Nursing Diagnosis in
Health Care Organizations:
Factors that facilitate – and
complicate - implementation
Medical Diagnosis
• Terminology used by physicians and
advanced practice nurses (nurse
practitioners) for a clinical judgment that
identifies or determines a specific
disease, condition, or pathological
state
Nursing Diagnosis
• Terminology used by professional nurses that
identifies actual, risk or wellness responses to a
health state, problem or condition
• Terminology used by professional nurses that
identifies a person’s, family’s, or community’s
motivation and desire to increase wellbeing
and actualize human health potential
Comparisons
• Medical Diagnoses
• Nursing Diagnoses
– Chronic obstructive
pulmonary disease
– Ineffective breathing
pattern
– Cerebrovascular attack
– Activity intolerance
– Amputation
– Disturbed body image
– Readiness for enhanced
coping
Nursing Diagnosis: Definition
• The NANDA definition of a nursing diagnosis
was adapted from a national, Delphi study by
Dr. Joyce Shoemaker (1984)
– Nursing diagnosis is a clinical judgment about individual, family,
or community responses to actual or potential health
problems/life processes. Nursing diagnoses provide the basis for
selection of nursing interventions to achieve outcomes for which
the nurse is accountable (NANDA, 1997).
Suggested Revision to Definition
of Nursing Diagnosis (2008)
A nursing diagnosis is a clinical judgment that nurses make
about individual, family and community responses to
conditions/life processes. Based on that judgment, the
nurse is responsible for monitoring of client
responses, decision-making culminating in a plan of
care, and implementing interventions, including
interdisciplinary collaboration and referral as
needed. The nurse is wholly or partially accountable
for the achievement of the desired outcomes.
The Diagnoses
• 206 NANDA-approved nursing diagnoses
as of 2008
• Level of Evidence (LOE) Criteria
Established for All New and Revised
Diagnoses
– Entry into the Taxonomy requires various
levels of clinical evidence
Diagnosis Requires Assessment
• Identifying human responses that are related to
medical diagnosis without a complete
assessment to determine the presence of
defining characteristics
– Lack of instruction on clustering assessment data to
derive a list of potential diagnoses
– Lack of hypothesis testing to determine best
diagnoses for each patient
“The List”
• Automating the electronic record to populate the
plan of care with nursing diagnoses when a
particular medical diagnosis is used
– Becomes a documentation tool rather than an
individualized plan of care to direct nursing
interventions to meet important patient outcomes
– Puts patients at risk / Negligence
• May ignore or miss important diagnoses for patients
• Plan of care does not address critical outcomes for patients
Teaching Methods
• Requiring students to develop and detail care plans with
“every possible diagnosis” creates resistance that carries
into practice
– Sets up situation that is not realistic
• Cannot address every possible diagnosis in a short hospital stay
– Becomes a “thing to do” rather than truly understanding and
applying diagnostic reasoning and differential diagnosis
• Nurses learn to “just pick a diagnosis” rather than making decisions
about the best explanation(s) for patient responses
Physician Barriers
• Lack of understanding of difference between nursing and
medicine
– Belief that medicine should direct all nursing care
– Lack of collegiality or interdisciplinary collaboration
• Nursing may not be seen as an autonomous profession
– “Practicing medicine without a license”
– Nursing seen as subservient to medicine
• Lack of understanding of purpose of nursing diagnosis
Organizational Buy-In
• Nurse administrator(s) must understand benefits and
support the use of standardized languages
– Nursing diagnoses articulate phenomena of concern to nurses,
and provide a common language for the conditions that nurses
treat
– Nursing outcomes provide measures of nursing effectiveness
– Nursing interventions demonstrate what nurses do
– Data can be used to demonstrate when nurses are more
effective than unlicensed personnel or when more nurses are
needed to achieve desirable outcomes
Organizational Buy-In
• Nursing staff must understand that diagnosis is
more than a “task”
– Articulates the critical thinking and clinical judgment of
nurses as they care for patients
– Consistent education is important
– Updating staff on revisions and new diagnoses is
critical
Provide On-Going Staff Education
• Highlight use of standardized nursing language
in organizational newsletters
• Email blasts with “diagnosis of the month” and
case studies to illustrate proper diagnosis
• Peer review / patient grand rounds with actual
patient information or use of case studies
Nursing Diagnosis Linkages
• Cannot stop with identifying the diagnosis
– Link to outcomes related to the diagnoses
– Identify nursing interventions related to the desired
outcomes
• Strength is in the combination of all three
components of standardized nursing language
– Diagnosis
outcomes
interventions
Physician Collaboration
• Articulate difference between nursing and
medicine
– Encourage collegiality and interdisciplinary
collaboration
• Identify purpose of nursing diagnosis and impact
on patient outcomes
• Demonstrate local impact of nursing diagnoses
on patient outcomes
Health Care Today
• Financial pressures
– Early discharges
– Fewer hospital admissions
• Diminished nurse-to-patient contact
– Less time to assess patients and identify accurate
diagnoses
– Less time to work with patients/families
• Patient/family education suffers
• Less time to support them in regaining health
Clinical Decision Making
• Health care professionals face complex
decisions daily regarding patient care— and
must do so with decreased resources (less staff,
less time, less money for equipment and
supplies)
– What is the area of concern that nurses can
treat/prevent/monitor? (Diagnosis)
– What is an appropriate goal for this patient?
(Outcome)
– What treatment is most effective? (Intervention)
Quality Nursing Care
• Accurate Assessment and Diagnosis
– Defining characteristics
– Related factors
– Risk factors
• Identify Attainable Patient Outcomes
– Efficiency
• Utilize Proven Interventions
– Effective
– Least resource-intensive
Standardized Nursing Language
• Critical for improving patient care
• Lack of standardization leads to:
– Inability to identify assessment criteria that are key to
diagnostic accuracy
– Inability to determine effective interventions that lead
to positive outcomes
– Inferior patient care
Standardized Nursing Language
• Provides evidence-based terminology
– Describes practice
– Drives research
– Documents the impact of nursing care on health care
quality
Implementation
•
•
•
•
Educate staff and other disciplines
Case review to improve diagnostic ability
Reflect diagnostic ability and usage in staff evaluations
Keep it practical – address diagnoses that can actually be
treated in your setting
– Refer to nurses in other settings for other diagnoses, as needed
• Home health care
• Hospice
• School Nursing
Implementation
• Teach managers / administrators how to track data to
demonstrate what nurses do and how they impact
patient outcomes
• Routinely share data with staff nurses and other
disciplines that demonstrates impact of nursing care on
clinical outcomes, through the use of standardized
nursing language
Implementation
• Identify gaps in the NANDA-I taxonomy
– Revise / develop diagnoses that are needed in your
practice
– Submit them to NANDA-I electronically for
acceptance (www.nanda.org)
Standardized Nursing Language
and Evidence-Based Practice
• Provide nurses with researched concepts
(diagnoses), outcomes for which nurses are
accountable and interventions that have been
proven to be effective
• Why would we use anything else?
What do we need?
• Emphasis on development, testing and
validation of new diagnostic concepts
• Revision of current diagnoses that lack
sufficient evidence-based defining
characteristics, risk factors or related
factors
The Future of Nursing Diagnoses
• NANDA-International’s aim is to link with
organizations across the world that have
as their purpose nursing language
development
– Increase diagnosis submission
– Increase clinical testing of diagnoses
– Ensure cultural sensitivity of diagnoses