ISSN 1803-4330
peer-reviewed journal for health professions
volume V/1 • April 2012
Validation of the Nursing Diagnosis Chronic Confusion in Slovak
and Czech Nursing Practices
Martina Tomagová, Ivana Bóriková
Department of Nursing, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava
ABSTRACT
Objective: Content validation of the nursing diagnosis Chronic Confusion and identification of the defining
characteristics in the Slovak and Czech nursing practices.
Methods: Fehring’s retrospective Diagnostic Content Validity Model (DCV Model) was used. Experts were nurses
who scored minimum 4 points according to modified Fehring’s criteria. The group of respondents consisted of
144 Slovak and 107 Czech nurses.
Results: Czech and Slovak experts alike considered the following characteristics to be defining (weighted score
WS higher than 0.75): altered interpretation/response to stimuli, progressive deterioration of intellect, clinical
evidence of organic brain impairment, time and space disorientation, and long-term cognitive impairment, which
are congruent with the characteristic features of dementia syndrome.
Conclusions: Experts did not regard all the defining characteristics to be of the same importance. This was due to
the composite of respondents, who only reached bottom level of criteria for an expert (6 points), incompatibility
of NANDA-I Taxonomy II with the List of nursing diagnosis used in the Slovak Republic and lastly the absence
of standardised nursing terminology in the Czech Republic.
KEY WORDS
nursing diagnosis, chronic confusion, defi ning characteristics, dementia, validation study
INTRODUCTION
The nursing diagnosis (ND) of Chronic Confusion
(CHC) was implemented in the classification system of
the NANDA Taxonomy I Nursing Diagnoses in 1994.
The current version of NANDA-I Taxonomy II classifies it under Domain 5 Perception/Cognition, Cognition Class. NANDA-I (2009, p 167) defines Chronic
Confusion as “irreversible, long-standing, and/or
progressive deterioration of intellect and personality
characterized by decreased ability to interpret environmental stimuli; decreased capacity for intellectual
thought processes; and manifested by disturbances of
memory, orientation, and behaviour.” These changes
in intellect, personality, and cognition are characteristic of organic mental disorders (Höschl et al., 2002,
p 452), which occur in specific groups of patients, such
as in gerontopsychiatry, neurology, neurosurgery, and
in the elderly in general. In nursing practice, this ND
is particularly applicable in patients with various types
of dementia (atrophic-degenerative, e. g. Alzheimertype dementia (AD), Parkinson’s disease dementia;
in secondary dementias, e. g. ischemic vascular de-
mentia) and with an organic amnestic syndrome (e. g.
post-traumatic changes in the brain). In connection
with research in nursing diagnosis, the importance
of validation studies of nursing diagnoses continues
to grow. Validation describes exactly how a diagnostic marker, in our case the defining characteristics of
a selected ND, describes the patient’s reaction to the
current health problem.
OBJECTIVE
The study aimed to validate the ND Chronic Confusion
in the Czech and Slovak nursing practices and establish
which defining characteristics are considered primary
and which secondary by experts.
PARTICIPANTS AND METHODS
The group of experts was selected on a non-random
basis. We addressed nurses whom we assumed, based
on the selected healthcare centre, were experienced in
the care of patients with impaired cognitive functions.
Experts were nurses who met inclusion criteria in the
environments of the Slovak Republic (SR) and Czech
ISSN 1803-4330 • volume V/1 • April 2012
25
Republic (CR) as defined by Zeleniková et al. (2010,
p 409). These criteria (50–100 for DCV model) based
on Fehring (1986, p 188; Levin, 2001, p 29), were met
by 144 nurses in SR and 107 nurses in CR. Scores of
the defined criteria ranged from 4 points (min.) to 17
points (max.); Table 1 shows the average scores in the
SR and CR groups.
Table 1 Characteristics of the expert participants
SR
criteria
CR
x
SD
x
SD
age (years)
40,22
8,51
36,2
7,01
work experience (years)
19,19
9,46
15,32
7,64
6,00
1,68
6,03
1,7
evaluation of experts (points)
(X = arithmetic mean, SD = standard deviation)
Table 2 contains the basic and supplementary inclusion
criteria required for the research participants. Not all
the nurses met the conditions of the supplementary
criteria.
Table 2 Participant inclusion criteria
inclusion criteria
basic
nursing training:
master’s degree (3 points)
bachelor’s degree (2 points)
secondary nursing school/
higher vocational school
(1 point)
clinical experience:
1–5 years (1 point)
over 5 years (2 points)
over 10 years (3 points)
SR
CR
n = 144 100% n = 107 100%
43
46
55
30
32
38
18
56
33
17
52
31
14
15
115
10
10
80
13
15
79
12
14
74
n = 56
100%
supplementary
n = 108 100%
specialization/certificate
(2 points)
thesis/PhDr thesis (1 point)
published article (2 points)
Phd thesis (3 points)
60/16
56/15 47/1
84/2
14/–
13
5
13/–
12
5
2/–
13
0
1/–
7
0
Data from the experts were collected from June 2009
until January 2010 at various healthcare and education
departments at the same time in SR and CR (Table 3).
Table 3 Data collection – departments
departments
SR
n = 144
CR
100%
n = 107
100%
psychiatry*
42
29
9
8
internal medicine**
39
27
42
39
surgery***
28
19
39
36
education
department****
27
19
7
7
home care services
8
6
3
3
hospice
–
–
7
7
* department of psychiatry, mental hospital; ** internal medicine,
neurology, and oncology clinics, department of tuberculosis and
lung diseases, geriatric/rehabilitation department; *** department
of surgery, department of orthopaedics and traumatology; **** secondary nursing school, university (faculty of health, nursing department)
The validation study is part of an APVV project titled
Nursing Diagnosis – Theory and Application in Nursing Practice. Consequently, the validation methods
were identical to those in the already published studies
of validation of other nursing diagnoses in the project,
for example, Tomagová, Bóriková (2011), Tabaková
(2011), Zeleníková et al. (2011a, 2011b), Gurková et al.
(2010).
The ND validation used the Diagnostic Content
Validity Model (DCV Model) by Fehring. This retrospective, most frequent model has a sufficient number
of experts (25–50) evaluate the defining characteristics
of the ND, assigning each with a particular significance
from 1 to 5 on Likert scale (Fehring, 1987, p 626). The
significance of the defining characteristics is evaluated with a validation form featuring 13 items. These
are subdivided into three groups based on experience
gained in similar studies (Gurková et al., 2010; Žiaková
et al., 2008). The first group consisted of the ND defining characteristics (9 items). When formulating the
second group (3 items), we applied the MMSE (MiniMental State Examination) measurement instrument
designed for assessing the cognitive functions of the
elderly (Folstein et al., 1975, p 190). In order to eliminate random assessment of the items’ significance, we
added one neutral item to the list (a third group as
a misleading/false character). The experts identified
the degree of importance of each item on Likert scale
(5 max significance, 4 great significance, 3 medium significance; 2 little significance; 1 no significance). After
collecting the data, basic statistical parameters (arithmetic mean x, standard deviation SD) and weighted
score (a sum of values assigned to each answer and its
subsequent division by the total number of responses,
WS) were calculated for each defining characteristic.
ISSN 1803-4330 • volume V/1 • April 2012
26
The numbers on Likert scale were allocated the following WS value 5 = 1; 4 = 0.75; 3 = 0.5; 2 = 0.25;
1 = 0. In the research, the main defining characteristics
were those that reached WS over 0.75, while secondary
characteristics ranged from 0.50 to 0.75 (Holmanová,
Žiaková, Čáp, 2006, p 27). The data were processed
with the computing programme MS Excel, SPSS 16.0
for Windows.
RESULTS
Table 4 gives an overview of all the validated items. The
defining characteristics that the experts considered as
the main ones are highlighted.
DISCUSSION
The relatively homogenous group of experts in terms
of age and years of experience reached the lower score
limit (6 points), only the minimum of the already modified expert criteria (Table 1). According to Fehring,
an expert must achieve a minimum of 5 points, while
4 points are given for a master’s degree. The higher the
number of points is the higher the expertise (Zeleníková et al., 2010, p 411). Slovak nurses scored higher in
this criterion, which may be due to their higher number
in the monitored group. The validation results in both
groups indicated very high compliance. The defining
characteristics identified as the primary are typical for
dementia syndrome (MKCH 10, 2006). In some literary
sources, the concept of dementia equals the concept of
chronic confusion (Hudson, 2011; NINR, 2006, p 3;
Ried, Dassen, 2000, p 51). Poor distinction between
these concepts and their use by nurses is considered
problematic (Ried, Gutzmann, 2003, p 297; Winnifred, 1991, p 4) because the comparison of the nursing
and medical concepts shows some characteristics as
identical (Table 5); the concepts are often treated as
synonyms and describe the same phenomenon (Ried,
Dassen, 200, p 54). In consequence, there are no or
hardly any validation studies concerning the diagnosis
in question in the NANDA-I sources (e. g. International
Journal of Nursing Terminologies and Classifications)
and other resources.
Experts across the whole group marked as primary
(Table 4) those items that dominated more in the medical concept of the dementia syndrome (NINR, 2006,
p 3; Ried, Dassen, 2000, p 55). Items 3, 4 and 10 form
part of the clinical picture of dementia (Hegyi, Krajčík,
2010, p 464) and are documented in the patient’s medical records as part of a medical finding; therefore, nurses consider these symptoms important. Other major
defining characteristics included: time and space disorientation and altered interpretation/response to stimuli. These are manifestations of the confusion symptom
as it is defined in medical terminology (Kolibáš, 2010,
p 36). Although the concept of confusion is mentioned
in the ND title, its definition is not compatible with
medical terminology (Höschl et al., 2002, p 296). Based
on NANDA-I, other defining characteristics of CHC
include impaired memory, impaired socialization, altered personality, and no change in level of conscious-
Table 4 Validated items
SR
item
CR
x ± SD
VS
x ± SD
VS
1 altered interpretation/response to stimuli (NANDA-I)
4,05 ± 0,82
0,76
4 ± 0,91
0,75
2 inability to follow instructions during the administration
of the cognition assessment tool (MMSE)
3,77 ± 1,04
0,69
3,65 ± 0,94
0,66
3 progressive deterioration of intellect (NANDA-I)
4,06 ± 0,90
0,76
4,04 ± 0,85
0,76
4 clinical evidence of organic brain impairment (NANDA-I)
4,41 ± 0,95
0,78
4,11 ± 0,87
0,78
5 disorientation (in time and space) (MMSE)
4,47 ± 0,76
0,87
4,44 ± 0,75
0,86
6 impaired long-term memory (NANDA-I)
3,74 ± 0,98
0,69
3,55 ± 0,99
0,64
7 impaired short-term memory (NANDA-I)
3,92 ± 0,96
0,73
3,86 ± 0,99
0,71
8 accelerated cognitive processes (MMSE)
2,74 ± 1,06
0,44
2,96 ± 1,01
0,49
9 impaired socialization (NANDA-I)
3,60 ± 0,97
0,65
3,49 ± 0,85
0,62
10 long-term cognitive impairment (NANDA-I)
4,13 ± 0,81
0,78
3,94 ± 0,82
0,74
11 no change in level of consciousness (NANDA-I)
2,88 ± 1,28
0,47
2,87 ± 1,16
0,47
12 inability to name objects (during the tool administration)
(MMSE)
3,38 ± 0,97
0,70
3,5 ± 0,97
0,62
13 altered personality (NANDA-I)
3,43 ± 1,23
0,61
3,31 ± 1,18
0,58
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27
ness. These the nurses marked as secondary with
significance below 0.75 despite the fact that they form
part of the definition of ND Chronic Confusion (this
was mentioned in the validation spreadsheet) and also
the clinical picture of dementia. The defining characteristic of “no change in level of consciousness” is also
considered secondary and thus less significant. This,
too, indicates the difference between the nursing terminology and the medical terminology. As mentioned
above, although ‘confusion’ is included in the name of
the ND, the term is absent from the definition of the
diagnosis and, moreover, NANDA-I lists no change in
level of consciousness in the defining characteristics. In
medicine, confusion is defined as a qualitative change
in consciousness (Kolibáš, 2010, p 36). As nurses prefer
the medical view of the concept, they considered this
defining characteristic secondary. Based on the experts’
evaluation, other secondary characteristics included
the inability to name objects (during the administration of MMSE) and the inability to follow instructions
during the administration. As MMSE is applied in
practice only in rare, specific cases, the nurses do not
have the clinical skills to use it.
The neutral item ‘accelerated cognitive processes’
scored less than 0.50, which is a positive finding as the
experts did not mark the items randomly. Accelerated
cognitive processes are not part of the clinical picture of
dementia, and therefore do not belong to the defining
characteristics of the validated ND. We believe that the
findings of the validation study (regarding SR) may be
affected by the fact that this ND is missing from the List
of Nursing Diagnoses (Decree of Ministry of Health
of SR, 2005) and therefore the nurses (not even from
psychiatry departments) have no clinical experience
with this ND. In CR, no standardized terminology is
used in nursing diagnosis (Jarošová et al., 2009, p 126).
CONCLUSIONS
The experts did not rate all the defining characteristics of the validated ND as equally significant. This is
partly due to the respondents, who, coming from the
Slovak and Czech practices, reached only the minimum
threshold of expert criteria. University-educated nurses
(despite their predominance) have varying levels of
knowledge and intellect skills related to nursing diagnosis. Other factors are the incompatibility of NANDAI Taxonomy II with the Nursing Diagnosis List, and the
ambiguity in terminology and legislation. Generally,
nurses still tend to use the medical terminology (terms
for clinical symptoms) and are not at all familiar with
chronic confusion as a name of an ND (and its other
diagnostic components). Comparison of the concepts
implies certain difficulties in differentiating between
these two related diagnoses. This is due to the fact that
in terms of the “related factors” component they both
focus on biomedical aspects, while psychology and sociology literature supports a multi-factorial approach
that includes social, environmental, and psychological
factors explaining the phenomenon of confusion (Ried,
Dassen, 2000, p 56). Although in recent years, validation studies of selected NDs are occasionally published
in nursing journals, there are no national validation
Table 5 Comparison of Chronic Confusion and Dementia
Chronic Confusion (00129)
Dementia (F00–F03)
Definition: Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased
ability to interpret environmental stimuli; decreased capacity for
intellectual thought processes; and manifested by disturbances of
memory, orientation, and behavior (NANDA-I, 2009).
Definition: A syndrome caused by a brain disease, usually chronic
or progressive, which is characterized by deterioration of multiple
higher cortical functions, including memory, cognition, orientation, understanding, counting, the capacity of learning, language,
and judgment. Consciousness remains clear. Cognitive disorders are
typically accompanied (sometimes preceded) by impaired control
of emotions, social behavior, and motivation (MKCH 10, 2006).
Related factors: AD, cerebrovascular disease, head injury, Korsa- Cause: AD, cerebrovascular disease, other disorders that primarily
koff ’s syndrome, multi-infarct dementia
or secondarily affect the brain
Development: long-term and/or progressive irreversible.
Development: long-term or progressive reversible.
Basic characteristics: deterioration of intellect and personality.
Basic characteristics: impaired higher cortical functions, deterioration of emotion control/social behavior/motivation.
Defining characteristics: clinical evidence of organic impairment, Symptoms: deteriorated/impaired memory, cognitive impairment,
altered interpretation/response to stimuli, progressive and long- deteriorated ability to carry out everyday activities
term cognitive impairment, impaired (short-term and long-term)
memory, altered personality and impaired socialization, no change
in level of consciousness
(MKCH 10, 2006, s. 220; NANDA-I, 2009, p. 167; Preiss a kol., 2006, s. 127; Ried, Dassen, 2000, p. 56)
ISSN 1803-4330 • volume V/1 • April 2012
28
processes available with respect to the social-cultural
context of clinical practice (Holman et al., 2006, p 28).
Unless nursing terminology is clearly distinguished and
defined, it is impossible to avoid errors and mistakes in
nursing diagnosis. The findings of the validation study
point to the need for a more detailed theoretical analysis of the diagnostic components, which will improve
the objectivity of the diagnostic process.
Dedicated to APVV projects SK-CZ-0151-09 and Ministry of Education MEB 0810029 Nursing Diagnosis –
Theory and Application in Nursing Practice.
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CONTACT DETAILS OF MAIN AUTHOR
Martina Tomagová
Department of Nursing
Jessenius Faculty of Medicine in Martin,
Comenius University in Bratislava
Malá Hora 5
SK-036 01 MARTIN
tomagova@jfmed.uniba.sk
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