Assessment, Clinical Judgment, and Nursing Diagnoses: How to Determine Accurate Diagnoses Margaret Lunney, RN, PhD Professor and Graduate Programs Coordinator College of Staten Islared, City University of New York Department of Nuesing Chair, Research Come NANDA International Assessment was identified as the first part of the nursing process. The nursing process is a theory of how nurses organize the care of indi- viduals, families, and communities. The theory of nursing, process has. been broadly accepted by nurses since 1967 (Yura and Walsh, 1967}. In the 1960s, it was thought that the nursing process was a four-part process of assessment, planning, implementation, and evaluation. But soon after the first description of the nursing process, nurse leaders recognized that assessment data must be clustered and interpreted before nurses could plan, implement, or evaluate a plan to help patients, The need to interpret data derives from the fact that short-term aiemory only holds 7 + 2 bits of data (Newell and Simon, 1972). Thus nurses, like other human beings, continuously convert data into inter- pretations. For example, people interpret whether a person is female or male, based an over 20 bits of data, e.g,, hair and dress styles, bady language, facial structure, name, and voice, If a nurse decides to assist a patient to move from a bed toa chair, it is based on an interpretation of data showing that the patient wants or needs to be out of bed and needs assistance with moving from bed to chair. Some of the data that a nurse might use for this interpretation is that the patient is one day post-abdominal surgery, the patient has expressed pain, and the patient said that she or he felt “shaky.” noses are scientific inter- pretations of assessment data that are used to guide nurses’ planning, implementation, and evaluation. Only 6 years after Yura and Walsh's description of the nursing process in 1967, two nurses from St Louis, (USA), organized the first conference to identify the interpretations of data that represent the phenomena of concern to nurses. These nurses, Mary Ann Lavin and Kristine Gebbie, invited 100 nurses from the United States and Canada to participate in this event (Gebbie, 1998). This was the first conference on nursing diagnosis, out of which 80 nursing diagnoses were identi- fied and defined. Since then, the list of approved diagnoses has been An Introduction to Nursing Diagnoses 3steadily grown and been refined through research-based submissions by nurses and the work of members of the nursing diagnosis associa~ tion that sponsors this book, now known as NANDA International (NANDA). Nurses are Diagnosticians With use of the term “nursing diagnosis,” it became apparent that nurses are diagnosticians. Before that time, the clinical judgment used in clinical practice to decide the focus of nursing care was invisible or not named. Today, in healtheare agencies where nurses do not use nursing diagnoses, ar use them without a concern for accuracy, the invisibility of the nurse's role asa diagnostician may still exist. With the start of this formal classification of nursing diagnoses, however, it was broadly accepted that nurses are diagnosticians who use diag nostic reasoning in collaboration with patients to identify the best diagnoses to guide nursing interventions to achieve positive patient outcomes, The diagnostic process in nursing differs from the diagnostic process in medicine in that, in situations when it is possible to do so, the person or persons who are the focus of nursing care should be intimately involved as partners with purses in the assessment and diagnostic process. This isbecause the focus of nursing care is the person’sachiewe- ment af well-being and self-actualization, People’s experiences and responses to health problems and life processes have specific meanings to them and these meanings are identified with the help of murses. It is also assumed that nurses do not make people healthy with their diagnoses and interventions; people make themselves healthy with their own behaviors. Thus, to achieve changes in behaviors that affect health, people and nurses together identify the most accurate diagno ses that have the potential to guide nursing care for achievement of positive health outcomes. Nursing interventions for diagnoses of human responses offer additional ways, besides treating medical prob Jems, that the health of people can be promoted, protected, and restored. The focus of nursing is the “health” of “human beings,” two of the most complex scientific concerns: more complex, for example, than chemistry and astronomy. Health-related phenomena, such as sleep, comfort, of nutrition, are complex because they involve human experi- ences, We can never know for sure what other human beings are experiencing; yet the goal of nursing is to identify people's experiences or responses in order to support them, With human responses, there is also-a tremendous overlap of cues to diagnoses and many contextual factors such as culture that can change the perspective of “what is the diagnosis?” Many studies have verified that interpretations of elinical cases have the potential to be less accurate than indicated by the data (Lunney, 2008). 4 Nursing Disgneses 2009-2011With nursing diagnoses as the foundat 1 to develop diagnostic compete on of nursing care, nurses in order to become good within diagnosticians. Diagnosticians are people who interpret dat their fields of expertise in order to provide needed services, e4 automobile mechanic must be ab! start in order to be able to fix it. A key element of data interpretations. is that they are subject to error. A good diagnostician must be mindful that there are always risks to the accuracy of data interpretations Becoming a nurse diagnostician, therefore, requires development of professional and personal skills and characteristics Two propositions are the basis for development of diagnostic to dia se why the car will competencies 1. Diagnosis in nursing requires competencies in intellectual, interper. sonal, and technical domains. 2. Diagnosis in nursing requires development of the personal strengths of tolerance for ambiguity and use of reflective practice Intellectual, Interpersonal and Technical Competencies Intellectual Competencies Intellectual competencies are discussed first because this is an invisible aspect of nursing that is very important for becoming a diagnostician Intellectual skills include boih knowledge of nursing diagnoses and the mental processes for use of knowledge. Nurses need to attain knowl edge of diagnoses, their definitions and defining characteristics, espe cially those that are common to the populations with which they work, the interventions to treat the diagnoses, and the diagnostic processe that are used to interpret patient data, This knowledge is extensive and complex, so nurses should not be expected to memorize the available knowledge, but rather they need to know how to access the informa. tion that they need; the resources to obtain this knowledge should be available when needed. Besides knowledge, thinking ability is the ather important aspect of the intellectual domain, Even though, traditionally, thinking processes have not been emphasized in nursing, they are critical to use of nursing diagnoses. The cognitive skills of analyzing, logical reasoning, and applying standards are just three of the thinking processes that a ded for accurate diagnosis in nursing, These skills are developed, for example, through discussions of how data should be clustered to generate accurate diagnoses, the relation of data clusters to diagnoses, and comparisons of existing data to expected data based on research findings. Research findings in cognitive science and nursing show that An Introduction to Nursing Diagnoses 5Sadults at the same levels of education and experience vary greatly in thinking abilities (Lunney, 1992; Sternberg, 1997). Research findings fram cognitive science and other disciplines also show that thinking processes can be improved (Sternberg, 1997) Willingham, 2007). In nursing, research studies have shown that critical thinking abilities vary widely and thateritical thinking can be improved with education and effort (Tanner, 2006). This is done through energy, focus, and support. To do this, students and nurses need to think about their thinking, referred to as metacognition (Pesut and Herman, 1992), by using the concepts of thinking that are relevant to nursing practice. A Delphi study of nurse experts in critical thinking (Scheffer and Rubenfeld, 2000) generated 7 cognitive skills and 10 habits of mind that were considered to be highly relevant to nursing practice (see list and definitions in Appendix}. These 17 concepts of thinking should be used by nurses to think about their thinking. In any nursing situation, we or more cognitive skills are probably being used, The habils of mind support the cognitive skills. The combination of these critical thinking abilities that are needed for clinical situations are probably unique, so nurses ned to cultivate all of these critical thinking processes and not just focus on a few of them. Critical thinking abilities are essential to achieve accurate interpreta- tions of patient data and appropriate selection of interventions and outcomes, so developing high-level thinking abilities is a high priority. To do this, nurses and nursing students can: 1 use thinking processes, cather than just receiving knowledge from others 8 when learning, think about the concepts, not just memorize know|- edge 1 seck support from others, e.g., teachers, ather aurses, patients, to validate thinking processes = develop confidence in ability to think. Interpersonal Competencies Nursing diagnoses are best used by nurses who have exquisite inter- personal communication skills. Such skills are needed so that patients Will trust nurses enough to tell them about their responses ta health problems and life processes. Trust is enhanced through a mature ability to communicate with others. Nurses must assume that they do not know other people (Munball, 1993), The only way other people can be known is through interper- sonal processes, especially listening. Nurses who assume that they know patients without listening to them will net achieve diagnostic accuracy. The best use of nursing diagnoses is in partnership with 6 Nursing Diegneses 2009-2011patients and families. To work in partnership, nurses need te speak to people with respect and care, effectively listen, respect other people’ opinions and views, and know how to validate perceptions with patients and families. Learning these skills is a challenge, so the inter petsonal aspects of nursing need to be an integral part af learning to use nursing diagnoses Technical Competencies Another baseline competency is the technical skill of conducting a nursing assessment. Obtaining valid and reliable data is the backbone of using nursing diagnoses, so nurses’ development of their ability to conduct comprehensive and focused health histories and physical examinations is essential. This technical skill is learned in courses on the topic and using nursing textbooks on health assessment, For example, the diagnosis and treatment of pain requires sophisticated assessment knowledge, including ways to explore the types and lacations of pain, factors that make the pain worse or better, ete. The same is true of many of the diagnostic concepts such as body image disturbance. An assessment is a “nursing” assessment if it yieldls the data that are needed for nursing care. The assessment data that are generated by a biological systems review, which is done to yield medical diagnoses, nt to yield the data needed for nursing diagnoses. Thus, other assessment frameworks such as the functional health patterns (Gerdon, 2007) are being used in healthcare systems where the accu tacy of aurses' diagnoses is considered important. The functional health pattern framework is used later in this chapter to demonstrate how to generate nursing diagnoses from assessment data, are insuffici Personal Strengths: Tolerance for Ambiguity and Reflective Practice The personal strengths of tolerance for ambiguity and reflective prac tice need to be developed because decisions are so complex in nursing and the use of clinical judgment needs to be an ongoing learning process, Each decision that a nurse makes is relativ the situation and to the specific nature of the individual, famil community with whom they are working. With experience, nur become familiar with many types of contextual situations that can positively influence diagnostic abilities. Tolerance for ambiguity and reflective practice enable nurses to incorporate these contextual experi ences to advance their professional development from novice to expert (Benner 1984; Benner ¢t al., 1996). to the context of or An Introduction to Nursing Diagnoses 7Tolerance for Ambiguity Tolerance for ambiguity is needed because there are numerous factors that influence clinical situations such as agency policies, the nurse's job description, and the availability of resources. Tolerance for aimbigu- ity enables nurses to consider the broad range of influencing factors within the diagnostic process and be able to focus on the most accurate diagnoses for quality-based services to individuals, families and communities. In addition, the human beings for whom nurses provide care are extremely complex and diverse, especially whea the focus is the per- san’s response or experience and not the illness itself, Thus, ambiguity is expected, so nurses need fo adjust to the ambiguity, Nurse leaders and teachers can help by pointing out the ambiguity, treating it as a fact of life as a nurse, and being role models for tolerance for ambiguity. Reflective Practice Reflective practice is the ability ta introspectively examine our own behaviors in relation to thinking, interpersonal events, and technical skills. This is a prerequisite to self-evaluation and, to accomplish it, to some extent we must expose ourselves, our frailties and our mistakes. There are good books and articles available that address the concept of reflection, (Johns 2007). Reflective practice supports continuous development or growth with the assumption that we benefit by think ing about our own behaviors and our own thinking. Assessment and Nursing Diagnosis Nursing assessments at all levels of analysis (individuals, families and communities), consist of subjective data from the person or persons and objective data from diagnostic tests and other sources. Assess~ ments of individuals consists of a health history (subjective data) and a physical examination (objective data) (Weber and Kelly, 2007). Assess- ments of families consist of obtaining specific infomation from the family (subjective data} and observing family interactions (objective data) (Wright and Leahey, 2005). Assessments of communities consist of obtaining information from key informants within the community (subjective data) and statistical data (objective data) (Anderson and McFarland, 20K06}. There are two types of assessments that are done fo generale accurate nursing diagnoses: comprehensive and focused. Comprehensive assess- ments caver all aspects of a nursing assessment framework such as the 11 functional health patterns te determine the health status of the individual, family, or community. Comprehensive assessments of 8 Nursing Diegnoses 2009-2011individuals are done, for example, when admitting a patient to a hos- pital or to home care services. Focused assessments focus on a particu- lar issue or concern, such as pain, sleep, or respiratory status. Focused assessments are done when specific symptoms need te be explored further, e.g.,a person says “lam having difficulty with breathing,” or something generates increased risk of a particular problem, eg., when a person needs the medication of coumadin, there is increased risk of bleeding. The goals for a nursing assessment are that: wit focuses on the data needed to identify human responses and experiences w it is conducted in partnership with the individual, family or com munity, wherever possible. @ the findings are based on research and other evidence. Assessment Framework For nursing, assessment frameworks need to be broad enough to yield data to guide nursing care for health promotion, health protection (primary, secondary, and tertiary prevention), and health restoration, “Health promotion is directed toward increasing the level of well- being or self actualization of a given individual or group, Health pro- motion focuses on efforts to approach or move toward a positive balenced state of high level health and well being” (Pender et al., 2006, p. 37). An example of a health promotion diagnosis is Readiness far Enkoviced Sleep. Health protection is a process of helping people to reduce risks to health and protect themselves from existing risk states (Pender et al., 2005). An example of a health protection diagnosis is Risk for Iifection. Health restoration, also referred to as illness manage- ment, is a process of helping people to manage health problems. The actual nursing diagnoses such as Pain, Anxiety, Fear, and Ineffective Self Health Managentent ate examples of diagnoses in the tealm of health: restoration. A nursing assessment framework that is widely used to generate acctirate nursing diagnoses is the functional health pattern framework (Gordan, 2007). This framework includes 11 patterns of individuals (see Assessment Tool, Appendix A), families, o comauunities. Diagnostic Reasoning Associated with Nursing Assessment Principles should include: = Diagnostic hypotheses are considered throughout the assessment process and are used along with the formal assessment guide to generate the data needed for diagnoses. An Introduction to Nursing Diagnoses 9© In a comprehensive assessment, diagnoses are not finalized until completion of the assessment, Assessment of each pattern informs the nurse and patient about the diagnostic hypotheses = When possible, the individual, family or community is involved from start to finish with the assessment and diagnostic processes. Recognizing the Existence of Cues ‘Nurses mentally recognize cues early in the diagnostic process and continue to integrate cue recognition throughout the process. Cues are units of data, (eg., a persnn’s rate of breathing), which a nurse collects during intentional or unintentional assessment. Inten- tional assessment involves deliberate collection of data as a foundation for nursing actions. Unintentional assessment involves noticing cues that are important without planning to do so. In clinical situa- tions, nurses notice cues to diagnoses by thinking about what they see, hear, smell, touch, and taste. Information pertaining to the health~ care consumer is thought about in relation to the nurse's knowledge of ‘the health state or life situation of the consumer. Nurses attend to information based on established ideas of what should occur in various situations. A nurse may not notice a person's rate of breathing, for example, unless it looks unusual in the context of a health problem (eg, the individual is one day post-abdominal surgery), or other aspects of the clinical situation (e.g., the individual has just completed vigorous exercise), A ntirse’s recognition of @ unit of data as acue with special meaning is dependent on knowledge stored in memory. Knowl- ecige bases in memory are used for comparison of current data with expected data. Mentally Generating Possible Diagnoses The meaning that nurses assign to cues noticed early in the diagnostic process can be understood only if there are possible and. plausible explanations for the cues within the context of the situation. This is an active thinking pracess whereby the nurse explores know ledge in memory for possible explanations of data, Often, there are many possible diag- noses of explanations that may be considered. Sometimes, there isonly one plausible meaning for cues noticed early in the diagnostic process, for example, ifa woman who is newly admitted to a hospital unit for a surgical procedure is rapidly asking the nurse many questions, and exhibits a fast rate of breathing, the cues are nat specific enough to consider only one possible diagnosis. The nurse in this instance would consider a mumber of possible explanations for this set of cues such as fear, anxiety, ineffective breathing pattern, and others. A nurse diag- nostician avoids deciding on a diagnosis prematurely; before there are 10 Nursing Diagnoses 2009-2011