Three phases of research in validating nursing diagnoses.

The purposes of this three-phase project consisting of concept analyses, nurse expert validation, and client validation were: identification of nursing definitions of anxiety and fear, validation of defining characteristics of the diagnoses by nurse experts, differentiation of the diagnoses by nurse experts, and validation of the nursing diagnosis anxiety by clients. The nurse expert sample consisted of 233 professional nurses, and the client sample consisted of 69 adult clients. Results include agreement on two critical defining characteristics of anxiety by nurse experts and clients, the differentiation of anxiety and fear by nurse experts, the suggestion of a fear-anxiety syndrome in the literature and by nurse experts and clients, and the suggestion by nurse experts that anxiety be defined using levels of anxiety. Recommendations for changes in the nursing diagnosis anxiety are discussed

As knowledge development in nursing has advanced, initial progress in identifying, defining, and organizing the phenomena of concern to nursing has made these phenomena more meaningful, capable of being communicated, and amenable to continuing research study. Such progress is critical because concepts acquire a common meaning within the discipline and provide a foundation for the development of empirically based interventions and outcomes. There is a continuing need to identify and validate nursing concepts through descriptive theory development and clinical validation of the concepts that are used to describe the phenomena pertinent to nursing.

EVOLUTION OF THE CONCEPTS

The conceptual framework for this study was The Unitary Person Framework, as developed by the North American Nursing Diagnosis Association (NANDA). The definition of nursing diagnoses used in the study is that accepted by NANDA:

A nursing diagnosis is a clinical judgment about individual, family, or

community responses to actual or potential health problems/life processes.

Nursing

diagnoses provide the basis for selection of nursing interventions to

achieve outcomes for which the nurse is accountable. (Carroll-Johnson, 1990,

p. 50)

The concepts that are the foci of this study, anxiety and fear, are subsumed under the Human Response Pattern of Feeling. The definition of feeling is "to experience a consciousness, sensation, apprehension, or sense; to be consciously or emotionally affected by a fact, event, or state" (Fitzpatrick, 1991, p. 25).

A review of the literature in nursing, psychology, psychiatry, philosophy, and other related health disciplines formed the bases for the concept analyses of anxiety and fear. The literature review began with the work of the existential philosopher Kierkegaard in 1844 and has encompassed efforts up to the present time.

Notably, Kierkegaard did not use the terms fear and anxiety interchangeably, as did some later scholars. He described fear as relating to a definite feared object (Fisher, 1970) and anxiety as a vague diffuse uneasiness, without a definite object being perceived as dangerous (Goodwin, 1986). Freud described neurotic anxiety in a manner that corresponds to current definitions of anxiety. He differentiated neurotic anxiety from reality anxiety (i.e., fear), which refers to a painful emotional experience based upon a dangerous situation in the external world (Fisher, 1970). Subsequent critical influences on conceptualizations of anxiety and fear came from the neo-Freudian theorists, who emphasized the importance of environmental rather than hereditary or constitutional influences on human behavior (Fisher, 1970).

Learning and behavioral theorists, whose focus is proximal rather than distal causes, also played an important role in the evolution of these concepts (Kaplan, 1974). Peplau led psychiatric-mental health nurses in much of the early work of clarifying nursing concepts relevant to their practice (Norris, 1982). Peplau's (1952) classic textbook included a chapter describing both conceptual and clinical elements of anxiety, using Sullivan's (1947) interpersonal relations framework. In a later work (1989), which reflects decades of scholarship and experience, Peplau offered a continuing refinement of her analysis of anxiety and its role in nursing. This work includes general characteristics, definition as a clinical construct, differentiation of degrees of anxiety, patterns of behavior to relieve anxiety, nursing interventions, related concepts, and relationships among related concepts.

Both fear and anxiety were established as nursing diagnoses in 1973 at the first nursing diagnosis conference. The initial definitions of both diagnoses designated levels of both fear and anxiety. However, after considerable debate, these initial definitions were changed in 1980 to the current diagnoses (Kim & Moritz, 1982), which include 17 subjective and 12 objective defining characteristics for anxiety and one defining characteristic for fear. Neither diagnosis has designated levels. Three subsequent studies (Burke, 1982; Jones & Jakob, 1984; Yocum, 1984) have indicated the need to clarify, define, and differentiate these nursing concepts, but they remain unchanged.

Multiple research studies have confirmed that the nursing diagnoses of fear and anxiety commonly occur. Frequencies ranging from third through eighth place were obtained in these studies (Castles, 1982; Jones, 1982; Jones & Jakob, 1984; Kim et al., 1982; Kim, McFarland, & McLane, 1984; Levin, Krainovich, Bahrenburg, & Mitchell, 1989; McKeehan & Gordon, 1982; Metzger & Hiltunen, 1987; Taylor-Loughran, O'Brien, LaChapelle, & Rangel, 1989). A recent study on nursing diagnoses done in Japan revealed that 79.6% of the nurse respondents indicated that anxiety was present in intensive care unit patients very often or quite often (Matsuki & Otani, 1994).

Several kinds of clinical validation studies have been completed on the nursing diagnoses anxiety and fear. These studies reveal common trends in identifying defining characteristics of anxiety, although client groups were distinctly different from study to study (Aukamp, 1986; Fadden, Fehring, & Rossi, 1987; Kim, Seritella, et al., 1984; Taylor-Loughran et al., 1989). Taylor-Loughran et al. studied fear and anxiety in all patient populations in a large university hospital and found that four characteristics occurred most frequently in anxiety: anxious, apprehension, worried, and facial tension. Apprehension, scared, and ability to identify the object of fear were the most frequently identified characteristics of fear. These researchers concluded that further investigation should be done to differentiate fear and anxiety and that the possibility of the existence of a fear-anxiety syndrome should be explored.

A comparison of four nurse-validation studies on anxiety (Levin et al., 1989; Lopez & Risey, 1988; Metzger & Hiltunen, 1987; Whitley, 1988), in which Fehring's (1986) diagnostic content validation (DCV) model was used, reveals that two characteristics, anxious and apprehension, were labeled as major indicators in all four; two characteristics, increased tension and worried, were labeled as major in three studies. An international nurse validation study using the DCV model identified anxious, panic, and nervous as major characteristics of anxiety (Wake, Fehring, & Fadden, 1991). Several of the results of these nurse-validation studies are similar to the findings of a nurse-validation study using magnitude estimation scaling as a measurement strategy for validation, in which five defining characteristics were labeled as critical (Guzetta & Kinney, 1988).

Whitley (1989) analyzed the findings from nine nurse-validation and clinical validation studies and identified several important issues emerging from these studies (Aukamp, 1986; Fadden et al., 1987; Guzetta & …