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Nursing Diagnoses in Inpatient Psychiatry
Fritz Frauenfelder, MNSc, RN, Theo van Achterberg, PhD, RN, Ian Needham, PhD, MNSc, RN, and
Maria Müller Staub, PhD, EdN, RN, FEANS
Fritz Frauenfelder, MNSc, RN, is the Vice Director of the Directorate of Nursing, Therapies and Social Work Psychiatric,
University Hospital Zürich, Zürich, Switzerland, Theo van Achterberg, PhD, RN, is a Professor of Quality of Care at KU
Leuven—Centre for Health Services and Nursing Research, Leuven, Belgium, and Professor of Quality of Care at the
Scientific Institute for Quality of Health Care, Radboud University Medical Centre, Nijmegen, The Netherlands, Ian
Needham, PhD, MNSc, RN, is the Head of Nursing Research, Center of Education & Research (COEUR), Wil, Switzerland, and
Maria Müller Staub, PhD, EdN, RN, FEANS, is the Director of Pflege PBS (Projects, Consulting, Research), Wil, Switzerland,
and a Professor Adjunct, Lectorat Nursing Diagnostics, Hanze University Groningen, The Netherlands.
Search terms:
Inpatient psychiatry, NANDA-I
classification, nursing
documentation
Author contact:
ffj@bluewin.ch, with a copy to the
Editor: journal@nanda.org
PURPOSE: This study explored how well NANDA-I covers the reality of adult
inpatient psychiatric nursing care.
METHODS: Patient observations documented by registered nurses in records
were analyzed using content analysis and mapped with the classification NANDA-I.
FINDINGS: A total of 1,818 notes were examined and contained 46 different
patient responses. Twenty-nine patient responses were recognizable as NANDA-I
diagnoses at the level of definitions, 15 as diagnoses-related factors, and 12 did not
match with any NANDA-I diagnosis.
CONCLUSIONS: This study demonstrates that NANDA-I describes the adult inpatient psychiatric nursing care to a large extent. Nevertheless, further development
of the classification is important.
IMPLICATIONS FOR NURSING PRACTICE: The results of this study will spur
nursing research and further classification development.
Nursing care promotes and maintains health, prevents
health problems, and assists people in treating illnesses and
in dealing with the consequences of illnesses and their therapies (International Council of Nurses, 2009). Yet, in the past,
there was no consistent way to describe the practice of
nursing care. Nursing documentation was characterized as a
mixture of medical terms and nurses’ own words (Keenan,
Tschannen, & Wesley, 2008). As a consequence, services
provided by nurses were generally invisible and not
comprehensible. The development of standardized nursing
terminologies has supported the crucial requirement to
adequately describe nursing practice in order to provide a
basis for decisions to ensure the efficacy of nursing care and
to improve care continuity (Keenan & Yakel, 2005; Keenan
et al., 2008; Müller-Staub, Needham, Odenbreit, Lavin, & van
Achterberg, 2007, 2008). According to a bibliometric analysis, the classification set NNN (NANDA-I, nursing outcomes
classification, and nursing interventions classification) was
identified as having the widest diffusion profile and demonstrated the most noteworthy patterns of sustainability in
comparison with other classification systems (Anderson,
Keenan, & Jones, 2009); several authors have reported
similar results (Müller-Staub, Lavin, Needham, & van
Achterberg, 2007; Odenbreit, Müller-Staub, Brokel, Avant, &
Keenan, 2012). The NNN system was also shown to best
fulfill the essential features of nursing classification
systems: standardized documentation of the nursing
© 2014 NANDA International, Inc.
International Journal of Nursing Knowledge Volume ••, No. ••, •• 2014
process, generation of a standard dataset, and practicability
of data exchange between different electronic data systems
(Just et al., 2005). Further, a conceptual data model for
electronic nursing process documentation was developed
that also defines nursing-related data for cost-centered
accounting procedures as part of the Swiss Nursing
Minimum Data Set (Bernhart-Just, Hillewerth, Holzer-Pruss,
Paprotny, & Zimmermann Heinrich, 2009). Johnson et al.
(2012) postulated that the NNN represents the domain of
nursing in all settings and their subdomains. In addition, the
application of NNN enhances the coherence among documented nursing diagnoses, interventions, and outcomes
(Müller-Staub, Lavin, Needham, & van Achterberg, 2006),
and improves the quality of nursing diagnosis documentation, etiology-specific nursing interventions, and nursingsensitive patient outcomes (Müller-Staub, Needham, et al.
2007).
The nursing diagnosis classification NANDA-I is one of the
classifications in the NNN taxonomy. Validation studies
addressing the accuracy of individual NANDA-I nursing
diagnoses were found in the literature, and some studies
addressed the relevance of NANDA-I in specific nursing settings. For instance, the most frequently used perioperative
NANDA-I diagnoses as well as their related factors and defining characteristics were analyzed, and the findings were
compared with a perioperative nursing dataset (De Souza
Viegas, Turrini, & Da Silva Bastos Cerullo, 2010). Speksnijder,
1
Nursing Diagnoses in Inpatient Psychiatry
Mank, and van Achterberg (2011) conducted an international
Delphi study on the prevalence of nursing diagnoses in
hematology-oncology nursing settings; Zampieron, Aldo,
and Corso (2011) analyzed nursing documentations in
a cardiology rehabilitation setting, and Thoroddsen and
Thorsteinsson (2002) in somatic acute care. In a systematic
literature review, nursing-relevant problems in nursing
journal articles about psychiatric inpatient nursing care
were identified (Frauenfelder, Müller-Staub, Needham, & van
Achterberg, 2011). The study indicated that the NANDA-I
classification largely covers essential phenomena of adult
inpatient psychiatry; however, a number of important
nursing phenomena that are not included in the classification were also identified. To strengthen the NANDA-I classification for use in the daily work of inpatient psychiatric
nurses, it is essential to investigate nursing phenomena in
direct clinical care (Frauenfelder et al., 2011). However,
studies addressing documented patient problems in psychiatric care and how these problems match the NANDA-I
classification were lacking.
The present study focused on patient observations documented by nurses in records of adult inpatient psychiatry.
The aim was to identify the gaps and inconsistencies
between the NANDA-I classification and nurses’ documentations, and to explore the potential for further development of psychiatry-specific nursing diagnoses to ensure
adequate descriptions of patients’ health responses in this
setting. No previous studies on this topic could be found.
The study was examined and approved by the ethical
committee of the canton of Zurich, Switzerland (KEK-ZHNR.2013-0268).
Background
Mental health care comprises various settings with a
wide range of special treatment approaches. Although in
recent decades the numbers of beds have been reduced in
favor of outpatient treatments (Roger & Gray, 2009;
Townsend, 2008), inpatient treatments are still important
(Aiyegbusi & Norton, 2009). Inpatient settings offer a safe
and structured environment for people who endanger
themselves or others due to mental disorders (Varcarolis,
2009). Sauter, Abderhalten, Needham, and Wolff (2011)
identified four conditions that justify admission to an inpatient setting: the patient is in an acute personal crisis and
needs services around the clock; the patient or his/her relatives are unable to perform daily self-care and needs help at
different times during the day; the patient’s situation
requires compulsory measures or special treatments that
can only be administered in an inpatient facility; and the
patient or his/her relatives need a temporary change of
setting. Three main aspects characterize the daily work of
psychiatric nurses: caring, attending, and patient advocacy
(Varcarolis, 2009). The interaction and assistance of nurses
are oriented toward resolving mental, emotional, and dysfunctional aspects of life crises, managing and alleviating or
easing painful symptoms of mental disorders, improving
2
F. Frauenfelder et al.
overall functioning, and decreasing personal and social consequences of mental illness, including the stigma attached
to mental disorders (Holoday Worret, 2008).
Research Aim and Question
Identifying gaps between patient problems and/or the
human responses of psychiatric patients and NANDA-I
will strengthen the classification. A diagnosis classification system that describes problems and/or the human
responses of patients suffering from mental and behavioral
disorders will improve the care quality of inpatient psychiatric settings.
The aims of this study were to identify human responses
to actual or potential health problems/life processes in
unstructured records written by nurses in free text and to
compare these with the NANDA-I classification.
The following research question was addressed:
• Which of the documented patients’ responses to actual or
potential health problems/life processes in inpatient psychiatry are included in the NANDA-I classification?
Methods
A nursing record audit was performed to identify
responses to actual or potential health problems/life
processes. Content analyses, a mapping procedure, and
descriptive statistics were applied to compare identified
patient responses from the records with NANDA-I nursing
diagnoses.
Setting
The study was performed in a specialized center for psychiatric adult inpatient rehabilitation in Switzerland. This
center comprises seven wards, with on average 15 beds for
patients with severe chronic mental health disorders. All
patients were between 18 and 65 years old, and suffered
from pronounced mental and behavioral symptoms. Most of
them were diagnosed with dual or triple psychiatric-medical
diagnoses: schizophrenia, personality disorders, and/or
legal drug abuse (e.g., alcohol). The social and economic
situations of these patients are often desolate, and negatively affect stigmatization and isolation. Treatment of
these patients is based on the recovery concept and
focuses on training in functioning in daily life and disease
management. This treatment approach enhances the integration of patients into outpatient psychiatric services, as
well as into appropriate residential and occupational surroundings (Hoff et al., 2011). Although most nurses working
in this setting had been exposed to nursing diagnoses
during their formal nursing education, their knowledge and
skills were not transferred to daily work and the NANDA-I
classification was not used on the wards.
F. Frauenfelder et al.
Sample
The present study included unstructured nursing records
(called nursing notes) written in free text to identify
descriptions of patient responses to actual or potential
health problems/life processes. The nursing notes are
written daily for each individual patient and contain diverse
unstructured information, for example, patients’ state
and behavior, as well as other occurrences observed by
nurses or reported by patients, their relatives, or significant
others. Therefore, the nursing notes represent nurses’ perspective on “daily business.” Not included in the present
study were other documents related to nursing (e.g.,
medical/treatment prescriptions, forms for monitoring
recovery processes or treatment agreements, interdisciplinary status reports).
During the data collection period between January 1 and
June 30 of 2009, 336 patients were hospitalized in seven
wards of the center. From this number of patients, 70
patients were randomly selected (10 per ward), and 3 weeks
worth of their nursing notes were analyzed: the first, the
middle, and the last week of the hospitalization within the
data search period. In the case of patients whose stays were
shorter than 3 weeks, all nursing notes were analyzed.
Analysis
All nursing notes in the identified records were paperbased and handwritten by nurses. The nursing notes
describe conditions, behaviors, and everyday appearance of
each individual patient.
A multistep approach using content analysis (Mayring,
2010) by building inductive categories was applied.
In the first step, all identified nursing notes were transcribed and paraphrased by a nursing scientist specialized
in psychiatric nursing care. The data were anonymized
to render locations and persons unidentifiable. Further,
orthography errors and incorrect word order were corrected without changing the content of the texts. The most
frequent corrections concerned words and phrases formulated in Swiss German dialects or by nurses with a different
first language than German.
The overall focus of the analytical process corresponds
with the definition of nursing diagnosis of the International
Nursing Diagnoses Association: “Responses to actual or
potential health problems/life processes of individual,
family or community that provide the basis for selection of
nursing interventions to achieve outcomes for which the
nurse is accountable” (Herdman, 2012).
In the generalization phase of content analysis, descriptions of patients’ responses (=references) to actual or
potential health problems/life processes were located and
labeled with key words. To ensure consistent content interpretation, each note was analyzed by the first researcher
at least twice. The interval between these analyses was
at least 1 month to avoid recall bias. In the case of interpretation variations, the corresponding original text was
Nursing Diagnoses in Inpatient Psychiatry
reassessed to clarify the findings. In the next step, the
researcher analyzed—where possible—defining and causal
descriptions specifying the phenomena that were described
in the labeled references.
In the reduction phase, all references with their corresponding defining and causal descriptions were grouped
according to key words. Repetitions were listed only once
within a group.
In the next step of the generalization process, all notes
with more than one labeled reference were identified.
Based on the original texts, interactions between references within a note were checked, and where possible
related to each other. If a previous response defined or
caused another one within the note, the corresponding
modification was adapted in the list of references labeled by
key words. All analysis phases were checked by the second
and last authors, and interpretations were compared
among the three researchers. In cases of differing findings,
the analysis process was repeated until agreement was
reached.
Mapping
Each key word represented a patient’s response with
corresponding descriptive and causal descriptions. The
mapping process was conducted using a systematic
approach. Each patient’s response was compared with the
NANDA-I diagnoses.
1. If an identified patient response was recognizable/
mappable in the label and definition of a NANDA-I diagnosis, the patient response was judged as a “full match.”
This patient response was named after the corresponding diagnosis.
2. If the identified patient response was not recognizable/
mappable in the label and definition of a NANDA-I
diagnosis, the patient response was mapped with the
defining characteristics/related factors or risk factors
of NANDA-I diagnoses. If a patient response was
recognizable/mappable in defining characteristics/
related factors or risk factors, the corresponding nursing
diagnoses were identified and allocated to the patient
response. The key word given to the patient response
was maintained (=working title).
3. If a patient response was neither recognizable/mappable
in labels and definitions, nor in defining characteristics /
related factors or risk factors of NANDA-I diagnoses, the
key word given to the patient response was maintained
(=working title).
Results
A total of 1,818 notes, written by registered nurses, were
examined. The analysis yielded 731 notes including one or
more references (N = 1,021) of patients’ identified
responses. These references were grouped into 142 differ3
Nursing Diagnoses in Inpatient Psychiatry
F. Frauenfelder et al.
Figure 1. Flowchart Results
1,818 analyzed entries
731 entries reflecting 1,021
references on patient
responses
(Box a)
451 references
reflecting patient
responses recognizable as a
NANDA-I diagnosis
(N = 29)
(Box b)
316 references
reflecting patient
responses not
recognizable as a
NANDA-I diagnosis but as diagnosesrelated factors
(N = 15)
ent patient responses. Twenty-nine patient responses with
451 references were recognizable as NANDA-I diagnoses at
the level of labels and definitions (Figure 1, Box a). Another
113 patient responses with 570 references could not be
mapped as a nursing diagnosis at the level of definitions.
These patient responses were allotted to working titles. Of
these, 15 patient responses (316 references) were identified
as defining characteristics, related factors, or risk factors of
NANDA-I diagnoses (Figure 1, Box b), and nine patient
responses (130 references) did not match with any NANDA-I
diagnosis at all (Figure 1, Box c). The remaining patient
responses with 124 references were indiscriminate and
vaguely written so that they could not be mapped (Figure 1,
Box d).
Patient Responses Fully Matching With NANDA-I
Diagnoses (at the Level of Definitions)
Table 1 presents an overview of the NANDA-I diagnoses
identified on the basis of the analysis and mapping processes. Pain was the most frequently identified patient
response reflected by NANDA-I diagnoses. A differentiation
between the diagnoses “acute pain” and “chronic pain” was
not possible from the nursing notes, so both diagnoses were
combined. Altogether, more than 80 references referred to
the nursing diagnoses of pain. Almost 80 references
referred to the nursing diagnosis “ineffective coping” and
were unambiguously mappable as NANDA-I diagnosis. The
third most frequently identified nursing diagnosis was “noncompliance,” with 68 references.
Forty references pointed out sleep impairments that
were mappable with the nursing diagnosis “insomnia.”
More than 30 references described situations of physical
weakness and exhaustion that could be mapped to the
nursing diagnosis “fatigue.” Exactly 30 references
4
1,087 entries reflecting no
references on patient responses
(Box c)
130 references
reflecting patient
responses neither
recognizable as a
NANDA-I diagnosis nor diagnosesrelated factors (N =
9)
(Box d)
124 references
reflecting patient
responses indiscriminate and too
vague in order to
recognize a definable focus (N = 89)
described patient feelings of anxiety and were mapped to
the nursing diagnosis “anxiety.” More than 20 references
described the nursing diagnosis “stress overload,” and
more than 10 references each were connected with
“impaired verbal communication,” “nausea,” and “risk of
suicide.” Further, gastrointestinal problems were represented by the diagnoses “diarrhea” (N = 9) and “constipation” (N = 7). The remaining 17 NANDA-I diagnoses were
identifiable in five or fewer references.
Patient Responses Fully Matching With
Diagnoses-Related Factors (Defining Characteristics,
Related Factors, or Risk Factors)
Fifteen patient responses were recognizable as defining
characteristics, related factors, or risk factors of nursing
diagnoses (Table 2). The patient response “restlessness”
(N = 68) describes physical states (restless legs) and communicative states (e.g., “very talkative”), as well as emotional states, primarily perceived by the patients
themselves (inner restlessness). This patient response is
listed as a defining characteristic of different NANDA-I
nursing diagnoses. About half of them seemed not to be a
priority for psychiatric nursing care (e.g., reflex urinary
incontinence, impaired gas exchange, and decreased
cardiac output). Of particular importance are the diagnoses
“ineffective protection,” “sleep deprivation,” “acute confusion,” “anxiety,” “decisional conflict,” and “impaired
comfort,” as well as “acute pain,” and “chronic pain.” The
patient response “emotional tension” was found in 40 references describing the perception of tension in the mental
state of the individual. This patient response is a defining
characteristic of the nursing diagnosis “stress overload.”
Further, the patient response “destructive influencing of
interactions” (N = 40) reflects behavioral patterns that
F. Frauenfelder et al.
Nursing Diagnoses in Inpatient Psychiatry
Table 1. Patient Responses Fully Matching With NANDA-I Diagnoses
NANDA-I diagnosis
N
Definition
Acute pain/chronic pain
81
Ineffective coping
79
Noncompliance
68
Insomnia/disturbed sleep
pattern
40
Fatigue
34
Anxiety
30
Stress overload
Impaired verbal
communication
Nausea
22
18
Risk for suicide
Diarrhea
Constipation
14
9
7
15
Hopelessness
5
Self-neglect
5
Impaired skin integrity
Impaired comfort
4
3
Impaired spontaneous
ventilation
Impaired physical mobility
2
Relocation stress
syndrome
Decisional conflict
2
Hyperthermia
Risk for unstable blood
glucose level
Risk for loneliness
Imbalanced nutrition: less
than body requirements
Bowel incontinence
Deficient fluid volume
1
1
Risk for self-directed
violence
Grieving
1
Post-trauma syndrome
1
2
2
1
1
1
1
1
Acute pain: Unpleasant sensory and emotional experience arising from actual or potential tissue
damage or described in terms of such damage; sudden or slow onset of any intensity from mild
to severe with an anticipated or predictable end and a duration of <6 months
Chronic pain: acute pain: Unpleasant sensory and emotional experience arising from actual or
potential tissue damage or described in terms of such damage; sudden or slow onset of any
intensity from mild to severe with an anticipated or predictable end and a duration of >6
months
Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses,
and/or inability to use available resources.
Behavior of person and/or caregiver that fails to coincide with a health-promoting or therapeutic
plan agreed on by the person (and/or family and/or community) and healthcare professional. In
the presence of an agreed upon, health-promoting, or therapeutic plan, the person’s or
caregiver’s behavior is fully or partially nonadherent and may lead to clinically ineffective or
partially ineffective outcomes.
Insomnia: A disruption in amount and quality of sleep that impairs functioning
Disturbed sleep pattern: Time-limited interruption of sleep amount and quality due to external
factors
An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental
work at the usual level
Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source
often nonspecific or unknown to the individual); a feeling of apprehension caused by
anticipation of danger. It is an alerting signal that warns of impending danger and enables the
individual to take measures to deal with threat.
Excessive amounts and types of demands that require action
Decreased delayed or absent ability to receive, process, transmit, and/or use a system of symbols
A subjective phenomenon of an unpleasant feeling in the back of the throat and stomach that
may or may not resulting in vomiting
At risk for self-inflicted, life-threatening injury
Passage of loose, unformed stools
Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of
stool and/or passage of excessively hard, dry stool
Subjective state in which an individual sees limited or no alternatives or personal choices available
and is unable to mobilize energy on own behalf
Self-neglect: A constellation of culturally framed behaviors involving one or more self-care
activities in which there is a failure to maintain a socially accepted standard of health and
well-being (Gibbons, Lauder, & Ludwick, 2006)
Altered epidermis and/or dermis
Perceived lack of ease, relief, and transcendence in physical, psychospiritual, environmental,
cultural, and social dimensions
Decreased energy reserves resulting in an inability to maintain independent breathing that is
adequate to support life
Limitation in independent, purposeful physical movement of the body or of one or more
extremities
Physiological and/or psychosocial disturbance following transfer from one environment to another
Uncertainty about course of action to be taken when choice among competing actions involves
risk, loss, or challenge to values and beliefs
Body temperature elevated above normal range
At risk for variation of blood glucose/sugar levels from the normal range that may compromise
health
At risk for experiencing discomfort associated with a desire or need for more contact with others
Intake of nutrients insufficient to meet metabolic needs
Change in normal bowel habits characterized by involuntary passage of stool
Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water
loss alone without change in sodium
At risk for behavior in which an individual demonstrates that he or she can be physically,
emotionally, and /or sexually harmful to self
A normal complex process that includes emotional, physical, spiritual, social, and intellectual
responses and behavior by which individuals, families, and communities incorporate an actual,
anticipated, or perceived loss into their daily lives
Sustained maladaptive response to a traumatic, overwhelming event
5
6
N
68
40
40
33
26
Working titles
Restlessness
Emotional tension
Destructive
influencing of
interactions
Odd interpretation
of reality
Aggressive
behavior
The patient’s response concerns behavioral aspects that jeopardize social
coexistence and the integrity of others or things. The manifestations are
characterized by hostile behavior toward objects or persons in differing degrees of
severity: subliminal aggression, latent aggression, violence against others (to
choke, to kick, to pull on hair, to claw, to hit, to bite), violence against oneself, and
violence against objects. Reasons include the personal interpretation of situations
(e.g., “to be harassed by fellow patients; the feeling of being observed”); feelings
of frustration, helplessness, despair, and anxiety; taxing situations (“separation/
divorce, death of a parent, loss of job, housing eviction”); and also environmental
factors (“noise”) and unscheduled, unexpected situations.
The patient’s response concerns emotional tension (“the patient seems to be tense,”
“the patient complains about inner tension”). The manifestations are described
from being slightly to being extremely tense. Reasons mentioned include
depressed mood (“it is normal for her to suffer from high tension during a
depressed episode”), anxiety, imminent discharge, somatic complaints, inability to
accept personal conditions (rage, powerlessness, vulnerability), reactions of fellow
patients (“the fellow patients are not happy with the meal cooked by the patient”),
partnership problems (divorce), problems with personal economy (job, apartment),
or the family.
The patient’s response concerns behaviors that negatively affect interpersonal
interaction with others. The manifestations include insulting or threatening others
(staff, fellow patients), as well as very demanding behavioral patterns, devaluating,
obtrusive, dominant, abusive, ignorant, manipulative, or provocative. Social
contacts within the patient group and with the staff and family members are
disturbed or are unable to be established. The following reasons are identified:
limited relatedness to reality (psychosis), testing limits in social contacts or as a
personal coping strategy in moments of frustration (e.g., when requests are not
immediately fulfilled), or interpersonal conflicts (quarrels with fellow patients).
The patient’s response concerns odd perception and interpretation of reality. The
manifestations are interpretable by inexplicable thoughts, such as situational
misbehavior, chronologically disoriented, misconstruing others or oneself, or
reports of hallucinations (acoustic, optical, etc.). The patients are often described
as scared, despaired, stressed, and/or gloomy. Psychotic episodes as well as
moments of stress (“stress with fellow patients”) are identified as reasons.
The patient’s response concerns physical (“restless leg”) and/or inner restlessness
that are not distinguishable from each other in most entries (“to be talkatively
very active and driven; to phone constantly”; “a little bit driven and seems to be
agitated as evening approaches”; “unable to sit on a chair for longer periods”; “I
feel an inner restlessness and can not fall asleep”). The manifestations are
described from moderate to very and intense restlessness. Usually obvious
reasons are not mentioned for this response in the documentation. One case
describes the process of changing a bandage as a reason for the response.
Descriptions based on identified descriptions in nursing
documentations
Ineffective protection: restlessness (DC)
Excess fluid volume: restlessness (DC)
Reflex urinary incontinence: restlessness (DC)
Impaired gas exchange: restlessness (DC)
Sleep deprivation: restlessness (DC)
Decreased cardiac output: restlessness (DC)
Impaired spontaneous ventilation: restlessness (DC)
Dysfunctional ventilatory weaning response: restlessness (DC)
Acute confusion: restlessness (DC)
Anxiety: restlessness (DC)
Decisional conflict: restlessness (DC)
Ineffective airway clearance: restlessness (DC)
Latex allergy response: restlessness (DC)
Impaired comfort: restlessness (DC)
Acute pain: restlessness (DC)
Chronic pain: restlessness (DC)
Stress overload: tension (DC)
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
Defensive coping: difficulty in perception of reality testing (DC); reality distortion (DC)
Disabled family coping: distortion of reality regarding client’s health problem (DC)
Sleep deprivation: perceptual disorders (e.g., disturbed body sensation, delusions, feeling afloat) (DC)
Sleep deprivation: perceptual disorders (DC); hallucinations (DC)
Disturbed personal identity: delusional description of self (DC)
Rape-trauma syndrome: paranoia (DC)
Acute confusion: hallucinations (DC)
Impaired verbal communication: psychological barriers (e.g., psychosis, lack of stimuli) (RF)
Self-neglect: paranoid personality disorders (RF)
Self-mutilation: psychotic state (e.g., command hallucinations) (RF)
Risk for other-directed violence: Psychotic symptomatology (e.g., auditory, visual, command hallucinations;
paranoid delusions; loose, rambling, or illogical thought processes) (risk factors)
Risk for disturbed personal identity: psychiatric disorders (e.g., psychoses, depression, dissociative
disorder) (risk factors)
Risk for thermal injury: cognitive impairment (e.g., dementia, psychoses) (risk factors)
Risk for self-directed violence: mental health problems (e.g., severe depression, psychosis, severe
personality disorder, alcoholism or drug abuse) (risk factors)
Post-trauma syndrome: aggression (DC)
Rape-trauma syndrome: aggression (DC)
Disabled family coping: aggression (DC)
— Risk for other-directed violence: body language (e.g., rigid posture, clenching of fists and jaw, hyperactivity,
pacing, breathlessness, threatening stances) (risk factors)
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
Integrated in defining characteristics (DC), related factors
(RF), or risk factors of nursing diagnoses (risk factors)
Table 2. Patient Responses Fully Matching With Diagnoses-Related Factors
Nursing Diagnoses in Inpatient Psychiatry
F. Frauenfelder et al.
11
10
8
7
Withdrawal
Impaired/limited
cognition
Enuresis
Obsessive
behavior
3
13
Confrontational
relationship
3
15
Lack of insight
Boredom
18
Substance abuse
Impatience
21
Nervousness
The patient’s response concerns bed-wetting. The manifestation is characterized by
wetting a bed, generally during or after nocturnal sleeping.
The patient’s response concerns obsessive behaviors. Manifestations include
“compulsion to sunbathe; compulsion to do fitness exercises; compulsion to
control weight; compulsion to control ones looks; compulsion to drink coffee;
compulsion to ask questions; compulsive cleaning.”
The patient’s response concerns the phenomenon of boredom, manifested by
complaining about boredom, or bored behavior (“to be lying around bored”).
The patient’s response concerns the phenomenon of impatience, manifested by
impatient behavior (“impatience at exercise; seems to be hectic and impatient,
impatience after a surgical intervention”).
The patient’s response concerns the status after discontinued or reduction of
substance abuse/drugs (e.g., alcohol). Manifestations include somatic and psychic
withdrawal symptoms (e.g., restlessness and tremor).
The patient’s response concerns limited intellectual capabilities (e.g., “mental
retardation”). Manifestations include chronological disorientation, concentration
disorders, forgetfulness, and confusion. Additionally, situations are depicted in
which patients are unable to understand conversations (analogously, rationally) or
repeatedly ask many things, have difficulty in pursuing games, or do not know the
answers to simple questions.
The patient’s response concerns discrepancies between the points of view or oneself
and others. Manifestations include a lack of patient insight toward required
treatment or the necessity of hospitalization, not accepting responsibility for the
contribution to negative ward dynamics or conflicts, as well as discharges against
medical advice combined with guilt toward relatives.
The patient’s response concerns behavioral aspects negatively affecting relationships
to others. Manifestations include interpersonal conflicts (e.g., “with fellow patients,
relatives”), accusations to others, verbal assaults and imputations by relatives,
termination of contact by relatives, and patients’ feelings of worthlessness and
guilt. The reasons are mainly obscure but may include relationship problems due
to negative behavior of patients (e.g., “breaching agreements or stealing objects”).
The patient’s response concerns a state of uneasiness, excitement, or apprehension
of varying magnitude. The manifestations contain different degrees of
severity—from slightly nervous to very nervous. Reasons underlying this response
include having blood sample taken, visits by the ex-partners, impending visit to a
dentist or psychologist, impending commencement of work therapy, and impending
discharge.
The patient’s response concerns the substances abuse (alcohol, medication, illicit
drugs). Manifestations included not only drug abuse but also in the context of
relapse and the increase of physical tolerance. Identified reasons are loss of
control, boredom, induced drinking (of alcohol), career disappointment, and
problems in all aspects of live.
Ineffective role performance: role conflict (DC); system conflict (DC)
Ineffective self-health management: family conflict (DC)
Caregiver role strain: family conflict (DC)
Dysfunctional family processes: escalating conflict (DC); lack of dealing with conflict (DC)
Ineffective family therapeutic regimen management: family conflict (RF)
Impaired parenting: marital conflict (RF)
Risk for impaired parenting: family conflict (risk factors)
Risk for impaired attachment: parental conflict resulting from disorganized infant behavior (risk factors)
Risk for autonomic dysreflexia: narcotic/opiate withdrawal (risk factors)
— Stress overload: impatient (DC)
— Wandering: emotional state (e.g., frustration, anxiety, boredom, depression, agitation) (RF)
— Self-neglect: obsessive–compulsive disorder (DC)
— Post-trauma syndrome: compulsive behavior (DC)
Chronic confusion: long-standing cognitive impairment (DC); progressive cognitive impairment (DC)
Ineffective health maintenance: cognitive impairment (RF)
Functional urinary incontinence: impaired cognition (RF)
Bowel incontinence: impaired cognition (RF)
Impaired bed mobility: cognitive impairment (RF)
Impaired physical mobility: cognitive impairment (RF)
Impaired wheelchair mobility: cognitive impairment (RF)
Impaired transfer ability: cognitive impairment (RF)
Impaired walking: cognitive impairment (RF)
Wandering: cognitive impairment (e.g., memory and recall deficits, disorientation, poor visuoconstructive or
visuospatial ability, language defects) (RF)
— Sleep deprivation: sleep-related enuresis (RF)
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
— Ineffective coping: substance abuse (DC)
— Post-trauma syndrome: substance abuse (DC)
— Dysfunctional family processes: enabling maintenance of substance use pattern (e.g., alcohol) (DC); family
special occasions are substance use-centered (DC); substance abuse; addictive personality (RF)
— Rape-trauma syndrome: substance abuse (DC)
— Anxiety: substance abuse (RF)
— Ineffective protection: substance abuse (RF)
— Self-neglect: substance abuse (RF)
— Ineffective impulse control: substance abuse (RF)
— Caregiver role strain: addiction/substance abuse (RF)
— Self-mutilation: substance abuse (RF)
— Ineffective relationship: substance abuse (RF)
— Ineffective role performance: substance abuse (RF)
— Risk for impaired liver function: substance abuse (e.g., alcohol, cocaine) (risk factors)
— Risk for decreased cardiac tissue perfusion: substance abuse (risk factors)
— Risk for acute confusion: substance abuse (risk factors)
— Risk for suicide: substance abuse (risk factors)
— Risk for impaired: substance abuse attachment (risk factors)
— Risk for spiritual distress: substance abuse (risk factors)
— Risk for self-directed violence: lack of insight manner (risk factors)
— Fear: nervousness (DC)
F. Frauenfelder et al.
Nursing Diagnoses in Inpatient Psychiatry
7
Nursing Diagnoses in Inpatient Psychiatry
directly and negatively interfere with interpersonal interactions and social contacts. This response was recognizable
as a risk factor of the nursing diagnosis “risk of otherdirected violence.” Thirty-three references in the nursing
notes constituted the patient response “odd interpretation
of reality” and referred to a patient’s reaction resulting
from his/her inadequate perception of the immediate
reality. This patient response relates to numerous nursing
diagnoses, either as defining characteristic (e.g., difficulty
in perception of reality testing, reality distortion in the diagnosis “defensive coping”) or a related factor (e.g., paranoid
personality disorders in the diagnosis “self-neglect”).
Further, this response is listed as a risk factor with risk
diagnoses (e.g., psychotic symptomatology in the diagnosis
“risk of other-directed violence”). The identified patient
response “aggressive behavior” (N = 26) described different forms of aggressive behavior (verbal aggression, violence against objects, others, or himself/herself) as well as
the manifestation of aggression. This response is listed as a
defining characteristic with the nursing diagnoses “posttrauma syndrome,” “rape-trauma syndrome,” and “disabled
family coping.” The response “nervousness” (N = 21)
describes the feelings expressed and signs of nervousness,
and is listed as a defining characteristic in the nursing diagnoses “fear.” The abusive intake of medication, alcohol, and
other drugs was determined by the patient response “substance abuse” (N = 18). This response is listed in numerous
nursing diagnoses as defining characteristics (e.g., in the
diagnoses “ineffective coping,” “post-trauma syndrome,”
and “dysfunctional family processes”), and especially as
related factors (e.g., in the diagnoses “ineffective protection,” “self-neglect,” and “self-mutilation”) and risk factors
(e.g., in the diagnoses “risk of acute confusion,” “risk of
suicide,” and “risk of spiritual distress”). The patient reaction “lack of insight manner” (N = 15) contains references to
patients’ lack of discernment regarding his/her health condition, treatment, and behaviors. This response is listed as a
risk factor within the nursing diagnosis “risk of self-directed
violence.” The remaining seven patient responses were
identifiable in less than 15 references.
Patient Responses Not Recognizable in Definitions of
Diagnoses and Diagnoses-Related Factors
Nine patient responses that were not recognizable were
identified, either at the level of nursing diagnoses or in
terms of defining characteristics, related factors, or
risk factors. The patient response “repeated negativeemotional reactions” (N = 50) is characterized by the
absence of positive perceptions of one’s own person, of
fellow human beings, and/or of the surroundings. An abundance of different recurring manifestations reflects this
response, comprising feelings of petulance, frustration, and
annoyance. The patient response “depressed mood” (N =
25) describes internal personal conditions of sadness and
gloominess. Fourteen references mentioned economic
problems of the patient, referring to the patient response
8
F. Frauenfelder et al.
“emotionally burdened by economic difficulties.” Further,
13 situations refer to patients’ withdrawal tendencies
resulting in “self-isolation.” The patient response “intellectual absorption” describes patients’ fixation on certain
thoughts. “Risk of relapse” describes the danger that
patients may revert to the consumption of alcohol or drugs
following a period of abstinence. The patient response “risk
of absconding” reflects indications of patients intending to
leave the treatment setting without permission. The patient
responses “dizziness” and “over excitation” were both identified four times in the analyzed notes.
Discussion
The analyzed daily nursing notes in patient records contained unstructured descriptions of observations of individual patients in inpatient adult psychiatry from the nurses’
perspective. The data under scrutiny reported patients’ individual states, occurrences, and circumstances over a period
of 3 weeks of hospitalization. Most of the 1,021 references
found could be mapped to a “response to actual or potential
health problems/life processes,” as described in NANDA-I
(Herdman, 2012). More than half of all responses were recognizable at the level of labels and definitions of NANDA-I
diagnoses. Further, a group of responses were recognizable
at the level of diagnosis-related factors (defining characteristics, related factors, or risk factors). Only a few responses
were not identifiable as any kind of element of NANDA-I
diagnoses. The present study confirms the findings of the
systematic literature review by Frauenfelder et al. (2011),
indicating that the NANDA-I classification largely covers
essential phenomena of adult inpatient psychiatric nursing
care. Nevertheless, the comparison of findings from the
present study and the literature review reveals new insights.
First, the literature review included all studies found on adult
inpatient psychiatric care, whereas the population in this
study was more narrowly defined. Second, this study was a
documentation analysis of nursing records, and the wellelaborated language used in published articles differs from
the language used in nursing notes directly describing inpatients’ problems.
Despite the fact that NANDA-I classification 2012–2014
had been refined, that is, some new diagnoses were added
and some were revised or retired, this classification revision
did not influence the comparability of the cited review and
the results of the current study because none of the new
diagnoses were found in the nursing records.
A number of patient responses (N = 89) found in 124
references were too indiscriminately or vaguely formulated
and could not be mapped with NANDA-I diagnoses. These
notes failed to understandably describe nurses’ observations of patients or facts on patients’ state/behavior.
Further, the frequency of identical references found in the
series of notes on the same patient may indicate nurses’
deficits in knowledge and skills to accurately state and
document nursing diagnoses. These findings reveal the
F. Frauenfelder et al.
need to educate nurses in improving structured documentation, as well as to introduce the NANDA-I classification
into daily practice.
Several patient responses found in this study are probably insufficiently covered by NANDA-I for the purpose of
use in inpatient psychiatric nursing care. Although these
responses could be linked to elements of the classification,
their essence is not represented in the current classification. Moreover, the literature indicates they are not unique
to our study but common in psychiatry, for which we
provide three examples here.
One of most frequently identified patient responses in
this study concerns physical and/or inner restlessness.
NANDA-I includes this phenomenon as a defining characteristic of different nursing diagnoses that are not primary
issues in psychiatric nursing care (e.g., latex allergy
response, ineffective airway clearance, and decreased
cardiac output) or that cover particular patient responses
(e.g., anxiety, decisional conflict, and impaired comfort).
This study indicates that restlessness in itself seems to be a
broad, common problem in psychiatry for different reasons.
Cassano et al. (2012) described psychomotor activation,
comprising thought acceleration, distractibility, hyperactivity, and restlessness, as one of the main characteristics of
patients with bipolar disorders. Further, Kim, Ann, Lee, Kim,
and Han (2013) detected an association among antipsychotic medications, altered heart rate, and subjective inner
restlessness. The relevance of restlessness indicates that a
specific nursing diagnosis is needed to describe this patient
response in the NANDA-I classification.
The patient response “impaired/limited cognition,” as
found in this study, describes limited intellectual capabilities from the perspective of psychiatry. This response
seems to be common for different psychiatric patient
groups. Jaracz, Patrzala, and Rybakowski (2012) reported
poor performance levels of creative thinking in patients
with schizophrenia, and Laes and Sponheim (2006) identified poor verbal memory functions and deficits in organization, planning, as well as problem solving by patients with
bipolar affective disorders. These impairments seriously
compromise the patient’s ability to negotiate demands in
daily living. The results of this study indicate that “cognitive
impairment” should be included in the NANDA-I classification. Despite the fact that “impaired/limited cognition”
is used as a defining characteristic and related factor
of different nursing diagnoses (e.g., functional urinary
incontinence, impaired wheelchair mobility, and wandering), the problematic nature of “impaired cognition” is not
adequately captured and needs to be developed as a
nursing diagnosis.
The patient response “lack of insight” was found in the
current study. Lack of insight was reported as a strong
predictor for involuntary admission in patients with firstepisode schizophrenia (Kelly et al., 2004). Schennach et al.
(2012) identified deficits in illness insight at admission in
almost 70% of patients with schizophrenia, which was associated with low treatment adherence, worse functioning,
Nursing Diagnoses in Inpatient Psychiatry
and enhanced perception of side effects (Schennach et al.,
2012). In manic patients, lack of insight negatively affects
the abilities of decision making (Adida et al., 2008). Based
on these findings and the results of the present study, it
seems questionable whether the patient response “lack of
insight” is adequately described when used only as a risk
factor of the nursing diagnosis “risk of self-directed violence.” “Lack of insight” not only relates to this risk diagnosis, but rather outlines a broader problem related to a
lack of insight in necessary treatments, and for not accepting responsibility for negative behaviors, as well as for
(self-) discharge against medical advice.
These three examples illustrate patients’ responses that
were given working titles in this study (see Table 2) but
have unsatisfactory coverage in NANDA-I. Although one
might argue these issues are covered in NANDA-I, their
place in the classification as a defining characteristic/
related factor does not reflect their importance and
meaning within inpatient psychiatry. For all of these, adjusting or extending NANDA-I to better cover important human
responses of psychiatric patients would seem necessary.
Some patient responses identified in the present study
were neither mapped at the level of labels and definitions
nor as related factors. Several psychiatric patients in this
study endured social and economic difficulties that affect
their well-being. This patient response was described as
“emotionally burdened by economic difficulties.” Although
the NANDA-I classification does not contain this patient
response, it is obviously also known in other nursing settings. Speksnijder et al. (2011) also identified this problem in
the context of hematology-oncology nursing care. The
patient response “self-isolation” describes a further problematic behavior commonly seen in psychiatric care, yet not
contained in the NANDA-I classification. Fluttert, Van Meijel,
Bjørkly, Van Leeuwen, and Grypdonck (2012) identified
social isolation as the second most frequent early warning
sign of aggression in forensic inpatient settings. The
recently identified phenomenon “Hikikomori” describes
self-isolation as a distinctive patient behavior, which was
characterized as severe social avoidance that can potentially be explained by underlying psychiatric disorders
(Tateno, Park, Kato, Umene-Nakano, & Saito, 2012).
Two patient responses identified in the present study
describe risk situations. Absconding is a common problem
within psychiatric care and may imply a danger for the
patient (suicide) or for others (other-directed violence)
(Mosel, Gerace, & Muir-Cochrane, 2010; Muir-Cochrane &
Mosel, 2008). Frauenfelder et al. (2011) described the need
for the diagnosis “risk of absconding” in order to protect
patients from harm. Suffering a relapse after a period of
abstinence depends on different factors (Sauter et al., 2011).
Also, nurses are often confronted with situations in which
patients suffering from substance abuse crave substances
they endeavor to resist in the course of their treatment. It is
essential that nurses are able to recognize and name risks
of relapse in order to prevent substance re-consumption
and to support patients during the abstinence process.
9
Nursing Diagnoses in Inpatient Psychiatry
F. Frauenfelder et al.
Table 3. Patient Responses Not Recognizable in Definitions of Diagnoses and Diagnosis-Related Factors
Working titles
N
Descriptions based on identified descriptions in nursing documentations
Negative-emotional
reactions
50
Depressed mood
25
Difficult
social/economic
situation
14
Self-isolation
13
The patient’s response concerns negative emotion (“to show disappointment, to be petulant, to be worried,
to be frustrated, to be moody, to be disgruntled/annoyed/to be upset, furious etc.”). The manifestations
include swearing, or tasteless abusive words by the patient, as well as crying or complaining about fellow
patients. This response is often related to the administration of medication, to corrective and/or
restrictive measures, to be bossed around by fellow patient; destruction of property by others as well as
to have the feeling of not being able to function; financial problems; or the deprivation of the driving
license, etc.
The patient’s response concerns the low mood of an individual. The manifestations are characterized by
impressions or recorded feelings of sadness, depression, or gloom. In this context, patients often cry,
seclude themselves/oneself, or convey the impression of concerns or of being incommunicative. The
reasons include memories of family and personal childhood, the loss of a loved one, not being visited by a
close person, financial problems, etc.
The patient’s response concerns the private, economic situation. The manifestations are diverse but refer to
difficulties in social/economic matters such as joblessness, debts, loss of the apartment, homelessness,
dependency on the welfare services, as well as being sentenced to do community service. The reasons
seem vague, most likely in the context of drug-related crime of patients or statements that the patient is
not able to live alone in the near future because of his/her psychic disorder.
The patient’s response concerns withdrawal from social contacts. The manifestations are diverse from
temporal tendencies of withdrawal to severe withdrawal or patients seemingly living in “their own world.”
Reasons underlying this response include descriptions of sadness, being frightened, or the feeling of
being without a personal perspective.
The patient’s response concerns the entanglement of thoughts that are manifested by rumination, being
occupied by thoughts, to be constricted in thinking, and the inability to evade intrusive thoughts. No
reasons are identifiable in the documentation.
The patient’s response concerns risk factors for relapse regarding substance/drug abuse. The
manifestations are characterized by the craving for or for being reminded of drugs (“strain of addiction;
increased strain of addiction; to dream of alcohol consumption; to express thoughts of getting drunk; to
long for drugs”).
The patient’s response concerns risk factors for absconding characterized by the patient’s remark of
departing from the hospital (“the patient is not able to rule out that he will not run away; concrete
planning of absconding; plans to visit relatives in spite of problematic relationships”).
The patient’s response concerns the phenomenon of vertigo. The manifestations are characterized by the
feeling of dizziness, mentioned by patients.
The patient’s response concerns the perception of overexcitement. The manifestations are characterized by
descriptions of overexcitement accompanied by inappropriate behavior (“squeaking, shrill noises, laughing
to oneself and move jigging away”). Usually obvious reasons are not mentioned for this response in the
documentation. One sole case interprets the remarriage of the ex-partner as the reason for the response.
Rumination
7
Risk of relapse
7
(Risk of)
absconding
6
Dizziness
4
Overexcited
4
Therefore, the nursing diagnosis “substance relapse”
should be added to the NANDA-I classification.
The relevance of the patient responses listed in Table 3
indicates their need for integration in the NANDA-I classification to better cover inpatient psychiatric nursing care.
Limitations
Various limitations pertain to the present study.
Although the sample included patients in adult inpatient
psychiatry who were affected by different mental disorders
and impairments, a population bias cannot be ruled out.
Patients in other adult inpatient settings may experience
other responses on health problems/life processes. Given
that the present study was performed in Switzerland, psychiatric patient problems in other countries and in other
social-cultural and economic areas may differ from those
of the present sample. To a certain extent, the mapping
process may depend on the personal perspective of the
researchers, their professional context, experiences, and
interpretation skills.
10
The present study represents a content analysis of
unstructured descriptions in nursing notes written for each
individual patient. Further studies on nursing diagnoses
in inpatient psychiatry may generate new insights. The
authors suggest different research methods, for example,
Delphi studies, concept analyses, and/or clinical validation
studies, to validate the findings of this study and to define
new diagnoses. It is also suggested that different data
sources (e.g., interviews with nurses and with patients) and
mixed-methods designs be included.
Conclusion
This study demonstrates that the NANDA-I classification
describes adult psychiatric inpatients’ problems to a large
extent. Nevertheless, further development of the classification is important to adequately describe and diagnose
patients’ problems and risk diagnoses, and support health
promotion in inpatient psychiatry. Differentiations must
exactly name relevant nursing diagnoses in psychiatric care
to serve as a basis for psychiatric nursing interventions.
F. Frauenfelder et al.
Based on the results of this study, further research
on psychiatric patient responses is essential. In-depth discussions with well-informed, competent representatives of
inpatient psychiatric nursing care are needed. There is a
need to study the relevance of the suggested new nursing
diagnoses found in this research. Their content, main focus,
levels of abstraction, and distinctions from existing diagnoses need further consideration.
The development of the NANDA-I classification as outlined in this study will not only reinforce the bedside work of
nurses. It will also spur nursing research as well as job
training content, and thus help in paving the way for further
steps toward the professionalization of psychiatric nursing
care.
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