A qualitative study to explain the criteria of nursing managers in selecting effective nursing diagnosis
Categoría del artículo: Original article
Publicado en línea: 16 dic 2024
Páginas: 469 - 477
Recibido: 18 ene 2023
Aceptado: 12 abr 2023
DOI: https://doi.org/10.2478/fon-2024-0051
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© 2024 Alaa Jawad Kadhim et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.
In the field of nursing, nursing diagnosis, as the second stage of the nursing process, refers to the practice of identifying health problems. It is one of the main concepts of nursing that strictly define and map the relevant knowledge.1,2 According to the theory presented by Yura and Walsh, nursing diagnosis is a clinical judgment regarding the care and response of the individual, family, or community to potential or actual health problems or life processes. In the formulation of any nursing care plan, patient examination and nursing diagnosis are two important components. Accurate and documented nursing diagnosis is considered as the basis for making decisions in nursing interventions.3,4 Nursing diagnosis classification systems have been developed to help nurses recognize patient problems to establish communication between nurses and other health care providers.2,5 The need for nursing diagnoses was first recognized at the first national conference in 1973. In 1982, the same conference team adopted the name the North American Nurses Diagnosis Association (NANDA) by recognizing the participation and assistance of nurses.6 The NANDA Nursing Diagnostic Standard Terminology is one of the most important and widely used international standard terminologies for nursing care worldwide. This classification system is currently translated into more than 15 languages and is used in more than 30 countries.1,2 Diagnosis is the major denominator of all fields of knowledge, especially those of medical disciplines.2
Studies on the integrity of nursing diagnoses are perceived to be strongly influenced by the methodological framework developed in the 1980s. However, the effectiveness of these models for validating elements of nursing diagnoses is widely debated.7 Regarding nurses’ attitudes toward diagnosis, D’Agostino et al.8 argued that classifying nurses based on belief patterns can help administrators and educators provide operational interventions in nursing diagnosis. Lotfi et al.9 showed that nurses are interested in implementing the nursing diagnosis, but there are obstacles in this regard, including the lack of human resources and electronic facilities. Moreover, Gazari et al.10 showed that low awareness, low nurse-to-patient ratio, lack of interest, lack of resources, and poor supervision are important challenges for nurses. Zamanzadeh et al.11 also stated that the most important challenge of nursing is the intangible understanding of the concept of the nursing process. Therefore, the nursing process and diagnoses are often cited as a practical and basic standard for selecting nursing interventions in achieving the expected outcomes.6,12 Considering the significance of nursing diagnoses in recording clinical care and the lack of studies on the selection of effective nursing by nurses and nursing managers, the purpose of the current study was to examine the criteria of nursing managers at various organizational levels in selecting effective nursing diagnosis.
This study was qualitative research that used conventional content analysis and was conducted in 2021 in Alborz province, Iran. This study aimed to explain the criteria of managers at different levels of nursing, including nursing managers, clinical and educational supervisors, and head nurses, in selecting effective nursing diagnosis.
Conventional content analysis is widely used by researchers as a systematic approach to explain a concept or notion on which there is not much information, leading to revision, valid inferences from information, and the production of new knowledge and insights. This approach is highly recommended for examining the experiences and attitudes of individuals toward a particular subject.13 Moreover, since there is not enough information about the views of nursing managers in the field under study, the qualitative method was used in this study.
Participants were selected from among nursing managers at various levels, including nursing managers, clinical and educational supervisors, and head nurses from intensive care and general wards. Purposeful sampling was performed with maximum variability for the study. Inclusion criteria included those having a bachelor’s degree or higher in nursing and at least 1 year of management experience at various levels of nursing. Exclusion criteria included those who did not did not consent to publish information in the final research report and did not want to attend a probing interview if necessary.
Individual, semi-structured, in-depth face-to-face interviews were used for data gathering. The interview was started by the first author using the following general question: “How do you think a nursing diagnosis system can be appropriate and useful?” The location of the interview was according to the request of the participants after their work shifts in the hospital; the interviews lasted from 30 min to 45 min. The participants were informed about the aim of the study; the interviews were carried out after the participants consented; moreover, the time and location of the interviews were based on the participants’ preference. After receiving demographic information from the participants, the main interview questions were asked in a semi-structured manner, and the interviews were recorded digitally with the informed consent of the participants.
Data analysis was performed using the Zhang–Wilde–muth analysis method at the same time as data collection (Table 1). In this method, codes and categories were extracted directly and inductively from raw data through a systematic and transparent 8-step process. (1) Only one interview was conducted in each session. Interviews were strictly transcribed by the first author immediately after each interview; (2) each interview was read and reviewed several times by the research team to extract semantic units, which were then reviewed and coded several times; (3) the extracted codes were classified based on the conceptual and semantic similarity and were formed into sub-categories; (4) the research team constantly reviewed the extracted codes to achieve clarity and consistency; (5) data collection then continued until saturation was reached; (6) re-check the accuracy and stability of the data by all authors and two external peer reviews, (7) finalizing and confirming categories and subsets, and (8) finally, full report of 8 steps of analysis.14
Demographic characteristics.
| Parameter | Frequencyq |
|---|---|
| Head nurse | 4 |
| Educational supervisor | 1 |
| Clinical supervisor | 3 |
| Nursing manager | 2 |
| Male | 3 |
| Female | 7 |
| Bachelor’s degree | 6 |
| Master’s degree | 3 |
| PhD | 1 |
| 15 ± 3 |
To enhance the validity of research data in this study, various data-optimizing methods were employed to ensure the credibility of the data, for example, allocating 3 months for collecting data, sustained daily involvement with the subject and research data by conducting a weekly interview, and constant appraisal of the extracted data by the research team. Confirmability was determined by seeking the help of an external reviewer expert in the field of qualitative studies. Moreover, all data were periodically reviewed by the authors. Several brainstorming sessions were also conducted during the data collection and analysis stages for fine-tuning the data. For transferability, data sampling was performed with maximum diversity, gender, age, and management levels (Table 1) and one data check was performed by 8 participants. For dependability, all stages of the research were written and reported in detail.15
This study was approved by the Ethics Committee of the Alborz University of Medical Sciences with registration number IR.ABZUMS.REC.1400.168. Informed consent was obtained from all participants, according to which the authors were permitted to have the voice of the interviewees recorded. Participants were informed about the purpose of the study and the confidentiality of the information collected and their names and were permitted to leave the study at any time.
Two nursing managers, one educational supervisor, 3 clinical supervisors, and 4 head nurses from intensive care and internal medicine wards were interviewed. Three were the male and seven had a bachelor’s degree in nursing (Tables 2 and 3). The results of the analysis lead to the extraction of two main categories: “centrality of the nursing profession,” with the sub-categories: having nursing function and compliance with organizational and professional principles of nursing, and “covering the patient care aspect,” with sub-categories of having potential of facilitating and adapting to patient care conditions (Table 2).
Categories and sub-categories.
| Category and sub-category | Codes |
|---|---|
| Compatibility with nursing practices | Being specific to the field of nursing; ability to establish team communication; usability in intercultural nursing; complying with task delegations; compatible with nursing concepts; being operational and clinical; ease of use for nurses; acceptance by clinical nurses and nursing managers; applicable in physical and mental illnesses |
| Compliance with organizational and professional principles of nursing | Usability in emerging and recurrent diseases; increasing patient–nurse satisfaction; time-effectivity; improving the responsibility of nurses; having a guide and systematic nursing diagnoses; being comprehensive; cost-effectivity; reducing the workload of nurses; being updatable |
| Having potential to facilitate | Ability to establish more patient–nurse communication; eliminating barriers to active involvement of nurses in bedsides; leading to the alteration of attitudes of staff and clients |
| Adaptation to patient care conditions | Being both process- and outcome-driven; compatibility with the conditions of patients in different wards; having a nursing diagnosis for all stages of care from hospitalization to death |
Demographic characteristics of participants.
| Participant number | Age (years) | Gender | Educational level | Clinical experience (years) | Managerial level |
|---|---|---|---|---|---|
| 1 | 36 | Female | Master’s degree | 12 | Clinical supervisor |
| 2 | 33 | Male | Bachelor’s degree | 6 | Head nurse; ICS |
| 3 | 44 | Female | Bachelor’s degree | 20 | Nursing manager |
| 4 | 44 | Female | Bachelor’s degree | 18 | Head nurse; general |
| 5 | 25 | Female | Master’s degree | 2 | Educational supervisor |
| 6 | 26 | Female | Bachelor’s degree | 3 | Clinical supervisor |
| 7 | 47 | Female | PhD | 23 | Nursing manager |
| 8 | 39 | Male | Bachelor’s degree | 14 | Head nurse; general |
| 9 | 31 | Male | Master’s degree | 3 | Head nurse; ICS |
| 10 | 33 | Female | Bachelor’s degree | 7 | Clinical supervisor |
This category consists of two sub-categories: “compatibility with nursing practices” and “compliance with organizational and professional principles of nursing.” Nursing managers generally argue that efficient diagnoses should not only bear the functional aspect of nursing but also be in line with all organizational and professional goals of nursing.
According to nursing managers, efficient nursing diagnoses should be based on criteria such as being specific to nursing and compliance with various delegation methods in nursing. Nursing managers stated that for nursing diagnoses to be practical, they must be compatible with nursing concepts. In this regard, participants 4 and 6 stated, respectively,
Nursing managers agreed that nursing diagnoses should have operational and clinical features as its ease of application would be welcomed by clinical nurses and nursing managers. It should also be applicable in all areas of nursing work, such as for patients with psychological and physical problems in the acute or chronic phase. As such, participants 2 and 5 stated, respectively,
Nursing managers further argued that the related diagnoses should have the actual and potential capacity of establishing relationships between nurses, physicians, and other medical staff. While being aligned with Iranian culture, the routines should be applied in cross-cultural scenarios as well. As such, since effective communication in nursing is critical to its integrity, nursing diagnoses should be enabling and rich in educational values. Participants 3 and 10 stated, respectively,
Mid-level and high-level nursing managers seek to determine the effectiveness of nursing diagnoses in the quantity and the quality of care, in actual medical applications, and the implementation of the goals of medical organizations and the nursing profession. Since they adopt a rather macro-level attitude, they also include non-clinical criteria that are in line with the goals of accreditation and clinical governance in their nursing diagnoses. Nursing managers are looking for important criteria such as improving the accuracy and responsibility of nurses and increasing patient and nurse satisfaction seeking the use of nursing diagnoses. Participants 2 and 5 stated, respectively,
Given that nursing managers are aware of the high workload of nurses in case of a low nurse-to-patient ratio, nursing managers actively seek out nursing diagnoses that do not increase the workload of nurses. That is, the nursing diagnoses deemed time-consuming is again discarded. In this regard, participants 2 and 4 stated, respectively,
Nursing managers argued that they were looking for nursing diagnoses that were flexible to the diseases and clinical cases of the medical world. Given the time and expense involved in trying to keep the skills and knowledge of the nursing staff up to date, the managers stressed the significance of nursing diagnoses in this regard, further arguing that nursing diagnoses should not only be comprehensive in various aspects but also should be able to be updated and used for emerging and recurrent diseases. As such, participants 2 and 7 stated, respectively,
This category consists of two sub-categories: “Having potential to facilitate” and “Adaptation to patient care conditions.” From the point of view of nursing managers, in addition to organizational aspects, nursing diagnoses should be compatible with all conditions of patients with different conditions and patient–nurse relationship. Nursing managers believe that the nursing diagnosis system should facilitate work issues.
For nursing managers, considering the importance of establishing a therapeutic relationship between the nurse and the patient and the ensuing satisfaction in the patient and family, which would, in turn, lead to the promotion of nursing care, the selected nursing diagnoses should facilitate the establishment and maintenance of a deep and effective relationship between the nurse and the patient and his/her family. High-level nursing managers cite that all elements of the treatment system will be negatively affected if the system is not able to establish the expected nurse–patient relationship. In this regard, participants 7 and 10 stated, respectively,
According to nursing managers, the rules issued by the Ministry of Health and medical universities cause nurses to spend a lot of time performing repetitive hand-written documentation in nursing stations, and hence, nurses cannot spend much time at the patient’s bedside and offer their nursing care. That is, nursing diagnoses should not only alleviate this issue but should also encourage the nurse to be present at the patient’s bedside as much as possible to provide actual care. In this regard, participant 10 stated
Nursing managers are actively seeking to alter the attitudes on nursing from a mere occupation and source of income to a humane and valuable profession that is different from other professions, an objective that seems possible only through the virtue of proper nursing diagnosis. According to nursing managers, a change in nursing attitude can lead to a change in the style of providing nursing care, as a result of which patients and their families can establish a friendly relationship with the nursing team. Participants 5 and 9 stated, respectively,
Most mid-level and lower-level nursing managers believe that the set of nursing diagnoses should be highly applicable and scalable to be used effectively in all wards of a hospital. They further believe that nursing diagnoses should be multidimensional, in general, to create unity of procedure and be applicable to different parts of a medical center. In this regard, participants 1 and 3 stated, respectively,
“In my opinion, the nursing diagnoses should be developed in such a way that even when a patient is transferred from one hospital to another, the previous flow of nursing is maintained.”
Nursing managers also believe that nursing diagnoses should include all phases of care from patient admission, triage, to end-of-life care. According to some nursing managers, current nursing diagnoses are specific to the middle days of a patient’s hospitalization and do not cover the entire timeline of admission to death. In this regard, participants 2 and 5, respectively,
Regardless of differences of opinion and consideration of different criteria by managers, they agreed that appropriate nursing diagnosis should consider both outcomes and processes. That is, being process-driven improves care safety and reduces work stress, while being outcome-driven leads to expected and determined success at the ward and hospital levels. According to nursing managers, these features lead to optimal nursing care. As such, participants 4 and 10 stated, respectively,
The present study was conducted to examine the criteria of nursing managers at different organizational levels in selecting effective nursing diagnosis. According to the participants, the nursing diagnosis consists of two parts, namely, (1) centrality of the nursing profession and (2) covering the patient care aspect. Based on the results of our study, nursing expertise and perspective is an efficient tool for enhancing the performance of nurses. Fukada16 argues that the preparation and development of specialized training for nurses is an efficient way to improve the educational performance of nursing staff. Furthermore, optimal diagnosis capacity is one of the key skills to increase the quality of nurses’ performance in the workplace. This is consistent with the findings of Tan Hovey et al. who reported that diagnosis capacities can be maintained through continuous practical and theoretical training deployed by senior nurses.16
The results of our study showed that accurate and timely diagnosis of nurses is very effective in the proper management of patients. Lack of familiarity of nurses with the scientific concepts of nursing will lead to their discouragement and confusion and would cause serious problems for the patients. As such, the nursing managers participating in this study believed that the implementation of continuous training can be very effective in achieving this feat. The findings of the current study are consistent with those of Anderson et al.17 who stated that familiarity of the nursing community with modern science and its accurate implementation, along with familiarity with the description of duties defined in each group according to the instructions of the Ministry and also the laws proposed in the judicial system, can provide strong support for the active and effective presence of nurses at the bedside and generate a performance free from all negligence and error. Bozorgzad and Hemati18 showed that the use of human resources without priory considering the ability of individuals, the use of expert but inexperienced personnel as managers, and the failure to assess one’s ability to manage a nursing department would have a highly detrimental effect on integrity of patient care. The researchers further stated that failure to provide the required in-service training routines and not being familiar with the job descriptions of the staff not only increase the probability of medical errors but also would increase the probability of lawsuits. The results of the present study are consistent with those of the study by Lewis et al.19 who stated that although it is not possible to eliminate work errors, reducing the workload, increasing the number of nurses, and using an accurate monitoring system and proper training can greatly reduce nursing errors.
According to the results of the research, the ability to create and strengthen the team relationship between nurses, doctors, and patients has a significant effect on strengthening the morale of patients and equipping the hospital’s medical staff with appropriate skills. In this regard, various studies have pointed to the need to enrich team communication between nurses and also the relationship between nurses and patients. Shohani and Tavan20 reported that because the training of communication skills and communication between patients and nurse can have an effect on patients’ conditions, managers and officials of nursing education should pay attention to improving the communication skills of nurses. In-service training courses can improve the communication skills of nurses, which would lead to a higher quality of services. The results of this study are consistent with those of a study conducted by Fawaz et al.21 who reported that the implementation of regular training programs for nurses in different care departments leads to better nursing performance and reduce the rate of errors. They also pointed out that regular training programs should be implemented in hospitals and also strongly recommended conducting pilot studies similar to their own.
Nursing managers also acknowledged that nursing diagnoses for clinical cases require up-to-date skills and knowledge of nurses. In line with the results of this study, Alshammari et al.22 reported that to adapt to the rapidly changing health care settings of the modern medical realm, nursing educators should regularly review their training curricula, teaching–learning strategies, and programs adopted to prepare new professional nurses. On the other hand, Dubey and Mlotshwa23 argued that the most important practical lesson that nurses can be taught is to what to observe, how to observe, what signs indicate that patients are recovering, and which symptoms are more important. In addition, linking professional nursing skills with mastery of scientific knowledge of environmental health concepts from interdisciplinary studies is essential to modify the educational process of health professions. Environmental impacts on the health and well-being of individuals, families, and communities are increasingly becoming interdisciplinary. These effects require integrated knowledge of prevention and improvement of environmental health consequences in the education of all health professions.
Establishing a proper therapeutic relationship between nurses and patients, as well as adopting measures to improve the satisfaction of patients and their families, will lead to sustained high-quality nursing care. In addition, the managers who participated in this study pointed out that the selected nursing diagnoses should facilitate the establishment and maintenance of a deep and effective patient–nurse relationship. The results of this study are consistent with those of Lotfi et al.23 who reported in their study that the weak communication between nurses and patients leads to lower levels of patient satisfaction. They also reported that improving patient satisfaction in the hospital should be a priority for hospital managers.24 Therefore, the training of personnel, especially nurses, and the identification of motivational factors and job dissatisfaction can be a prelude to the development of patient satisfaction. On the other hand, sparing a lot of time on training medical staff and nurses increases costs for manual and repetitive documentation in nursing stations, and nurses hence cannot spend much time at the patient’s bedside, leading to the poor performance of nurses. Kieft et al.25 reported that the inclusion of the element of education and daily practice for nursing lead to positive experiences for nurses and patients. However, given that nurses work in the field of health care, they must reconcile efficiency, cost, and responsibility with their willingness to provide nursing care based on the patient’s needs and preferences. Nurses should have autonomy in their performance to be able to practice nursing.25
One of the key factors in improving nursing performances is to change their attitude toward their profession, from being perceived as a simple employee to being deemed as an effective element in the process of diagnosing and treating patients. Our study revealed that nursing managers believed that enhancing the quality of nursing education can unearth its gold standard. Similarly, John et al.26 reported that even though the majority of nurses were satisfied with their job description, they were not satisfied with their performance incentives/bonuses. Nurses generally think that having the title of an employee with a fixed salary makes them less satisfied, in turn leading to poor performance. Therefore, top-level nursing managers acknowledge the constructive effect of nursing care and hence provide optimal ground for their efficient performance.
Nurses should be equipped with high levels of diagnosis capacity to be able to efficiently manage patients from one ward to another. During the study, managers stated that nursing diagnoses should apply to all stages of care, from the moment the patient is admitted to the triage to end-of-life care in the inpatient or intensive care unit. In a similar study, Schewe et al.27 reported that enhancing the diagnosis capacity of nurses enables proper and optimal management of patients and increases the quality of their treatment during the period of hospital care. On the other hand, the number of elderly patients referred to the emergency department is higher than that of other patients. However, according to their studies, the diagnosis capacity of nurses and treatment staff decreases as the age of patients increases.
The findings of this study indicate that nursing managers of different organizational levels have varying views, yet all agree that an effective system should cover all elements involved in the field of treatment, including patients, nurses, and ward conditions. In determining the effectiveness of nursing diagnoses, high-level nursing managers have rather organizational and macro-scale perspectives, while mid- and lower-level managers have an operational and functional attitude toward nursing.