication

6. Solution: Theoretical Explanations Theories to describe, explain and predict reasons to use N/N/N: • Linguistic Theory Hayakawa (1990). Language in thought and action. • Critical thinking theory/concepts Scheffer & Rubenfeld (2000). Consensus statement on CT • Concept of Accuracy Lunney (2000). Critical thinking and nursing diagnosis

7. Linguistic Theory Languages are: • fundamental mechanism of survival • most highly developed symbolic processes • tools for communication with self & others • sources of cooperative actions with others • tools to improve human experiences

8. Linguistic Theory • Scientific names are needed because word usage varies • Naming is a “great” step forward; it makes discussion possible • There are no “right” names for anything • Definitions are statements of linguistic habits; not law

9. Linguistic Theory • Naming is classifying • Classifications are developed for specific purposes • Classifications =pooled knowledge • Pooled knowledge helps us to deal with the physical world • Science seeks generally useful classifications, ones that produce results • Results in nursing = quality of nursing care

10. Maps to the Territory • Many maps needed to “know” a territory • No maps “fully” represent the territory • All maps do not “equal” the territory • Goal- Make “good maps” of the territory • NANDA, NIC and NOC are the “good maps”

11. Meaning, Context, Experience • Meanings known through context • Context gained through experience • Using N/N/N increases experience by: • depicting interrelationships • reducing complexity • available in one source

12. Extensional/Intensional Meanings • Extensional • relates to the physical world • Intensional • relates to individual connotations • focus on intensional = Prejudice • N/N/N - extensional & intensional

13. How We Know What We Know • We experience a small fraction of phenomena • We abstract the objects of our experiences • It makes no sense to distrust abstractions • We need to be AWARE of abstracting • Words always need to be connected with what they stand for. Avoid this: words defining words

14. Abstraction Ladder (read from bottom) 8. Wealth 7. Asset 6. Farm asset 5. Livestock 4. Cow 3. Bessie 2. Perception 1. Process_______________________ Words are abstractions of similarities, not differences (Hayakawa, 1990)

15. Abstraction Ladder: Nursing 8. Human-Environment Interaction 7. Nurse-Client Partnership 6. Functional Health Patterns 5. Cognitive-Perceptual Pattern 4. Decision Making 3. Decisional Conflict re: infant feeding choice 2. Cheryl’s Breastfeeding • Experience of breastfeeding ____________________________ Gigliotti & Lunney, 1998

16. Application to N/N/N • Explain relation of naming to knowing • Acknowledge reality of naming • Describe essential nature of abstraction & levels of abstraction • Demonstrate connections to the extensional world through case studies

17. Complexity of NNN and Theory • Indicators of Complexity: • ~1000 concepts with related information/knowledge • Ambiguous relationships among concepts • Extreme # of choices • Reducing complexity of N/N/N improves: • Efficiency and effectiveness of thinking • Accuracy of diagnoses • Discernment of best interventions and outcomes

18. What is Critical thinking (CT)? Consensus of 57 Nurse Experts: • Cognitive Skills (7) • Analyzing • Applying Standards • Discriminating • Information Seeking • Logical Reasoning • Predicting • Habits of mind (10) Scheffer & Rubenfeld, 2000 Lunney, 2001, Ch 1

19. Why Critical Thinking? • Thinking abilities of adults vary from low to high • The thinking processes needed for the nursing process are complex • Each clinical case requires specific types of thinking abilities • Thinking affects choices of diagnoses, interventions and outcomes

20. What is Accuracy of NDx? • Definition “A rater’s judgment of the degree to which a diagnostic statement matches the cues in a client situation.” (Lunney, 1990) • Characteristics • Ranges from high to low • Relative to interactive elements • Simple to complex according to # of cues, types of cues, characteristics of cues • Includes supporting and conflicting cues • Relative to the whole situation

21. Why Accuracy of NDx? • Accuracy is an outcome of CT • Client data lead to many possible dx choices, including etiologies • Research findings show that low accuracy is a reality • Diagnoses are the foundation of interventions and outcomes

22. Why discernment of outcomes/interventions? • Clinical situations differ based on contextual factors (e.g., culture, age, history) • Many outcomes and interventions are possible • The most appropriate outcomes and interventions need to be selected through CT

23. Using N/N/N Improves CT for Accuracy/Discernment • More efficient and effective: Analyzing Discriminating Information seeking Applying standards Logical reasoning Predicting

24. Effects on Quality Words & Critical Accuracy & Phrases + Thinking + Discernment Communication & Cooperation Improved Actions Improved Quality Lunney, 1999, 2001

25. Using N/N/N • Mitigate criticisms, e.g., • Be conscious that the labels of N/N/N/ are NOT nursing • Show connections of N/N/N to thinking & actions through case studies • Demonstrate through theories and research that using N/N/N improves quality