SUBSET OF NANDA-I NURSING DIAGNOSES FOR INTENSIVE CARE: DELPHI TECHNIQUE AND FOCUS GROUP

Mirko Masciullo ¹, Flavio Marti ^1,2*, Antonello Cocchieri ³, Lucia Mitello¹, Andrea Fidanza ¹, Anna Rita Marucci ¹

 

1. Department of Health Profession, San Camillo Forlanini Hospital, 00152 Rome, Italy
2. School of Nursing and Midwifery, Faculty of Medicine and Psychology, Sapienza University of Rome, 00189 Rome, Italy
3. Section of Hygiene, Woman and Child Health and Public Health, Gemelli IRCCS University Hospital Foundation, Catholic University of the Sacred Heart, 00168 Rome, Italy

 

* Corresponding author: Flavio Marti, School of Nursing and Midwifery, Faculty of Medicine and Psychology, Sapienza University of Rome, San Camillo Forlanini Hospital, 00152 Rome, Italy – ORCID:  https://orcid.org/0000-0001-9569-3329 – Email: flavio.marti@uniroma1.it

Cite this article

 

ABSTRACT

Introduction: The NANDA-I taxonomy classifies nursing diagnoses to standardise communication and illustrate the impact of nursing on health outcomes. To improve usability in clinical practice, subsets of diagnoses, interventions, and outcomes have been developed for specific healthcare settings. These subsets facilitate documentation and decision making while supporting, rather than replacing, the clinical judgment of the nurse.

Objective: The study aims to develop a Subset of NANDA-I Nursing Diagnoses that nurses consider relevant in an intensive care setting.

Materials and Methods: A two-round Delphi study was carried out at the A.O. San Camillo Forlanini of Rome to identify the most appropriate diagnoses to constitute the Subset. Using the Delphi technique, two anonymous online questionnaires were submitted to a group of 10 experts. The nurses involved expressed their level of consensus on each of the most used NANDA-I diagnoses in intensive care.

Results: Nurses evaluated a total of 51 NANDA-I nursing diagnoses using 5-level Likert scales, including 47 diagnoses in the Subset. The most representative ones were: “(00004) Risk of infection”, “(00047) Risk of compromised skin integrity”, “(00030) Compromised gas exchange”, “(00091) Compromised mobility in bed”, “(00198) Model of disturbed sleep”, “(00249) Risk of pressure injury in adults”.

Conclusion: Among the included diagnoses, “Risk of infection” received unanimous agreement, confirming its essential role in intensive care. Other highly rated diagnoses, such as “Risk of compromised skin integrity,” “Impaired gas exchange,” and “Deficit in Self-Care: Bathroom,” aligns with findings from previous studies. Some diagnoses, including “Compromised mobility in bed” and “Disturbed sleep pattern,” were less commonly used in other ICUs, but were considered highly relevant by Delphi participants. The results highlight the focus of nurses on infection prevention, hygiene, gas exchange, pain management, mobilisation, and prevention of pressure injury. In particular, diagnoses related to stress, family conditions, and emotional needs received a lower consensus, suggesting the need for future research on holistic nursing care.

 

Keywords: nursing diagnoses, standardised nursing terminology, intensive care units, NANDA-International.

 

INTRODUCTION

The NANDA-I taxonomy was developed to classify nursing diagnoses related to interventions and outcomes that define the nursing process, allowing the integration of a common language within the nursing profession to improve communication, standardise care and improve patient outcomes. [1]. Standardised nursing terminology arises from the need to accurately and uniformly describe patient care. These terminologies facilitate communication by accurately describing the nursing process and illustrating the impact of nursing on health outcomes [2]. The use of standardised and validated language in clinical practice remains less widespread than expected, in part due to the challenges of integrating a common language into routine nursing documentation [1]. To simplify the use of standardised nursing languages, subsets of diagnoses, interventions, and outcomes have been developed to describe nursing actions in specific healthcare settings [3]. Subsets include specific nursing diagnoses for a specific healthcare context or condition. They are very useful tools for directing appropriate interventions and outcomes based on the clinical judgment of the nurse, who can thus focus on each individual care need of the patient [4]. The concept of Subset was introduced to respond to the need of professionals to have standardised terminology available but at the same time less confusing and easy to use. It is important, however, to specify that a Subset does not replace the nurse’s judgment in any way, but rather facilitates the documentation phase of care [5].

 

Objective: The study aims to develop a Subset of NANDA-I Nursing Diagnoses that nurses consider relevant in an intensive care setting. The most commonly used NANDA-I diagnoses in Intensive Care, identified in a recent scoping review [6], were evaluated by a group of Intensive Care nurses.

 

MATERIALS AND METHODS

A two-round Delphi study was carried out to identify relevant nursing diagnoses following Skulmoski’s methodology [7]. The main purpose of the Delphi technique is to generate consensus among a group of experts through a process of questionnaires interspersed with controlled [8]. It involves a structured group interaction, where members interact anonymously using questionnaires, thus preserving open discussions from influencing results [9]. Multistage interactions are envisaged to reduce the range of responses as much as possible and obtain consensus from the majority of experts [10].

 

Inclusion criteria

Inclusion criteria required having at least 24 months of experience in an intensive care unit of the A.O. San Camillo Forlanini in Rome.

 

Sample size

A group of 10 nurses were recruited, with two representatives for each of the five Intensive Care Units (ICU) of the A.O. San Camillo Forlanini of Rome (Shock and Trauma ICU, Cardiovascular ICU, Thoracic ICU, Post-surgical ICU and Neurosurgical ICU). Studies suggest an optimal Delphi group size of 10 and 15 participants [10].

 

Focus Group

In September 2023, the 10 study participants joined an online focus group via Google Meet. The group received a briefing on the Delphi technique and study procedures. During this session (Round 1), the first anonymous questionnaire was administered through Google Forms. The questionnaire asked to evaluate nursing diagnoses according to the NANDA-I 2020-2023 taxonomy most used in intensive care settings.  After completing the questionnaire, an open discussion between participants was held to indicate further NANDA-I nursing diagnoses that should be included in the second questionnaire.

At this stage, the experts’ clinical judgments were recorded in free terms and converted into NANDA-I 2020-2023 nursing diagnoses by the authors (Table 2). One author acted as moderator, while the other was responsible for recording the clinical judgments expressed by the experts.

 

Survey tool

The questionnaire evaluated nursing diagnoses based on the NANDA-I 2020-2023 taxonomy, specifically those most commonly used in Intensive Care, emerged from the Scoping Review underlying this study [6]. The questionnaire asked to evaluate nursing diagnoses according to the NANDA-I 2020-2023 taxonomy most used in intensive care settings. Subsequently, the results of the first questionnaire were processed and sent to each of the participants. At the end of September 2023, the second questionnaire was sent by email, consisting of diagnoses that needed re-evaluation according to the predefined criteria and diagnoses added by the nurses in the Focus Group.

 

Data collection and analysis

The first questionnaire asked to evaluate each of the proposed NANDA-I diagnoses on a Likert scale with a score of 1 to 5, quantifying the degree of appropriateness of the single nursing diagnosis in an Intensive Care Unit context. The interpretation of the results based on the average scores obtained for the first questionnaire was as follows: diagnoses with a low degree of consensus (range 1-2.33) were excluded from the Subset; diagnoses with an uncertain degree of consensus (2.34-3.66) or with at least an evaluation of score 3, were re-evaluated in the second questionnaire; diagnoses with a high degree of consensus (3.67-5) were included in the Subset. A summary table of the results including group ratings and diagnoses added during the focus group was prepared. This table was used to provide controlled feedback and statistical group response to participants, two important characteristics of the Delphi technique [11].

The second questionnaire, in addition to diagnoses with uncertain results, also served to evaluate the NANDA-I diagnoses added directly by nurses during the Focus Group. In this phase, the interpretation of the results included the following criteria: diagnoses with a low or medium degree of consensus (1-3.66) were excluded from the Subset; diagnoses with a high degree of consensus (3.67-5) were included in the Subset. Since this was the last planned questionnaire, all diagnoses that did not reach a high degree of consensus were excluded.

 

Ethical considerations

The study protocol matched the ethical guidelines of the Declaration of Helsinki for clinical studies and was submitted to the Ethics Committee of Lazio 1 that notified the acknowledgement with protocol number 1295 on 13 December 2022. Eligible participants were informed about the study’s purpose and their right to withdraw at any time without any consequences. Informed consent was obtained from all participants prior to their inclusion in the study, ensuring voluntary participation.

 

RESULTS

Sample description

The panel included 7 female and 3 male nurses, with an average age of 36.9 years (SD=8.5; range=26-49) and an average of years of service in the ICU of 9.1 years (SD=6.74; range=2-22). Seven nurses have a bachelor’s degree in Nursing and three have a master’s degree in Nursing and Midwifery.

 

First Delphi Round

The first questionnaire evaluated 44 NANDA-I nursing diagnoses commonly used in ICU settings. Of these, 34 diagnoses were directly included in the Subset; 9 diagnoses obtained uncertain results or at least an uncertainty rating and were re-evaluated in the second questionnaire; a diagnosis was excluded directly from the Subset, without the need for re-evaluation. The results are summarised in Table 1 and are provided as mean scores and standard deviation for each NANDA-I Nursing Diagnosis 2020-2023.

 

(Code) Nursing Diagnosis NANDA-I	Average Score	SD
(00002) Unbalanced nutrition: less than metabolic needs	4.1	0.83
(00004) Infection risk	5	0
(00011) Constipation	4.6	0.49
(00013) Diarrhea	4.4	0.49
(00022) Risk of urgent urinary incontinence	1.7	1.19
(00025) Risk of unbalanced fluid volume	4.4	0.92
(00027) Insufficient fluid volume	4	1.09
(00029) Reduced cardiac output	3.7	1.19
(00030) Compromised gas exchange	4.8	0.4
(00031) Ineffective airway clearance	4.2	1.17
(00032) Ineffective breathing pattern	4.6	0.49
(00033) Impaired spontaneous ventilation*	4.2*	0.6
(00039) Risk of aspiration	4	1.09
(00040) Risk of immobilization syndrome	4.2	0.87
(00044) Compromised tissue integrity	4.2	0.87
(00045) Compromised oral mucosa	4.4	0.49
(00046) Compromised skin integrity	4.6	0.49
(00047) Risk of compromised skin integrity	4.9	0.3
(00052) Impaired social interactions*	4.2*	0.98
(00060) Interrupted family processes	4.1	1.14
(00085) Compromised mobility	4.6	0.49
(00087) Risk of injury from perioperative positioning	3.9	1.04
(00091) Impaired mobility in bed	4.8	0.4
(00092) Reduced activity tolerance*	4.4*	0.66
(00102) Self-care deficit: nutrition	4.3	0.9
(00108) Self-care deficit: bathroom	4.7	0.9
(00110) Self-care deficit: toilet*	4*	1.34
(00114) Transfer stress syndrome*	3.3*	1.42
(00126) Insufficient knowledge	4.2	0.87
(00128) Acute mental confusion	4.5	0.92
(00155) Risk of falls in adults**	3.3**	1.34
(00177) Psychophysical overload from stress*	2.9*	1.37
(00179) Risk of unstable blood sugar	4.2	0.4
(00195) Risk of electrolyte imbalance	4.3	0.9
(00198) Disturbed sleep pattern	4.8	0.4
(00200) Risk of reduced cardiac tissue perfusion*	3.1*	1.51
(00201) Risk of Ineffective Cerebral Tissue Perfusion*	3.9*	1.14
(00204) Ineffective peripheral tissue perfusion	4.2	0.87
(00206) Risk of bleeding	4.4	0.49
(00213) Risk of Vascular Trauma	4.2	1.17
(00219) Risk of dry eyes	4	1.09
(00228) Risk of ineffective peripheral tissue perfusion	4.3	0.9
(00247) Risk of compromised oral mucosal integrity	4.6	0.49
(00249) Risk of pressure injury in adults	4.8	0.4
* Diagnosis with at least a grade 3 (uncertain) rating: to be re-evaluated in round 2. ** Diagnosis with an average score between 2.34 and 3.66: to be re-evaluated in round 2

Table 1: Results of the first questionnaire (in ascending order by code NANDA-I 2020-2023

Focus group

The open discussion among the Intensive Care nurses in the Delphi group led to the inclusion of seven additional NANDA-I nursing diagnoses in the study. Participants freely expressed their clinical judgments, which were recorded and later coded by the researchers according to the NANDA-I 2020–2023 taxonomy. Expert evaluations helped identify the care needs of Intensive Care patients that best represented their clinical context but had not previously emerged from the scientific literature. This phase was essential to refine the Subset to better align with specific care settings. The results of the focus group are summarised in Table 2.

 

Clinical judgment	(Code) NANDA-I Nursing Diagnosis
“Communication alterations due to tracheostomy or language barrier”	(00051) Impaired verbal communication
“Dysphagia”	(00103) Impaired swallowing
“Postoperative or other pain (after trauma, pressure ulcer, positioning)”	(00132) Acute pain
“Thermoregulation problems (post-surgery, post-traumatic, or fever)”	(00006) Hypothermia
	(00007) Hyperthermia
“Problems in the phase of weaning from the mechanical ventilator”	(00034) Response to weaning from the dysfunctional ventilator
“Alteration of body image in tracheostomized or mutilated patients”	(00118) Body image disorder

Table 2: Clinical judgments expressed by nurses in the Focus Group and coded according to the NANDA-I taxonomy

 

Second Delphi Round

In the second questionnaire, a total of 16 diagnoses were evaluated, nine diagnoses were re-assessed based on predefined criteria, while 7 were newly added by participants during the focus group. After completion of this questionnaire, 3 additional diagnoses were excluded from the Subset, leaving a final total of 13. The results of this phase of the Delphi study are presented in Table 3.

(Code) NANDA-I Nursing Diagnosis	Average Score	SD
(00006) Hypothermia *	4.4	0.92
(00007) Hyperthermia *	4.4	0.92
(00033) Impaired spontaneous ventilation	4.5	0.5
(00034) Response to weaning from the dysfunctional ventilator *	4.4	0.49
(00051) Impaired verbal communication *	4.4	0.49
(00052) Impaired social interactions	4.5	0.5
(00092) Reduced activity tolerance	4.6	0.49
(00103) Impaired swallowing *	4.6	0.49
(00110) Self-care deficit: toilet	4.1	1.3
(00114) Transfer stress syndrome	3.7	1.42
(00118) Body image disorder *	3.4	1.43
(00132) Acute pain*	4.5	0.5
(00155) Risk of falls in adults	3.3	1.35
(00177) Psychophysical overload due to stress	3.4	1.43
(00200) Risk of reduced cardiac tissue perfusion	4.1	1.4
(00201) Risk of ineffective cerebral tissue perfusion	4.6	0.49
* Diagnoses added during the Focus Group

Table 3: Results of the round 2 questionnaire

 

Subset of NANDA-I nursing diagnoses

In the first questionnaire of Round 1 (Table 1), the expert panel evaluated the NANDA-I nursing diagnoses identified through the Scoping Review by Masciullo [6]. Subsequent focus group, through open discussion among participants, helped identify additional nursing diagnoses (Table 2) considered relevant in Adult Intensive Care Unit (ICU) context. In the second questionnaire (Table 3), nurses re-evaluated diagnoses that had not achieved a sufficient score for inclusion in the Subset or had raised uncertainty for at least one participant. During this phase, the panel also evaluated the diagnoses added during the focus group. The results of the Delphi study led to the development of a validated Subset comprising 47 nursing diagnoses, approved by a panel of adult intensive care nurses. The final NANDA-I Nursing Diagnosis Subset for the ICU is presented in Table 4, ranked in descending order of Delphi consensus.

 

(code) Nursing diagnosis NANDA-I	Average score	SD
(00004) Risk of infection	5.0	0.0
(00047) Risk of compromised skin integrity	4.9	0.3
(00030) Compromised gas exchange	4.8	0.4
(00091) Impaired mobility in bed	4.8	0.4
(00198) Disturbed sleep pattern	4.8	0.4
(00249) Risk of pressure injury in adults	4.8	0.4
(00108) Self-care deficit: bathroom	4.7	0.9
(00011) Constipation	4.6	0.49
(00032) Ineffective breathing pattern	4.6	0.49
(00046) Compromised skin integrity	4.6	0.49
(00085) Compromised mobility	4.6	0.49
(00092) Reduced activity tolerance	4.6	0.49
(00103) Impaired swallowing	4.6	0.49
(00201) Risk of ineffective cerebral tissue perfusion	4.6	0.49
(00247) Risk of compromised oral mucosal integrity	4.6	0.49
(00033) Impaired spontaneous ventilation	4.5	0.5
(00052) Impaired social interactions	4.5	0.5
(00132) Acute pain	4.5	0.5
(00128) Acute mental confusion	4.5	0.92
(00013) Diarrhea	4.4	0.49
(00034) Response to weaning from the dysfunctional ventilator	4.4	0.49
(00045) Compromised oral mucosa	4.4	0.49
(00051) Impaired verbal communication	4.4	0.49
(00206) Risk of bleeding	4.4	0.49
(00006) Hypothermia	4.4	0.92
(00007) Hyperthermia	4.4	0.92
(00025) Risk of unbalanced fluid volume	4.4	0.92
(00102) Self-care deficit: nutrition	4.3	0.9
(00195) Risk of electrolyte imbalance	4.3	0.9
(00228) Risk of ineffective peripheral tissue perfusion	4.3	0.9
(00179) Risk of unstable blood sugar	4.2	0.4
(00040) Risk of immobilization syndrome	4.2	0.87
(00044) Compromised tissue integrity	4.2	0.87
(00126) Insufficient knowledge	4.2	0.87
(00204) Ineffective peripheral tissue perfusion	4.2	0.87
(00031) Ineffective airway clearance	4.2	1.17
(00213) Risk of Vascular Trauma	4.2	1.17
(00002) Unbalanced nutrition: less than metabolic needs	4.1	0.83
(00060) Interrupted family processes	4.1	1.14
(00110) Self-care deficit: toilet	4.1	1.3
(00200) Risk of reduced cardiac tissue perfusion	4.1	1.4
(00027) Insufficient fluid volume	4	1.09
(00039) Risk of aspiration	4	1.09
(00219) Risk of dry eyes	4	1.09
(00087) Risk of injury from perioperative positioning	3.9	1.04
(00029) Reduced cardiac output	3.7	1.19
(00114) Transfer stress syndrome	3.7	1.42

Table 4: Subset of Nursing Diagnoses according to NANDA-International taxonomy 2020-2023

 

DISCUSSION

The specific Subset for the adult Intensive Care context, identified through this study, includes 47 NANDA-International Nursing Diagnoses. The expert panel excluded only one diagnosis in Round 1 and three diagnoses in Round 2. The excluded diagnoses were: (00022) Risk of urge urinary incontinence, which received a very low average score (1.7) and was unanimously considered inappropriate for the Intensive Care setting. Diagnoses (00155) Risk of falls in adults and (00177) Stress overload, initially assessed with uncertainty in Round 1 and reevaluated in Round 2, failed to achieve sufficient consensus. Finally, (00118) Disturbed body image was also excluded due to a high standard deviation (1.43), indicating inconsistent evaluations among nurses and highlighting a topic that warrants further investigation.

Among the included diagnoses, (00004) Risk of infection stood out, achieving the highest score and being unanimously recognised as essential in an ICU setting. This finding aligns with the existing literature, since the same diagnosis has been reported to be the most frequently used in similar care settings [12–16].

Other diagnoses received a high degree of consensus, being among the most representative according to experts. These diagnoses also appear frequently in similar contexts described in previous studies, including (00047) Risk of impaired skin integrity [13,14], (00030) Impaired gas exchange [17,18], and (00108) Self-care deficit: bathing [12,13,19]. These findings suggest that, for the most part, the results obtained using the Delphi technique are consistent with those of other studies. However, some diagnoses that achieved a high level of consensus differed from those commonly used in other ICUs, including (00091) Impaired bed mobility, (00198) Disturbed sleep pattern, and (00249) Risk of pressure injury in adults. Despite their lower prevalence in other Intensive Care settings, the Delphi study participants considered them highly representative of their respective operational units. The NANDA diagnosis subset is intended to support nurses in choosing the most appropriate nursing diagnoses that reflect the specific care needs of patients admitted to the ICU. However, it is not a substitute for professional judgment and therefore, it is the nurse’s responsibility to formulate additional diagnoses to ensure individualization of care.

 

CONCLUSION

The creation of a subset of nursing diagnoses has allowed the identification of the main areas of care in which ICU nurses have focused their attention. The key themes that emerged include infection prevention, hygiene, gas exchange, pain management, patient mobilisation, and prevention of pressure injuries. Diagnoses that received a high level of consensus reflect the essential responsibilities of nurses in high-complexity care settings. These diagnoses addressed not only the patient’s actual needs but also potential problems, whose identification through risk diagnoses proved crucial for the implementation of effective preventive measures.

Furthermore, the analysis of the diagnoses included in the subset revealed a tendency to exclude or assign minimal relevance to diagnoses related to stress, family conditions, knowledge, and situational acceptance. This finding highlighted a widespread difficulty among nurses in identifying needs related to the patient’s emotional and spiritual well-being, instead of prioritising physiological problems. Therefore, it will be essential to further explore this aspect of nursing care through future studies that integrate not only NANDA-I Nursing Diagnoses but also the NIC and NOC classifications.

 

Limitations

To ensure greater methodological consistency, it would be advisable to conduct a literature review that aims not only to identify nursing diagnoses but also to define specific outcomes and interventions for adult ICU. An additional limitation of this study concerns the level of knowledge of the participants regarding the use of NANDA-International nursing diagnoses. Although they were experienced ICU nurses, their familiarity with NANDA-I diagnoses was not optimal. This issue reflects a broader challenge within the Italian nursing context, where the use of standardised nursing languages is not yet fully widespread. Due to the difficulty in recruiting nurses who were experts in intensive clinical practice and experienced in the use of NANDA-I diagnoses, the primary inclusion criterion was experience in ICU patient care. Finally, it would be necessary to replicate a multicentred Delphi study to generalise the findings to other adult ICU care settings.

Funding statement

This research did not receive specific grants from funding agencies in the public, commercial, or non-profit sectors.

 

Conflict of interest  

The authors report no conflict of interest.

 

Authors’ contribution

M.M: Investigation, Writing – original draft. F.M.: Conceptualization, Writing – original draft, Writing – review & editing.  A.C.: Writing – review & editing, Supervision. L.M.: Writing – review & editing, Supervision. A.F.: Conceptualization, Writing – review & editing. A.R.M.: Conceptualization, Supervision. All authors have read and agreed to the published version of the manuscript.

 

Acknowledgements

The authors wish to thank the nurses who participated in this study. A heartfelt thanks to Federica Mauri Kurera for English editing support.

 

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