Implementing nursing diagnostics effectively: cluster randomized trial

Title. Implementing nursing diagnostics effectively: cluster randomized trial. Aim. This paper is a report of a study to investigate the effect of guided clinical reasoning. This method was chosen as a follow‐up educational measure (refresher) after initial implementation of standardized language. Background. Research has demonstrated nurses’ need for education in diagnostic reasoning to state and document accurate nursing diagnoses, and to choose effective nursing interventions to attain favourable patient outcomes. Methods. In a cluster randomized controlled experimental study, nurses from three wards received guided clinical reasoning, an interactive learning method. Three wards, receiving classic case discussions, functioned as control group. Data were collected in 2004–2005. The quality of 225 randomly selected nursing records, containing 444 documented nursing diagnoses, corresponding interventions and outcomes was evaluated by applying 18 Likert‐type items with a 0–4 scale of the instrument Quality of Nursing Diagnoses, Interventions and Outcomes. The effect of guided clinical reasoning was tested against classic case discussions using T‐tests and mixed effects model analyses. Findings. The mean scores for nursing diagnoses, interventions and outcomes increased significantly in the intervention group. Guided clinical reasoning led to higher quality of nursing diagnosis documentation; to aetiology‐specific interventions and to enhanced nursing‐sensitive patient outcomes. In the control group, the quality was unchanged. Conclusion. Guided clinical reasoning supported nurses’ abilities to state accurate nursing diagnoses, to select effective nursing interventions and to reach and document favourable patient outcomes. The results support the use of the North American Nursing Diagnosis Association, Nursing Interventions Classification and Nursing Outcomes Classification classifications and demonstrate implications for the electronic nursing documentation.     

Case Study: Home Nursing Care for a 62‐Year‐Old Woman with Multiple Health Problems

PURPOSE. This case study illustrates the characteristics of, and challenges for, a woman in the United States with multiple health problems. DATA SOURCES. Data were obtained through the authors' experience and knowledge of community health nursing and from published literature. DATA SYNTHESIS. NANDA International, Nursing Interventions Classification, and Nursing Outcomes Classification were utilized to identify appropriate nursing diagnoses, interventions, and outcomes for the client. CONCLUSION. This case study illustrates and provides appropriate nursing diagnoses, interventions, and outcomes relevant to a woman with many health concerns. It provides guidance for nurses in community health settings when caring for patients with multiple health problems. IMPLICATIONS FOR NURSING PRACTICE. Utilizing the standardized nursing languages of NANDA International, Nursing Interventions Classification, and Nursing Outcomes Classification can provide the necessary framework for enhancing and improving the management of care for patients with many health concerns in the community setting.     

Case Study: Home Nursing Care for a 62-Year-Old Woman with Multiple Health Problems

PURPOSE.  This case study illustrates the characteristics of, and challenges for, a woman in the United States with multiple health problems.
DATA SOURCES.  Data were obtained through the authors' experience and knowledge of community health nursing and from published literature.
DATA SYNTHESIS.  NANDA International, Nursing Interventions Classification, and Nursing Outcomes Classification were utilized to identify appropriate nursing diagnoses, interventions, and outcomes for the client.
CONCLUSION.  This case study illustrates and provides appropriate nursing diagnoses, interventions, and outcomes relevant to a woman with many health concerns. It provides guidance for nurses in community health settings when caring for patients with multiple health problems.
IMPLICATIONS FOR NURSING PRACTICE.  Utilizing the standardized nursing languages of NANDA International, Nursing Interventions Classification, and Nursing Outcomes Classification can provide the necessary framework for enhancing and improving the management of care for patients with many health concerns in the community setting.     

The national post-baccalaureate graduate nurse residency program: a model for excellence in transition to practice.

The Chief Nursing Officers (CNOs) of the University HealthSystems Consortium (UHC) of Academic Hospitals desired to increase the numbers of baccalaureate graduate nurses hired by their facilities and provide a more consistent, uniform transition into practice for these graduate nurses. A partnership between the UHC CNOs and the American Association of Colleges of Nursing (AACN) led to establishing a National Post-Baccalaureate Graduate Nurse Residency Program. The structure, curriculum, and outcomes measures were developed and the program was implemented, with growth from six original pilot sites to 34 academic hospitals. Outcomes from the first year of program operation at these six sites show a high rate of retention, decreased stress by graduate nurses over time, improved organization and prioritization of care, and increased satisfaction in the first year of practice.     

A Pilot Study to Validate the Priority Nursing Interventions Classification Interventions and Nursing Outcomes Classification Outcomes for the Nursing Diagnosis "Excess Fluid Volume" in Cardiac Patients

PURPOSE.  To validate the content of the priority Nursing Interventions Classification (NIC) interventions and Nursing Outcomes Classification (NOC)-suggested outcomes for cardiac patients with the nursing diagnosis excess fluid volume in the Brazilian context.
METHODS.  The content of the interventions and outcomes was scored by seven expert nurses using a Likert scale, using the Fehring model.
FINDINGS.  From the 83 activities of the priority NIC interventions, nine had scores lower than 0.5 (nonuseful) and 50 had scores higher than 0.8 (major); from the 53 indicators of the suggested NOC outcomes, eight scored lower than 0.5 and 26 had scores higher than 0.8.
CONCLUSIONS.  The majority of the NIC interventions and NOC outcomes were considered useful by the Brazilian Cardiology expert nurses.
IMPLICATIONS FOR PRACTICE.  Clinical studies are an important strategy for validation of the usefulness of North American Nursing Diagnosis Association, NIC, and NOC language in clinical protocols. Additional studies are necessary to confirm the findings of this pilot study.     

Older Adult Who Falls: A Case Study

PURPOSE. The purpose of this case study is to illustrate the nursing process by incorporating the standardized nursing languages of NANDA International, the Nursing Interventions Classification, and the Nursing Outcomes Classification to assist an older adult with a history of falls. DATA SOURCES. The data sources were the author's clinical nursing practice and research‐based evidence related to falls of older adults. DATA SYNTHESIS. The data were synthesized by using clinical reasoning to select the best possible nursing diagnoses, interventions, and patient outcomes. CONCLUSIONS. To provide a framework for nurses to achieve positive patient outcomes, standardized nursing languages should be incorporated into patients' clinical nursing databases. IMPLICATIONS FOR NURSING. In determining factors that relate to falls, nurses need to obtain baseline data, set goals with patients, and identify milestones, while encouraging patients to be active participants in plans of care.     

Consensus‐Validation Study Identifies Relevant Nursing Diagnoses,Nursing Interventions,and Health Outcomes for People with Traumatic Brain Injuries

A consensus‐validation study used action research methods to identify relevant nursing diagnoses, nursing interventions, and patient outcomes for a population of adults with traumatic brain injury (TBI) in long‐term care. In meetings totaling 159 hours to reach 100% consensus through group discussions, the three classifications of NANDA International's (NANDA‐I's) approved nursing diagnoses, the Nursing Interventions Classification (NIC), and the Nursing Outcomes Classification (NOC) were used as the basis for three nurses experienced in working with adults with TBI to select the elements of nursing care. Among almost 200 NANDA‐I nursing diagnoses, 29 were identified as relevant for comprehensive nursing care of this population. Each nursing diagnosis was associated with 3–11 of the more than 500 NIC interventions and 1–13 of more than 300 NOC outcomes. The nurses became aware of the complexity and the need for critical thinking. The findings were used to refine the facility's nursing standards of care, which were to be combined with the interdisciplinary plan of care and included in future electronic health records.     

Case Study: The Challenges of Self‐Management of Exacerbation of Pulmonary Symptoms

PURPOSE. This case study demonstrates the signs and symptoms of pulmonary exacerbation and the challenges of self‐management for a female veteran. DATA SOURCES. Data were obtained through the author's clinical practice in primary care nursing and research literature sources. DATA SYNTHESIS. The appropriate nursing diagnosis, nursing interventions, and patient outcomes were identified through the use of NANDA‐International, the Nursing Interventions Classification, and the Nursing Outcomes Classification. CONCLUSIONS. This case study illustrates the appropriate nursing diagnosis, interventions, and outcomes pertinent to an individual with pulmonary exacerbations. It provides a framework for nurses in primary care when caring for individuals with pulmonary exacerbations. IMPLICATIONS FOR NURSING PRACTICE. Employing the NANDA‐International standardized nursing diagnoses, the Nursing Interventions Classification and the Nursing Outcomes Classification provided the needed constructs for improving care for a patient that had pulmonary issues in a primary care setting.     

NANDA diagnoses, NIC interventions, and NOC outcomes used in an electronic health record with elementary school children.

This is a report of a secondary analysis of data from a published quasi-experimental feasibility study of the effects of implementing diagnoses from North American Nursing Diagnosis Association International, interventions from the Nursing Interventions Classification, and outcomes from the Nursing Outcomes Classification (referred to as NNN) on nurses' power and children's health outcomes. For this study, the NNN terms that were frequently used by nurses in the original study were identified through the nurses' printed reports of health-related visits (N = 766) with 103 New York City children in the 4th and 5th grades in six schools. The findings indicate that a large majority of nurses' efforts were focused on health promotion and management of risk states. Health problems such as pain and ineffective airway clearance were identified and were treated when present. Findings from this study can be combined with findings from previous studies to identify the diagnoses, interventions, and outcomes that are relevant for school settings. Use of the relevant NNN terms will provide data to support evidenced-based school nursing practice, education of school nurses, development of policies, and communication of the value of school nursing practice to stakeholders.     

Validity and community-health-nursing sensitivity of six outcomes for community health nursing with older clients

A survey research design was used to assess the importance, sensitivity to nursing interventions, and content validity of six client outcomes from the Nursing Outcomes Classification (NOC)). Outcomes relevant for elderly community residents and caregivers were included in a questionnaire mailed to American Nurses Credentialing Center-certified expert community health nurses. Two hundred thirty-nine experts rated specific indicators of the six outcomes for their importance in determining the outcomes and the contribution of nursing to their achievement. Outcomes also were rated for their importance for community health nursing clients and responsiveness to community health nursing intervention. Results strongly support the content validity and nursing sensitivity of outcomes and specific indicators. Experts judged all six outcomes to be important and 90% of indicators as important in determining the outcome. All outcomes and 78% of indicators were judged to be responsive to community health nursing intervention. Recommendations include the testing of NOC outcomes in community health nursing clinical practice and inclusion in community health nursing curricula. Areas for further research include development and validation of community-level outcomes, validation of outcomes with rural and home health nursing experts, and exploration of the community health nursing-sensitivity of one study outcome.     

Shaping positive work environments for nurses: the contributions of nurses at various organizational levels

This paper focuses on nurses' perceptions of their individual contributions to the work environment. Fourteen community hospitals participated in the study. A positive nursing work environment was selected in each agency by its Director of Nursing. Selection was based on subjective and objective criteria. All staff nurses, nurse managers and the director of nursing associated with these units were asked to respond to an open-ended question describing their perceived contributions to the work settings. Ninety-two nurses responded for a response rate of 42%. Overall the three themes of People, Practice and Place surfaced from 15 categories of responses. The same three themes surfaced for all three nurse groups but variation was noted with regards to the categories of contributions the groups most frequently reported within the theme. In this time of continuous change throughout the health care system, nurses need to be able to articulate and affirm their important contributions to the effective shaping of positive health care settings. A focus on contributions could assist with team building, leadership development and have an important impact on quality patient care outcomes.     

Evaluation of the reliability and validity of nursing outcomes classification patient outcomes and measures

One hundred sixty-nine of the Nursing Outcomes Classification (NOC) patient outcomes were tested for interrater reliability, criterion validity, and sensitivity. In 10 field sites, ranging from hospitals to home care, pairs of nurses rated the outcome measures for 5 to 130 patients. Inter-class correlations were greater than or equal to 0.70 for 63 outcomes. Pearson's correlations with criterion measures were greater than or equal to 0.60 for 40 outcomes and from 0.39 to 0.60 for 43 additional ones. Change scores for 99 outcomes ranged from 0 to 2.0 from first to second and second to third rating. Most NOC measures demonstrated good inter-rater reliability, substantial criterion validity, and sensitivity to change. More testing and thorough training of nurses using NOC outcomes are needed.     

Case Study: The Challenges of Self-Management of Exacerbation of Pulmonary Symptoms

PURPOSE.  This case study demonstrates the signs and symptoms of pulmonary exacerbation and the challenges of self-management for a female veteran.
DATA SOURCES.  Data were obtained through the author's clinical practice in primary care nursing and research literature sources.
DATA SYNTHESIS.  The appropriate nursing diagnosis, nursing interventions, and patient outcomes were identified through the use of NANDA-International, the Nursing Interventions Classification, and the Nursing Outcomes Classification.
CONCLUSIONS.  This case study illustrates the appropriate nursing diagnosis, interventions, and outcomes pertinent to an individual with pulmonary exacerbations. It provides a framework for nurses in primary care when caring for individuals with pulmonary exacerbations.
IMPLICATIONS FOR NURSING PRACTICE.  Employing the NANDA-International standardized nursing diagnoses, the Nursing Interventions Classification and the Nursing Outcomes Classification provided the needed constructs for improving care for a patient that had pulmonary issues in a primary care setting.     

Outcomes for community health nursing practice.

OBJECTIVE: The purpose of this study was to develop an easy, practical list of outcomes amenable to community health nursing interventions. This study sought to answer the following question: What outcomes are sensitive to nursing interventions in the community health setting? SUMMARY BACKGROUND DATA: Nursing literature discusses many client outcomes. However, available outcome lists are not always sensitive to nursing interventions by community health nurses. Nurses need a precise list to measure client outcomes resulting from contact between nurses and clients in a variety of community health settings. METHODS AND SUBJECTS: The study used a modified Delphi technique to ensure adequate response from the subjects. Initially, focus groups generated items for the Delphi questionnaires. Using items from the focus groups, the researchers developed three rounds of questionnaires. In each round, nurses stated a level of agreement with each item as an outcome for community health nurses. Twenty-two community health nurses in one Southeastern state participated in four focus groups. One hundred fifty-two community health nurses returned round 1 questionnaires, 68 nurses returned round 2 questionnaires, and 48 nurses returned round 3 questionnaires. RESULTS: The researchers grouped the outcomes into four domains: client's psychosocial components of care, client's physiologic components of care, nursing intervention/implementation components of care, and environmental/community safety components of care. CONCLUSIONS: The findings produced an easy, practical list of 48 nursing outcomes for use in decision making and research by community health nurses in all settings.     

The Nursing Outcomes Classification: Validation by Rehabilitation Nurses

Measuring patient outcomes is important to rehabilitation nurses and the patients they serve. This article describes research conducted at the University of Iowa College of Nursing to develop the Nursing Outcomes Classification (NOC) and the validation of this research by surveys conducted through specialty nursing organizations, particularly the Association of Rehabilitation Nurses. Nurses responded to surveys designed to validate (a) the importance of outcome indicators to the achievement of an outcome and (b) nursing's contribution to the achievement of the indicators. The results of the surveys indicated that rehabilitation nurses believe that nursing makes a substantial contribution to most outcomes and indicators.     

Better care in nursing homes: advanced practice nurses' strategies for improving staff use of protocols

This article describes a set of strategies used by gerontologic advanced practice nurses (GAPNs) in three nursing homes to integrate the use of protocols into the daily care of residents. The protocols were developed as part of a larger study on the quality of care in nursing homes carried out by nurse researchers at the University of Minnesota and funded by the National Institute of Nursing Research (R01-NR03490). The GAPNs worked regularly with nursing home staff to incorporate aspects of protocols into daily care routines for residents with four specific problems common in elderly residents of nursing homes: pressure ulcers, incontinence, depression, and aggressive behavior. Outcomes of the larger study showed that residents with these four problems had better outcomes in the homes in which care was planned by the GAPNs using protocols that were integrated into the daily routines of staff.     

Case Study: A Woman Who Hemorrhages 24 Hours Post Tonsillectomy

PURPOSE. This case study focused on the emergency nursing care of a 32‐year‐old female, less than 24 hours post operatively from a tonsillectomy. The purpose is to identify the priority nursing diagnoses, patient outcomes, and nursing interventions that guided nursing care during this emergency. DATA SOURCES. Data were obtained through the author's clinical practice in emergency nursing and literature sources. DATA SYNTHESIS. NANDA International Classification, the Nursing Outcomes Classification, and the Nursing Interventions Classification were used to identify the appropriate nursing diagnosis, patient outcomes, and nursing interventions of an adult with a postoperative hemorrhage. CONCLUSIONS. This case study provides emergency nurses and students with the pertinent nursing diagnoses, patient outcomes, and nursing interventions for persons with post‐op hemorrhage after tonsillectomy.     

Development of a nursing data set for school nursing.

School nurses need to clearly identify how they promote the health and educational achievement of children. School nurses contribute to student health by providing health assessment and nursing interventions, advocating for healthy living, and contributing to prevention of illness and disease management. A Nursing Data Set for School Nursing can identify those data elements that are needed to prove that school nurses have a positive effect on children, families, and the community. The purpose of this project was to develop a Nursing Data Set for School Nursing that would describe and validate school nursing practice. Building on the Nursing Minimum Data Set developed by Werley, Devine, and Zorn, a Nursing Data Set for School Nursing was developed with guidance from experts in the field of school nursing. A Nursing Data Set for School Nursing has the potential to assist school nurses in documentation and validation of their nursing practice. It can validate the complexity of the role of the school nurse, the resources needed, and the effect school nurses have on improving the health and educational outcomes of students.