Validation of the Nursing Diagnosis Chronic Confusion in Slovak and Czech Nursing Practices

ISSN 1803-4330 peer-reviewed journal for health professions volume V/1 April 2012 Validation of the Nursing Diagnosis Chronic Confusion in Slovak and Czech Nursing Practices Martina Tomagová, Ivana Bóriková Department of Nursing, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava ABSTRACT Objective: Content validation of the nursing diagnosis Chronic Confusion and identification of the defining characteristics in the Slovak and Czech nursing practices. Methods: Fehring s retrospective Diagnostic Content Validity Model (DCV Model) was used. Experts were nurses who scored minimum 4 points according to modified Fehring s criteria. The group of respondents consisted of 144 Slovak and 107 Czech nurses. Results: Czech and Slovak experts alike considered the following characteristics to be defining (weighted score WS higher than 0.75): altered interpretation/response to stimuli, progressive deterioration of intellect, clinical evidence of organic brain impairment, time and space disorientation, and long-term cognitive impairment, which are congruent with the characteristic features of dementia syndrome. Conclusions: Experts did not regard all the defining characteristics to be of the same importance. This was due to the composite of respondents, who only reached bottom level of criteria for an expert (6 points), incompatibility of NANDA-I Taxonomy II with the List of nursing diagnosis used in the Slovak Republic and lastly the absence of standardised nursing terminology in the Czech Republic. KEY WORDS nursing diagnosis, chronic confusion, defi ning characteristics, dementia, validation study INTRODUCTION The nursing diagnosis (ND) of Chronic Confusion (CHC) was implemented in the classification system of the NANDA Taxonomy I Nursing Diagnoses in 1994. The current version of NANDA-I Taxonomy II classifies it under Domain 5 Perception/Cognition, Cognition Class. NANDA-I (2009, p 167) defines Chronic Confusion as irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli; decreased capacity for intellectual thought processes; and manifested by disturbances of memory, orientation, and behaviour. These changes in intellect, personality, and cognition are characteristic of organic mental disorders (Höschl et al., 2002, p 452), which occur in specific groups of patients, such as in gerontopsychiatry, neurology, neurosurgery, and in the elderly in general. In nursing practice, this ND is particularly applicable in patients with various types of dementia (atrophic-degenerative, e. g. Alzheimertype dementia (AD), Parkinson s disease dementia; in secondary dementias, e. g. ischemic vascular dementia) and with an organic amnestic syndrome (e. g. post-traumatic changes in the brain). In connection with research in nursing diagnosis, the importance of validation studies of nursing diagnoses continues to grow. Validation describes exactly how a diagnostic marker, in our case the defining characteristics of a selected ND, describes the patient s reaction to the current health problem. OBJECTIVE The study aimed to validate the ND Chronic Confusion in the Czech and Slovak nursing practices and establish which defining characteristics are considered primary and which secondary by experts. PARTICIPANTS AND METHODS The group of experts was selected on a non-random basis. We addressed nurses whom we assumed, based on the selected healthcare centre, were experienced in the care of patients with impaired cognitive functions. Experts were nurses who met inclusion criteria in the environments of the Slovak Republic (SR) and Czech 25

Republic (CR) as defined by Zeleniková et al. (2010, p 409). These criteria (50 100 for DCV model) based on Fehring (1986, p 188; Levin, 2001, p 29), were met by 144 nurses in SR and 107 nurses in CR. Scores of the defined criteria ranged from 4 points (min.) to 17 points (max.); Table 1 shows the average scores in the SR and CR groups. Table 1 Characteristics of the expert participants SR CR criteria x SD x SD age (years) 40,22 8,51 36,2 7,01 work experience (years) 19,19 9,46 15,32 7,64 evaluation of experts (points) 6,00 1,68 6,03 1,7 (X = arithmetic mean, SD = standard deviation) Table 2 contains the basic and supplementary inclusion criteria required for the research participants. Not all the nurses met the conditions of the supplementary criteria. Table 2 Participant inclusion criteria inclusion criteria SR CR basic n = 144 100% n = 107 100% nursing training: master s degree (3 points) bachelor s degree (2 points) secondary nursing school/ higher vocational school (1 point) clinical experience: 1 5 years (1 point) over 5 years (2 points) over 10 years (3 points) 43 46 55 14 15 115 30 32 38 10 10 80 18 56 33 13 15 79 17 52 31 12 14 74 supplementary n = 108 100% n = 56 100% specialization/certificate (2 points) thesis/phdr thesis (1 point) published article (2 points) Phd thesis (3 points) 60/16 14/ 13 5 56/15 13/ 12 5 47/1 1/ 7 0 84/2 2/ 13 0 Data from the experts were collected from June 2009 until January 2010 at various healthcare and education departments at the same time in SR and CR (Table 3). Table 3 Data collection departments departments SR CR n = 144 100% n = 107 100% psychiatry* 42 29 9 8 internal medicine** 39 27 42 39 surgery*** 28 19 39 36 education department**** 27 19 7 7 home care services 8 6 3 3 hospice 7 7 * department of psychiatry, mental hospital; ** internal medicine, neurology, and oncology clinics, department of tuberculosis and lung diseases, geriatric/rehabilitation department; *** department of surgery, department of orthopaedics and traumatology; **** secondary nursing school, university (faculty of health, nursing department) The validation study is part of an APVV project titled Nursing Diagnosis Theory and Application in Nursing Practice. Consequently, the validation methods were identical to those in the already published studies of validation of other nursing diagnoses in the project, for example, Tomagová, Bóriková (2011), Tabaková (2011), Zeleníková et al. (2011a, 2011b), Gurková et al. (2010). The ND validation used the Diagnostic Content Validity Model (DCV Model) by Fehring. This retrospective, most frequent model has a sufficient number of experts (25 50) evaluate the defining characteristics of the ND, assigning each with a particular significance from 1 to 5 on Likert scale (Fehring, 1987, p 626). The significance of the defining characteristics is evaluated with a validation form featuring 13 items. These are subdivided into three groups based on experience gained in similar studies (Gurková et al., 2010; Žiaková et al., 2008). The first group consisted of the ND defining characteristics (9 items). When formulating the second group (3 items), we applied the MMSE (Mini- Mental State Examination) measurement instrument designed for assessing the cognitive functions of the elderly (Folstein et al., 1975, p 190). In order to eliminate random assessment of the items significance, we added one neutral item to the list (a third group as a misleading/false character). The experts identified the degree of importance of each item on Likert scale (5 max significance, 4 great significance, 3 medium significance; 2 little significance; 1 no significance). After collecting the data, basic statistical parameters (arithmetic mean x, standard deviation SD) and weighted score (a sum of values assigned to each answer and its subsequent division by the total number of responses, WS) were calculated for each defining characteristic. 26

The numbers on Likert scale were allocated the following WS value 5 = 1; 4 = 0.75; 3 = 0.5; 2 = 0.25; 1 = 0. In the research, the main defining characteristics were those that reached WS over 0.75, while secondary characteristics ranged from 0.50 to 0.75 (Holmanová, Žiaková, Čáp, 2006, p 27). The data were processed with the computing programme MS Excel, SPSS 16.0 for Windows. RESULTS Table 4 gives an overview of all the validated items. The defining characteristics that the experts considered as the main ones are highlighted. DISCUSSION The relatively homogenous group of experts in terms of age and years of experience reached the lower score limit (6 points), only the minimum of the already modified expert criteria (Table 1). According to Fehring, an expert must achieve a minimum of 5 points, while 4 points are given for a master s degree. The higher the number of points is the higher the expertise (Zeleníková et al., 2010, p 411). Slovak nurses scored higher in this criterion, which may be due to their higher number in the monitored group. The validation results in both groups indicated very high compliance. The defining characteristics identified as the primary are typical for dementia syndrome (MKCH 10, 2006). In some literary sources, the concept of dementia equals the concept of chronic confusion (Hudson, 2011; NINR, 2006, p 3; Ried, Dassen, 2000, p 51). Poor distinction between these concepts and their use by nurses is considered problematic (Ried, Gutzmann, 2003, p 297; Winnifred, 1991, p 4) because the comparison of the nursing and medical concepts shows some characteristics as identical (Table 5); the concepts are often treated as synonyms and describe the same phenomenon (Ried, Dassen, 200, p 54). In consequence, there are no or hardly any validation studies concerning the diagnosis in question in the NANDA-I sources (e. g. International Journal of Nursing Terminologies and Classifications) and other resources. Experts across the whole group marked as primary (Table 4) those items that dominated more in the medical concept of the dementia syndrome (NINR, 2006, p 3; Ried, Dassen, 2000, p 55). Items 3, 4 and 10 form part of the clinical picture of dementia (Hegyi, Krajčík, 2010, p 464) and are documented in the patient s medical records as part of a medical finding; therefore, nurses consider these symptoms important. Other major defining characteristics included: time and space disorientation and altered interpretation/response to stimuli. These are manifestations of the confusion symptom as it is defined in medical terminology (Kolibáš, 2010, p 36). Although the concept of confusion is mentioned in the ND title, its definition is not compatible with medical terminology (Höschl et al., 2002, p 296). Based on NANDA-I, other defining characteristics of CHC include impaired memory, impaired socialization, altered personality, and no change in level of conscious- Table 4 Validated items SR CR item x ± SD VS x ± SD VS 1 altered interpretation/response to stimuli (NANDA-I) 4,05 ± 0,82 0,76 4 ± 0,91 0,75 2 inability to follow instructions during the administration of the cognition assessment tool (MMSE) 3,77 ± 1,04 0,69 3,65 ± 0,94 0,66 3 progressive deterioration of intellect (NANDA-I) 4,06 ± 0,90 0,76 4,04 ± 0,85 0,76 4 clinical evidence of organic brain impairment (NANDA-I) 4,41 ± 0,95 0,78 4,11 ± 0,87 0,78 5 disorientation (in time and space) (MMSE) 4,47 ± 0,76 0,87 4,44 ± 0,75 0,86 6 impaired long-term memory (NANDA-I) 3,74 ± 0,98 0,69 3,55 ± 0,99 0,64 7 impaired short-term memory (NANDA-I) 3,92 ± 0,96 0,73 3,86 ± 0,99 0,71 8 accelerated cognitive processes (MMSE) 2,74 ± 1,06 0,44 2,96 ± 1,01 0,49 9 impaired socialization (NANDA-I) 3,60 ± 0,97 0,65 3,49 ± 0,85 0,62 10 long-term cognitive impairment (NANDA-I) 4,13 ± 0,81 0,78 3,94 ± 0,82 0,74 11 no change in level of consciousness (NANDA-I) 2,88 ± 1,28 0,47 2,87 ± 1,16 0,47 12 inability to name objects (during the tool administration) (MMSE) 3,38 ± 0,97 0,70 3,5 ± 0,97 0,62 13 altered personality (NANDA-I) 3,43 ± 1,23 0,61 3,31 ± 1,18 0,58 27

ness. These the nurses marked as secondary with significance below 0.75 despite the fact that they form part of the definition of ND Chronic Confusion (this was mentioned in the validation spreadsheet) and also the clinical picture of dementia. The defining characteristic of no change in level of consciousness is also considered secondary and thus less significant. This, too, indicates the difference between the nursing terminology and the medical terminology. As mentioned above, although confusion is included in the name of the ND, the term is absent from the definition of the diagnosis and, moreover, NANDA-I lists no change in level of consciousness in the defining characteristics. In medicine, confusion is defined as a qualitative change in consciousness (Kolibáš, 2010, p 36). As nurses prefer the medical view of the concept, they considered this defining characteristic secondary. Based on the experts evaluation, other secondary characteristics included the inability to name objects (during the administration of MMSE) and the inability to follow instructions during the administration. As MMSE is applied in practice only in rare, specific cases, the nurses do not have the clinical skills to use it. The neutral item accelerated cognitive processes scored less than 0.50, which is a positive finding as the experts did not mark the items randomly. Accelerated cognitive processes are not part of the clinical picture of dementia, and therefore do not belong to the defining characteristics of the validated ND. We believe that the findings of the validation study (regarding SR) may be affected by the fact that this ND is missing from the List of Nursing Diagnoses (Decree of Ministry of Health of SR, 2005) and therefore the nurses (not even from psychiatry departments) have no clinical experience with this ND. In CR, no standardized terminology is used in nursing diagnosis (Jarošová et al., 2009, p 126). CONCLUSIONS The experts did not rate all the defining characteristics of the validated ND as equally significant. This is partly due to the respondents, who, coming from the Slovak and Czech practices, reached only the minimum threshold of expert criteria. University-educated nurses (despite their predominance) have varying levels of knowledge and intellect skills related to nursing diagnosis. Other factors are the incompatibility of NANDA- I Taxonomy II with the Nursing Diagnosis List, and the ambiguity in terminology and legislation. Generally, nurses still tend to use the medical terminology (terms for clinical symptoms) and are not at all familiar with chronic confusion as a name of an ND (and its other diagnostic components). Comparison of the concepts implies certain difficulties in differentiating between these two related diagnoses. This is due to the fact that in terms of the related factors component they both focus on biomedical aspects, while psychology and sociology literature supports a multi-factorial approach that includes social, environmental, and psychological factors explaining the phenomenon of confusion (Ried, Dassen, 2000, p 56). Although in recent years, validation studies of selected NDs are occasionally published in nursing journals, there are no national validation Table 5 Comparison of Chronic Confusion and Dementia Chronic Confusion (00129) Definition: Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli; decreased capacity for intellectual thought processes; and manifested by disturbances of memory, orientation, and behavior (NANDA-I, 2009). Related factors: AD, cerebrovascular disease, head injury, Korsakoff s syndrome, multi-infarct dementia Development: long-term and/or progressive irreversible. Basic characteristics: deterioration of intellect and personality. Defining characteristics: clinical evidence of organic impairment, altered interpretation/response to stimuli, progressive and longterm cognitive impairment, impaired (short-term and long-term) memory, altered personality and impaired socialization, no change in level of consciousness (MKCH 10, 2006, s. 220; NANDA-I, 2009, p. 167; Preiss a kol., 2006, s. 127; Ried, Dassen, 2000, p. 56) Dementia (F00 F03) Definition: A syndrome caused by a brain disease, usually chronic or progressive, which is characterized by deterioration of multiple higher cortical functions, including memory, cognition, orientation, understanding, counting, the capacity of learning, language, and judgment. Consciousness remains clear. Cognitive disorders are typically accompanied (sometimes preceded) by impaired control of emotions, social behavior, and motivation (MKCH 10, 2006). Cause: AD, cerebrovascular disease, other disorders that primarily or secondarily affect the brain Development: long-term or progressive reversible. Basic characteristics: impaired higher cortical functions, deterioration of emotion control/social behavior/motivation. Symptoms: deteriorated/impaired memory, cognitive impairment, deteriorated ability to carry out everyday activities 28

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ŽIAKOVÁ, K., ČÁP, J., GURKOVÁ, E. 2008. Content Validation of Hopelessness in Slovakia. Acta Medica Martiniana. 2008, vol. 8, no. 2, p. 31 36. ISSN 1335-8421. CONTACT DETAILS OF MAIN AUTHOR Martina Tomagová Department of Nursing Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava Malá Hora 5 SK-036 01 MARTIN tomagova@jfmed.uniba.sk 30