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and decisions intuitively (King and Clark 2002, Hedburg and Satterlund Larsson 2003, Peden-McAlpine and Clark 2002), reflecting Benner’s 1984 renowned novice-to-expert theory. However, others argue that all nurses use a logical process of clinical reasoning in order to identify patients’ needs for nursing care and that, while this becomes more automatic with experience and perhaps more subconscious, it should always be possible for a nurse to explain how they arrive at a decision about an individual within their care (Gordon 1994, Putzier and Padrick 1984, Rolfe 1999). A further notion is that of a continuum, where our ability to make clinical judgements about our patients lies on a spectrum, with intuition at one end and linear, logical decisions (based on clinical trials, for example) at the other (Cader et al. 2005, Thompson 1999). Factors that may influence the process of decision making include time, complexity of the judgement or decision to be made, as well as the knowledge, experience and attitude of the individual nurse.

Nursing diagnosis is a term which describes both a clinical judgement that is made about an individual’s response to health or illness, and the process of decision making that leads to that judgement; Box 2.8 illustrates the process of making a nursing diagnosis. The importance of thorough assessment within this process cannot be overestimated. The gathering of comprehensive and appropriate data from patients, including the meanings attributed to events by the patient, is associated with greater diagnostic accuracy and thus more timely and effective intervention (Alfaro-Lefevre 2002, Gordon 1994, Hunter 1998).

Box 2.8 The process of nursing diagnosis

Collect information using an appropriate assessment framework.

Identify clusters of information and consider possible nursing judgements (nursing diagnoses).

Collect further information to verify these judgements.

Arrive at an accurate nursing judgement (nursing diagnosis).

(Gordon 1994, Tanner et al. 1987)

The concept of a ‘nursing diagnosis’ has historically generated much debate within the nursing literature, and it is therefore important to clarify the difference between a nursing diagnosis and a patient problem or care need. ‘Patient problems’ or ‘needs’ are common terms used within nursing to facilitate communication about nursing care (Hogston 1997). As patient problems/needs may involve solutions or treatments from disciplines other than nursing, the concept of a ‘patient problem’ is similar to but broader than a nursing diagnosis. Nursing diagnoses describe problems that may be dealt with by nursing expertise (Leih and Salentijn 1994) (Box 2.9).

Box 2.9 Characteristics of conditions labelled as nursing diagnoses (Gordon, 1994)

1 Nurses can identify the condition through a process of diagnostic reasoning (assessment, problem identification).

2 The condition can be resolved primarily by nursing interventions.

3 Nurses assume accountability for patient/outcomes.

4 Nurses assume responsibility for research on the condition and its treatment.

The term ‘nursing diagnosis’ also refers to a standardized nursing language, to describe patients’ needs for nursing care, that originated in America over 30 years ago and has now been developed, adapted and translated for use in numerous other countries. The language of nursing diagnosis provides a classification of over 200 terms (NANDA-I 2009), representing judgements that are commonly made with patients/clients about phenomena of concern to nurses, enabling more consistent communication and documentation of nursing care (see Box 2.10 for an example of a nursing diagnosis).

Box 2.10 Example of a nursing diagnosis

Label

Definition

Provides a clear meaning of the diagnosis. Acute pain: an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage (IASP 2007). Sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of <3 months.

Defining characteristics For example: