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Nursing Diagnosis Development of Longing: Content Validation With Nursing Experts Shelley-Rae Pehler, PhD, RN, Michelle Markwardt, BSN, and Danielle Hibbard, BSN Shelley-Rae Pehler, PhD, RN, is an Associate Professor, College of Nursing and Health Sciences, University of Wisconsin, Eau Claire, Wisconsin, Michelle Markwardt, BSN, is a Nursing Student, College of Nursing and Health Sciences, University of Wisconsin, Eau Claire, Wisconsin, and Danielle Hibbard, BSN, is a Nursing Student, College of Nursing and Health Sciences, University of Wisconsin, Eau Claire, Wisconsin.
Search terms: Fehring’s Diagnostic Content Validation (DCV) model, longing, nursing diagnosis development Author contact: [email protected], with a copy to the Editor: [email protected]
OBJECTIVES: Validate the defining characteristics, related factors, and definition of proposed nursing diagnosis: longing. METHOD: Using Fehring’s Diagnostic Content Validation model, expert nurses rated the frequency of longing seen in patients/caregivers. Agreement with the proposed definition was also tabulated. FINDINGS: None of the defining characteristics reached major criteria (>0.80). Six of the 84 characteristics achieved a weighted ratio of less than 0.50. The proposed definition and related factors were supported. CONCLUSION: Current research supports the proposed development of a nursing diagnosis for the human response of longing. PRACTICE IMPLICATIONS: Because the psychosocial characteristics do not make longing easy to assess, continued research is needed to ask patients and caregivers about their personal experience with this human response.
Patients with chronic or life-threatening illnesses are often faced with physical, emotional, and/or social limitations (such as changes required in job or roles at home). These changes may lead a person to redefine who they are or feel that they are unsettled or “groundless” (Bruce, Schreiber, Petrovskaya, & Boston, 2011). It is during this time that the person often expresses longing to go back to the way things were before the disease. This human response of longing can be emotionally draining and take energy away from other tasks a person may need to accomplish (Bruce et al., 2011; Lohne & Severinsson, 2005; Roscigno, Swanson, Vavilala, & Solchany, 2011). Negative consequences of longing may include changes in relationships (Carlsson, Dahlberg, Ekebergh, & Dahlberg, 2006; Martin, 2004; Marwit, Chibnall, Dougherty, Jenkins, & Shawgo, 2008; Sallady, 1985; Ternestedt & Franklin, 2006), loss of self-esteem (Carlsson, Hallberg, & Odberg Pettersson, 2009; Ternestedt & Franklin, 2006), increased fears (Al-Gamal, Long, & Livesley, 2009), and loss of hope (Al-Gamal et al., 2009; Baumann, 1996; Talseth, Gilje, & Norberg, 2003; Ternestedt & Franklin, 2006). Nurses are in a key position to assess longing in patients and intervene to decrease negative consequences. In order to accomplish this assessment, nursing must be able to recognize and diagnose a patient’s human response of longing. A concept analysis of longing revealed substantial support for the potential of a new nursing diagnosis to be used to name the phenomenon of longing in individuals and
© 2014 NANDA International, Inc. International Journal of Nursing Knowledge Volume 26, No. 3, July 2015
families (Pehler, Sjostrom, & Markwardt, 2014). A major outcome of this research was a proposed definition, which guided this research project. Longing is defined as the intense desire for some thing, some state, or some relationship without which one’s life feels incomplete. The next step for nursing diagnosis creation is to verify if the attributes (defining characteristics), situations (related factors), and definition that were the result of the concept analysis can be supported through content validation using expert nurses. The objective of this research project was to carry out the second phase of nursing diagnosis development by surveying expert nurses to provide content validation for the diagnosis of longing (Herdman, 2012a). Results of this study will inform the next research project when patients and caregivers will be asked to identify if they have experienced longing. Background Patients who are experiencing chronic or life-changing events are most at risk for the human response of longing. Diagnosis of a chronic or life-threatening illness or a traumatic event leads to both physical and psychosocial changes. The person may lose physical abilities, leaving them dependent on another person. They may no longer be able to work, either due to the illness itself, or because their treatment plan may leave them too fatigued to carry out their daily activities. The person experiences a 121
Longing: Validation by Expert Nurses disconnection from their present situation and longs to get back to life before the disease (Bruce et al., 2011; Öhlén & Holm, 2006). Unaddressed, longing can progress to loss of self-esteem, increased fears, and loss of hope (Al-Gamal et al., 2009; Farkas & Yorker, 1993; Gostecnik, Repic, & Cvetek, 2008; Holm & Severinsson, 2010; Massie & Szajnberg, 2006; Ternestedt & Franklin, 2006). Longing also has been seen in the caregivers of people with chronic or life-changing health issues. Those caring for a family member diagnosed with Alzheimer’s disease, for example, often experience a disconnection or detachment from the person with the disease (Johansson, Sundh, Wijk, & Grimby, 2013; Marwit & Meuser, 2005). Because the caregiver is often a spouse or significant other, as the person with Alzheimer’s loses their identity, the relationship changes, and the caregiver no longer has shared experiences with the partner. This leads to feelings of loss, confusion, fear, and uncertainty. The caregiver feels detached, which can lead to feelings of guilt and despair, affecting the caregiver’s own health (Davis, Tremont, Bishop, & Fortinsky, 2011; Gonyea, Paris, & de Saxe Zerden, 2008; Kelly, 2010; Silva, 2014). To decrease the potential impact of longing, nurses must be able to identify and communicate longing to the stakeholders in order to develop interventions. Development of a nursing diagnosis for longing would be the first step to communicate with other healthcare professionals and provide the foundation to develop interventions to treat this human response. Research Methodology Based on criteria developed by NANDA-I (Herdman, 2012b; Scroggins, 2012) for the level of evidence for the submission of a new diagnosis, this second phase of nursing diagnosis development used Fehring’s Diagnostic Content Validation (DCV) model (Fehring, 1994) to validate the defining characteristics, related factors, and definition of a proposed nursing diagnosis label for the human response of longing. Research Participants A purposive sample of nurses who work with patients who might experience longing was sought. Members of the Association of Rehabilitation Nurses and the Academy of Medical-Surgical Nurses were contacted. Once approval was received from the University of Wisconsin–Eau Claire Institutional Review Board Committee, the Academy of Medical-Surgical Nurses sent e-mail invitations with a link to the survey to its 10,929 members. A cover letter with a copy of the survey was sent to 500 members of the Association of Rehabilitation Nurses via postal mail. Demographic information collected was used to not only describe the sample but to identify those respondents who met at least a 5 on Fehring’s criteria for “Expert” (see Table 1) (Fehring, 1994). Confidentiality was maintained for both participant groups. Since the Academy of Medical-Surgical Nurses sent 122
S.-R. Pehler et al. Table 1. Fehring Expert Rating System Criteria
Points
Master’s degree in nursing Master’s degree in nursing with a thesis in content relevant to the diagnosis of interest Published research on the given diagnoses or relevant content Published article on the diagnoses in a refereed journal Nursing PhD Doctoral dissertation on diagnosis Current clinical practice of at least 1 year duration in an area relevant to the diagnoses of interest Certification in an area of clinical practice relevant to the diagnosis of interest
4 1 2 2 2 1 1 2
the e-mail to its membership, the research team was not aware of who received the survey or responded to it. One participant did send an unsigned, personal e-mail to the researcher thanking the team for completing this research project. The e-mail address of this participant was eliminated to maintain that person’s anonymity. The addresses used for the paper surveys sent via postal mail to potential participants from the Association of Rehabilitation Nurses were printed on address labels from a spreadsheet obtained from the association. Once the surveys were mailed, the spreadsheet was destroyed so there would be no risk of linking participant responses to their contact information. Returned surveys were entered into a master database for analysis. Due to the nature of how the invitations were sent, cost of mailings, and in order to maintain confidentiality, no follow-up reminders were sent. Research Design Based on the DCV model, expert nurses were asked to measure each of the 84 attributes/defining characteristics found during the concept analysis on the frequency seen in patients or caregivers based on a Likert scale: 1-Not Present, 2-Rarely Present, 3-Occasionally Present, 4-Frequently Present, and 5-Nearly Always Present. Next, weighted ratios were calculated for each attribute where the 1–5 scale was converted to a weighted score (1 = 0, 2 = 0.25, 3 = 0.5; 4 = 0.75; and 5 = 1). Any of the items that received a weighted score of less than 0.5 were rejected. Items that received a 0.50–0.79 were termed “tentative minor” characteristics; while attributes that had weighted scores 0.50 or greater were identified as “tentative major” characteristics (Fehring, 1987). Minor and major characteristic designations are used to develop a succinct list of defining characteristics based on research findings (Lunney & Muller-Staub, 2012) compared to a potentially longer list that is identified during a concept analysis. Participants also identified if the proposed definition accurately described longing in patients. A simple
S.-R. Pehler et al.
Longing: Validation by Expert Nurses
Table 2. Demographics of Sample Education
#
%
Years working in nursing
#
%
Master’s in Nursing DNP PhD in Nursing
60 4 1
92 6 2
Less than 1 year 1–5 years 5–10 10+ years
0 1 6 58
0 2 9 89
0 2
0 3
7
11
17
26
35 4
54 6
Area currently working Adult Medical Adult Surgical Rehabilitation Cardiac Oncology Veterans Intensive/Critical Care Behavioral/Mental Health Public Health, Geriatric, Oncology-Surgery Pediatric
Experience with nursing diagnoses 48 39 13 11 11 8 7 6 5
74 60 20 17 17 12 11 9 8
3
5
I have never used Nursing Diagnoses I have heard of Nursing Diagnoses but have never used them I have used Nursing Diagnoses, but only when in nursing school I have used Nursing Diagnoses in the past, but I am not currently using them in my practice I consistently use Nursing Diagnoses in my practice Other- Please Describe: (Two Written Responses: 1. Use as needed for staff education. 2. Electronic documentation does not allow.)
percentage was calculated of those who agreed with the definition as written, and suggestions for changes were tabulated. Finally, participants were asked in what situations patients experienced longing. Participants chose from a checklist developed from the literature but were also able to add any situations not included on the list. Results Demographic information from those who did participate is listed in Table 2. The final sample of 65 participants (n = 292 total) who had either an MSN, DNP, or PhD in Nursing and met at least one of Fehring’s other criteria for expert represented 22% of the population of respondents. Of this sample, the majority have their master’s degree (92%) and have worked at least 5 or more years in nursing (98%). Most of the participants (91%) stated they used nursing diagnoses in school, while only 66% currently use nursing diagnoses in practice.
sample, the total DCV score was equal to 0.63, which is slightly above the proposed minimum requirement. Definition Ninety percent of the respondents agreed with the proposed definition. One respondent felt the definition did not capture the sadness and distress that comes with longing. A second wanted a place, activity, or ability added, while a third respondent offered a separate definition: “Longing is a mental state in which the patient compares and contrasts life before and after medical diagnosis (new state of reality), and finds ‘touch points’ where the two states can somehow, in some facets, conjoin.” Although this suggestion does incorporate many of the components of the proposed definition, it is too narrow in only identifying longing as the response of a medical diagnosis and does not allow for the other situations identified in the literature review. Situations in Which Longing Is Seen
Attributes Of the 84 attributes that were identified through the concept analysis, none achieved the designation of major characteristics (a weighted ratio of greater than 0.80). Six attributes received a weighted ratio of 0.49 or below. The remaining 78 attributes achieved tentative minor characteristic status, with a weighted ratio of 0.50–0.79 (see Table 3). Fehring (1986) also proposed calculating a total DCV score. After discarding the attributes with
Nursing Diagnosis Development of Longing: Content Validation With Nursing Experts Shelley-Rae Pehler, PhD, RN, Michelle Markwardt, BSN, and Danielle Hibbard, BSN Shelley-Rae Pehler, PhD, RN, is an Associate Professor, College of Nursing and Health Sciences, University of Wisconsin, Eau Claire, Wisconsin, Michelle Markwardt, BSN, is a Nursing Student, College of Nursing and Health Sciences, University of Wisconsin, Eau Claire, Wisconsin, and Danielle Hibbard, BSN, is a Nursing Student, College of Nursing and Health Sciences, University of Wisconsin, Eau Claire, Wisconsin.
Search terms: Fehring’s Diagnostic Content Validation (DCV) model, longing, nursing diagnosis development Author contact: [email protected], with a copy to the Editor: [email protected]
OBJECTIVES: Validate the defining characteristics, related factors, and definition of proposed nursing diagnosis: longing. METHOD: Using Fehring’s Diagnostic Content Validation model, expert nurses rated the frequency of longing seen in patients/caregivers. Agreement with the proposed definition was also tabulated. FINDINGS: None of the defining characteristics reached major criteria (>0.80). Six of the 84 characteristics achieved a weighted ratio of less than 0.50. The proposed definition and related factors were supported. CONCLUSION: Current research supports the proposed development of a nursing diagnosis for the human response of longing. PRACTICE IMPLICATIONS: Because the psychosocial characteristics do not make longing easy to assess, continued research is needed to ask patients and caregivers about their personal experience with this human response.
Patients with chronic or life-threatening illnesses are often faced with physical, emotional, and/or social limitations (such as changes required in job or roles at home). These changes may lead a person to redefine who they are or feel that they are unsettled or “groundless” (Bruce, Schreiber, Petrovskaya, & Boston, 2011). It is during this time that the person often expresses longing to go back to the way things were before the disease. This human response of longing can be emotionally draining and take energy away from other tasks a person may need to accomplish (Bruce et al., 2011; Lohne & Severinsson, 2005; Roscigno, Swanson, Vavilala, & Solchany, 2011). Negative consequences of longing may include changes in relationships (Carlsson, Dahlberg, Ekebergh, & Dahlberg, 2006; Martin, 2004; Marwit, Chibnall, Dougherty, Jenkins, & Shawgo, 2008; Sallady, 1985; Ternestedt & Franklin, 2006), loss of self-esteem (Carlsson, Hallberg, & Odberg Pettersson, 2009; Ternestedt & Franklin, 2006), increased fears (Al-Gamal, Long, & Livesley, 2009), and loss of hope (Al-Gamal et al., 2009; Baumann, 1996; Talseth, Gilje, & Norberg, 2003; Ternestedt & Franklin, 2006). Nurses are in a key position to assess longing in patients and intervene to decrease negative consequences. In order to accomplish this assessment, nursing must be able to recognize and diagnose a patient’s human response of longing. A concept analysis of longing revealed substantial support for the potential of a new nursing diagnosis to be used to name the phenomenon of longing in individuals and
© 2014 NANDA International, Inc. International Journal of Nursing Knowledge Volume 26, No. 3, July 2015
families (Pehler, Sjostrom, & Markwardt, 2014). A major outcome of this research was a proposed definition, which guided this research project. Longing is defined as the intense desire for some thing, some state, or some relationship without which one’s life feels incomplete. The next step for nursing diagnosis creation is to verify if the attributes (defining characteristics), situations (related factors), and definition that were the result of the concept analysis can be supported through content validation using expert nurses. The objective of this research project was to carry out the second phase of nursing diagnosis development by surveying expert nurses to provide content validation for the diagnosis of longing (Herdman, 2012a). Results of this study will inform the next research project when patients and caregivers will be asked to identify if they have experienced longing. Background Patients who are experiencing chronic or life-changing events are most at risk for the human response of longing. Diagnosis of a chronic or life-threatening illness or a traumatic event leads to both physical and psychosocial changes. The person may lose physical abilities, leaving them dependent on another person. They may no longer be able to work, either due to the illness itself, or because their treatment plan may leave them too fatigued to carry out their daily activities. The person experiences a 121
Longing: Validation by Expert Nurses disconnection from their present situation and longs to get back to life before the disease (Bruce et al., 2011; Öhlén & Holm, 2006). Unaddressed, longing can progress to loss of self-esteem, increased fears, and loss of hope (Al-Gamal et al., 2009; Farkas & Yorker, 1993; Gostecnik, Repic, & Cvetek, 2008; Holm & Severinsson, 2010; Massie & Szajnberg, 2006; Ternestedt & Franklin, 2006). Longing also has been seen in the caregivers of people with chronic or life-changing health issues. Those caring for a family member diagnosed with Alzheimer’s disease, for example, often experience a disconnection or detachment from the person with the disease (Johansson, Sundh, Wijk, & Grimby, 2013; Marwit & Meuser, 2005). Because the caregiver is often a spouse or significant other, as the person with Alzheimer’s loses their identity, the relationship changes, and the caregiver no longer has shared experiences with the partner. This leads to feelings of loss, confusion, fear, and uncertainty. The caregiver feels detached, which can lead to feelings of guilt and despair, affecting the caregiver’s own health (Davis, Tremont, Bishop, & Fortinsky, 2011; Gonyea, Paris, & de Saxe Zerden, 2008; Kelly, 2010; Silva, 2014). To decrease the potential impact of longing, nurses must be able to identify and communicate longing to the stakeholders in order to develop interventions. Development of a nursing diagnosis for longing would be the first step to communicate with other healthcare professionals and provide the foundation to develop interventions to treat this human response. Research Methodology Based on criteria developed by NANDA-I (Herdman, 2012b; Scroggins, 2012) for the level of evidence for the submission of a new diagnosis, this second phase of nursing diagnosis development used Fehring’s Diagnostic Content Validation (DCV) model (Fehring, 1994) to validate the defining characteristics, related factors, and definition of a proposed nursing diagnosis label for the human response of longing. Research Participants A purposive sample of nurses who work with patients who might experience longing was sought. Members of the Association of Rehabilitation Nurses and the Academy of Medical-Surgical Nurses were contacted. Once approval was received from the University of Wisconsin–Eau Claire Institutional Review Board Committee, the Academy of Medical-Surgical Nurses sent e-mail invitations with a link to the survey to its 10,929 members. A cover letter with a copy of the survey was sent to 500 members of the Association of Rehabilitation Nurses via postal mail. Demographic information collected was used to not only describe the sample but to identify those respondents who met at least a 5 on Fehring’s criteria for “Expert” (see Table 1) (Fehring, 1994). Confidentiality was maintained for both participant groups. Since the Academy of Medical-Surgical Nurses sent 122
S.-R. Pehler et al. Table 1. Fehring Expert Rating System Criteria
Points
Master’s degree in nursing Master’s degree in nursing with a thesis in content relevant to the diagnosis of interest Published research on the given diagnoses or relevant content Published article on the diagnoses in a refereed journal Nursing PhD Doctoral dissertation on diagnosis Current clinical practice of at least 1 year duration in an area relevant to the diagnoses of interest Certification in an area of clinical practice relevant to the diagnosis of interest
4 1 2 2 2 1 1 2
the e-mail to its membership, the research team was not aware of who received the survey or responded to it. One participant did send an unsigned, personal e-mail to the researcher thanking the team for completing this research project. The e-mail address of this participant was eliminated to maintain that person’s anonymity. The addresses used for the paper surveys sent via postal mail to potential participants from the Association of Rehabilitation Nurses were printed on address labels from a spreadsheet obtained from the association. Once the surveys were mailed, the spreadsheet was destroyed so there would be no risk of linking participant responses to their contact information. Returned surveys were entered into a master database for analysis. Due to the nature of how the invitations were sent, cost of mailings, and in order to maintain confidentiality, no follow-up reminders were sent. Research Design Based on the DCV model, expert nurses were asked to measure each of the 84 attributes/defining characteristics found during the concept analysis on the frequency seen in patients or caregivers based on a Likert scale: 1-Not Present, 2-Rarely Present, 3-Occasionally Present, 4-Frequently Present, and 5-Nearly Always Present. Next, weighted ratios were calculated for each attribute where the 1–5 scale was converted to a weighted score (1 = 0, 2 = 0.25, 3 = 0.5; 4 = 0.75; and 5 = 1). Any of the items that received a weighted score of less than 0.5 were rejected. Items that received a 0.50–0.79 were termed “tentative minor” characteristics; while attributes that had weighted scores 0.50 or greater were identified as “tentative major” characteristics (Fehring, 1987). Minor and major characteristic designations are used to develop a succinct list of defining characteristics based on research findings (Lunney & Muller-Staub, 2012) compared to a potentially longer list that is identified during a concept analysis. Participants also identified if the proposed definition accurately described longing in patients. A simple
S.-R. Pehler et al.
Longing: Validation by Expert Nurses
Table 2. Demographics of Sample Education
#
%
Years working in nursing
#
%
Master’s in Nursing DNP PhD in Nursing
60 4 1
92 6 2
Less than 1 year 1–5 years 5–10 10+ years
0 1 6 58
0 2 9 89
0 2
0 3
7
11
17
26
35 4
54 6
Area currently working Adult Medical Adult Surgical Rehabilitation Cardiac Oncology Veterans Intensive/Critical Care Behavioral/Mental Health Public Health, Geriatric, Oncology-Surgery Pediatric
Experience with nursing diagnoses 48 39 13 11 11 8 7 6 5
74 60 20 17 17 12 11 9 8
3
5
I have never used Nursing Diagnoses I have heard of Nursing Diagnoses but have never used them I have used Nursing Diagnoses, but only when in nursing school I have used Nursing Diagnoses in the past, but I am not currently using them in my practice I consistently use Nursing Diagnoses in my practice Other- Please Describe: (Two Written Responses: 1. Use as needed for staff education. 2. Electronic documentation does not allow.)
percentage was calculated of those who agreed with the definition as written, and suggestions for changes were tabulated. Finally, participants were asked in what situations patients experienced longing. Participants chose from a checklist developed from the literature but were also able to add any situations not included on the list. Results Demographic information from those who did participate is listed in Table 2. The final sample of 65 participants (n = 292 total) who had either an MSN, DNP, or PhD in Nursing and met at least one of Fehring’s other criteria for expert represented 22% of the population of respondents. Of this sample, the majority have their master’s degree (92%) and have worked at least 5 or more years in nursing (98%). Most of the participants (91%) stated they used nursing diagnoses in school, while only 66% currently use nursing diagnoses in practice.
sample, the total DCV score was equal to 0.63, which is slightly above the proposed minimum requirement. Definition Ninety percent of the respondents agreed with the proposed definition. One respondent felt the definition did not capture the sadness and distress that comes with longing. A second wanted a place, activity, or ability added, while a third respondent offered a separate definition: “Longing is a mental state in which the patient compares and contrasts life before and after medical diagnosis (new state of reality), and finds ‘touch points’ where the two states can somehow, in some facets, conjoin.” Although this suggestion does incorporate many of the components of the proposed definition, it is too narrow in only identifying longing as the response of a medical diagnosis and does not allow for the other situations identified in the literature review. Situations in Which Longing Is Seen
Attributes Of the 84 attributes that were identified through the concept analysis, none achieved the designation of major characteristics (a weighted ratio of greater than 0.80). Six attributes received a weighted ratio of 0.49 or below. The remaining 78 attributes achieved tentative minor characteristic status, with a weighted ratio of 0.50–0.79 (see Table 3). Fehring (1986) also proposed calculating a total DCV score. After discarding the attributes with
