Teaching NANDA, NIC and NOC: Novice to Expert

1. Teaching NANDA, NIC and NOC: Novice to Expert Margaret Lunney, RN, PhD College of Staten Island, CUNY Presentation at the Center for Nursing Classification Informatics Conference, Iowa City, IA, June 2005

2. Learning Objectives • Explain 3 propositions r. t. teaching NNN • Set expectations for students at Novice to Expert stages of development • Implement teaching strategies • Integrate NNN with nursing curricula

3. Objective 1: Explain Propositions • Use of NNN requires intellectual, interpersonal, & technical competencies, tolerance for ambiguity & reflection • Accurate diagnoses are the basis for use of NIC & NOC • Use of NNN differs from the traditional nursing process

4. Proposition # 1Skills/Competencies Intellectual • Knowledge related to: Diagnoses, interventions, & outcomes • Thinking processes Research findings • Human beings vary in thinking process abilities • Thinking process abilities can be improved

5. Variation in Nurses’ Thinking Abilities, N = 86 (Lunney 1992)

6. Intellectual Skills:Research Findings r.t. Women • Thinking processes of women develop through relationships • Women’s perspectives on thinking (Belenkey, et al., 1986) • Silence • Received Knowledge • Subjective Knowledge • Procedural Knowledge • Constructed Knowledge • Nursing students and nurses may have lower level perspectives

7. Intellectual Skills:Critical Thinking (CT) • Thinking (CT) processes can be improved • Stimulate to use • Expect use • Validate appropriate use • Demonstrate support & confidence in abilities • CT abilities -essential for accuracy of diagnoses & use of NOC & NIC

8. Intellectual Skills:What is CT in Nursing? • Delphi study of 55 nurse experts (Scheffer & Rubenfeld, 2000) • Purpose: Identify the components of CT that relate to nursing • Results- Definition for nursing • 7 Cognitive Skills • 10 Habits of Mind

9. Cognitive Skills • Analyzing • Applying Standards • Discriminating • Information Seeking • Logical Reasoning • Predicting • Transforming Knowledge

10. Confidence Contextual perspective Creativity Flexibility Inquisitiveness Intellectual integrity Intuition Open-mindedness Perseverance Reflection Habits of Mind

11. Intellectual Skills:CT Processes • CT involves continuous processing of data and inferences • In any situation, two or more cognitive skills are probably being used • Habits of mind support cognitive skills • The combination of CT abilities needed is unique to the situation

12. Proposition # 1 (cont.)Interpersonal Skills • Exquisite communication • Promote Trust • Work in partnership, share power • Validate perceptions • Accept that we do not “know” others

13. Proposition # 1 (cont.)Technical Skills • Obtain valid and reliable data • Health histories Comprehensive • Physical exams Focused • Perform nursing interventions • Technical aspects of using NNN

15. Proposition #1(cont.)Personal Strengths • Tolerate ambiguity • Decisions are relative to context & specific nature of individuals • Multiple factors influence clinical situations • Human beings are complex and diverse • Ambiguity is the norm

16. Proposition #1(cont.)Personal Strengths • Reflect on practice experiences • Accept possible flaws • Thinking • Interpersonal • Technical • Aim - develop & grow

17. Proposition # 2: Accurate Interpretations-Foundational • Cues/data may be incorrect Examples • Objective Data: Diagnostic tests • Subjective Data • Patients • Families

18. Proposition # 2: Accurate Interpretations-Foundational • Use of NNN requires many decisions • All decisions are based on patient data • Data amounts are overwhelming Short tem memory = 7 ± 2 bits of data • Data are converted to interpretations

19. Proposition #2: Accurate Interpretations -Foundational • Interpretations determine actions • Additional data collection • Subsequent decisions • Possible outcomes to consider • Choices of interventions • High potential for inaccuracy • Diagnosis and etiology

20. High Potential for Inaccuracy, e.g., Marian Hughes • 16 y.o. Diabetic (#1) • Hospitalized, DKA (#2) • “did not follow prescribed diet” (#3) • NDX: Ineffective management of therapeutic regimen r.t. _______ (fill in the blank)

21. Possible Interpretation/Diagnosis • Knowledge deficit • Disconfirming Cues: • Meals eaten at school are consistent with diet (#9) • Able to explain what she should be eating (12) • She can adjust her diet to her lifestyle (#13) • Conclusion: Low accuracy diagnosis • Teaching is waste of time, effort, & money

22. Highest Accuracy Diagnosis • Ineffective Management of Therapeutic Regimen related to communication difficulties between Marion and her mother • Patient Outcome (NOC): • Communication = 3 (moderately compromised), Increase to 5 (not compromised) • Nursing Intervention • Communication enhancement

23. 44 Diagnoses by 80 Nurses • Examples • Communication difficulties mother/daughter • Stressful mother/child relationship • Altered family dynamics • Ineffective coping • Ineffective time management • Adolescent image • Low self esteem • Denial • Knowledge deficit

24. Seven Levels of Accuracy +5 Highest level of accuracy +4 Close to the highest level but not quite +3 General idea but not specific enough +2 Not enough highly relevant cues or not the highest priority +1 Suggested by only one or a few cues 0 Not indicated by data -1 Should be rejected, disconfirming cues

25. Diagnostic Accuracy Scores • Communication difficulties between mother and daughter +5 • Stressful mother/child +4 • Altered family dynamics +3 • Ineffective coping +2 • Ineffective time management +2 • Adolescent image +1 • Low self esteem +1 • Denial 0 • Knowledge deficit -1

26. Research Findings • Studies: 1966 to present • Conclusions: Interpretations vary widely • All interpretations are not high accuracy • Influencing factors (Carnevali & Gordon): • Nurse Diagnostician • Diagnostic Task • Situational Context

27. Research: Positive Influences • Diagnostic Task • Lesser amounts and complexity of data • Nurse Diagnostician • Education related to nursing diagnoses • Knowledge of diagnostic process and concepts • Teaching aids for diagnostic reasoning • Variety of thinking processes • Experience specific to diagnostic task

28. Challenge: Achieving Accuracy Puzzle: What is the Diagnosis?

29. Solving the Puzzle

30. Accurate Interpretations-Foundational (cont.) Supporting Factors: • Acknowledge that data interpretations areprobabilistic; question accuracy • Use CT, interpersonal & technical skills • Develop tolerance for ambiguity • It’s OK not to have an answer • Accept that we might make mistakes • Develop reflective practice

31. Traditional Limited # concepts Collect comprehensive data No accountability for diagnoses Intervene based on data Behavioral outcomes Disorganized follow-up Use of NNN More than 1000 concepts Cue-based & hypothesis-driven data collection Fully accountable for diagnoses Intervene based on data interpretations Neutral terms with scale Systematic follow-up Proposition # 3: New Perspective on Nursing Process

32. Changing from Traditional to Use of NNN • Acknowledge difficulty level: Simple to complex • Influencing factors: • Similarity of terms in three systems • Structure of classifications • Resources (books, pamphlets, other) • Complexity of clinical situations • Nurses perspective/model for practice • Experience with NNN

33. Examples: User-Friendly Simplicity

34. Changing from Traditional to Use of NNN • Use theoretical perspective: • Change theory • Diffusion of Innovations (Rogers, 2003) • S shaped diffusion curve • Perceived characteristics: • Relative advantage (+) • Compatibility (+) • Complexity (-) • Trail Ability (+) • Observability (+)

35. Changing From Traditional to Use of NNN • Be a champion • Sell first to opinion leaders • Goal: Create a critical mass • Share demonstration projects e.g., Protocols; Journals • Faculty development program; adoption by system adoption by individuals

36. Objective # 2: Set Expectations, Novice to Expert • Novices & Advanced Beginners (ABs) learn to use NNN as well as experienced nurses • Novices & ABs may be easier to teach than nurses at Competent, Proficient & Expert (Expert) stages • Expert nurses must be “sold” on new way to think and document

37. Selling NNN to Experts • EHR is imminent (IOM 1997, 2001) • NNN = file names for EHR • NNN describes what nurses bring to the table • NNN makes knowledge available at bedside • Aggregated data knowledge • Measurement of care improved quality • Linguistics theory supports SNLS • Fits with nursing theories

38. Set Expectations • Expect (at all levels of expertise): • Correct use of the three systems, e.g., • Nursing diagnoses are used to guide interventions, not for labeling per se • Intervention label is the intervention, not the activities • Outcome label is outcome, not indicators • Correct use of concepts, e.g., • NANDA- Social Isolation • NIC- Coping Enhancement • NOC- Knowledge (specify)

39. Set Expectations Do not underestimate nursing students or nurses: “…nursing and nursing knowledge must be presented in all its complexity…. Help students and nurses to “…experience the complex and messy world of nursing….and learn how to navigate through it…” (Doane & Varcoe, 2005, p. xi)

40. Set Expectations • All Levels: • Self evaluation • Integrate with new theories, e.g., • Pender’s health promotion model • Integrate with strategies for evidence-based nursing

41. Set Expectations • Encourage experts to: • Integrate with previous knowledge • Use NNN in: • Communicating scope of practice • Developing standards of care • Evidence-based nursing projects • Research projects • Evaluate clinical applications of NNN • Teach CE programs to nursing personnel

42. Objective 3:Teaching Strategies, Intellectual • Assume that thinking is human, imperfect, attainable • Encourage thinking in class & clinical: • Ask questions instead of giving answers • Provide opportunities for problem solving

43. Teaching Strategies: Intellectual • Deflate authority

44. Teaching Strategies: Intellectual • Think out loud WITH students • Act as midwife or coach • Help them think about thinking: • Ask: what kind of thinking is needed • Use the 17 CT terms and definitions • Evaluate thinking processes • Expect self evaluation of thinking

45. Teaching Strategies: Intellectual • Share paradigm cases (e.g. Marian Hughes) • Simplify representations, identify high relevance cues (e.g., Carlson-Catalano, 2001) • Conduct iterative hypothesis testing

46. Teaching Strategies: Intellectual • Seminars instead of lectures: Why? • Groups represent wide variations in thinking abilities • Promotes in-class thinking • Recognizes students’ abilities to think & learn without authority/experts • Supports future work in groups to describe, analyze, & synthesize information, solve problems (e.g., what is the diagnosis?)

47. Teaching Strategies: Intellectual • Seminars: How? • Assign readings, Provide discussion questions • Lead the group, Ask the discussion questions • Be respectful; Protect students’ self esteem • Address: • what is the author saying? • What is the fit with previous knowledge? • how does this information apply to practice? • 25-30% of grade for discussion of readings

48. Teaching Strategies: Intellectual • Expect self evaluation • Ask questions, instead of giving answers • Discussion in class • Discussion online • Journal writing (Degazon & Lunney,1996)

49. Teaching Strategies: Interpersonal • Expect accountability for patient relationships • Demonstrate: • Good interviewing • Validation of diagnoses • Partnership processes to select outcomes & interventions • Reward power sharing • Teach & support assertiveness

50. Teaching Strategies: Technical • Expect accountability for using standardized methods • Demonstrate use of diagnostic reasoning • Show technical use of NNN using case studies