Too often, nurses who return to school to pursue a BSN degree express frustration when practicing within a diagnostic framework, as they frequently find the North American Nursing Diagnosis Association's (NANDA) approved diagnostic labels clinically irrelevant. This is because the current NANDA list is incomplete. Many admit to making up their own diagnoses, which they feel have a better fit. As Fehring (1987) points out, the problem arises from too few defining characteristics that have been identified and agreed upon by nurses. Additionally, nurses again undertaking the role of student find the traditional care plan assignment overdone and trite.
The need for empirical validation of nursing diagnosis is well established. As Gordon (1989) explained, formulation of nursing diagnoses and subsequent clinical implementation has surpassed the clinical research on phenomena represented by nursing diagnoses.
In an attempt to encourage RN-to-BSN students to continue practicing within a diagnostic framework, the concept of diagnostic validation was introduced during an advanced clinical nursing course. It was hoped that exposure to the process of validating diagnoses would provide students with a better understanding of the ongoing development of nursing as a science. The experience was also a means by which students used the nursing process without being required to write another care plan to complete a clinical course.
Description of the Experience
The students were given the assignment of clinically validating the nursing diagnosis of their choice. The goals of this activity were to foster an appreciation for the process by which NANDA approves a diagnosis and a better understanding of why the NANDA list is incomplete. It was hoped that this would decrease the frustration expressed when working with an incomplete list as well as stimulate proposals for new diagnoses.
Thirteen RN-to-BSN students were enrolled in the final senior BSN clinical course, which focuses on crisis intervention in both medical-surgical and psychiatric settings. The experience took place during the eight- week medical-surgical rotation. Information on the process of validating nursing diagnoses was presented prior to the clinical experience. Methods reported by Fehring (1987), Gordon and Sweeney (1979), Knafl (1989), and Grant, Kinney, and Guzzetta (1990) were discussed in class.
Students were assigned to their choice of a variety of clinical units including various specialty intensive care units, oncology, hospice, and high-risk obstetrics. The first clinical day was spent familiarizing themselves with staff and patients.
Care plans were reviewed to determine which nursing diagnoses were commonly identified by the nurses. This was an important element because of time constraints. Students had seven clinical days remaining in which to observe defining characteristics of a selected diagnosis. It was speculated that if students selected a diagnosis that was recurrent, the likelihood of observing defining characteristics was greater.
After selecting the nursing diagnosis that they wished to explore, students conducted a review of the literature. Descriptions and terminology were taken to begin developing a list of characteristics. The list was further refined through consultation with staff nurses and clinical specialists. These were then compared with characteristics observed during interactions with patients. It is interesting to note that while reviewing charts, students found documentation of the listed characteristics in nurses* notes, yet no diagnosis had been made by the nursing staff.
Outcomes of the Experience
Students probed a variety of nursing diagnoses associated with psychosocial aspects of crisis, such as anticipatory grieving, powerlessness, and anxiety. At the completion of the rotation, students submitted a written report of their findings using the criteria set forth by NANDA for submitting a nursing diagnosis. The reports included the actual diagnosis examined, definition of the diagnosis, defining characteristics (major and minor), related factors, supporting literature review, and clinical observations. Students also presented an overview of the validation process and their findings to the clinical agencies through staff conferences.
The response by both students and staff was overwhelming and most encouraging. Students expressed renewed enthusiasm for the nursing process and nursing diagnosis. Many stated that it afforded them an opportunity to become more familiar with the process of diagnosing and felt that prior exposure to this component of the nursing process was superficial in comparison. Nursing staff involved with students during this experience have requested additional in-service seminars and reading lists. Nurse managers requested that their units be used again in order to involve more staff in the validation process.
An eight-week medical-surgical clinical rotation was used to expose RN students to the process of validating nursing diagnoses. Although limited in scope, students gathered data from the literature, nurse experts, and clinical observations to support defining characteristics of selected nursing diagnoses. Because of the response from students and agency nurses, a more comprehensive experience, to be offered as a nursing elective, is being planned.
- Fehring, R.J. (1987). Methods to validate nursing diagnoses. Heart and Lung, 16, 625-629.
- Gordon, M. (1989). Welcome address. Monograph of the Invitational Conference on Research Methods for Validating Nursing Diagnoses (p. 3). St. Louis, MO: NANDA.
- Gordon, M., & Sweeney, M. (1979). Methodological problems and issues in identifying and standardizing nursing diagnoses. Advances in Nursing Science, 2, 1-15.
- Grant, J., Kinney, M.. & Gozzetta, C. (1990). A methodology for validating nursing diagnoses. Advances in Nursing Science, 12, 65-74.
- Knafl, K. (1989). Concept development. Monograph of the Invitational Conference on Research Methods for Validating Nursing Diagnoses (pp. 37-63). St. Louis, MO: NANDA.