PASADO, PRESENTE Y FUTURO DE LOS DIAGNÓSTICOS DE ENFERMERÍA

RESUMEN Con este trabajo la autora pretende crear una línea de discusión acerca del Pasado, Presente y Futuro de los Diagnósticos de Enfermería contextualizando el término desde dos perspectivas distintas: como una "categoría" y por otro lado como un "proceso". En el desarrollo del artículo se muestran los hechos que han ido sentando las bases para el desarrollo de los Diagnósticos de Enfermería dentro de la práctica clínica.

En este trabajo me gustaría hablar acerca del Pasado, presente y futuro de los diagnósticos de Enfermería, como una categoría y como un proceso.De hecho, se han dado a lo largo de la historia una serie de acontecimientos que fueron cruciales para el desarrollo de estos diagnósticos y de las habilidades para el razonamiento clínico de las enfermeras/os.

TRANSICIONES DEL PASADO AL PRESENTE:
Me gustaría sugerir que la práctica enfermera ha experimentado cambios drásticos en todo el mundo a partir de la segunda mitad del siglo XX.Los historiadores han interpretado estos cambios como signos de una revolución cultural o profesional, mientras que para otros ha significado un cambio paradigmático.El aspecto central explicativo de todos estos cambios es el hecho de que las enfermeras reconocen que ellas mismas hacen juicios clínicos paralelamente a aquellos que están asociados directamente con la enfermedad o patología, es decir, los juicios médicos.Los profesionales de Enfermería llevan a cabo actividades en relación a esos juicios propios y en el proceso de desarrollo del diagnóstico de Enfermería aumenta la calidad de la salud de la comunidad o grupo sobre el que se actúa.
Desde hace 25 años las enfermeras vienen dándose cuenta de la importancia de los juicios clí-nicos que ellas mismas producen para identificar y clasificar las características de aquello con lo que tratan, es decir, existe la necesidad de dar un nombre a las actividades que mejor responden a la intervención que lleva a cabo Enfermería.Este reconocimiento por parte del colectivo enfermero ha sido el que ha cambiado totalmente la práctica de la Enfermería en muchos países.De hecho, se ha dado un momento de transición en relación con la forma de hablar y expresarse dentro del desarrollo de nuestra práctica y de nuestra forma de pensar como enfermeras/os.

NURSING DIAGNOSIS: PAST, PRESENT, FUTURE
The term, nursing diagnosis, refers to both a category and a process.A diagnostic category is used to describe diagnostic judgments.In the last 26 years 158 diagnostic categories have been identified by the NANDA, theNorth American Nursing Diagnosis Association, and many more are contained in the International Classification for Nursing Practice.Each of these categories has to be examined for its cultural sensitivity.The term, nursing diagnosis, also refers to the process of clinical reasoning and judgment that leads lo "making" a nursing diagnosis.
In this paper I would like to discuss the Past, Present, and Future of the nursing diagnosis, as a category and as a process.There were a series of events that set the stage for the development of nursing diagnoses and a focus on nurses clinical reasoning skills

PAST TO PRESENT TRANSITIONS
I would like to suggest that nursing practice around the world has changed dramatically in the last half of the 20th century.Perhaps historians will view it as a cultural or professional revolution or at least a paradigm shift.There is one core aspect of these changes.Nurses recognize that they make clinical judgments beyond those directly associated with a disease.They act on those judgments and in the process raise the quality of health care in the country.SLIDE 1 Transitions Nurses are developing a language to communicate judgments related to their nursing diagnosis, interventions, and outcomes.This change has emphasized the importance of nursing assessment and the kind of information that is collected for diagnosis, care planning, and evaluation.The interest in nursing-focused assessment, and particularly the functional health patterns, suggests that nurses recognize that diagnosis and treatment will not be based on valid and reliable judgments unless assessment provides valid and reliable information.Let us consider some transitions from the past that are characteristic of nursing practice in many countries.About 25 years ago nurses began to recognize that they make important.clinical judgments and that they need to identify and ñame the conditions that they treat.That is, ñame the conditions that respond best to nursing intervention.This recognition has totally changed the practice ofnursing in many countries.There has been a transition in the way we talk about our practice and'the way we think about our practice.SL1DE-2 Past (list of three) SLIDE-3 Present (list of three) Rather than rushing in with emotional support we now stop to make a differential diagnosis between fear and anxiety Rather than saying, needs teaching, we diagnosis a knowledge déficit or a motivational problem; perhaps even a cultural conflict regarding the prescribed treatment.Some patients need teaching and some patients do not--the latter may need to deal with an underlying problem such as, denial or motivation.When a nurse judges that the patient has ineffective airway clearance, more than suctioning comes to mind.Why does the patient have this problem?Viscous (thick) secretions that require increased fluids?Ineffective coughing?
A need for assistance in bringing up secretions-through suctioning?These and other questions come to mind.
SLIDE-4 appears to be bleeding Some in this audience will not believe thisbut in the área of judgment nurses used to be taught to say-appears to be bleeding.Now we say that diagnostic, therapeutic and ethical judgment is within the nurse's professional role.Another was appears to be dead.What a transition!
The International Council of Nurses in Geneva has appointed a Task Forcé to develop an international classification for nursing practice.Members and echnical advisors are from Denmark, England, and the United States.
SLIDE 5 1CNP ' • •.The project is called, nursing's next advance.The Task Forcé is working on an international classification that will describe and classify agnoses, actions, and outcomes.After the first working paper in 1993, an alpha versión of the classifica-tion system was published, and a working paper, the beta versión is on the ICN web (internet) site.
The International Classification for Nursing Practice (ICNP) is not based on any conceptual framework, probably due to the theoretical pluralism that prevails in nursing in nearly all countries.(Theoretical pluralism, as you may recall, was a term used by James and Dickoff

SLIDE 8 EXAMPLES
In the 70's to describe the co-existence of many theories of nursing, such as self care agency adaptation, life patterns, and others.Diagnoses in the ICN classification are listed under phenomena, and the remaining section is just referred to as actions.Outcomes are defined SLIDE 10 (definition-outcome)as-the status of a nursing diagnosis at points of time after a nursing intervention (International Council of Nurses, 1999,p. 4-5).
The purpose of the ICNP, and I quote from an article by two of the consultants to the Task forcé, is-to capture nursing's contributions to health, enable cross-country comparison of nursing practice, and promote the development of nursing science (Wake and Coenen, 1998, p. 112).Now let us consider diagnostic judment.Do nurses diagnose?This is an important question in our history.Diagnostic judgment in nursing has a long, but choppy history.Although Florence Nightingale diagnosed and treated nutritional déficits and other problems exhibited by the Crimean War casualties, this aspect of her many contributions was not integrated into the concept of professional nursing in its early development.It is only recently that courses on clinical judgment were included in the curriculum and integrated into clinical practice.
There were a number of developments that led to the interest in nursing diagnosis.Nursing process, the problem identification-problem solving model of nursing care delivery, started a new phase in the profession.Yet in the 1950's and 60's the problems identified were disease-based.In the next twenty years nursing theories were published.These frameworks provided a conceptual focus for nursing process.Frameworks for practice shifted the focu s of assessment from only diseaserelated problems to a nursing focus but also included the disease, if present.In addition, nurses had gained some professional autonomy in World War II and the post-war era.
This was the social and professional context in which two faculty from St. Louis University called the First National Conference on Classification of Nursing Diagnoses in 1973.They were Mary Ann Lavin, a clinical specialist in cardiac nursing, and Kristine Gebbie.a psychiatric mental health nursing specialist.Their reasons for calling the conference were two-fold: computerization of clinical records in the University Hospital and use of nurses in ambulatory care.The purpose of the conference was to identify and classify conditions diagnosed and treated by nurses.
I had the priviledge of chairing a Task Forcé that was begun at this national conference.Callista Roy was a also member of this Task Forcé which continued until 1982 when the formal organization of NANDA, was incorporated.
Currently classification conferences are held every two years, the 13th Conference was in Aprll, 2000 and quite a number of nurses from Spain participated.NANDA differs from other classification developers in that they see diagnostic category development, not only as a labelling of conditions, but as concept development.There is a process used for acceptance, revisión, and deletion that attempts to involve as many nurses as possibleincluding international committee review-in 1." y 2.° Semestres 2000 • Afio IV -N." 7 y 8 which Spain participates.This is one way to attend to the cultural sensitivity of diagnoses.In addition, this year we had a submission of a new diagnosis from Spain.This was the first country outside North America to submit a diagnosis.A member of the NANDA Diagnosis Review Committee is working with this person.
What is the present status of nursing diagnosis in North America?Nursing diagnosis has been integrated to a high extent since the mid 1980's.
It is in every clinical textbook, taught in schools of nursing, and increasingly the subject of research.It is integrated into practice in about 75% of the hospitals (that figure is based on some research in some states and personal observations).Today it has become a taken-for-granted aspect of practice.Yet, I suspect its use will decrease if attention is not given to its incorporation into recent developments in the workplace.These developments include managed care, decreased length of stay a focus on disease outcomes in critical paths, and decreased length of stay in hospitals.Yet I doubt that we will go backwards; nursing diagnoses account for the variances, that is the differences, among patients who proceed along the critical paths and those who don't.When patients don't attain outcomes it is usually because a nursing diagnosis or risk state has not been identified.A facilitating factor that influences the incorporation of nursing diagnosis into practice is the computerized patient record.Documentation on computers requires concise terms, not paragraphs.Thus nursing diagnoses are required when a health care agency institutes a computerized information processing system.

REFLECTIONS ON THE FUTURE
Let us now consider the future of nursing diagnosis.There are a number of factors that will influence the future work of NANDA or other groups within countries or regions.These are six that I would see as important: 1) Changes in the health care system.For example, there is a shift from hospital to ambulatory and community care.These changes include day-surgery and early discharge, It will be important to study the diagnoses thal occur frequently in community settings.For example, we haven't developed the diagnoses basic to health teaching, involving the patient's knowledge, comprehension, and application of health care Information.Similarly we haven't íound ways to help people modify their behavior that produce lasting change in health practices.Is it because we haven't really got a grasp on the problems and facilitating factors?
2) Demographíc changes in our patient populations.In most countries there is an aging population.Future efforts have to go into looking at the pplicability of our diagnostic categories for this population?What are the high risk conditions?Are they identified?One diagnsosi that I have been working on is support system déficit, both affective and instrumental.Do you think this might be one reason for depression in this older adult?Home care is another área of increased emphasis because of changes in the health care delivery system and the aging of the population.What are the patient problems characteristic of this population?We may have identified some.In a small study using 100 home health care nurses the three most frequently occurring diagnoses in their practice were self care déficits, knowledge déficit, and activity intolerance.Have we developed state of the art interventions for these conditions.?
3) Nursing Science Development with a focus on first level concepts or middle range theory.As Avant has said, theories are just explanations in our mind of how things look and work (Avant lOth).Laudan's (1977) view of scientific progress is interesting.He states that it is not the well-formulated theories, per se,-that are the measure of new knowledge and progress.Rather, it is how well these products of scientific activity contribute to solving problems encountered in clinical practice.Given the social mándate of nursing in society-and the obligations that come from that mándate-can we expect less from nursing science?The expectation is that nursing science will produce knowledge to solve problemsknowledge that can be used to solve the health problems encountered in practice.Valid and reliable diagnosis-intervention-outcome linkages are the building blocks of nursing science.Thus, each needs to be viewed as basic concepts and developed as such.Using concepts in clinical reasoning and judgment is very different than the attitude that says diagnosis is labelling that is picking problems from a book that lists the disease and associated diagnoses.
Identifying the highly prevalent conditions that are high treatment priority will aid in identifying priorities for research and development.In a project working toward this end the íollowing áreas of diagnoses were identified based on data from 1300 nurses in adult and neonatal inteñsive care, rehabilitation nursing and home care nursing.These were the diagnoses most frequently encountered and had high treatment priority.SLIDE 4) Computerization of clinical records.The one thing that will shape practice in the later part of this century and in the next is the computerization of clinical records.It will be important that we have further developed diagnoses for the next generation of computers.
It will also be important to have the diagnoses developed for incorporation into the WHO International Classification through the 1CN International Classifications for Nursing Practice.
5) Teaching clinical judgment and common diagnostic categories.Current theory suggest that the diagnostic process involves analytical (logical) and non-analytical (intuitive) processes.Analytical reasoning uses inductive and deductive processes and is sometimes referred to as logical, critical, or rational thinking.Understanding is gained from analysis and interpretation of information.
Non-analytical reasoning includes intutition and other processes that bring an immediate comprehension of a situaüon.Understanding is gained directly, without analysis, through intuition.The degree lo which analytic or non-analytic reasoning predominates in clinical reasoning is problably influenced by three things: the amount of experience of the diagnostician, situational requirements, and the diagnostic task.
Novices are limited to the more analytical processes.Experts with in-depth clinical knowledge and experience can use a variety of cognitive processes appropriate to the situation and the judgment task.Further reseach is needed on nurses' clinical reasoning and judgment.In addition efforts have to be directed to how we teach and/or how students develop reasoning and judgment skills.Associated with this is the need to develop methods of testing competencies in this área.In the development of clinical intuition, the selection of clinical experiences is important 6) Research in collaboration with nurses making diagnoses in their practice.Research will add to our body of nursing knowledge.In particular, some diagnoses need to be more precise, high risk populations have to be ideñtified, and interventions and outcomes linked to diagnostic categories.Studies of different populations will determine 1) cultural differences in the anifestation of a condition and 2) diagnosis-specific interventions that take into account cultural practices.
There is much challenging work ahead as we develop our clinical science and the art of using it in our diagnostic and therapeutic judgments.A diagnostic concept is merely an approximation of reality If the concept is a useful approximation, it will be used in clinical practice-it will "survive in the marketplace" of ideas.If nursing knowledge, purpose, or valúes change, the models will change.To quote a philosopher of science who urged classifiers to categorize their world but to maintain an "openness to new formulations, realizing that there is not just one truth or one perspective, and especially avoiding "hardening of the categories" (Webster,1984).As has been said in the ICN Task Forcé: As one member of the ICN Task Forcé has said-Without a language, nursing is invisible in health care systems and its valué and importance go unrecognized and unrewarded.Is nursing invisible in our countries?
Thank you for the invitation to your conference, Culture in Caring, onjune 15-18, 2000.I will be pleased to talk on the subject you suggested, Nursing Diagnosis: Past, Present, and Future.Are there any aspects that you wish to have emphasized?In order to determine the correct level of presentation, may I ask if nurses are beginning to use nursing diagnosis in education and ractice.Or, shall I emphasize the importance of diagnosis and diagnostic reasoning?I will arrive in Alicante from Frankfurt on Cóndor Airlines # 2422 at 8am.onjune 13 and will plan to leave on the 20th so there is a day or so to see your city.As Dr. Spector may have told you I am scheduled to speak in Ljublja, Slovenia.I will be there from early June until I come to Alicante.
The transatlantic portion of the airline ticket will be split between Alicante and Slovenia.
Dr. Spector mentioned that you will be paying transportation, room, andboard during the conference days.Will there be an honorarium?
Are slides or overheads better for your auditorium?I will be sending the paper in the next few weeks.Also, I would like to have some handouts that will update diagnosis development after the April, North American, Biennial Conference in Orlando.Any information that you can share with me to make the presentation meetyour needs will be appreciated.
Looking forward to the conference.Could you just reply with a YES so that I know you received this.