Helping Nurses Use NANDA, NOC, And

NURSE EDUCATOR Volume 31, Number 1, pp 40–46 * 2006 Lippincott Williams & Wilkins, Inc. Helping Nurses Use NANDA, NOC, and NIC Novice to Expert In the United States, implementation of an electronic health record (EHR) is imminent; by 2010, all healthcare Margaret Lunney, PhD, RN events will be electronically recorded and healthcare agencies will be required to submit data elements to regional and national data banks.1,2 The electronic health record (EHR) requires the use of standardized With an EHR, nursing data elements nursing languages such as NANDA, NOC, and NIC. Helping nurses use will be documented through the use these languages for an EHR requires different educational strategies in 3 of standardized nursing languages such as those published by NANDA domains: intellectual, interpersonal, and technical. The author explains the rationale for changes in educational methods, expectations that International and the project teams of educators and managers should set for students and nurses at various the Nursing Outcomes Classification levels of expertise, and teaching strategies in each of the domains. (NOC) and the Nursing Interventions Classification (NIC).3-5 These and other standardized languages that were approved by the American Nurses Association for use in elec- of standardized nursing languages ages of cues with diagnoses, and tronic records provide a broad base of requires increased attention to devel- diagnoses with outcomes and inter- nursing knowledge at the point of opment of intellectual, interpersonal, ventions. Without the use of NNN in care and enable the documentation and technical competencies; and an EHR, nurses are often encouraged of nursing care elements in formats 6 (c) accurate diagnosing is the basis to collect large amounts of data with- that support the aggregation of data. for appropriate selection of patient out naming data interpretations. With Aggregation of nursing data enables outcomes and nursing interventions. the use of NNN in an EHR, decisions the development of knowledge These reasons are explained as the about data collection are based on related to the quality and cost of care basis for helping nurses to implement initial cues to diagnoses and diagnos- in agency units and comparison of NANDA, NOC, and NIC (herein tic hypotheses being considered for quality and cost across localities and referred to as NNN) and other nursing individual patients. time periods. languages. The systems of NNN are Without the use of NNN in an EHR, addressed in this article but a majority nurses describe patient outcomes and Rationale for Educational of these teaching methods also apply interventions in a narrative format with Changes to other languages. little consistency among nurses. With the use of NNN in an EHR, the names Three major reasons for changes in used for patient outcomes and nursing educational methods are: (a) use of Differences in the Nursing interventions are easily available to all standardized nursing languages in Process With Use of NNN nurses so consistency and continuity the nursing process differs from the will be expected. traditional nursing process; (b) use When nurses have opportunities to Without the use of NNN in an EHR, use standardized languages such as nurses may not be held accountable NNN, significant differences exist from for the accuracy of their data interpre- Author Affiliation: Professor and Grad- use of the traditional nursing process. tations. With the use of NNN in an EHR, uate Programs Coordinator, Department of Without use of NNN, nurses are prob- nurses’ diagnoses are easily noted and Nursing, College of Staten Island, The City ably not aware of the extensive num- addressed, so accountability for accu- University of New York, Staten Island, NY. ber of data interpretations, outcomes, racy will be critically important to save Correspondence: Department of Nurs- and interventions to consider for indi- the time and money involved when ing, College of Staten Island, 2800 vidual patient situations. With use of Victory Boulevard, Staten Island, NY 10314 many nurses provide care for inaccu- ([email protected]). NNN in an EHR, knowledge of 172 rate diagnoses. For example, if one diagnoses, 330 patient outcomes, and This article was adapted from a Key- nurse selects the diagnosis of Deficient 514 nursing interventions can be Knowledge when a patient has note Address given at the 2005 Institute on 3-5 Nursing Informatics and Classification, easily available. adequate knowledge and then many hosted by the University of Iowa College Decision support systems can nurses waste time in teaching, there of Nursing, Center for Nursing Classifica- also be included in an EHR that will be excessive costs without posi- tions and Clinical Effectiveness. prompt nurses to consider the link- tive outcomes.

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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Development of Competencies potential for inaccuracy in nurses’ ical Mobility is only appropriate if identification of diagnoses and contrib- nurses currently plan to help this Intellectual, interpersonal, and techni- uting factors.8 In every study of patient to improve mobility. The pur- cal competencies support the account- nurses’ interpretations of the same pose of nurses’ diagnoses should be ability that is needed for collection data elements, there were wide varia- to guide nursing interventions, not to and interpretation of patient data, as tions in interpretations of data, even label patients with nursing diagnoses. well as appropriate selection of with strong data support for the most New users often do not realize that patient outcomes and nursing inter- accurate diagnoses. These variations the neutral outcome labels (eg, Weight ventions. Based on the improved in interpretations are influenced by 3 Control) and the associated overall organization of an EHR over paper major factors: the diagnostic task (eg, score on specific scales (eg, 3 = records, the choices of individual complexity and amounts of data), the sometimes demonstrated), are the out- nurses’ diagnoses, outcomes, and situational context (eg, organizational come, not the indicators, and the interventions will be addressed by all policies, nurses’ roles), and nurses’ abil- intervention labels (eg, Presence) are nurses involved in care of the same ities as diagnosticians (eg, thinking the interventions, not the activities.4,5 patients. Thus, nurses’ choices will abilities, experience with similar For the outcomes in NOC, the indica- have broader, more profound effects cases).8-10 Studies have shown that tors serve as evidence to help patients on nursing care in general, not just the high accuracy is associated with nurses and providers to identify overall care provided by themselves. In being educated as diagnosticians.8 scores prior to and after nursing theory, continuity of care was sup- interventions. For the NIC interven- posed to occur with use of paper tions, the activities represent how to records, but, with the inability to do the intervention and are individu- effectively track data, continuity of Set Expectations: Novice 2 ally applied according to patients’ care was not realized. to Expert needs. In setting expectations for students Students and nurses should be Accurate Interpretations of Data and nurses, it is important that educa- expected to correctly use the concepts are Foundational tors and managers do not underesti- in each system in accordance with the mate nurses’ abilities to effectively use concept definitions, descriptions, and In a classic study, it was established standardized nursing languages and the context of each clinical situation. that short-term memory only holds 7 T incorporate them with other knowl- For example, the NANDA Interna- 2 bits of data,7 so nurses, as all human edge bases. Based on the author’s tional diagnosis of Social Isolation is beings, continuously convert bits of experience teaching NNN to nurses not used unless the patient is being data or cues to interpretations. For at all levels of expertise, novices and rejected by others, not if he or she example, the interpretation that a advanced beginners learn to use NNN chooses to be alone.3 The NOC out- person is a male or female is based as well, if not better and easier than, come of Knowledge: Diet should not on the cues of hairstyle, facial struc- experienced nurses. This is because be used if the person already has ture, body type, body language, they have not had enough experience extensive information about the rec- clothes, name, and others. It is com- in nursing to know other ways of ommended diet. There are many rea- mon to think of such interpretations as doing things. The languages of NNN sons why people do not follow ‘‘fact’’ because these interpretations can be used throughout basic nursing recommended diets besides Deficient are relatively valid and reliable. Other programs, from the first week, as Knowledge. interpretations, however, such as the part of a framework for practice The NIC intervention of Coping patient is happy, sad, or anxious, are along with theories and models of Enhancement should not be used if not likely to be valid and reliable nursing.11 In contrast, nurses at com- the patient problem to be treated is unless nurses attend to the accuracy petent, proficient, and expert stages Stress Overload rather than Ineffective of interpretations. need to be ‘‘sold’’ on new ways to Coping. With stress overload, a better In clinical situations, data bits are think and document nursing care intervention might be Environmental continuously converted to interpreta- (Figure 1). Management. The diagnosis of Stress tions to save space in short-term Expectations should be set for Overload is not currently on the memory. The advantage of naming nurses at all levels of expertise to NANDA International approved list of these interpretations, instead of inter- correctly use NNN. If students and diagnoses, but this taxonomy is not vening without naming them, as when nurses are shown how to apply the complete, so nurses should be devel- nurses’ diagnoses are not stated, is languages using written or computer- oping their own diagnostic labels that accuracy can be discussed with ized case studies, they can success- when indicated. others and challenged when indi- fully implement the languages with Regardless of whether patient and cated. Nurses’ interpretations of new cases. Some common errors that family cues are a ‘‘good fit’’ with the patient data determine all subsequent might occur are restating medical definition and description of a con- actions, including additional data to diagnoses as nursing diagnoses with- cept in one of these systems, the collect, possible outcomes to con- out providing added information context of a clinical situation may sider, and choices of interventions. about the patient; for example, if a indicate that the concepts are not Additionally, studies since 1966 patient had an amputation 2 years relevant. For example, if patients pre- have shown that there is a high ago, the diagnosis of Impaired Phys- fer assistance with a different aspect of

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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Figure 1. Ten selling points for the use of NANDA, NOC, and NIC (NNN) in EHR. their health than nurses’ diagnoses, use of NNN is ideal to communicate software, whereas definitions, descrip- nurses should consider following advanced practice nursing competen- tions, and bibliographies can be in the patients’ preferences. cies such as developing standards of background for use as needed. At all levels of expertise, learners care. Standards of care can be devel- To effectively use these systems, should be encouraged to perform oped for specific patient populations the thinking processes of nurses must ongoing self-evaluation or reflection by identifying the relevant diagnoses, be enhanced. Like other adults, the to generate continued professional outcomes, and interventions and the thinking process abilities of nurses growth in use of these languages. linkages of diagnoses, outcomes, and vary widely. For example, the wide This process involves purposeful eval- interventions that are important to range of nurses’ thinking abilities was uation of one’s own thoughts or meet quality-based standards. evident in the findings from a study behaviors to facilitate learning from of basic divergent thinking abilities of experiences. Benner12 and Smith and 86 nurses with generic baccalaureate Jack13 described reflective practice as Strategies education and 1 to 5 years experi- a key aspect of growth in professional To enable the use of NNN, intellec- ence.16 The 2 rater averages of scores expertise. In a Delphi study of 55 tual, interpersonal, and technical abili- ranged from 6 to 41.5 for fluency, nurse experts in critical thinking, ties must be developed. There are from 0 to 27.5 for flexibility, and from reflection was identified as a habit of specific strategies that can be em- 7 to 30.5 for elaboration. Thinking mind for critical thinkers in nursing.14 ployed to develop abilities in each abilities such as these can be im- With ongoing reflective practice, category. proved with education and effort.17 nurses’ choices of terms from NNN The increased emphasis on criti- are likely to improve so that they Intellectual Domain cal thinking in nursing that has more accurately reflect the complexity occurred in response to accreditation of patient care. The most significant change in teach- criteria may contribute to improved Nurses who are at competent, ing strategies needs to occur in the thinking abilities. Findings from a proficient, or expert stages of exper- intellectual domain, with educators Delphi study of 55 nurse experts in tise should be assisted to integrate and managers promoting nurses’ critical thinking yielded a model of NNN with previous knowledge bases development as diagnosticians.15 The critical thinkers that can easily be used and to use NNN for communication of intellectual competencies needed are by educators and managers to help various aspects of advanced practice (a) attainment of knowledge related to students and nurses grow in thinking nursing. When nurses are assisted to diagnoses, outcomes, and interven- abilities.14 Seven cognitive skills and integrate NNN with previous knowl- tions and (b) development of related 10 habits of mind were identified as edge, it demonstrates the usefulness thinking abilities. With over 1,000 relevant for nursing practice. Use of of these systems to existing practice. concepts, definitions, and descriptors these 17 critical thinking concepts can For example, community health in NNN, the knowledge required is facilitate both beginning students and nurses can be shown how to use the extensive and complex. With elec- experienced nurses to think about health promotion diagnoses, out- tronic systems, however, the concepts their thinking (ie, metacognition) comes, and interventions from NNN. for diagnoses, outcomes, and inter- and, subsequently, improve their For nurses in graduate programs, the ventions can be frontloaded in the thinking processes.18

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To help students and nurses and nurses are capable of appropriate ask questions instead of providing improve their thinking processes, edu- thinking processes; they should ex- answers, provide opportunities for cators and managers should assume pect to make mistakes in thinking; and problem solving, and deflate author- that thinking is human, imperfect, and thinking abilities can be improved. To ity. Deflation of authority enables attainable.19 This means that students promote thinking, educators should students to stop expecting the ‘‘right’’

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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. answers from teachers and other intervention and provides learners (Figure 3), the nurse could say, ‘‘it experts and, instead, to depend on with a few beginning cues, such as seems to me that, as a caregiver, you their own abilities to process informa- gender, age, and reason for contact. are tired and may be at risk of high tion and make decisions. Educators After that, the teacher only provides amounts of stress in the caregiver role. can show students how to think data if students request it, along with Is that correct?’’ through problems by thinking aloud the reasons why the question was with students and acting as midwives asked. For example, a student might or coaches to help learners apply a ask, ‘‘how did you feel about that?’’. Technical Domain range of thinking processes.19 The student could accompany this Seminar methods of teaching question with a rationale of, ‘‘I am Teaching strategies for students’ should be used throughout basic and considering issues related to coping, development in the technical domain advanced nursing education to pro- anxiety or fear.’’ This process contin- are similar to current methods with mote the use of thinking processes. ues until the class as a whole attains greater emphasis on collecting valid This method is achieved by assigning an accurate diagnosis or time runs out. and reliable data, developing diagnos- readings for each class, organizing This is a time-consuming but effective tic reasoning abilities, teaching how classes according to the readings, pro- method to teach diagnostic reasoning. to perform a broad range of NIC viding students with discussion ques- interventions, and learning how to document nursing care using NNN. tions so they can be prepared, recording Interpersonal Domain the number of times that students Knowing how to collect specific participate, giving a grade each week Increased attention to interpersonal data to rule in or rule out diagnoses in accordance with specific grading competencies is needed so that nurses (eg, Pain or Disturbance in Body criteria, and rewarding students with will be able to obtain valid and reliable Image)3 will enable nurses to achieve 25% to 30% of their overall grade. The data and work in partnership with higher accuracy by obtaining the goal of each class is to address what the patients and families to select the best essential data to support or reject diag- author is saying, the fit with previous diagnoses, outcomes, and interven- nostic hypotheses. Applying evidence- knowledge, and the practice applica- tions. With the complexity of choosing based practice protocols facilitates tion. The teacher grades students on the most appropriate concepts to fit the selection of the best diagnoses for their participation and on evidence diverse clinical situations that nurses individual patients especially because that they have done the readings, not address, the best use of NNN requires identifying patient preferences is on giving ‘‘correct’’ answers. As sea- that nurses work in partnership with one aspect of such protocols.24 With soned teachers are aware, students patients and families. Developing part- the ease of selecting intervention participate when teachers avoid lectur- nership relationships enables nurses to labels in electronic systems, nurses ing, sit at eye level with students, and avoid inappropriate and unethical can select interventions without suffi- show respect for students’ answers. labeling, for example, using the diag- cient knowledge of how to perform The seminar method promotes nosis of Impaired Parenting3 for a the interventions. Knowing how to improved thinking because it stimu- Mexican American couple when the perform complex nursing interven- lates thinking processes, recognizes father does not participate in infant tions (eg, Reminiscence Therapy, students’ and nurses’ abilities to think care. Mexican American women use a Biofeedback, Acid-Base Manage- without authorities, and demonstrates Doula, a woman with childcare expe- ment)4 will facilitate appropriate use that collaboration with the thinking of rience, instead of expecting help from of the intervention labels to help others is productive.20 the father.23 patients. Sharing paradigm cases (Figures 2 Developing partnership relation- Use of professional practice and 3) helps learners visualize and ships requires exquisite communica- standards that articulate evidence- experience use of the 3 languages. tion. Curricula in schools of nursing based knowledge may indicate that The patient’s story is told so that and healthcare agencies should be additional education is needed for students and nurses have the context examined for whether additional specific interventions. With respect to of the situation21 and not just the cues course work on communication, espe- documentation of NNN, for example, to diagnoses. Educators can also sim- cially Assertiveness Training and Com- learners need to know how to use the plify cases as needed for learners to plex Relationship Building,5 is indicators to rate outcomes both be able to see the connections among warranted. Assertiveness training before and after interventions. In as- data, diagnoses, outcomes, and inter- helpslearnersexpresstheirideas signments, incentives can be provided ventions. An interactive case study while respecting the ideas of others. for the correct use of NNN (eg, a method called iterative hypothesis test- Interviewing skills can be demon- percent of students’ grades are allo- ing provides learners with experience strated by educators through role cated to following directions regard- in asking questions to obtain diagnos- playing and video tapes. Students ing the use of these systems). tic data.15,22 With this method, the and nurses can be videotaped during goal is for learners to identify the most history taking for them to evaluate accurate diagnosis. Using role-playing their own development. They also Conclusions techniques, the teacher pretends to be need to be taught the language of a specific clinical case with a human validating interpretations with patients Although NNN and other nursing lan- response that requires diagnosis and and families; for example, with Stella guages represent the knowledge that

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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. educators have been teaching for de- A-Glance. Available at: http://www.hhs. 14. Scheffer BK, Rubenfeld MG. A consensus cades, the evolution of standardized gov/news/press/2004pres/20040721.html. statement on critical thinking. JNurs nursing languages and their impor- Accessed June 21, 2005. Educ. 2000;39:352-359. tance in an EHR requires a bold em- 2. Institute of Medicine. Keeping Patients 15. Carlson-Catalano J. Teaching diagnostic Safe. Washington, DC: National Academy reasoning. In: Lunney M, ed. Critical phasis on teaching methods. The Press; 2004. Thinking and Nursing Diagnoses: Case routines with electronic systems will 3. NANDA International. Nursing Diagnoses: Studies and Analyses. Philadelphia: include systematic follow-up of nurses’ Definitions and Classification, 2005- NANDA International; 2001:44-65. diagnoses, outcomes, and interven- 2006. Philadelphia: Author; 2005. 16. Lunney M. Divergent productive thinking tions and examination of the effects of 4. Moorhead S, Johnson M, Maas M. Nursing and accuracy of nursing diagnoses. Res these choices on quality and cost. Outcomes Classification (NOC). St. Louis: Nurs. 1992;15(4):303-311. These routines will prompt more strin- Mosby; 2004. 17. Sternberg RJ. Successful Intelligence: How gent accountability for naming the 5. Dochterman JC, Bulechek GM. Nursing Practical and Creative Intelligence Deter- Interventions Classification (NIC).St. mine Success in Life. New York: Plume elements of nursing care.2 Educators Louis: Mosby; 2004. Books; 1997. and managers who encourage and 6. American Nurses Association. NIDSEC: 18. Rubenfeld MG, Scheffer BK. Critical support students and nurses at novice Standards and Scoring Guidelines. Wash- Thinking TACTICS in Nursing. Boston: to expert stages to develop the intel- ington, DC: Nursesbooks.org; 1997. Jones & Bones; 2006. lectual, interpersonal, and technical 7. Miller CA. The magical number seven, 19. Belenkey MF, Clinchy BM, Goldberger abilities for use of NNN will be re- plus or minus two: some limits on our NR, Tarule JM. Women’s Ways of Know- warded by seeing the learners grow in capacity for processing information. Psy- ing: The Development of Self, Voice, and chol Rev. 1956;63:81-97. Mind. New York: Basic Books; 1983. these abilities. 8. Lunney M. Critical Thinking and Nursing 20. Hayakawa SI, Hayakawa AR. Language in Diagnosis: Case Studies and Analyses. Thought and Action. New York: Basic Philadelphia: NANDA International; 2001. Books; 1990. Acknowledgments 9. Carnevali DL, Thomas MD. Diagnostic 21. Pesut D, Herman J. Clinical Reasoning: The Reasoning and Treatment Decision Mak- Art and Science of Critical and Creative The author thanks Professor Arlene ing. Philadelphia: Lippincott; 1993. Thinking. Albany, NY: Delmar; 1999. Farren, College of Staten Island, for 10. Gordon M. Nursing Diagnosis: Process and 22. Kassirer JP. Teaching clinical medicine by permission to use the case study of Application. New York: McGraw-Hill; 1994. iterative hypothesis testing. Let’s preach Laura and Professor Coleen Kumar, 11. Gigliotti E. A theory-based clinical nurse what we practice. N Engl J Med. 1983; specialist practice exemplar using Neu- 309(15):921-923. Kingsborough Community College, man’s Systems model and nursing’s taxon- 23. Levine MA. Nursing diagnosis in cross- for permission to use the case study omies. Clin Nurse Spec. 2001;16(1):10-16. cultural settings. In: Lunney M, ed. Critical of Stella. 12. Benner PA. Novice to Expert: Promoting Thinking and Nursing Diagnoses: Case Excellence and Power in Professional Studies and Analyses. Philadelphia: NANDA Nursing Practice. Menlo Park, CA: Addi- International; 2001:106-107, 208-210. son Wesley; 1984. 24. Levin RF, Lunney M, Krainovich-Miller B. References 13. Smith A, Jack K. Reflective practice: a Improving diagnostic accuracy using an 1. U.S. Department of Health and Human meaningful task for students. Nurs Stand. evidenced-based nursing model. Int J Services. HHS Fact Sheet—HIT Report At- 2005;19(26):33-37. Nurs Terminol Classif. 2005;15(4):114-122.

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