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Why nursing diagnoses are important in perioperative nursing
AORN JOURNAL
AUGUST 1984, VOL 40. NO 2
Education Why nursing diagnoses are important in perioperative nursing
R
ecently an operating room supervisor told of a concerned physician who asked if “her nurses” were going to start wearing stethoscopes around their necks. His question apparently came after seeing operating room nurses engaged in assessment practices on the surgical unit and in the holding area of the operating room. In contrast to that physician’s attitude, Lynda Carpenito, member of the task force, National Group for the Classification of Nursing Diagnosis, states that nursing diagnoses will “assist to define nursing in its present state, classify nursing’s domain, differentiate nursing from medicine. ”* Diagnosis follows the assessmentphase of the nursing process. Standard II of the AORN Standards of Perioperative Nursing Practice states, “Nursing diagnoses are derived from health status data. ” Webster defines diagnosis as “a careful examination and analysis of the facts in an attempt to understand or explain something. ” Traditionally, only physicians have diagnosed patients’ conditions, and some health care professionals, including some nurses, still question whether diagnosis is an appropriatenursing function. But the concept of nursing diagnosis is not new. The term was first used in nursing literature in 1953 when Vera Fry described a creative approach to planning patient care.* She identified five areas in which nursing diagnoses were needed to facilitatethe individualizationof nursing care plans. These needs included treatment and medication, personal hygiene, environmental, guidance and teaching, and human or self. In 268
1969, Faye Abdellah wrote of the necessity of making nursing diagnoses and prescribed actions a part of the science of n u r ~ i n g . ~
Development
I
t was not until 1973, though, that there was
an organized effort in nursing to further de-
velop and implement nursing diagnosis in practice. Kristine Gebbie and Mary Ann Lavin organized the First National Conference: Classification of Nursing Diagnoses, which was called by the St Louis University School of Nursing and Allied Health Professionals. The purpose was to classify health problems or health status, which are diagnosed by nurses and treated by nursing interventions. The motivating factors for calling the conference were the need to delineate nursing roles, and the fact that a newly automated university record system necessitated description of nursing actions.4 Six national conferences have been held in St Louis in the intervening 11 years. Nursing diagnoses, generated by nurse clinicians, educators, researchers, and theorists, have been identified, tested, evaluated, and revised or omitted. The process for classifying those patient problems that can be treated by professional nurses ’ interventions is arduous. Although most nursing diagnoses have been formulated using the inductive research method, the deductive method can be used. Inducrion is the process of making inferences from some specific observations to a more general rule. Deduction is the process of logical reasoning
AORN JOURNAL
AUGUST 1984, VOL 40, NO 2
Patient care interventions made by nurses are identified as independent, interdependent and dependent actions. from premises to conclusions. The following is an example using the inductive method to establish a nursing diagnosis. The nurse in the preoperative holding area makes the following observations of Mrs Smith, who was just transferredfrom the surgical unit. Mrs Smith is scheduledfor a right cataract extraction. She is unable to state her exact physical location in the hospital, questions whether anyone is present at the side of her transport cart, gropes for the nurse’s hand when spoken to, and does not make eye contact. From these specific observations, the nurse can generalize the patient’s problem and arrive at the nursing diagnosis of alteration in visual sensory perception. This diagnosis will direct the nurse as she plans appropriateinterventions. Using deductive methodology, the nurse would first generalize that Mrs Smith was experiencing visual sensory-perceptual alteration and then observe the patient for specific data to support the diagnosis. Attempts to classify and validate nursing diagnoseshave continuedthrough the Sixth Conference held in St Louis last April. This was the first conference with open registration, and Kathleen Justice, AORN program spekialist, and I attended. The organization now has international membership and is known as the North America Nursing Diagnosis Association (NANDA). Mi Ja Kim, RN, PhD, keynote speaker, projected the future activities of NANDA will include the continued development of a classification system, research funding, and regional networking. She also sees NANDA as the central organization for coordination and communication of activities relevant to the development of nursing diagnosis and its testing. As Dr Kim emphasized, the appropriate place for the future identification and testing of nursing diagnoses is in the clincial setting. One of the major issues Dr Kim discussed was definition of nursing diagnosis relative to the
degree of nursing autonomy. Patient care interventions made by nurses are identified as independent, interdependent, and dependentactions. Independentinterventionsare those nursing activities which registered nurses perform independently. Interdependent interventions are responsibilities of practice shared by nurses with other health care providers. Dependent interventionsare those activities performed by professional nurses, which require written orders, usually initiated by a physician. Results from one research study Dr Kim cited indicated that there are no currently identified nursing diagnosis based on 100% independent nursing action. Should diagnoses be based on nursing interventionswith 100%independentaction, or would 70% be better? Definition, therefore, is an issue yet to be resolved.
Impact on Nursing
S
hould nursing become discouraged at the slow progress of describing what is uniquely ours? Not at all! In 1770, the medical profession began its initial attempts to classify disease processes, and its classification systems are still being revised today. And the full impact of the diagnostic process on nursing has not yet been realized. By focusing on a specific diagnosis, the nurse engages in purposeful planning, which identifies nursing interventions appropriate for the specific patient involved. Individualized patient care is the result. By developing a diagnostic classification system, nursing will establishcommon terminology from which the entire profession can operate. When appendicitis is diagnosed by a physician, it enables him to communicate more effectively with his colleagues and other health care providers. The connotation of the language di-
& 269
AUGUST 1984. VOL 40, NO 2
AORN J O U R N A L
rects that patient’s medical care. With common terminology, nurses can retrieve nursing data from patient records. The nursing profession has discussed the necessity for establishing a scientific body of knowledge for clinical and educational purposes. As the number of nurse researchers increases, this goal becomes realistic and achievable. This will enable nursing education to base curricula on nursing knowledge rather than medical diagnoses. Retrievable, valid nursing data will help nurse researchers establish this knowledge base. Much of nursing’s clinical practice continues to be based on tradition and opinion. A strong scientific knowledge base will provide greater credibility and effectiveness to our practice. Although the nursing diagnosis movement is still in its infancy, it is healthy and growing. It is an indicatorof changetaking place, which promises an exciting future for the profession of nursing. JANICE R ALLEN,RN, MS PROGRAM SPECIALIST c O N T I ” 0 EDUCATION Notes 1. Lynda Juall Carpenito, Nursing Diagnosis: Application to Clinical Practice (F’hiladelphia: J B Lippincott Co, 1983)3. 2. Vera S Fry, ‘The creative approach to nursing,” American Journal ofNursing 53 (March 1953)
301-302. 3. Faye G Abdellah, “The nature of nursing science, ” Nursing Research 18 (September-October 1%9) 390-393. 4. Kristine M Gebbie, Mary Ann Lavin, eds, Proceedings of the First National Conference:ClassiJicarion of Nursing Diagnoses (St Louis: C V Mosby, 1975). 5. Claire Selltiz, Lawrence S Wrightsman, Stuart W Cook, Research Methods in Social Relations, 3rd ed (New Yo&: Holt, Rinehart and Winston, 1976) 576-578.
212
Manuel Resigns Bradley J Manuel
Bradley J Manuel, AORN seniorcoordinatorfor continuing education, resigned his post June 29 to work full time on completing his F’hD in curriculum instruction and administration in higher education. Manuel will receive his d e p from the University of Colorado at Boulder. An AORN staff member for seven years, Manuel was responsible for coordinating all for-credit continuing education activities. He was the staffconsultantfor the Nursing Practices Committee, and oversaw staff consultants on four other AORN committees. “They’ve been seven years of great personal and professional growth,” Manuel reminisced. Interaction with the membership and the opportunity to meet OR nurses were the most enjoyable aspectsof his job, he said. Manuel will continue to co-present AORN certification seminars during the following year. Manuel received his MSN from the University of Texas at Austin, and his BSN from Northwestern State University of Louisiana, Natchitoches. He earned his AD in nursing from Sacramento City College in California. Manuel will remain available to AORN for “assorted other activities as needed,” and he will continue to expand his model hippo collection.
AUGUST 1984, VOL 40. NO 2
Education Why nursing diagnoses are important in perioperative nursing
R
ecently an operating room supervisor told of a concerned physician who asked if “her nurses” were going to start wearing stethoscopes around their necks. His question apparently came after seeing operating room nurses engaged in assessment practices on the surgical unit and in the holding area of the operating room. In contrast to that physician’s attitude, Lynda Carpenito, member of the task force, National Group for the Classification of Nursing Diagnosis, states that nursing diagnoses will “assist to define nursing in its present state, classify nursing’s domain, differentiate nursing from medicine. ”* Diagnosis follows the assessmentphase of the nursing process. Standard II of the AORN Standards of Perioperative Nursing Practice states, “Nursing diagnoses are derived from health status data. ” Webster defines diagnosis as “a careful examination and analysis of the facts in an attempt to understand or explain something. ” Traditionally, only physicians have diagnosed patients’ conditions, and some health care professionals, including some nurses, still question whether diagnosis is an appropriatenursing function. But the concept of nursing diagnosis is not new. The term was first used in nursing literature in 1953 when Vera Fry described a creative approach to planning patient care.* She identified five areas in which nursing diagnoses were needed to facilitatethe individualizationof nursing care plans. These needs included treatment and medication, personal hygiene, environmental, guidance and teaching, and human or self. In 268
1969, Faye Abdellah wrote of the necessity of making nursing diagnoses and prescribed actions a part of the science of n u r ~ i n g . ~
Development
I
t was not until 1973, though, that there was
an organized effort in nursing to further de-
velop and implement nursing diagnosis in practice. Kristine Gebbie and Mary Ann Lavin organized the First National Conference: Classification of Nursing Diagnoses, which was called by the St Louis University School of Nursing and Allied Health Professionals. The purpose was to classify health problems or health status, which are diagnosed by nurses and treated by nursing interventions. The motivating factors for calling the conference were the need to delineate nursing roles, and the fact that a newly automated university record system necessitated description of nursing actions.4 Six national conferences have been held in St Louis in the intervening 11 years. Nursing diagnoses, generated by nurse clinicians, educators, researchers, and theorists, have been identified, tested, evaluated, and revised or omitted. The process for classifying those patient problems that can be treated by professional nurses ’ interventions is arduous. Although most nursing diagnoses have been formulated using the inductive research method, the deductive method can be used. Inducrion is the process of making inferences from some specific observations to a more general rule. Deduction is the process of logical reasoning
AORN JOURNAL
AUGUST 1984, VOL 40, NO 2
Patient care interventions made by nurses are identified as independent, interdependent and dependent actions. from premises to conclusions. The following is an example using the inductive method to establish a nursing diagnosis. The nurse in the preoperative holding area makes the following observations of Mrs Smith, who was just transferredfrom the surgical unit. Mrs Smith is scheduledfor a right cataract extraction. She is unable to state her exact physical location in the hospital, questions whether anyone is present at the side of her transport cart, gropes for the nurse’s hand when spoken to, and does not make eye contact. From these specific observations, the nurse can generalize the patient’s problem and arrive at the nursing diagnosis of alteration in visual sensory perception. This diagnosis will direct the nurse as she plans appropriateinterventions. Using deductive methodology, the nurse would first generalize that Mrs Smith was experiencing visual sensory-perceptual alteration and then observe the patient for specific data to support the diagnosis. Attempts to classify and validate nursing diagnoseshave continuedthrough the Sixth Conference held in St Louis last April. This was the first conference with open registration, and Kathleen Justice, AORN program spekialist, and I attended. The organization now has international membership and is known as the North America Nursing Diagnosis Association (NANDA). Mi Ja Kim, RN, PhD, keynote speaker, projected the future activities of NANDA will include the continued development of a classification system, research funding, and regional networking. She also sees NANDA as the central organization for coordination and communication of activities relevant to the development of nursing diagnosis and its testing. As Dr Kim emphasized, the appropriate place for the future identification and testing of nursing diagnoses is in the clincial setting. One of the major issues Dr Kim discussed was definition of nursing diagnosis relative to the
degree of nursing autonomy. Patient care interventions made by nurses are identified as independent, interdependent, and dependentactions. Independentinterventionsare those nursing activities which registered nurses perform independently. Interdependent interventions are responsibilities of practice shared by nurses with other health care providers. Dependent interventionsare those activities performed by professional nurses, which require written orders, usually initiated by a physician. Results from one research study Dr Kim cited indicated that there are no currently identified nursing diagnosis based on 100% independent nursing action. Should diagnoses be based on nursing interventionswith 100%independentaction, or would 70% be better? Definition, therefore, is an issue yet to be resolved.
Impact on Nursing
S
hould nursing become discouraged at the slow progress of describing what is uniquely ours? Not at all! In 1770, the medical profession began its initial attempts to classify disease processes, and its classification systems are still being revised today. And the full impact of the diagnostic process on nursing has not yet been realized. By focusing on a specific diagnosis, the nurse engages in purposeful planning, which identifies nursing interventions appropriate for the specific patient involved. Individualized patient care is the result. By developing a diagnostic classification system, nursing will establishcommon terminology from which the entire profession can operate. When appendicitis is diagnosed by a physician, it enables him to communicate more effectively with his colleagues and other health care providers. The connotation of the language di-
& 269
AUGUST 1984. VOL 40, NO 2
AORN J O U R N A L
rects that patient’s medical care. With common terminology, nurses can retrieve nursing data from patient records. The nursing profession has discussed the necessity for establishing a scientific body of knowledge for clinical and educational purposes. As the number of nurse researchers increases, this goal becomes realistic and achievable. This will enable nursing education to base curricula on nursing knowledge rather than medical diagnoses. Retrievable, valid nursing data will help nurse researchers establish this knowledge base. Much of nursing’s clinical practice continues to be based on tradition and opinion. A strong scientific knowledge base will provide greater credibility and effectiveness to our practice. Although the nursing diagnosis movement is still in its infancy, it is healthy and growing. It is an indicatorof changetaking place, which promises an exciting future for the profession of nursing. JANICE R ALLEN,RN, MS PROGRAM SPECIALIST c O N T I ” 0 EDUCATION Notes 1. Lynda Juall Carpenito, Nursing Diagnosis: Application to Clinical Practice (F’hiladelphia: J B Lippincott Co, 1983)3. 2. Vera S Fry, ‘The creative approach to nursing,” American Journal ofNursing 53 (March 1953)
301-302. 3. Faye G Abdellah, “The nature of nursing science, ” Nursing Research 18 (September-October 1%9) 390-393. 4. Kristine M Gebbie, Mary Ann Lavin, eds, Proceedings of the First National Conference:ClassiJicarion of Nursing Diagnoses (St Louis: C V Mosby, 1975). 5. Claire Selltiz, Lawrence S Wrightsman, Stuart W Cook, Research Methods in Social Relations, 3rd ed (New Yo&: Holt, Rinehart and Winston, 1976) 576-578.
212
Manuel Resigns Bradley J Manuel
Bradley J Manuel, AORN seniorcoordinatorfor continuing education, resigned his post June 29 to work full time on completing his F’hD in curriculum instruction and administration in higher education. Manuel will receive his d e p from the University of Colorado at Boulder. An AORN staff member for seven years, Manuel was responsible for coordinating all for-credit continuing education activities. He was the staffconsultantfor the Nursing Practices Committee, and oversaw staff consultants on four other AORN committees. “They’ve been seven years of great personal and professional growth,” Manuel reminisced. Interaction with the membership and the opportunity to meet OR nurses were the most enjoyable aspectsof his job, he said. Manuel will continue to co-present AORN certification seminars during the following year. Manuel received his MSN from the University of Texas at Austin, and his BSN from Northwestern State University of Louisiana, Natchitoches. He earned his AD in nursing from Sacramento City College in California. Manuel will remain available to AORN for “assorted other activities as needed,” and he will continue to expand his model hippo collection.