Successful Clinical Experiences of
Using Standardized Nursing
Languages
T. Heather Herdman, PhD; RN
Executive Director
NANDA International
Patient Safety
• Patient safety is the number one concern in all
delivery of health care
• Assuring patient safety requires, at a minimum:
• Competent, intelligent health care professionals
• Expertise in critical thinking and clinical judgment
• Holistic approach to care that considers the patient’s
priorities, not simply the health care providers’
priorities
• Sufficient resources for delivery of care
• Patient/family participation in care
Quality of Care
• Institute of Medicine (2001) identified health outcomes of
consumers as the most important indicator of quality
health care
• Identification of those outcomes is critical for
identification, evaluation and prediction of successful
interventions
• Assumptions underpinning this include:
• Effectiveness of interventions varies among providers
• Knowledge development of the effectiveness of interventions is
the responsibility of health care providers
• When effectiveness is compromised, health care consumers may
be better off without providers
• (Lunney, 2009)
Quality of Care
• 2008 research on quality of care in 73 hospital systems
(1,510 hospitals) demonstrated significant variation in
care and outcomes for patients with myocardial infarction,
congestive heart failure, pneumonia and surgical infection
prevention
(Hines & Joshi, 2008)
• These are well defined conditions with research-based signs &
symptoms
• How is this possible?
• 80% of all health care worldwide is delivered by nurses
(NPR, 2009)
• Nurses are professionally accountable for interventions
based on diagnoses (nursing and medical)
Quality of Care
• Evidence-based practice
• Decrease variation in care
• Improve reliance on research in daily practice
• Improve patient outcomes
• This approach relies on:
• Definitive knowledge base for nursing science and
practice
• Distinct, research-based conceptual analysis of
phenomena of concern to nursing science and practice
• Use of this knowledge in clinical judgment
• Use of standardized terminology to represent these
concepts
Evidence-based Practice & Standardized Nursing Languages
• NANDA, NOC, NIC developed through research
• NANDA-I is continually revised based on latest
research
• Evidence-based languages require, at a
minimum, the following things which must be
based on research & clinical literature:
• Clear, concise, conceptual label
• Standardized definitions of terms
• Standardized defining characteristics
Lack of Standardization & Evidence-Based Practice
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Confusion in clinical practice
Misdiagnosis
Inappropriate outcome determination
Ineffective interventions
What’s in a definition?
Axis 1
Axis 2
Axis 3
Axis 4
Axis 5
Axis 6
Axis 7
Diagnostic Subject of Judgment
concept
diagnosis
Location
Age
Time
Status of
diagnosis
Anxiety
Individual
Compromised
Auditory
Infant
Acute
Actual
Fear
Family
Dysfunctional
Cerebral
Toddler
Chronic
Health
promotion
Coping
Group
Excessive
Kinesthetic
Preschool
Child
Intermittent
Risk
Hopelessness
Community
Imbalanced Tactile
Schoolaged child
Continuous
Memory
Ineffective
Adolescent
Moral
distress
Low
Adult
Thought
process
Perceived
Older adult
Visual
ISO Reference Terminology Model for a Nursing Diagnosis
Diagnostic concept
(Axis 1)
Judgment
(Axis 3)
Status of
diagnosis
(Axis 7)
Location
(Axis 4)
Subject of diagnosis
(Axis 2)
Age
(Axis 5)
Time
(Axis 6)
Perils of Clinical Creation of a Nursing Diagnosis
• Case study
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78 year old man whose wife has just died
Easily distracted
Paranoid
Unable to keep track of time / forgetful
Loses glasses, keys, medicine frequently
Not sleeping well – wakens frequently
Poor concentration
Jittery
Irritable
Worried
Perils of Clinical Creation of a Nursing Diagnosis
Acute imbalanced thought process
Thought process
(Axis 1)
Imbalanced
(Axis 3)
Actual
(Axis 7)
N/A
(Axis 4)
(Individual)
(Axis 2)
Older adult
(Axis 5)
Actual
(Axis 6)
Chronic imbalanced thought process
• ACUTE
• Lasting less than six months
• IMPAIRED
• Damaged, weakened
• THOUGHT PROCESS
• Cognitive operations and activities
• Defining characteristics
• NONE
• Related factors
• NONE
Chronic Pain: What is the definition?
Which is the correct definition – and why should we
care???
1. Unpleasant sensory & emotional experience arising from actual or
potential tissue damage or described in terms of such damage;
sudden or slow onset of any intensity from mild to severe,
constant or recurring without an anticipated or predictable end
and a duration of greater than 6 months
OR
2. Unpleasant sensory & emotional experience arising from actual or
potential tissue damage or described in terms of such damage;
slow onset of any intensity from mild to severe, constant in
nature, without an anticipated or predictable end and a duration of
greater than 3 months
Diagnostic Reasoning in Nursing
• Complexity of the phenomena of concern for
nursing are “unrivaled” (Webster, 1994) – due to
the holistic nature of nursing’s focus: human
responses
• The mere complexity of the phenomena
necessitate that nurses clearly understand and
can identify them when they occur in practice
• Requires conceptual analysis of these phenomena,
including identification of the “signs & symptoms”, or
defining characteristics?
• How else can we measure diagnostic accuracy?
Requisites for successful clinical experiences
• Identification and use of a holistic nursing
assessment framework that lends itself to the
identification of defining characteristics
• Nurses must have expertise in:
• Assessment and reevaluation of those assessments
• Standardized nursing languages and their component
parts
• Hypothesis generation
• Planning of care in conjunction with patients, families
and other health care providers
• Evaluating and refining of that plan of care
Assessment
• Many texts teach the nursing process as a subset
of medical diagnosis
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Ignores importance of nursing assessment
Lacks focus on patient/family individuality
Ignores patient/family priorities
Assumes that all human responses to an actual health
problem are the same
• Linking the planning of patient care to the nursing
and interdisciplinary assessment is more
meaningful
Successful clinical experiences
• Involve staff using evidence-based care
• Identify high priority patient segments
• Identify high priority human responses (nursing
diagnoses)
• Identify high frequency human responses (nursing
diagnoses)
• Determine realistic outcomes for each area of care
• Identify critical interventions
Successful clinical experiences: Post-operative care
Acute Pain
Recovery
Room
Surgical Unit
Home Health
Outpatient
Clinic
Moderate pain
Mild to
moderate pain
Mild pain
Minimal pain
• Encourage use of research to guide potential diagnoses
• Require link to assessment data to ensure patient-centered
care
• Discuss & acknowledge difficulties with languages
• Syntax
• Translation
• Lack of “natural” speech
• Contrast Standardized Language – and ability to computerize it
– with handwritten, “home grown” terms or terms that are “put
together” from a list of standardized terms – but with no
accessible standardized definitions or defining characteristics
Successful clinical experiences: Electronic health record
• Begin with nursing assessment, ensuring that
defining characteristics, risk and related factors
are present in the assessment screens
• Use defining characteristics to suggest a list of
potential diagnoses (hypothesis generation)
• Use assessment – or reassessment – to refine
this list to most appropriate nursing diagnoses
• Identify achievable outcomes
• Identify interventions most likely to have positive
impact at lowest cost
Strategies
• Top level nurse administrators
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Must understand need for standardized languages
Lead drive to incorporate into organization
Appoint committed leaders to implement
Identify how data from languages will be used to:
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Improve patient outcomes
Improve effectiveness of nursing care
Identify nurses’ impact on patient outcomes
Validate need for more nurses
Drive cost of care down
Strategies
• Engage key stakeholders
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Formal and informal leaders
Instructors / clinical educators
Informaticists
Quality improvement specialists
Strongest clinical nurses
• Set mission and vision for the project
• Keep nursing discipline at the center but highlight
impact on the patient
Strategies
• Use consultants or experts to initiate project
• Build excitement
• Improve buy-in
• Shows commitment of organization
• Support teams by providing time
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Team building
Planning for implementation
“Train the trainer” curriculum design
Roll out slowly – start in areas with key champions to
gain small successes
• Celebrate success
Strategies
• Provide ongoing educational updates
• Encourage membership in NANDA-I to enable
international dialogue and partnership
• Consistently review progress
• Impact on patient outcome critical
• Identify changes in communication among nurses and
between disciplines
• Engage patients and families to improve satisfaction
Successful clinical experiences
• Identify lack of appropriate standardized terms
• Encourage and support staff to develop new
terms or adapt current terms
• Submit to NANDA International, NOC and/or NIC
to improve the taxonomies
• Review training with each new edition of
NANDA/NOC/NIC
• Emphasize changes, but also provide general
overview of use of the languages
Contact me at:
[email protected]
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Successful Clinical Experiences of Using Standardized