T-NDX Diagram: Educational Technology Used to

Teach Diagnostic Reasoning Based on Nursing

Theories
Rafael Oliveira Pitta Lopes, RN, MSN , Cândida Caniçali Primo, RN, MSN, PhD, Jaqueline Santos de Andrade
Martins, RN, MSN, PhD, Juliana Faria Campos, RN, MSN, PhD, Genesis Souza Barbosa, RN, MSN , Mauricio de Abreu
Pinto Peixoto, MD, PhD, and Marcos Antônio Gomes Brandão, RN, MSN, PhD
Rafael Oliveira Pitta Lopes, RN, MSN, is a PhD student at Anna Nery School of Nursing, Federal University of Rio de Janeiro,
Rio de Janeiro, Brazil, and Assistant Professor at Nursing and Midwifery Graduate Course, Federal University of Rio de Janeiro,
Macaé, Brazil, Cândida Caniçali Primo, RN, MSN, PhD, is Adjunct Professor at Nursing Department, Federal University of
Espírito Santo, Vitória, Espírito Santo, Brazil, Jaqueline Santos de Andrade Martins, RN, MSN, PhD, is Adjunct Professor at
Associação Brasileira de Ensino Universitário, Belford Roxo, Rio de Janeiro, Brazil, Juliana Faria Campos, RN, MSN, PhD, is
Adjunct Professor at Anna Nery School of Nursing, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil, Genesis Souza
Barbosa, RN, MSN, is Assistant Professor at Nursing and Midwifery Graduate Course, Federal University of Rio de Janeiro,
Macaé, Brazil, Mauricio de Abreu Pinto Peixoto, MD, PhD, is Associate Professor at Nucleus of Educational Technology for
Health, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil, and Marcos Antônio Gomes Brandão, RN, MSN, PhD, is
Associate Professor at Anna Nery School of Nursing, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil

Search terms: PURPOSE: To describe an educational technology to be applied to the teaching

Nursing diagnosis, nursing
education, nursing theory,
methodological research in nursing,
theoretical models
PALAVRAS-CHAVE:
Diagnóstico de Enfermagem, Teoria
de Enfermagem, Educação em
enfermagem, Modelos Teóricos,
Pesquisa Metodológica em
Enfermagem
and learning of diagnostic judgment based on nursing theories.
METHODS: A methodological study with 10 stages for the development of educa-
tional technology.
FINDINGS: An innovative educational technology is proposed to incorporate the-
oretical and methodological domains in a V-shaped diagram for the diagnosis judg-
ment.
CONCLUSIONS: The technology is innovative in integrating theory and method
in a more comprehensive and original way, considering the philosophies and world
views of students throughout the reasoning process.
IMPLICATIONS FOR NURSING PRACTICE: T-NDx Diagram may be useful in en-
hancing the integration of philosophical and theoretical knowledge and diagnostic
judgment, especially for nursing undergraduate students.

Funding
This study was financed in part by the
Coordenação de Aperfeiçoamento
de Pessoal de Nível Superior – Brasil
(CAPES) – Finance Code 001.
RESUMO: Objetivo: descrever uma tecnologia educacional para ensinar e apren-
der o raciocínio diagnóstico baseado em teorias de enfermagem.
Métodos: estudo metodológico dividido em dez etapas para o desenvolvimento de
uma tecnologia educacional.
Resultados: uma tecnologia educacional inovadora é proposta para incorporar
domínios teóricos e metodológicos em um diagrama em forma de V para fins de
julgamento de diagnóstico.
Conclusão: a tecnologia é inovadora na integração de teoria e método de um
modo mais abrangente e inovador, considerando as filosofias e visões de mundo
dos alunos ao longo do processo de raciocínio.
Implicações para a prática de enfermagem: O Diagrama T-NDx pode ser útil para
melhorar a integração de conhecimento filosófico e teórico e julgamento diagnós-
tico, especialmente para estudantes de graduação em enfermagem.

Introduction The nursing process has been considered as suitable meth-

ods adopted to apply theoretical concepts to nursing clinical
Nursing diagnosis results from a complex intellectual ac- practices (Ramalho Neto, Bezerra, Nóbrega, Soares, & Fer-
tivity, incorporated in the nursing process, that requires nandes, 2012). The relation between theories and the nurs-
knowledge about nursing theories for their development. ing process is set by nursing theorists and researchers who


C 2019 NANDA International, Inc. 1
International Journal of Nursing Knowledge Volume 00, No. 0, July 2019
T-NDX Diagram
incorporate or articulate the nursing process to their theo-
retical work and nursing research. This process includes as-
sessment, nursing diagnosis, planning, outcome setting, in-
tervention, and evaluation (Herdman & Kamitsuru, 2014).
The relation between theory and nursing process is
expressed by the proposition of a “Modified Nursing Pro-
cess” capable of incorporating theories, nursing science,
and underlying nursing concepts (Herdman & Kamitsuru,
2014). Some scholars believe that elements as theories
and philosophies precede the identification of patterns
expressed in clinical data and the consequent determination
of accurate diagnoses (Silva, Peixoto, Brandão, Ferreira, &
Martins, 2011).
The nursing process and its steps are interdependent
and apply nursing knowledge to healthcare practices as a
methodological strategy. However, the multiple theoretical
approaches used in nursing discipline and their different
abstraction levels and worldviews turn the teaching of the
nursing process based on a specific nursing theory into a
challenge.
Background
To faculty is a difficult task associate nursing theory to
nursing process with the use of innovative strategies or
educational technology, probably because of the complexity
of the task and the requirements of the learner. For exam-
ple, researches highlight the overall challenges in learning
and teaching the nursing diagnostic process (Amante,
Anders, Meirelles, Padilha, & Kletemberg, 2010; de Sousa, de
Oliveira Lopes, Keenan, & Lopez, 2018; Lira & Lopes, 2011).
Problems result from a lack of critical and reflexive thinking
(Renpenning, SozWiss, Denyes, Orem, & Taylor, 2011), which
is essential for diagnostic reasoning. Other limitations have
been pointed out since the 1990s, which are as follows:
diagnostic teaching is not encouraged and addressed in the
first nursing classes; incipient use of the diagnostic during
training; lack of knowledge about the taxonomies and the
pathophysiology related to diagnoses; difficulty to make
diagnosis based on a theoretical nursing framework; and dis-
interest of some staffs, nurses, and faculties in the diagnosis
(Almeida, 2002; Carvalho et al., 1996; de Sousa et al., 2018).
Underlying concepts of nursing sciences have been con-
sidered essential for the identification of patterns in clini-
cal data and for an accurate diagnostic judgment (Herdman
& Kamitsuru, 2014). The linkages between concepts of nurs-
ing sciences and the nursing process are usually constructed
by a nursing theory, but other epistemic elements such
as philosophies, metaparadigms, and taxonomies are also
needed. However, the lack of more comprehensive strate-
gies or technologies about the relation between theoretical
framework and empirical indicators remains a fact. Facul-
ties need educational technologies that create links between
conceptual dimension and clinical judgment, especially in
the diagnostic task. However, no studies were found on this
issue.
2
R. O. P. Lopes et al.
Purpose of the Study
The purpose of the current article is to describe an ed-
ucational technology (T-NDx Diagram) to be applied to the
teaching and learning of diagnostic judgment based on nurs-
ing theories.
Methods
Development of T-NDx Diagram as an Educational
Technology
The development of educational technology, called T-NDx
Diagram, followed 10 stages in line with the recommenda-
tions of the Ed Tech Developer’s Guide: a primer for soft-
ware developers, startups, and entrepreneurs published by
the U.S. Department of Education (2015).
The T-NDx Diagram is based on a concept of educational
technology derived from the Association for Educational
Communications & Technology definition of educational
technology as “study and ethical practice of facilitating
learning and improving performance by creating, using,
and managing appropriate technological processes and
resources.” This definition incorporates resources (hard-
ware and software, videos, satellite uplinks, and the like) or
processes, usually considered “nontechnological,” that can
be used in planning and implementing instruction, such as
decision making of faculties or students. (Januszewski &
Molenda, 2008).
Stage 1 focused on defining the guiding question: “How
do I judge the nursing diagnosis based on nursing theories
applied to individuals, families, or communities by using data
from a clinical case?” The aim of the question was to set the
central matter of educational technology and to guide the
selection of its contents.
Stage 2 was conducted for the extraction of the key con-
cepts of diagnosis and nursing theory. The guiding ques-
tion was used to define and delimit the core elements of
the technology. The concept of nursing diagnosis was se-
lected by analysis and interpretation of the following def-
initions: following definitions: the International Council of
Nurses, adopted in the International Classification for Nurs-
ing Practice (ICNP); NANDA International Inc. (Herdman &
Kamitsuru, 2014); and Brazilian Federal Council of Nursing
(Conselho Federal de Enfermagem, 2009). The concept pro-
posed by NANDA International Inc. (NANDA-I) was selected
after this process. The nursing theory definition was pro-
vided by Fawcett and DeSanto-Madeya (2013).
Stage 3 defined the criteria to select bibliographic mate-
rial to support content incorporation to T-NDx. These criteria
were as follows: (a) content should address key concepts and
their relations; (b) publication type (scientific articles and
textbooks); and (c) publication year (since NANDA’s defini-
tion of nursing diagnosis, proposed in 1990).
Stage 4 focused on the selection of appropriate materi-
als to develop a technology based on nursing theories and
diagnoses and learning sciences. The following materials
R. O. P. Lopes et al.
were chosen: (a) the textbook Nursing Diagnoses 2015-17:
definitions and classification (Herdman & Kamitsuru, 2014)—
the main reference for diagnostic reasoning procedures and
for the comparison to other articles for clarification pur-
poses (Cerullo & Cruz, 2010; Lunney, 2011; Menezes, Corrêa,
Silva, & Cruz, 2015); (b) the textbook Contemporary nursing
knowledge: analysis and evaluation of nursing models and
theories (Fawcett, DeSanto-Madeya, 2013)—the main source
of contents about nursing models and theories; and (c) The
art of Educating with V diagrams (Gowin & Alvarez, 2005)—
the main source of contents about the constructivist frame-
work adopted in the educational technology.
Stage 5 concerned the analytical reading of the selected
material to set the basis for the elaboration of nursing di-
agnosis and contents about nursing theories. The refer-
ences helped to analyze contents about (a) the fundamentals
of nursing diagnosis, data collection aspects, and diagno-
sis elaboration—based on NANDA-I (Herdman & Kamitsuru,
2014)—and (b) the structural holarchy of contemporary nurs-
ing knowledge, concepts, and definitions of models and the-
ories (Fawcett & DeSanto-Madeya, 2013).
Stage 6 comprised the selection of diagrammatic and log-
ical structures to articulate nursing theory and methodolog-
ical diagnostic procedures based on previous analysis and
supported by a constructivist framework for teaching and
learning. The diagramming form and the logic underlying
Gowin’s V Diagram were taken as reference basis (Gowin &
Alvarez, 2005).
Stages 7–9 focused on developing the educational tech-
nology. Stage 7 allocated theoretical and methodological
contents analogous to the V Diagram arrangement. Stage 8
concerned the adaptations, inclusions, creations, and propo-
sitions of constitutive contents in the technology structure
according to the guiding question, as well as the nature of
the diagnostic task and disciplinary characteristics. Stage 9
focused on the final diagramming of the schematic repre-
sentation of all elements in the technology. The process was
R
conducted by a graphic designer in Corel Draw x7 software.
Stage 10 focused on developing the script with the guide-
lines about the use and understanding of technology compo-
nents to help professors use it. This stage was not described
in the current article.
The study was not submitted to the Research Ethics Com-
mittee, given its methodological nature and nonparticipation
of human subjects.
Findings
The Frame of T-NDx Diagram
The educational technology was guided by the graphical
representation of a V-shaped diagram (Figure 1).
The “V” shape delimits the theoretical domain that sup-
ports the diagnosis (on the left side) and the methodological
domain that incorporates the diagnostic strategies (on the
right side). The upper central part of the V presents the ba-
sic question, which assures the interaction between domains
T-NDX Diagram
and should be answered based on the content of the clini-
cal case (lower central part of the V). The double arrow to
the center shows that both domains, and their constituent
elements, continuously interact with each other. Five consti-
tutive elements of the conceptual domain and 15 elements
of the methodological domain are arranged in the educa-
tional technology. The theoretical and methodological ele-
ments represent what should be considered to apply the
technology and have nursing diagnoses based on nursing
theories.
The arrow below the expression “clinical case” indicates
the meaning compatible with the diagnostic reasoning flow
based on theories. The clinical case at the base of the tech-
nology is the object of study and presents the phenomenon
of interest.
Guideline for Application of T-NDx Diagram
The T-NDx Diagram uses an Attribution-NonCommercial-
ShareAlike 3.0 Unported (CC BY-NC-SA 3.0 BR) creative com-
mons license for free share and adaptation by educators,
nurses, and researchers. These licensing characteristics are
compatible with nondirective principles about teaching and
highlight a learner-centered design process. Thus, a guide-
line for the application of the T-NDx Diagram should be taken
from a broad perspective without being considered a “cook-
book.” The guideline was based on the International Society
for Technology in Education (ISTE) Standards for Educators.
These standards aim to deepen the practice of educators,
promote collaboration with peers, challenge educators to re-
think traditional approaches, and prepare students to drive
their own learning (ISTE, 2018). Two included standards for
the guideline were as follows: educator as a designer and ed-
ucator as a facilitator.
Educators are encouraged to use T-NDx Diagram as an
educational technology to create, adapt, and personalize
the nursing student learning experience with a clinical case,
which can maximize and deepen the development of their
knowledge. To do so, the following preparatory requirements
are required: to select the basic references that present
knowledge about nursing philosophies and nursing theories
and to incorporate middle-range theories; clinical character-
istics (defining characteristics or risk factors, related factors,
problems, data from laboratory exams, etc.); incorporate a
framework to connect concepts and statements of a spe-
cific nursing theory and that can facilitate the description
or explanation of the central phenomena to be communi-
cated in the clinical case; provide students with prior nursing
theoretical knowledge and clinical judgment instruction for
application in the case; and discuss with one or more stu-
dents the purpose of the learning experience, verifying their
understanding.
For the application of T-NDx Diagram to a group of
students, initially develop the conceptual domain in a
top-down orientation by discussing with students their
knowledge about metaparadigmatic concepts and nursing
3
T-NDX Diagram
Figure 1. T-NDX DIAGRAM: Educational technology to teach diagnostic reasoning based on nursing theories applied to
clinical cases.
philosophies by asking the following questions: In general,
how you see the human being, his family, his group, and his
community? What is the relevance of nursing science and
profession to the individual, family, and/or community? What
is an environment for you and how do you understand its re-
lations with the individual or collective human being? What is
health and how does nursing relate to health? Subsequently,
recommend that students individually reflect on what they
have answered on the knowledge of the metaparadigm and
nursing. And ask the students to consider the nursing the-
ory that will be useful for the nursing judgment in the clinical
case.
After the students have made their personal reflections
on the metaparadigmatic, philosophical, and theoretical
issues, ask them to present them in their own words. En-
courage group discussion in students’ own language or
individual awareness. Make punctual corrections of con-
ceptual errors and provide additional knowledge about
nursing theories (assumptions, purpose, concepts, axioms,
statements of existence, relational statements, and laws
and models) as needed. More specifically, move to the
conceptual domain base by verifying students’ knowledge
about diagnostic classification systems.
4
R. O. P. Lopes et al.
To begin the development of the methodological domain
(right side of the vee), ask the student to read the case care-
fully and then highlight: (a) data that relate to nursing theory
and nursing domains previously selected; (b) separate ob-
jective and subjective data; (c) identify the contexts of the
case. Subsequently, assist the students in the process of di-
agnostic judgment supported by the knowledge of nursing
theories through activities such as clustering of information,
encouraging the identification of common characteristics of
information, return to aspects of the domain(s) and nurs-
ing theory to help in the understanding of this information;
(d) creation of classes of information according to common
characteristics; (e) elaboration of a “picture” of the patient’s
situation; and (f) identification of standards and classes that
would require in-depth assessment.
Finally, all steps of the nursing diagnostic judgment (ele-
ments 6 to 15 on the right side of T-NDX Diagram) should be
developed according to the diagnostic models widely avail-
able in the literature or supported by Diagnostic Decision
Support Systems or applications developed for these pur-
poses. However, the educator should encourage and explore
connections with the knowledge of the theoretical domain
to avoid creating a gap between theory and practice.
R. O. P. Lopes et al.
Discussion
The Gowin’s V Diagram (Gowin & Alvarez, 2005) was used
for two reasons. First, because it can be applied to differ-
ent knowledge fields and contexts and help on developing
an educational technology focused on theory and method
integration. Such technology would be more comprehensive
than the currently available propositions about nursing pro-
cesses guided by specific nursing theories. Second, because
the Gowin’s proposition is based on constructivism. There-
fore, this method helps dynamically organizing the epistemic
elements from conceptual and methodological processes, in
an undissociated way (Gallavan & Kottler, 2007).
The representation of a continuous V-shaped line from
one domain to another, without interruption, suggests that
there should be no ruptures between theory and practice.
The lack of interruption highlights the authors’ goal to de-
velop a technology to integrate the conceptual domain to the
methodological one. Such continuity complies with the most
contemporary perspective of the nursing process (Herdman
& Kamitsuru, 2014), which starts from theoretical and con-
ceptual backgrounds (theory and underlying concepts of
nursing science) and advances toward the methodological
elements of diagnosis.
The educational technology-use path starts from the
top of the conceptual domain and heads toward the base
of the “V.” It follows a deductive orientation. On the other
hand, the methodological domain heads toward induction,
in which the elements at the base of the “V” operate at a
more empirical level. However, the inductive process of nurs-
ing diagnostic judgment guided by educational technology
is not linear; the first movement goes from the most con-
crete elements toward the most abstract ones, because it
goes from the initial data collection (methodological element
6) to diagnostic hypothesis formulation (methodological el-
ement 9). A new inductive movement starts in the in-depth
data collection (methodological element 10) and ends in
diagnostic prioritization determination (methodological el-
ement 14). This conformation preserves the benefits of us-
ing different inductive and deductive mechanisms in clinical
judgment, which are algorithm use, pattern recognition, ex-
haustive mechanisms, and hypothetical-deductive reasoning
(Thompson & Dowding, 2009).
Reasoning continually flows through the interaction
between the conceptual and methodological domains. The
relation between these domains is clearly expressed in the
interaction indicated by the arrow at the center of the “V.”
The same guiding question used in the development
of educational technology was incorporated to the center of
the “V.” The question represents the motivating element of
the diagnostic judgment and clearly indicates the goal to be
reached at the end of the application of T-NDx Diagram.
The conceptual domain incorporates epistemic elements
such as philosophical, theoretical, and conceptual elements,
which constitute the so-called theoretical background. In its
turn, these epistemic elements guide the data collection
and the decision for the appropriate nursing diagnosis. They
T-NDX Diagram
offer contents about nursing theory/science/concepts that
sustain the nursing practice, allowing the development of the
methodological domain according to the “modified nursing
process” proposed by Herdman and Kamitsuru (2014).
The concepts that form the disciplinary paradigm are the
most abstract epistemic elements. The metaparadigmatic
concepts of person, health, environment, and nursing, which
are the most widely disseminated ones, were introduced by
Yura and Torres, in 1975, and reinforced by Fawcett, in 1984.
However, other theorists have suggested different concepts
that indicate the paradigmatic plurality that could be supp-
orted by educational technology (Kim, 2010). Users could
use other approaches, such as the “metaparadigmatic fram-
ework” (Kim, 2010) or the cultural contextualization of meta-
paradigmatic concepts (Kao, Reeder, Hsu, & Cheng, 2006).
Like what happens to paradigms, nursing philosophies
can vary among theorists. This variation indicates the plu-
rality of worldviews and reflects systems of beliefs and ideas
from different or specific groups (Chou & Lee, 2007). The
authors incorporated this element to the educational tech-
nology to encourage users to understand the philosophies of
the nursing discipline. The student’s personal reflections on
the paradigmatic, philosophical, and theoretical issues help
them in comparing their worldviews and personal theories
with those theorists. Educational interventions from a con-
structivist pedagogical approach that combines a focus on
epistemic beliefs and approaches to learning may be useful
for beneficial epistemic changes (Muis & Duffy, 2013).
The nursing theory is the main element of the conceptual
domain. Nursing theory generates a descriptive, explana-
tory, predictive, and/or prescriptive reasoning that affects
the interpretation of clinical cases. In order to develop the
educational technology, we assumed that the nursing the-
ory would determine the diagnostic judgment and data ma-
nipulation in the methodological domain in function of its
relational and nonrelational statements and organization of
their concepts.
The domains of diagnostic classification (in the taxon-
omy) are the most concrete elements of the conceptual
domain of T-NDx Diagram. The taxonomic domains of diag-
nosis in NANDA-I are the upper diagnostic knowledge organi-
zation structure to allocate classes and diagnostic concepts
(Herdman & Kamitsuru, 2014). The NANDA-International Inc.
taxonomy would be considered a descriptive middle-range
theory (Oliveira Lopes, Silva, & Herdman, 2015), and given
its specificity, the nursing taxonomy provides information
on sets of knowledge (domains), classes of concepts, pat-
terns of human responses, and nursing diagnostic focus;
consequently, it facilitates the search for data in the initial
assessment.
The path through the methodological domain starts with
initial data collection (screening assessment), as shown in
the lower part of the left side of the “V.” Initial assessment
and analysis procedures depend on case content and con-
verge to a strategy based on understanding the situation in
a more comprehensive context, that is, on looking at the “big
picture” (Sørensen & Hall, 2011). The structure of diagnostic
5
T-NDX Diagram
domains and the assessment patterns set by the Functional
Health Pattern (FHP) are similar (Herdman & Kamitsuru,
2014). Probably, the semantic convergence between the con-
ceptual element (NANDA taxonomy) and the methodologi-
cal structure of evaluation (Functional Health Standards) is
advantageous to preserve the continuity between the de-
ductive and inductive reasoning in the base of the T-NDx
Diagram.
Clustering of information and identification of patterns in
methodological element 8 are strategies developed for nurs-
ing diagnostic judgment. Based on the premise of the pro-
posed educational technology, clustering of information and
patterning processes are supported by the diagnostic do-
main(s) and by the nursing theory. The diagnostic reasoning
process depends on assessment, information interpretation,
clustering, and denomination of this clustering (Bittencourt
& Crossetti, 2017).
Data clustering and denomination processes can strongly
depend on the recognition of patterns or similarities, that
is, on situations in which the identification of signs dur-
ing diagnosis is based on knowledge about the case or on
diagnosticians’ experience with similar cases. For the recog-
nition, patterns stored in the memory of diagnostician are
compared to signs and symptoms reported in each case
(Banning, 2008a). Despite the value of this strategy, which
is based on heuristic reasoning, it is not error free; thus, the
investigated phenomenon should be formalized as a diag-
nostic hypothesis to be tested.
The application of methodological elements 9 to 11 is
guided by a more comprehensive clinical reasoning and/or,
in a more particular way, by the hypothetical-deductive rea-
soning. Clinical reasoning skills are categorized as cognitive
abilities, behavioral skills, and habits of mind (Carvalho,
Oliveira-Kumakura, & Morais, 2017). The hypothetical-
deductive reasoning is based on steps such as recognition
and gathering of evidence, development of the hypothe-
sis, interpretation of evidence, and evaluation of hypothesis
(Banning, 2008b). Data must have the potential to confirm
or refute the initial diagnostic hypothesis, or yet, they must
be noncontributive to the reasoning process. The pros and
cons of each possible explanation (concurrent diagnostic hy-
potheses) should be weighed at the end of the process, and
the most likely explanation should be selected, based on the
majority or relevance of the evidence (Thompson & Dowding,
2009). The most likely hypothesis becomes the diagnosis ac-
cepted as the best judgment made about the data.
The taxonomic clarification step confronts the diagnostic
hypothesis with contents of the nursing diagnosis of NANDA-
I’s taxonomy, by comparisons between different classes in-
serted in the domain or by the diagnostic label most similar
to the diagnostic hypothesis.
The diagnostic validation methodological element checks
the opinions of other diagnosticians to see whether they
agree or not with the selected diagnosis. The “second opin-
ion” is a good practice, given the possible misconceptions
that can arise from anchoring (trend to remain stuck to first
impressions and disregard new information), diagnosis avail-
6
R. O. P. Lopes et al.
ability (thinking that the diagnosis that most easily come to
our minds is the most likely one), representativeness errors
(trend to reason based on prototypes or standards that meet
the data), overconfidence (trend to rely too much on our-
selves and believe to know more than we really know), and
confirmatory evidence (trend to search for evidences that
confirm our hypotheses and disregard those that would dis-
miss them) (Thompson & Dowding, 2009).
The methodological domain ends at the step of diagnos-
tic prioritization, which should converge to the users’ needs
and to the nursing intervention. In the scope of the T-NDx
Diagram, the prioritization is not only a clinical decision, de-
pending strongly on the nursing philosophies and theories.
Priorities are related to a set of meanings and values at-
tributed by those who analyze the situation. Thus, theories
are useful knowledge categories for the description and ex-
planation of human experiences in relation to the nursing
diagnosis.
Studies have indicated the use of the Gowin’s V Dia-
gram to link theory and practice or manage information and
knowledge (Fox, 2007; Smith, 1992; Silva et al., 2013; Sousa,
Formiga, Oliveira, Costa, & Soares, 2015). However, the pro-
posal to integrate nursing theories to the nursing diagnosis
judgment through a technology based on the V diagram is
innovative.
Conclusions
Current research has described an educational technol-
ogy with the potential to promote the integration of concep-
tual and methodological elements to aid an integrative di-
agnostic judgment. Thus, the T-NDx could contribute to the
application of the nursing process and its teaching.
Although the teaching of the nursing process is relevant,
it is also necessary to improve education for using nursing
theories; however, the usual pedagogical practice has been
separating these contents. Because of its integrating charac-
teristics, the T-NDx Diagram can make this teaching indisso-
ciable. Considering its constructivist approach, educational
technology described in this study is innovative and, presum-
ably, could be used by nursing students from different grades
and with different levels of experience.
Implications for Nursing Knowledge
The T-NDx Diagram may be useful in enhancing the inte-
gration of philosophical and theoretical knowledge and diag-
nostic judgment, especially for nursing undergraduate stu-
dents. It can also be a new tool to facilitate the teaching and
learning of the modified nursing process.
Knowledge Translation
For nursing educators, the work expands the pedagogical
applications available for teaching diagnostic judgment.
The use of the T-NDX allows future investigation
about strategies used by learners, in the integration of
R. O. P. Lopes et al.
theoretical and methodological knowledge in the diagnostic
task.
This research is an important step to the future develop-
ment of a computational prototype to support methodologi-
cal procedures of diagnostic judgment integrated to nursing
theories.
Author contributions. Rafael Oliveira Pitta Lopes and Mar-
cos Antônio Gomes Brandão contributed to the study con-
ception, design, data management, data interpretation, and
writing of the manuscript. Jaqueline Santos de Andrade Mar-
tins, Juliana Faria Campos, and Cândida Caniçali Primo con-
tributed to the study conception, design, and data interpre-
tation. Mauricio de Abreu Pinto Peixoto and Genesis Souza
Barbosa contributed to the data interpretation, manuscript
editing, and manuscript review. All authors contributed to
the preparation of the manuscript and approved the final
version submitted for publication.
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