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Consensus-Validation Study Identifies Relevant Nursing Diagnoses, Nursing Interventions, and Health Outcomes for People with Traumatic Brain Injuries
A consensus-validation study used action research methods to identify relevant nursing diagnoses, nursing interventions, and patient outcomes for a population of adults with traumatic brain injury (TBI) in long-term care. In meetings totaling 159 hours to reach 100% consensus through group discussions, the three classifications of NANDA International’s (NANDA-I’s) approved nursing diagnoses, the Nursing Interventions Classification (NIC), and the Nursing Outcomes Classification (NOC) were used as the basis for three nurses experienced in working with adults with TBI to select the elements of nursing care. Among almost 200 NANDA-I nursing diagnoses, 29 were identified as relevant for comprehensive nursing care of this population. Each nursing diagnosis was associated with 3–11 of the more than 500 NIC interventions and 1–13 of more than 300 NOC outcomes. The nurses became aware of the complexity and the need for critical thinking. The findings were used to refine the facility’s nursing standards of care, which were to be combined with the interdisciplinary plan of care and included in future electronic health records.
During rehabilitation to improve health functioning, people with traumatic brain injury (TBI) need assistance from many healthcare providers such as nurses, physicians, and physical therapists (Semlyen, Summers, & Barnes, 1998). Because many disciplines contribute to patients’ health outcomes, it is important to distinguish how nurses contribute to patient care and the achievement of health outcomes. Rehabilitation nursing is a distinct discipline with a focus on helping people respond to health problems and life processes and self-manage issues (American Nurses Association [ANA], 2003, 2004; Association of Rehabilitation Nurses, n.d.). In the United States, many state nurse practice acts designate the diagnosis and treatment of human responses within nursing’s legal scope of practice (e.g., New York State Office of the Professions, 2009). Three research-based nursing classifications for use in standards of care and electronic health records have been developed since 1973: the Classification of Nursing Diagnoses (NANDA International [NANDA-I], 2009), the Nursing Interventions Classification (NIC; Bulechek, Butcher, & Dochterman, 2008), and the Nursing Outcomes Classification (NOC; Moorhead, Johnson, Maas, & Swanson, 2008).
The NANDA-I includes 206 research-based nursing diagnoses with definitions, defining characteristics, and related factors. The NIC includes 542 research-based nursing interventions (both direct and indirect care) with definitions and activities. The NOC includes 385 research-based patient outcomes with definitions and indicators that are sensitive to changes in quality of nursing care. The difficulty of using these classifications in specialty settings, however, is that there are 1,133 terms to consider. In an electronic health record, there would be too many terms to examine for relevance, so the relevant terms for diagnoses, interventions, and outcomes for specific populations need to be identified on the front screens of computerized systems. All other terms can be placed behind the front screens and can be used as needed. Without standardized terms to represent nursing care elements, the quality of nurses’ work could not be described. With electronic health records, the use of standardized terms to collect nursing data enables the aggregation of nursing data to examine quality and compare quality across systems (Lunney, Delaney, Duffy, Moorhead, & Welton, 2005).
People with TBI have specific nursing care needs (American Association of Neuroscience Nursing [AANN], 2004). A unit for long-term care of people older than 16 years with TBI was established in 1992 at Sea View Hospital Rehabilitation Center and Home, a facility of the Health and Hospital Corporation of New York City. This was the first TBI program certified by the New York State Department of Health, and the first of its kind in New York City. The program is accredited by the Joint Commission and received the 2007 Ernest Codman Award in the long-term-care category for an initiative to decrease incontinence, which can lead to skin breakdown, falls, and other complications. This 21-bed unit is devoted to care of people with TBI whose rehabilitation potential is 3–18 months. To be accepted, patients must be medically stable (no ventilation), have no active history of alcohol or drug abuse, and not pose danger to themselves or others. The purpose of this study was to obtain 100% consensus from nurses experienced in the care of adults with TBI to identify the relevant NANDA, NIC, and NOC categories for adults with TBI in this setting.
TBI “results from an external force to the brain causing transient or permanent neurological dysfunction. It is a relatively high prevalence injury, being 10 times more common than spinal cord injury” (Khan, Baguley, & Cameron, 2003, p. 290). In the United States, approximately 1.4 million people sustain a TBI each year, and the direct and indirect costs are estimated at $60 billion (Centers for Disease Control and Prevention, 2006). Brain damage from external injuries can be immediate or secondary to a variety of pathophysiological changes, and it leads to long-term or lifelong needs for assistance from others. Immediate medical and nursing care takes place in emergency departments and other acute-care settings; after the person with TBI is medically stable, rehabilitation often is needed. Rehabilitation can take place at home or in specialty rehabilitation units. Generally, the time frame is long (years for improvement of neurological dysfunctions and associated disabilities), so it involves specialty care by rehabilitation nurses (AANN, 2004). In a study that compared multidisciplinary rehabilitation with a single-provider approach, multidisciplinary services were shown to yield more benefits in patients’ health functioning (Semlyen et al., 1998).
Rehabilitation nurses assist adults with head injuries by helping them deal with emotional responses such as grieving (Reitzel, 2009), social responses such as aggression (Fitzwater & Gates, 2004), lack of inhibitions (Reitzel), social isolation (Holley, 2007), and physical problems such as confusion (Mullins, Thomason, & Legro, 2005).
Both medical and nursing studies are needed to support rehabilitation strategies with research evidence (Chestnut et al., 1999; Jacelon, Pierce, & Buhrer, 2007). One of the recommendations of Chestnut and colleagues’ summary report of research evidence was that health outcomes need to be specified. The rehabilitation nursing research agenda reflects a broad holistic focus in three main categories: nursing interventions and nurse-led interdisciplinary interventions, the experience of disability and chronic health problems, and rehabilitation practices. This study identified nurses’ perspectives related to two of these categories, the experiences of people with TBI and interventions and outcomes for current use in long-term care settings. The research questions were
This was a consensus-validation study using action research methods to identify the nursing diagnoses, nursing interventions, and patient outcomes relevant to the care of people with TBI. The study was conducted in 2006–2007, so previous editions of the NANDA-I, NIC, and NOC books were used to select the diagnoses, interventions, and outcomes.
The consensus-validation strategies described by Carlson (2006) and a modification of the principles and methods of action research (Baum, MacDougall, & Smith, 2006; Casey, 2007; Stringer, 2007) were used for the study design. Action research methods were designed to answer the questions of participant stakeholders (e.g., healthcare consumers); in this study, the research questions were proposed by nurse leaders and answered by participant nurses who are stakeholders in the use of nursing diagnoses, nursing interventions, and patient outcomes. The study was approved by the institutional review board of the College of Staten Island, City University of New York.
Registered professional nurses who worked at the Sea View Hospital Rehabilitation Center and Home for at least 1 year and had been licensed as registered professional nurses for at least 3 years were recruited to participate in the study. The three nurses who volunteered for the study were the head nurse of the TBI unit who had 9 years’ experience working with adults with TBI, and two staff nurses with 13 years’ experience working with adults with TBI. The three participants remained in the study for the full time period. The three nurses were paid by the facility for after-work hours that were spent in meetings. They were not paid for the time they spent at home studying these three classifications and making decisions about their individual choices. Each nurse signed the informed consent form, which specified that they could leave the study at any time without penalty.
This study was led by two nurses who were facility leaders in charge of nursing education, standards development, and quality monitoring for all patients served by the facility. The nurse leaders were trained in the study procedures by an experienced nurse researcher who studied under Carlson (2006), developer of this research method. During training, study procedures were explained and the associated leadership competencies were clarified. The researcher audited the study procedures at intervals during the study. The leadership emphasis was on action research methods, which specifically require leaders in group discussions to facilitate participants’ decision making and not impose their own views (which can occur in other nurse leadership situations). One of the leaders was responsible for developing the lists of diagnoses, interventions, and outcomes as they were identified in each meeting and documenting changes that occurred during meetings.
The meetings took place during 1½ years because sometimes the two leaders or the three participant nurses were not available for group meetings and it was time consuming to make decisions about more than 1,000 terms in the three classification systems. Each meeting was planned for 1–2-hour sessions.
The participating nurses familiarized themselves at home with the three classifications one at a time and selected categories that each thought were relevant to the population. In the group meetings, individual category selections were reviewed and compared. The definitions and descriptions of each diagnosis, intervention, and outcome then were examined in the group to verify relevance. The goal was 100% consensus for selection of nursing diagnoses and the associated nursing interventions and patient outcomes. The final product represents numerous discussions and revisions throughout the process.
Twenty-nine NANDA-I diagnoses, each with 3–11 NIC interventions and 1–13 NOC outcomes, were identified as relevant to the TBI population served by nurses at this facility. Of the selected diagnoses, 19 represented common physical problems and risk states; the 14 problems included ineffective airway clearance, bowel incontinence, and hyperthermia, and the 5 risk states included risk for aspiration, risk for imbalanced body temperature, and risk for falls (NANDA, 2009). The remaining 10 of the selected diagnoses were psychosocial responses to the health problems and life processes of living with the effects of a TBI such as anxiety, impaired diversional activity, and grieving. These 29 diagnoses do not apply to every patient but were selected as the basis for nursing assessment for TBI.
The interventions that were selected specifically addressed the diagnoses that had been selected (Table 1), but at times an intervention was selected for which no relevant diagnosis had been identified (socialization enhancement). This meant that the list of diagnoses that had been selected was reevaluated. Nurses found that the NIC effectively captured the usual interventions that rehabilitation nurses had been using to help people with TBI at this facility. The NIC interventions selected to address deficient diversional activity were animal-assisted therapy, art therapy, music therapy, recreation therapy, reminiscence therapy, therapeutic play, and visitation facilitation (Bulechek et al., 2008). These interventions generally are used on this TBI unit.
The outcomes that were selected represent categories that would show changes in patients’ conditions and enable nurses and others to describe patient progress toward meeting rehabilitation goals. Nurses identified these outcomes as helpful for identifying patients’ rehabilitation progress: health status acceptance; adaptation to physical disability; and self-care outcomes related to activities of daily living, bathing, toileting, dressing, and eating. A significant outcome associated with cognitive abilities can be that a person who previously was aphasic states a simple word.
The cost of conducting this study was inexpensive compared to the valuable data generated for use in further development of the standards of care and for the electronic health record the facility plans to implement. The nurse participants spent 159 hours in meetings for consensus building. The time spent by the two nurse leaders was not computed in the cost. The 159 hours were multiplied by an average nursing cost at $35 per hour, which equaled $5,565. The cost of the three books for the three participants and the two leaders was $600.
Throughout the study processes, the team learned the NANDA, NIC, and NOC classifications. For each decision, they used the definition and description of the diagnostic, intervention, and outcome concepts. They realized that some concepts they previously did not use in nursing care are relevant and should be used to ensure high-quality care.
The task of arriving at 100% consensus on the nursing diagnoses, nursing interventions, and patient outcomes was challenging and took more time than expected, but often was fun and exhilarating for the nurses and team leaders. The group developed a bond and had many laughs throughout their efforts, which included agreements and disagreements. The group became acutely aware of the complexity of nursing and realized the importance of using critical thinking to decide on diagnoses, outcomes, and interventions (Cruz, Pimenta, & Lunney, 2009; Lunney, 2001, 2009; Pesut & Herman, 1999). The group also appreciated the value of nurse-to-nurse collaboration in the processes of deciding on the details of patient care.
The advantage of identifying, through nurses’ consensus building, a list of nursing diagnoses to consider for people with TBI is that these diagnoses can be used to further develop minimum standards of care for this setting and population (see example in Table 1). Establishing minimum standards of care based on nursing diagnoses ensures that nurses conduct assessments for these diagnoses on all patients with TBI. When a nurse decides that a specific diagnosis applies to a patient, the minimum standard of care for that diagnosis is implemented. The NANDA-I, NIC, and NOC classifications provide more comprehensive research-based lists from which to choose than other standardized nursing classifications such as the Omaha System (Yu & Lang, 2008).
The nursing diagnoses that were selected were partially, but not completely, validated in the rehabilitation literature. No previous studies were reported that identified the human responses or nursing diagnoses that should be considered when providing nursing care to people with TBI. Some of the diagnostic concepts selected in this study are consistent with research reports in the rehabilitation literature (e.g., impaired skin integrity and risk for impaired skin integrity [Mullins et al., 2005]). The reported prevalence of pressure ulcers in the TBI population is unclear, however, because rehabilitation nurses have been using a variety of measures for staging. Mullins and colleagues recommended that rehabilitation nurses should adopt one type of pressure-ulcer staging method. Further research is needed for rehabilitation nurses to make this decision.
The physical problems related to self-care deficits that were identified in this study are consistent with a description of the rehabilitation experience by Broadway (2009), a nurse whose poem, “Welcome to Rehab,” described her own experiences of living with TBI. In addition to other aspects of rehabilitation, this poem depicts the daily struggles of a person in rehabilitation who is trying to learn new ways to function to accomplish self-care.
Interventions that were determined to be important, especially those that addressed multifaceted cognitive deficits, included, but were not limited to, reality orientation; cognitive stimulation; calming technique; self-care assistance, bathing/hygiene; and coping enhancement (Bulechek et al., 2008). Many of the interventions identified for use with nursing diagnoses in this study also were included in the list of 43 nursing interventions for rehabilitation nursing in the NIC book (Bulechek et al., p. 831). An advantage of using the NIC is that it presents an evidence-based summary of nursing knowledge about possible interventions, which provides more potential interventions than nurses are likely to recall from their readings and previous experiences. The NIC helps nurses summarize (weekly and monthly) the interventions used with patients as a basis for resource management. The availability of minimum standards of care based on the study data will improve the systematic selection of interventions when diagnoses are relevant to specific patients.
Nurses in this agency plan that the minimum standards of care developed from these findings will be integrated with aesthetic knowledge, as recommended by Alverzo (2004). Standardized languages express the similarities of care in working with people with TBI, not the differences. Using aesthetic knowledge gained through working in partnership with patients fosters optimum care by enabling nurses to notice differences and similarities and base the application of standards on the unique needs of patients with TBI.
Conclusions and Implications
For similar populations, the diagnoses, interventions, and outcomes from this study may be adopted by nurses to guide development of standards and inclusion in electronic health records.
This study helped identify the standardized terms that will be used in nursing standards of care to be combined with the interdisciplinary plan of care and the electronic records of this facility. Further studies are needed at this facility to validate these diagnoses, interventions, and outcomes for patients with TBI and their families. Action research methods are recommended for use by consumers to identify their needs (Stringer, 2007).
If the findings of this study are not relevant to adults with TBI at other facilities, the consensus-validation method used for this study can be used with a group of stakeholders such as experienced nurses or people with TBI. Participant-action-research methods allow practicing nurses to provide input regarding the daily nursing care to be provided to the patients they serve. For small facilities, this type of nursing research is manageable and relatively inexpensive. To improve the quality of research studies, it is also recommended that facility leaders develop collaborative relationships with experienced nurse researchers.
The authors thank Carol Morgan, director of nursing, Angelo Mascia, executive director, and Violet Huie, associate executive director, for financial and tacit support of the study. Most important to thank are the nurses who did the work of the study: Dorothy McIntosh-Waddy, BS RN, Patricia Decker, RN, and Shereen Ravindran, RN.
About the Authors
Margaret Lunney, PhD RN, is a professor and graduate program coordinator at College of Staten Island, City University of New York in Staten Island, NY. Address correspondence to her at firstname.lastname@example.org.
Maria McGuire, MPA RN, is director of Care Management at Sea View Hospital Rehabilitation Center and Home in Staten Island, NY.
Nancy Endozo, BSN RN, is associate director of Nursing at Sea View Hospital Rehabilitation Center and Home in Staten Island, NY.
Dorothy McIntosh-Waddy, BS RN, is head nurse at Sea View Hospital Rehabilitation Center and Home in Staten Island, NY.
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