ISSU ES I N CLINICA L NUR SIN G doi: 10.1111/j.1365-2702.2006.01459.

Swedish Registered Nurses’ incentives to use nursing diagnoses in

clinical practice
Lena Axelsson BSc, RN
Sophiahemmet University College, Stockholm, Sweden

Catrin Björvell PhD, RN

Division of Nursing Research, Karolinska Institutet, Stockholm, Sweden

Anne-Cathrine Mattiasson PhD, RNT

Associate Professor of Nursing, Karolinska Institutet Danderyd Hospital and Sophiahemmet University College, Stockholm,
Sweden

Ingrid Randers PhD, RNT

Senior Lecturer, Department of Clinical Neuroscience, Occupational Therapy and Elderly Care Research, Division of Geriatric
Medicine, Karolinska Institutet and Sophiahemmet University College, Stockholm, Sweden

Submitted for publication: 17 February 2005

Accepted for publication: 8 September 2005

Correspondence: O R V E L L C , M A T T I A S S O N A - C , R A N D E R S I ( 2 0 0 6 ) Journal of
A X E L S S O N L , B J Ö
Lena Axelsson Clinical Nursing 15, 936–945
Sophiahemmet University College Swedish Registered Nurses’ incentives to use nursing diagnoses in clinical practice
Box 5605
Aims and objectives. The purpose of this study was to describe Registered Nurses’
114 86 Stockholm
incentives to use nursing diagnoses in clinical practice.
Sweden
Telephone: þ46 8 406 21 60 or Background. The use of nursing diagnoses is scarce in Swedish patient records.
þ46 70 848 93 08 However, there are hospital wards were all nurses formulate and use nursing
E-mail: diagnoses in their daily work. This leads to the question of what motivates these
lena.axelsson@sophiahemmethogskola.se nurses who do use nursing diagnoses in clinical practice.
Design. A qualitative descriptive design.
Methods. A purposeful sampling of 12 Registered Nurses was used. Qualitative
interviews to collect data and a content analysis were performed.
Results. Five categories were identified: identification of the patient as an indi-
vidual and as a whole, a working tool for facilitating nursing care, increasing
awareness within nursing, support from the management and influence on the
professional role. The principle findings of this study were: (i) that the Registered
Nurses perceived that nursing diagnoses clarified the patient’s individual needs
and thereby enabled them to decide on more specific nursing interventions, (ii)
that nursing diagnoses were found to facilitate communication between col-
leagues concerning patient care and thus promoted continuity of care and saved
time and (iii) that nursing diagnoses were perceived to increase the Registered
Nurses’ reflective thinking leading to a continuous development of professional
knowledge.
Conclusions. The present findings suggest that the incentives to use nursing
diagnoses originate from effects generated from performing a deeper analysis of
the patient’s nursing needs. Further research is needed to test and validate the
usability and consequences of using nursing diagnoses in clinical practice.

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2006 Blackwell Publishing Ltd

Issues in clinical nursing Nursing diagnoses in clinical practice

Relevance to clinical practice. Motivating factors found in this study may be

valuable to Registered Nurses for the use and development of nursing diagnoses
in clinical care. Moreover, these factors may be of relevance in other countries
that are in a similar situation as Sweden concerning application of nursing
diagnoses.

Key words: individual care, nurses, nursing diagnosis, nursing documentation,

nursing process, nursing profession

Australia and USA. Delaney et al. (1994) found that nursing

Introduction
The nursing diagnosis is the basis for planning, implementing
and evaluating nursing care. It is the result of reflection and
analysis after assessment of the patient’s nursing needs
(Ehnfors 1993). The nursing diagnosis focuses on the
individual patient’s responses to health-related problems,
while the medical diagnosis focuses on the disease and does
not differentiate among individual needs of care (Ehrenberg
& Ehnfors 1999). Thus, medical diagnosis and nursing
diagnosis complement each other and to use nursing
diagnoses enables an increased quality of care by addressing
patients’ individual needs (Ehnfors 1994).
Since 1973, an elaborate work to classify nursing phe-
nomena into a taxonomy has been performed by the North
American Nursing Diagnosis Association (NANDA 1990).
An international collaboration concerning development of
classifications of nursing diagnoses has been under way since
1996 through the International Classification of Nursing
Practice (ICNP; Ehnfors et al. 2003) and in Europe, The
Association for Common European Nursing Diagnoses,
Interventions and Outcomes (ACENDIO) was founded in
1995 to promote the development of a professional nursing
language (Clark 2003). This indicates that the development
and use of nursing diagnoses in clinical care is an important
issue in present as well as future healthcare.
Nursing diagnosis and nursing informatics
Naming clinical phenomena by using nursing diagnosis clas-
sifications facilitates nursing communication. The need for
identification of specific nursing data for clinical, professional,
managerial, research and policy purposes has also been
recognized (Werley 1988, Clark & Lang 1992, Sermeus &
Delesie 1994). These predetermined data are often named
Nursing Minimum Data Sets (NMDS). The purpose of NMDS
is to add nursing data to existing medical statistics and to
establish comparability of nursing data across populations,
clinical settings, geographical areas and over time (Werley
1988, Goossen 2002). A review by Goossen et al. (1998) shows
that nursing diagnosis is included in NMDS in the Netherlands,
diagnosis in NMDS facilitated the development of patient
profiles and validated defining characteristics for nursing
diagnoses. Ryan et al. (1994) used the NMDS to compare the
prevalence of the most frequent nursing diagnoses for different
medical diagnoses and surgical procedures.
The use of nursing diagnosis in clinical practice
In Sweden, the nurses are used to formulate nursing diagnoses
in free text using their own words, with a focus on the
functional health status and consequences for daily living as
described by Carnevali (1984). Hence, they are not used to
use classifications. However, now there is an increasing
interest for nursing diagnosis classifications and a standard-
ized terminology among Swedish nurses (Ehnfors et al. 2003).
Gordon (1994) describes the PES – structure for formula-
tion of nursing diagnosis, where P stands for problem, E for
aetiology and S for symptoms or defining characteristics.
This way is the most commonly used in Sweden to
formulate the diagnosis.
Since 1986, Registered Nurses (RNs) in Sweden are
required by law to document nursing care in the patient
record (SFS 1985). Regulations by the Swedish National
Board of Health and Welfare (SOSFS 1993) concerning
nursing and nursing documentation specify the nurse’s
responsibility to keep a patient record, including nursing
diagnoses. However, the following Swedish studies have
shown that nursing diagnoses are scarce in the patient
records, indicating that it has been difficult to implement the
use of nursing diagnoses in practice. In a questionnaire study
by Törnkvist et al. (1997) 81% of the nurses reported that
they documented nursing diagnoses for none, or a few of
their patients and 14% of the nurses reported that they
documented diagnosis for all, or almost all of their patients.
Moreover, in a number of studies documentation of specific
problem areas such as sleep pattern, pain, wound care and
risk of fall were examined and only a few nursing diagnoses
were found to be recorded (Edéll-Gustafsson et al. 1994,
Udén et al. 1999, Gunningberg et al. 2000, Idvall &
Ehrenberg 2002, Ehrenberg & Birgersson 2003).

2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 936–945 937
L Axelsson et al.
Ehrenberg and Ehnfors (2001) compared patient records
with nurses’ reports and found that between 41% and 89%
of the patient problems identified by the nurses were not
recorded. Similar results were found in Denmark by Adamsen
and Tewes (2000) revealing that the nurse did not document
69% of the problems perceived by the patient.
Ehrenberg and Birgersson (2003) suggested that the lack of
nursing diagnoses in nursing records was because of nurses’
lack of knowledge and skills in formulating nursing diagno-
ses. It has also been described in a group of nurses that the
formulation of nursing diagnoses requires critical thinking
and reflection and, therefore, is perceived to be the most
difficult and time-consuming part of the documentation
(Björvell et al. 2003b). The factors of knowledge deficit and
time constraints have also been reported in Swedish studies
concerning barriers to nursing documentation in general
(Ehnfors 1993, Törnkvist et al. 1997, Ehrenberg 2001).
Despite the scarcity of nursing diagnoses in the patient
record, Björvell et al. (2003a) found in a descriptive study
that 68% of the nurses rated documentation of nursing
diagnoses as meaningful or very meaningful and 4% rated it
as totally meaningless.
Aims of the study
Although nursing diagnoses are scarce in Swedish patient
records, there are hospital wards where all nurses formulate
and use nursing diagnoses for their patients. This leads to the
question of what motivates these nurses who do use nursing
diagnoses in clinical practice. Therefore, the aim of this study
was to describe RN’s incentives to use nursing diagnoses in
clinical practice.
Definitions
In this study, a nursing diagnosis is defined as an analysis
performed by the nurse, identifying the patient’s nursing need
and documented in the patient’s record using a free text
format, which means the nurse uses her own words.
A nursing need is defined as the individual responses to
actual or potential health problems or life processes that the
nurse is capable and qualified to treat due to her education
and experience (inspired by NANDA 1990 and Gordon
1994).
Method
Qualitative research was chosen as it is person-centred and
holistic and refers in the broadest sense to research that
produces descriptive data. Through this approach, the
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2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 936–945
authors could gain a rich base of knowledge and insights
about RNs’ individual experiences, which is important when
focusing on caring (cf. Holloway & Wheeler 2002).
Participants
In general, qualitative studies focus in depth on relatively
small samples. However, these samples have to be purpose-
fully selected. The strength of this kind of sampling lies in
selecting information-rich cases. One of several different
strategies for purposefully selecting information-rich cases is
criterion sampling. The logical objective of such sampling is
to study cases that meet some predetermined criterion of
importance (Patton 2001). Therefore, the selection criteria
for this study were as follows: RNs who, in their daily
practice, formulate and document nursing diagnoses in
accordance with the definition above and the PES structure
and who work in hospital wards where nursing diagnoses
generally are in use. The first author performed an audit of
the nursing documentation in order to identify nurses who
met these criteria. Patient records were reviewed from four
infection wards known to use nursing diagnoses at a hospital
in an urban area of Sweden. All these nursing diagnoses were
formulated in free text.
Twelve RNs, who fulfilled the criteria and agreed to
participate in the study, were selected from three of the
wards. The participants had between 6 months and 18 years
of practice as a RN and their experience of using nursing
diagnoses ranged between 6 months and 9 years in time.
Some worked part time and some worked full time, all
participants worked day shifts. Eleven participants had
previous theoretical training in nursing diagnosis. One
participant had no theoretical training in nursing diagnosis
but had 2 years of experience in using nursing diagnosis in
clinical practice.
Interview process
Pilot interview
A pilot interview was performed in order to pre-test an
interview guide (Patton 2001), which was developed by the
first author to cover areas relating to the aim of the study. No
changes in the guide were made after the testing.
Interviews
Qualitative interviews (Kvale 1996) were conducted by the
first author in December 2003 at the actual hospital in a place
where the participants would not be distracted. The inter-
views, were semi-structured, i.e. the interviewer had to cover
the specific areas listed in the interview guide but had no
Issues in clinical nursing
specific order when and how to address them. This openness
made it possible to have a conversation with the participants
(Kvale 1996). However, all the interviews started with invi-
ting the participants to freely describe their motivation for
using nursing diagnoses. The interviews lasted about
60 minutes and were audiotaped with the participants’ per-
mission. Twelve RNs were included in this study, because
when being interviewed they gave repetitive data, where little
new information was obtained (Kvale 1996).
Content analysis
The first author transcribed all interviews verbatim. A
qualitative content analysis with an inductive approach was
applied when analysing the data (Berg 2004). According to
Berg (2004), the interviews were read through several times
in order to grasp the overall content. Thereafter, they were
read sentence by sentence to identify text units corresponding
to the aim of the study. These text units, i.e. words, sentences,
or a whole paragraph were marked and notes about the
content were made in the margin. The text units were then
coded and lists of the coded units were printed out, re-read,
compared and recombined when pertinent. The first author
performed this coding process. The codes were then organ-
ized into themes by three of the authors (LA, A-C M, IR).
Thereafter, the organization into categories was discussed
between all the authors, until a negotiated consensus was
reached. The software Open Code (2001) was used in the
process of coding, to more easily print lists of the lines
belonging to each code.
For complete data reporting and illustration of the research
findings representative quotations are presented in the results
(Sandelowski 1994). As spoken language in writing may be
difficult to understand (Kvale 1996), these quotations have
required certain grammatical revisions when translating them
into English.
Ethical considerations
A core principle of research ethics is the participants’
possibility to freely give their informed consent for research
(Darlington & Scott 2002). Therefore, this research included
the following: all participants received information about the
aim of the study, stating that participation was voluntary,
that they could discontinue the interview at any time and that
data would be treated confidentially (Hermerén 1996). Thus,
when reporting the findings, the confidentiality of the
participants has been protected. Formal approval was given
by the Ethical Committee at Huddinge University Hospital,
Stockholm, Sweden, Dnr 506/03.

2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 936–945
Nursing diagnoses in clinical practice
Results
The following categories were identified concerning the
participating RNs’ incentive to use nursing diagnoses in
clinical practice, i.e. identification of the patient as an
individual and as a whole, a working tool for facilitating
nursing care, increasing awareness within nursing, support
from the management and influence on the professional role.
Identification of the patient as an individual and as a
whole
This category is conceptualized by themes describing how
identification of nursing diagnoses was perceived to increase
patient participation in their care and to promote individual
and holistic nursing care.
Increases patient participation
Identifying nursing diagnoses was described to have a positive
effect on patient participation as to be able to make diag-
nostic statements, the nurse needed more knowledge about
the patient’s situation. This led to an increased interaction
between patient and nurse. The participants described that
they listened carefully to the patients in order to understand
their needs, accordingly the nurses asked the patients more
questions and made sure that they had understood the pa-
tient’s view of his situation and needs. Furthermore, nursing
diagnoses were described to facilitate explaining to the pa-
tient the rationale behind specific nursing interventions:
When analysing…sometimes I return to the patient and ask
additional questions. At the same time, I check that I have understood
the patient’s needs correctly.
Promotes individual and holistic care
The participants stressed that using nursing diagnoses con-
tributed to individual and holistic nursing care. When iden-
tifying nursing diagnoses the nurses focused on patient’s
reactions to and consequences of actual or potential health-
related problems, besides the medical problems. This was
perceived to lead to a deeper understanding of the individual
patient and a more complete view of the patient’s situation:
When documenting nursing diagnoses you have a holistic thinking
and think profoundly on each patient’s situation.
You see the patient as a whole and gain a better picture of the patient
as an individual.
Documented nursing diagnosis also helped nurses to maintain
individualized care when they were under stress because of a
high workload:
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L Axelsson et al.
Under stress, nursing care easily becomes routine, but a well-
formulated nursing diagnosis helps to maintain an individualized
nursing care.
A working tool for facilitating nursing care
This category describes how nursing diagnosis was experi-
enced as a tool to facilitate decisions on nursing actions, to
give a quick overview of the patient’s nursing needs at change
of shifts and to evaluate nursing care.
Facilitates the choice of specific nursing interventions
Using nursing diagnoses as the basis for planning nursing care
was stressed as necessary to clarify the patient’s problems and
needs, and hence facilitate the choice and decision of specific
nursing interventions:
It becomes so obvious what you need to do when you have a well-
formulated nursing diagnosis. It facilitates decisions on nursing care.
How can you plan nursing care if you do not use nursing diagnoses?
Sometimes lack of time made the nurse decide on nursing
interventions prior to identifying a nursing diagnosis. When
she at a later time, did identify a nursing diagnosis after a
more thorough analysis of the patient’s needs, she often
changed the interventions to more specific ones. Identification
of nursing diagnoses was perceived to increase the quality of
nursing care by decreasing the risk of missing any of the
patient’s needs and hence missing adequate interventions:
Nursing diagnoses can assist in detecting matters otherwise over-
looked. They may result in a different conclusion. I think that
patients may receive treatment that they would not have received, if a
nursing diagnosis had not been identified.
Promotes continuity of nursing care
Nursing diagnoses recorded in the patient’s nursing care plan,
were described as a way to visualize the patient’s nursing
needs, and thereby facilitate an understanding of the ration-
ale behind prescribed interventions. By increasing the nurses
understanding of the care plan, the nursing diagnosis also
promoted motivation to follow the plan and perform pre-
scribed nursing interventions, hence contributing to conti-
nuity of nursing care. This was perceived to be especially
important when taking over the care of a patient at change of
shifts:
When I know the patients’ nursing diagnoses I get a complete picture
of the patient’s need of care, even if I haven’t met the patient before.
Then I understand the rationale behind the nursing care plan and this
increases continuity and thereby quality of the given care.
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2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 936–945
A nursing diagnosis increases the understanding of, and thus the
motivation for caregivers, to perform prescribed nursing interven-
tions.
Saves time for a more appropriate nursing care
Recorded nursing diagnoses were perceived as timesaving. By
reading the diagnoses, the nurses could more easily get an
understanding of the patient’s situation and, therefore, more
quickly carry on with appropriate nursing care. Nursing
diagnoses were found to be timesaving especially when the
former oral shift reports had been replaced with ‘reading’
shift reports:
With documented nursing diagnoses you may more quickly under-
take appropriate nursing care than if each nurse has to assess the
patient all over again.
In the beginning of using nursing diagnoses, the participants
had perceived nursing diagnoses to be difficult to formulate
and therefore time-consuming. However, this changed with
experience, and formulation of a nursing diagnosis was found
to be a matter of training, and was now considered a natural
part of their daily work:
I do not find it (documenting nursing diagnosis) that time consuming
any more. When it is part of the daily work you don’t see it as extra
time spent, but rather as an integrated part.
It is so rewarding, which justifies the time it takes. Its also a matter of
training. The more you write (nursing diagnosis) the less time the
formulation takes.
The general lack of time in healthcare was also mentioned as
affecting the use of nursing diagnoses:
Patients with many nursing care needs are in need of a well-
formulated nursing care plan including nursing diagnoses. I am
convinced that it is beneficial, even if there is always lack of
time.
Facilitates evaluation of nursing care
With documented nursing diagnoses participants found it
easier to evaluate nursing care. If a nursing diagnosis was
present in the record, the nurse was reminded that she at all
times, had to evaluate its presence. By doing so, she auto-
matically evaluated the effects of given nursing care. This
evaluation was otherwise often forgotten:
Documentation of a nursing diagnosis entails a follow-up of the care.
It is yet another instrument to evaluate the result of given care. If you
only have documented assessment and interventions (without the
analysis of a nursing diagnosis) you easily forget the evaluation. This
is also a matter of security for the patient.
Issues in clinical nursing Nursing diagnoses in clinical practice

Increasing awareness within nursing I think that nursing diagnoses will help to define nursing science. If
more research is performed on nursing diagnosis the benefits of
This category concerns how working with nursing diagnoses
nursing science may be evident.
was perceived to affect the participants’ reflective thinking
and increase their professional knowledge.
Support from the management
Promotes a reflective behaviour
This category deals with the importance of support from the
The participants stressed that using nursing diagnoses in-
management when using nursing diagnoses. The head nurse’s
creased their reflective behaviour when analysing causes and
support for using nursing diagnoses was described as
consequences of the patient’s problems and needs. The in-
important. Showing an interest in reading the diagnoses,
creased reflective thinking was described as vital to ensure
demanding documented nursing diagnoses and discussing
quality of nursing care:
them at ward meetings were described as motivating factors.
The responsibility to formulate nursing diagnoses makes you reflect The significance of the head nurse’s attitude was explained as:
more upon patients’ nursing needs, it requires thoughtfulness.
I think that the head nurse has a significant role in the development of
The patients get better care when there is a written nursing process using nursing diagnoses. If you don’t have support from the
containing nursing diagnoses, because then someone has really management then it is very difficult to change things. A lot has to
reflected upon the patient’s situation and written it down for be originated by us but the head nurse needs to support development,
colleagues to consider. by allowing for education and time. If the head nurse doesn’t take an
interest, it will affect the nurses’ actions.
Increases professional knowledge
Participants reported that a reason to start using nursing diagnosis was
The participants perceived that their responsibility to identify
the fact that they were expected to do so by their peers and superiors. It
and formulate nursing diagnoses increased their need for im-
was part of their duties and when other nurses formulated nursing
proved knowledge. They stated that they actively sought more
diagnoses, they felt obligated to do so as well. Some of the participants
knowledge in literature and in discussions with colleagues:
stated that there was a consensus at their ward to document nursing
I have to analyse reasons behind the patient’s problem and if I can’t diagnoses. Some participants described that their medical chief of staff
find it I need more knowledge. To be able to formulate a nursing supported nursing development and considered nursing documenta-
diagnosis you have to discuss with colleagues, or to read up on the tion to be important. They were also supported by the director of
literature to gain more knowledge and thus find reasons for the nursing who took an interest in the use of nursing diagnoses.
problem. Moreover, nursing diagnoses were reported to be a useful instrument
for the head nurse to estimate nursing workload.
Identifying a nursing diagnosis motivated the nurses to keep
learning and developing in their profession. A recorded
nursing diagnosis was perceived to increase the nurses’ Influence on the professional role
knowledge as they learned by reading each other’s analyses
This category describes how using nursing diagnoses was
of the patients’ needs. This was seen as an advantage,
perceived to affect the professional role. The participants
especially for the less experienced nurses. The nursing
pointed out that using nursing diagnoses required them to
knowledge also increased as a result of evaluating the effects
focus on nursing. The nursing diagnoses made the concept of
of nursing interventions on the nursing diagnosis:
nursing easier to distinguish in the otherwise biomedical
(When using nursing diagnoses) you have to consider your nursing paradigm:
interventions, and when each nurse increases her individual nursing
When formulating nursing diagnosis you are focused on nursing.
knowledge the general level of knowledge increases on the ward, and
Medical problems are not as focused, they are the physicians’
thus the quality of care.
responsibility. Therefore, I think that nursing diagnoses highlights the
Moreover, nursing diagnoses were considered to have poss- importance of nursing. The diagnosis reminds you about your
ible effects on the development of nursing science. Firstly, in responsibility as a nursing expert.
the sense that when nurses use nursing diagnoses and hence
The responsibility to independently analyse and make deci-
demand more knowledge this may change nursing education.
sions in nursing became visible by using nursing diagnosis.
Secondly, that research on nursing diagnoses may contribute
The nursing field became more explicit. The participants
to nursing science:

2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 936–945 941
L Axelsson et al.
described that this strengthened their professional identity,
their professional role became more important. Feelings of
professional pride were expressed in relation to using nursing
diagnoses.
Discussion
The principle findings of this qualitative study concerning
incentive to use nursing diagnoses in clinical practice were
the following. The RN perceived that nursing diagnoses
clarified the patient’s individual needs and thereby enabled
them to decide on more specific nursing interventions.
Nursing diagnoses were found to facilitate communication
between colleagues concerning patient care and thus
promoted a continuity of care and saved time. Nursing
diagnoses were perceived to increase the RNs reflective
thinking leading to a continuous development of profes-
sional knowledge.
The strengths and weaknesses of the study should be
acknowledged. One strength is that, as far as we know, there
are no previous studies focusing on the incentive for RNs to
use nursing diagnoses in clinical practice, although there are a
number of studies (Edéll-Gustafsson et al. 1994, Törnkvist
et al. 1997, Udén et al. 1999, Gunningberg et al. 2000, Idvall
& Ehrenberg 2002, Ehrenberg & Birgersson 2003) reporting
on the lack of using nursing diagnoses. Another strength is
that the selection of participants was preceded by an audit of
nursing diagnoses recorded in the patient records. This
confirms that the participants had knowledge in nursing
diagnostics and were in fact using nursing diagnoses in their
clinical practice. A disadvantage of the study may be that the
first author who interviewed the participants had previous
experience and knowledge of nursing diagnoses and therefore
may have been inclined to interpret the participants’ state-
ments without asking them to elaborate further.
It may seem surprising that only positive reflections are
reported. However, this is owing to the aim and the sampling
of this study. A study concerning the general opinion of
Swedish nurses today may generate other findings, as the use
of nursing diagnoses is not widespread.
The participants indicated that using nursing diagnoses
increased patient participation and contributed to a holistic
view of the patient’s situation. The interviewed nurses
reported an increased interaction with the patient, as they
required a more thorough knowledge of the patient’s
situation to identify and formulate nursing diagnoses. This
is vital, as the discrepancy between problems perceived by the
patients and problems identified and documented by the
nurse has been described in other studies (Adamsen & Tewes
2000, Ehrenberg & Ehnfors 2001). The importance of
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2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 936–945
patient participation is also emphasized in the Swedish
healthcare policy (SFS 1982).
The participants stated that when identifying nursing
diagnoses they decided on more specific nursing actions than
would otherwise have been considered. Nursing diagnosis
was thus regarded as a tool, beneficial for planning individual
care. This is in agreement with Ehnfors (1994) stating that
nursing diagnosis enables an increased quality of care
regarding the patient’s individual needs. Lessow (1987) had
already found that nurses perceived nursing diagnosis to be
helpful in planning nursing care.
The nurses in the present study emphasized that recorded
nursing diagnoses was a tool to visualize and communicate
the patient’s individual needs. They stressed that this made it
easier for colleagues to promote continuity of care, by
discovering the motivation behind the reason for the pre-
scribed interventions. Kärkkäinen and Eriksson (2004) state
that continuity of care is vital for the quality of patient care
and that therefore, communication between nurses is of
critical importance. Likewise, an attitude survey (Smith
Higuchi et al. 1999) on reasons for documenting nursing
diagnoses, yielded in an open answer question that nurses
documented nursing diagnoses to communicate with other
health-care professionals, for identification of patient prob-
lems, and for planning and improving patient care.
The nurses interviewed stressed that use of a nursing
diagnosis forced them to increase their reflective thinking.
This coincides with Björvell et al. (2003b)) who described
that documentation including a nursing diagnosis was
perceived to make the nurses reflect more. This is not
surprising as nursing diagnostics may be seen as synonymous
to critical thinking. Lunney (2003) describes the requirement
of critical thinking for interpretation of patient data and thus
accurate nursing diagnoses.
Earlier studies have reported on nurses’ perception of lack
of time for nursing documentation (Howse & Bailey 1992,
Ehrenberg 2001, Taylor 2003). Nursing diagnosis has also
been found to be the most difficult part of nursing
documentation, hence time-consuming (Björvell et al.
2003b), and time constraints have been reported to be a
reason not to document nursing diagnoses (Smith Higuchi
et al. 1999). This is in contrast to the present findings where
participants not only stated that they were motivated to take
the time needed to formulate nursing diagnoses, but also
regarded recorded diagnoses as a time saving tool in nursing
practice.
The participants stressed that the independent responsibil-
ity to analyse and make decisions in nursing care was clarified
by the use of nursing diagnoses, which helped them to focus
on nursing. This is in agreement with Ehrenberg and Ehnfors
Issues in clinical nursing
(1999) who conclude that using nursing diagnoses will bring
nurses to make independent judgements and decisions about
care. It also coincides with findings by Björvell et al. (2003b))
showing that nursing documentation, according to the
nursing process, was perceived to change the professional
role from a medical technical focus to a more nursing
expertise orientation. Similar are the findings of Thoroddsen
and Thorsteinsson (2002) concerning the use of nursing
diagnoses, suggesting that nurses think more in terms of a
nursing language instead of a medical language.
The participants felt their professional identity to be
strengthened when they perceived their area of responsibility
and nursing to be more explicit. Findings by Öhlén and
Segesten (1998) suggest that the RN has been invisible and
that she for her professional identity needs a nursing
language, which is developed by individual care planning.
Their findings also included that professional knowledge and
reflective discussions with colleagues are significant for the
nurse’s professional identity. In the present study, nursing
diagnosis was described to contribute to these factors by
stimulating the nurses to gain more knowledge by reading
and by discussions. The participants also stressed that the use
of nursing diagnoses demonstrated nursing knowledge and
their role as nurse experts.
The interviewed nurses described that support from man-
agement is of importance for the motivation to use nursing
diagnoses. This result is in accordance with findings by Smith
Higuchi et al. (1999) showing that institutional support is a
factor resulting in nursing diagnosis utilization.
It is interesting that the head nurse was reported to use
nursing diagnoses as an instrument to estimate nursing
workload. Nursing diagnosis in NMDS has earlier been
described as able to predict the intensity of nursing care and
thus resource requirements (Saba & Zuckerman 1992,
Delaney et al. 1994).
Legal requirements were not mentioned by the partici-
pants as an incentive to record nursing diagnoses, although
legal reasons have previously been reported to motivate
documentation of nursing care. In a study by Ehrenberg
(2001) 24% of the nurses stated legal requirements as a
motive to record nursing. The different finding in the
present study may be explained by that extrinsic factors
have been found to dominate early stages of performance,
while intrinsic factors are increasingly important for
progression and maintenance (Ingledew et al. 1998). This
is in accordance with the present findings, illustrated by
obligation and social approval being reported as reasons to
first begin to use nursing diagnoses, but with experience
other incentives were identified and described. Motivational
factors described by the participants are in agreement with

2006 Blackwell Publishing Ltd, Journal of Clinical Nursing, 15, 936–945
Nursing diagnoses in clinical practice
aspects of motivation described by Vallerand (2001) in a
model of intrinsic and extrinsic motivation, intended for
understanding of motivational processes in sport. Motiva-
tion by increased knowledge and increased quality of care
coincide with the intrinsic factors to know and to
accomplish, described in this model. Motivation by a more
explicit and independent nursing expert role corresponds to
description of competence in the motivation model and
autonomy as influencing motivation. The motivation model
also describes that other people have powerful influence on
the individual’s motivation, and that positive feedback
increases intrinsic motivation. This coincides with the
present findings concerning the importance of support
from the head nurse. According to the motivation model
described by Vallerand (2001), there is one type of
extrinsic factor where the performance is out of one’s
own choice, which is when the performance is identified
and highly valued and considered as important by the
individual. This can be found in the participants’ descrip-
tions of reasons why they use nursing diagnoses.
The present findings suggest that the incentives to use
nursing diagnoses originate from effects generated from
performing a deeper analysis of the patient’s nursing needs.
Further research is needed to test and validate the usability
and consequences of using nursing diagnoses in clinical
practice. Also of interest is an investigation of the incentives
and effects of using nursing diagnosis classifications com-
pared with using nursing diagnoses formulated in free text.
Clinical implications
Motivating factors found in this study may be valuable to
RNs for the use and development of nursing diagnoses in
clinical care. Moreover, these factors may be of relevance in
other countries that are in a similar situation as Sweden
concerning application of nursing diagnoses.
Contributions
Study design: LA, CB, A-CM, IR; collection of data: LA; data
analysis: LA, CB, A-CM, IR; manuscript preparation: LA,
CB, A-CM, IR.
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