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 conlirsion 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.
I
Some History of Terminology
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 Cointiiittee. She also served as co-chair and chait- o f the International Conitiiittee and was part o f the organizational gr-oupfor the I n ternational ( h f e r e n c e on Clinic-al Decision Making and Nursing Diagnosis held in Calgary in 1987.
Nursing Diagnosis
Great progress in the evolution of professional nursing occurred in North America following World War 11. As numbers o f 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 (1960) definition of nursing was based on the belief that the service a nurse performs addresses the individual’s 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. I n 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), patierit needs (Orlando, 1961; Quigley & Wagner, 19 6 4 ; 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 tial frameworks and the early descriptioris of the nursing process. I n 1963 Komorita dest I-ihed the confusion surrounding the use of the iernis cliiigriosis,judgnient, nursing diagnosis, probleni, a r i d needs. She deploreci the lack ofclarit!, in tising terniinoloR and concluded that “iiursing tiiagiiosis involves discriminative judgn i r n 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 requirenieltl 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 ~ St o identif\. and label the (,linical protdenis etidencect in an anibrilatoI-ycare setting rst;iblished the scene for the first riational ctriifriwice on classification of nursing diagnoses i n I 9 7 3 . 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 prodtic t I ) f‘ n u 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 4
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), “cornnio n 1y 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-definition o r consensus on their meanings. The clefiiiition 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 ill health. “Nursing diagnosis is the statement of a patient’s response which is actually o r 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). Mundinger and J a u r o n also coninicnted o i i the conf’iision 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 limiting the meaning est ahlished in the first conference definition. She stated, “Nursing diagnoses, o r c I i n ic al diagnoses I nade b y p 1-0 fe ss i o n al n 11rscs, describe actual o r potential health pi~obleiiis which nurses, b y virtue o f their educatioii and experience, are capable and licensed t o treat” (
Nursing as an evolving science etitertaina the usage of terminology that la& clarity and the singular application of ~erms.The resulting semantic conlirsion 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.
I
Some History of Terminology
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 Cointiiittee. She also served as co-chair and chait- o f the International Conitiiittee and was part o f the organizational gr-oupfor the I n ternational ( h f e r e n c e on Clinic-al Decision Making and Nursing Diagnosis held in Calgary in 1987.
Nursing Diagnosis
Great progress in the evolution of professional nursing occurred in North America following World War 11. As numbers o f 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 (1960) definition of nursing was based on the belief that the service a nurse performs addresses the individual’s 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. I n 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), patierit needs (Orlando, 1961; Quigley & Wagner, 19 6 4 ; 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 tial frameworks and the early descriptioris of the nursing process. I n 1963 Komorita dest I-ihed the confusion surrounding the use of the iernis cliiigriosis,judgnient, nursing diagnosis, probleni, a r i d needs. She deploreci the lack ofclarit!, in tising terniinoloR and concluded that “iiursing tiiagiiosis involves discriminative judgn i r n 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 requirenieltl 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 ~ St o identif\. and label the (,linical protdenis etidencect in an anibrilatoI-ycare setting rst;iblished the scene for the first riational ctriifriwice on classification of nursing diagnoses i n I 9 7 3 . 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 prodtic t I ) f‘ n u 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 4
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), “cornnio n 1y 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-definition o r consensus on their meanings. The clefiiiition 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 ill health. “Nursing diagnosis is the statement of a patient’s response which is actually o r 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). Mundinger and J a u r o n also coninicnted o i i the conf’iision 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 limiting the meaning est ahlished in the first conference definition. She stated, “Nursing diagnoses, o r c I i n ic al diagnoses I nade b y p 1-0 fe ss i o n al n 11rscs, describe actual o r potential health pi~obleiiis which nurses, b y virtue o f their educatioii and experience, are capable and licensed t o treat” (
