Which type of nursing diagnosis is validated by the presence of major defining characteristics?

Nursing is part of the healthcare system and includes activities for the maintenance and promotion of health status; prevention of disease; and care for individual, family, and community in all healthcare environments. To guarantee the adequacy of nursing care, nursing staff share the task of planning with healthcare professionals (; ). While providing nursing care, nurses use the nursing process to solve a patient problem that includes assessments, diagnoses, plans/interventions, and evaluations (; ). The five sequential steps of the nursing process are essential for nursing education and practice because they help minimize mistakes or omissions by systematizing nursing through a dynamic and cyclical process to improve health status of the patients and guide nurses to patient-centered nursing care (; ; ; ).

In Korea, since the 1980s, the nursing process has been actively applied in clinical practice; nursing students receive education on major subjects and have the opportunity to clinically apply the nursing process. In particular, the nursing process helps them to accurately understand the health problems of patients in clinical practice and study scientific evidence. Thus, the Korean Accreditation Board of Nursing has set the nursing process as one of the major learning outcomes to be achieved before graduation. As nurses’ ability to perform the nursing process leads to evidence-based practical competency, continuous attention to the nursing process is required in education and practice (; ; ).

Despite the fact that the nursing process is an important indicator covering a high proportion of guidance and evaluation areas in clinical practice education, it is reported that nursing students still have difficulties in the clinical application of this process. In other words, the significance of the nursing process in clinical practice has been emphasized, but specific efforts for improvement remain insufficient (; ; ; ).

Therefore, it is necessary to review the nursing process written by nursing students in the undergraduate course first, as part of a specific effort to reduce difficulties of nursing students in applying the nursing process and to help them apply the nursing process correctly. For this, it is necessary to review the nursing course report that nursing students actually write after clinical practice. In particular, it is necessary to examine whether the nursing diagnosis, which is the essence of the nursing process, is being made correctly.

Nursing diagnosis is a statement that reflects whether nursing students well identified the patient’s problem (signs or symptoms) and related/risk factors in the initial assessment stage. When a correct nursing diagnosis is made, it leads to correct nursing intervention and evaluation, but when a diagnosis is made incorrectly, the direction of intervention and evaluation is also wrong.

The ability to identify patient problems is a very important factor in patient care, and precise description of patient problems or demands in the statement of nursing diagnosis is also an important precondition to ensure quality patient care. Therefore, in order to analyze whether nursing students made the correct nursing diagnosis by properly selecting the defining characteristic and related/risk factors that are indicators of nursing diagnosis, it is necessary to closely examine the nursing diagnosis actually made by nursing students. In the review process, we used quality of nursing diagnosis (QOD), a quality evaluation tool for nursing diagnosis () to more objectively measure the accuracy and QOD.

Therefore, the purpose of this study was to identify the frequent nursing diagnosis applied to rehabilitation patients, and to identify the defining characteristics and related or risk factors of each diagnosis by reviewing case reports reported by nursing students during clinical practice in the rehabilitation unit. In addition, in order to evaluate the accuracy of nursing diagnosis described by students, the QOD is also evaluated.

MATERIALS AND METHODS

Research design

This was a retrospective study using the North American Nursing Diagnosis Association (NANDA) International, Inc. nursing diagnoses to analyze and identify the key nursing diagnoses in case reports submitted by 4th grade nursing students who had completed rehabilitation nursing practice.

Data collection

This study analyzed nursing diagnoses extracted from 190 case reports submitted by 4th grade nursing students in the department of nursing at Kyungpook National University (approval number: 2022-0157) who had completed rehabilitation nursing practice from the first semester and the second semester from 2018 to 2019 (clinical practice for 8 weeks at one general hospital in Korea). Case reports that include nursing processes consisting of patient assessment and intervention data are the basis for nursing diagnoses recorded by students during the clinical practice period. Usually, students observe and provide nursing care to patients and then select one of them to write a case report focusing on the nursing process. Students are required to make at least one nursing diagnosis per patient.

Data analysis

Using the case reports recorded by nursing students, the researchers entered demographic information, code of selected NANDA International, Inc. nursing diagnoses, defining characteristics (symptoms or signs), and related/risk factors into Microsoft Access. The validity of the analysis process was secured by categorizing it based on opinions agreed upon through discussion between two researchers.

Data preprocessing

As preprocessing for the analysis, we refined the nursing diagnoses recorded in the students’ case reports. Nursing students can make more than one diagnosis when multiple problems are identified in a patient. The diagnoses were reviewed, and in the case of different translations of English nursing diagnosis, the same type of diagnosis was unified according to the NANDA International, Inc. list (). If the students used the defining characteristic and related/risk factors suggested by NANDA International, Inc. but did not find the appropriate diagnosis, we were matched with the most appropriate diagnosis from the list of diagnoses. A small number of other medical diagnoses and nursing problems with ambiguous meanings were excluded from the analysis.

NANDA International, Inc. nursing diagnoses

A nursing diagnosis is a scientific decision of the response of individuals, families, or communities about actual/potential-health problems and processes of life. The NANDA International, Inc. nursing diagnoses included 244 diagnoses for clinical practice, test, and refinement. The diagnoses are classified with 13 domains and 47 classes. The domain is an area of interest (e.g., health promotion, nutrition, elimination/exchange, activity and rest, perception and cognition, self-perception, role of relationships, sexuality, coping and stress tolerance, life principles, safety and protection, and comfort) for nurses. The domains are classified into classes, which are groupings that sharing properties in common. The NANDA International, Inc. nursing diagnoses are submitted and reviewed by nurses based on evidence from various countries. The association is continuously revised and developed every 4 years with the approval of practicing nurses, nursing researchers, and nursing educators worldwide (; ).

Appropriateness and quality of nursing diagnoses

When evaluating the adequacy of nursing diagnoses, it is important to note that just having a diagnosis or a list of diagnoses is not enough. As each nursing diagnosis has a definition and label, the researcher must know the diagnostic indicators. Thus, the appropriateness of nursing diagnoses was confirmed through a quantitative evaluation of the extent to which the defining characteristics of the diagnoses were reflected at the nursing assessment stage. Diagnostic indicators are the information used to distinguish different diagnoses and include defining characteristics, related or risk factors. Defining characteristics are observable clues that are categorized as signs or symptoms of a problem-focused or health-promotion diagnosis. Nursing assessments support the accuracy of the diagnosis by identifying a number of defining characteristics (; ).

The quality of nursing diagnostic statements was assessed using the QOD tool. The QOD scale consists of four components and 14 criteria that evaluate diagnostic structure and relevance. The four components reflect the problem, etiology, and signs/symptoms (PES) format with an additional general component. Each criterion was given one point, with a maximum score of 14 points. Higher scores indicated better quality of the nursing diagnostic statements. The quality evaluation was performed by two experts with experience in clinical practice guidance. In a previous study, the Cronbach alpha value was reported as 0.86 (), and the value derived from the Kuder–Richardson formula for this study was 0.80.

Ethical considerations

This study was approved by the Institutional Review Board (IRB) of Kyungpook National University (approval number: 2022-0157). The case reports used for data analysis were submitted and used in the study after deleting all personally identifiable information. The IRB approved the waiver of consent to access the data.

RESULTS

General characteristics of the patients in rehabilitation units

The sample for the study composed of nursing records of patients in rehabilitation units. A total of 190 case reports were collected for analysis. The sample for research consisted of data from 108 men and 82 women with an average age of 62.2 and 63.4 years, correspondingly. Almost half of the patients were over 65 years old, and the age range was 22 to 82 years. The most prevalent medical diagnoses were stroke (n=70, 36.8%), hemiplegia (n=44, 23.2%), paraplegia or tetraplegia (n=34, 17.9%), intracerebral hemorrhage (n=11, 5.8%), intracranial injury (n=9, 4.7%), spinal cord injury (n=9, 4.7%), neuropathy (n=6, 3.2%), cancer (n=5, 2.6%), and others (n=2, 1.1%). The collaboration departments most visited by rehabilitation patients were neurology (n=83) and internal medicine (n=48), followed by orthopedics (n=32), family medicine (n=8), neuropsychiatry (n=6), and pain clinics (n=6). The types of rehabilitation treatments were as follows: exercise therapy (n=157), thermotherapy (n=143), occupational therapy (n=125), and speech therapy (n=64) ().

The frequent nursing diagnoses

Thirty nursing diagnoses were decided by the nursing students. The most prevailing nursing diagnoses were impaired physical mobility (n=68, 14.6%), activity intolerance (n=63, 13.5%), deficient knowledge (n=60, 12.9%), bathing self-care deficits (n=34, 7.3%), risk for injury (n=34, 7.3%), toileting self-care deficits (n=31, 6.7%), chronic pain (n=28, 6.0%), impaired comfort (n=26, 5.6%), powerlessness (n=15, 3.2%), and disturbed body image (n=11, 2.4%). Ten nursing diagnoses constituted 79.5% of diagnoses for patients in rehabilitation units. Of these, the top five nursing diagnoses (impaired physical mobility, activity intolerance, deficient knowledge, bathing self-care deficit, risk for injury) constituted nearly 50% of diagnoses for patients in rehabilitation units ().

Thirty different nursing diagnoses selected by nursing students were distributed across 10 domains and 20 classes of the NANDA International, Inc. I human response patterns: health promotion (domain code (1), nutrition (2), elimination and exchange (3), activity/rest (4), perception/cognition (5), self-perception (6), role relationship (7), coping/stress tolerance (9), safety/protection (11), and comfort (12). The domains most often chosen by the nursing students were activity/rest (46.4%), perception/cognition (15.5%), comfort (12.0%), safety/protection (8.7%), self-care (17.4%), activity/exercise (15.5%), cardiovascular/pulmonary responses (13.5%), and cognition (12.9%) ().

Top two defining characteristics related to the top ten nursing diagnoses

The defining characteristics of the top ten nursing diagnoses are listed in . The most prevalent defining characteristics for each NANDA International, Inc. diagnoses were (a) decrease in gross motor skills for impaired physical mobility, (b) fatigue for activity intolerance, (c) insufficient knowledge for deficient knowledge, (d) impaired ability to access bathroom for bathing self-care deficit, (e) impaired ability to complete toilet hygiene for toileting self-care deficit, (f) proxy report of pain behavior/activity changes for chronic pain, (g) discontent with situation for impaired comfort, (h) dependency for powerlessness, and (i) alteration in body function for disturbed body image.

Top two related or risk factors related to the top ten nursing diagnoses

The related or risk factors to the top 10 nursing diagnoses are listed in . Activity intolerance was most frequently used for impaired physical mobility, physical deconditioning for activity intolerance, insufficient information for deficient knowledge, environmental barrier for bathing self-care deficit, physical barrier for risk for injury, impaired mobility for toileting self-care deficit, injury agent for chronic pain, insufficient environmental control for impaired comfort, anxiety for powerlessness, and alteration in self-perception for disturbed body image.

The quality of nursing diagnostic statements for the top five nursing diagnoses

The average quality of the nursing diagnosis statements written by the students is shown in . The average score for the nursing problem component was 2.77±0.19, etiologic component 2.41±0.29, signs/symptoms component 1.64±0.47, and general component 3.47±036.

DISCUSSION

The study aimed to analyze nursing diagnoses using NANDA International, Inc. nursing diagnoses to identify the key nursing diagnoses in case analysis reports submitted by 4th grade nursing students who have completed rehabilitation nursing practice. Based on the analysis results, we suggest a specific and rational direction for the nursing process applied in clinical practice, in addition to evaluating the appropriateness of clinical reasoning and diagnosis and the quality of diagnosis focusing on the key nursing diagnosis. The following discussion is based on the data obtained from the study results.

First, the most frequent nursing diagnoses in the nursing process made by the nursing students were “impaired physical mobility,” “activity intolerance,” and “deficient knowledge,” in that order. In a study analyzing the physical function and immobility problems of stroke patients in the rehabilitation ward, it can be seen that “body mobility impairment” appears as a priority problem that must be solved (). In this study, it seems that the frequency of diagnosis related to physical mobility was high as stroke, paraplegia/tetraplegia, and hemiplegia patients accounted for 80%. In this regard, a previous study also reported that “impaired physical mobility” was a common nursing diagnosis for patients with cerebral vascular disease, and it was included as a necessary nursing diagnosis for stroke patients in previous studies (; ; ). The high frequency of these nursing diagnoses is justified by the fact that cerebrovascular disease is a motor neuron disease that can lead to loss of voluntary movement control. As motor neurons in the cerebral hemispheres cross over in the brainstem, voluntary motor control disorders on one side of the body reflect motor neuron lesions on the other side of the brain, which can lead to disorders such as hemiplegia (; ). Since the nursing process in clinical case studies is also applied according to priority among the health problems of the patients, nursing diagnoses with high priority, such as impaired physical mobility, should be given importance. In other words, nursing educators need to keep track of nursing processes that are frequently applied in practice, such as impaired physical mobility, and conduct research so that the latest knowledge can be implemented in clinical practice.

Second, according to the results found in this research, the top five nursing diagnoses were distributed in the activity/rest (4), perception/cognition (5), and safety/protection (11) domains. The domain distribution of these diagnoses reflects the fact that patients in the rehabilitation unit experience mobility impairment among disabilities, and in terms of functionality, they are considered unable to move freely. In addition, analysis of the top five domains in which diagnoses were distributed and the classes by domain revealed that the diagnoses were distributed in classes 2 (activity/exercise) and 5 (self-care) in domain 4 (activity/rest), class 4 (cognition) in domain 5 (perception/cognition), class 2 (physical injury) in domain 11 (safety/protection), class 1 (physical comfort) and 2 (environmental comfort) in domain 12 (comfort), and class 3 (body image) in domain 6 (self-perception). These findings suggest that physical restrictions may appear abruptly or slowly, depending on their severity and duration, but may also contribute to health problems, ranging from lack of self-management to impaired social interaction. Most of the other nursing diagnoses found in this study (such as bathing self-care deficit, toileting self-care deficit, risk for injury, impaired comfort, powerlessness, disturbed body image, impaired swallowing, impaired verbal communication, and constipation) also occurred due to motor impairment, indicating that disability affects the entire life of rehabilitation patients. It can also be seen that nursing students reflected not only the physical problems of rehabilitation patients, but also psychosocial problems in the nursing process. According to the preceding literature, the occurrence of self-care deficit after stroke is usually aftereffects of cerebral hypoperfusion (; ; ), and nursing diagnosis associated with self-care deficits also show an association with motor and sensorial aftereffects.

Third, it is necessary to examine the diagnostic indicators that includes defining characteristics, related/risk factors of each nursing diagnosis that nursing students select for rehabilitation patients. Defining characteristics are used to make a nursing diagnosis and are one of the diagnostic indicators used to distinguish different diagnoses. They are observable clues that are categorized as signs or symptoms of a problem-focused or health-promotion diagnosis. Related or risk factors are essential elements of all problem-based diagnoses and etiologies, which have some type of relationship with nursing diagnoses (; ). A review of patients’ history is helpful in identifying related or risk factors. The signs and symptoms related to the top 10 diagnoses are described in . Most nursing students are educated to follow the PES format for problem-focused or health-promotion diagnosis when stating a nursing diagnosis (; ). Problems refer to the response of the patients, etiology refers to the related or risk factor that causes nursing problems, and signs or symptoms are specific responses that occur in a patient, supporting that the cause is related to the nursing problem (; ; ). For example, with the statement “impaired physical mobility related to activity intolerance,” it is difficult to clearly ascertain the evidence for making the diagnosis. However, if the statement is revised to “impaired physical mobility related to activity intolerance with a decrease in gross motor skills,” the rationale for the diagnosis will be more clearly understood. However, the disadvantage of the PES format is that the sentences are long and can be more complicated; therefore, the two-part nursing diagnosis is more common. In addition, in the case of a risk nursing diagnosis in which the patient does not show symptoms, three-part nursing diagnosis cannot be used. Therefore, since most two-part nursing diagnoses consist only of related factors and problems without mentioning signs or symptoms, it is also necessary to check the signs and symptoms, which are mostly confirmed in the assessment data in the form of defining characteristics. The PES format is recommended for nursing students who are not skilled in diagnosis because the problem statement is more descriptive, containing symptoms and signs to provide the basis for making a diagnosis.

Fourth, as a result of evaluating the quality of nursing students’ nursing diagnosis statements to identify the accuracy of the diagnoses, the average quality was 8.63 out of 14 points. Although direct comparison is difficult because there are no preceding studies evaluating the QOD statements among nursing students, compared with the results of 8.8 points in a nursing course education intervention study for nurses (), the quality of nursing students’ nursing diagnosis statements in this study is relatively good. In conclusion, it can be seen that the rehabilitation nursing unit is a special unit, and nursing diagnoses reflecting the characteristics of rehabilitation patients are mainly selected by students. It can be confirmed that the definitions of characteristics for each major nursing diagnosis and related factors or risk factors differ from those of other nursing units. Therefore, considering that nursing students can appropriately select clinically applicable diagnoses through theoretical and practical education, efforts are needed to establish a continuous curriculum and feedback through which nursing students can identify and review procedural errors in the usage of the nursing process. In addition, in the process of deriving a nursing diagnosis, the practice field leader or academic advisor should allocate sufficient time for practice guidance to provide feedback and make an effort to review the improvements.

Based on these results, this study intends to make the following proposals: This study analyzed the nursing diagnosis statements written by the nursing students and evaluated the accuracy and quality of the nursing diagoses. The key nursing diagnoses were impaired physical mobility, activity intolerance, deficient knowledge, risk for injury, bathing self-care deficit. And defining characteristics, related or risk factors were analyzed together. However, the study is limited in that it is difficult to generalize the characteristics of the nursing process because data were collected from a single nursing college. In addition, the evaluation based on the opinions of experts is limited as no tools have yet been prepared to evaluate errors in the nursing process. Therefore, future research should aim to develop a tool that can objectively evaluate and quantify errors in the nursing process. Furthermore, in order to generalize the research results, we propose repeated research for nursing students in different regions in consideration of variations in conditions such as the learning environment and university location as well as nursing practice involving children, women, and psychiatric nursing practice.

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