The use of nursing diagnoses to describe the health problems that nurses treat has increased substantially since the early 1970's, largely due to the work of the North American Nursing Diagnosis Association (NANDA). Nursing diagnoses provide a standardized terminology of names for clusters of signs and symptoms of specific conditions and their etiologies and thus focus the treatment that nurses can use to reverse the etiologies and achieve desired outcomes.
Maas described a number of advantages of the use of nursing diagnoses:1
Nursing diagnoses . . . promote autonomy, accountability, and participation of nurses in the achievement of clinical and organizational program objectives. Nursing diagnoses aid the delivery of quality nursing care and the building of meaningful research, quality assurance, and staff development programs. Nursing diagnoses provide a mechanism for costing out nursing services, implementing computerized information systems, and promoting collaboration. Nursing diagnoses are a vehicle to enhance the power, influence, and marketability of nursing service (p 39).
Thus, it is important that nurses, who work with the elderly and in long-term care settings, expand their knowledge about nursing diagnosis and use nursing diagnoses in their practice. Expanding knowledge and use of nursing diagnoses should include increased understanding of diagnostic concepts, interventions, and outcomes; data about the incidence and accuracy of diagnoses of clients in their settings as well as others; and an awareness of developments in the profession toward building an intellectual basis for nursing practice.
The purpose of this article is to promote sharing of clinical use and research of nursing diagnoses among nurses who work with elderly and longterm care clients. This article briefly reviews the results of five studies of the prevalence of nursing diagnoses among elderly and long-term care populations. Diagnoses presented in this article were selected from those that were prevalent in the five epidemiological studies.2,6 Studies that assess the reliability and validity of these nursing diagnoses in elderly and long-term care populations are also reviewed. Future directions for research to test nursing interventions for these diagnoses are outlined. The remainder of this issue is devoted to sharing knowledge about selected nursing diagnoses which are prevalent among elderly and long-term care clients.
Gordon and Sweeney note the need for epidemiological studies of nursing diagnoses in a variety of settings and populations.7 These studies are needed for early detection of problems that nurses can treat or prevent. Gordon notes that these studies increase nurses' awareness of signs and symptoms in certain populations that may indicate a high probability that certain diagnoses exist. Further, studies are needed to determine specific diagnoses that are more apt to be prevalent in groups of persons because of their age, length of stay, medical diagnosis, and other factors.
Five epidemiological studies of nursing diagnoses among elderly and longterm care populations were found in the literature. HaIIaI surveyed the nursing diagnoses in nursing student care plans for a convenience sample of 106 hospitalized geriatric patients.2 Leslie reviewed the nursing diagnoses in the problem-oriented records from all the residents in a 210-bed, long-term care facility.3 Rantz et al4 and Rantz and Miller5 extracted nursing diagnoses from an audit of patient records in a 328-bed, long-term care facility. Hardy et al6 described the nursing diagnoses from clinical records for a sample of (N = 121) of long-term care residents of a state veterans' facility.
Nursing diagnoses which were prevalent (occurred in at least 10% of the subjects) in all of the five epidemiological studies of elderly and long-term care populations/samples were: Self-care deficit: Total; Impaired physical mobility; Alteration in thought processes; Impaired skin integrity; Alteration in comfort: Pain; Alteration in nutrition: less than body requirements; and Alteration in bowel elimination: Constipation.26 Alteration in urinary elimination: Incontinence; Sensory perceptual alteration; and Potential for injury were prevalent in four of the five studies.
Data for groups of residents by age, sex, length of stay, or level of nursing care intensity were only reported by Hallal2 and Hardy et al.6 In these studies, there was considerable consistency in the prevalence of diagnoses among the subgroups. Hallal2 reported only on gender and age groups. Diagnoses that were prevalent in all five studies were also prevalent for both males and females in the Maas and Hardy study.
Overall, the prevalence of diagnoses was also consistent among age groups: young (less than 65), young-old (65-79), and old-old (80 and older). The prevalence of Sensory perceptual alteration and Alteration in fluid volume: excess, among the old-old; Disturbance in self concept in the young group; and Alteration in nutrition; less than body requirements in the youngold were exceptions.
Self-care deficit, Impaired physical mobility, and Alteration in thought processes were prevalent in each of the five length of stay groups: less than 1 year; 1 year to less than 3 years; 3 years to less than 10 years; 10 years to less than 20 years; and more than 20 years. For residents grouped by the intensity of nursing care that they required (Category I = most intense, Category IV = least intense), Alteration in thought processes and Alteration in health maintenance were prevalent in all four groups.
The prevalence of diagnoses was most consistent among the three groups requiring the most nursing care. Ineffective coping: potential and Disturbance in self concept were prevalent only in the group that required the lowest intensity of care, who were mostly residents living in the residential care area. These results illustrate the importance of epidemiological studies that report the incidence of diagnoses by age, gender, and other characteristics. Results of studies in a variety of settings can then be compared and generalizations regarding diverse elderly and long-term clients can be prevented. Considerable replication of findings between the studies also provides evidence that the NANDA taxonomy has validity for describing the responses to actual and potential illness that nurses treat among elderly and long-term care clients, and provides a framework for further research.
Validation research sets out to determine the extent that defining characteristics of selected nursing diagnoses are nearly always or frequently present when clinicians make the diagnoses in a practice setting.8 Some studies to validate the diagnoses presented in this volume have been included in Table 1. Creason, Pogue, Nelson, and Hoy t conducted a study to validate the etiologies and signs and symptoms of Impaired physical mobility in a sample of rehabilitation patients using a retrospective audit of nursing process papers, of students in an RN baccalaureate degree completion program.9 Seventy-five percent of the defining characteristics were included in four broad categories: inability to perform self-care; decreased muscle strength, control, mass; limited range of motion; and other functional alterations. The most frequent etiologies identified were neuromuscular impairment, musculoskeletal impairment, and medial diagnoses. Investigators questioned whether Self-care deficit was often a more appropriate diagnosis with an etiology of Impaired physical mobility in order to focus interventions on compensation of mobility limitations to promote maximum functional abilities.
SELECTED VALIDATION STUDIES OF NURSING DIAGNOSES PERTINENT TO ELDERLY AND LONG-TERM CLIENTS
McShane and McLane reported the results of a validation study of Altered bowel elimination: constipation.10 Results of this study are discussed by the investigators in their article on constipation, along with additional work which has been done to validate the diagnosis. Coffman studied Altered bowel elimination in a sample of 33 children with meningomyelocele in an outpatient clinic.11 While the subjects for this study were children, etiologies found for these long-term care clients (decreased activity, not enough roughage, inadequte fruits and vegetables in diet) may also be relevant for the elderly.
In her article, Alteration in Urinary Elimination: Incontinence, Tunink reviews studies by Voith, Madson, and Smith and Youngbauer12 to validate six specific incontinence diagnoses. Tunink also discusses additional work by Specht, Tunink, Maas, and BuIechek13 to specify and validate types of incontinence in the elderly.
Proceedings of the Seventh National Conference of NANDA contains several studies reporting validation of nursing diagnoses discussed in this volume, including Impaired skin integrity; Self care deficit; Impaired physical mobility; Alteration in comfort: pain; Alteration in urinary elimination; and Alteration in nutrition: less than body requirements.14 A variety of methods were used for validating these diagnoses, their etiologies, and defining characteristics.
There are also a number of validation studies in the literature of diagnoses that occur among the elderly, other than those discussed in this issue. The investigators, diagnoses studied, and the publication date are contained in Table 1. Clearly, there is need for many more studies to validate diagnoses among the elderly. These efforts should be focused on the nursing diagnoses reported as most prevalent in epidemiological studies of elderly and long-term care clients.
Too few epidemiological studies in elderly and long-term care populations have been reported for conclusions to be drawn about the incidence of nursing diagnoses. Therefore, many more studies of the prevalence of nursing diagnoses in this population should be completed and reported. Examination of the methods used in the five epidemiological studies reported here, as well as others, will assist clinicians in doing and reporting prevalence studies. Nurses can use these findings to arrange further research, education, and practice priorities.
Validation of diagnoses, etiologies, and signs and symptoms in elderly and long-term care populations is another priority need. The prevalence of nursing diagnoses in specific populations and settings is a rational basis for arranging priorities to study their validity. Methods of validation have been described by Gordon and Sweeney7 and Fehring.15 One volume of Nursing Clinics of North America has been devoted to reports of research to validate specific diagnoses.16 Thus, a variety of methodologies are available for nurses to use to validate diagnoses in diverse clinical settings. The NANDA Board of Directors is currently discussing the need for a conference on the subject of validation of nursing diagnoses. The involvement of nurses in clinical settings is critical for the effort to validate and refine diagnostic categories and their critical indicators. This is especially required for the identification of appropriate outcomes and for the assessment of the quality of nursing care.
Evidence of the validity of diagnoses is essential for further research efforts. Assessment tools can then be tested for reliability and validity. Outcome standards can be systematically defined, and the effects of interventions to achieve the outcomes can be analyzed. Identification of interventions to treat specific diagnoses is a critical need17 and will be enhanced.
Historically, nursing has been taskoriented and has lagged in the development of treatment concepts. The result is that few interventions, explicitly defined and linked to diagnoses, have been developed and clinically tested. Accountability to clients demands that nurses correct this deficit.
Refinement and validation of diagnostic skills are other research priorities that will be facilitated by epidemiological and validation studies of diagnoses. If nursing diagnoses are to guide practice, and serve as the definition of nursing, diagnoses and diagnostic reasoning must be reliable and valid. Ethical issues associated with nursing diagnosis and treatment of specific problems must also be assessed.18 In an environment of cost effectiveness and containment, nurses cannot ignore accountability for accurate judgments and ethical actions.
Further, costs of treatment compared to effectiveness can be examined. The work can be communicated to the nursing public through the nursing literature and at local, regional, and national nursing diagnoses meetings. These activities should encourage funding of research and support the communication of findings by NANDA and other nursing and health-related organizations.
Finally, nursing must continue to develop and validate a standard nomenclature for diagnoses and interventions so that information can be documented and processed efficiently. Computer technology has revolutionized the storage, analysis, and retrieval of information to the advantage of those who are prepared to use it. However, nursing information has not been in a form easily adapted for computer processing.
To a great extent, nurses remain disadvantaged by manual documentation, analysis, and retrieval of clinical data. Furthermore, nursing care problems and 3. The involvement of nurses in clinical settings is critical for the effort to validate and refine diagnostic categories and their critical indicators. This is required especially for the identification of appropriate outcomes and for the assessment of the quality of nursing care.
treatments have not been included in institutional or national minimum health data sets. The result is that nursing information has typically been underrepresented in the review of health needs and trends for policy decisions and resource allocation at institutional, state, and federal levels.
Diagnoses presented in this special issue are brief accounts of the diagnostic concepts and interventions that nurses use to treat the diagnoses. The authors have attempted to provide research based content wherever possible. Much of this knowledge is derived from theory or based on the experiences of clinical nurses. The content is intended to assist nurses to care for their clients.
The focus on nursing diagnoses, that research has shown to be prevalent among elderly and long-term care clients, will hopefully promote their use and testing in clinical settings, the conduction of research to describe their incidence in a variety of elderly and long-term care client groups, and encourage sharing of these results. This issue is a challenge to nurses in gerontological and long-term care settings to use nursing diagnoses in their practice, conduct research on nursing diagnoses, and report their clinical research experiences.
- 1. Maas M: Nursing diagnoses in a professional model of nursing: Keystone for effective nursing administration. J Nurs Adm 1986; 16(12):39-42.
- 2. Hallal J: Nursing diagnosis: An essential step to quality care. J Gerontol Nurs 1985; 11(19):35-38.
- 3. Leslie FM: Nursing diagnosis in long term care. Am J Nurs 1981; 81(5):1012-1014.
- 4. Rantz M, Miller T, Jacobs C: Nursing diagnosis in long term care. Am J Nurs 1985; 85(5):916-926.
- 5. Rantz M, Miller T: How diagnoses are changing in long term care. Am J Nurs 1987; 87(3):360-361.
- 6. Hardy M, Maas M, Akin J: The prevalence of nursing diagnoses among elderly and long term care residents: A descriptive comparison. Recent Advances in Nursing 1988; (in press).
- 7. Gordon M, Sweeney M: Methodological problems and issues in identifying and standardizing nursing diagnoses. Advanced Nursing Science 1987; 1(2): 1-15.
- 8. Vincent K: The validation of a nursing diagnosis: A nurse consensus survey. Nurs Clin North Am 1985; 20(4):63l-640.
- 9. Creason N, Pogue N. Nelson A. Hoyt C: Validating the nursing diagnosis of impaired physical mobility. Nurs Clin North Am 1985; 20(4):669-684.
- 10. McShane R, Mc Lane A: Constipation: Consensual and empirical validation. Nurs Clin North Am 1985; 20(4):801-808.
- 11. Coffman S: Description of a nursing diagnosis: Alteration in bowel elimination related to neurogenic bowel with myelomeningocele. Issues Compr Pediatr Nurs 1986; 8:179-191.
- 12. Voith A , Smith D, Madson L, Youngbauer P: Validation of nursing diagnoses regarding alterations in urinary elimination, in McLane AM (ed): Classification of Nursing Diagnoses: Proceedings of the Seventh National Conference. St Louis. CV Mosby, 1986, ? 281.
- 13. Specht J, Tunink P, Maas M, Bulechek G: Alteration in urinary elimination: Incontinence, in Maas M, Buckwalter K (eds): Nursing Diagnoses and Interventions for the Elderly. Menlo Park, California, AddisonWesley, in press.
- 14. McClane AM (ed): Classification of Nursing Diagnoses: Proceedings of the Seventh National Conference. St Louis, CV Mosby, 1987.
- 15. Fehring R: Validation, in Hurley M (ed): Classification of Nursing Diagnoses: Proceedings of the Sixth Conference. St Louis, CV Mosby, 1986, pp 183-190.
- 16. Symposium on nursing diagnosis, Dougherty C (ed). Nurs Clin North Am 1985; 20(4).
- 17. Bulechek GM, McCloskey JC: Nursing diagnoses and intervention, in Bulechek G, McCloskey J (eds): Nursing Interventions: Treatments for Nursing Diagnoses. Philadephia, WB Saunders, 1985.
- 18. Gordon M: Issues in nursing diagnosis, in McLane AM (ed): Classification of Nursing Diagnoses: Proceedings of the Seventh National Conference. St Louis, CV Mosby, 1987, pp 17-20.
- 19. Jones P, Jakob D: Nursing diagnosis: Differentiating fear and anxiety. Nurs Pap 1981; 13(Winter):20-29.
- 20. Dalton J: A descriptive study: Defining characteristics of the nursing diagnosis cardiac output, alterations in: decreased, image 1985; 17(4):113-117.
- 21. Baird S: Development of a nursing assessment tool to diagnose altered body image in immobilized patients. Orthop Nurs 1985; 4(1):47-54.
- 22. Meis M: Loneliness in the elderly. Orthop Nurs 1985; 4(3):63-66.
- 23. Thomas M, Sanger E, Whitney J: Nursing diagnosis of depression. J Psychosoc Nurs Ment Health Serv 1986; 24(8):6-12.
- 24 . Dougherty C: Decreased cardiac output: validation of a nursing diagnosis. ACCN Dimens Crit Care Nurs 1986; 5(3): 182-188.
- 25. Classification of Nursing Diagnoses: Proceedings of the Fifth National Conference. Kim M, McParland G, McLane A (eds). St Louis, CV Mosby, 1984.
- 26. Classification of Nursing Diagnoses: Proceedings of the Sixth National Conference, Hurley M (ed). St Louis, CV Mosby, 1986.
SELECTED VALIDATION STUDIES OF NURSING DIAGNOSES PERTINENT TO ELDERLY AND LONG-TERM CLIENTS