Consensus Validation Process: A Standardized Research Method to Identify and Link Relevant NNN Terms for Professional Practice

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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

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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)

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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 ??

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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

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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.

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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

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Steps of a Consensus Validation Process

• Identify clinical leaders
• Identify at least 3 clinicians
• Obtain resources

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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

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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

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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

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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

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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 individuals 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
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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

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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

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CVP Phase II - Nursing Interventions

• The interventions 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 intervention, definition,
  and activity
• The clinical leader and/or researcher guide the
  discussions
• The nursing interventions are then linked to the
  specific nursing diagnoses

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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.

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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?

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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

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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

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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)

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CVP Phase III - Nursing Outcomes

• If there are outcomes that do not fit with a
  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.

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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

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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

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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

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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

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Researchers Role

• Maintain a non-judgmental, enthusiastic and
  supportive 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
  mind- state 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.

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Researchers 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?

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Researchers Role

• Objectify areas of disagreements
• Summarize where the group is during a difficult
  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

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Implications for Consensus Validation Process Use

• The CVP can be implemented on any practice 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?

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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

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Questions??
QUESTIONS?

• The End with Beautiful picture of Hawaii