Chapter Three Teaching NANDA-I NIC and NOC: Novice to Expert Teaching NANDA-I NIC and NOC: Novice to Expert Contributor Margaret Lunney Learning Objectives • Explain Three Propositions Related to Teaching NNN • Set Expectations for Students at Novice to Expert Stages of Development • Implement Teaching Strategies • Integrate NNN With Nursing Curricula (Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008) Objective 1: Explain Propositions • Use of NNN Requires Intellectual, Interpersonal, and Technical Competencies, Tolerance of Ambiguity and Reflection • Accurate Diagnoses are the Basis for Use of NIC and NOC • Use of NNN Differs from the Traditional Nursing Process (Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008) Proposition #1: Skills/Competencies •Intellectual •Knowledge Related to: •Diagnoses •Interventions •Outcomes •Thinking Processes •Research Findings: •Human Beings Vary in Thinking Process Abilities •Thinking Process Abilities can be Improved Variation in Nurses’ Thinking Abilities Basic Thinking Abilities Mean SD Range DMU-Fluency 21.3 7.2 6–41.5 DMC-Flexibility 10.8 6.5 0–27.5 DMI-Elaboration 17.8 4.9 7–30.5 N = 86 (Lunney 1992) Intellectual Skills Research Findings related to Women •Thinking Processes of Women Develop Through Relationships •Women’s Perspectives on Thinking (Belenkey et al. 1986) •Silence •Received Knowledge •Subjective Knowledge •Procedural Knowledge •Constructed Knowledge •Nursing Students and Nurses may have Lower Level Perspectives Intellectual Skills: Critical Thinking •Critical Thinking (CT) Processes can be Improved •Stimulate to Use •Expect Use •Validate Appropriate Use •Demonstrate Support and Confidence in Abilities •CT Abilities - Essential for Accuracy of Diagnoses and Use of NOC and NIC (Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008) Intellectual Skills: What is CT in Nursing? •Delphi Study of 55 Nurse Experts (Scheffer and Rubenfeld 2000) •Purpose: Identify the Components of CT that Relate to Nursing •Results - Definition for Nursing: •7 Cognitive Skills •10 Habits of Mind Cognitive Skills •Analyzing •Applying Standards •Discriminating •Information •Logical Seeking Reasoning •Predicting •Transforming Knowledge Habits of Mind •Confidence •Contextual •Intellectual Perspective Integrity •Intuition •Creativity •Open-Mindedness •Flexibility •Perseverance •Inquisitiveness •Reflection Intellectual Skills: CT Process •CT Involves Continuous Processing of Data and Inferences •In Any Situation, Two or More Cognitive Skills are Probably Being Used •Habits •The of Mind Support Cognitive Skills Combination of CT Abilities Needed is Unique to the Situation Proposition #1: Interpersonal Skills •Exquisite •Promote •Work Communication Trust n Partnership, Share Power •Validate •Accept Perceptions That We Do Not “Know” Others Proposition #1: Technical Skills •Obtain Valid and Reliable Data •Health Histories: Comprehensive •Physical Exams: Focused •Perform Nursing Interventions •Technical Aspects of Using NNN Proposition #1: Personal Strengths •Tolerate Ambiguity •Decisions are Relative to Context and Specific Nature of Individuals •Multiple Factors Influence Clinical Situations •Human Beings are Complex and Diverse •Ambiguity is the Norm Proposition #1: Personal Strengths •Reflect on Practice Experiences •Accept Possible Flaws •Thinking •Interpersonal •Technical •Aim - Develop and Grow Proposition #2: Accurate Interpretations Foundational •Cues/Data may be Incorrect •Examples Objective Data: •Diagnostic Tests Subjective Data: •Patients •Families Proposition #2: Accurate Interpretations Foundational •Use of NNN Requires Many Decisions •All Decisions are Based on Patient Data •Data Amounts are Overwhelming •Short-Term Memory = 7 ± 2 Bits of Data •Data are Converted to Interpretations (Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008) Proposition #2: Accurate Interpretations Foundational •Interpretations Determine Actions •Additional Data Collection •Subsequent Decisions •Possible Outcomes to Consider •Choices of Interventions •High Potential for Inaccuracy •Diagnosis and Etiology High Potential for Inaccuracy Case Study: Marian Hughes (1) Marian Hughes is a 16-year-old girl with a medical diagnosis of diabetes mellitus. (2) She was admitted 3days ago for treatment of an acute episode of diabetic ketoacidosis. (3) When Marian discussed with you how she managed the therapeutic regimen before hospitalization, she states that she was not adhering to her prescribed diet. (4) You decide that Marian needs assistance to improve her management of the therapeutic regimen, especially the types of foods she eats. (5) Marian's stay in the hospital unit is uneventful in that medical treatments are successfully resolving the crisis. (6) Marian's daily habits include getting up for school about 7.00 a.m. and rushing to get the bus by 7.30. (7) She says that she should get up about 6.30 but she likes to sleep. (8) She states that she does not want her mother to help her get up earlier. (9) The meal that she eats at school is consistent with her prescribed diet while the two meals at home are not. (10) In the morning she grabs whatever is quick and easy, usually toast and butter. (11) In the evening, her mother makes meals that comply with the diabetic diet but Marian states that she does not like them so she only eats part of her supper and then snacks on other foods later. (12) Marian is able to explain to you what she should be eating and she can adjust her diet to her lifestyle. (13) The knowledge of what foods are on her diet that she likes was not discussed with her mother because she doesn't want to sit down and talk with her. (14) In general, Marian and her mother argue over many of Marian's behaviors, such as school grades, smoking, and coming in late at night. High Potential for Inaccuracy Case Study: Marian Hughes •16-Year-Old Diabetic (#1) •Hospitalized, •“Did DKA (#2) Not Follow Prescribed Diet” (#3) •NDx: Ineffective Management of Therapeutic Regimen, Related to _______ (Fill in the Blank) High Potential for Inaccuracy Case Study: Marian Hughes Possible Interpretation/Diagnosis •Knowledge Deficit •Disconfirming Cues: •Meals Eaten at School are Consistent with Diet (#9) •Able to Explain What She Should be Eating (#12) •She can Adjust Her Diet to Her Lifestyle (#13) •Conclusion: •Teaching (Herdman 2012) Low Accuracy Diagnosis is Waste of Time, Effort, and Money High Potential for Inaccuracy Case Study: Marian Hughes Highest Accuracy Diagnosis •Ineffective Self-Health Management, Related to Communication Difficulties Between Marian and Her Mother •Patient Outcome (NOC): •Communication = 3 (Moderately Compromised), Increase to 5 (Not Compromised) •Nursing Intervention •Communication Enhancement (Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008) 44 Diagnoses by 80 Nurses Examples •Communication Difficulties Mother/Daughter •Stressful Mother/Child Relationship •Altered Family Dynamics •Ineffective Coping •Ineffective Time Management •Adolescent Image •Low Self-Esteem •Denial •Deficient Knowledge Seven Levels of Accuracy +5 Highest Level of Accuracy +4 Close to the Highest Level But Not Quite +3 General Idea But Not Specific Enough +2 Not Enough Highly Relevant Cues or Not the Highest Priority +1 Suggested by Only One or a Few Cues 0 Not Indicated by Data -1 Should be Rejected, Disconfirming Cues Diagnostic Accuracy Scores •Communication Difficulties Between Mother and Daughter •Stressful Mother/Child Relationship •Altered Family Dynamics •Ineffective Coping •Ineffective Time Management •Adolescent Image •Low Self-Esteem •Denial •Deficient Knowledge +5 +4 +3 +2 +2 +1 +1 0 -1 Research Findings •Studies: 1966 to Present •Conclusions: Interpretations Vary Widely •All Interpretations are Not High Accuracy •Influencing Factors (Carnevali 1983; Gordon 1982) •Nurse Diagnostician •Diagnostic Task •Situational Context Research: Positive Influences •Diagnostic •Lesser •Nurse Task Amounts and Complexity of Data Diagnostician •Education Related to Nursing Diagnoses •Knowledge •Teaching •Variety of Diagnostic Process and Concepts Aids for Diagnostic Reasoning of Thinking Processes •Experience Specific to Diagnostic Task Challenge: Achieving Accuracy Puzzle: What is the Diagnosis? Solving the Puzzle Is It This? Or This? Or This? Proposition #2: Accurate Interpretations Foundational •Supporting Factors: •Acknowledge that Data Interpretations are Probabilistic; Question Accuracy •Use CT, Interpersonal and Technical Skills •Develop Tolerance ofAmbiguity •It’s OK Not to Have an Answer •Accept that We Might Make Mistakes •Develop Reflective Practice Proposition #2: New Perspectives on Nursing Process Traditional •Limited # of Concepts •Collect Comprehensive Data •No Accountability for Diagnoses •Intervene Based on Data •Behavioral Outcomes •Disorganized Follow-Up (Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008) Use of NNN •Currently 1147 Concepts •Cue-Based and Hypothesis-Driven Data Collection •Fully Accountable for Diagnoses •Intervene Based on Data Interpretations •Neutral Terms with Scale •Systematic Follow-Up Changing from Traditional to Use of NNN •Acknowledge •Influencing Difficulty Level: Simple to Complex Factors: •Similarity of Terms in Three Systems •Structure of Classifications •Resources (Books, Pamphlets, Other) •Complexity of Clinical Situations •Nurses Perspective/Model for Practice •Experience With NNN (Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008) Examples: User-Friendly Simplicity NANDA-I NOC NIC Anxiety: Vague uneasy feeling; autonomic response; feeling of apprehension; altering signal warning of impending danger Anxiety Control: Personal actions to eliminate or reduce feelings of apprehension and tension from an unidentifiable source Anxiety Reduction: Minimizing apprehension, dread, foreboding or uneasiness related to unidentified source of anticipated danger Risk ofInfection: Increased risk ofbeing invaded by pathogens Infection Status: Infection Protection: Presence and extent of Prevention and early infection detection of infection in a patient at risk (Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008) Changing from Traditional to Use of NNN •Use Theoretical Perspective •Change Theory •Diffusion of Innovations •S-Shaped (Rogers 2003) Diffusion Curve •Perceived Characteristics: •Relative Advantage (+) •Compatibility •Complexity •Trial (+) (-) Ability (+) •Observability (+) (Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008) Changing from Traditional to Use of NNN •Be a Champion •Sell First to Opinion Leaders •Goal: Create a Critical Mass •Share Demonstration Projects (For Example, Protocols and Journals) •Faculty Development Program •Adoption by System •Adoption by Individuals (Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008) Objective 2: Set Expectations Novice to Expert •Novices and Advanced Beginners (ABS) Learn to Use NNN as Well as Experienced Nurses •Novices and ABS may be Easier to Teach than Nurses at Competent, Proficient and Expert (Expert) Stages •Expert Nurses must be “Sold” on New Way to Think and Document (Benner 1984; Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008) Selling NNN to Experts •EHR is Imminent •NNN = File Names for EHR •NNN Describes What Nurses Bring to the Table •NNN Makes Knowledge Available at Bedside •Aggregated Data = Knowledge •Measurement of Care = Improved Quality •Linguistics Theory Supports SNLS •Fits with Nursing Theories Set Expectations •Expect (At All Levels of Expertise): •Correct Use of the Three Systems: •Nursing Diagnoses are used to Guide Interventions, Not for Labeling per se •Intervention Label is the Intervention, Not the Activities •Outcome Label is the Outcome, Not the Indicators •Correct Use of Concepts: •NANDA-I: Social Isolation •NIC: Coping Enhancement •NOC: Knowledge (Specify) (Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008) Set Expectations •Do Not Underestimate Nursing Students or Nurses: “…Nursing and Nursing Knowledge must be Presented in All Its Complexity … • • Help Students and Nurses to “… Experience the Complex and Messy World of Nursing … and Learn How to Navigate Through It …” (Doane and Varcoe 2005, p.xi) Set Expectations •All Levels: •Self-Evaluation •Integrate with New Theories, for Example: •Pender’s Health Promotion Model •Integrate (Pender et al. 2010) with Strategies for Evidence-Based Nursing Set Expectations •Encourage •Integrate •Use Experts to: with Previous Knowledge NNN in: •Communicating Scope of Practice •Developing Standards of Care •Evidence-Based Nursing Projects •Research Projects •Evaluate •Teach Clinical Applications of NNN CE Programs to Nursing Personnel (Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008) Objective 3: Teaching Strategies Intellectual •Assume that Thinking Is Human, Imperfect, Attainable •Encourage Thinking in Class and Clinical: •Ask Questions Instead of Giving Answers •Provide Opportunities for Problem Solving Objective 3: Teaching Strategies Intellectual: Deflate Authority Objective 3: Teaching Strategies Intellectual •Think •Act Out Loud with Students as Midwife or Coach •Help them Think About Thinking: •Ask: What Kind of Thinking is Needed? •Use the 17 CT Terms and Definitions •Evaluate •Expect Thinking Processes Self-Evaluation of Thinking Objective 3: Teaching Strategies •Share Paradigm Cases (e.g. Marian Hughes) •Simplify Representations, Identify High Relevance Cues •Conduct Iterative Hypothesis Testing Objective 3: Teaching Strategies Intellectual •Seminars Instead of Lectures: Why? •Groups Represent Wide Variations in Thinking Abilities •Promotes “In-Class” Thinking •Recognizes Students’ Abilities to Think and Learn without Authority/Experts •Supports Future Work in Groups to Describe, Analyze and Synthesize Information, Solve Problems (e.g. What is the diagnosis?) Objective 3: Teaching Strategies Intellectual •Seminars: How? •Assign Readings, Provide Discussion Questions •Lead the Group, Ask the Discussion Questions •Be Respectful; Protect Students’ Self-Esteem •Address: •What is the Author Saying? •What is the Fit with Previous Knowledge? •How Does This Information Apply to Practice? •25-30% of Grade for Discussion of Readings Objective 3: Teaching Strategies Intellectual •Expect Self Evaluation •Ask Questions, Instead of Giving Answers •Discussion in Class •Discussion Online •Journal Writing (Degazon and Lunney 1996) Objective 3: Teaching Strategies Interpersonal •Expect Accountability For Patient Relationships •Demonstrate: •Good Interviewing •Validation of Diagnoses •Partnership Processes to Select Outcomes and Interventions •Reward •Teach Power Sharing and Support Assertiveness Objective 3: Teaching Strategies Interpersonal •Expect Accountability For Using Standardized Methods •Demonstrate •Show Use of Diagnostic Reasoning Technical Use of NNN Using Case Studies (Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008) Objective 3: Teaching Strategies General •Demonstrate •Provide Correct Use of NNN Incentives for Correct Use of NNN, e.g. Percentage of Grade •Integrate with Theories of Nursing (Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008) Case Study With Permission of Dr Arlene Farren •30-Year-Old Woman in Good Health •Smokes 1-1.5 Packs Per Day for >12 years •Asked for assistance to quit •Stated “I know it’s not good for me and I want to stay healthy” What is the Diagnosis? •Readiness for Enhanced Self-Health Management Definition: A Pattern of Regulating and Integrating Into Daily Living a Therapeutic Regime for Treatment of Illness and Its Sequelae that is Sufficient for Meeting Health-Related Goals and can be Strengthened (Herdman 2012) What is the Outcome? Smoking Cessation Behavior •Personal •Rarely Actions to Eliminate Tobacco Use Demonstrated (3), Goal = 5 •Indicators: •Expresses •Identifies •Adjusts •Uses Benefits of Smoking Cessation (3) Tobacco Elimination Strategies as Needed (3) Strategies to Cope with Withdrawal Symptoms (2) •Develops (Moorhead et al. 2008) Willingness to Stop Smoking (3) Effective Strategies to Eliminate Tobacco Use (2) What are the Interventions? •Smoking Cessation Assistance •Teaching: Medication, Nicotine Replacement Therapy (Bulecheck et al. 2008) NIC: Smoking Cessation Assistance Helping Another to Stop Smoking •Activities: •Give Laura Clear, Consistent Advice to Quit •Assist Laura in Choosing Strategies •Motivate Her to Set a Quit Date •Refer to Group Programs/Individual Therapy •Inform Laura of Possible Symptoms •Help Plan Coping Strategies and Problem Resolution (Bulecheck et al. 2008) Evaluation of Outcomes Smoking Cessation Behavior •After 6 Weeks, Nurse and Laura Rate Outcome as 5 •Laura Consistently Monitors Her Environment and Personal Behaviors for Factors that Affect Her Tobacco Use •Laura Developed Effective Strategies and Remains Consistently Committed to Controlling Her Use •Laura Uses Friends and Group for Help •Laura Has Not Smoked for 6 Weeks (Moorhead et al. 2008) Case Study With Permission of Coleen Kumar •49 Years Old; Single, Italian-American Woman •Type 2 Diabetes Mellitus (DM) with Adequate Control •Overweight •Head of Household; 80-Year-Old Dependent Mother •Works Full Time, Provides Care for Self and Mother •Accepts Care of Mother But has Many Frustrations •Attempts to Reduce Her Workload have Failed •Mother Thinks Stella “Can Do It All” •Mother Discourages Son’s Involvement •Stella Expresses Conflicting Emotions, Stress, Lack of Control What are the Diagnoses? •The Diagnostic Process: •Which are Important Cues? •What are Possible Diagnoses? •Which Diagnoses Have the Best Support? •Are the Diagnoses Consistent with the Situational Context? •Can the Nurse Help Stella with the Diagnoses? What are the Diagnoses? •NANDA-I Diagnoses: •Risk of Caregiver Role Strain •Readiness for Enhanced Family Coping •Checking •Are for Accuracy: There a Sufficient Number of Confirming Cues? •Are There Any Disconfirming Cues? •Did Stella Validate the Diagnosis? •Should Other Providers be Consulted? (Herdman 2012) What are the Outcomes? Caregiver Well-Being •Caregiver Satisfaction with Health and Lifestyle Circumstances •Moderately Compromised (3), Goal = 4 or 5 •Indicators: •Satisfaction with Physical Health (3) •Satisfaction with Emotional Health (2) •Satisfaction with Usual Lifestyle (3) •Satisfaction with Instrumental Support (2) •Satisfaction with Social Relationships (3) (Moorhead et al. 2008) What are the Outcomes? Family Coping •Family Actions to Manage Stressors that Tax Family Resources •Moderately Compromised (3); Goal = 4 or 5 •Indicators: •Demonstrates •Family Enables Member Role Flexibility (3) •Expresses •Arranges •Seeks •Uses Role Flexibility (3) Feelings and Emotions Freely (2) for Respite Care (2) Assistance When Appropriate (3) Social Support (3) (Moorhead et al. 2008) What are the Interventions? •Assertiveness Training •Self-Esteem Enhancement •Emotional Support •Caregiver Support •Role Enhancement •Family Involvement Promotion •Respite Care (Bulecheck et al. 2008) NIC Example Assertiveness Training •Assistance with the Effective Expression of Feelings, Needs, and Ideas While Respecting the Rights of Others •Activities: •Determine •Help Stella Recognize and Reduce Cognitive Distortions •Instruct Stella in Different Ways to Act Assertively •Facilitate •Help Barriers to Assertiveness (for Example, Family Roles) Practice Opportunities Using Discussion, Modeling and Role Playing Stella Practice Conversational Skills (Bulecheck et al. 2008) Evaluation of Outcomes Caregiver Well-Being After 4 Weeks, Nurse and Stella Rate Outcome as 4 •Stella’s Physical Health has Improved; Satisfaction with Physical Health (4) •Stella Uses Assertiveness Skills to Make Time for Herself After Work and to Plan Recreation; Satisfaction with Emotional Health (4) •Stella Continues to Need Help in The Performance of Caregiver Roles; Satisfaction with Performance of Usual Roles (4) •Stella Feels n Control of Her Caregiver Routines; Satisfaction with Caregiver Role (4) (Moorhead et al. 2008) Evaluation of Outcomes Family Coping After 4 Weeks, Nurse and Stella Rate Outcome as 4 •Stella’s Assertiveness Behaviors Work Well to Accomplish Goals; Demonstrates Role Flexibility (4) •Stella’s Mother Agrees with the Plan to Relieve Her of Some of the Workload; Family Enables Member Role Flexibility (4) •Stella’s Brother Stays with Her Mother So Stella can Go Away for Short Periods; Arranges For Respite Care (4) •Family (Moorhead et al. 2008) Exhibits a Wider Repertoire of Coping Behaviors (4) Use Case Studies •Case Studies Help Students to Practice Thinking and Clinical Judgment in a Safe Environment •Standardized: •Additional (2009) Everyone Uses the Same Clinical Data Case Studies, and Their Interpretations, can be Found in Lunney Teaching Strategies: Summary Observe Students Grow in Abilities through Encouragement, Trust, and Respect Objective 4: Integrate with Curricula •Prepare Faculty •Diffusion of Innovations (Rogers 2003) •Talking Points: •Electronic Health Record •Quality-Based •Ability •Involve Nursing Care to Develop Information and Knowledge Clinical Faculty •Evaluation/Peer Observation Objective 4: Integrate with Curricula •Simplify Complexity-Map of Diagnoses, Interventions and Outcomes for Courses •All Faculty Evaluate Students’: •Correct Use of NNN •Partnership Processes, Use of “We” •Technical Skills •Individualize NNN Content with Patients (Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008) Objective 4: Integrate with Curricula •Fundamentals of Nursing •NNN - Framework for Skills Learning •Thinking - High Priority Diagnoses, Include in Testing •Expect Students to Use CT Terms and Definitions (for Example, in Journal Writing and Discussion) •Develop Case Studies (Lunney 1992) •Iterative Hypothesis Testing (Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008) Objective 4: Integrate with Curricula •Educators and Practice-Based Leaders: Spread the Word to Nurses in Other Agencies •Meet with Leaders; Use Marketing Strategies •Demonstrate •Provide Advantages of NNN CE Programs •Disseminate Your Success in Using NNN to Others (Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008) Questions/Discussion •“Teamwork is the Fuel that Allows Common People to Attain Uncommon Results” (Unknown) “The Illiterate of the 21st Century will Not be Those Who Cannot Read and Write, But Those Who Cannot Learn, Unlearn and Relearn” • (Alvin Toffler) References Benner PA. (1984) Novice to Expert: Promoting Excellence and Power in Professional Nursing Practice. Menlo Park, CA: Addison Wesley. Bulechek GM, Butcher H, Dochterman JC. (2008) Nursing Interventions Classification (NIC), 5th edn. St Louis, MO: Mosby. Carnevali DL. (1983) Nursing Care Planning: Diagnosis and Management. Philadelphia: Lippincott Williams and Wilkins. Degazon CE, Lunney M. (1995) Clinical journal: a tool to foster critical thinking for advanced levels of competence. Clinical Nurse Specialist 9(5): 270-274. Doane GH, Varcoe C. (2005) Family Nursing as Relational Inquiry: Developing Health Promoting Behavior. Philadelphia: Lippincott. Gordon M. (1982) Nursing Diagnosis: Process and Application. New York: McGraw- Hill. Herdman TH. (ed). (2012) NANDA International Nursing Diagnoses: Definitions and Classification, 20122014. Oxford: Wiley-Blackwell. Lunney M. (1992) Divergent productive thinking and accuracy of nursing diagnoses. Research in Nursing and Health 15: 303-311. Lunney M. (2009) Critical thinking to achieve positive health outcomes: nursing case studies and analyses. Ames, IA: Wiley-Blackwell. Moorhead S, Johnson M, Maas M, Swanson E. (2008) Nursing Outcomes Classification (NOC). 4th edn. St Louis, MO: Mosby. Pender NJ, Murdaugh C, Parsons MA. Health Promotion in Nursing Practice, 6th edn. Upper Saddle River, NJ: Pearson/Prentice-Hall, 2010. Rogers M. (2003) Diffusion of Innovations, 5th edn. New York: Free Press. Scheffer BK, Rubenfeld MG. (2000) A consensus statement on critical thinking. Journal of Nursing Education 39: 352-359.