CONFEDERATION OF AUSTRALIAN CRITICAL CARE NURSES JOURNAL

FACTORS TO CONSIDER ON THE USE OFNURSING DIAGNOSIS IN CRITICAL CARE

Paper given at the 13th Australian and New Zealand & Scientific Meeting on Intensive Care, Melbourne, 1988

Sue WilliamsStaff Development Co-ordinatorFremantle HospitalWestern Australia

Nursing Diagnoses have been documented in theliterature since the 1950's but only recently has theconcept been debated in Australia. The RoyalAustralian Nursing Federation (RAN.F.) held aNational Workshop on Standards for NursingPractice, in December 1987. At this workshop,there was evidence during the plenary sessions,that Australian nurses are not all in favour ofNursing Diagnosis becoming part of nursing.Debate was active, issues were highlighted and nodecisions were reached at that time.

Many hospitals have elected to implement NursingDiagnosis, as described by the North AmericanNursing Diagnosis Association (N.AN.D.A)(l), intotheir Nursing Process format. Some Schools ofNursing are teaching Nursing Diagnosis whileothers prefer to teach the students to write problemstatements.

Why is there such resistance to accept this conceptof Nursing Diagnosis? There are many reasons,not least of which is the questioning by nurses, of aconcept that is somewhat alien to us. Theeducation to understand Nursing Diagnosis has notbeen available to many nurses, the fact that doctorsdiagnose, not nurses, is still very much part ofsome nurses beliefs.

Let us consider a few definitions of what a NursingDiagnosis is:

A clinical diagnosis made by aprofessional nurse that describes actualor potential health problems which thenurse, by virtue of her experience iscapable of and licenced to treat(2).

A clinical judgement about an individual,family, or community that is derivedthrough a deliberate, systematicprocess of data collection and analysis.It provides the basis for prescriptions

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for definite therapy for which the nurseis accountable. It is expressedconcisely and includes the etiology ofthe condition when knownrgj,

A statement that describes the humanresponse (health state oractual/potential altered interactionpattern) of an individual or group,which the nurse can legally identifyand for which the nurse can order thedefinite interventions to maintain thehealth state, to reduce, eliminate orprevent alterations.aj,

Such definitions focus on the independent actionswhich a nurse may employ to overcome or prevent aproblem. Other authors argue that nursingdiagnoses should encompass all that nursing doesindependently and interdependently.gj.

Critically ill patients have many problems that areamendable to independent nursing actions. Forexample, anxiety, ineffective individual/familycoping, self care deficits. However many problemsrequire nurses to collaborate with medicalpersonnel. An example is alteration in cardiacoutput. The nurse would assess the patient,identify that a drop in cardiac output occurred,initiate some nursing interventions, but wouldrequire a medical prescription for fluid and/or drugadministration. The patient outcomes aredependent on collaboration with medical andparamedical staff. This, then leads to anotherconsideration, if nurses use a classification systemof nursing diagnoses, will our colleaguesunderstand what we are stating?

At a workshop held at Curtin University ofTechnology, Western Australia, in January, 1988,nurses were asked to identify some pros and consof nursing diagnosis. Response are represented inTable 1. It can be seen from this list, that some

VOL.l NO.4 1988

Let us consider what some differences are

NURSING DIAGNOSIS

Focus on individual's response to illness orother factors that adversely affect theattainment and maintenance of optimalwellness.

Focus on effects of illness and needs itproduces

Understanding of illness sought atindividual, personal level.

Focus on people and people skills, andactivities.

Changes as patients condition changes.

Guides independent nursing care.

No universally accepted classificationsystem.

pros and cons are perceived as both a pro and a con.

For example, the use of nursing diagnosis requiresaccurate assessment of patients. This is perceivedby some nurses as a pro, but others who perceiveassessment skills as beyond the realm of nursing,would perceive it as a con.

In Western Australia, nursing diagnoses, using theN.A.N.D.A. classification, are being taught tostudents of nursing in the tertiary sector. Manyhospitals have implemented, or are in the process ofimplementing, nursing process and are includingnursing diagnosis. Some of the major problemsencountered with nursing diagnosisimplementation are identified in Table 2. It can beseen from this listing, that underlying theproblems, is the resistance to change. Why changewhen we have a system already, why change when

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between a medical and a nursing diagnosis.

MEDICAL DIAGNOSIS

Focus on pathology, treatment and cure ofdisease at the cellular of subcellular level.

Focus on physiological, biochemicalstructures and effect disease produces.

Understanding of illness sought at amolecular level.

Focus on scientific explanations andgeneralizations.

Remains constant throughout duration ofillness.

Guides medical management.

Has well developed classification system.

it takes time and effort. The change process is along one and if it is to be successful, there must becommitment to the change, realistic expectations ofimplementation timeframe and patience.

What are some strategies that can be used forimplementation? First and foremost is to ensurethat the nursing division is committed to theconcept. Without the support of management, staffdevelopment and' clinical staff, the change will notbe successful. Other strategies have been identifiedin Table 3. At Fremantle Hospital, all of thesestrategies were employed during theimplementation phase and continue to be employedas ongoing evaluations occur. Inservice is requiredon an ongoing basis as new staff are employed, asexisting staff identify new problems and thelearning process continues.

CONFEDERATION OF AUSTRALIAN CRITICAL CARE NURSES JOURNAL

NURSING DIAGNOSIS

PROS

* Patient orientated

* Standardised

* Consistent terminology

* Professional credibility

* Promotes accountability

* Encourages critical thinking

* Requires accurate assessment

* Quality assurance tool

* Research based (U.s.A.)

* Computer interface

* Own body of knowledge

• Directs patient care

* Integral part of process

* Reduces potential subjectivity

CONS

* Verbose

* Rigid, standardised

* Time consuming

* Measurable

* Increases accountability

* Requires critical thinking

* Requires accurate assessment

* May narrow nursing

* Requires change

* Requires education

* Problems don't "fit"

* New, unknown, scary

* ? Does it improve care

* Americanism Vs Australianism

Table1.Pros and Cons of Nursing Diagnosis as perceived by workshop participants.

Curtin University of Technolog)r, W.A. 1988.

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VOL.! NO.4 1988

MAIN PROBLEMS TO IMPLEMENTING NURSING PROCESS

* Lack of Commitment to Concept of Nursing Diagnosis

* Lack of Role Models

* Bureaucracy

* Negativity

* Medical Domination

* Lack of Knowledge of Nursing Diagnosis

* Perceived Lack of Time

* Lack of Staff

* Change and Overload

* Resistance to "Americanisation" of Australian Nursing

* Lack of Assessment Skills

* Lack of Professional and Personal Self EsteemIt may not work well with existing documentation formatI.E. S.o.A.P. notes

* A tool to implement nursing diagnosis that works will need to be developed

* Lack of knowledge of other health professional Re: What's happening

* It's difficult for nurses to move away from the medical model

* Lack of understanding of what it is

* Inconsistency in understanding the nursing care plans

* Pure "Bloody - Mindedness"

* Lack of educational resources and professional support

Table 2.Identified problems when implementing nursing diagnosis into the workplace,

Fremantle Hospital, 1988

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CONFEDERATION OF AUSTRALIAN CRITICAL CARE NURSES JOURNAL

1. Define the target" population and modulate approach and tactics developed.

Financial

Human2. Identify resources

Key facilities or agencies

Timing aspects

3. Networking to determine availability of human resources to disseminate information.

4. Publish ideas and philosophy within the institution.

5. Create a forum to allow for debate.

6. Involve the RANF, CNA, and forge links across academic institutions for nursing education.

7. Develop inservice education programmes .

8. Develop incentives for participation in workshops.

9. Public relations networking - liaise with other health professionals and public so they knowwhat is changing.

10. Begin role modelling.

11. Develop standards for nursing practice with incorporate nursing diagnosis.

12. Elicit bureaucratic support.

13. Develop quality assurance programmes that incorporate nursing diagnosis.

14. Examine all aspects of legal implications of nursing diagnosis.

15. Specifically include nursing diagnosis in the steps of nursing process in education.

16 . Establish academic leadership.

17. Encourage research.

18. Revise current documentation forms to include nursing diagnosis.

Table 3

Strategies for Implementation of Nursing Diagnosis

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VOL.l NO.4 1988

Madeline Wake(6J presented a paper at the 3rd

International Intensive Care Conference in

Montreal. She aptly identified the major benefits of

Nursing Diagnosis.

A. Provide efficiency, clarification, standardization

B. Provide purpose and direction.

C. Facilitate research and education.

D. Delineate independent nursing function.

E. Increase accountability.

The challenges of nursing diagnosis of:

A. The taxonony is incomplete and imperfect In

its current state.

B. The educational needs of nurses must be

addressed.

C. Implementation is not easy.

D. Australian research is needed to identifywhether or not the N.A.N.D.A. taxonony IS

viable in the Australian nursing arena.

Each nurse must decide on the nursing diagnosis

Issue. It is not without problems, and requires

careful consideration prior to implementation.However, the rewards can be great; an international

language for nurses; development of a body ofnursing knowledge; ease with computer interface; a

learning challenge.

I challenge critical care nurses to consider all thefacts before rejecting or accepting the concept of

nursing diagnosis. Critical thinking is paramountto professional accountability and professional

accountability has to be the goal for nurses.

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REFERENCES

1. McLANE, A (ed). (1987). Classification ofNursing Diagnoses Proceedings of the SeventhConference. St. Louis: C.Y. Mosby Company

2. GORDON, M. (1987). Nursing Diagnosis:Process & Application. 2nd Ed. New York:McGraw-Hill

3. SHOEMAKER, J.K. (1985) 'Characteristics of aNursing Diagnosis" Occupational Health Nurse33, pp387-389

4. CARPENITO, L.J. (1985). Handbook of NursingDiagnosis. Philadelphia: J.B3 Lippincott

5. KIM, M.J. "The dilemma of PhysiologyProblems. Without collaboration what's left?"American Journal of Nursing 85

6. WAKE, M. (1988). Nursing Diagnosis inCritical Care in International Conference Book:Critical Care Knows no Borders. Canada:American Association of Critical Care Nurses.pp 136-139