nursing diagnosis: the importance of a definition

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hls. Mills, nursing consultant for qu;ility assurance with the Allwi-ta Associ;irion of Registered nurses. was an elected tiieinbei- o f the N A N D A Board o f Directors from I OX:3 t o 1987 and is currently a nietnber o f the Taxonomy Coin- tiiittee. She also served as co-chair and chait- o f the International Conitiiittee and was part of the organizational gr-oup for the I n - ternational ( h f e r e n c e on Clini- c-al Decision Making and Nursing Diagnosis held in Calgary in 1987.

Nursing Diagnosis: The Importance of a Definition Winnifred C. Mills, MEd, BScN, RN

Nursing as an evolving science etitertaina the usage of terminology that la& clarity and the singular application of ~erms. The resulting semantic conlir- sion lea& to Mculry in operationalizing definitions for use in taxoiioinic efforts and in research. Examples of this confusion exist whew tlic term nursing diagnosis is u d as concept. category, process. and prtdurt. Fout suggestions are nude to alleviate these difficultiem.

Kw Word.: nursing dmgnnsis

A t the ninth Conference on Classification of Nursing Diagnoses, the North American Nursing Diagnosis Association (NANDA) made a landmark decision. A working definition of a nursing diagnosis was proposed, debated, amended, and finally accepted. This occurrence offers the basis for further important dialogue among professional nurses addressing concept clarification and semantics in nursing diagnosis as these issues contribute to the development of the discipline.

This article will briefly discuss nursing diagnosis terminology generated prior to the first conference, through the 1970s, the 1980s, and to the present. The importance of a definition will be explored together with the concepts of process and product. The difference between a diagnostic statement and a diagnostic title will be identified, along with some of the problems arising from semantic confusion. A brief critique will be provided of the definition accepted at the ninth conference.

Some History of Terminology

Great progress in the evolution of professional nursing oc- curred in North America following World War 11. As numbers of individual nurses accessed advanced education, influences from the social sciences, education, and other disciplines shaped thinking about nursing as a science. Germane to this thinking were questions about the nature of nursing, the process of nursing, and the focus o f nursing.

As early as 1950, the term nursing diagnosis appeared in the literature (McManus, 1950). Theoretical concepts underlying nursing practice were largely undefined although retrospective analyses of Florence Nightingale’s Notes on Nuning have identified pervading themes. Henderson’s (1 960) definition of nursing was based on the belief that the service a nurse performs addresses the individual’s

Nursing Diagnosis 3

immediate and long-term need for physical care, emotional support, and re-education. Reference t o the individual did not exclude the recognized service the nurse performs for families and groups (Henderson, 1960). This definition reflected Nightingale’s themes anti continues t o serve man!’ nurses today a s an adequate description o f their practice.

In 1961, Abdellah provided one of the first categorizations of nursing with publication of the 2 1 nursing problems. Although called nursing problems, these statements clearly emerged from perceived patient needs. Throughout [he 1960s the ternis nursing problems (Ahdellah. 196 1 ; (:hainhers. 1962; Haindi & Hutelmyer, 1970; Smith, 19681, patient probleiiis (Little, 1 Y67), pa- tierit needs (Orlando, 1961; Quigley & Wagner, 1964; Sch\\.ai-tz, 1967), arid nursing diagnosis (Honriey X. Kothberg, 1 9 6 3 ; Durand & Prince. 1066; Norris, 1964; Rothberg, 1967) all appeared in the nursing literature. The inconsistencies in use of terminology parallel the evolution of nursing concept t ia l frameworks and the early descrip- tioris of the nursing process. I n 1963 Komorita dest I-ihed the confusion surrounding the use of the iernis cliiigriosis, judgnient, nursing diagnosis, probleni, ar id needs. She deploreci the lack ofclar- it!, in tising terniinoloR and concluded that “iiursing tiiagiiosis involves discriminative judg- n i rn t . is h s e d on a body of scientific knoivledge and is a process which pi-ovides nursing with ;I

teniatic ivav o f assessing patient problems and n e c ~ i s ” (1). Ni). Also about this time the require- nieltl of aLl~oniatrd tems for standardized nursing documentatioii was recognized (Kosenberg X- (:art-ikei., I M 6 ) .

Concepts and Definitions, Process and Product

A neeti f o i - I I L I I ‘ S ~ S t o identif\. and label the (,linical protdenis etidencect in an anibrilatoI-y care setting rst;iblished the scene for the first riational ctriifriwice on classification of nursing diagnoses i n I 973. A definition of nursing diagnosis used I > \ partic i p i r i t h in the first conference states “that jiitlgment 01- ~~onc~lusion \vhich occiii‘s iis ;i result of n i l 1 \ins iisse>siiieiit” (Gebbie. 1 !)7.b, p. 7 0 ) . This ticfinition i t l m t i f i r t l ;1 nursing diagiosis as ii prod- tic t I ) f ‘ nu 1% I I g J r itlgnieri t .

I‘hc pxi.iicipmts i n the first conference, tliro~igli p;iiivl discussion. g a \ ~ consideration t o

the use of a classification system by each of the “subsystems of nursing, clinical practice, education and research” (Gebbie & Lavin, 1975, p. 2 1). Given that conceptual frameworks were in early stages and that the four-step nursing process was slowly diffusing into practice, it is not surprising that the ternis “patient problerns” (p. 22), “corn- nio n 1 y occur rin g pro b I ems ’ ’ ( p . 2 4), ‘ ‘ unn anied concepts and categories” (p. 25), and “diagnostic categories” (p. 26) all emerged without clear- defi- nition or consensus on their meanings. The clefiiii- tion of nursing diagnosis used by participants at that first conference could, however, still be of value to us today.

The proceedings of the second conference, held in 19’75, included iiseful coninirnts and challenges offered by Lhe nurse theorists w h o were present. By the time the proceedings of the third and fourth conferences, held in 1978 arid 1980, were published in 1982, the literature contained many different definitions of nursing diagnosis. Mundinger and Jauron (1 975) set parameters on the concept o f nursing diagnoses by using references t o i l l health. “Nursing diagnosis is the statement of a patient’s response which is actually or potentially unhealthful and which nursing intervention can help t o change in the direction of health. I t should also identify essential factors related t o the unhealthful response” (11. 96). Mun- dinger and Jauron also coninicnted o i i the conf’ii- sion in our nomenclature where patient’s health problems, nursing needs, nursing probleins, arid nursing goals are ill-defined arid the iniprecise use of these lei-ins by m a n y niirsc‘s.

Gordon’s ( 1 976) widely circulated definition included the Lvortls “health pi-oblems,” again limit- ing the meaning est ahlished in the first conference definition. She stated, “Nursing diagnoses, or c I i n ic al diagnoses I nade by p 1-0 fe ss i o n al n 11 rscs, describe actual o r potential health pi~obleiiis which nurses, b y virtue of their educatioii and ex- perience, are capable and licensed t o treat” (<;or- don, 1976, p. 1299). Throughout this article (;or- don uses the term diagnostic category to represent a state-of-patient and notes that each is distin- guished t i? its label and defining cluster of signs

Cai-ne\ali ( 1 98 1) in discussing nursing diagnosis and the nature ofconcepts, reniiricietl 11s that not o n l y facts, oh-jects, 01- phenonieiia were o f concern t o nurses, but also knowledge a h n i t these elements. To organire this knowledge in ways ~ise-

and sympt011is.

4 Volume 2, Number 1, January/March 1991

ful to the clinical decisionmaker is the work of taxonomy, and a format similar to the organiza- tion of medical diagnostic concepts was suggested.

Nursing diagnosis, discussed as both concept and process by Bircher (1 982), encompassed a pattern of known or observable facts, a symbol or name that represented the entity and a set of refer- ents. Again, for taxonomic purposes, systems of categorization used in medicine were suggested as appropriate for ordering the knowledge available for each taxon. Both Carnevali and Bircher note the importance of taxonomy in organizing knowledge useful to the clinician, the educator, and the student.

I n 1982, at the fifth conference, Shoemaker (1984) presented the results of a Delphi study, conducted as part of her doctoral work and de- signed to come to a clearer understanding of the meaning of the term nursing diagnosis. The Soltis (1 9’18) paradigm for analysis of concepts guided the study. The definition derived from the study was

A nursing diagnosis is a clinical judgement about an individual, family or community that is derived through a deliberate, systematic process of data collection and analysis. It provides the basis for prescriptions for defin- itive therapy for which the nurse is accountable. I t is expressed concisely and includes the etiology of the condition when known. (Shoemaker, 1984) (p. 109)

This definition clearly addresses the concept of nursing diagnosis in its first phrase, then includes process in its second phrase (“. . . that is derived through a deliberate, systematic process of data collection and analysis”). With its basis in research, this definition has proven valuable to nurses in all functional areas. For taxonomic purposes, however, the inclusion of etiology is a problem, since a taxonomy can properly deal only with the diagnostic name or title as the unit of categorization or taxon.

The definitions developed subsequent to the first conference, while expanding and making more explicit the concept of nursing diagnosis from a structural and process perspective, compli- cated taxonomic endeavors. Is a nursing diagnosis complete with only a title? Must it be accompanied by etiology? Should there be signs and symptoms attached? These medical terms are gradually fad- ing from the literature with terms etiology now replaced by “related factors” and signs and symp-

toms replaced by “defining characteristics.” Should we not include wellness diagnoses? Can wellness be a problem? Is a nursing dia<gnosis re- ally only a problem?

Users remained confused on the basic ques- tion, “What is a nursing diagnosis?” When the or- ganization became formally constituted as the North American Nursing Diagnosis Association in 1982, and with the formation of a Diagnosis Re- view Committee and a Taxonomy Committee, these questions became more pervasive. N o offi- cial definition of nursing diagnosis existed although both the Gordon and Shoemaker definitions were widely accepted.

Even with the presentation of Tuxononly I Ru- vised to the assembly of the eighth conference in March 1988, there was evidence of confused terminology as the terms “diagnostic categories” and “labels” appeared together in titles and text (Carroll-Johnson, 1988, p. 515). At the general assembly of this conference a motion was ap- proved that “a working definition of nursing diagnosis will be submitted to the 1990 general asseni- bly for approval” (Carroll-Johnson, 1988, p. 501). At the ninth conference in March 1990, a definition, developed under the direction of the NANDA Board of Directors, was proposed and amended. The accepted version reads:

A nursing diagnosis is a clinical judgement about individual, family or community re- sponses t o actual or potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable (Carroll-Johnson, 1990, p. 50).

Discussion ensued at the assembly concerning inclusion of the sentence about interventions, outcomes, and accountability. This sentence in the accepted definition reflects Carnevali’s belief that there is knowledge related to facts, objects, and phenomena of concern to nurses and forming parts of a concept, in this case the concept of nursing diagnosis. But the concept of nursing diagnosis may also include the importance of assessment, the process of assessment, theoretical constructs guiding assessment, the observation of relationships among identified cues, the genera- tion of hypotheses, the testing and rejecting of hypotheses, the influence of intuition, the search for underlying factors, the validation of data with the client, and many more aspects. Included in

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this definition is a statement moving beyond the concept of diagnosis and into the realm of intervention and outconies. Again we may be niuddy- ing the waters with unnecessary words. Much de- pends on the purpose for which the definition will be used. The additional statement is not incorrect, it may simpl>- be unnecessary in the context o f a definition t o be used for screening new diagnoses submitted for review and entering those accepted into the taxononiv.

Why is a Definition Necessary?

At the hrst conference an underlying purpose of the group activity was “the clear articulation o f those health problems that comprise the domain of nursing and the classification of the problems into a taxonomic system” (Gebbie and I,avin, 197.5, p. v) .

Articulation

The need t o identify our phenomena of concern has a very pragmatic base in today’s health care system. Increasing demands to identify what nursing does, for whom, and why service is needed are placed upon us by both government and en- t repreneurial funding sources. Not only is identi- fication o f phenoniena necessaly, hut also careful labeling and definition, s o that our conimunica- tion with one another, with those in other disciplines and with the consumers of our service, can be direc-t, clear, and effec-tive. The information we wish to coinmunicate must be s o structured that it will he congruent with the demands of automated systeins, now an integral part o f eveiy functional area in nursing.

The terininolog): used in our communication must be cohrrent and consistent within our discipline so that in all instances practitioners, educa- tors, administratoi-s. and researchers are speaking a common language for describing, identifying, treating, and comparing the human phenomena that are nursing’s concern.

Classification

T;ixonoinists who contributed to the dialogue at thr first conference, discussed two elements essential to classification. The first element demands a principle of‘ order to determine which entities are elipble for inclusion in the system. The second

element is somewhat dependent on the first and requires that the purpose o f the classification be established (Gebbie and Lavin, 1975). It is possi- ble that lack of clarity about the second element has caused confusion. What is the purpose in classification of nursing diagnoses?

One purpose is t o relieve the cognitive bur- den imposed by masses of information. The nuni- ber o f identified nursing diagnoses has steadily in- creased since the first conference. Our human lim- itations require that we order data in ways that have meaning for us according to the uses we wish to make of it and that the ordering is such that the information is readily accessible when needed. For the average practicing nurse or beginning stir- dent, the alphabet has served as a useful mecha- nisms for ordering nursing diagnoses. But a list for easy reference is not the only purpose in classification.

The desire to classify beyond the alphabet conies from that sense of scholarly inquiry present among niembei-s o f the profession arid role mod- eled by Florence Nightingale. Nursing as an evolving science and a developing discipline recognizes the need not only t o identify the phenomena o f concern but also to determine the relationships among these entities. As relationships are recognized, patterns may be discerned and hypotheses may be generated for further investigation to en- hance the practice of care giving.

Nursing Diagnosis and Theory Development

Gebbie (1 982) noted that while theorists were present at each of the first three conferences, theory development was not seen as a primary focus. Terminology development took precedence through a group empiricism approach. It was ac- knowledged, however, “that while the labels might be generated in an atheoretical environment, their classification must be founded on some theory . . . generalized enough t o allow nurses who accept one of several extant theories of nursing to find their way through the system” (p. 10).

At the third conference, Kritek (1 982) re- viewed the state of theory development in professional nursing and related this state to the genera- tion and classification of nursing diagnoses. Her observations continue to be important today. Throughout her discussion, a concern with terminology emerges since she maintains that nursing


has moved to levels of prescriptive theory development without addressing the basic step of defining clearly our phenomena of concern. In the 12 years since this paper was presented, a considerable body of work has emerged helping to validate cer- tain diagnostic terminology. Nevertheless, philo- sophic differences result in biases that continue to separate practicing nurses, as well as nurse theorists and their followers, in viewing the human condition and naming the phenomena of concern to professional nursing.

Let us stop using the words nursing diagnosis to denote both

a process and a product.

More recently, Hinshaw (1988) saw nurse researchers as forging a link between theory and practice despite the many challenges provided by the nursing diagnosis process and product model. Avant (1990) refers to the importance of parallel work by “expert discoverers” and “expert testers” of concepts and labels whose joint efforts are needed to provide sound diagnosis development and associated theoretical relationships. Opera- tional definitions are, however, essential to any research proposal and design. Fitzpatrick (1 990) has noted the importance of the words we choose and use. Until a consensus exists in terms and definitions, even the best research efforts may be frus- trated and confounded.

Some Recommendations

In an effort to move us upward out of this quagmire of words in which we are entrapped, several bold suggestions are presented. First, in the interest of clarity, we could use different terminology for process and product. Let us stop using the words nursing diagnosis to denote a process and instead use the words “making a clinical nursing diagnostic judgment following assessment.” It is true that nurses make judgments throughout the cycle of the nursing process. These may be diagnostic judgments, therapeutic judgments, or ethical judgments. Assessment (or reassessment following evaluation) must, however, precede the

judgment that determines the requirement for nursing intervention.

As a second bold step, we could name the product of making a clinical nursing diagnoses judgment following assessment a nursing diagnostic statement. Three necessary eletnents of the statement would include the nursing diagnosis title, related factors where known, and the defining characteristics presented.

The third step would see us define nursing diagnosis as the accepted title or name of an actual or potential human response evidenced by spe- cific defining characteristics and amenable to nursing. This definition would allow both wellness- and illness-oriented titles to be used. We might also add that the human response has, throughout the nursing literature, been labeled variously the client’s need for nursing and a health problem.

Finally, the term nursing diagnostic category could be defined as the accepted title/name of a human response described at level 2 in Taxonomy II proposed at the ninth conference. An example of a nursing diagnostic category would be altered urinary elimination. Under this are subsumed related diagnostic titles/names that are more spe- cific and therefore more useful in everyday clinical practice such as stress incontinence or urge incontinence.

Conclusion Our science is emerging slowly but we have

only limited cognizance of the actual realms of our discipline much less the parameters thereof. Courage is needed to define clearly the meaning of the labels we leave on guideposts for those who follow after us. To date much of our literature lacks precision in use of terms. The time to correct this is now.

References Abdellah, F., et al. (1961). Patient centered approaches lo

Avant, K.C. (1990). The art and science in nursing nursing. New York: MacMillan.

diagnosis development. Nursing Diagnosis, I, 5 1- 55.

Bircher, A.U. (1982). The concept of nursing diagnosis. In M. J. Kim 8c D. Moritz (Eds.), Clmsijcation of nursing diagnoses: Proceedings of the third and fourth national conferences (pp. 30-43). St. Louis: McGraw-Hill.

Nursing Diagnosis 7

NURSES CARE FOR AMERICA National Nurses Week, May 6-1 0, 1991


nursing diagnosis: the importance of a definition

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