The development
and refinement
of nursing diagnoses
NANDA International
Develops terminology (Nursing Diagnoses)
to describe clinical judgments made by nurses as
they provide care for individuals, families, groups
and communities.
The Diagnoses
• 206 NANDA-approved nursing diagnoses as of
2008
• Level of Evidence (LOE) Criteria Established
for All New and Revised Diagnoses
– Entry into the Taxonomy requires various levels of
clinical evidence
Diagnosis Development Committee
• Responded to concerns from the membership that the
concept analysis requirement for acceptance of a
diagnosis into the taxonomy may be a barrier to
submissions
• The DDC developed rules for evaluating submissions
• DDC reviewed and revised the Level of Evidence
Requirements
Level of Evidence Criteria
• 2.1 Label, Definition, Defining Characteristics or Risk
Factors (for risk diagnoses), Related Factors (for
actual diagnoses) and References
– At 2.1, references are cited for the definition, each defining
characteristic or risk factor, and each related factor. In addition,
it is recommended that the submitter provide examples of
nursing interventions (NIC or other nursing intervention) and
nursing outcomes (NOC or other nursing outcome).
– Acceptance at this level is required for entrance into the
taxonomy.
Level of Evidence Criteria
• 2.2 Concept Analysis
– The criteria in 2.1 are met. In addition, a narrative review of
relevant literature, culminating in a written concept analysis, is
required to demonstrate the existence of a substantive body of
knowledge underlying the diagnosis.
– The literature review/concept analysis supports the label and
definition, and includes discussion and support of the defining
characteristics or risk factors (for risk diagnoses) and related
factors (for actual diagnoses).
Level of Evidence Criteria
• 2.3 Consensus Studies Related to Diagnosis
Using Experts
– The criteria in 2.2 are met. Studies include those
soliciting expert opinion, Delphi, and similar studies of
diagnostic components in which nurses are subjects.
Level of Evidence Criteria
• 3.1 Literature Synthesis
– The criteria in 2.2 are met. The synthesis is in
the form of an integrated review of the
literature. Search terms/MESH terms used in
the review are provided to assist future
researchers.
Level of Evidence Criteria
• 3.2 Clinical Studies Related to Diagnosis, But Not
Generalizable to the Population
– The criteria in 2.2 are met. The narrative includes a description
of studies related to the diagnosis, which includes defining
characteristics or risk factors, and related factors.
– Studies may be qualitative in nature, or quantitative studies
using nonrandom samples in which patients are subjects.
Level of Evidence Criteria
• 3.3 Well-Designed Clinical Studies with Small
Sample Sizes
– The criteria in 2.2 are met. The narrative includes a
description of studies related to the diagnosis, which
includes defining characteristics or risk factors.
– Random sampling is used in these studies, but the
sample size is limited.
Level of Evidence Criteria
• 3.4 Well-Designed Clinical Studies with Random
Samples of Sufficient Size to Allow for
Generalizability to the Overall Population
– The criteria in 2.2 are met. The narrative includes a description
of studies related to the diagnosis, which includes defining
characteristics or risk factors, and related factors.
– Random sampling is used in these studies and the sample size
is sufficient to allow for generalizability of results to the overall
population.
Defining Characteristics (DCs)
• Reflect assessment data, including subjective and
objective data:
–
–
–
–
–
Client verbalizations
Provider observations
Patient, family or community perceptions, behaviors and attributes
Client report
Physical and/or behavioral data
• Outcome indicators are the obverse of DCs
• Nursing Diagnoses and related factors are inferred
from DCs
Risk Factors
• Increase the vulnerability of the individual,
family or community to an unhealthful event:
–
–
–
–
–
Environmental factors
Physiological elements
Psychological elements
Genetic elements
Chemical elements
Related Factors
• The part of the diagnostic statement that
guides the specific nursing intervention
– The etiology (cause) of the diagnosis (problem to be
treated)
– Factors that are typically associated with the
diagnosis
– The focus for interventions
Coding of Nursing Diagnostic Language
• Barriers to the Coding of Nursing Diagnostic Language
have been identified
– Multiple concepts within a single defining characteristic, risk
factor or related factor
• Self-Care Deficit: Bathing/Hygiene
– “Inability to wash body or body parts, obtain or get to water
source, regulate temperature or flow of bath water, get bath
supplies, dry body, get in and out of bathroom”
• Delayed Growth and Development
– “Listlessness, decreased response time”
– “Inability to perform self-care or self-control activities
appropriate for age”
Coding of Nursing Diagnostic Language
• Diagnoses which include “specify”
– Health-Seeking Behaviors (specify)
– Deficient Knowledge (specify)
– Readiness for Enhanced Knowledge (specify)
• Labels with primary concept as descriptor
rather than as a noun
– Self Care Deficit
What do we need?
• Emphasis on development, testing and
validation of new diagnostic concepts
• Revision of current diagnoses that lack sufficient
evidence-based defining characteristics, risk
factors or related factors
– Any of the diagnoses in the book that do not show a
LOE need to be reviewed and evidence provided
Concept Analysis
• Identification and exploration of phenomena of
concern to nursing remains critical today in order
to fill in the gaps in our taxonomy
"I use the word nursing for want of a better...
I believe...that the very elements of nursing
are all but unknown."
(Nightingale, 1860)
Concept Analysis
• Distinguish between the defining characteristics
of a concept & its irrelevant attributes
– Refine ambiguous concepts
• Examine published sources
• Compare literature to experience/practice
• Examine consistencies between literature and
experience/practice
Development
• Where do you start?
– Area of interest
– Area that is missing from the taxonomy
– Clinical need
Development
• Obtain the most recent edition of NANDA-I’s Nursing
Diagnoses: Definitions & Classification and review
related diagnoses, if these exist
• Find the Diagnosis Submission Guidelines
(www.nanda.org), following the “Diagnostic Review” link
• Follow the guidelines on the web in case they have
been updated since publication of the most recent
Nursing Diagnoses: Definitions & Classification book
Steps in Development
• Review the literature
– Nursing discipline
• If none exists, identify this in your submission
– Other disciplines
•
•
•
•
Concept analysis
Literature reviews/syntheses
Qualitative research
Quantitative research
Literature Review Tips
• Look for information on the phenomenon or outcomes
related to it, but NOT intervention studies or information
on how to teach the use of standardized nursing
languages
• Articles, NOT books (unless “classics”)
• Research-based articles, not editorials or quality
improvement projects / unit-based implementation
articles that are not based on research studies
– If the research does not exist, indicate this on your submission
Development
• Review “Glossary of Terms” in the most recent
edition of the NANDA-I Nursing Diagnoses:
Definitions & Classification text
• Determine whether your diagnosis is an actual,
risk, wellness or health-promotion diagnosis (or
whether the concept can cross multiple facets)
Development
• Develop the label for your diagnosis
• Provide a definition for the diagnosis that
is supported by references
– Identify those references in your submission
• Keep the language clear and concise
Development
• Identify themes that arise in your literature review
– Appearance of a particular defining characteristic / related / risk
factor in one study does not mean it is a critical characteristic
– Look for consensus in the defining characteristics / related / risk
factors across the majority of your literature
– Less IS more!
• Assists with diagnostic accuracy if we can focus in on the major
defining characteristics / related / risk factor
– Consider the continuum of care if appropriate for your concept
Development
• Defining Characteristics are required for:
– Actual diagnoses
– Wellness diagnoses
– Health-promotion diagnoses
• Risk Factors are required for:
– Risk diagnoses
• Related Factors are required for:
– Actual diagnoses
Development
• Each defining characteristic and risk / related factor
must contain a single concept rather than multiple
concepts
• Tinnitus
• Hearing
impairment
NOT
• Tinnitus and/or
hearing
impairment
• References are required for each defining characteristic
and risk / related factor
Development
• Provide examples of appropriate nursing
outcomes and nursing interventions for the
diagnosis
– Assists DDC members in understanding the intent of
the diagnosis
– May be critical in differentiating this diagnosis from
another that is already in the taxonomy
Submission
• Submit on-line via the www.nanda.org website
• PLEASE use the prepared forms for diagnosis
submission when sending your work in to NANDA-I for
review if you are not submitting via our on-line website
Revision
• Where do you start?
– Oldest diagnoses
• 1970s – 3
• 1980s – 30
• 1990s - 79
– Area of interest
– Area that is missing from the taxonomy
– Clinical need
Refinement
• Need to compare changes to the existing
diagnosis
• All revisions must be supported by the
literature
Non-English Language Submission
• IF submitting in English, but English is not your primary
language, try if possible to have another Englishspeaker review your translation prior to submission
– IF NOT, submit it anyway!!!
• DDC will work with you to find someone to translate your
work into English if you do not have a contact to do this
for you
– This will increase the review cycle
– We want your work—we will work with you!
Content Validation
• Refinement of current diagnoses
• Development of new diagnoses
– Studies involving patients who are experiencing the
diagnosis are needed
• Clinical validation studies
– Assess for defining characteristics as patients are
experiencing a particular nursing diagnosis
– Decrease the number of defining characteristics to
improve diagnostic accuracy
The Future
• NANDA-International’s aim is to link with
organizations across the world that have
as their purpose nursing language
development
– Increase diagnosis submission
– Increase clinical testing of diagnoses
– Ensure cultural sensitivity of diagnoses
"If we cannot name it, we
cannot control it, finance it,
research it, teach it, or put it
into public policy."
(Lang, 1993).
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NANDA International: The development and refinement of