Dr. Judy Carlson Nurse Researcher PV/PHN Tripler Army Medical Center Honolulu, Hawaii

1. Consensus Validation Process: A Standardized Research Method to Identify and Link Relevant NNN Terms for Professional Practice Dr. Judy Carlson Nurse Researcher PV/PHN Tripler Army Medical Center Honolulu, Hawaii NANDA-I Presentation, March 2006

2. Co-Presenters: • NANDA Research Committee • Margaret Lunney, RN, PhD (New York, U.S.) • Margaret Clifford, RN, PhD (Rhode Island, U.S.) • Dina Almeida Monteiro da Cruz, PhD (Nurse, Sao Paulo, Brazil) • Maria Mueller Staub, MS, PhD(c) (Nurse, Bern, Switzerland)

3. Identification and Linkage of NNN • With 172 Diagnoses, 514 Interventions, & 330 Outcomes, use is impractical • Lists of labels • Not conceptually understood or connected • General linkages often not relevant and cumbersome in actual practice • Pre-packaged linkages may not be relevant to specific settings • Efforts to link by physiological ??

4. Identification and Linkage of NNN • Core content and linkages needed for specific units, populations, or health foci • Consensus Validation Process (CVP)-developed to accomplish this goal • The Output of CVP becomes Standard of Practice for specific units, populations or health foci • CVP developed as Participatory Action Research • Nurses participate with researcher to construct and use knowledge

5. Consensus Validation Definition: • Process by which clinicians with expertise in particular clinical areas review a domain of knowledge relating to their expertise and work to achieve 100% consensus on the relationship of the domain of knowledge, for example diagnoses, outcomes and interventions, to one or more predetermined objectives.

6. Steps of a Consensus Validation Process: 1. Identify purpose(s) of study, e.g., • Determine core nursing diagnoses, nursing interventions, patient outcomes and their linkages • Determine applicable intervention activities and outcome indicators

7. Steps of a Consensus Validation Process: • Identify clinical leaders • Identify at least 3 clinicians • Obtain resources

8. Steps of a Consensus Validation Process: 5. Describe procedures, e.g. • Determine the core diagnoses for the critical care units • Determine the core nursing interventions for the critical care units • Link the core nursing interventions to each diagnosis • Determine the core patient outcomes for the critical care units • Link the core patient outcomes in relation to each diagnosis and interventions • Determine the applicable intervention activities and outcome indicators

9. Steps of a Consensus Validation Process: 6. Seek IRB Approval 7. Conduct Study – Four Phases • Phase I: Nursing Diagnoses • Phase II: Nursing Interventions • Phase III: Patient Outcomes • Phase IV: Intervention Activities & Outcome Indicators

10. CVP: Phase I - Nursing Diagnoses • The clinical leader: • distributes nursing diagnoses with definitions • asks each clinician to place a check mark next to diagnoses that he/she determines to be at least somewhat relevant to the clinical practice area • tallies the responses • compiles diagnoses selected by clinicians

11. CVP: Phase I - Nursing Diagnoses • The diagnoses are put in a table format • Display the diagnoses that were selected by the number of nurses • The table is distributed and reviewed carefully by clinicians • The clinicians meet as a group with the clinical leader and review each diagnosis, definition, and defining characteristic

13. CVP: Phase I - Nursing Diagnoses • The clinical leader guides the discussions • Each diagnosis must have 100% consensus that the diagnoses is at least somewhat relevant to the clinical practice area • Those in support of diagnoses must give reasons or examples of how diagnoses are relevant • Those not in support must explain why diagnoses are not relevant • The clinical leader distributes the compilation of diagnosis selected by 100% of the clinicians

14. CVP: Phase II - Nursing Interventions • The clinical leader: • distributes a list of nursing interventions • asks each clinician to place a check mark next to interventions that he/she determines to be at least somewhat relevant to the clinical practice area • tallies the responses • compiles the interventions that clinicians selected

15. CVP: Phase II - Nursing Interventions • The interventions are put in a table format • The table is distributed and reviewed carefully by clinicians • The clinicians meet as a group with the clinical leader and review each intervention, definition, and activity • The clinical leader and/or researcher guide the discussions • The nursing interventions are then linked to the specific nursing diagnoses

16. CVP: Phase II - Nursing Interventions • Linking interventions to specific nursing diagnoses • Carefully review the definition and defining characteristics and in some cases the related to factors • Consider the general outcome to be accomplish for that diagnosis • Select interventions that can specifically address that particular diagnoses.

17. CVP: Phase II - Nursing Interventions • Linking Considerations • If there are interventions that do not fit with a diagnosis yet are found relevant by 100% of the clinicians, a review of diagnoses is undertaken to determine the most appropriate fit. It may be found that a diagnosis needs to be added • Interventions believed at first to be relevant with the linking process may be found to be irrelevant • Audits need to be conducted • Documentation under some- why?

18. CVP: Phase III - Nursing Outcomes • The clinical leader: • distributes the list of nursing sensitive patient outcomes (NOC) • asks each clinician to place a check mark next to outcomes that he/she determines to be at least somewhat relevant to the clinical practice area • tallies the responses • Compiles the outcomes that clinicians selected

19. CVP: Phase III - Nursing Outcomes • The outcomes are put in a table format • The table is distributed and reviewed carefully by clinicians • The clinicians meet as a group with the clinical leader and review each outcome, definition, and indicant • The clinical leader and/or researcher guide the discussions • The patient outcomes are then linked to the specific nursing diagnoses

20. CVP: Phase III - Nursing Outcomes • Linking outcomes to specific nursing diagnoses • Carefully review the definition and defining characteristics and in some cases the related to factors of diagnosis • Consider the specific outcome to be accomplished for that diagnosis • At times, outcomes need to be selected for the intervention as well (e.g. Medication Administration & Medication Response)

21. CVP: Phase III - Nursing Outcomes • If there are outcomes that do not fit with a diagnosis or an intervention, yet are found relevant by 100% of the clinicians, a review of diagnoses and interventions is undertaken to determine the most appropriate fit • It may be found that a diagnosis and/or intervention needs to be added. • Changes are made throughout the process, e.g., there are instances when nurses dismiss an outcome believed at first to be relevant but, after discussion, it is found to be irrelevant.

22. CVP: Phase IV – Intervention Activities & Outcome Indicants • Clinicians review and select the activities under each intervention that are relevant to their practice. • Clinicians review and select the indicators under each outcome that are relevant to their practice

23. Developing Standards of Practice Using Consensus Validation Process • Nurse Researcher/Leader • 3-5 Clinical Experts • Can meet weekly (1 to 2 hours) for up to 8 months or • 2-3 weeks of 8 hour days

24. Developing Standards of Practice: Checks & Balances • 100% consensus is a powerful tool • Discussions with rationale for choices and respectful challenges by others served to validate decisions • Internal Audits of standards are conducted by researcher and audit team throughout process • Development will continue with clinical use & validation of Standards of Practice

25. Development of Five Standards of Practice • Joint New Parent Support Program • 3 Expert Clinicians • Latent Tuberculosis Infection (LTBI) Program • 5 Expert Clinicians • Care and Prevention of Impaired Skin Integrity • 3 Expert Clinicians • Risk for Infection for ICU patients • 3 Expert Clinicians • Risk for Impaired Skin Integrity for ICU patients • 3 Expert Clinicians

26. Researcher’s Role • Maintain a non-judgmental, enthusiastic and supportive approach throughout the project • Ensure confidentiality of nurses • Work in 1-2 hour time blocks • Overview process and time commitment • Discuss commitment to attend every meeting. 100% consensus requires 100% attendance. • Carefully go over home work assignments and necessity to bring NIC, NOC, NANDA to every meeting. • Each member is equal, all status is equal, no bosses or rank • No one need to defend original choice, if change mind- state new judgment • As meeting begins, quickly review ground rules, thinking processes from previous meetings, what has been accomplished to date and goals to be achieved for that day.

27. Researcher’s Role • Support nurses’ decision-making • show complete and absolute respect for nurses in the study • maintain as positive an attitude as possible (avoid anger, resentment, frustration, disappointment, and other negative responses) • do not make decisions for nurse participants • do not pressure the nurses to make specific decisions • accept nurses’ decisions and choices regardless of whether you agree or not • when nurses choose unlikely diagnoses, interventions or outcomes, make it possible for other members of the group to consider and reconsider these choices, e.g., • Ask questions, rather than making statements e.g., does everyone agree that this choice is relevant?

28. Researcher’s Role • Objectify areas of disagreements • Summarize where the group is during a difficult decision-making episode • Frequent reminder of goal and purposes of study • Keep the discussion moving by putting aside controversial items until the end of the process • Nurses can become passionate during this process, encourage respectful passion • Keep good records of the process and obtain approval of the records from the nurses

29. Implications for Consensus Validation Process Use • The CVP can be implemented on any practice unit, for any patient population or health focus by nurses to self-determine the NNN terms for practice standards. • As a research project, it enhances the professionalism of practicing nurses. • When used in an EHR, it provides the framework for aggregating data to describe, explain and predict nursing care. • With implementation of the Standards of Practice, nurses will be able to unequivocally answer the question, “what do nurses in this setting do and what is their value?”

30. Implications for Standards of Practice Use in an EHR • Standards of Practice based on NANDA, NIC & NOC in an Electronic Health Record will enable: • Professional practice enhancement • Performance improvement • Provision of economic evidence • Streamlining of documentation

31. Questions?? QUESTIONS? • The End with Beautiful picture of Hawaii