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Chapter Two. Nursing Assessment, Clinical Judgment and Nursing Diagnoses: How to Determine Accuracy. TEACHING NANDA-I NIC AND NOC: NOVICE TO EXPERT. Teaching NANDA-I NIC and NOC: Novice to Expert. Contributor Margaret Lunney. Explain 3 Propositions Related to Teaching NNN

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  1. Chapter Two Nursing Assessment, Clinical Judgmentand Nursing Diagnoses: How to Determine Accuracy TEACHING NANDA-I NIC AND NOC: NOVICE TO EXPERT

  2. Teaching NANDA-I NIC and NOC: Novice to Expert ContributorMargaret Lunney

  3. Explain 3 Propositions Related to Teaching NNN Set Expectations for Students at Novice to Expert Stages of Development Implement Teaching Strategies Integrate NNN With Nursing Curricula Learning Objectives

  4. Objective 1: Explain Propositions • Use of NNN Requires Intellectual, Interpersonal, And Technical Competencies, Tolerance for Ambiguity And Reflection • Accurate Diagnoses are the Basis for Use of NIC and NOC • Use of NNN Differs from the Traditional Nursing Process

  5. Intellectual Knowledge Related to:Diagnoses, Interventions and Outcomes Thinking Processes Research Findings: Human Beings Vary in Thinking Process Abilities Thinking Process Abilities can be Improved Proposition # 1: Skills/Competencies

  6. Variation in Nurses’ Thinking Abilities N = 86 (Lunney 1992)

  7. Thinking Processes of Women Develop Through Relationships Women’s Perspectives on Thinking (Belenkeyet al. 1986) Silence Received Knowledge Subjective Knowledge Procedural Knowledge Constructed Knowledge Nursing Students and Nurses may have Lower Level Perspectives Intellectual Skills: Research Findings Related to Women

  8. 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 Intellectual Skills: Critical Thinking (CT)

  9. 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 Intellectual Skills: What is CT in Nursing?

  10. Analyzing Applying Standards Discriminating Information Seeking Logical Reasoning Predicting Transforming Knowledge Cognitive Skills

  11. Confidence Contextual Perspective Creativity Flexibility Inquisitiveness Intellectual Integrity Intuition Open-Mindedness Perseverance Reflection Habits of Mind

  12. CT Involves Continuous Processing of Data and Inferences In Any Situation, Two or More Cognitive Skills are Probably Being Used Habits of Mind Support Cognitive Skills The Combination of CT Abilities Needed is Unique to the Situation Intellectual Skills: CT Processes

  13. Exquisite Communication Promote Trust Work in Partnership, Share Power Validate Perceptions Accept that We Do Not “Know” Others Proposition # 1: Interpersonal Skills (continued)

  14. Obtain Valid and Reliable Data Health Histories: Comprehensive Physical Exams: Focused Perform Nursing Interventions Technical Aspects of Using NNN Proposition # 1: Technical Skills (continued)

  15. 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(continued)

  16. Reflect on Practice Experiences Accept Possible Flaws: Thinking Interpersonal Technical Aim - Develop and Grow Proposition # 1: Personal Strengths(continued)

  17. Cues/Data may be Incorrect Examples: Objective Data: Diagnostic Tests Subjective Data Patients Families Proposition # 2: Accurate Interpretations -Foundational

  18. 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 into Interpretations Proposition # 2: Accurate Interpretations -Foundational

  19. Interpretations Determine Actions Additional Data Collection Subsequent Decisions Possible Outcomes to Consider Choices of Interventions High Potential for Inaccuracy Diagnosis and Etiology Proposition # 2: Accurate Interpretations -Foundational

  20. (1) Marian Hughes is a 16-year-old female with a medical diagnosis of diabetes mellitus. (2) She was admitted 3 days 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. High Potential for Inaccuracy, e.g. Marian Hughes – A Case Study

  21. Marian Hughes (continued) (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 Marian 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.

  22. 16 Year Old Diabetic (#1) Hospitalized, DKA (#2) “Did Not Follow Prescribed Diet” (#3) NDX: Ineffective Management of Therapeutic Regimen, Related to _______ (Fill in the Blank) High Potential for Inaccuracy, e.g. Marian Hughes

  23. 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: Low Accuracy Diagnosis Teaching is Waste of Time, Effort, and Money Possible Interpretation/Diagnosis

  24. 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 Highest Accuracy Diagnosis

  25. Examples: Communication Difficulties Between Mother/Daughter Stressful Mother/Child Relationship Altered Family Dynamics Ineffective Coping Ineffective Time Management Adolescent Image Low Self-Esteem Denial Knowledge Deficit 44 Diagnoses by 80 Nurses

  26. +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 Seven Levels of Accuracy

  27. Communication Difficulties Between Mother and Daughter +5 Stressful Mother/Child Relationship +4 Altered Family Dynamics +3 Ineffective Coping +2 Ineffective Time Management +2 Adolescent Image +1 Low Self-Esteem +1 Denial 0 Knowledge Deficit -1 Diagnostic Accuracy Scores

  28. 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 Findings

  29. Diagnostic Task Lesser Amounts and Complexity of Data Nurse Diagnostician Education Related to Nursing Diagnoses Knowledge of Diagnostic Process and Concepts Teaching Aids for Diagnostic Reasoning Variety of Thinking Processes Experience Specific to Diagnostic Task Research: Positive Influences

  30. Challenge: Achieving Accuracy Puzzle: What is the Diagnosis?

  31. Solving the Puzzle

  32. Supporting Factors: Acknowledge That Data Interpretations AreProbabilistic; Question Accuracy Use CT, Interpersonal and Technical Skills Develop Tolerance for Ambiguity It’s OK Not to Have an Answer Accept that We Might Make Mistakes Develop Reflective Practice Proposition # 2: Accurate Interpretations -Foundational

  33. Traditional Limited # Concepts Collect Comprehensive Data No Accountability for Diagnoses Intervene Based on Data Behavioral Outcomes Disorganized Follow-up 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 Proposition # 3: New Perspective on Nursing Process

  34. Acknowledge Difficulty Level: Simple to Complex Influencing 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 Changing from Traditional to Use of NNN

  35. Examples: User-Friendly Simplicity

  36. Use Theoretical Perspective: Change theory Diffusion of Innovations (Rogers 2003) S-Shaped Diffusion Curve Perceived Characteristics: Relative Advantage (+) Compatibility (+) Complexity (-) Trial Ability (+) Observability (+) Changing from Traditional to Use of NNN

  37. Be a Champion Sell First to Opinion Leaders Goal: Create a Critical Mass Share Demonstration Projects, e.g. Protocols, Journals Faculty Development Program; Adoption by System, Adoption by Individuals Changing from Traditional to Use of NNN

  38. 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 Objective # 2: Set Expectations, Novice to Expert

  39. HER 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 Selling NNN to Experts

  40. Expect (At All Levels of Expertise) Correct Use of the Three Systems, e.g.: Nursing Diagnoses are Used to Guide Interventions, Not for Labeling Per Se Intervention Label is the Intervention, Not the Activities Outcome Label is Outcome, Not Indicators Correct Use of Concepts, e.g.: NANDA-I: Social Isolation NIC: Coping Enhancement NOC: Knowledge (Specify) Set Expectations

  41. 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

  42. All Levels: Self-Evaluation Integrate With New Theories, e.g. Pender’s Health Promotion Model Integrate with Strategies for Evidence-Based Nursing Set Expectations

  43. Encourage Experts to: Integrate with Previous Knowledge Use NNN in: Communicating Scope of Practice Developing Standards of Care Evidence-Based Nursing Projects Research Projects Evaluate Clinical Applications of NNN Teach CE Programs to Nursing Personnel Set Expectations

  44. 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

  45. Deflate Authority Teaching Strategies: Intellectual

  46. Think Out Loud with Students Act as Midwife or Coach Help Them Think About Thinking: Ask: What Kind of Thinking is Needed? Use the 17 CT Terms and Definitions Evaluate Thinking Processes Expect Self-Evaluation of Thinking Teaching Strategies: Intellectual

  47. Share Paradigm Cases (e.g. Marian Hughes) Simplify Representations, Identify High Relevance Cues Conduct Iterative Hypothesis Testing Teaching Strategies: Intellectual

  48. 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?) Teaching Strategies: Intellectual

  49. 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 Teaching Strategies: Intellectual

  50. Expect Self-Evaluation Ask Questions, Instead of Giving Answers Discussion in Class Discussion Online Journal Writing (Degazon and Lunney 1995) Teaching Strategies: Intellectual

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