A clinical paper researching a previously unidentified problem and creating a nursing diagnosis label is an interesting and instructive assignment for a graduate nursing students. Creating a nursing diagnosis in graduate school directs students to focus on previously unnoticed clinical problems - and there are many unaddressed gerontological nursing problems.
This article presents an assignment to create a nursing diagnosis for a gerontological clinical class at the master's level that incorporates clinical skills, analysis, and synthesis.
Graduate nursing education offers advanced practice skills at the master's level. The nurse student develops specific clinical expertise to guide practice throughout his or her career. In education, the nurse starts out as a generalist at the BSN level, develops a specialty at the graduate level, and adds to the knowledge base of that specialty at the doctoral level. As the nurse moves through these scholarly levels, ways of teaching and testing the nurse's knowledge change as well.
At the generalist level, the student nurse masters basic skills and experiences the multiple choice test. At the masters level, the student is required to develop writing skills, to analyze, and to synthesize. Finally, at the doctoral level, the student is expected to test, refine, and add to the existing body of knowledge in the chosen specialty area.
Gerontological nursing is a generally new area for graduate education, producing its first specialty journal only 20 years ago (Haight, 1989). Recruiting nurses to this specialty area traditionally has been difficult, which has resulted in a shortage of specialists to care for a rapidly growing aging population and a continuing recruitment problem for nurse educators. Philipose and associates (1991) stated that many factors contribute to the educational problems inherent in this specialty area: attitudes of nurses towards aging patients, gerontology as a career choice, gerontological nursing content, clinical experiences, and the nursing faculty's attitude and preparation.
Nurse researchers make a strong case for the lack of positive attitudes toward the elderly in both teachers and students (Benson, 1982; Collins, 1989; Marsh, 1983). Others strongly argue for positive and innovative clinical experiences to create good impressions of aging for matriculating students (Collins, 1989; Gass, 1986). Taylor and Gallagher (1988) singled out faculty for their lack of interest in older people and their belief that nursing care of the elderly requires little specific knowledge. The need to persuade curriculum committees to include gerontology in the school curriculum is ongoing (Harrington, 1984).
Recently, two agencies (one regional and one national) produced strategic plans for increasing the gerontological content in nursing education (Denton, 1990; Johnson, 1990). Another group of authors strongly recommended that we change the nursing education question, "Should gerontology be included?" to "How much is necessary?" (Solon, 1988). The need for nurses prepared at the graduate level in gerontology continues to increase.
At the graduate (specialization) level, the problems differ from those at the undergraduate level. Though attitudes remain a problem for recruitment to gerontological nursing, the graduate students who choose gerontological nursing do so because they experience the need to know more about older people, see job opportunities in the field, or simply like nursing older people.
Teachers at the graduate level usually possess a degree in the specialty area and are qualified to act as role models to students. One problem that exists for gerontological nursing at both levels is the limited choice in content and clinical experiences to enhance the educational process and pique the interest of the students. This is particularly true for clinical course instructors, who must find ways to make required papers clinically relevant while challenging students to think critically.
Individualized patient assessment and clinical judgment are strong components of a graduate nursing program. The use of nursing diagnoses to assist in these processes becomes second nature as graduate students manage their clients. However, in gerontological nursing, there are so many problems not addressed by nursing diagnosis that it becomes difficult to teach graduate nurses to organize their nursing care through nursing diagnosis. Thus, the problem inherent in gerontological nursing education offers a solution for the creation of a clinically relevant paper in a graduate nursing course.
A UNIQUE GRADUATE EDUCATION PROGRAM
The first clinical course in this graduate gerontological nursing program focuses on the hospital and clinic setting, and the second clinical course focuses on the community and nursing home setting. Students are instructed to observe the older client's environment and to look for problems not addressed due to lack of appropriate nursing diagnoses.
Many students with prior gerontological nursing experience anticipate the second clinical, eager to address problems they encountered in their own practice areas. There is no shortage of problems to identify for older people that might result in a nursing diagnosis. For one such class the problem list included apathy, loneliness, wandering, caregiver burden, failure to thrive, relocation syndrome, strength deficit, and learned helplessness. Each of these problems lacked a nursing diagnosis label, which resulted in ignored issues, even though these unlabeled issues often caused other problems.
After the problems were identified and discussed in class as potential nursing diagnoses, each student reviewed the literature for information concerning the particular problem he or she identified. The review of the literature caused students to explore disciplines outside nursing and to experience the "thrill of the quest" as they defined their problems.
Each week short portions of class were set aside so that students could bounce ideas off one another; the idea of solving clinical problems in a classroom was exciting. Next, the studente were given directions for creating a nursing diagnosis (Table 1), and directions for submitting the diagnosis to the North American Nursing Diagnosis Association (NANDA).
When students identified problems, they took ownership of them and became invested in solving them. Each student first gave his or her problem a name or label as he or she saw it. The label sometimes changed throughout the process as the student gained new and different information, providing new insights into his or her notion of the problem.
At the completion of thorough literature searches, the students selected cues they thought would serve as defining characteristics. One seminar period was devoted to a discussion of the defining characteristics; the students provided peer review for one another.
After deciding the defining characteristics, the students listed them with dictionary definitions in a likerttype scale. They then conducted a small survey using 20 colleagues working in the field, lay people, older people themselves, and /or others who might have insight into the existing problem. These consultants rated the defining characteristics on a scale of 1 to 5; 1 indicated the characteristic was rarely present, 5 indicated the characteristic was always present when the problem was present. Then students calculated the responses for each item.
Directions for Creating a Hursing Diagnosis
After calculating the percentage for each cue that signaled the problem, the students divided the characteristics according to the percentages. The top 20% became the major defining characteristics, the next 30% became the minor defining characteristics, and those characteristics receiving less than 50% of the vote were discarded.
This exercise gave the students a quasi-research experience. They set up their cues in a Likert format and thus became acquainted with questionnaire design. They surveyed colleagues and others and became acquainted with sampling techniques. They also were able to post hoc critique their choice of respondents. For example, the student researching the diagnosis failure to thrive found that the best informants were professional caregivers rather than patients themselves, because patients themselves did not recognize the phenomenon of failure to thrive. Thus, the survey process was as invigorating as the initial idea discussion.
The outcome of this intellectual process was three new and unique nursing diagnoses, all pertinent to gerontological nursing and needed for practice:
* Failure to thrive;
* Caregiver burden; and
* Relocation syndrome.
The students submitted their nursing diagnoses to the instructor and, as a course requirement, to NANDA. In this way, the srudente actually developed their own scholarly and creative piece; they had to refine the product until they fulfilled the NANDA requirements.
Proposed Nursing Diagnosis: Failure to Thrive
Ironically, the year these students submitted to NANDA, NANDA was refining its own process and not accepting many new diagnoses. Thus, the students also experienced their first scholarly rejection; however, learning to accept rejection may be one of the most important parts of the process of scholarly development. Many authors are intimidated by their first rejection, and never publish again or take several years before they see the rejection as developmental. With the help of the professor, the students were able to accept the diagnosis review as another tool for fine tuning.
Failure to thrive, the first diagnosis, is used as a medical diagnosis by the pediatric community. Failure to thrive can be extended to anyone exhibiting the defining characteristics, without being limited to a specific population (Table 2).
Generally, failure to thrive encompasses so many causes and circumstances that it leads to "shotgun" evaluations (Casey, 1984). But the incidence is surprisingly high and the sequelae, although not defined precisely as yet, can be long lasting or can cause permanent physical, cognitive, and behavioral disorders leading to death. If one searches for a descriptive phase in the language of adult medicine, one may have to go back to the old days when an adult who failed to thrive was said to "go into a decline." Nonorganic failure to thrive is a clinical syndrome that is poorly understood and inadequately studied (Holmes, 1979).
Newbern (1992) recently presented the problem of failure to thrive in older people and said that only two other authors had noted this problem before her. She stressed that failure to thrive does not reflect normal aging changes and pointed out the similarities to marasmus in children who present with pronounced lethargy, lack of interest, deterioration of body reflexes, and increased pallor. Newbern warned against using failure to thrive as a blanket term and encouraged assessment and treatment, which will occur more readily with a nursing diagnosis label.
Failure to thrive also is useful in understanding the older person's transcendence from life and indicates a significant role for nurses and other caregivers. Recent research points out that psychological, social, and physiological impairment may be simply early warning signs of later decline in health that leads to death, or it may reveal stress and maladaptation that directly causes a decline in health and early death (Palmore, 1971). Both reasons contribute pieces to the puzzle of the failure to thrive phenomenon. Gerontological nurses must remember that failure to thrive is not limited to a particular age group.
Family caregiver burden, the next diagnosis, is one that is becoming more needed as the population ages and caregivers become older (Table 3). The rising number of people suffering from Alzheimer's disease also makes the burden of caregiving more common.
In the 1980s, family caregiving became a topic for intensive research, alluding to its importance. Caregiver burden is a commonly recognized phenomenon, defined by George and Gwyther (1986) as physical, psychosocial, and emotional problems experienced by family members caring for older adults. There are many tools to measure caregiver burden. At least 10 were the subject of a review of their measure of efficacy (Vitaliano, 1991). This intense scrutiny makes one wonder why there is not a nursing diagnosis for caregiver burden.
Caregiver burden may include negative self-concept and attitude, loss of concern and feeling for others, and a loss of focus in one's life. The family caretakers called upon to nurture and care for those other family members in need often experiences these feelings (Meyer, 1987). Family caregivers tend to be spouses, brothers, sisters, sons, daughters, and often daughters-in-law (Henderson, 1987). Whatever their place in the family, they are in need of treatment and attention and a diagnosis will help target attention on their needs.
Relocation syndrome is the third diagnosis (Table 4). Adjustment to change can be difficult for anyone - especially when it involves a change in residence. The familiar no longer exists, routines are disrupted, and adjustment to change is required. This disruption is especially difficult for older people who might be dealing with preexisting physical, mental, and social problems. The multiple stressors created by relocation and the presence of preexisting problems can overwhelm the elderly person's coping mechanisms.
Responses to relocation of residence have been studied extensively by disciplines other than nursing. For many years, physicians, psychologists, and sociologists have researched responses to relocation in the elderly. The most commonly used technique was to measure mortality as a result of location (Lawton, 1970). Some researchers failed to find negative or debilitating effects (Borup, 1981; Wittels, 1974). Other researchers reported adverse reactions and described characteristics of people who experienced problems, such as the following:
* A decreased sense of perceived predictability and controllability of events surrounding the move (Schulz, 1977);
* Being moved involuntarily (Schulz, 1977);
* Functional impairment of a physical nature (Goldfarb, 1972);
Proposed Nursing Diagnosis: Caregiver Burden
Proposed Nursing Diagnosist Relocation Syndrome
* Chronic brain syndrome (Czank, 1980);
* Psychotic or near-psychotic behavior (Aldrich, 1963); and
* Neurotic, depressed, or compulsive behavior.
Many of these studies used mortality as the only measure for successful relocation, ignoring behavioral changes indicative of maladaptation to a change in residence (Aldrich, 1963; Czank, 1980; Goldfarb, 1972; Lawton, 1970; Wìttels, 1974). These behavior changes might well be treated if looked for and noticed at the time of relocation; such treatment may influence mortality rates.
The students agreed that creating nursing diagnoses was an interesting and exciting assignment. They believed that they added to the body of knowledge for gerontological nursing. Though their diagnoses were not approved by NANDA, the students found themselves using one anothers' diagnoses during the second semester clinical experience. They believed the diagnoses addressed otherwise ignored phenomena that greatly affected the individual patient's well-being. For example, when placed on the plan of care, the diagnosis relocation syndrome focused nursing personnel to look for any problems created by relocation, and to plan activities to orient the relocated client and assist in the client's adjustment.
The student's diagnoses were foremost in their minds as they worked their way through their clinical experiences. They complained that there was not enough time to think, read, do, and submit in one semester. Consequently, the assignment was constructed differently the next year: Students focused on a problem of choice and analyzed the problem through a concept analysis paper in the first semester. The second semester they proceeded with the nursing diagnosis, conducted a survey, and prepared the diagnosis for submission. Second-year students were encouraged but not required to submit to NANDA. The addition of the concept analysis paper gave the students more time to think and the opportunity to truly understand the problems they identified.
Students participating in this clinical exercise learned to critically evaluate problems occurring in their practice areas. In addition, they learned ways of addressing problems through nursing diagnosis. They experienced research as they conducted surveys, calculated results, and listed characteristics. The students had the opportunity to create a product.
Unfortunately, as students graduated and became busy with their new positions, they no longer pursued the academic activity of getting a diagnosis accepted by NANDA. The acceptance process seemed particularly formidable after the initial rejection. An even more serious loss exists for gradutes who work in gerontological nursing - that of not having these existent problems readily identified and labeled.
As educators continue to instruct graduate students - and to marry existing clinical problems with academic exercises - they not only create a meaningful academic experience, but also create solutions for many of the problem areas existing in practice.
McLane (1987) spoke of the need for young researchers to relate thenwork experience with nursing diagnosis to their research programs. The nursing diagnosis assignment relates practice to theory, while providing a meaningful student experience and a practical evaluation of clinical problems. Through writing the paper, the students learn to research problems and create answers. An academic exercise, such as the one described in this article, may lay the groundwork for future research in nursing diagnosis^ - as well as teach new ways of problem solving to nurses in practice.
There are multiple clinical nursing implications for such an exercise. As students begin to work in their specialty, they will be more aware of problems that do not fit into the medical mold. They will look at problems as potential, solvable nursing diagnoses and work toward a solution using the nursing process, nursing diagnoses, and care planning. They will be familiar with using the literature and research to analyze and solve clinical problems. As a result, their contributions to clinical gerontological nursing should help move the speciality forward.
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Directions for Creating a Hursing Diagnosis
Proposed Nursing Diagnosis: Failure to Thrive
Proposed Nursing Diagnosis: Caregiver Burden
Proposed Nursing Diagnosist Relocation Syndrome