nurse educator 2006 lippincott williams &...

In the United States, implementationof an electronic health record (EHR) isimminent; by 2010, all healthcareevents will be electronically recordedand healthcare agencies will berequired to submit data elements toregional and national data banks.1,2

With an EHR, nursing data elementswill be documented through the useof standardized nursing languagessuch as those published by NANDAInternational and the project teams ofthe Nursing Outcomes Classification(NOC) and the Nursing InterventionsClassification (NIC).3-5 These andother standardized languages thatwere approved by the AmericanNurses Association for use in elec-tronic records provide a broad base ofnursing knowledge at the point ofcare and enable the documentationof nursing care elements in formatsthat support the aggregation of data.6

Aggregation of nursing data enablesthe development of knowledgerelated to the quality and cost of carein agency units and comparison ofquality and cost across localities andtime periods.

Rationale for EducationalChanges

Three major reasons for changes ineducational methods are: (a) use ofstandardized nursing languages inthe nursing process differs from thetraditional nursing process; (b) use

of standardized nursing languagesrequires increased attention to devel-opment of intellectual, interpersonal,and technical competencies; and(c) accurate diagnosing is the basisfor appropriate selection of patientoutcomes and nursing interventions.These reasons are explained as thebasis for helping nurses to implementNANDA, NOC, and NIC (hereinreferred to as NNN) and other nursinglanguages. The systems of NNN areaddressed in this article but a majorityof these teaching methods also applyto other languages.

Differences in the NursingProcess With Use of NNN

When nurses have opportunities touse standardized languages such asNNN, significant differences exist fromuse of the traditional nursing process.Without use of NNN, nurses are prob-ably not aware of the extensive num-ber of data interpretations, outcomes,and interventions to consider for indi-vidual patient situations. With use ofNNN in an EHR, knowledge of 172diagnoses, 330 patient outcomes, and514 nursing interventions can beeasily available.3-5

Decision support systems canalso be included in an EHR thatprompt nurses to consider the link-

ages of cues with diagnoses, anddiagnoses with outcomes and inter-ventions. Without the use of NNN inan EHR, nurses are often encouragedto collect large amounts of data with-out naming data interpretations. Withthe use of NNN in an EHR, decisionsabout data collection are based oninitial cues to diagnoses and diagnos-tic hypotheses being considered forindividual patients.

Without the use of NNN in an EHR,nurses describe patient outcomes andinterventions in a narrative format withlittle consistency among nurses. Withthe use of NNN in an EHR, the namesused for patient outcomes and nursinginterventions are easily available to allnurses so consistency and continuitywill be expected.

Without the use of NNN in an EHR,nurses may not be held accountablefor the accuracy of their data interpre-tations. With the use of NNN in an EHR,nurses’ diagnoses are easily noted andaddressed, so accountability for accu-racy will be critically important to savethe time and money involved whenmany nurses provide care for inaccu-rate diagnoses. For example, if onenurse selects the diagnosis of DeficientKnowledge when a patient hasadequate knowledge and then manynurses waste time in teaching, therewill be excessive costs without posi-tive outcomes.

40 NURSE EDUCATOR Volume 31, Number 1 January/February 2006

NURSE EDUCATORVolume 31, Number 1, pp 40–46* 2006 Lippincott Williams & Wilkins, Inc.

Helping Nurses Use NANDA,NOC, and NICNovice to Expert

Margaret Lunney, PhD, RN

The electronic health record (EHR) requires the use of standardized

nursing languages such as NANDA, NOC, and NIC. Helping nurses use

these languages for an EHR requires different educational strategies in 3

domains: intellectual, interpersonal, and technical. The author explains

the rationale for changes in educational methods, expectations that

educators and managers should set for students and nurses at various

levels of expertise, and teaching strategies in each of the domains.

Author Affiliation: Professor and Grad-uate Programs Coordinator, Department ofNursing, College of Staten Island, The CityUniversity of New York, Staten Island, NY.

Correspondence: Department of Nurs-ing, College of Staten Island, 2800Victory Boulevard, Staten Island, NY 10314([email protected]).

This article was adapted from a Key-note Address given at the 2005 Institute onNursing Informatics and Classification,hosted by the University of Iowa Collegeof Nursing, Center for Nursing Classifica-tions and Clinical Effectiveness.

Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

Development of Competencies

Intellectual, interpersonal, and techni-cal competencies support the account-ability that is needed for collectionand interpretation of patient data, aswell as appropriate selection ofpatient outcomes and nursing inter-ventions. Based on the improvedorganization of an EHR over paperrecords, the choices of individualnurses’ diagnoses, outcomes, andinterventions will be addressed by allnurses involved in care of the samepatients. Thus, nurses’ choices willhave broader, more profound effectson nursing care in general, not just thecare provided by themselves. Intheory, continuity of care was sup-posed to occur with use of paperrecords, but, with the inability toeffectively track data, continuity ofcare was not realized.2

Accurate Interpretations of Dataare Foundational

In a classic study, it was establishedthat short-term memory only holds 7 T2 bits of data,7 so nurses, as all humanbeings, continuously convert bits ofdata or cues to interpretations. Forexample, the interpretation that aperson is a male or female is basedon the cues of hairstyle, facial struc-ture, body type, body language,clothes, name, and others. It is com-mon to think of such interpretations as‘‘fact’’ because these interpretationsare relatively valid and reliable. Otherinterpretations, however, such as thepatient is happy, sad, or anxious, arenot likely to be valid and reliableunless nurses attend to the accuracyof interpretations.

In clinical situations, data bits arecontinuously converted to interpreta-tions to save space in short-termmemory. The advantage of namingthese interpretations, instead of inter-vening without naming them, as whennurses’ diagnoses are not stated, isthat accuracy can be discussed withothers and challenged when indi-cated. Nurses’ interpretations ofpatient data determine all subsequentactions, including additional data tocollect, possible outcomes to con-sider, and choices of interventions.

Additionally, studies since 1966have shown that there is a high

potential for inaccuracy in nurses’identification of diagnoses and contrib-uting factors.8 In every study ofnurses’ interpretations of the samedata elements, there were wide varia-tions in interpretations of data, evenwith strong data support for the mostaccurate diagnoses. These variationsin interpretations are influenced by 3major factors: the diagnostic task (eg,complexity and amounts of data), thesituational context (eg, organizationalpolicies, nurses’ roles), and nurses’ abil-ities as diagnosticians (eg, thinkingabilities, experience with similarcases).8-10 Studies have shown thathigh accuracy is associated with nursesbeing educated as diagnosticians.8

Set Expectations: Noviceto Expert

In setting expectations for studentsand nurses, it is important that educa-tors and managers do not underesti-mate nurses’ abilities to effectively usestandardized nursing languages andincorporate them with other knowl-edge bases. Based on the author’sexperience teaching NNN to nursesat all levels of expertise, novices andadvanced beginners learn to use NNNas well, if not better and easier than,experienced nurses. This is becausethey have not had enough experiencein nursing to know other ways ofdoing things. The languages of NNNcan be used throughout basic nursingprograms, from the first week, aspart of a framework for practicealong with theories and models ofnursing.11 In contrast, nurses at com-petent, proficient, and expert stagesneed to be ‘‘sold’’ on new ways tothink and document nursing care(Figure 1).

Expectations should be set fornurses at all levels of expertise tocorrectly use NNN. If students andnurses are shown how to apply thelanguages using written or computer-ized case studies, they can success-fully implement the languages withnew cases. Some common errors thatmight occur are restating medicaldiagnoses as nursing diagnoses with-out providing added informationabout the patient; for example, if apatient had an amputation 2 yearsago, the diagnosis of Impaired Phys-

ical Mobility is only appropriate ifnurses currently plan to help thispatient to improve mobility. The pur-pose of nurses’ diagnoses should beto guide nursing interventions, not tolabel patients with nursing diagnoses.

New users often do not realize thatthe neutral outcome labels (eg, WeightControl) and the associated overallscore on specific scales (eg, 3 =sometimes demonstrated), are the out-come, not the indicators, and theintervention labels (eg, Presence) arethe interventions, not the activities.4,5

For the outcomes in NOC, the indica-tors serve as evidence to help patientsand providers to identify overallscores prior to and after nursinginterventions. For the NIC interven-tions, the activities represent how todo the intervention and are individu-ally applied according to patients’needs.

Students and nurses should beexpected to correctly use the conceptsin each system in accordance with theconcept definitions, descriptions, andthe context of each clinical situation.For example, the NANDA Interna-tional diagnosis of Social Isolation isnot used unless the patient is beingrejected by others, not if he or shechooses to be alone.3 The NOC out-come of Knowledge: Diet should notbe used if the person already hasextensive information about the rec-ommended diet. There are many rea-sons why people do not followrecommended diets besides DeficientKnowledge.

The NIC intervention of CopingEnhancement should not be used ifthe patient problem to be treated isStress Overload rather than IneffectiveCoping. With stress overload, a betterintervention might be EnvironmentalManagement. The diagnosis of StressOverload is not currently on theNANDA International approved list ofdiagnoses, but this taxonomy is notcomplete, so nurses should be devel-oping their own diagnostic labelswhen indicated.

Regardless of whether patient andfamily cues are a ‘‘good fit’’ with thedefinition and description of a con-cept in one of these systems, thecontext of a clinical situation mayindicate that the concepts are notrelevant. For example, if patients pre-fer assistance with a different aspect of

NURSE EDUCATOR Volume 31, Number 1 January/February 2006 41


their health than nurses’ diagnoses,nurses should consider followingpatients’ preferences.

At all levels of expertise, learnersshould be encouraged to performongoing self-evaluation or reflectionto generate continued professionalgrowth in use of these languages.This process involves purposeful eval-uation of one’s own thoughts orbehaviors to facilitate learning fromexperiences. Benner12 and Smith andJack13 described reflective practice asa key aspect of growth in professionalexpertise. In a Delphi study of 55nurse experts in critical thinking,reflection was identified as a habit ofmind for critical thinkers in nursing.14

With ongoing reflective practice,nurses’ choices of terms from NNNare likely to improve so that theymore accurately reflect the complexityof patient care.

Nurses who are at competent,proficient, or expert stages of exper-tise should be assisted to integrateNNN with previous knowledge basesand to use NNN for communication ofvarious aspects of advanced practicenursing. When nurses are assisted tointegrate NNN with previous knowl-edge, it demonstrates the usefulnessof these systems to existing practice.For example, community healthnurses can be shown how to use thehealth promotion diagnoses, out-comes, and interventions from NNN.For nurses in graduate programs, the

use of NNN is ideal to communicateadvanced practice nursing competen-cies such as developing standards ofcare. Standards of care can be devel-oped for specific patient populationsby identifying the relevant diagnoses,outcomes, and interventions and thelinkages of diagnoses, outcomes, andinterventions that are important tomeet quality-based standards.

Strategies

To enable the use of NNN, intellec-tual, interpersonal, and technical abili-ties must be developed. There arespecific strategies that can be em-ployed to develop abilities in eachcategory.

Intellectual Domain

The most significant change in teach-ing strategies needs to occur in theintellectual domain, with educatorsand managers promoting nurses’development as diagnosticians.15 Theintellectual competencies needed are(a) attainment of knowledge related todiagnoses, outcomes, and interven-tions and (b) development of relatedthinking abilities. With over 1,000concepts, definitions, and descriptorsin NNN, the knowledge required isextensive and complex. With elec-tronic systems, however, the conceptsfor diagnoses, outcomes, and inter-ventions can be frontloaded in the

software, whereas definitions, descrip-tions, and bibliographies can be in thebackground for use as needed.

To effectively use these systems,the thinking processes of nurses mustbe enhanced. Like other adults, thethinking process abilities of nursesvary widely. For example, the widerange of nurses’ thinking abilities wasevident in the findings from a studyof basic divergent thinking abilities of86 nurses with generic baccalaureateeducation and 1 to 5 years experi-ence.16 The 2 rater averages of scoresranged from 6 to 41.5 for fluency,from 0 to 27.5 for flexibility, and from7 to 30.5 for elaboration. Thinkingabilities such as these can be im-proved with education and effort.17

The increased emphasis on criti-cal thinking in nursing that hasoccurred in response to accreditationcriteria may contribute to improvedthinking abilities. Findings from aDelphi study of 55 nurse experts incritical thinking yielded a model ofcritical thinkers that can easily be usedby educators and managers to helpstudents and nurses grow in thinkingabilities.14 Seven cognitive skills and10 habits of mind were identified asrelevant for nursing practice. Use ofthese 17 critical thinking concepts canfacilitate both beginning students andexperienced nurses to think abouttheir thinking (ie, metacognition)and, subsequently, improve theirthinking processes.18

Figure 1. Ten selling points for the use of NANDA, NOC, and NIC (NNN) in EHR.



To help students and nursesimprove their thinking processes, edu-cators and managers should assumethat thinking is human, imperfect, andattainable.19 This means that students

and nurses are capable of appropriatethinking processes; they should ex-pect to make mistakes in thinking; andthinking abilities can be improved. Topromote thinking, educators should

ask questions instead of providinganswers, provide opportunities forproblem solving, and deflate author-ity. Deflation of authority enablesstudents to stop expecting the ‘‘right’’

Figure 2. Case Study: Laura.



Figure 3. Case Study: Stella.



answers from teachers and otherexperts and, instead, to depend ontheir own abilities to process informa-tion and make decisions. Educatorscan show students how to thinkthrough problems by thinking aloudwith students and acting as midwivesor coaches to help learners apply arange of thinking processes.19

Seminar methods of teachingshould be used throughout basic andadvanced nursing education to pro-mote the use of thinking processes.This method is achieved by assigningreadings for each class, organizingclasses according to the readings, pro-viding students with discussion ques-tions so they can be prepared, recordingthe number of times that studentsparticipate, giving a grade each weekin accordance with specific gradingcriteria, and rewarding students with25% to 30% of their overall grade. Thegoal of each class is to address what theauthor is saying, the fit with previousknowledge, and the practice applica-tion. The teacher grades students ontheir participation and on evidencethat they have done the readings, noton giving ‘‘correct’’ answers. As sea-soned teachers are aware, studentsparticipate when teachers avoid lectur-ing, sit at eye level with students, andshow respect for students’ answers.The seminar method promotesimproved thinking because it stimu-lates thinking processes, recognizesstudents’ and nurses’ abilities to thinkwithout authorities, and demonstratesthat collaboration with the thinking ofothers is productive.20

Sharing paradigm cases (Figures 2and 3) helps learners visualize andexperience use of the 3 languages.The patient’s story is told so thatstudents and nurses have the contextof the situation21 and not just the cuesto diagnoses. Educators can also sim-plify cases as needed for learners tobe able to see the connections amongdata, diagnoses, outcomes, and inter-ventions. An interactive case studymethod called iterative hypothesis test-ing provides learners with experiencein asking questions to obtain diagnos-tic data.15,22 With this method, thegoal is for learners to identify the mostaccurate diagnosis. Using role-playingtechniques, the teacher pretends to bea specific clinical case with a humanresponse that requires diagnosis and

intervention and provides learnerswith a few beginning cues, such asgender, age, and reason for contact.After that, the teacher only providesdata if students request it, along withthe reasons why the question wasasked. For example, a student mightask, ‘‘how did you feel about that?’’.The student could accompany thisquestion with a rationale of, ‘‘I amconsidering issues related to coping,anxiety or fear.’’ This process contin-ues until the class as a whole attainsan accurate diagnosis or time runs out.This is a time-consuming but effectivemethod to teach diagnostic reasoning.

Interpersonal Domain

Increased attention to interpersonalcompetencies is needed so that nurseswill be able to obtain valid and reliabledata and work in partnership withpatients and families to select the bestdiagnoses, outcomes, and interven-tions. With the complexity of choosingthe most appropriate concepts to fit thediverse clinical situations that nursesaddress, the best use of NNN requiresthat nurses work in partnership withpatients and families. Developing part-nership relationships enables nurses toavoid inappropriate and unethicallabeling, for example, using the diag-nosis of Impaired Parenting3 for aMexican American couple when thefather does not participate in infantcare. Mexican American women use aDoula, a woman with childcare expe-rience, instead of expecting help fromthe father.23

Developing partnership relation-ships requires exquisite communica-tion. Curricula in schools of nursingand healthcare agencies should beexamined for whether additionalcourse work on communication, espe-cially Assertiveness Training and Com-plex Relationship Building ,5 iswarranted. Assertiveness traininghelps learners express their ideaswhile respecting the ideas of others.

Interviewing skills can be demon-strated by educators through roleplaying and video tapes. Studentsand nurses can be videotaped duringhistory taking for them to evaluatetheir own development. They alsoneed to be taught the language ofvalidating interpretations with patientsand families; for example, with Stella

(Figure 3), the nurse could say, ‘‘itseems to me that, as a caregiver, youare tired and may be at risk of highamounts of stress in the caregiver role.Is that correct?’’

Technical Domain

Teaching strategies for students’development in the technical domainare similar to current methods withgreater emphasis on collecting validand reliable data, developing diagnos-tic reasoning abilities, teaching howto perform a broad range of NICinterventions, and learning how todocument nursing care using NNN.Knowing how to collect specificdata to rule in or rule out diagnoses(eg, Pain or Disturbance in BodyImage)3 will enable nurses to achievehigher accuracy by obtaining theessential data to support or reject diag-nostic hypotheses. Applying evidence-based practice protocols facilitatesselection of the best diagnoses forindividual patients especially becauseidentifying patient preferences isone aspect of such protocols.24 Withthe ease of selecting interventionlabels in electronic systems, nursescan select interventions without suffi-cient knowledge of how to performthe interventions. Knowing how toperform complex nursing interven-tions (eg, Reminiscence Therapy,Biofeedback, Acid-Base Manage-ment)4 will facilitate appropriate useof the intervention labels to helppatients.

Use of professional practicestandards that articulate evidence-based knowledge may indicate thatadditional education is needed forspecific interventions. With respect todocumentation of NNN, for example,learners need to know how to use theindicators to rate outcomes bothbefore and after interventions. In as-signments, incentives can be providedfor the correct use of NNN (eg, apercent of students’ grades are allo-cated to following directions regard-ing the use of these systems).

Conclusions

Although NNN and other nursing lan-guages represent the knowledge that



educators have been teaching for de-cades, the evolution of standardizednursing languages and their impor-tance in an EHR requires a bold em-phasis on teaching methods. Theroutines with electronic systems willinclude systematic follow-up of nurses’diagnoses, outcomes, and interven-tions and examination of the effects ofthese choices on quality and cost.These routines will prompt more strin-gent accountability for naming theelements of nursing care.2 Educatorsand managers who encourage andsupport students and nurses at noviceto expert stages to develop the intel-lectual, interpersonal, and technical

abilities for use of NNN will be re-

warded by seeing the learners grow in

these abilities.

Acknowledgments

The author thanks Professor ArleneFarren, College of Staten Island, forpermission to use the case study ofLaura and Professor Coleen Kumar,Kingsborough Community College,for permission to use the case studyof Stella.

References

1. U.S. Department of Health and Human

Services. HHS Fact Sheet—HIT Report At-

A-Glance. Available at: http://www.hhs.

gov/news/press/2004pres/20040721.html.

Accessed June 21, 2005.

2. Institute of Medicine. Keeping Patients

Safe. Washington, DC: National Academy

Press; 2004.

3. NANDA International. Nursing Diagnoses:

Definitions and Classification, 2005-

2006. Philadelphia: Author; 2005.

4. Moorhead S, Johnson M, Maas M. Nursing

Outcomes Classification (NOC). St. Louis:

Mosby; 2004.

5. Dochterman JC, Bulechek GM. Nursing

Interventions Classification (NIC). St.

Louis: Mosby; 2004.

6. American Nurses Association. NIDSEC:

Standards and Scoring Guidelines. Wash-

ington, DC: Nursesbooks.org; 1997.

7. Miller CA. The magical number seven,

plus or minus two: some limits on our

capacity for processing information. Psy-

chol Rev. 1956;63:81-97.

8. Lunney M. Critical Thinking and Nursing

Diagnosis: Case Studies and Analyses.

Philadelphia: NANDA International; 2001.

9. Carnevali DL, Thomas MD. Diagnostic

Reasoning and Treatment Decision Mak-

ing. Philadelphia: Lippincott; 1993.

10. Gordon M. Nursing Diagnosis: Process and

Application. New York: McGraw-Hill; 1994.

11. Gigliotti E. A theory-based clinical nurse

specialist practice exemplar using Neu-

man’s Systems model and nursing’s taxon-

omies. Clin Nurse Spec. 2001;16(1):10-16.

12. Benner PA. Novice to Expert: Promoting

Excellence and Power in Professional

Nursing Practice. Menlo Park, CA: Addi-

son Wesley; 1984.

13. Smith A, Jack K. Reflective practice: a

meaningful task for students. Nurs Stand.

2005;19(26):33-37.

14. Scheffer BK, Rubenfeld MG. A consensus

statement on critical thinking. J Nurs

Educ. 2000;39:352-359.

15. Carlson-Catalano J. Teaching diagnostic

reasoning. In: Lunney M, ed. Critical

Thinking and Nursing Diagnoses: Case

Studies and Analyses. Philadelphia:

NANDA International; 2001:44-65.

16. Lunney M. Divergent productive thinking

and accuracy of nursing diagnoses. Res

Nurs. 1992;15(4):303-311.

17. Sternberg RJ. Successful Intelligence: How

Practical and Creative Intelligence Deter-

mine Success in Life. New York: Plume

Books; 1997.

18. Rubenfeld MG, Scheffer BK. Critical

Thinking TACTICS in Nursing. Boston:

Jones & Bones; 2006.

19. Belenkey MF, Clinchy BM, Goldberger

NR, Tarule JM. Women’s Ways of Know-

ing: The Development of Self, Voice, and

Mind. New York: Basic Books; 1983.

20. Hayakawa SI, Hayakawa AR. Language in

Thought and Action. New York: Basic

Books; 1990.

21. Pesut D, Herman J. Clinical Reasoning: The

Art and Science of Critical and Creative

Thinking. Albany, NY: Delmar; 1999.

22. Kassirer JP. Teaching clinical medicine by

iterative hypothesis testing. Let’s preach

what we practice. N Engl J Med. 1983;

309(15):921-923.

23. Levine MA. Nursing diagnosis in cross-

cultural settings. In: Lunney M, ed. Critical

Thinking and Nursing Diagnoses: Case

Studies and Analyses. Philadelphia: NANDA

International; 2001:106-107, 208-210.

24. Levin RF, Lunney M, Krainovich-Miller B.

Improving diagnostic accuracy using an

evidenced-based nursing model. Int J

Nurs Terminol Classif. 2005;15(4):114-122.



nurse educator 2006 lippincott williams &...

Documents