Chapter Three

Teaching NANDA-I
NIC and NOC: Novice to Expert

Teaching NANDA-I
NIC and NOC: Novice to Expert
Contributor
Margaret Lunney

Learning Objectives
Explain Three Propositions Related to Teaching NNN
Set Expectations for Students at Novice to Expert Stages of
Development
Implement Teaching Strategies
Integrate NNN With Nursing Curricula
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Objective 1: Explain Propositions

Use of NNN Requires Intellectual, Interpersonal, and Technical
Competencies, Tolerance of Ambiguity and Reflection
Accurate Diagnoses are the Basis for Use of NIC and NOC
Use of NNN Differs from the Traditional Nursing Process
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Proposition #1: Skills/Competencies

Intellectual
Knowledge

Related to:

Diagnoses
Interventions
Outcomes

Thinking

Processes

Research

Findings:

Human

Beings Vary in Thinking Process Abilities

Thinking

Process Abilities can be Improved

Variation in Nurses Thinking Abilities

Basic Thinking Abilities

Mean

SD

Range

DMU-Fluency

21.3

7.2

641.5

DMC-Flexibility

10.8

6.5

027.5

DMI-Elaboration

17.8

4.9

730.5

N = 86 (Lunney 1992)

Intellectual Skills
Research Findings related to Women
Thinking

Processes of Women Develop Through Relationships

Womens

Perspectives on Thinking (Belenkey et al. 1986)

Silence
Received

Knowledge

Subjective
Procedural

Knowledge
Knowledge

Constructed
Nursing

Knowledge

Students and Nurses may have Lower Level Perspectives

Intellectual Skills: Critical Thinking

Critical

Thinking (CT) Processes can be Improved

Stimulate to Use
Expect Use
Validate Appropriate Use
Demonstrate Support and Confidence in Abilities

CT

Abilities - Essential for Accuracy of Diagnoses and Use of

NOC and NIC
(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Intellectual Skills: What is CT in Nursing?

Delphi

Study of 55 Nurse Experts

(Scheffer and Rubenfeld 2000)

Purpose:

Identify the Components of CT that Relate to Nursing

Results

- Definition for Nursing:

7 Cognitive Skills
10 Habits of Mind

Cognitive Skills
Analyzing
Applying

Standards

Discriminating
Information
Logical

Seeking

Reasoning

Predicting
Transforming

Knowledge

Habits of Mind
Confidence

Intellectual

Contextual

Intuition

Perspective

Integrity

Creativity

Open-Mindedness

Flexibility

Perseverance

Inquisitiveness

Reflection

Intellectual Skills: CT Process

CT

Involves Continuous Processing of Data and Inferences

In

Any Situation, Two or More Cognitive Skills are Probably Being

Used

Habits
The

of Mind Support Cognitive Skills

Combination of CT Abilities Needed is Unique

to the Situation

Proposition #1: Interpersonal Skills

Exquisite
Promote
Work

Communication

Trust

n Partnership, Share Power

Validate
Accept

Perceptions

That We Do Not Know Others

Proposition #1: Technical Skills

Obtain

Valid and Reliable Data

Health

Histories: Comprehensive

Physical

Exams: Focused

Perform

Nursing Interventions

Technical

Aspects of Using NNN

Proposition #1: Personal Strengths

Tolerate

Ambiguity

Decisions

are Relative to Context and Specific Nature of Individuals

Multiple

Factors Influence Clinical Situations

Human

Beings are Complex and Diverse

Ambiguity

is the Norm

Proposition #1: Personal Strengths

Reflect

on Practice Experiences

Accept

Possible Flaws

Thinking
Interpersonal
Technical
Aim

- Develop and Grow

Proposition #2: Accurate Interpretations

Foundational
Cues/Data

may be Incorrect

Examples

Objective Data:
Diagnostic

Tests

Subjective Data:
Patients
Families

Proposition #2: Accurate Interpretations

Foundational
Use
All

of NNN Requires Many Decisions

Decisions are Based on Patient Data

Data

Amounts are Overwhelming

Short-Term
Data

Memory = 7 2 Bits of Data

are Converted to Interpretations

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Proposition #2: Accurate Interpretations

Foundational
Interpretations
Additional

Determine Actions

Data Collection

Subsequent

Decisions

Possible

Outcomes to Consider

Choices

of Interventions

High

Potential for Inaccuracy

Diagnosis

and Etiology

High Potential for Inaccuracy

Case Study: Marian Hughes
(1) Marian Hughes is a 16-year-old girl with a medical diagnosis of diabetes mellitus. (2) She was admitted 3days
ago for treatment of an acute episode of diabetic ketoacidosis. (3) When Marian discussed with you how she
managed the therapeutic regimen before hospitalization, she states that she was not adhering to her prescribed
diet. (4) You decide that Marian needs assistance to improve her management of the therapeutic regimen,
especially the types of foods she eats. (5) Marian's stay in the hospital unit is uneventful in that medical treatments
are successfully resolving the crisis.
(6) Marian's daily habits include getting up for school about 7.00 a.m. and rushing to get the bus by 7.30. (7) She
says that she should get up about 6.30 but she likes to sleep. (8) She states that she does not want her mother to
help her get up earlier. (9) The meal that she eats at school is consistent with her prescribed diet while the two
meals at home are not. (10) In the morning she grabs whatever is quick and easy, usually toast and butter. (11) In
the evening, her mother makes meals that comply with the diabetic diet but Marian states that she does not like
them so she only eats part of her supper and then snacks on other foods later.
(12) Marian is able to explain to you what she should be eating and she can adjust her diet to her lifestyle. (13) The
knowledge of what foods are on her diet that she likes was not discussed with her mother because she doesn't
want to sit down and talk with her. (14) In general, Marian and her mother argue over many of Marian's behaviors,
such as school grades, smoking, and coming in late at night.

High Potential for Inaccuracy

Case Study: Marian Hughes
16-Year-Old

Diabetic (#1)

Hospitalized,
Did

DKA (#2)

Not Follow Prescribed Diet (#3)

NDx:

Ineffective Management of Therapeutic Regimen, Related to _______

(Fill in the Blank)

High Potential for Inaccuracy

Case Study: Marian Hughes
Possible Interpretation/Diagnosis
Knowledge

Deficit

Disconfirming
Meals

Cues:

Eaten at School are Consistent with Diet (#9)

Able

to Explain What She Should be Eating (#12)

She

can Adjust Her Diet to Her Lifestyle (#13)

Conclusion:
Teaching
(Herdman 2012)

Low Accuracy Diagnosis

is Waste of Time, Effort, and Money

High Potential for Inaccuracy

Case Study: Marian Hughes
Highest Accuracy Diagnosis
Ineffective

Self-Health Management, Related to Communication Difficulties

Between Marian and Her Mother
Patient

Outcome (NOC):

Communication

= 3 (Moderately Compromised), Increase to 5 (Not

Compromised)
Nursing

Intervention

Communication

Enhancement

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

44 Diagnoses by 80 Nurses
Examples
Communication
Stressful
Altered

Difficulties Mother/Daughter

Mother/Child Relationship

Family Dynamics

Ineffective

Coping

Ineffective

Time Management

Adolescent
Low

Image

Self-Esteem

Denial
Deficient

Knowledge

Seven Levels of Accuracy

+5 Highest Level of Accuracy
+4 Close to the Highest Level But Not Quite
+3 General Idea But Not Specific Enough
+2 Not Enough Highly Relevant Cues or Not
the Highest Priority
+1 Suggested by Only One or a Few Cues
0 Not Indicated by Data
-1 Should be Rejected, Disconfirming Cues

Diagnostic Accuracy Scores

Communication

Difficulties Between
Mother and Daughter
Stressful Mother/Child Relationship
Altered Family Dynamics
Ineffective Coping
Ineffective Time Management
Adolescent Image
Low Self-Esteem
Denial
Deficient Knowledge

+5
+4
+3
+2
+2
+1
+1
0
-1

Research Findings
Studies:

1966 to Present
Conclusions: Interpretations Vary Widely
All Interpretations are Not High Accuracy
Influencing Factors (Carnevali 1983; Gordon 1982)
Nurse Diagnostician
Diagnostic Task
Situational Context

Research: Positive Influences

Diagnostic
Lesser
Nurse

Task

Amounts and Complexity of Data

Diagnostician

Education

Related to Nursing Diagnoses

Knowledge
Teaching
Variety

of Diagnostic Process and Concepts

Aids for Diagnostic Reasoning

of Thinking Processes

Experience

Specific to Diagnostic Task

Challenge: Achieving Accuracy

Puzzle: What is the Diagnosis?

Solving the Puzzle

Is It This?

Or This?

Or This?

Proposition #2: Accurate Interpretations

Foundational
Supporting

Factors:

Acknowledge

that Data Interpretations are Probabilistic; Question

Accuracy
Use

CT, Interpersonal and Technical Skills

Develop
Its

Tolerance ofAmbiguity

OK Not to Have an Answer

Accept
Develop

that We Might Make Mistakes

Reflective Practice

Proposition #2:
New Perspectives on Nursing Process
Traditional
Limited

# of Concepts

Collect

Comprehensive Data

No

Accountability for
Diagnoses

Intervene

Based on Data

Behavioral

Outcomes

Disorganized

Follow-Up

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Use of NNN
Currently 1147 Concepts
Cue-Based and Hypothesis-Driven
Data Collection
Fully Accountable for Diagnoses
Intervene Based on Data
Interpretations
Neutral Terms with Scale
Systematic Follow-Up

Changing from Traditional to Use of NNN

Acknowledge
Influencing

Difficulty Level: Simple to Complex

Factors:

Similarity

of Terms in Three Systems

Structure

of Classifications

Resources

(Books, Pamphlets, Other)

Complexity

of Clinical Situations

Nurses

Perspective/Model for Practice

Experience

With NNN

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Examples: User-Friendly Simplicity

NANDA-I

NOC

NIC

Anxiety:
Vague uneasy feeling;
autonomic response;
feeling of apprehension;
altering signal warning of
impending danger

Anxiety Control:
Personal actions to
eliminate or reduce
feelings of
apprehension and
tension from an
unidentifiable source

Anxiety Reduction:
Minimizing
apprehension, dread,
foreboding or
uneasiness related to
unidentified source of
anticipated danger

Risk ofInfection:
Increased risk ofbeing
invaded by pathogens

Infection Status:
Infection Protection:
Presence and extent of Prevention and early
infection
detection of infection in
a patient at risk

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Changing from Traditional to Use of NNN

Use

Theoretical Perspective

Change

Theory

Diffusion

of Innovations (Rogers 2003)

S-Shaped

Diffusion Curve

Perceived

Characteristics:

Relative

Advantage (+)

Compatibility
Complexity
Trial

(+)

(-)

Ability (+)

Observability

(+)

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Changing from Traditional to Use of NNN

Be

a Champion
Sell First to Opinion Leaders
Goal: Create a Critical Mass
Share Demonstration Projects
(For Example, Protocols and Journals)
Faculty Development Program
Adoption by System
Adoption by Individuals

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Objective 2: Set Expectations

Novice to Expert
Novices

and Advanced Beginners (ABS) Learn to Use NNN as Well

as Experienced Nurses

Novices

and ABS may be Easier to Teach than Nurses at Competent,

Proficient and Expert (Expert) Stages
Expert

Nurses must be Sold on New Way to Think and Document

(Benner 1984; Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Selling NNN to Experts

EHR

is Imminent
NNN = File Names for EHR
NNN Describes What Nurses Bring to the Table
NNN Makes Knowledge Available at Bedside
Aggregated Data = Knowledge
Measurement of Care = Improved Quality
Linguistics Theory Supports SNLS
Fits with Nursing Theories

Set Expectations
Expect

(At All Levels of Expertise):

Correct Use of the Three Systems:
Nursing

Diagnoses are used to Guide Interventions, Not for

Labeling per se
Intervention
Outcome

Correct

Label is the Intervention, Not the Activities

Label is the Outcome, Not the Indicators

Use of Concepts:

NANDA-I:
NIC:

Social Isolation

Coping Enhancement

NOC:

Knowledge (Specify)

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Set Expectations
Do

Not Underestimate Nursing Students or Nurses:

Nursing and Nursing Knowledge must be Presented in All Its

Complexity

Help Students and Nurses to Experience the Complex and Messy

World of Nursing and Learn How to Navigate Through It

(Doane and Varcoe 2005, p.xi)

Set Expectations
All

Levels:
Self-Evaluation
Integrate

with New Theories, for Example:

Penders
Integrate

(Pender et al. 2010)

Health Promotion Model

with Strategies for Evidence-Based Nursing

Set Expectations
Encourage
Integrate

Use

Experts to:
with Previous Knowledge

NNN in:

Communicating
Developing

Scope of Practice

Standards of Care

Evidence-Based
Research

Evaluate

Nursing Projects

Projects

Clinical Applications of NNN

et al. 2008;
2012; Moorhead et al.
2008)Nursing
(Bulecheck
Teach
CEHerdman
Programs
to

Personnel

Objective 3: Teaching Strategies

Intellectual
Assume

that Thinking Is Human, Imperfect, Attainable

Encourage
Ask

Thinking in Class and Clinical:

Questions Instead of Giving Answers

Provide

Opportunities for Problem Solving

Objective 3: Teaching Strategies

Intellectual: Deflate Authority

Objective 3: Teaching Strategies

Intellectual
Think
Act

Out Loud with Students

as Midwife or Coach

Help

them Think About Thinking:

Ask:

What Kind of Thinking is Needed?

Use

the 17 CT Terms and Definitions

Evaluate
Expect

Thinking Processes

Self-Evaluation of Thinking

Objective 3: Teaching Strategies

Share

Paradigm Cases (e.g. Marian Hughes)

Simplify
Conduct

Representations, Identify High Relevance Cues

Iterative Hypothesis Testing

Objective 3: Teaching Strategies

Intellectual
Seminars

Instead of Lectures: Why?

Groups

Represent Wide Variations in Thinking Abilities

Promotes

In-Class Thinking

Recognizes

Students Abilities to Think and Learn without

Authority/Experts

Supports

Future Work in Groups to Describe, Analyze and

Synthesize Information, Solve Problems (e.g. What is the
diagnosis?)

Objective 3: Teaching Strategies

Intellectual
Seminars:
Assign
Lead
Be

How?
Readings, Provide Discussion Questions

the Group, Ask the Discussion Questions

Respectful; Protect Students Self-Esteem

Address:
What

is the Author Saying?

What

is the Fit with Previous Knowledge?

How
25-30%

Does This Information Apply to Practice?

of Grade for Discussion of Readings

Objective 3: Teaching Strategies

Intellectual
Expect
Ask

Self Evaluation
Questions, Instead of Giving Answers

Discussion

in Class

Discussion

Online

Journal

Writing (Degazon and Lunney 1996)

Objective 3: Teaching Strategies

Interpersonal
Expect

Accountability For Patient Relationships

Demonstrate:
Good

Interviewing

Validation

of Diagnoses

Partnership

Processes to Select
Outcomes and Interventions
Reward
Teach

Power Sharing

and Support Assertiveness

Objective 3: Teaching Strategies

Interpersonal
Expect

Accountability For Using Standardized Methods

Demonstrate
Show

Use of Diagnostic Reasoning

Technical Use of NNN Using Case Studies

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Objective 3: Teaching Strategies

General
Demonstrate
Provide

Correct Use of NNN

Incentives for Correct Use of NNN, e.g. Percentage of Grade

Integrate

with Theories of Nursing

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Case Study
With Permission of Dr Arlene Farren
30-Year-Old
Smokes

Woman in Good Health

1-1.5 Packs Per Day for >12 years

Asked

for assistance to quit

Stated

I know its not good for me and I want to stay healthy

What is the Diagnosis?

Readiness

for Enhanced Self-Health Management

Definition: A Pattern of Regulating and Integrating Into Daily Living a

Therapeutic Regime for Treatment of Illness and Its Sequelae that is
Sufficient for Meeting Health-Related Goals and can be Strengthened

(Herdman 2012)

What is the Outcome?

Smoking Cessation Behavior
Personal
Rarely

Actions to Eliminate Tobacco Use

Demonstrated (3), Goal = 5

Indicators:
Expresses
Identifies
Adjusts
Uses

Benefits of Smoking Cessation (3)

Tobacco Elimination Strategies as Needed (3)

Strategies to Cope with Withdrawal Symptoms (2)

Develops

(Moorhead et al. 2008)

Willingness to Stop Smoking (3)

Effective Strategies to Eliminate Tobacco Use (2)

What are the Interventions?

Smoking

Cessation Assistance
Teaching: Medication, Nicotine Replacement Therapy

(Bulecheck et al. 2008)

NIC: Smoking Cessation Assistance

Helping Another to Stop Smoking
Activities:
Give

Laura Clear, Consistent Advice to Quit

Assist

Laura in Choosing Strategies

Motivate
Refer

to Group Programs/Individual Therapy

Inform
Help

Her to Set a Quit Date

Laura of Possible Symptoms

Plan Coping Strategies and Problem Resolution

(Bulecheck et al. 2008)

Evaluation of Outcomes
Smoking Cessation Behavior
After

6 Weeks, Nurse and Laura Rate Outcome as 5

Laura

Consistently Monitors Her Environment and Personal Behaviors

for Factors that Affect Her Tobacco Use
Laura

Developed Effective Strategies and Remains Consistently

Committed to Controlling Her Use
Laura

Uses Friends and Group for Help

Laura

Has Not Smoked for 6 Weeks

(Moorhead et al. 2008)

Case Study
With Permission of Coleen Kumar
49

Years Old; Single, Italian-American Woman

Type

2 Diabetes Mellitus (DM) with Adequate Control

Overweight
Head

of Household; 80-Year-Old Dependent Mother

Works

Full Time, Provides Care for Self and Mother

Accepts

Care of Mother But has Many Frustrations

Attempts

to Reduce Her Workload have Failed

Mother

Thinks Stella Can Do It All

Mother

Discourages Sons Involvement

Stella

Expresses Conflicting Emotions, Stress, Lack of Control

What are the Diagnoses?

The

Diagnostic Process:

Which
What

are Possible Diagnoses?

Which
Are

are Important Cues?

Diagnoses Have the Best Support?

the Diagnoses Consistent with the Situational Context?

Can

the Nurse Help Stella with the Diagnoses?

What are the Diagnoses?

NANDA-I
Risk

Diagnoses:

of Caregiver Role Strain

Readiness

Checking

for Enhanced Family Coping

for Accuracy:

Are

There a Sufficient Number of Confirming Cues?

Are

There Any Disconfirming Cues?

Did

Stella Validate the Diagnosis?

Should

(Herdman 2012)

Other Providers be Consulted?

What are the Outcomes?

Caregiver Well-Being
Caregiver

Satisfaction with Health and Lifestyle Circumstances

Moderately

Compromised (3), Goal = 4 or 5

Indicators:
Satisfaction

with Physical Health (3)

Satisfaction

with Emotional Health (2)

Satisfaction

with Usual Lifestyle (3)

Satisfaction

with Instrumental Support (2)

Satisfaction

with Social Relationships (3)

(Moorhead et al. 2008)

What are the Outcomes?

Family Coping
Family

Actions to Manage Stressors that Tax Family Resources

Moderately

Compromised (3); Goal = 4 or 5

Indicators:
Demonstrates
Family

Enables Member Role Flexibility (3)

Expresses
Arranges
Seeks
Uses

Role Flexibility (3)

Feelings and Emotions Freely (2)

for Respite Care (2)

Assistance When Appropriate (3)

Social Support (3)

(Moorhead et al. 2008)

What are the Interventions?

Assertiveness

Training
Self-Esteem Enhancement
Emotional Support
Caregiver Support
Role Enhancement
Family Involvement Promotion
Respite Care

(Bulecheck et al. 2008)

NIC Example
Assertiveness Training
Assistance

with the Effective Expression of Feelings, Needs, and Ideas

While Respecting the Rights of Others
Activities:
Determine
Help

Stella Recognize and Reduce Cognitive Distortions

Instruct

Stella in Different Ways to Act Assertively

Facilitate
Help

Barriers to Assertiveness (for Example, Family Roles)

Practice Opportunities Using Discussion, Modeling and Role Playing

Stella Practice Conversational Skills

(Bulecheck et al. 2008)

Evaluation of Outcomes
Caregiver Well-Being
After 4 Weeks, Nurse and Stella Rate Outcome as 4
Stellas

Physical Health has Improved; Satisfaction with Physical Health (4)

Stella

Uses Assertiveness Skills to Make Time for Herself After Work and to Plan
Recreation; Satisfaction with Emotional Health (4)
Stella

Continues to Need Help in The Performance of Caregiver Roles;

Satisfaction with Performance of Usual Roles (4)
Stella

Feels n Control of Her Caregiver Routines; Satisfaction with Caregiver

Role (4)

(Moorhead et al. 2008)

Evaluation of Outcomes
Family Coping
After 4 Weeks, Nurse and Stella Rate Outcome as 4
Stellas

Assertiveness Behaviors Work Well to Accomplish Goals; Demonstrates

Role Flexibility (4)
Stellas

Mother Agrees with the Plan to Relieve Her of Some of the Workload;
Family Enables Member Role Flexibility (4)
Stellas

Brother Stays with Her Mother So Stella can Go Away for Short Periods;
Arranges For Respite Care (4)
Family

(Moorhead et al. 2008)

Exhibits a Wider Repertoire of Coping Behaviors (4)

Use Case Studies

Case

Studies Help Students to Practice Thinking and Clinical Judgment in a

Safe Environment
Standardized:
Additional

(2009)

Everyone Uses the Same Clinical Data

Case Studies, and Their Interpretations, can be Found in Lunney

Teaching Strategies: Summary

Observe Students Grow in Abilities through Encouragement,
Trust, and Respect

Objective 4: Integrate with Curricula

Prepare

Faculty

Diffusion
Talking

of Innovations (Rogers 2003)

Points:

Electronic

Health Record

Quality-Based
Ability

Involve

Nursing Care

to Develop Information and Knowledge

Clinical Faculty

Evaluation/Peer

Observation

Objective 4: Integrate with Curricula

Simplify

Complexity-Map of Diagnoses, Interventions and Outcomes

for Courses

All

Faculty Evaluate Students:

Correct Use of NNN
Partnership Processes, Use of We
Technical Skills
Individualize NNN Content with Patients

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Objective 4: Integrate with Curricula

Fundamentals
NNN

of Nursing

- Framework for Skills Learning

Thinking

- High Priority Diagnoses, Include in Testing

Expect

Students to Use CT Terms and Definitions (for Example, in

Journal Writing and Discussion)
Develop

Case Studies (Lunney 1992)

Iterative

Hypothesis Testing

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Objective 4: Integrate with Curricula

Educators

and Practice-Based Leaders: Spread the Word to Nurses

in Other Agencies
Meet

with Leaders; Use Marketing Strategies

Demonstrate
Provide

Advantages of NNN

CE Programs

Disseminate

Your Success in Using NNN to Others

(Bulecheck et al. 2008; Herdman 2012; Moorhead et al. 2008)

Questions/Discussion
Teamwork is the Fuel that Allows Common People to Attain

Uncommon Results (Unknown)

The Illiterate of the 21st Century will Not be Those Who Cannot
Read and Write, But Those Who Cannot Learn, Unlearn and Relearn

(Alvin Toffler)

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