Teaching NANDA, NIC and NOC: Novice to Expert

Teaching NANDA, NIC and NOC: Novice to

Expert

Margaret Lunney, RN, PhDCollege of Staten Island, CUNYPresentation at the Center for

Nursing Classification Informatics Conference, Iowa City, IA, June 2005

Learning Objectives

1.Explain 3 propositions r. t. teaching NNN

2.Set expectations for students at Novice to Expert stages of development

3.Implement teaching strategies4.Integrate NNN with nursing curricula

Objective 1: Explain Propositions

1.Use of NNN requires intellectual, interpersonal, & technical competencies, tolerance for ambiguity & reflection

2.Accurate diagnoses are the basis for use of NIC & NOC

3.Use of NNN differs from the traditional nursing process

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

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

Basic Thinking Abilities

Mean

S.D. Range

DMU-Fluency 21.3

7.2 6 - 41.5

DMC-Flexibility 10.8 6.5 0 – 27.5

DMI-Elaboration 17.8 4.9 7 – 30.5

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

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

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 nursing7 Cognitive Skills10 Habits of Mind

Cognitive Skills

Analyzing Applying Standards Discriminating Information Seeking Logical Reasoning Predicting Transforming Knowledge

Habits of Mind

Confidence Contextual

perspective Creativity Flexibility Inquisitiveness

Intellectual integrity

Intuition Open-

mindedness Perseverance Reflection

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

Proposition # 1 (cont.)Interpersonal Skills

Exquisite communicationPromote TrustWork in partnership, share powerValidate perceptions

Accept that we do not “know” others

Proposition # 1 (cont.)Technical Skills

Obtain valid and reliable dataHealth histories

ComprehensivePhysical exams Focused

Perform nursing interventions Technical aspects of using NNN

Shortcut to super_woman_run_md_wht.lnk

Proposition #1(cont.)Personal Strengths

Tolerate ambiguityDecisions are relative to context &

specific nature of individualsMultiple factors influence clinical

situationsHuman beings are complex and

diverseAmbiguity is the norm

Proposition #1(cont.)Personal Strengths

Reflect on practice experiences Accept possible flaws

Thinking InterpersonalTechnical

Aim - develop & grow

Proposition # 2: Accurate Interpretations-Foundational

Cues/data may be incorrect Examples

Objective Data: Diagnostic testsSubjective Data

PatientsFamilies

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

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

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)

Possible Interpretation/Diagnosis

Knowledge deficitDisconfirming 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 diagnosisTeaching is waste of time, effort, &

money

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

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

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

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

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

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

Challenge: Achieving Accuracy

Puzzle: What is the Diagnosis?

Solving the Puzzle

Is it this? Or this? Or this?

Accurate Interpretations-Foundational (cont.)

Supporting Factors: Acknowledge that data interpretations

are probabilistic; 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

Proposition # 3: New Perspective on Nursing Process

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

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

Examples: User-Friendly Simplicity

NANDA NOC NIC Anxiety: -Vague uneasy feeling; autonomic response; feeling of apprehension; altering signal warning of impending danger

Anxiety Control: Personal actions to eliminate or reduce feelings of apprehension and tension from an unidentifiable source

Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to unidentified source of anticipated danger

Risk for Infection: -Increased risk for being invaded by pathogens

Infection Status: Presence and extent of infection

Infection Protection: Prevention and early detection of infection in a patient at risk

Changing from Traditional to Use of NNN

Use theoretical perspective:Change theoryDiffusion of Innovations (Rogers,

2003)S shaped diffusion curve Perceived characteristics:

Relative advantage (+) Compatibility (+) Complexity (-) Trail Ability (+) Observability (+)

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

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

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

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)

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)

Set Expectations

All Levels:Self evaluation Integrate with new theories, e.g.,

Pender’s health promotion model Integrate with strategies for evidence-

based nursing

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

Objective 3:Teaching Strategies, Intellectual

Assume that thinking ishuman, imperfect, attainable

Encourage thinking in class & clinical:Ask questions instead of giving

answersProvide opportunities

for problem solving

Teaching Strategies: Intellectual

Deflate authority


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


Share paradigm cases (e.g. Marian Hughes)

Simplify representations, identify high relevance cues (e.g., Carlson-Catalano, 2001)

Conduct iterative hypothesis testing


Seminars instead of lectures: Why?Groups represent wide variations in

thinking abilitiesPromotes in-class thinkingRecognizes students’ abilities to think &

learn without authority/expertsSupports future work in groups to

describe, analyze, & synthesize information, solve problems (e.g., what is the diagnosis?)


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


Expect self evaluationAsk questions, instead of giving

answersDiscussion in classDiscussion online Journal writing (Degazon &

Lunney,1996)

Teaching Strategies: Interpersonal

Expect accountability forpatient relationships

Demonstrate: Good interviewing Validation of diagnoses Partnership processes to select

outcomes & interventions Reward power sharing Teach & support assertiveness

Teaching Strategies: Technical

Expect accountabilityfor using standardizedmethods

Demonstrate useof diagnostic reasoning

Show technical use of NNN using case studies

Teaching Strategies: General

Demonstrate correct use of NNN Provide incentives for correct use

of NNN, e.g., percent of grade Integrate with theories of nursing,

e.g., Neuman’s Systems Model Roger’s Science of Unitary Human Beings Leininger’s Sunrise Model AACN Synergy Model of Patient Care

Case Study: Laura

30 y.o. woman in good health

Smokes 1 - 1.5 packs per day for > twelve years

Asked for assistance to quit

Stated “I know it’s not good for me and I want to stay healthy.”

What is the Diagnosis?

Health Seeking Behavior: Smoking Cessation (00084)

Definition: Active seeking (by a person in stable health) of ways to alter personal health habits and/or the environment in order to more toward a higher level of health.

What is the Outcome?

Risk Control: Tobacco Use (1906) Actions to eliminate or reduce tobacco use Rarely demonstrated (2), Goal = 5 Indicators:

03 Monitors environment for encouraging tobacco use (2)

04 Monitors personal behavior for tobacco use (2) 05 Develops strategies to eliminate tobacco use (3) 07 Commits to tobacco use control strategies (3) 13 Uses support group to eliminate tobacco use (1) 16 Eliminates tobacco use (1)

What are the Interventions?

Smoking Cessation Assistance (4490) Teaching: Medication, Nicotine

Replacement Therapy (5616)

NIC: Smoking Cessation Assistance (4490)

Helping another to stop smoking Activities:

Give Laura clear, consistent advice to quit Assist Laura in choosing strategies Motivate her to set a quit date Refer to group programs/individual therapy Inform Laura of possible symptoms Help plan coping strategies and resolve

problems

Evaluation of Outcomes

Risk Control: Tobacco Use After 6 wks, nurse & Laura rate outcome as

5 03 & 04: Laura consistently monitors her

environment and personal behaviors for factors that affect her tobacco use

05 & 07: Laura developed effective strategies and remains consistently commit0ted to controlling her use

13: Laura uses friends & group for help 16: Laura has not smoked for six weeks

Case Study: Stella C 49 y.o. single, Italian American woman Type 2 DM with adequate control Overweight Head of household; 80 y.o. dependent mother Works full time, provides care for self & mother Accepts care of mother but has many

frustrations Attempts to reduce her workload have failed Mother thinks Stella “can do it all” Mother discourages son’s involvement Stella expresses conflicting emotions, stress,

lack of control

What are the Diagnoses?

The diagnostic process: Which are important cues? What are possible diagnoses? Which diagnoses have the best support?

Are the diagnoses consistent with the situational context?

Can the nurse help Stella with the diagnoses?

What are the diagnoses?

NANDA Diagnoses: Risk of Caregiver Role Strain (00062) Readiness for Enhanced Family Coping

(00075) Checking for accuracy:

Are there a sufficient number of confirming cues?

Are there any disconfirming cues? Did Stella C validate the diagnosis? Should other providers be consulted?

What are the Outcomes?

Caregiver Well-Being (2508) Caregiver satisfaction with health and

lifestyle circumstances Moderately compromised (3), Goal = 4 or 5 Indicators:

01: Satisfaction with physical health (3) 02: Satisfaction with emotional health (2) 03: Satisfaction with usual lifestyle (3) 06: Satisfaction with instrumental support (2) 08: Satisfaction with social relationships (3)

What are the Outcomes?

Family Coping (2600) Family actions to manage stressors that tax

family resources Moderately compromised (3); Goal = 4 or 5 Indicators:

01: Demonstrates role flexibility (3) 02: Family enables member role flexibility (3) 07: Expresses feelings and emotions freely (2) 13: Arranges for respite care (2) 16: Seeks assistance when appropriate (3) 17: Uses social support (3)

What are the Interventions?

Assertiveness Training (4340) Self Esteem Enhancement (5400) Emotional Support (5270) Caregiver Support (7040) Role Enhancement (5370) Family Involvement Promotion (7110) Respite Care (7260)

NIC Example: Assertiveness Training

Assistance with the effective expression of feelings, needs, and ideas while respecting the rights of others

Activities: Determine barriers to assertiveness, e.g., family

roles Help Stella recognize & reduce cognitive

distortions Instruct Stella in different ways to act assertively Facilitate practice opportunities using discussion,

modeling and role playing Help Stella practice conversational skills


Caregiver Well-Being After 4 wks, nurse & Stella rate outcome as 4

01: Stella’s physical health has improved; satisfaction with physical health (4)

02: Stella uses assertiveness skills to make time for herself after work and to plan recreation; satisfaction with emotional health (4)

04: Stella continues to need help in the performance of caregiver roles; satisfaction with performance of usual roles (4)

09: Stella feels in control of her caregiver routines; satisfaction with caregiver role (4)


Family Coping After 4 wks, nurse & Stella rate outcome as 4

01: Stella’s assertiveness behaviors work well to accomplish goals; demonstrates role flexibility (4)

02: Stella’s mother agrees with the plan to relieve her of some of the workload; family enables member role flexibility (4)

13: Stella’s brother stays with her mother so Stella can go away for short periods; arranges for respite care (4)

18: Family exhibits a wider repertoire of coping behaviors (4)

Case Study by Mitchell, In Lunney, 2001

Use of non-approved nursing diagnoses, Risk of Disease Progression

Relation of nurses’ role to diagnoses, interventions, & outcomes

NOCs NICs Outcome Evaluation

Teaching Strategies: Summary

Observe students grow in abilities through encouragement, trust, respect

Objective 4:Integrate with Curricula

Prepare Faculty Diffusion of Innovations

(Rogers, 2003)

Talking points: Electronic Health Record Quality-based nursing care Ability to develop information & knowledge

Involve clinical faculty Evaluation/Peer Observation

Integrate with Curricula

Simplify complexity-map diagnoses, interventions & outcomes for courses

All faculty evaluate students’Correct use of NNNPartnership processes, use of “we”Technical skills Individualize NNN content with

patients


Fundamentals of Nursing NNN - Framework for skills learning Thinking - High priority, include in testing Expect students to use CT terms &

definitions, e.g., journal writing, discussion Develop case studies (Lunney, 1992) Iterative hypothesis testing


Educators & Practice-Based Leaders: Spread the word to nurses in other agencies Meet with leaders; use marketing strategies Demonstrate advantages of NNN Provide CE programs Disseminate your success in using NNN to

others

Questions/Discussion?

“Teamwork is the fuel that allows common

people to attain uncommon results.” Unknown

“The illiterate of the 21st century will not be

those who cannot read and write, but those

who cannot learn, unlearn and relearn.” Alvin

Toffler

Documents

Teaching NANDA, NIC and NOC: Novice to Expert