Transcript Consensus Validation Process: A Standardized Research

Consensus Validation Process:
A Standardized Research Method to
Identify and Link Relevant NNN Terms
for Professional Practice
Dr. Judy Carlson
Nurse Researcher PV/PHN
Tripler Army Medical Center
Honolulu, Hawaii
NANDA-I Presentation, March 2006
Co-Presenters:
• NANDA Research Committee
– Margaret Lunney, RN, PhD
(New York, U.S.)
– Margaret Clifford, RN, PhD
(Rhode Island, U.S.)
– Dina Almeida Monteiro da Cruz, PhD
(Nurse, Sao Paulo, Brazil)
– Maria Mueller Staub, MS, PhD(c)
(Nurse, Bern, Switzerland)
Identification and Linkage of NNN
• With 172 Diagnoses, 514 Interventions, &
330 Outcomes, use is impractical
– Lists of labels
– Not conceptually understood or connected
• General linkages often not relevant and
cumbersome in actual practice
• Pre-packaged linkages may not be
relevant to specific settings
• Efforts to link by physiological ??
Identification and Linkage of NNN
• Core content and linkages needed for specific
units, populations, or health foci
• Consensus Validation Process (CVP)developed to accomplish this goal
• The Output of CVP becomes Standard of
Practice for specific units, populations or
health foci
• CVP developed as Participatory Action
Research
– Nurses participate with researcher to
construct and use knowledge
Consensus Validation Definition:
• Process by which clinicians with
expertise in particular clinical areas
review a domain of knowledge relating
to their expertise and work to achieve
100% consensus on the relationship of
the domain of knowledge, for example
diagnoses, outcomes and
interventions, to one or more
predetermined objectives.
Steps of a Consensus Validation
Process:
1. Identify purpose(s) of study, e.g.,
– Determine core nursing diagnoses,
nursing interventions, patient outcomes
and their linkages
– Determine applicable intervention
activities and outcome indicators
Steps of a Consensus Validation
Process:
2. Identify clinical leaders
3. Identify at least 3 clinicians
4. Obtain resources
Steps of a Consensus Validation
Process:
5. Describe procedures, e.g.
– Determine the core diagnoses for the critical care units
– Determine the core nursing interventions for the
critical care units
– Link the core nursing interventions to each diagnosis
– Determine the core patient outcomes for the critical
care units
– Link the core patient outcomes in relation to each
diagnosis and interventions
– Determine the applicable intervention activities and
outcome indicators
Steps of a Consensus Validation
Process:
6. Seek IRB Approval
7. Conduct Study – Four Phases
– Phase I: Nursing Diagnoses
– Phase II: Nursing Interventions
– Phase III: Patient Outcomes
– Phase IV: Intervention Activities &
Outcome Indicators
CVP: Phase I - Nursing Diagnoses
• The clinical leader:
– distributes nursing diagnoses with
definitions
– asks each clinician to place a check mark
next to diagnoses that he/she determines
to be at least somewhat relevant to the
clinical practice area
– tallies the responses
– compiles diagnoses selected by clinicians
CVP: Phase I - Nursing Diagnoses
• The diagnoses are put in a table format
– Display the diagnoses that were selected by
the number of nurses
• The table is distributed and reviewed
carefully by clinicians
• The clinicians meet as a group with the
clinical leader and review each diagnosis,
definition, and defining characteristic
# selected
Diagnoses
Definition
3
Airway clearance, Ineffective
Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway
3
Aspiration, Risk for
At risk for entry of gastrointestinal secretions, orophayngeal secretions, solids, or fluids into
tracheobronchial passages
3
Failure to Thrive, Adult
Progressive functional deterioration of a physical and cognitive nature. The individual’s ability to live
with multisystem diseases, cope with ensuing problems, and manage his/her care are remarkable
diminished.
3
Gas Exchange, Impaired
Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.
3
Incontinence, Total Urinary
Continuous and unpredictable loss of urine
3
Infection, Risk for
At increased risk for being invaded by pathogenic organisms
2
Bowel Incontinence
Change in normal bowel habits characterized by involuntary passage of stool
2
Breathing Pattern, Ineffective
Inspiration and/or expiration that does not provide adequate ventilation
2
Diarrhea
Passage of loose, unformed stools
2
Disuse Syndrome, Risk for
At risk for deterioration of body systems as the result of prescribed or unavoidable musculoskeletal
inactivity
1
Activity Intolerance
Insufficient physiological or psychological energy to endure or complete required or desired daily
activities
1
Activity Intolerance, Risk for
At risk for experiencing insufficient physiological or psychological energy to endure or complete
required or desired daily activities
1
Allergy Response, Latex
An allergic response to natural latex rubber products
1
Allergy Response, Risk for Latex
At risk for allergic response to natural latex rubber products
1
Cardiac Output, Decreased
Inadequate blood pumped by the heart to meet metabolic demands of the body
1
Constipation
Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool
and/or passage of excessively hard, dry stool
CVP: Phase I - Nursing Diagnoses
• The clinical leader guides the discussions
– Each diagnosis must have 100% consensus that the
diagnoses is at least somewhat relevant to the
clinical practice area
– Those in support of diagnoses must give reasons or
examples of how diagnoses are relevant
– Those not in support must explain why diagnoses
are not relevant
• The clinical leader distributes the compilation
of diagnosis selected by 100% of the clinicians
CVP: Phase II - Nursing Interventions
• The clinical leader:
– distributes a list of nursing interventions
– asks each clinician to place a check mark next to
interventions that he/she determines to be at
least somewhat relevant to the clinical practice
area
– tallies the responses
– compiles the interventions that clinicians
selected
CVP: Phase II - Nursing Interventions
• The interventions are put in a table format
• The table is distributed and reviewed
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carefully by clinicians
The clinicians meet as a group with the
clinical leader and review each intervention,
definition, and activity
The clinical leader and/or researcher guide
the discussions
The nursing interventions are then linked to
the specific nursing diagnoses
CVP: Phase II - Nursing Interventions
• Linking interventions to specific
nursing diagnoses
– Carefully review the definition and defining
characteristics and in some cases the
related to factors
– Consider the general outcome to be
accomplish for that diagnosis
– Select interventions that can specifically
address that particular diagnoses.
CVP: Phase II - Nursing Interventions
• Linking Considerations
– If there are interventions that do not fit with
a diagnosis yet are found relevant by 100%
of the clinicians, a review of diagnoses is
undertaken to determine the most
appropriate fit. It may be found that a
diagnosis needs to be added
– Interventions believed at first to be relevant
with the linking process may be found to be
irrelevant
– Audits need to be conducted
• Documentation under some- why?
CVP: Phase III - Nursing Outcomes
• The clinical leader:
– distributes the list of nursing sensitive
patient outcomes (NOC)
– asks each clinician to place a check mark
next to outcomes that he/she determines to
be at least somewhat relevant to the clinical
practice area
– tallies the responses
– Compiles the outcomes that clinicians
selected
CVP: Phase III - Nursing Outcomes
• The outcomes are put in a table format
• The table is distributed and reviewed
carefully by clinicians
• The clinicians meet as a group with the
clinical leader and review each outcome,
definition, and indicant
• The clinical leader and/or researcher
guide the discussions
• The patient outcomes are then linked to
the specific nursing diagnoses
CVP: Phase III - Nursing Outcomes
• Linking outcomes to specific nursing
diagnoses
– Carefully review the definition and defining
characteristics and in some cases the related
to factors of diagnosis
– Consider the specific outcome to be
accomplished for that diagnosis
– At times, outcomes need to be selected for
the intervention as well (e.g. Medication
Administration & Medication Response)
CVP: Phase III - Nursing Outcomes
• If there are outcomes that do not fit with a
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diagnosis or an intervention, yet are found
relevant by 100% of the clinicians, a review of
diagnoses and interventions is undertaken to
determine the most appropriate fit
It may be found that a diagnosis and/or
intervention needs to be added.
Changes are made throughout the process,
e.g., there are instances when nurses dismiss
an outcome believed at first to be relevant
but, after discussion, it is found to be
irrelevant.
CVP: Phase IV – Intervention
Activities & Outcome Indicants
• Clinicians review and select the
activities under each intervention that
are relevant to their practice.
• Clinicians review and select the
indicators under each outcome that are
relevant to their practice
Developing Standards of Practice
Using Consensus Validation Process
• Nurse Researcher/Leader
• 3-5 Clinical Experts
• Can meet weekly (1 to 2 hours) for up to 8
months or
• 2-3 weeks of 8 hour days
Developing Standards of Practice:
Checks & Balances
• 100% consensus is a powerful tool
• Discussions with rationale for choices and
respectful challenges by others served to
validate decisions
• Internal Audits of standards are conducted
by researcher and audit team throughout
process
• Development will continue with clinical use
& validation of Standards of Practice
Development of Five Standards of Practice
• Joint New Parent Support Program
– 3 Expert Clinicians
• Latent Tuberculosis Infection (LTBI) Program
– 5 Expert Clinicians
• Care and Prevention of Impaired Skin Integrity
– 3 Expert Clinicians
• Risk for Infection for ICU patients
– 3 Expert Clinicians
• Risk for Impaired Skin Integrity for ICU patients
– 3 Expert Clinicians
Researcher’s Role
• Maintain a non-judgmental, enthusiastic and supportive
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approach throughout the project
Ensure confidentiality of nurses
Work in 1-2 hour time blocks
Overview process and time commitment
Discuss commitment to attend every meeting. 100%
consensus requires 100% attendance.
Carefully go over home work assignments and necessity
to bring NIC, NOC, NANDA to every meeting.
Each member is equal, all status is equal, no bosses or
rank
No one need to defend original choice, if change mindstate new judgment
As meeting begins, quickly review ground rules, thinking
processes from previous meetings, what has been
accomplished to date and goals to be achieved for that
day.
Researcher’s Role
• Support nurses’ decision-making
– show complete and absolute respect for nurses in the study
– maintain as positive an attitude as possible (avoid anger,
resentment, frustration, disappointment, and other negative
responses)
– do not make decisions for nurse participants
– do not pressure the nurses to make specific decisions
– accept nurses’ decisions and choices regardless of whether you
agree or not
– when nurses choose unlikely diagnoses, interventions or
outcomes, make it possible for other members of the group to
consider and reconsider these choices, e.g.,
• Ask questions, rather than making statements
e.g., does everyone agree that this choice is relevant?
Researcher’s Role
• Objectify areas of disagreements
• Summarize where the group is during a difficult
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decision-making episode
Frequent reminder of goal and purposes of study
Keep the discussion moving by putting aside
controversial items until the end of the process
Nurses can become passionate during this
process, encourage respectful passion
Keep good records of the process and obtain
approval of the records from the nurses
Implications for Consensus Validation
Process Use
• The CVP can be implemented on any practice
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unit, for any patient population or health focus by
nurses to self-determine the NNN terms for
practice standards.
As a research project, it enhances the
professionalism of practicing nurses.
When used in an EHR, it provides the framework
for aggregating data to describe, explain and
predict nursing care.
With implementation of the Standards of Practice,
nurses will be able to unequivocally answer the
question, “what do nurses in this setting do and
what is their value?”
Implications for Standards of
Practice Use in an EHR
• Standards of Practice based on NANDA,
NIC & NOC in an Electronic Health Record
will enable:
– Professional practice enhancement
– Performance improvement
– Provision of economic evidence
– Streamlining of documentation
QUESTIONS?
Questions??
• The End with Beautiful picture of Hawaii