Behavior Diagnoses by a Multidisciplinary Team To create a plan of care for an elderly patient in a nursing h ome , m e m b e r s of multidisciplinary teams must find a c o m m o n language.

BY BARBARA AYN W R I G I I T

T he interdisciplinary team practice of psychogeri- atr ics in the nursing home setting for elderly adults needing care for chronic health problems

presents enormous challenges to health care professionals who participate in creating the plan of care.

Nursing homes are run by nurses. Nursing is the pri- mary activity that takes place in a nursing home. There are more nurses than there are doctors, social workers, di- eticians, and geropsychiatrists. The main action is nurs- ing action. The main interactions are nursing interac- tions. The treatment is nursing based.

The reasons for the elderly adult being in the nursing home are often complex. Diagnosis of chronic disease is one factor. Diagnosis of psychiatric disease may be an- other. Diagnosis of psychiatric disease is made on the ba- sis of criteria in the Diagnostic and Statistical Manual o f Mental Disorders, Third Edition, revised. Signs and symptoms are recognized, and the diagnosis follows in a system of five axes based on the history of the patient. Ex- act behaviors are seen as symptoms of a disease entity. Attention is turned toward recognizing the patterns that signal a pathologic condition and naming that condition. This viewpoint or angle identifies a problem to be ad- dressed. The focus is not on strengths or needs.

Needs are addressed only if they are within the orien- tation of the axes. The benefit to other members of the team of health care professionals in an accurate psychi- atric diagnosis may be to offer an underlying cause of dis- ease for behaviors seen or attitudes taken by the elderly adult. Yet all such behaviors or attitudes taken may not reflect disease when separated out of the diagnostic cat- egory. Anger, for example, is a normal emotion common to human beings. The absence of the ability to feel and recognize anger is the pathologic response.

BARBARA AYN WRIGttT, RN, CFNP, CGNP, is in private prac- tice in otolaryngology with Andrew Pulliam, MD, in Sarasota, Florida. Copyright © 1993 by Mosby-Year Book, Inc. ISSN 0197-4572/93/$1.00 + .10 34/1/40.]38

Therefore the multidisciplinary team looking at exhib- ited behaviors and responses does so by identifying what the individual health care professional sees on that day at that point in time. The team meets to discuss assessments and to find a common ground in the various assessments to name those things for which resident-centered goals may be set and for which staff interventions may be de- vised. The conference i~ a way to reach consensus assess- ment and document in words that mean the same thing to all parties.

The members of a multidisciplinary

team need an order, or format, to

follow, a structure of interaction.

Health care professionals who participate in multidis- ciplinary team meetings to create a plan of care need help to do so. To create a plan of care, members of the team need an order, or format, to follow, a structure of inter- action, and a common language. The group needs a leader and a recorder to document the goals and inter- ventions. The responsible health care professional for each intervention, whether it is an individual or a team ef- fort, must be assigned. Responsibility for each interven- tion being done and documentation of resident response and progress toward the goal is decided and designated. The process involves participation by all members of the team.

The organization and teaching of the team care plan formulation is imperative to the operation of a nursing home. Team members come and go, but the process of care plan formulation goes on. A choice must be made on the method taught to team members. Because the major- ity of the care given is done by nurses, a care plan based on nursing theory was taught to the team in our nursing home. In a nursing theory-based care plan, the medical

30 Geriatric Nursing January/February 1993 Wright

diagnosis or psychiatric diagnosis is not the basis for the plan of care; the behavior exhibited is the basis. The un- derlying cause of the behavior exhibited may be a med- ical or a psychiatric condition or may be unknown: the signs, symptoms, and behaviors are the focus of the plan of care. In addition, needs and strengths that may be un- related to disease but which are based in the human con- dition are identified and documented when the elderly person is compromised in meeting those needs or support- ing his or her strengths unaided.

The way that each team performs the care plan is based on multiple factors. In this article we describe how members of a multidisciplinary team applied their knowl- edge to formulate a care plan and the consensus naming that was the result. The team was taught nursing theo- ry-specifically nursing diagnosis theory--to use as the communication vehicle in care plan formulation. The cognitive task for the team was first to assess the resident behavior. Second, the team expressed that identified be- havior in the form of nursing diagnosis of that behavior as a problem, need, or strength for which a resident- centered goal could be formulated and for which staff ac- tion could be devised to assist in reaching the resident- centered goal.

Review of the Literature

In 1980 the American Nurses Association (ANA) is- sued and endorsed "Nursing, a Social Policy Statement." This publication set forth a new definition of nursing practice that stated, "Nursing is the diagnosis and treat- ment of human responses to actual and potential health problems. ''l Thus nursing diagnosis was established as an essential component of the nursingprocess. Nursing di- agnoses are derived from data collected through the nurs- ing assessment. Nursing diagnoses summarize nursing assessment data by describing clients' response to actual or potential health problems. The definition accepted by the North American Nursing Diagnosis Association (NANDA)" membership for nursing diagnosis conceptu- ally allows inclusion of strength diagnoses.

Nursing diagnosis is based in nursing theory. Theory development in nursing continues within a historical framework. The work of many theorists is augmented in nursing diagnosis theory. Research and interest in nurs- ing diagnoses are encouraged by NANDA. NANDA was organized in 1973 to develop and classify nursing diag- noses for clinical testing. Accepted nursing diagnoses were listed, alphabetically, starting in 1982. In 1986 the first taxonomic structure for nursing diagnoses (NAN- DA Taxonomy I), which replaced the alphabetic list, was published and sent to the NANDA membership. 2 The first international conference for nursing diagnosis was held in Calgary, Alberta, Canada in 1987.

The conceptual base of the NANDA taxonomy is nine central human response patterns; these are used as the category headings of the taxonomy. 2 The taxonomy is pe- riodically revised as new diagnoses are developed, tested, and accepted)

The nine central patterns of human responses "repre-

sent the dimensions of person-environment interacting: exchanging, communicating, relating, valuing, choosing, moving, perceiving, feeling and knowing. ''4 The catego- ries are not mutually exclusive. The nursing diagnoses are placed within the taxonomic tree at lower levels.

Berry 5 noted that broad labels in nursing diagnosis (es- pecially for psychiatric nurses) may not be concrete or of- fer enough description: "A diagnosis that is too abstract to direct specific intervention is of little clinical value. To be useful, a diagnosis must accurately label a patient's condition and give direction for intervention." Thus "ma- nipulative behavior" may be too broad and abstract to provide direction for patient-specific nursing interven- tions, without identifying what specific behaviors are ex- hibited as a result of the underlying disorder. Berry sug- gested that the efforts of the team may be better ex- pended in ident i fy ing subcategories of behavior exhibited.

Strength or wellness behaviors found in geriatric resi- dents in a nursing home may be used in care plans to pro- mote health. 6 Reported research of strengths identified by a multidisciplinary team in long-term care supports strength diagnoses as conceptually paramount in the NANDA framework of nine human response patterns. 7 Perceiving and feeling--the most abstract of the human response patterns--yielded the least agreement in a sort- ing of strength diagnoses done by experts in this study.

Psychologic factors have been reported for residents in long-term care who frequently fall. 8 Three defining char- acteristics of independence, denial, and refusing help are behaviors found as a cluster in elders who repeatedly fall.

There appears to be a consensus among the members of the multidisciplinary team in naming relatively "pure" physiologic phenomena that is helped by knowledge and application of the nursing diagnosis taxonomy. Within the psychosocial domain, a shortfall exists in helping the team to name complex behavior phenomena or clusters of behavior using the nursing diagnosis taxonomy.

Background a n d Setting

In 1984, in a 240-bed skilled and intermediate chronic care nursing home for the elderly, a committee compris- ing a clinical nurse specialist in gerontology, a nurse prac- titioner, and a social worker was formed. These profes- sionals taught care plan formulation to the multidisci- plinary team responsible for elderly residents' care. This instruction focused on the nursing process, including nursing diagnosis, and the strengths of each resident. Strengths were defined as "anything that supports a res- ident." The multidisciplinary team consisted of at least one member of the care plan committee along with a staff nurse, a nursing assistant, an activity worker, a physical therapy worker, and, occasionally, significant others, stu- dents, a member of the clergy, or an administrative rep- resentative. Medical input was obtained by chart review. The multidisciplinary team met 5 days a week to review and rewrite four care plans each day. By this schedule, each care plan was reviewed every 3 months. New staff were oriented to this method.

Wright Geriatric Nursing Volume 14, Number I 31

The established rote care plan, or standard care plan, is a reality in some settings. 9 In such cases, the multidisci- plinary team meetings may be a perfunctory exercise in which standard plans are exchanged.

Care plans generated in this study were handwritten at the time of the team conference and created as a result of team interaction. The problems identified and docu- mented were conclusions reached by consensus of the team members.

In teaching the team to use nursing diagnosis, a list of NANDA-accepted nursing diagnoses was distributed to each team member to consult as a cue to problem/need identification. The NANDA-accepted nursing list was limited in development at that time. Behavior or psycho- logic problems/needs were limited to concepts of altered or impaired thought process, behavior, or coping. The team was instructed to plunge in to narrowly and specif- ically identify and name the problem/need so that inter- ventions could address the behavior.

The philosophy of the institution and the team was to support the residents in their rights and autonomy as much as possible in the nursing home setting. A resis- tance was noted in the team to giving labels that could prove detrimental to the resident in the future. Therefore the choice of words used by the team to name behaviors is of special interest.

The following factors were not addressed: state regu- lations and reimbursement, participation level and edu- cational level of the members of the multidisciplinary team members, and the scope, quality, and specificity of individual team member's assessment instruments.

Results

Three years later, in 1987, an audit was done of care plans (N = 235) prepared by the multidisciplinary team. The purpose of the audit was to assess the use of a new care plan format. Functional areas, behavior, and mental status areas were printed on the care plan to act as cues to the team. These cue areas could be followed to give or- der to the team meeting. The cue areas were chosen to fo- cus the team to ensure that each area would receive as- sessment and be included, if appropriate, in the total plan of care.

Problems were identified as actual (e.g., self-care def- icit: bathing). Potential problems were also identified in each area (e.g., potential for weight loss). Both actual and potential identified problems were totalled together in each cue area (see "Problems/Needs Identification" table).

The care plan is the reason for this documentation. Im- plementing the plan takes time and increased numbers of staff to perform the interventions noted on the plan of care. Resident progress toward goals and response to planned staff interventions represents increased staff time for implementing interventions and documentation. The audit was done to assess the total number of problems in each cue area in the resident population to gauge staffing needs for intervention and documentation time.

The characteristics of the resident population illus- trated in the table reflect the level of pathophysiologic conditions present in this population and the degree of impact these conditions have had on activities of daily liv- ing. (The mean, median, and modal age was 86 years; age ranged from 63 years to 102 years.)

The functional areas assessed demonstrate the degree of loss of function of this population as a whole. Rantz et al. I° found similar frequencies of nursing diagnosis iden- tification in functional areas in a nursing home popula- tion. Kane et al. il noted incontinence prevalence at 30% to 60% in nursing homes.

Mental status problems/needs were named mainly as "alteration in thought process." The most common med- ical diagnoses for these conditions are Alzheimer's dis- ease or mult i infarct dementia. More than 60% of our nursing home population had "'alteration in thought pro- cess" on care plans.

In the areas of behavior, mental status, activities, and socialization, 809 problems were identified. These prob- lems were identified in both the actual and potential for states (e.g., depression or potential for depression).

The most frequently named nursing diagnoses based on accepted nursing diagnoses are listed in the "Nursing Di- agnosis" box. These labels are general and not descriptive of specific behaviors. The diagnoses are listed as actual problems. The team also described these problems as po- tential problems (e.g., potential for social isolation).

Neuropsychogenie phenomena named are listed (see box). The level of abstraction varies widely in this group- ing. Some labels are specific. The similarity of the behav- iors found in acute settings versus this chronic setting is of interest. Many are comparable to the behavior system phenomena identified by Reisberg et al. 12 in Alzheimer's disease. Alzheimer's disease may be the underlying cause

32 Geriatric Nursing January/February 1993 Wright

of the behavior system phenomena observed and catego- rized as psychotic symptoms, depressive symptoms, or af- fective symptoms.

Heber t3 identified 10 clusters of behaviors in a Cana- dian psychiatric setting. Behavior clusters were related to medical diagnosis:

• Anxious behavior (anxiety disorder) • Manipulative behavior (personality disorder) • Overactive behavior (manic disorder) • Underactive behavior (depressive disorder) • Suspicious behavior (paranoid disorder) • Confusion (organic brain syndrome or functional) • Combination of above • Specific (e.g., suicide attempt) • Withdrawn (schizophrenic disorder) • Wellness pattern of behavior

Heber described these 10 clusters as open ended and nursing theory based. Many of these behaviors are found in our list of neuropsychogenic phenomena.

Need phenomena named (not NANDA approved) are listed (see box). Needs were found as "need for" and "need to." The degree of abstraction is high in these iden- tified needs. The " I n t i m a c y Needs" box gives the NANDA format we propose. Intimacy needs describes a pattern of defining characteristics and related factors that we found exhibited in nursing home residents. The format of definition, defining characteristics, and related factors illustrates how any nursing diagnosis is presented for testing and validation by NANDA.

Strength phenomena are also listed (see box). No at- tempt is made to separate this grouping of strengths into categories of human response patterns. The level of ab- straction varies widely in the identified strengths but tends toward concrete descriptions.

D i s c u s s i o n

In 1985 Bergener 14 said, "We give lip service to the multi-disciplinary team in geriatrics."

Going beyond lip service requires effort, of course--an

expenditure of time, energy, and resources. A plan is needed with action steps to reach the goal of a function- ing multidisciplinary team. The team concept has been compared to a sports team in which specialty players are chosen for position and skill to make a successful team. Nevertheless, this comparison does not seem apt.when the goal is not to win a competition but to achieve resident- centered goals. The sports team is playing a game; the multidisciplinary team is working at life processes. The error of reason is similar to equating body function to ma- chine function: the human element is not considered. In the actions of the multidisciplinary team, the human element is the purpose.

Wright Geriatric Nursing Volume 14, Number I 33

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Health planning for the elderly is multidisciplinary. This team is made up of various health professionals. Each member brings his or her own assessment, knowl- edge, experience, and personal issues to the conference. Many members of the team are professionals. One crite- ria of a professional is theory development. The at- tempted integration of theoretical concepts from different disciplines may add to the chaos of health care planning.

In our nursing home, nursing theory was chosen and taught to the team as an umbrella over the functional areas. For instance, a client who cannot wash in a bath because of joint disease would be listed under the nursing diagnosis of "'self-care deficit: bathing." Nursing diag-

noses are not fully developed, and nursing diagnosis la- bels for behaviors are lacking. Team members need to name behaviors of the clients and use these names as a taxonomy to develop a common language among the var- ious disciplines. The behaviors (cues, symptoms) become the driving force of the care plan.

The cause of any behavior may be obscure. Many be- haviors are exhibited; not all are problems. The 96-year- old woman who, since the time of the Tsar, has organized her day around a daily self-administered enema has a problem when her arthritis becomes so severe that she can no longer self-administer her enema. When she is ad- mitted to a nursing home, the daily enema becomes a staff problem. Weaning the woman from seven enemas a week to three may be achievable. But this woman may want two enemas a day and believe this to be necessary for her health. Negotiation ensues. The goal set must be resident centered and achievable (realistic). Such situa- tions are commonplace in nursing homes, where all pos- sible behaviors of human beings may be observed.

The creation of a common language with which to de- scribe problems, needs, and strengths for care plan for- mulation is essential. The theoretical framework of the assessment and care plan should serve to focus the mul- tidisciplinary team to the task at hand. The goal is to for-

34 G e r i a t r i c N u r s i n g J a n u a r y / F e b r u a r y 1993 W r i g h t

mulate a holistic picture of the resident in all dimensions of human response. In acute settings, focus must be on the acute problem, yet the further dimensions of the nine h u m a n response patterns cannot be ignored. In chronic care settings, such as nursing homes, the individual plan of care reflects wider dimensions of human response and time frames are different. The resident has a history. The history reflects a lifetime of experience and includes de- cisions, beliefs, choices, and values. Adaptat ion patterns may be lifelong behaviors. The language used for com- munication and documentat ion at tempts to align a mul- tidisciplinary team to diagnose, treat, support, and help the whole person.

Allen 15 identifies a further responsibility for action:

Much of the activity that nurses interact with, however, is fully human, value impregnated action. Intervention(s) in- fluencing this action requires negotiation, not simply di- agnosis and treatment, and the client needs to occupy the same conceptual space as a person as the nurse does.

As a corners tone of the in teract ion, the mult idisci- plinary team, as well, needs to occupy the same concep- t u a l s p a c e as the e l d e r l y a d u l t w i t h r e s p e c t f o r differences. •

REFERENCES

1. American Nurses Association. Nursing: a social policy statement. Kansas City, Missouri: ANA, 1980.

2. NANDA. Nursing diagnosis taxonomy I (pamphlet). St. Louis: North Amer- ican Nursing Diagnosis Association, 1986.

3. NANDA. Nursing diagnosis taxonomy I revised with official diagnostic cat- egories. St. Louis: North American Nursing Diagnosis Association, 1989.

4. Newman M. Looking at the whole. Am J Nuts 1984;84:1496-9. 5. Berry KN. Let's create diagnoses psych nurses can use. Am J Nurse

1987;707-8. 6. Aizenstein S, Wright BA. Using strengths of geriatric residents in long term

care. Am J Nurs 1988;88:1403-6. 7. Wright BA, Aizensteln S. Strengths and NANDA taxonomy I: how do

strength phenomena distribule in an elderly adult population? Florida Nurs- ing Review 1989;3(4):1-7.

8. Wright BA, Aizenstein S, Vogler G, Rowe M, Miller C. Frequent railers: leading groups to identify psychological factors. J Gerontol Nurs 1990;16(4): 15-19.

9. Kampy E, Enderston M. Care diagnosis, the important link between assess- ment and planning by the interdisciplinary team. In: Hannah K J, Reimer M, Mills W, LeTourneau S, eds. Clinical judgement and decision making: the fu- ture with nursing diagnosis. New York: Wiley & Sons, 1987.

10. Rantz M, Miller T, Jacobs C. Nursing diagnosis in long-term care. Am J Nurs 1985;85:916-26.

I 1. Kane RL, Ouslander JG, Abrass lB. Essentials of clinical geriatrics. New York: McGraw Hill, 1984.

12. Reisberg B, Borenstein J, Salob S, Ferris S, Fransscn E, Georgutas A. Be- havioral symptoms in Alzheimer's disease: phenomenology and treatment. J Clin Psychol 1987;48(suppl):9-15.

13. Heber L. Nursing diagnosis is professional psychiatric nursing practice. In ltannah K J, Reimer M, Mills W, LeTourneau S, eds. Clinical judgement and decision making: the future with nursing diagnosis. New York: Wiley & Sons, 1987.

14. Bergener M. "Muhi-disciplinary treatment of the elderly: innovations in psy- chogeriatrics.'" Lecture, Center for Applied Gerontology, Evanston, Illinois, 1985.

15. Allen DG. The concepts of person and society underlying nursing diagnosis: a critique. In: ttannah K J, Refiner M, Mills W, LeTourneau S, eds. Clinical judgement and decision making: the future with nursing diagnosis. New York: Wiley & Sons, 1987.

Wright

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