Learning Objectives
By the end of this section, you will be able to:
- Describe the development and evolution of a nursing diagnosis
- Explain how a nursing diagnosis is used as a problem-solving approach for planning patient care
- Understand the rationale for transitioning to the clinical judgment measurement model
Most people have heard of medical diagnoses, but few outside the healthcare profession know about nursing diagnosis or what its purpose is. The role of nursing has evolved in health care, and in today’s healthcare world, it is often up to nurses to facilitate a patient’s entry into the healthcare system. There must be a systematic and structured method of obtaining the necessary data to achieve that outcome. The development of nursing diagnosis began with the need for a common language to communicate across the profession.
In carefully constructed, concise statements, the nursing diagnosis identifies patient issues (clinical and psychosocial) and articulates potential causes of the problem. Using this statement structure and medical terminology as part of this system allows a patient with diabetes to go from being described as “a diabetic” or “a person with type 2 diabetes mellitus” to the more detailed and descriptive statement of “risk for unstable blood glucose levels related to insufficient diabetes management.” Changing the medical diagnosis to the nursing diagnosis allows the nurse to identify a patient’s specific needs—which, in the case of a patient who has diabetes, may be unstable glucose levels. Now, the nurse can develop a plan of care to help the patient manage the identified problem.
Given the many factors involved in caring for complex patients, a common and concise form of communication was essential for the growth of the nursing profession. This problem-solving approach to articulating patient problems or needs is the basis for planning care and interventions, as it lays the foundation for critical thinking.
Development of Nursing Diagnosis
Nursing diagnosis began in the 1960s, first as the nursing process. The nursing process is a five-step method of guiding decision-making for nurses:
- assessment
- diagnosis
- planning
- implementation
- evaluation
These five steps of the nursing process are also named by the American Nurses Association (ANA) as the approved Standards of Practice to designate a “competent level of nursing care . . . and forms the foundation of the nurse’s decision-making” (American Nurses Association [ANA], 2015a). However, more standardization and commonality were needed to develop this process further. In the 1970s, the North American Nursing Diagnosis Association (NANDA) developed a list of nursing diagnoses, which were delineated, patient-focused statements formed through this nursing process and selected through patient assessment.
A methodical way to provide and evaluate appropriate patient care is called nursing diagnosis. These diagnoses were updated and modified several times throughout the next four decades, with the last update in 2024 of NANDA-I International Nursing Diagnoses: Definitions & Classification, 2024–2026, 13th edition by T. Heather Herdman, Shigemi Kamitsuru, and Camila Lopes.
The NANDA diagnosis list utilizes a problem-solving approach that helps provide individualized nursing care to patients. In short, it provides a framework for decision-making based on collected data related to the patient’s condition. Articulating these nursing-focused problems as diagnoses created a way for nurses to begin their patient care in a planned and organized fashion, and using the NANDA-approved diagnoses gave nurses the common language to understand these interventions across the profession.
Nursing diagnosis became the foundation of what makes nursing a distinct and autonomous profession in health care. The dynamic ability of nursing diagnoses enables nurses to address multiple facets of their patients’ healthcare needs, including clinical, pathophysiological, psychosocial, and environmental.
Nursing diagnosis is a step-by-step way to gather patient data and to create, deploy, and evaluate a plan for patient care. It helps nurses conduct research and drives quality initiatives in clinical and outpatient settings. Most importantly, it provides a common language and decision-making framework that enable nurse educators to teach future generations of nurses.
Link to Learning
This quick video explains how to write a nursing diagnosis when developing patient plans of care.
ANA Standards of Practice
The Standards of Practice designed by the ANA and based on the nursing process provided a problem-solving-focused approach to nursing practice. The Standards of Practice was the beginning of the definition of nursing as a clinically, technically rigorous, and autonomous profession. Within the Standards of Practice, the ANA defines the job of the nurse as including “the diagnosis and treatment of human responses to actual or potential health problems” (ANA, 2015b). This statement and these standards bolster the strength of nursing diagnosis as a decision-making tool of an autonomous profession. These standards outline the level of care that should be provided by a competent level nurse modeling the nursing process as a critical thinking model.
ANA Competencies for Nursing Diagnosis
The nursing process has six competencies that nurses use as part of their critical thinking process and decision-making (ANA, 2015a). As you learned in 12.4 Cognitive Process for Analyzing Assessment Data, critical thinking describes a process of thought that uses structured methods of observation, reasoning, and thought to make educated and rational decisions. Critical thinking sets nurses apart from those who simply “follow orders.” Steps in the nursing-specific critical thinking process include the following:
- Assessment: The nurse gathers data from the patient’s history and physical symptoms and compares them to normal values. Refer back to Chapter 12 Assessment: Recognizing Cues for a recap on nursing assessment.
- Diagnosis: The nurse groups the data and uses them to focus on one or more patient problems. These problems can then be prioritized.
- Identifying expected outcomes: The nurse focuses on one problem and then thinks about the best end result or desired outcome for this specific patient.
- Creating a plan to achieve these expected outcomes: The nurse will decide on planned activities the patient must complete to meet the determined result or desired outcome. These are tasks that the patient must be able to do alone or collaboratively with healthcare professionals.
- Implementing the plan: This is the phase in which the patient completes the planned activities. This step is where the action happens.
- Evaluating the plan’s effectiveness: The nurse reviews the patient’s progress toward the desired outcome or intended results. Was the goal met—fully, partially, or not at all? Is the patient making progress toward the intended results? Does anything about the plan need to be changed? Or can it continue as planned? Or, perhaps, more time is needed for the patient to achieve the goal? The answers to these questions will determine if the plan is continued, modified, or discontinued completely.
It is important to note when engaging in this process that nurses do not only consider the patient themselves but all those involved in providing care. Families, significant others, loved ones, and perhaps even friends can all be part of the patient’s support network. Therefore, each of them has a collaborative part in this process alongside the patient.
Problem-Solving Approach
The problem-solving approach to planning patient care nursing began with the development of a diagnosis and identifying the relevant problems. To pinpoint those, the nurse must conduct an assessment. The nurse’s assessment is focused on the collection and analysis of clinical data.
The first data point is the patient’s problem. The nurse must start by identifying the patient’s chief complaint. Using collected data referred to as the patient’s signs and symptoms, the nurse will determine if the identified problem is currently happening or at risk of happening. The problem-solving approach to care planning gives the nurse a clear starting point to assign interventions and evaluate their effectiveness.
Methods to complete the problem-solving approach have evolved over time and consist of three tactics. The first was NANDA-I, followed by Tanner’s Clinical Judgement Model (CJM), which transitioned into the Clinical Judgement Measurement Model (CJMM). Research states that no one tactic is better than the other; rather, nurses should be able to incorporate a combination of all three.
NANDA International (NANDA-I)
In 2002, NANDA officially became NANDA International. The name changed again in 2011, to NANDA International, Inc., after considering the significant growth of membership outside North America. The organization continues to use “NANDA” as part of its name due to its familiarity (NANDA-I, 2024). However, “NANDA” is no longer the appropriate acronym. The organization is now known as NANDA-I, whose purpose is still to facilitate the development, modification, distribution, and use of standardized nursing diagnostic terminology.
NANDA-I nursing diagnoses are easily identified as clear statements written and developed by the evidence-based organization. The terminology gives nurses a starting point for the problem-solving approach used to develop a nursing diagnosis. For clarity, the organization created a taxonomy, or classification system, for arranging or listing the patient’s identified problem. In 2002, the work of Dr. Mary Gordon’s Functional Health Assessment Patterns was used as the framework to develop what is known as Taxonomy II. Taxonomy II, the current classification method for listing nursing diagnoses, has three levels: domains, classes, and nursing diagnosis (Figure 13.2).
The domains are broken out into thirteen groups. The domains consist of topics such as health promotion, activity, comfort, and safety. The domains are further organized into forty-seven classes directly related to each domain. For instance, the domain of health promotion has two classes: health awareness and health management. The domain of comfort has three classes: physical comfort, social comfort, and environmental comfort. The nursing diagnoses are coded according to seven different criteria and include the diagnostic concept, time, unit of care, age, health status, descriptor, and topology.
In addition, nursing diagnoses are listed alphabetically by their concept, not by the first word in the diagnosis. NANDA-I and Taxonomy II are both used today in clinical practice as a problem-solving approach to clinical decision-making.
Tanner’s Clinical Judgment Model (CJM)
After years of growing the nursing profession to one that is based on evidence and research, nurses started to realize that only those experienced in the profession could truly understand how to incorporate NANDA-I and the development of a nursing diagnosis into the patient’s plan of care accurately and efficiently. New nurses were struggling with not knowing what they didn’t know.
In 2006, a nursing educator, Christine Tanner, published a researched model of clinical judgment, which was the product of extensive research and synthesis used to identify the essential themes of how new nurses develop strong clinical judgment skills (Tanner, 2006). Tanner’s Clinical Judgement Model (CJM) is a helpful framework that offers a different articulated perspective to the problem-solving approach for developing nursing diagnoses. Tanner’s model consists of four steps (Tanner, 2006):
- Noticing: What are the clinical cues, and why are they relevant? The key to effective nursing and safe patient care begins with the ability to recognize when the data are relevant and important.
- Interpreting: What do the data mean? Understanding the data and processing them in terms of the patient’s pathophysiology is essential to interpreting the data correctly.
- Responding: Now that the nurse has recognized necessary data and has interpreted them correctly, what is the course of action taken by the nurse? Knowing the appropriate response is key to planning and implementing an intervention.
- Reflecting: Once the plan is implemented and the intervention accomplished, it is time to reassess and see if the patient’s response to the intervention was as expected. Tanner elaborates on this last step by identifying two methods of reflection:
- Reflection in action—decisions that are made to the plan of care immediately and in the moment.
- Reflection on action—thinking done after the care is provided to determine if the decisions made were the right ones, and if not, what could be done differently going forward (Rischer, 2020).
Patient Conversations
A Therapeutic Conversation: Responding
Scenario: A patient is in the medical-surgical floor and is complaining of pain. The nurse was called to the room to assess the situation.
Nurse: Good morning, Levi. How are you feeling today?
Patient: Not so good, the pain in my back is still bothering me.
Nurse: I’m sorry to hear that. Can you tell me more about your pain?
Patient: It’s a sharp pain in my lower back, and it gets worse when I try to move. Right now, it’s a 9 out of 10.
Nurse: I see you have been taking your pain medication the doctor ordered. Does the medication seem to help your pain?
Patient: Not really, even when I take the pain medication it only comes down to a 7 out of 10. They helped for a little while, but the pain comes back so strong, well before my next does is available.
Nurse: I understand. I am going to call your provider to discuss possible options to help with your pain.
Patient: Thank you. I appreciate you listening and responding to my needs.
Tanner’s model is important because of what sets it apart from the nursing process. Its focus was to help develop the beginning nurse’s clinical judgment skills, as they have no prior nursing experience. The realistic assumption is that nurses need to be taught through a combination of education and clinical experience. The model reframes the thought processes that are needed for clinical judgment.
Transition to the Clinical Judgment Measurement Model (CJMM)
However, healthcare technology continues to evolve, and patient populations are becoming increasingly complex with both clinical and psychosocial demands. It has now become clear that while North American Nursing Diagnosis Association (NANDA) provided a good framework for developing nursing diagnoses, it does not always work well with the complexities of today’s patient needs.
For example, unexpected changes in patient conditions require immediate changes to the plan of care. Many of these unexpected changes do not fit into a ready-made diagnosis. Nurses started having trouble thinking outside the box.
As a profession, nurses realized they needed to develop critical thinking and clinical judgment skills that are required to dynamically revise nursing diagnoses as needed. This need led to the development of a more flexible and focused method of learning how to think and develop clinical judgment skills, the Clinical Judgement Measure Model.
The Clinical Judgment Measurement Model (CJMM) is the latest framework developed by the National Council of State Boards of Nursing (NCSBN) to aid in identifying nursing-focused clinical problems. The CJMM is based on the most current research and literature in nursing pedagogy, nursing science, and psychology (NCSBN, 2020) (Figure 13.3.
Link to Learning
The NCSBN created the Clinical Judgement Measurement Model (CJMM) to explore new ways of testing clinical judgment in nursing as part of the National Council Licensure Examination (NCLEX). The diagram at this site shows the layers of the model.
The CJMM incorporates elements of the nursing process and Tanner’s model of clinical judgment with two additional levels of modeling thought that help build complexity into decision-making. Understanding the components of this framework provides yet another method of clinical decision-making.
Clinical Judgment Measurement Model
Prioritize a Hypothesis: Developing a Nursing Diagnosis
A nurse hears a patient’s vital sign monitor go off. She walks into the room and sees several things at once: the patient looks very uncomfortable—they are grimacing, their eyes are wide, their skin is pale, and they are diaphoretic (sweaty). The patient’s respirations are 22 breaths a minute, and he is saying, “I can’t catch my breath, and my chest hurts.” His blood pressure is elevated at 160/90 mm Hg, heart rate is 128 beats per minute, and the patient is sitting up in bed in a tripod position. The nurse quickly asks how the patient is feeling, and they respond with, “I can’t catch my breath, and I don’t feel good at all.”
- Recognizing cues: The nurse swiftly identifies alarming cues, including the patient's grimacing, diaphoresis, and complaints of difficulty breathing and chest pain. These cues prompt immediate attention and further assessment.
- Analyzing cues: Through rapid analysis, the nurse interprets the patient's symptoms as indicative of distress. Recognizing the urgency, the nurse correlates the respiratory distress with elevated vital signs, indicating a potential critical condition.
- Prioritizing a hypothesis: Prioritization comes from Airway, Breathing, and Circulation (ABCs) in acute or emergent situations. ABCs is an effective priority framework that focuses on lifesaving interventions. Understanding the gravity of the situation, the nurse prioritizes hypotheses focused on acute respiratory distress or cardiac compromise, recognizing the patient has a potential breathing and circulation issue. This prioritization will guide subsequent interventions and decision-making.
Based on the presented scenario, a potential nursing diagnosis for the patient could be “impaired gas exchange related to inadequate ventilation secondary to respiratory distress as evidenced by tachypnea (22 breaths per minute), dyspnea (“I can't catch my breath”), elevated blood pressure (160/90 mm Hg), elevated heart rate (128 beats per minute), diaphoresis, and the patient's inability to lie flat (sitting up in bed in a tripod position).”
Six Cognitive Skills
The CJMM includes six cognitive skills each nurse must master to think critically through a patient care situation. The cognitive skills needed to implement the CJMM are as follows:
- Recognize Cues can be defined as identifying relevant clinical data using multiple sources available to the nurse, including the presenting scenario, medical history, vital signs, nursing assessment, and laboratory values, then extracting important clinical data from these sources.
- Analyze Cues can be defined as taking the data that have been collected and interpreting it using an existing knowledge base. It also includes organizing the clinical data, recognizing patterns, and generating hypotheses regarding the clinical cues collected.
- Prioritize a Hypothesis is described as using the data articulated as hypotheses, narrowing down what the most pressing problem is, and thus identifying which is the priority.
- Generate Solutions is determining the expected outcomes or goals for the patient. This skill also includes developing a plan of care and identifying nursing interventions that need to be in place to bring about the expected outcome.
- Take Action can be described as implementing the solutions generated that will address the identified priority hypothesis as well as subsequent priorities as they exist. This requires nurses to determine which interventions are the most appropriate and to implement them in order of importance to the patient’s health and well-being.
- Evaluate Outcomes is determining whether patient outcomes were met. They can be either fully or partially met and may require revision to continuously work toward achieving the expected outcome. They can also be marked as complete if it is determined that the outcome has been achieved.
Link to Learning
Read this evidence-based research article on the importance of critical skills in nursing to learn how they are used to develop critical thinking.
The six cognitive steps are needed to incorporate the CJMM into developing accurate and efficient critical thinking skills. As nurses transition from school to clinical settings, they will understand the six cognitive skills and how practicing nurses really think when determining the best possible care for their patients.