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“A descriptive study to validate the defining characteristics of ‘Impaired Physical Mobility’ NANDA nursing diagnosis diagnosed among patients who underwent Total Knee Replacement from selected hospital in Mumbai using Fehring’s CDV model.”
A RESEARCH PROJECT BY
IIND^ YEAR POST BASIC BSC NURSING STUDENTS
Mrs. Mrunal Bhopalbade Mrs. Anita Bande Mrs. Jisha Roy
Miss. Ayshabi Patel Miss. Suchita Gaonkar Miss Anita Wakshe
CERTIFIED THAT THIS IS A BONAFIDE WORK
OF
Mrs. Mrunal Bhopalbade Mrs. Anita Bande Mrs. Jisha Roy Ms. Ayeshabi Patel Ms. Suchita Gaonkar Ms. Anita Wakshe THE FORTIS INSTITUTE OF NURSING MUMBAI
IN PARTIAL FULFILLMENT OF THE REQUIREMENT OF THE DEGREE OF POST BASIC BSC NURSING 2014-
PRINCIPAL GUIDE RESEARCH (HOD)
PROF. RITA LAKHANI MS. SEEMA SAMUDRE
Fortis Institute of Nsg Fortis Institute of Nsg
Bhandup (W) Bhandup (W)
Mumbai-400 078 Mumbai-400 078
patients were undergraduates and 30% were graduates.70%of patients were from middle- class socioeconomic status and 20%were from higher class and 10% were from lower class.
Total 12 defining characteristics along with their weighted reliability ratio are as follows: reluctance in attempt to move(1), difficulty in purposefully moving within the physical environment(1), limited range of motion(1), fear of falling(0.95), report of pain(1), gait changes(0.9), postural instability(0.92), slowed movement(1), decreased muscle endurance strength(1), uncoordinated movement(0.76), fear of dislocation of prosthesis(0), decreased reaction time(0.92). Results indicated 10 major (weighted ratio=0.8 and above) and 1 minor (weighted ratio=0.5 to 0.79) defining characteristic and 1 defining characteristic was irrelevant (weighted ratio below 0.5).Total DCV score was 0.87.Early intervention and identification of impaired physical mobility in TKR patient is crucial. As much evidence based research is not available, further refining in this area is needed.
CONCLUSION: The aim of the present study was to develop and validate the defining characteristics, operationally defined through ROL for the nursing diagnosis, impaired physical mobility in TKR patients on their first and second postoperative day. The defining characteristics should be assessed in patients with TKR using the selected sample of expert nurses and categorize them into major and minor .We found that total 10 defining characteristics such as reluctance in attempt to move, difficulty in purposefully moving within the physical environment, limited range of motion, fear of falling, report of pain, gait changes, postural instability, slowed movement ,decreased muscle endurance strength, decreased reaction time were characterized as major and uncoordinated movement was classified as minor and fear of dislocation of prosthesis became irrelevant. Total DCV score was 0.87.This evidence will help a nurse in timely identification of defining characteristics and to form accurate nursing diagnosis. This evidence based practice will come in handy for newly recruited staffs and student nurses for practicing nursing process. By using this, more and more nurses will have more confidence in the use of official NANDA nursing diagnosis Impaired Physical Mobility.
ACKNOWLEDGEMENT
"Gratitude makes sense of our past, bring peace for today, and create a vision for tomorrow"
-Melody Beattie It is our pleasure to extend our sincere gratitude towards all those who made this study possible, with their unconditional support and encouragement. With due apologies to anyone whom we might have missed out, we would like to thank the following people who have contributed much more than many of them realize.
In the very beginning we would like to express our sincere thanks to "Almighty God" whose grace & blessing, we experienced throughout the study.
First and foremost we express a deep sense of gratitude to our principal Madam Rita Lakhani whose creativity and commitment to excellence has helped us to turn this manual script into a finished product. We would like to extend our whole hearted gratitude to our research guide Ms. Seema Samudre for her cordial support, valuable information & guidance, which helped us in completing this task through various stages. We acknowledge her valuable and constructive suggestions during the planning and development of this research work. Her willingness to give her time so generously is much appreciated. Her help, stimulating suggestions, knowledge, experience & encouragement helped us in all times of study & analysis of the project. We have enjoyed every moment of insightful discussions with her.
We are obliged to all the faculty members, librarian, facilitators of our college, for the inspiring ideas & advices provided by them especially during the validity period, in their respective areas of expertise.
Our grateful thanks are also extended to the practical guidance given by our statistician Mrs. Vasundhra Padmanaban and Mr. Clifford for enriching us with knowledge of
TABLE OF CONTENTS
CHAPTER CONTENT PAGE No.
I
Acknowledgement Abstract INTRODUCTION. Need for the study Statement of the problem Objectives Operational definitions Assumptions Delimitations Limitations Hypothesis Scope of the study Ethical principles Conceptual framework II REVIEW OF LITERATURE.
III RESEARCH METHODOLOGY. Research approach Research design Validation Setting of the study Population Sample and sample size Sampling technique Validity Development of tool Data collection process Plan for data analysis IV ANALYSIS, INTERPRETATION AND DISSCUSSION. V SUMMARY, FINDINGS, CONCLUSION AND RECOMMENDATIONS.
VI
REFERENCES.
BIBLIOGRAPHY
LIST OF APPENDICES
LIST OF TABLES & FIGURES
Table No. Title Page No.
1(A)
1(B)
2(A)
2(B)
2(C)
2(D)
2(E)
2(F)
3(A)
Demographic data of expert nurses: Age of expert nurses Clinical experience of expert nurses Demographic data of respondents: Gender of TKR patients Age of TKR patients High risk groups in TKR patients Socio-economic status of TKR patients Diet followed by TKR patients Educational status of TKR patients Weighted ratio of reliability:-Defining characteristics of Impaired Physical Mobility
Appendix No.
Title Page No.
A. B. C. D.
Informed consent Covering Letter for validation Tool: Observational checklist Master code sheet
than this periodic nursing audits (external and internal), optimum use of nursing process and standardized accreditation plays a major role in maintaining nursing standard.
In providing care, nurses implement the nursing care plan using the nursing process. The nursing process is the method used to assess and diagnose the needs, plan outcomes and interventions, implement interventions and evaluate the outcomes of the care provided. The nursing process uses clinical judgment to strike a balance of epistemology between personal, interpersonal and research evidence in which critical thinking plays a major part to categorize the patients issue and course of action.
The term nursing diagnosis is used to describe the sign and symptoms; defining characteristics that are derived from the nurses assessment of the patient to exclude problems that are treated by physician’s interventions. Practice is the center of nursing, and nursing diagnosis has been the primary instrument for refining the content upon which practice is based (Aydelott & Peterson, 1987).
A nursing diagnosis is a part of the nursing process and clinical judgment about individual, family and community experiences/responses to actual or potential health problems/ life processes. NANDA (North American Nursing Diagnosis Association) is universally accepted for formulating nursing diagnosis. It was founded in 1982. The organization grew out of the National Conference Group, a task force established in 1973, the First National Conference on the classification of nursing diagnoses, held in St. Louis, Missouri, USA.NANDA International has approved more than 200 nursing diagnoses for clinical use, testing and refinement.
Nursing diagnoses are developed on data obtained during the nursing assessment and it provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability (approved at the ninth NANDA conference; amended in 2009 and 2013). In order to make a ‘problem focused diagnosis’ each of them must be supported by the defining characteristics.
Defining characteristics are observable cues/inferences that cluster as manifestations of a problem-focused, health-promotion diagnosis or syndrome. This does not only imply those
things that the nurse can see, but things that are seen, heard (e.g. the patient/family tells us), touched or smelled.
Nurses who use the official North American Nursing Diagnosis Association (NANDA) list of nursing diagnosis often find the diagnostic labels and their defining characteristics are not relevant and are not what they actually identify in clinical practice. Many of them were included with little empirical evidence. It is evidenced with study of validation of nursing diagnosis of anxiety by expert Brazilian nurses and clinicians using NANDA international defining characteristics in 2008 with semi structured questionnaire and sample of 120 nurses ,based on the framework of the diagnostic content validation model. The results showed that among the 71 characteristic of anxiety, 8 were identified as critical defining characteristics of anxiety (score>or =0.8) by the expert nurses.
Nursing diagnoses consists of Common related factor (those aetiologies associated with diagnosis for an actual problem), defining characteristic (assessment data that supports the nursing diagnosis), common risk factors (those situations or conditions that contribute to the patience potential to develop a problem or diagnoses), common expected outcome, Ongoing assessment (both independent and collaborative) and defining g characteristics.
Gathering evidence that nurses actually do identify common defining characteristics is the process of validation. Gordon and Sweeney have stated that the process of validation "involves determining if the pre-identified defining characteristics occur as a cluster in a sufficient number of cases." Although there is a need for empirical validation of nursing diagnosis, few practical approaches on how to proceed have been developed. Several models for validation of nursing diagnosis have been proposed and applied. The models of Richard Fehring are the most utilised, primarily the diagnostic content validation model (DCV) and the clinical diagnostic validity model (CDV) and differential diagnostic validation model (DDV).
Impaired physical mobility a nursing diagnosis approved by the North American Nursing Diagnosis Association, defined as the state in which an individual has a limitation in independent, purposeful physical movement of the body or of one or more extremities.
In the care of orthopaedic patients i.e. Total Knee replacement the establishment of accurate Nursing Diagnosis can contribute to improvement in the patients’ quality of life. Nursing goals are to maintain functional ability, prevent additional impairment of physical activity and ensure safe environment.
NEED OF THE STUDY
“The logic of validation allows us to moves between two limits of dogmatism and
sceptism’’ - Anonymous.
The lack of research based literature and of research model for validating nursing diagnosis results in some in research efforts.
Research must however move forward if there has to be progress in nursing and medical diagnostic models and use of nursing diagnosis to improve communication among nurses.
The problem with nursing diagnosis is that there are few defining characteristics that nurses agree on as commonly identifiable and as suitable for labelling.
The nursing process has been the main methodological instrument for a professional practice systematic performance. Nursing diagnosis is understood as a stage of the process responsible for providing means for proposing exclusively nursing interventions regarding the detected health problems. In addition to being a work tool for those professionals, they provide the use of appropriate language, facilitating the communication with patients (1).
The 2008 NANDA edition, used in this study, comprises the taxonomic structure II, with 13 domains, 47 classes and 187 nursing diagnoses.
Among those domains, Activity/Rest has five classes. One of them is denominated Activity/Exercise and comprises eleven approved nursing diagnoses. That is defined as moving body parts (mobility), performing work or actions frequently (but not always) against resistance.
Among diagnoses in that class, impaired physical mobility is included, understood as physical movement limitation, whether independent or intentional, of one or more extremities.
Generally, impaired mobility is seen under a functional perspective by the individual's inability to move freely. Such inability can vary among individuals under similar conditions, and in the same individual, throughout different stages.
The presence of Impaired Physical Mobility diagnosis implies in changes in the gait speed, which can generate an increased risk of falls, in addition to higher dependency regarding daily activities, restraining individuals from returning to their working activities, causing difficulties in moving around their own home and to other locations.
It is very important to assess impaired physical mobility as prima facie as it can result in longer hospital stay, impaired, skin integrity, DVT, pulmonary embolism, respiratory infections etc.
This problem can be mainly identified or observed in patients who have undergone TKR.
One of the conditions that generally interfere in patients' mobility is total knee replacement. It is believed that the establishing of the nursing diagnosis of ‘Impaired physical mobility’ in orthopaedic patients may favour nursing implementation for the management of the impaired physical mobility in TKR patients and guide measures for its prevention. This study also proposes to highlight this diagnosis, validating the meaning of each defining characteristic.
Thus, the objective of this study is to validate the defining characteristics of the NANDA nursing diagnosis Impaired physical mobility and categorize them into major and minor in TKR patient.
In our study, it refers to validation of defining characteristics of impaired physical mobility nursing diagnosis diagnosed among TKR patients on their first and second postoperative day, by using CDV model and classifying them into major and minor depending on their frequency of occurrence.
NANDA: NANDA INTERNATIONAL (formerly the North American Nursing Diagnosis Association) is a professional organization of nurse’s standardized nursing terminology that was officially founded in 1982 and develops researches, disseminates and refines the nomenclature, criteria and taxonomy of nursing diagnosis.
Our study refers to the classification in the Taxonomy II North American Nursing Diagnosis Association.
EXPERT NURSES: Expert nurses are the one who is highly competent in their field of practice and has thorough knowledge and skills in assessing the defining characteristic of NANDA nursing diagnosis.
More recently Fehring’s (1994) defined experts as “having a minimum of a master degree in nursing with a defined area of clinical expertise’’ (p.59). Although he believed that a master degree was a minimum criterion, so criteria have been described so that a nurse may be considered an expert on nursing diagnosis. Each criterion described a score, and to be considered an expert, the person needs to obtain a minimum five points (criterion/points: Master degree in nursing:4; Master degree in nursing with dissertation content directed to nursing diagnosis study:1; publication of article in nursing diagnosis in reference journals:2;Article published on nursing on nursing diagnoses with relevant content to the area:2; PhD in the field of nursing diagnosis:2; Clinical experience, at least one year in the study area of diagnosis:1; and Certificate (specialization)of relevant clinical practice in the field of the diagnostic studies :2.
The higher the score, the greater the strength of the assessment evidence.
In our study, two expert nurses has thorough knowledge and skills in assessing the defining characteristic of NANDA diagnosis of Impaired physical mobility in post TKR patient on the first and second postoperative day. They have completed their diploma in nursing (G.N.M.) and are registered with Maharashtra Nursing Council and are pursuing their 2nd^ year studies of Post Basic B.Sc. Nursing. One of the expert nurse has 4 years’ experience in orthopedic and 3 years’ experience in midwifery and other expert nurse has 3 years’ experience in C.V.T.S.
Defining characteristics : Observable cues/ inferences that cluster as manifestations of a problem-focused, health-promotion diagnosis or syndrome. This does not only imply those things that the nurse can see, but things that are seen, heard (e.g. the patient/family tells us), touched or smelled. It is the character peculiar quality of a person or thing, typical or distinctive.
In our study defining characteristics are the selected manifestation experienced by TKR patients due to impaired physical mobility. A list of total 12 defining characteristic selected from NANDA and other nursing care plans, as reluctance in attempt to move, difficulty in purposefully moving within the physical environment, limited range of motion, fear of falling, report of pain, gait changes, postural instability, slowed movement, decreased muscle endurance strength, uncoordinated movement, fear of dislocation of prosthesis, decreased reaction time, were taken.
Impaired physical mobility :- A nursing diagnosis approved by the North American Nursing Diagnosis Association, defined as the state in which the individual has a limitation in independent, purposeful physical movement of the body or of one or more extremities.
In our research impaired physical mobility is the restriction of movement experienced by the patients on the first and second day of TKR surgery.
TKR: Total Knee Replacement is a surgical procedure to replace the weight bearing surfaces of the knee joint to relieve pain and disability
In our research TKR patients upto 2nd^ postoperative day are the participants.
SCOPE OF THE STUDY
This study helps to validate one NANDA nursing diagnosis.
This study helps us to categorize defining characteristics into major and minor.
This study evidence will help a nurse in timely identification of defining characteristics and to form accurate nursing diagnosis
This study will help the nurse to know which defining characteristics to be identified before the diagnosis can be made.
This validation studies are important for advancing evidence based practice.
ETHICAL PRINCIPLES :
- The research title was validated by the ethical committee of Fortis institute of nursing.
- Before observation the patient was given an informed consent, which reveals willingness to participate.
- Confidentiality about patient’s details was maintained.
- Complete privacy was given to the patient when observation was carried out.
- The patient was assured that no harm will be done to him /her when the study is being conducted.
- The patient was given an option of dropping out of the study at any point of the time.
CONCEPTUAL FRAMEWORK
A framework is a brief explanation of theory or those portions of a theory which are to be tested in quantitative study. Theoretical and conceptual framework is commonly used in quantitative research studies, which help to organize the study and provide a context for the interpretation of the study results. The terms theoretical and conceptual frameworks are used interchangeably, but actually they are different. Charter (1975) has stated that the conceptual framework formalizes the thinking process, so that others may read and know the frame of reference, basic to the research problem.
This study is validation of defining characteristics of impaired physical mobility of TKR patients on first and second postoperative day based on “FEHRING CONTENT VALIDATION MODEL” so the step of that model reflected by this conceptual framework.
In This Study:
OBSERVATIONAL CHECKLIST OF DEFINING CHRACTERISTIC:
First in our study, we need to develop an observational checklist of defining characteristic of impaired physical mobility in TKR patients. We referred defining characteristics of impaired physical mobility given by NANDA and also through ROL. The list of defining characteristic of impaired physical mobility in TKR patients on their first and second postoperative day. Each defining characteristic was operationally defined as to see in them in postoperative TKR patients.
Then the observational checklist was validated by 11 MSC teachers in Fortis Institute of Nursing. Changes were made in checklist as per feedback from teachers. In the scheduled week data was collected by observing the TKR patients by using the interrater reliability method the defining characteristics were classified as minor and major criteria.
As the model opted was content validity model – Clinical diagnostic validation model (CDV) by Inter-rater method. This model is based on obtaining evidence for the existence of a given diagnosis from the actual clinical setting. The original CDV model used a clinical
