Bridging the Gap: Research to Practice

Heather Herdman (: 00:01

Welcome to NandaCast. I'm Dr. Heather Hirdman, the Chief Executive Officer of Nanda International. Thank you for joining us for this episode. Today, I have the pleasure of introducing Dr. Marcos Vinicius Lopez de Silva. Dr. Marcos Lopez de Silva. What? Did she do it wrong too? my God, she did.

Marcos Lopes (: 00:20

Heather, I'm equal to Camila. I'm not Sima. Sima is Viviani.

Heather Herdman (: 00:28

She told me she did that and then I didn't look and change it.

Heather Herdman (: 00:36

When I said it, I thought that's not right. Okay, hang on a second here. And then she even told me, Marco, she said, can't believe I did that. And then I did it too. All right, so we'll try again. Okay, here we go. Welcome to Nandacast. I'm Dr. Heather Herdman.

Marcos Lopes (: 00:44

Thank you.

Marcos Lopes (: 00:53

Okay.

Marcos Lopes (: 00:58

Thank you.

Heather Herdman (: 01:04

Chief Executive Officer of Nanda International. Thank you for joining us for this episode. Today, I have the distinct pleasure of introducing Dr. Marcos Vinicius Lopez. Dr. Lopez is a doctorally prepared nurse who also holds degrees in statistics and psychology. He's currently a full professor at the Federal University of Ceará in Brazil. He's a member of the Nursing Process Research Network.

low of NANDA International in: 2018

In: 2019

Marcos Lopes (: 02:24

Thank you.

Heather Herdman (: 02:25

Professor Marcus, you have been dedicated to diagnosis research for many years and have made a notable contribution to the advancement of NANDA International nursing diagnoses. What advances in nursing diagnosis research do you consider to be the most significant?

Marcos Lopes (: 02:47

Firstly, thank you for the introduction and the invitation. It's a pleasure to be here. When we're thinking about significant advances in research on non-syn diagnosis, we can first highlight the methodological maturation of investigations. We have moved from an initial phase based exclusively on models proposed by Professor Richard Farring.

stic structures. From the mid-: 2000

have been incorporated into the validation process and discussions about the role of expertise have been expanded to improve content validation studies. Another highlight is the strengthening of diagnostic rezoning as an object of a study. Today, researchers from various countries are working on strategies to improve the diagnostic accuracy of nursing.

which directly impacts the quality of care. This approach has provided important insights into the quality of clinical data used and has also delivered qualitative information about role of each defining characteristic in terms of suspicions and confirmations of diagnosis based on sensitivity and specificity concepts. Another notable advancement

is the deepening of studies on related factors with a more clinical and context-alized perspective. The pursuit of understanding causal process as well as the comprehension of causal networks in which one diagnosis can serve as the etiology of another, or even that a set diagnosis may be intrinsically related, diagnosis begun

Marcos Lopes (: 05:11

to be reviewed more frequently by NANDA International, based on the advances produced by these studies, make the taxonomy increasingly uncorrect in evidence-based products. Finally, it's important to highlight that the new levels of evidence incorporated by NANDA not only guide the research toward the development of diagnostic structures. These levels are strongly

connected to professional practices issues, such as which indicators can be used for rapid decision-making in urgent or emergency settings, and which indicators allow us to identify patients with a tendency to clinical deterioration, which indicators can be used to identify the same

diagnoses under different clinical conditions or different population groups, among many other clinically relevant questions that help guide our nurse actions more effectively. I think it's important.

Heather Herdman (: 06:24

That's a lot of advancement. But despite this, we sometimes still will see a gap between diagnosis research and its results that are published and clinical practice, and even gaps in research to nursing education. So can you comment on the importance of incorporating this knowledge into clinical practice and nursing education?

Marcos Lopes (: 06:26

Yeah.

Marcos Lopes (: 06:53

This is a fundamental and important issue. The gap between scientific production and clinical practice is a historical challenge in nursing. But in the case of nursing diagnosis, this can directly compromise decision making and consequently patient safety. It's essential that the knowledge generated by research on nursing diagnosis

be incorporated into both education and daily routines of health services. In education, this means training professionals with critical and reflective skills to identify diagnosis based on real evidence, not just based on memorization or checklists. In clinical practice, the incorporation of this knowledge translates into greater diagnostic accuracy.

more effective care plans, better patient outcomes. Furthermore, it contributes to the recognition of nursing's professional identity as an autonomous sciences with its own body of knowledge. For this to happen, we need institutional policies

that value the use of standardised language and the Nanda taxonomy in addition to a strategy for continued education, clinical audits and research and support with the healthcare services themselves. There is also a strong need for nursing research and educators to have a broad understanding of the research methods by and developed

to foster greater alignments between what is produced and what is taught. This means extra workload, of course, and study in a world that way seems rushed and short on time. In this sense, teaching undergraduate students to qualify defining characteristics as sensitive or specific.

Marcos Lopes (: 09:13

or even treating the role of each etiological factor enables more accurate diagnosis and more effective actions toward better outcomes.

Heather Herdman (: 09:28

Yeah, I couldn't agree with you more. So what gap or gaps do you think exist in relation to this knowledge? And how do we move forward so that educators are able to do exactly what you said and clinicians are able to start to take that knowledge and apply it in practice?

Marcos Lopes (: 09:52

Despite the advances, there are still many gaps to overcome. These include, among others, clinical validations of diagnosis in specific populations, validation in culturally diverse populations, and development of studies with individuals from minority groups, such as neurodivergent people or those with diverse sexual identities.

We also have many diagnoses that have only been validated in adult populations, for instance, but which could also be used in pediatrics or geriatrics. Some diagnoses were initially developed for mental health, but could be used in other clinical settings. Unfortunately, these broader applications still lack a solid empirical foundation. Another gap...

is the integration of diagnosis with nursing outcomes and intervention. In other words, how diagnoses are effectively articulated in the complete care process. We need more longitudinal studies that show in practice the impact of correct diagnostic use on patient outcomes. Recently, there has been concern regarding to predictive capacity of nursing diagnosis in terms of

red emissions and or the influence on the patient's overall therapeutic response. A large portion of these studies is based on clinical records and use big data analysis techniques such as data mining. While very interesting and important, these studies depend on the quality and availability of data, which is still not a reality everywhere.

Moreover, there is no effective control of over data collection and recording process, making compatibility across studies questionable. And finally, there is an educational gap. Many professionals still graduate with difficulty in formulating appropriate diagnosis. This demonstrates the need to review pedagogical approach and curricula

Marcos Lopes (: 12:16

with greater emphasis on clinical decision making and diagnostic rezoning from the earlier semesters.

Heather Herdman (: 12:25

Yeah, thank you for that. So could you talk a little bit about the validation methods that have been used most in nursing research and their relationship to the types of studies conducted and the levels of evidence of nursing diagnoses?

Marcos Lopes (: 12:43

Certainly, as I mentioned earlier, there is a greater diversity in methods applicable to research on nursing diagnosis. Broadly, we can divide these methods in three main groups, theoretical development, establishment of a content domain, and clinical application. About theoretical development, this phase focuses on the need to conceptualize a hypothetical diagnostic structure.

These stages often include concept analysis, development of middle range, or situation-specific theories. These methods can be developed using different approaches. For example, concept analysis can be applied to build a structure based on attributes, antecedents, and consequences of a diagnosis.

These methods can also include evolutionary or historical approach to understand the changes needed in diagnostic structures influenced by societal change. It is also possible to study diagnostic concepts from symbolic dimensions or identifying diagnostic components shared across different diagnosis shedding light on differential diagnosis. Middle range theories

also offer new perspectives on a nursing diagnosis by thinking to establish both the structurally and clinical relationships among its components and with other diagnostic concepts. This allows the creation of a normal logical networks, networks of diagnostic concepts and the identifications of clearly causal relationships.

This set of methods also includes various literature review approach from narrative to systematic reviews. These have become more popular due to advances in database and article indexes process and have been boosted by the evidence-based practice movements. It has become common for researchers to use a more general

Marcos Lopes (: 15:00

scoping review to gather information for development and concept analysis or even middle range theory. Another common approach is development of two systematic reviews, one on etiology and risk and another on diagnostic accuracy. Data from these reviews are typically used to build the initial diagnostic history, develop empirical reference and establish causal relationships in middle range theory.

And in relation to content domain, it's often an intermediate step and involves a group of presumed experts who analyze the relevance of the elements constituting the theoretical structure produced in the previous stage. This step has always been difficult and is no more undervalued.

than ever, part of this is due to ongoing debates and debates in various fields regarding to the concept of expertise, especially when it comes to operationalizing it. It is common to seek individuals with high levels of expertise and just as common not to find them or even found

to not receive the expected inputs, often because these individuals are frequently in high demand. There are also broad discussions on sample size, sampling techniques, statistical windows to be used, and more. All of this makes content validation studies extremely complex. To give an idea, I recently had the opportunity to analyze a set of

18 different content validity indexes using statistical simulation techniques, also known as Monte Carlo methods. In these studies, the most commonly used index in nursing diagnosis research, Fering's DCV, showed the worst performance among all evaluated indexes. Poor performance was also observed

Marcos Lopes (: 17:26

with proportion-based methods such as LINZ, IVC, and LOSH, RVC, and another index, interpretative mistakes among the inks are also common. For example, interpreting them as index of agreement, consistencies, or reproducibility, which are concepts linked to readability.

In our analysis, using weighted means based on expertise level performed better among the analyzed index. However, it's important to remember that this improved performance depends on how we define expertise and we return to the original problem. Many classification alternatives have been proposed to determine expertise level.

all based either on individual performance using predefined characteristics and scores or comparative classifications within a candidate expert group. A more recent approach I've used considers group expertise based on the diversity of experience, known as the wisdom of the crowd. In this approach, expertise is defined more by group diversity

than by individual performance. Among its advantages are the possibility of a multidisciplinary approach, a more generalizable perspective on the diagnostic structure, a broader range of possible group members, and greater appreciation for different perspectives, heuristics, and evaluated models used by access to the extruder. However,

This process also presents challenges, including the need for more participants resistant from professionals to participate in evaluating a diagnostic structure intended to guide the work of a specific professional and resistance from nurses to incorporate other professional perspectives into a nursing diagnosis structure. And the application process has also expanded in addition to verifying whether

Marcos Lopes (: 19:44

The diagnostic components are a clinical expression of a human response among care recipients. Other approach included methods aiming for a global clinical view of diagnosis and identification of relevant clinical information to determine the most significant components for different practice-related diagnostic issues. Obviously, each of these different methods requires specific study protocols.

which will provide complementary information about the clinical use of diagnosis. For this reason, when we speak to validity of a diagnosis, we are referring to an accumulation of produced evidence. A diagnosis will be more relevant to clinical practice. To more studies, use different approaches are developed.

Heather Herdman (: 20:41

So I think what you're saying is we don't have the answer yet. We've made a lot of progress, but there still a lot of pros and cons for each method. So let me ask you one last question. Is there an example of a recent impactful research study on nursing diagnosis that sticks with you that you'd like to share with us?

Marcos Lopes (: 21:06

yes, definitely. In fact, there are several interesting studies I could mention. I will highlight two recent studies available as early-review articles. One of these studies, which I find kit impactful, focuses on using ultrasound data in patients with kidney injury to identify the finding characteristics of excessive fluid volume.

This study was conducted by a researcher team in São Paulo, Brazil. The title of this study is Diagnostic Accuracy of Nursing Performed Lung Ultrasound for Pulmonary Congestion in a Good Kid in Jury, an exploratory study. And it is available in the International Journal of Nurse Knowledge. Another study I also found very interesting was also developed by Brazilian researchers.

and is available in Juneau Clinical Nursing. Its title is empirical testing of a middle range theory for ineffective breath pattern in children with congenital heart disease. This article goes beyond simply describing a theory about the diagnosis of ineffective breath pattern. It's described the entire clinical testing process of the theory that supports

supported the clinical validation of this diagnosis in children with congenital heart disease using specific statistical techniques, log linear models for empirical testing of the theory's proposition. These studies demonstrate how applied research can generate concrete changes in the taxonomy and most importantly in clinical nursing practices.

Heather Herdman (: 22:57

Well, I'm not familiar with the second one that you mentioned, so I'm gonna have to go find that study. Thank you so much for your time this evening and for joining us here on Nandacast. For those of you who don't know Dr. Lopez's work, you can certainly find many of his studies in our own journal, the International Journal of Nursing Knowledge, as well as in multiple other publications. So I encourage you to go look for those studies. And I hope that you enjoyed our conversation today.

Don't forget to subscribe to our newsletter at nanda.org. Follow us on LinkedIn, Instagram, and Facebook. You can find links to purchase the Nanda International Nursing Diagnosis Definitions and Classification textbook on our website. And until next time, let's continue defining nursing knowledge one concept at a time. Thanks.