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Nursing diagnoses for psychiatric patients in China
Nursing Diagnoses for Psychiatric Patients in China Marlys Bueber, Huie Tang, Xuiyu Ma, Anzhen Wang, and Ciuoai Liu This report describes the development of a preliminary Chinese psychiatric classification system with nine categories and 211 separate diagnoses, and the corresponding diagnostic interview that enables psychiatric nurses in China to systematically assess the presence or absence of the various diagnoses. Using this interview with 30 representative inpatients. the authors identified 152 of the 211 (72%) diagnoses. On average, each patfent was gfven 26 different nursing diagnoses. The inter-rater reliabilky of the four nurses who independentiy coded the diagnostic lntetvlew for these 30 patients was excellent: in over 77% of the identified diagnoses the generalbed kappa was greater than 0.75. These findings show that further work on this classification of nursing diagnoses is warranted.
Copyright 0 1993 bg W.B. Saunders Company
C
OMPARING PSYCHIATRIC nursing diagnoses of persons from different countries with similar illnesses is a necessary step in developing an international classification system of nursing diagnoses. As yet there have been no cross-cultural studies of psychiatric nursing diagnoses that address questions such as, are the nursing diagnoses of a person with paranoid schizophrenia in China similar to those of a person with the same illness in the United States? Several obstacles+specially in developing countries-need to be overcome before such collaborative studies can be conducted. Differences in educational preparation, culture, and society necessitate that nurses in developing nations develop nursing diagnoses and nomenclatures suitable to their psychosociocultural environment, rather than adopt unmodified versions of North American diagnostic taxonomies . In China, for example, most psychiatric nurses are trained in basic 3-year nursing programs in From the Department of Nwsing, Shashi Psychiatric Hospital, Shashi, Hubei, People’s Republic of China. Address reprint requests to Mar& Bueber, RN, MN, Shashi Psychiatric Hospital, Shashi, Hubei, People’s Republic of China, 434000. Copyright 0 1993 by WB. Saunders Company m83-9417/93/0701 -ooo4$3.00/0
16
which they receive no psychiatric training. (In the past 5 years China has developed twelve 5year nursing programs, but no advanced nursing degree programs exist.) As a result, few nurses in China have the necessary knowledge to conduct scientific research and systematically develop psychiatric nursing diagnoses according to Western methods. Direct translations of Western nursing diagnoses classification systems are available to some nurses working in China’s most prestigious psychiatric institutions, but these often befuddle Chinese psychiatric nurses who lack the needed conceptual and theoretical background. The authors believe that a widespread introduction of psychiatric nursing diagnoses in China would have two major benefits. First, it would help professionalize Chinese psychiatric nursing and, thus, improve the quality of nursing care provided to patients. Second, it would enable Chinese psychiatric nurses to participate in collaborative research and exchange with nurses from other countries. However, to achieve these goals Chinese nurses must first identify the nursing diagnoses that are reliable and valid in the Chinese context. This will require a series of high-quality research studies that systematically assess several aspects of each diagnosis before including it in a formal classification system: the clarity of the di-
Archives of Psychiatric Nursing, Vol. VII, No. 1 (February), 1993:
pp. 1E-22
PSYCHIATRIC
NURSING
DIAGNOSES
17
FOR CHINA
agnostic criteria, the frequency of the diagnosis in the target population, the consistency of the diagnosis between evaluators, and the relevance of the diagnosis to patients’ and family members’ clinical and psychosocial status. As a first step in this process, this article reports on a research study undertaken at Shashi Psychiatric Hospital that developed a preliminary classification of psychiatric nursing diagnoses for use in China, designed a corresponding diagnostic interview, trained four nurse clinicians in the use of the interview, and then administered the interview to 30 representative psychiatric inpatients.
The first
of
these patients. Some probes and all of the information taken from the patients’ medical records were designed to
Actual diagnosis:
Disturbance in perception/auditory hallucinations Item: (Probe) “In the past week have you heard voices or noises that other people did not hear?” (If yes, ask the following.) “What did you hear?” “Can you tell me about the voices?” “Did you hear the voices telling you to do something?” “Are you frightened by the voices?” Potential diagnosis: Potential for disturbed nutrition Item: Did the patient have problems with eating or appetite before hospitalization? (Information taken from medical record. )
The third phase of the research was to train the nursing researchers to administer and code the di-
18
BUEBER
agnostic assessment instrument. Over a 2-week period, two nurses were trained to administer the instrument. These two nurses and another two nurses were then trained for 4 weeks in the coding of the instrument. A pilot test with eight patients was conducted and problems in the use of the instrument were identified and rectified. Some probes were revised to obtain more precise information and some diagnostic criteria were clarified to decrease the difficulty in coding. The interview took 1 to 1M hours to administer. The fourth phase of the research was to assess the interrater reliability of the instrument. To do this the instrument was administered to 30 inpatients at the acute-care Shashi Psychiatric Hospital. Subjects had to be willing and able to participate in the lengthy interview; uncooperative patients or patients who were disoriented or confused were not included. To make the sample as representative as possible, subjects were selected from five adult inpatient wards on the basis of length of hospitalization and gender. Ten subjects had been hospitalized for less than 24 hours at the time of the evaluation, 10 had been hospitalized 9 to 11 days, and 10 had been hospitalized 26 to 32 days. Fifteen of the subjects were men and 15 were women. Each subject was interviewed by one of the two interviewers, who read the questions verbatim from the diagnostic instrument. Questions were repeated as often as needed to ensure that the patient clearly understood the intent of the question. During the interview the four researchers independently coded their assessments on separate coding sheets. At the end of each interview all four researchers reviewed the subject’s medical record to obtain additional information about potential nursing problems not mentioned by the subject during the interview. The four coding sheets for each of the 30 subjects were then compared to determine the level of agreement among the different researchers’ diagnoses, i.e., the interrater reliability of the instrument, The generalized kappa statistic (Fleiss, 1981) was used to measure interrater reliability. RESULTS
The basic characteristics of the patients were as follows. The 30 patients had a mean age of 31 years (SD f 10 years; range 18-53); 16 (53.3%) were married; 16 (53.3%) lived in urban areas and
ET AL.
14 (46.7%) lived in rural areas; 27 (90%) had a medical diagnosis of schizophrenia; 28 (93.3%) were involuntarily admitted to the hospital; and 15 (50%) paid for the hospitalization costs with private funds. The mean number of hospitalizations was 2.93 (SD ? 2.64; range 1-13); the mean duration of illness was 2.57 years (SD rt 7.83; range O.l-25.0), and the mean years of schooling was 8.20 years (SD + 2.89; range 1-15). Eleven of the patients were on level I nursing care (given to acutely disturbed patients) at the time of evaluation, 18 were on level II nursing care (given to recovering patients), and one was on level III nursing care (the least intensive degree of nursing supervision for rehabilitation patients). Of the 211 possible diagnoses, 152 (72%) were considered present by at least one researcher for at least one patient. A total of 780 diagnoses were given to the 30 subjects. In 584 of these diagnoses (74.9%) all four researchers agreed the diagnosis was present; in 74 diagnoses (9.5%) three researchers agreed the diagnosis was present; in 51 diagnoses (6.5%) two researchers agreed that the diagnosis was present; and in 7 1 diagnoses (9.1%) only one researcher believed that the diagnosis was present. The mean number of nursing diagnoses given to each patient was 26 (SD & 9.4; range 12-50), of which 19.5 (SD + 6.9, range 8-34) diagnoses were coded as present by all four researchers. The number and percent of diagnoses rated present in each category of diagnosis is listed in Table 1. All the diagnoses in categories VII through IX-responses to illness, responses to relationships/functions in society, and potential responses-were identified in one or more of the patients, and the interrater reliability for these diagnoses was either excellent or good. Categories II and IV-other physiological responses and perceptual responses-had the lowest percentages of identified diagnoses (~60%). Table 1 shows that 117 of the 152 identified diagnoses (77.0%) had excellent interrater reliability whereas 19 (12.5%) had unacceptable reliability. Of the 19 diagnoses with unacceptable interrater reliability, 9 were diagnoses rated as present in only one patient by only one coder, 7 were diagnoses rated as present in only one patient by two coders, and 3 were diagnoses rated as present in two patients by one or two coders.
PSYCHIATRIC NURSING
Table 1. Interrater
DIAGNOSES
Rrliabiiii
19
FOR CHINA
of Nine Categories of Nursing Diagnoses for Four Coders’ Assessments
of 30 Chinese
Psychiatric Inpatients Interrater Possible
Identified
Diagnoses
Diagnoses
kappa
P 0.75
kappa
(excellentl
Reliability
= 0.06-0.75
in identified
Diagnoses
kappa
= 0.40-0.60
kappa
s 0.40
(good)
0.0
6
21.4
25
14
56.0
12
85.7
0
0.0
7.1
1
7.1
37
25
67.6
15
60.0
1
4.0
16.0
5
20.0
11
6
54.5
2
33.3
3
50.0
0.0
1
16.7
25
22
88.0
18
81.8
2
9.1
0.0
2
9.1
31
21
67.7
15
71.4
2
9.5
0.0
4
19.0
13
13
100.0
12
92.3
1
7.7
0.0
0
0.0
5
5
100.0
5
100.0
0
0.0
0.0
0
0.0
18
18
100.0
17
94.4
1
5.5
0.0
0
0.0
211
152
72.0
117
77.0
11
7.2
3.3
19
12.5
NOTE. Kappa values are generalized. According to Fleiss (1981), a kappa value so.75 in social science research indicates excellent reliability, kappa = 0.60-0.75 indicates good reliability, kappa = 0.40-0.60 indicates poor but acceptable reliability, and kappa ~0.40 is unacceptable.
Thirty-one of the 211 diagnoses (14.7%) occurred in more than one fourth of the patients. These common diagnoses are listed by category in Table 2. Common diagnoses included two of the 25 (8.0%) other physiological responses (category II) diagnoses, 3 of 25 ( 12.O%) emotional responses (category V) diagnoses, 6 of 3 1 (19.4%) behavioral responses (category VI) diagnoses, 5 of 13 (38.5%) responses to illness (category VII) diagnoses, 4 of 5 (80%) responses to relationships/ functions in society (category VIII) diagnoses, and 11 of 18 (6 1.1%) potential responses (category IX) diagnoses. None of the diagnoses in the basic functional responses category (I), the cognitive responses category (III), or the perceptual responses category (IV) were common in this sample of patients. Some diagnosis that are only seen in a few patients are, nonetheless, important because they are problems that, when present, are given high prior-
ity on the nursing care plan. A selection of these diagnoses by category and subcategory are presented in Table 3. DISCUSSION
The primary aim of this study was to develop a preliminary classification system for all possible nursing diagnoses for psychiatric patients in China and to design a reliable and valid instrument that could assist nurses to systematically assess whether these diagnoses are present. Extensive discussion between the five authors generated a classification system with 211 separate diagnoses divided into nine categories and led to the construction of a corresponding diagnostic interview. The results of a small pilot study were used to revise the diagnostic criteria and the interview schedule. After training the interviewers and the coders, the reliability of the diagnostic instrument was formally tested by comparing the diagnoses of four indepen-
20
BUEBER ET AL.
Table 2. Common Nursing Diagnoses Identified in 30 Chinese Psychiatric Inpatients Frequency
CategolylDiagnosis
N
96
16
53.3
9
30.0
9
30.0
9
30.0
8
26.7
II: Other physiological responses Side effects from medication Abnormal
hormone regulation/
menstrual irregularity V: Emotional responses Frustration Avoidance
behavior
Loneliness VI: Behavioral responses Potential for violence/destroying property Potential for violence toward others
13
43.3
13
43.3
Social isolation/withdrawal
11
36.7
Impaired nonverbal communication
8
26.7
Suicidal ideation
8
26.7
Potential for suicide
a
26.7
28
93.3
25
03.3
17
56.7
13
43.3
0
26.7
VII: Responses to illness Lack of knowledge about illness Lack of knowledge
about
medication/treatment Fear of stigma associated with mental illness Denial of illness Fear of medication/treatments VIII: Responses to relationships/functions
in society 14
46.7
14
46.7
0
26.7
a
26.7
Potential for disturbed sleep patterns
27
90.0
Potential for aggressive/violent
26
86.7
behavior
23
76.7
Potential for disturbed activity level
23
76.7
17
56.7
16
53.3
Impaired relationships with friends Impaired relationships with immediate family Impaired relationships with family of origin Impaired relationships at school or work Xl: Potential responses
Potential for inappropriate
behavior
Potential for difficulty with outpatient follow-up treatment Potential for disturbance in self-care Potential for noncompliance
with 15
50.0
Potential for disturbed socialization
14
46.7
Potential for financial difficulties
12
40.0
12
40.0
10
33.3
treatment
recommendations
Potential for disturbed function in school or work Potential for disturbed nutrition
dent coders for 30 representative psychiatric inpatients. Limitations of the Study
The study had some limitations that need to be considered when interpreting the results. The sam-
ple size, although large enough to assess reliability, was too small to make generalizations about the frequency of nursing diagnoses in psychiatric patients. The sample, although representative of inpatients at our acute-care psychiatric hospital, was primarily composed of inpatients with a medical diagnosis of schizophrenia who were well enough to cooperate with a lY&hour interview. The pattern of nursing diagnoses and their respective reliabilities may be different in patients with other types of mental illnesses, patients who are severely ill, or patients seen at outpatient clinics or chronic care hospitals. And we did not follow-up patients’ nursing diagnoses over time, so we are unable to comment on the relative stability of the diagnoses (i.e., their test-retest reliability). Major Results
Despite these limitations, the study had a number of important findings. Using the most rigorous parameter for assessing interrater reliabilitygeneralized kappa-we found that there was excellent inter-rater reliability (kappa 2 0.75) in 117 of the 152 (77.0%) identified diagnoses. If the 59 diagnoses that the four coders agreed were not present for any of the patients are also considered, then the reliability was excellent for 176 (117 + 59) of the 211 diagnoses (83.4%) in the classification system. Thus, for most of the diagnoses the diagnostic criteria were clear enough and the information obtained by the interview was detailed enough to reliably discern the presence or absence of the diagnosis. This finding confirms the reliability of the proposed classification system. The study also provides preliminary data about the frequencies of different nursing diagnoses that merit further investigation. The high frequency of diagnoses in categories VII through IX-responses to illness, responses to relationships/functions in society, and potential responses-suggests that nurses should (1) teach patients more about their illnesses and treatments, (2) plan nursing interventions that improve patients’ social skills, and (3) routinely obtain more information about potential problems from family members at the time of patients’ hospital admission. The mean number of nursing diagnoses per patient (26.0 diagnosis of which 19.5 diagnoses were coded as present by all four coders) was comparable with that of a U.S. study (Thomas et al., 1988) in which psychiatric patients were given an aver-
21
PSYCHIATRIC NURSING DIAGNOSES FOR CHINA
Table 3. Selected Uncommon but Importent Nursing Diagnoses Identified in 30 Chinese Psychiatric Inpatients Frequency
Frequency
Impaired coordination
3
10.0
Psychomotor
2
6.7
Abnormal
7
23.3
4
13.3
Cognition deficits
motor behavior retardation
%
ill. Cognitive responses
I. Basic functional responses Abnormal
N
Short-term
memory loss
Decreased concentration Cognition distortions
sleep patterns
Somnolence
5
16.7
Decreased self-esteem
6
20.0
Early morning awakening
4
13.3
Persecutory delusions
5
16.7
Difficulty falling asleep
4
13.3
Delusions of reference
5
16.7
Insomnia
3
10.0
Nightmares
3
10.0
Difficulty waking up
3
10.0
Decreased vision
7
23.3
Decreased hearing
3
10.0
6
20.0
1
3.3
Abnormal
nutrition 13.3
IV. Perceptual responses Perception deficits
Perception distortions
Nausea
4
Vomiting
2
6.7
2
6.7
Constipation
4
13.3
Dysfunctional self-care behavior
Diarrhea
4
13.3
Abnormal grooming/hygiene
4
13.3
Retention of urine
0
0.0
Lack of care for general health
0
0.0
Anorexia Abnormal elimination
age of 22 diagnosis (range 13-35). Of course, not all of a patient’s diagnoses require immediate intervention; nurses in clinical settings should develop nursing care plans for the three or four primary diagnoses and then revise the care plan as the patient’s condition changes during hospitalization. Revision of the Classijication System and the Diagnostic Interview The interrater reliability and relative frequency of the diagnoses also provide information that will be helpful in the next round of revision and reevaluation of the classification system and its corresponding diagnostic interview. The 19 diagnoses with unacceptable interrater reliability were all coded as present in only one or two patients by only one or two coders; they reflect the occasional uncertainty of coders about how to code an uncommon diagnosis. Some of these diagnoses were difficult to confirm without additional sources of data that could verify the patient’s reports (e.g., “lying behavior,” “ delusion of poverty, ” “somatization’ ‘). Some diagnoses required the coder to combine different sources of information to determine the diagnosis (e.g., the diagnosis “eats less food than required by body” required the researcher to consider both the response to the question, “Have you been losing weight?” and whether the patient appeared cachectic); and in some diagnoses the
Auditory hallucinations Visual hallucinations VI. Behavioral responses
coder did not know what to code when the patient gave an ambiguous response (e.g., by first admitting a symptom and then denying it). These problems can be resolved by clarifying the diagnostic criteria, changing the probes for the items in the diagnostic interview, and writing a formal instruction booklet in the use of the diagnostic interview that clearly specifies how to code the many ambiguous situations that may arise during the interview. In some cases the diagnoses with poor interrater reliability are, on reflection, inappropriate and must be either deleted or combined with another diagnosis. The criteria and coding directions for diagnoses that occur more frequently or less frequently than expected (given the clinical status of the sample of patients) must also be reviewed. The absence or infrequent occurrence of many of the physiological responses diagnoses in categories I and II (e.g., “high blood pressure”) was expected because most psychiatric patients do not have serious physical problems. But the absence of 12 of the 37 (32.4%) cognitive responses diagnoses (Table 1) and the relatively infrequent occurrence of the abnormal sleep patterns diagnoses (Table 3) were surprising in a sample that was primarily composed of schizophrenic inpatients. In revising the classification system, these problems will be resolved by combining some of the rare cognitive
22
ET AL.
responses diagnoses and by relaxing the diagnostic criteria for the sleep pattern diagnoses so more patients will be given these diagnoses. In the early stages of developing a classification system it is also important to use the clinical trials of the system to identify other possible diagnoses that were not included in the preliminary classification. In this study we found two such conditions: suspiciousness and seizures. These diagnoses will be added to the revised version of the diagnostic system. FUTURE
WORK
Development of a culture-sensitive diagnostic classification system and a corresponding diagnostic instrument that is both reliable and valid is a lengthy process that involves multiple steps of revision and re-evaluation. This study has taken a first step in the development of a classification system for psychiatric nursing diagnoses in China, but there is much work still to do. The information from the current study must be used to revise the classification system, the diagnostic criteria, and the diagnostic interview. The revised interview must then be administered to a large sample of representative psychiatric patients (including inpatients and outpatients) to determine the relative frequencies of the various diagnoses. To facilitate the diagnosis of severely ill and uncooperative patients, an abbreviated version of the diagnostic instrument based solely on nurses’ observations and family members’ comments should be developed. Longitudinal studies that look at the changes in nursing diagnoses over time are needed to assess the relative stability of the diagnoses. The relationship between nursing and medical diagnoses needs to be analyzed. And, most importantly, sociocultural studies are needed to assess the validity of the classification system; this involves determining whether the included diagnoses are considered problems in need of solution by participants in the care-delivery process (patients, family members, and clinicians), and whether there are other biopsychosocial problems related to poor mental health that should have a corresponding nursing diagnosis. There is never a final version of a diagnostic classification system because classification systems must be responsive to theoretical and thera-
peutic advances in the field; they must be flexible enough to allow for the addition of new diagnoses or the revision of old diagnoses. However, once a set of diagnoses has been shown to be reliable and valid, it becomes the “current” classification system, that is, the set of diagnoses that are consistent with the current state of knowledge in the field. This relatively stable classification system can then be used as the basis for a coherent, long-range plan of teaching and research that will promote the aims of the profession. A Chinese classification of psychiatric nursing diagnoses, for example, will be an ideal tool for training Chinese nurses in the assessment of psychiatric problems. It will promote the use of uniform terminology to describe patients’ problems and, thus, greatly improve the efficacy of communication between nurses. And the development of diagnosis-specific nursing care plans will improve the quality of nursing care provided to patients. To achieve these worthy goals, Chinese psychiatric nurses at several sites around the country must undertake a coordinated series of studies that will improve on the preliminary classification system proposed in this article and, once a stable classification system is developed, promote the use of the classification system by all psychiatric nurses in China. When these goals are accomplished Chinese nurses will be able to contribute to the knowledge of their Western colleagues in the development of an international classification system of nursing diagnoses. ACKNOWLEDGMENT
The authors thank Michael Phillips, MD, MA, MPH, of Shashi Psychiatric Hospital for his assistance in preparing the manuscript. REFERENCES Fleiss, J.L. (1981). The Measurement of interrater agreement. In Statistical methods for rates and proportions (2nd ed.) (pp. 212-236). New York: John Wiley & Sons. Gordon, M. (1985). Manual of nursing diagnosis. New York: McGraw-Hill. Loomis, M., O’Toole, A. W., Brown, MS., Pothier, P., West, P., & Wilson, H.S. (1987). Classification of human responses of concern for psychiatric mental health nursing practice. Kansas City, MO; American Nurses’ As-
sociation. Thomas, M.D., Sanger, E., Wolf-Wilets, V., & Whitney, J.D. (1988). Nursing diagnosis of patients with manic and thought disorders. Archives of Psychiatric Nursing, 2(6), 339-344.
Copyright 0 1993 bg W.B. Saunders Company
C
OMPARING PSYCHIATRIC nursing diagnoses of persons from different countries with similar illnesses is a necessary step in developing an international classification system of nursing diagnoses. As yet there have been no cross-cultural studies of psychiatric nursing diagnoses that address questions such as, are the nursing diagnoses of a person with paranoid schizophrenia in China similar to those of a person with the same illness in the United States? Several obstacles+specially in developing countries-need to be overcome before such collaborative studies can be conducted. Differences in educational preparation, culture, and society necessitate that nurses in developing nations develop nursing diagnoses and nomenclatures suitable to their psychosociocultural environment, rather than adopt unmodified versions of North American diagnostic taxonomies . In China, for example, most psychiatric nurses are trained in basic 3-year nursing programs in From the Department of Nwsing, Shashi Psychiatric Hospital, Shashi, Hubei, People’s Republic of China. Address reprint requests to Mar& Bueber, RN, MN, Shashi Psychiatric Hospital, Shashi, Hubei, People’s Republic of China, 434000. Copyright 0 1993 by WB. Saunders Company m83-9417/93/0701 -ooo4$3.00/0
16
which they receive no psychiatric training. (In the past 5 years China has developed twelve 5year nursing programs, but no advanced nursing degree programs exist.) As a result, few nurses in China have the necessary knowledge to conduct scientific research and systematically develop psychiatric nursing diagnoses according to Western methods. Direct translations of Western nursing diagnoses classification systems are available to some nurses working in China’s most prestigious psychiatric institutions, but these often befuddle Chinese psychiatric nurses who lack the needed conceptual and theoretical background. The authors believe that a widespread introduction of psychiatric nursing diagnoses in China would have two major benefits. First, it would help professionalize Chinese psychiatric nursing and, thus, improve the quality of nursing care provided to patients. Second, it would enable Chinese psychiatric nurses to participate in collaborative research and exchange with nurses from other countries. However, to achieve these goals Chinese nurses must first identify the nursing diagnoses that are reliable and valid in the Chinese context. This will require a series of high-quality research studies that systematically assess several aspects of each diagnosis before including it in a formal classification system: the clarity of the di-
Archives of Psychiatric Nursing, Vol. VII, No. 1 (February), 1993:
pp. 1E-22
PSYCHIATRIC
NURSING
DIAGNOSES
17
FOR CHINA
agnostic criteria, the frequency of the diagnosis in the target population, the consistency of the diagnosis between evaluators, and the relevance of the diagnosis to patients’ and family members’ clinical and psychosocial status. As a first step in this process, this article reports on a research study undertaken at Shashi Psychiatric Hospital that developed a preliminary classification of psychiatric nursing diagnoses for use in China, designed a corresponding diagnostic interview, trained four nurse clinicians in the use of the interview, and then administered the interview to 30 representative psychiatric inpatients.
The first
of
these patients. Some probes and all of the information taken from the patients’ medical records were designed to
Actual diagnosis:
Disturbance in perception/auditory hallucinations Item: (Probe) “In the past week have you heard voices or noises that other people did not hear?” (If yes, ask the following.) “What did you hear?” “Can you tell me about the voices?” “Did you hear the voices telling you to do something?” “Are you frightened by the voices?” Potential diagnosis: Potential for disturbed nutrition Item: Did the patient have problems with eating or appetite before hospitalization? (Information taken from medical record. )
The third phase of the research was to train the nursing researchers to administer and code the di-
18
BUEBER
agnostic assessment instrument. Over a 2-week period, two nurses were trained to administer the instrument. These two nurses and another two nurses were then trained for 4 weeks in the coding of the instrument. A pilot test with eight patients was conducted and problems in the use of the instrument were identified and rectified. Some probes were revised to obtain more precise information and some diagnostic criteria were clarified to decrease the difficulty in coding. The interview took 1 to 1M hours to administer. The fourth phase of the research was to assess the interrater reliability of the instrument. To do this the instrument was administered to 30 inpatients at the acute-care Shashi Psychiatric Hospital. Subjects had to be willing and able to participate in the lengthy interview; uncooperative patients or patients who were disoriented or confused were not included. To make the sample as representative as possible, subjects were selected from five adult inpatient wards on the basis of length of hospitalization and gender. Ten subjects had been hospitalized for less than 24 hours at the time of the evaluation, 10 had been hospitalized 9 to 11 days, and 10 had been hospitalized 26 to 32 days. Fifteen of the subjects were men and 15 were women. Each subject was interviewed by one of the two interviewers, who read the questions verbatim from the diagnostic instrument. Questions were repeated as often as needed to ensure that the patient clearly understood the intent of the question. During the interview the four researchers independently coded their assessments on separate coding sheets. At the end of each interview all four researchers reviewed the subject’s medical record to obtain additional information about potential nursing problems not mentioned by the subject during the interview. The four coding sheets for each of the 30 subjects were then compared to determine the level of agreement among the different researchers’ diagnoses, i.e., the interrater reliability of the instrument, The generalized kappa statistic (Fleiss, 1981) was used to measure interrater reliability. RESULTS
The basic characteristics of the patients were as follows. The 30 patients had a mean age of 31 years (SD f 10 years; range 18-53); 16 (53.3%) were married; 16 (53.3%) lived in urban areas and
ET AL.
14 (46.7%) lived in rural areas; 27 (90%) had a medical diagnosis of schizophrenia; 28 (93.3%) were involuntarily admitted to the hospital; and 15 (50%) paid for the hospitalization costs with private funds. The mean number of hospitalizations was 2.93 (SD ? 2.64; range 1-13); the mean duration of illness was 2.57 years (SD rt 7.83; range O.l-25.0), and the mean years of schooling was 8.20 years (SD + 2.89; range 1-15). Eleven of the patients were on level I nursing care (given to acutely disturbed patients) at the time of evaluation, 18 were on level II nursing care (given to recovering patients), and one was on level III nursing care (the least intensive degree of nursing supervision for rehabilitation patients). Of the 211 possible diagnoses, 152 (72%) were considered present by at least one researcher for at least one patient. A total of 780 diagnoses were given to the 30 subjects. In 584 of these diagnoses (74.9%) all four researchers agreed the diagnosis was present; in 74 diagnoses (9.5%) three researchers agreed the diagnosis was present; in 51 diagnoses (6.5%) two researchers agreed that the diagnosis was present; and in 7 1 diagnoses (9.1%) only one researcher believed that the diagnosis was present. The mean number of nursing diagnoses given to each patient was 26 (SD & 9.4; range 12-50), of which 19.5 (SD + 6.9, range 8-34) diagnoses were coded as present by all four researchers. The number and percent of diagnoses rated present in each category of diagnosis is listed in Table 1. All the diagnoses in categories VII through IX-responses to illness, responses to relationships/functions in society, and potential responses-were identified in one or more of the patients, and the interrater reliability for these diagnoses was either excellent or good. Categories II and IV-other physiological responses and perceptual responses-had the lowest percentages of identified diagnoses (~60%). Table 1 shows that 117 of the 152 identified diagnoses (77.0%) had excellent interrater reliability whereas 19 (12.5%) had unacceptable reliability. Of the 19 diagnoses with unacceptable interrater reliability, 9 were diagnoses rated as present in only one patient by only one coder, 7 were diagnoses rated as present in only one patient by two coders, and 3 were diagnoses rated as present in two patients by one or two coders.
PSYCHIATRIC NURSING
Table 1. Interrater
DIAGNOSES
Rrliabiiii
19
FOR CHINA
of Nine Categories of Nursing Diagnoses for Four Coders’ Assessments
of 30 Chinese
Psychiatric Inpatients Interrater Possible
Identified
Diagnoses
Diagnoses
kappa
P 0.75
kappa
(excellentl
Reliability
= 0.06-0.75
in identified
Diagnoses
kappa
= 0.40-0.60
kappa
s 0.40
(good)
0.0
6
21.4
25
14
56.0
12
85.7
0
0.0
7.1
1
7.1
37
25
67.6
15
60.0
1
4.0
16.0
5
20.0
11
6
54.5
2
33.3
3
50.0
0.0
1
16.7
25
22
88.0
18
81.8
2
9.1
0.0
2
9.1
31
21
67.7
15
71.4
2
9.5
0.0
4
19.0
13
13
100.0
12
92.3
1
7.7
0.0
0
0.0
5
5
100.0
5
100.0
0
0.0
0.0
0
0.0
18
18
100.0
17
94.4
1
5.5
0.0
0
0.0
211
152
72.0
117
77.0
11
7.2
3.3
19
12.5
NOTE. Kappa values are generalized. According to Fleiss (1981), a kappa value so.75 in social science research indicates excellent reliability, kappa = 0.60-0.75 indicates good reliability, kappa = 0.40-0.60 indicates poor but acceptable reliability, and kappa ~0.40 is unacceptable.
Thirty-one of the 211 diagnoses (14.7%) occurred in more than one fourth of the patients. These common diagnoses are listed by category in Table 2. Common diagnoses included two of the 25 (8.0%) other physiological responses (category II) diagnoses, 3 of 25 ( 12.O%) emotional responses (category V) diagnoses, 6 of 3 1 (19.4%) behavioral responses (category VI) diagnoses, 5 of 13 (38.5%) responses to illness (category VII) diagnoses, 4 of 5 (80%) responses to relationships/ functions in society (category VIII) diagnoses, and 11 of 18 (6 1.1%) potential responses (category IX) diagnoses. None of the diagnoses in the basic functional responses category (I), the cognitive responses category (III), or the perceptual responses category (IV) were common in this sample of patients. Some diagnosis that are only seen in a few patients are, nonetheless, important because they are problems that, when present, are given high prior-
ity on the nursing care plan. A selection of these diagnoses by category and subcategory are presented in Table 3. DISCUSSION
The primary aim of this study was to develop a preliminary classification system for all possible nursing diagnoses for psychiatric patients in China and to design a reliable and valid instrument that could assist nurses to systematically assess whether these diagnoses are present. Extensive discussion between the five authors generated a classification system with 211 separate diagnoses divided into nine categories and led to the construction of a corresponding diagnostic interview. The results of a small pilot study were used to revise the diagnostic criteria and the interview schedule. After training the interviewers and the coders, the reliability of the diagnostic instrument was formally tested by comparing the diagnoses of four indepen-
20
BUEBER ET AL.
Table 2. Common Nursing Diagnoses Identified in 30 Chinese Psychiatric Inpatients Frequency
CategolylDiagnosis
N
96
16
53.3
9
30.0
9
30.0
9
30.0
8
26.7
II: Other physiological responses Side effects from medication Abnormal
hormone regulation/
menstrual irregularity V: Emotional responses Frustration Avoidance
behavior
Loneliness VI: Behavioral responses Potential for violence/destroying property Potential for violence toward others
13
43.3
13
43.3
Social isolation/withdrawal
11
36.7
Impaired nonverbal communication
8
26.7
Suicidal ideation
8
26.7
Potential for suicide
a
26.7
28
93.3
25
03.3
17
56.7
13
43.3
0
26.7
VII: Responses to illness Lack of knowledge about illness Lack of knowledge
about
medication/treatment Fear of stigma associated with mental illness Denial of illness Fear of medication/treatments VIII: Responses to relationships/functions
in society 14
46.7
14
46.7
0
26.7
a
26.7
Potential for disturbed sleep patterns
27
90.0
Potential for aggressive/violent
26
86.7
behavior
23
76.7
Potential for disturbed activity level
23
76.7
17
56.7
16
53.3
Impaired relationships with friends Impaired relationships with immediate family Impaired relationships with family of origin Impaired relationships at school or work Xl: Potential responses
Potential for inappropriate
behavior
Potential for difficulty with outpatient follow-up treatment Potential for disturbance in self-care Potential for noncompliance
with 15
50.0
Potential for disturbed socialization
14
46.7
Potential for financial difficulties
12
40.0
12
40.0
10
33.3
treatment
recommendations
Potential for disturbed function in school or work Potential for disturbed nutrition
dent coders for 30 representative psychiatric inpatients. Limitations of the Study
The study had some limitations that need to be considered when interpreting the results. The sam-
ple size, although large enough to assess reliability, was too small to make generalizations about the frequency of nursing diagnoses in psychiatric patients. The sample, although representative of inpatients at our acute-care psychiatric hospital, was primarily composed of inpatients with a medical diagnosis of schizophrenia who were well enough to cooperate with a lY&hour interview. The pattern of nursing diagnoses and their respective reliabilities may be different in patients with other types of mental illnesses, patients who are severely ill, or patients seen at outpatient clinics or chronic care hospitals. And we did not follow-up patients’ nursing diagnoses over time, so we are unable to comment on the relative stability of the diagnoses (i.e., their test-retest reliability). Major Results
Despite these limitations, the study had a number of important findings. Using the most rigorous parameter for assessing interrater reliabilitygeneralized kappa-we found that there was excellent inter-rater reliability (kappa 2 0.75) in 117 of the 152 (77.0%) identified diagnoses. If the 59 diagnoses that the four coders agreed were not present for any of the patients are also considered, then the reliability was excellent for 176 (117 + 59) of the 211 diagnoses (83.4%) in the classification system. Thus, for most of the diagnoses the diagnostic criteria were clear enough and the information obtained by the interview was detailed enough to reliably discern the presence or absence of the diagnosis. This finding confirms the reliability of the proposed classification system. The study also provides preliminary data about the frequencies of different nursing diagnoses that merit further investigation. The high frequency of diagnoses in categories VII through IX-responses to illness, responses to relationships/functions in society, and potential responses-suggests that nurses should (1) teach patients more about their illnesses and treatments, (2) plan nursing interventions that improve patients’ social skills, and (3) routinely obtain more information about potential problems from family members at the time of patients’ hospital admission. The mean number of nursing diagnoses per patient (26.0 diagnosis of which 19.5 diagnoses were coded as present by all four coders) was comparable with that of a U.S. study (Thomas et al., 1988) in which psychiatric patients were given an aver-
21
PSYCHIATRIC NURSING DIAGNOSES FOR CHINA
Table 3. Selected Uncommon but Importent Nursing Diagnoses Identified in 30 Chinese Psychiatric Inpatients Frequency
Frequency
Impaired coordination
3
10.0
Psychomotor
2
6.7
Abnormal
7
23.3
4
13.3
Cognition deficits
motor behavior retardation
%
ill. Cognitive responses
I. Basic functional responses Abnormal
N
Short-term
memory loss
Decreased concentration Cognition distortions
sleep patterns
Somnolence
5
16.7
Decreased self-esteem
6
20.0
Early morning awakening
4
13.3
Persecutory delusions
5
16.7
Difficulty falling asleep
4
13.3
Delusions of reference
5
16.7
Insomnia
3
10.0
Nightmares
3
10.0
Difficulty waking up
3
10.0
Decreased vision
7
23.3
Decreased hearing
3
10.0
6
20.0
1
3.3
Abnormal
nutrition 13.3
IV. Perceptual responses Perception deficits
Perception distortions
Nausea
4
Vomiting
2
6.7
2
6.7
Constipation
4
13.3
Dysfunctional self-care behavior
Diarrhea
4
13.3
Abnormal grooming/hygiene
4
13.3
Retention of urine
0
0.0
Lack of care for general health
0
0.0
Anorexia Abnormal elimination
age of 22 diagnosis (range 13-35). Of course, not all of a patient’s diagnoses require immediate intervention; nurses in clinical settings should develop nursing care plans for the three or four primary diagnoses and then revise the care plan as the patient’s condition changes during hospitalization. Revision of the Classijication System and the Diagnostic Interview The interrater reliability and relative frequency of the diagnoses also provide information that will be helpful in the next round of revision and reevaluation of the classification system and its corresponding diagnostic interview. The 19 diagnoses with unacceptable interrater reliability were all coded as present in only one or two patients by only one or two coders; they reflect the occasional uncertainty of coders about how to code an uncommon diagnosis. Some of these diagnoses were difficult to confirm without additional sources of data that could verify the patient’s reports (e.g., “lying behavior,” “ delusion of poverty, ” “somatization’ ‘). Some diagnoses required the coder to combine different sources of information to determine the diagnosis (e.g., the diagnosis “eats less food than required by body” required the researcher to consider both the response to the question, “Have you been losing weight?” and whether the patient appeared cachectic); and in some diagnoses the
Auditory hallucinations Visual hallucinations VI. Behavioral responses
coder did not know what to code when the patient gave an ambiguous response (e.g., by first admitting a symptom and then denying it). These problems can be resolved by clarifying the diagnostic criteria, changing the probes for the items in the diagnostic interview, and writing a formal instruction booklet in the use of the diagnostic interview that clearly specifies how to code the many ambiguous situations that may arise during the interview. In some cases the diagnoses with poor interrater reliability are, on reflection, inappropriate and must be either deleted or combined with another diagnosis. The criteria and coding directions for diagnoses that occur more frequently or less frequently than expected (given the clinical status of the sample of patients) must also be reviewed. The absence or infrequent occurrence of many of the physiological responses diagnoses in categories I and II (e.g., “high blood pressure”) was expected because most psychiatric patients do not have serious physical problems. But the absence of 12 of the 37 (32.4%) cognitive responses diagnoses (Table 1) and the relatively infrequent occurrence of the abnormal sleep patterns diagnoses (Table 3) were surprising in a sample that was primarily composed of schizophrenic inpatients. In revising the classification system, these problems will be resolved by combining some of the rare cognitive
22
ET AL.
responses diagnoses and by relaxing the diagnostic criteria for the sleep pattern diagnoses so more patients will be given these diagnoses. In the early stages of developing a classification system it is also important to use the clinical trials of the system to identify other possible diagnoses that were not included in the preliminary classification. In this study we found two such conditions: suspiciousness and seizures. These diagnoses will be added to the revised version of the diagnostic system. FUTURE
WORK
Development of a culture-sensitive diagnostic classification system and a corresponding diagnostic instrument that is both reliable and valid is a lengthy process that involves multiple steps of revision and re-evaluation. This study has taken a first step in the development of a classification system for psychiatric nursing diagnoses in China, but there is much work still to do. The information from the current study must be used to revise the classification system, the diagnostic criteria, and the diagnostic interview. The revised interview must then be administered to a large sample of representative psychiatric patients (including inpatients and outpatients) to determine the relative frequencies of the various diagnoses. To facilitate the diagnosis of severely ill and uncooperative patients, an abbreviated version of the diagnostic instrument based solely on nurses’ observations and family members’ comments should be developed. Longitudinal studies that look at the changes in nursing diagnoses over time are needed to assess the relative stability of the diagnoses. The relationship between nursing and medical diagnoses needs to be analyzed. And, most importantly, sociocultural studies are needed to assess the validity of the classification system; this involves determining whether the included diagnoses are considered problems in need of solution by participants in the care-delivery process (patients, family members, and clinicians), and whether there are other biopsychosocial problems related to poor mental health that should have a corresponding nursing diagnosis. There is never a final version of a diagnostic classification system because classification systems must be responsive to theoretical and thera-
peutic advances in the field; they must be flexible enough to allow for the addition of new diagnoses or the revision of old diagnoses. However, once a set of diagnoses has been shown to be reliable and valid, it becomes the “current” classification system, that is, the set of diagnoses that are consistent with the current state of knowledge in the field. This relatively stable classification system can then be used as the basis for a coherent, long-range plan of teaching and research that will promote the aims of the profession. A Chinese classification of psychiatric nursing diagnoses, for example, will be an ideal tool for training Chinese nurses in the assessment of psychiatric problems. It will promote the use of uniform terminology to describe patients’ problems and, thus, greatly improve the efficacy of communication between nurses. And the development of diagnosis-specific nursing care plans will improve the quality of nursing care provided to patients. To achieve these worthy goals, Chinese psychiatric nurses at several sites around the country must undertake a coordinated series of studies that will improve on the preliminary classification system proposed in this article and, once a stable classification system is developed, promote the use of the classification system by all psychiatric nurses in China. When these goals are accomplished Chinese nurses will be able to contribute to the knowledge of their Western colleagues in the development of an international classification system of nursing diagnoses. ACKNOWLEDGMENT
The authors thank Michael Phillips, MD, MA, MPH, of Shashi Psychiatric Hospital for his assistance in preparing the manuscript. REFERENCES Fleiss, J.L. (1981). The Measurement of interrater agreement. In Statistical methods for rates and proportions (2nd ed.) (pp. 212-236). New York: John Wiley & Sons. Gordon, M. (1985). Manual of nursing diagnosis. New York: McGraw-Hill. Loomis, M., O’Toole, A. W., Brown, MS., Pothier, P., West, P., & Wilson, H.S. (1987). Classification of human responses of concern for psychiatric mental health nursing practice. Kansas City, MO; American Nurses’ As-
sociation. Thomas, M.D., Sanger, E., Wolf-Wilets, V., & Whitney, J.D. (1988). Nursing diagnosis of patients with manic and thought disorders. Archives of Psychiatric Nursing, 2(6), 339-344.