Dr. Judy Carlson Nurse Researcher PV/PHN Tripler Army Medical Center Honolulu, Hawaii

Consensus Validation Process: Consensus Validation Process: A Standardized Research Method to A Standardized Research Method to

Identify and Link Relevant NNN Terms Identify and Link Relevant NNN Terms for Professional Practicefor Professional Practice

Dr. Judy CarlsonDr. Judy CarlsonNurse Researcher PV/PHNNurse Researcher PV/PHN

Tripler Army Medical CenterTripler Army Medical CenterHonolulu, HawaiiHonolulu, Hawaii

NANDA-I Presentation, March 2006NANDA-I Presentation, March 2006

Co-Presenters:Co-Presenters:

• NANDA Research CommitteeNANDA Research Committee– Margaret Lunney, RN, PhDMargaret Lunney, RN, PhD

(New York, U.S.)(New York, U.S.)

– Margaret Clifford, RN, PhDMargaret Clifford, RN, PhD

(Rhode Island, U.S.)(Rhode Island, U.S.)

– Dina Almeida Monteiro da Cruz, Dina Almeida Monteiro da Cruz, PhDPhD (Nurse, Sao Paulo, Brazil) (Nurse, Sao Paulo, Brazil)

– Maria Mueller Staub, MS, PhD(c)Maria Mueller Staub, MS, PhD(c)

(Nurse, Bern, Switzerland)(Nurse, Bern, Switzerland)

Identification and Linkage of Identification and Linkage of NNNNNN• With 172 Diagnoses, 514 With 172 Diagnoses, 514

Interventions, & 330 Outcomes, use is Interventions, & 330 Outcomes, use is impractical impractical – Lists of labelsLists of labels– Not conceptually understood or Not conceptually understood or

connectedconnected

• General linkages often not relevant General linkages often not relevant and cumbersome in actual practiceand cumbersome in actual practice

• Pre-packaged linkages may not be Pre-packaged linkages may not be relevant to specific settingsrelevant to specific settings

• Efforts to link by physiological ??Efforts to link by physiological ??

Identification and Linkage of Identification and Linkage of NNNNNN• Core content and linkages needed for Core content and linkages needed for

specific units, populations, or health specific units, populations, or health focifoci

• Consensus Validation Process (CVP)-Consensus Validation Process (CVP)-developed to accomplish this goaldeveloped to accomplish this goal

• The Output of CVP becomes Standard The Output of CVP becomes Standard of Practice for specific units, of Practice for specific units, populations or health focipopulations or health foci

• CVP developed as Participatory Action CVP developed as Participatory Action ResearchResearch– Nurses participate with researcher to Nurses participate with researcher to

construct and use knowledgeconstruct and use knowledge

Consensus Validation Definition:Consensus Validation Definition:

• Process by which clinicians with Process by which clinicians with expertise in particular clinical areas expertise in particular clinical areas review a domain of knowledge relating review a domain of knowledge relating to their expertise and work to achieve to their expertise and work to achieve 100% consensus on the relationship of 100% consensus on the relationship of the domain of knowledge, for example the domain of knowledge, for example diagnoses, outcomes and diagnoses, outcomes and interventions, to one or more interventions, to one or more predetermined objectives.predetermined objectives.

Steps of a Consensus Validation Steps of a Consensus Validation Process:Process:1.1. Identify purpose(s) of study, e.g., Identify purpose(s) of study, e.g.,

– Determine core nursing diagnoses, Determine core nursing diagnoses, nursing interventions, patient outcomes nursing interventions, patient outcomes and their linkagesand their linkages

– Determine applicable intervention Determine applicable intervention activities and outcome indicatorsactivities and outcome indicators

Steps of a Consensus Validation Steps of a Consensus Validation Process:Process:

2.2. Identify clinical leadersIdentify clinical leaders

3.3. Identify at least 3 cliniciansIdentify at least 3 clinicians

4.4. Obtain resourcesObtain resources


5.5. Describe procedures, e.g. Describe procedures, e.g.

– Determine the core diagnoses for the critical care unitsDetermine the core diagnoses for the critical care units– Determine the core nursing interventions for the Determine the core nursing interventions for the

critical care unitscritical care units– Link the core nursing interventions to each diagnosisLink the core nursing interventions to each diagnosis– Determine the core patient outcomes for the critical Determine the core patient outcomes for the critical

care unitscare units– Link the core patient outcomes in relation to each Link the core patient outcomes in relation to each

diagnosis and interventionsdiagnosis and interventions– Determine the applicable intervention activities and Determine the applicable intervention activities and

outcome indicatorsoutcome indicators


66. Seek IRB Approval. Seek IRB Approval

7.7. Conduct Study – Four Phases Conduct Study – Four Phases – Phase I: Nursing DiagnosesPhase I: Nursing Diagnoses– Phase II: Nursing InterventionsPhase II: Nursing Interventions – Phase III: Patient OutcomesPhase III: Patient Outcomes– Phase IV: Intervention Activities & Phase IV: Intervention Activities &

Outcome IndicatorsOutcome Indicators

CVP: Phase I - Nursing DiagnosesCVP: Phase I - Nursing Diagnoses

• The clinical leader:The clinical leader:– distributes nursing diagnoses with distributes nursing diagnoses with

definitions definitions – asks each clinician to place a check mark asks each clinician to place a check mark

next to diagnoses that he/she determines next to diagnoses that he/she determines to be at least somewhat relevant to the to be at least somewhat relevant to the clinical practice areaclinical practice area

– tallies the responses tallies the responses – compiles diagnoses selected by clinicianscompiles diagnoses selected by clinicians


• The diagnoses are put in a table formatThe diagnoses are put in a table format– Display the diagnoses that were selected by Display the diagnoses that were selected by

the number of nursesthe number of nurses

• The table is distributed and reviewed The table is distributed and reviewed carefully by clinicianscarefully by clinicians

• The clinicians meet as a group with the The clinicians meet as a group with the clinical leader and review each diagnosis, clinical leader and review each diagnosis, definition, and defining characteristicdefinition, and defining characteristic

# selected

Diagnoses Definition

33 Airway clearance, Ineffective Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway

33 Aspiration, Risk for At risk for entry of gastrointestinal secretions, orophayngeal secretions, solids, or fluids into tracheobronchial passages

33 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.

33 Gas Exchange, Impaired Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.

33 Incontinence, Total Urinary Continuous and unpredictable loss of urine

33 Infection, Risk for At increased risk for being invaded by pathogenic organisms22 Bowel Incontinence Change in normal bowel habits characterized by involuntary passage of stool

22 Breathing Pattern, Ineffective Inspiration and/or expiration that does not provide adequate ventilation

22 Diarrhea Passage of loose, unformed stools

22 Disuse Syndrome, Risk for At risk for deterioration of body systems as the result of prescribed or unavoidable musculoskeletal inactivity

11 Activity Intolerance Insufficient physiological or psychological energy to endure or complete required or desired daily activities

11 Activity Intolerance, Risk for At risk for experiencing insufficient physiological or psychological energy to endure or complete required or desired daily activities

11 Allergy Response, Latex An allergic response to natural latex rubber products

11 Allergy Response, Risk for Latex At risk for allergic response to natural latex rubber products

11 Cardiac Output, Decreased Inadequate blood pumped by the heart to meet metabolic demands of the body

11 Constipation Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool


• The clinical leader guides the discussionsThe clinical leader guides the discussions – Each diagnosis must have 100% consensus that the Each diagnosis must have 100% consensus that the

diagnoses is at diagnoses is at least somewhat relevantleast somewhat relevant to the to the clinical practice area clinical practice area

– Those in support of diagnoses must give reasons or Those in support of diagnoses must give reasons or examples of how diagnoses are relevantexamples of how diagnoses are relevant

– Those not in support must explain why diagnoses Those not in support must explain why diagnoses are not relevant are not relevant

• The clinical leader distributes the compilation The clinical leader distributes the compilation of diagnosis selected by 100% of the cliniciansof diagnosis selected by 100% of the clinicians

CVP: Phase II - Nursing InterventionsCVP: Phase II - Nursing Interventions

• The clinical leader:The clinical leader:– distributes a list of nursing interventionsdistributes a list of nursing interventions

– asks each clinician to place a check mark next to asks each clinician to place a check mark next to interventions that he/she determines to be at interventions that he/she determines to be at least least somewhat relevantsomewhat relevant to the clinical practice to the clinical practice areaarea

– tallies the responses tallies the responses

– compiles the interventions that clinicians compiles the interventions that clinicians selectedselected


• The interventions are put in a table formatThe interventions are put in a table format

• The table is distributed and reviewed The table is distributed and reviewed carefully by clinicianscarefully by clinicians

• The clinicians meet as a group with the The clinicians meet as a group with the clinical leader and review each intervention, clinical leader and review each intervention, definition, and activitydefinition, and activity

• The clinical leader and/or researcher guide The clinical leader and/or researcher guide the discussionsthe discussions

• The nursing interventions are then linked to The nursing interventions are then linked to the specific nursing diagnosesthe specific nursing diagnoses


• Linking interventions to specific Linking interventions to specific nursing diagnosesnursing diagnoses– Carefully review the definition and defining Carefully review the definition and defining

characteristics and in some cases the characteristics and in some cases the related to factorsrelated to factors

– Consider the general outcome to be Consider the general outcome to be accomplish for that diagnosis accomplish for that diagnosis

– Select interventions that can specifically Select interventions that can specifically address that particular diagnoses.address that particular diagnoses.


• Linking ConsiderationsLinking Considerations– If there are interventions that do not fit with If there are interventions that do not fit with

a diagnosis yet are found relevant by 100% a diagnosis yet are found relevant by 100% of the clinicians, a review of diagnoses is of the clinicians, a review of diagnoses is undertaken to determine the most undertaken to determine the most appropriate fit. It may be found that a appropriate fit. It may be found that a diagnosis needs to be addeddiagnosis needs to be added

– Interventions believed at first to be relevant Interventions believed at first to be relevant with the linking process may be found to be with the linking process may be found to be irrelevantirrelevant

– Audits need to be conducted Audits need to be conducted • Documentation under some- why?Documentation under some- why?

CVP: Phase III - Nursing OutcomesCVP: Phase III - Nursing Outcomes

• The clinical leader:The clinical leader:– distributes the list of nursing sensitive distributes the list of nursing sensitive

patient outcomes (NOC)patient outcomes (NOC)– asks each clinician to place a check mark asks each clinician to place a check mark

next to outcomes that he/she determines to next to outcomes that he/she determines to be at least somewhat relevant to the clinical be at least somewhat relevant to the clinical practice areapractice area

– tallies the responses tallies the responses – Compiles the outcomes that clinicians Compiles the outcomes that clinicians

selectedselected


• The outcomes are put in a table formatThe outcomes are put in a table format• The table is distributed and reviewed The table is distributed and reviewed

carefully by clinicianscarefully by clinicians• The clinicians meet as a group with the The clinicians meet as a group with the

clinical leader and review each outcome, clinical leader and review each outcome, definition, and indicantdefinition, and indicant

• The clinical leader and/or researcher The clinical leader and/or researcher guide the discussionsguide the discussions

• The patient outcomes are then linked to The patient outcomes are then linked to the specific nursing diagnosesthe specific nursing diagnoses


• Linking outcomes to specific nursing Linking outcomes to specific nursing diagnosesdiagnoses– Carefully review the definition and defining Carefully review the definition and defining

characteristics and in some cases the related characteristics and in some cases the related to factors of diagnosisto factors of diagnosis

– Consider the specific outcome to be Consider the specific outcome to be accomplished for that diagnosis accomplished for that diagnosis

– At times, outcomes need to be selected for At times, outcomes need to be selected for the intervention as well (e.g. Medication the intervention as well (e.g. Medication Administration & Medication Response)Administration & Medication Response)


• If there are outcomes that do not fit with a If there are outcomes that do not fit with a diagnosis or an intervention, yet are found diagnosis or an intervention, yet are found relevant by 100% of the clinicians, a review of relevant by 100% of the clinicians, a review of diagnoses and interventions is undertaken to diagnoses and interventions is undertaken to determine the most appropriate fitdetermine the most appropriate fit

• It may be found that a diagnosis and/or It may be found that a diagnosis and/or intervention needs to be added. intervention needs to be added.

• Changes are made throughout the process, Changes are made throughout the process, e.g., there are instances when nurses dismiss e.g., there are instances when nurses dismiss an outcome believed at first to be relevant an outcome believed at first to be relevant but, after discussion, it is found to be but, after discussion, it is found to be irrelevant.irrelevant.

CVP: Phase IV – Intervention CVP: Phase IV – Intervention Activities & Outcome IndicantsActivities & Outcome Indicants

• Clinicians review and select the Clinicians review and select the activities under each intervention that activities under each intervention that are relevant to their practice.are relevant to their practice.

• Clinicians review and select the Clinicians review and select the indicators under each outcome that are indicators under each outcome that are relevant to their practicerelevant to their practice

Developing Standards of Practice Developing Standards of Practice Using Consensus Validation ProcessUsing Consensus Validation Process

• Nurse Researcher/LeaderNurse Researcher/Leader

• 3-5 Clinical Experts 3-5 Clinical Experts

• Can meet weekly (1 to 2 hours) for up to 8 Can meet weekly (1 to 2 hours) for up to 8 months months oror

• 2-3 weeks of 8 hour days2-3 weeks of 8 hour days

Developing Standards of Practice: Developing Standards of Practice: Checks & BalancesChecks & Balances

• 100% consensus is a powerful tool100% consensus is a powerful tool

• Discussions with rationale for choices and Discussions with rationale for choices and respectful challenges by others served to respectful challenges by others served to validate decisionsvalidate decisions

• Internal Audits of standards are conducted Internal Audits of standards are conducted by researcher and audit team throughout by researcher and audit team throughout process process

• Development will continue with clinical use Development will continue with clinical use & validation of Standards of Practice& validation of Standards of Practice

Development of Five Standards of PracticeDevelopment of Five Standards of Practice• Joint New Parent Support ProgramJoint New Parent Support Program

– 3 Expert Clinicians3 Expert Clinicians

• Latent Tuberculosis Infection (LTBI) ProgramLatent Tuberculosis Infection (LTBI) Program– 5 Expert Clinicians5 Expert Clinicians

• Care and Prevention of Impaired Skin IntegrityCare and Prevention of Impaired Skin Integrity– 3 Expert Clinicians3 Expert Clinicians

• Risk for Infection for ICU patientsRisk for Infection for ICU patients– 3 Expert Clinicians3 Expert Clinicians

• Risk for Impaired Skin Integrity for ICU patientsRisk for Impaired Skin Integrity for ICU patients– 3 Expert Clinicians3 Expert Clinicians

Researcher’s RoleResearcher’s Role• Maintain a non-judgmental, enthusiastic and supportive Maintain a non-judgmental, enthusiastic and supportive

approach throughout the project approach throughout the project • Ensure confidentiality of nursesEnsure confidentiality of nurses• Work in 1-2 hour time blocksWork in 1-2 hour time blocks• Overview process and time commitment Overview process and time commitment • Discuss commitment to attend every meeting. 100% Discuss commitment to attend every meeting. 100%

consensus requires 100% attendance.consensus requires 100% attendance.• Carefully go over home work assignments and necessity Carefully go over home work assignments and necessity

to bring NIC, NOC, NANDA to every meeting.to bring NIC, NOC, NANDA to every meeting.• Each member is equal, all status is equal, no bosses or Each member is equal, all status is equal, no bosses or

rank rank • No one need to defend original choice, if change mind- No one need to defend original choice, if change mind-

state new judgment state new judgment • As meeting begins, quickly review ground rules, thinking As meeting begins, quickly review ground rules, thinking

processes from previous meetings, what has been processes from previous meetings, what has been accomplished to date and goals to be achieved for that accomplished to date and goals to be achieved for that day.day.

Researcher’s RoleResearcher’s Role

• Support nurses’ decision-makingSupport nurses’ decision-making

– show complete and absolute respect for nurses in the studyshow complete and absolute respect for nurses in the study– maintain as positive an attitude as possible (avoid anger, maintain as positive an attitude as possible (avoid anger,

resentment, frustration, disappointment, and other negative resentment, frustration, disappointment, and other negative responses)responses)

– do not make decisions for nurse participantsdo not make decisions for nurse participants– do not pressure the nurses to make specific decisionsdo not pressure the nurses to make specific decisions– accept nurses’ decisions and choices regardless of whether you accept nurses’ decisions and choices regardless of whether you

agree or notagree or not– when nurses choose unlikely diagnoses, interventions or when nurses choose unlikely diagnoses, interventions or

outcomes, make it possible for other members of the group to outcomes, make it possible for other members of the group to consider and reconsider these choices, e.g.,consider and reconsider these choices, e.g.,

• Ask questions, rather than making statementsAsk questions, rather than making statements

e.g., does everyone agree that this choice is relevant?e.g., does everyone agree that this choice is relevant?

Researcher’s RoleResearcher’s Role

• Objectify areas of disagreements Objectify areas of disagreements

• Summarize where the group is during a difficult Summarize where the group is during a difficult decision-making episode decision-making episode

• Frequent reminder of goal and purposes of studyFrequent reminder of goal and purposes of study

• Keep the discussion moving by putting aside Keep the discussion moving by putting aside controversial items until the end of the process controversial items until the end of the process

• Nurses can become passionate during this Nurses can become passionate during this process, encourage respectful passion process, encourage respectful passion

• Keep good records of the process and obtain Keep good records of the process and obtain approval of the records from the nursesapproval of the records from the nurses

Implications for Consensus Validation Implications for Consensus Validation Process UseProcess Use

• The CVP can be implemented on any practice The CVP can be implemented on any practice unit, for any patient population or health focus by unit, for any patient population or health focus by nurses to self-determine the NNN terms for nurses to self-determine the NNN terms for practice standards. practice standards.

• As a research project, it enhances the As a research project, it enhances the professionalism of practicing nurses. professionalism of practicing nurses.

• When used in an EHR, it provides the framework When used in an EHR, it provides the framework for aggregating data to describe, explain and for aggregating data to describe, explain and predict nursing care. predict nursing care.

• With implementation of the Standards of Practice, With implementation of the Standards of Practice, nurses will be able to unequivocally answer the nurses will be able to unequivocally answer the question, “what do nurses in this setting do and question, “what do nurses in this setting do and what is their value?”what is their value?”

Implications for Standards of Implications for Standards of Practice Use in an EHRPractice Use in an EHR

• Standards of Practice based on Standards of Practice based on NANDA, NIC & NOC in an Electronic NANDA, NIC & NOC in an Electronic Health Record will enable:Health Record will enable:– Professional practice enhancementProfessional practice enhancement– Performance improvementPerformance improvement– Provision of economic evidenceProvision of economic evidence– Streamlining of documentationStreamlining of documentation

Questions??Questions??

• The End with Beautiful picture of The End with Beautiful picture of HawaiiHawaii

QUESTIONS?

Documents

Dr. Judy Carlson Nurse Researcher PV/PHN Tripler Army Medical Center Honolulu, Hawaii