Nursing Diagnoses: Useless Statements secondary to Professional Insecurity

[Fribblet]

I vowed upon my graduation from nursing school (second semester into nursing school really. I skipped graduation.) that I would devote my career to abolishing the utterly useless institutions of NIC, NOC, NANDA. It's now been 2 years since my graduation, but I have not made any effort. Why? Because I've largely forgotten about nursing diagnoses.

But then I remembered, and their existence irritated me. Why? Because their mere existence is a testament to the insecurity and defensiveness nursing presents as a profession.

As nurses we are a distinct profession with unique duties and professional autonomy. While to the public it may appear that we are physician handmaidens and that physicians are the one's calling all the shots, we have a very specific, invaluable role to play in healthcare. Let's face it: Without nurses, how does a hospital function? How would patient's survive?

Though it often seems that physician's are taught in medical school that nursing is a profession that is inferior and that our duties are limited only to bedpans and husband shopping, we know better. But, we also know that the public generally does not know better. Although nursing consistently ranks as a trusted profession, we are held in lower regard than physicians. This is partly related to the fact that many of our duties are related helping patients with basic activities of daily living. It, of course, does not take advanced training and education to help someone to the toilet or provide oral care. But our duties that do rely on our medical training and scientific knowledge - recognition and prevention of potentially life threatening complications - and our role as patient advocate, are typically unseen by a patient and his family. And, of course, many physicians see our patient advocacy role, which manifests itself as repeated phone calls requesting orders that should have been written in the first place and to relay signs and symptoms of decompensation, as a nuisance or as insubordination. ("How dare you question my order! I'm a physician. You're just a nurse! etc..")

So what does the Nursing Profession do? It comes up with the stupid idea of Nursing Diagnoses. Any student nurse can tell you that diagnosing belongs in the realm of the physician. Nurses do not diagnose. Oh, but we are so insecure! Our jobs are important too! We have our own unique diagnoses to make! According to NANDA nursing diagnoses are "a clinical judgement 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."

So, as nurses we see a clinical problem (actual or potential). We "diagnose" the problem, then we solve it. Most nurses, I would hazard to guess, are able to do this without stopping to think of the official NANDA "diagnosis." We see a patient in pain, we administer pain medication as ordered or we call the physician for an appropriate order. If we have a patient that is admitted for pneumonia, we do not stop and "diagnose" the patient, we work with them to improve their lung function.

Nursing diagnoses really are elaborate ways of stating the obvious. Of course a patient who s/p abdominal surgery is going to have an "alteration in comfort." Of course someone with pneumonia is going to have "impaired gas exchange." These are obvious to anyone with an IQ above 70. Surgery hurts, and when your lungs are infected you don't breathe so good. So what must the other members of the health care team think of such painfully obvious "diagnoses?" It comes off as nurses trying, pathetically, to elevate their profession to the same level as physicians. But we aren't physicians. We are nurses. Our role is vital, but different. Why not, then, spend our efforts at educating the public about what we do, and why we're important. Why are we wasting our time trying to be "diagnose" the obvious?

So, who's with me?

(Sorry that this is rather incoherent. This is a rambling post about my thoughts on nursing diagnoses. I plan on coming up with something a bit more cogent later. I just felt the need to get this off my chest now.)

[carolinapooh, BSN, RN]

I understand how you feel. I felt, in nursing school, that the whole nursing diagnosis thing was actually condescending to nurses. Feeling a lack of respect? Awww. Here's a bone we can throw you. Look! You can diagnose too! You're just as important. Me, I don't need to be given permission to diagnose in order to feel like an important and respected member of the team.

But...maybe nursing diagnoses serve a purpose. Maybe the physicians do need to see that in order to realize that we are colleagues and peers, not handmaidens working FOR them. As older physician retire and younger ones rotate in the mix, I see this as less and less of an issue (except with some, but for the most part, it's getting better).

Another thing I've realized since leaving nursing school is that the NANDA is a really good tool for learning and teaching. It makes student nurses figure out the "why" of what they're doing instead of just blindly following an order. Why do you check a pedal pulse in a cath patient every 15 minutes, then every 30, then every hour, then every two? Because of potential for altered tissue perfusion related to invasive procedure.

I think that they need to exist, if for no other reason than to be used as a teaching tool.

Here's the part of the post I have a problem with:

"But...maybe nursing diagnoses serve a purpose. Maybe the physicians do need to see that in order to realize that we are colleagues and peers, not handmaidens working FOR them."

Not only do MDs have no clue what nursing diagnoses are, they serve no purpose for a doctor. It's dumb. It's condescending and it's a waste of our time. I for one am glad that I never see these where I work (and haven't since I left school), because they're stupid.

We're given the medical diagnosis. We know what to do with that. How I know that has absolutely nothing to do with the waste of space known as a nursing diagnosis. I'm not the doctor and I know that - but I da*n well know what do with whatever's wrong with the patient.

All ND's do is make us look ridiculous. Really - would you take a profession seriously that actually had as an acceptable diagnosis the term "altered energy field"? That alone would make us only look more stupid in the eyes of the public, not to mention what some MD's would and probably do think as a result.

Give me medical stuff within the nursing scope of practice - I'm a MEDICAL PROFESSIONAL, for God's sake, not some incompetent fetcher of water and bedpans. NO ONE who does what we do is that.

(And neither are the care techs who take care of stuff like that for me when I have other stuff I have to do, so please don't flame me for that either.)

[carolinapooh, BSN, RN]

Does anyone chart electronically??? Have you ever heard of CPG's! (Clinical Practice Guidelines!) CPG's are care plans which drive our practice based on evidence based medicine, this is an interdisciplinary approach........Assessments/interventions, goals and outcomes, and of course education. So all those care plans that nurses are saying are a waste of time are integrated into electronic charts that EVERY nurse will be charting on by 2016!! If you haven't experienced EHR, you will understand when you do and you will look at nursing care plans a little bit differently! There not so bad!

Most of us aren't blasting care plans (although a good deal of them get pencil-whipped as well). The problem is the asinine nursing diagnoses.

And I wouldn't give a timeline for that or bank on one either. My guess is most of us are already charting against a care plan anyway, in some form or another.

[carolinapooh, BSN, RN]

Reading the various posts in the threads of this website, I am frequently struck by the number of posts that claim, in effect, that what we do as nurses should be recognized as a profession in and of itself. But as we discuss one of the taxonomies describing what nursing practice entails, there are many who have written in this thread about the uselessness of the NANDA, NIC and NOC diagnostic system in daily practice. If nursing is indeed a profession in its own right, then, on what basis do nurses claim professionalism? If nursing is a profession, then there needs to be a defined foundation upon which our practice and authority occurs. Nursing scholars are making efforts to do that. The NANDA system is one result, the OMAHA system is another. Professional nurses do not practice using a vaguely defined "common sense" but rather with a specific "nursing sense" developed within the educational process then demonstrated and confirmed by evidence in daily practice. Tewdles has provided for us, in two postings within this thread, a succinct and eloquent summary of the how and why of the nursing process that begins with the nursing diagnosis. Florence would be proud!

There is "a defined foundation" - it's been around for hundreds of years - it's called medicine. We do it within a different scope of practice. That doesn't mean we need ridiculous ways of stating the obvious to do it.

PAs are considered medical professionals and don't have their own language - and they're not practicing within the scope of practice of a physician. So I seriously doubt we need a separate language that other medical professionals can't interpret.

I don't hear the cardiologist who comes up to my floor to consult on a bone marrow transplant patient speaking to our chief in a different language just because he's the cardio god and my chief is the oncology god. He talks about his concerns in the same language that the onc guy does - but his scope and focus are different.

I also doubt that an FNP, when prescribing antibiotics for a child's ear infection, is doing it with a nursing diagnosis in mind. Or the acute care NP who works in the ED is ordering a stat cardiac consult because the patient with an extensive cardiac hx who has come in with symptoms of heartburn and a tingling in his arm and nausea and the whole other bag of horrors is experiencing an "alteration in comfort".

That's medicine, folks!

To think otherwise is just preposterous.

Personally, I think Florence would be telling us to advance the profession - and I don't think some language that the rest of the medical world disregards (because they do - I've heard it) is the way to do that. I personally think that the sooner we drop this farce and start accepting that we're MEDICAL PROFESSIONALS (a title I'm rather proud of) - and therefore should tailor our scope within the preexisting one of MEDICINE, the better off we'll all be. It's the 21st century and if we want to identify ourselves as part of the modern-day medical team - and we are - then we should start acting like it.

[jjjoy, LPN]

If nursing is a profession, then there needs to be a defined foundation upon which our practice and authority occurs.

Is nursing a profession? Depends upon your definition of profession. By some definitions, nursing probably doesn't fill all of the requirements for profession. So what? Nursing tools should be developed that contribute to nursing practice, not as a means of demonstrating 'hey, we're a profession, too, see, we can make independent diagnoses!'.

Many nursing diagnoses are simply a way of restating a problem the nurse needs to address - patient can't walk = impaired mobility, patient moans and winces with movement = pain. Meanwhile, nurses DO take medical diagnoses into account when planning care, so there doesn't seem a practical practical purpose to labeling what nurses do in planning care as "diagnosing". Assess, plan, implement, evaluate is a generic problem-solving formula that doesn't have to include "diagnose". If a nurses assesses pain, a swallowing disorder, a potential for skin breakdown then they make a plan to deal with it. Again, no need to diagnose.

Understanding the why IS important, but it doesn't belong in a "diagnosis" anyway. If medical diagnoses followed the pattern of nursing diagnoses, it might look like this: breast cancer r/t oncogenetic cells aeb rapid multiplication of cells or stroke r/t brain cell death d/t decreased oxygen to the brain aeb paralysis of left side of body. If teachers used the nursing diagnosis model it might look like this: impaired receptive communication r/t altered vision aeb inability to visually distinguish letters on the page (=kid needs glasses to read).

[sharpeiluv]

"I personally think that the sooner we drop this farce and start accepting that we're MEDICAL PROFESSIONALS (a title I'm rather proud of) - and therefore should tailor our scope within the preexisting one of MEDICINE, the better off we'll all be."

I don't practice medicine-I practice Nursing, and am very proud to be called a Nursing Professional. You see, because I look at my patient's medical diagnosis and from there, determine what are the appropriate nursing diagnosis associated with the medical diagnosis, and begin to formulate my nursing interventions from there. Once I meet said patient, I do a nursing assessment and individualize the plan of care from the new information that I learn. My nursing prescription for care is broader than the medical diagnosis alone, because nursing assessment includes but processes more than the physical and biomedical processes associated with medical practice. The nursing history and assessment provides many clues about appropriate, individualized nursing diagnosis and interventions for my patient. It also determines the outcomes and helps me to see when the outcomes of the intervention are met-or not.

I don't argue that the language of nursing diagnosis is awkward. The language of the nursing diagnosis is not the way that I communicate with physicians, but it is the way that nurses communicate with each other for now in order to provide continuity of care for patients. This will likely change in the future as our profession finds its true voice. For now, however, the nursing interventions generated from the foundations of the nursing diagnosis provide a basis for education, patient care and for research (why am I doing what I do? Tradition? Sacred cow? Common sense [whatever that is] Scientific evidence?).

Florence Nightingale shook the foundations of medical practice with her nursing interventions. In the Crimean War, mortality among the wounded surviving surgery improved by nearly 60%! (This eccentric, well educated woman was a statistician as well). So, along with Florence, I am proud to be a Nursing Professional.

[sharpeiluv]

Understanding the why IS important, but it doesn't belong in a "diagnosis" anyway. If medical diagnoses followed the pattern of nursing diagnoses, it might look like this: breast cancer r/t oncogenetic cells aeb rapid multiplication of cells or stroke r/t brain cell death d/t decreased oxygen to the brain aeb paralysis of left side of body. If teachers used the nursing diagnosis model it might look like this: impaired receptive communication r/t altered vision aeb inability to visually distinguish letters on the page (=kid needs glasses to read).

Medical diagnosis do indeed look something like nursing diagnosis! To wit:

Presenting problem per patient is abdominal pain. The doctor writes: Abdominal Pain. After obtaining a history of the pain and doing a physical exam, the physician develops a list of differential diagnosis that may be the source of the pain. The physician may then proceed to the appropriate lab and/or radiologic studies indicated in an attempt to narrow down the differential list. Once the physician believes that there is evidence for a particular diagnosis, treatiment (intervention) is prescribed. So we have a pattern; assessment/diagnosis/intervention/outcome. Sound familiar?

Other professions, such as physical therapists and occupational therapists use a similar assessment/ diagnosis/intervention track to ensure their patients receive optimal care. Nursing is newer to the process as it has gone from the "nurses as handmaiden" stage where nurses performed only delegated tasks and custodial care to becoming a mindful profession in its own right. We are defining our own assessment/diagnosis/intervention/outcome from our distinct perspective of nursing. And with transition, there are certainly growing pains as has been in evidence throughout this thread.

[nursel56]

QUOTE=sharpeiluv;4388386. . . .I don't argue that the language of nursing diagnosis is awkward. The language of the nursing diagnosis is not the way that I communicate with physicians, but it is the way that nurses communicate with each other for now in order to provide continuity of care for patients.

This isn't the way nurses communicate with each other. Beyond nursing school, I can say I've never heard a nurse refer to a nursing diagnosis. If nurses think it's silly, they will not use it unless forced to. The language is awkward, and the nursing diagnoses are vague and overlap, resulting in a huge time and energy drain for very little return benefit. In my specialty, home health the 485 or POC, (care plan, a good thing!) is a unified document that contains both MD orders and nursing interventions, goals and time frames. The whole thing is signed by both the doctor and the Case Manager. How is this deficient in any way without including the NANDA info? If there was a separate document (and the fact that there isn't is quite telling imo), it would likely moulder there, ignored.

Nursing is newer to the process as it has gone from the "nurses as handmaiden" stage where nurses performed only delegated tasks and custodial care to becoming a mindful profession in its own right. We are defining our own assessment/diagnosis/intervention/outcome from our distinct perspective of nursing. And with transition, there are certainly growing pains as has been in evidence throughout this thread.

I think we've been progressing out of the handmaiden stage right along with progressing of women in general in the workplace, and I think nurses were every bit as respected in 1976 when I started as they are now, at least where I worked. In fact, the interns and residents were the doofuses, regardless of their gender, and a certain look from my Nurse Manager could reduce them to a quivering bowl of jello in an instant.

Every profession has things coming out of the academic wing, that are supposed to be huge breaththroughs for vexing problems, that when implemented, are not as advertised, confusing, ineffective, etc. Teachers may recall the invented spelling, whole language craze of the 80s, now in the dustbin. If we want to be seen as professionals, we have to be flexible. Stubbornly clinging to an unworkable idea just because it came out of academia does nothing to make people in or observing the profession respect us more.

[jjjoy, LPN]

I still see no need for nursing "diagnoses" as they are taught in most schools...

Hmm.... so the nurse assesses the patients... patient winces and says "that hurts!" It doesn't take any special nursing knowledge or assessment skills to "diagnose" pain, does it? Patient recently lost wife and says "I miss her so much"... what nursing diagnosis could it possibly be? Grief perhaps? Patient has the medical diagnosis of pneumonia... are there special nursing methods that will determine if the patient does in fact merit the nursing diagnosis of impaired gas exchange?

[SharonH, RN]

I still see no need for nursing "diagnoses" as they are taught in most schools...

Hmm.... so the nurse assesses the patients... patient winces and says "that hurts!" It doesn't take any special nursing knowledge or assessment skills to "diagnose" pain, does it? Patient recently lost wife and says "I miss her so much"... what nursing diagnosis could it possibly be? Grief perhaps? Patient has the medical diagnosis of pneumonia... are there special nursing methods that will determine if the patient does in fact merit the nursing diagnosis of impaired gas exchange?

And yet pain and grief are valid nursing and medical diagnoses:

338.1 Pain, acute

338.2 Pain, chronic

309.0 Grief reaction

All billable. Medicare recognizes them. The medical profession recognizes them. But it's silly for nursing to do so?

[SharonH, RN]

I had to teach this in in-services and it was hard to teach because I, too, don't believe in Nursing Diagnosis. Care plans? Yes. Nsg dx? No.

Yes, if the patient has a cast and is in traction, our goals (nurses' goals) are different from that of the physician. The physician wants the leg to heal. We want to be sure that the pt doesn't develop decubiti, that he eats and eliminates well, has good pain control and so on. Don't need "diagnosis" for that but a care plan goes a long way to be sure that everyone on the team does everything.

How do you develop interventions without diagnosing the problem first. Why does he need pain control? For what problem? Why are we afraid he will develop decubiti? What's his problem? Impaired mobility? There has to be a correlating problem to the intervention otherwise how do you justify what you are doing for the patient?

You just can't say "oh the patient needs physical therapy, IVFs and pain meds". You must assess, diagnose and then develop your interventions.

[jjjoy, LPN]

And yet pain and grief are valid nursing and medical diagnoses:

338.1 Pain, acute

338.2 Pain, chronic

309.0 Grief reaction

All billable. Medicare recognizes them. The medical profession recognizes them. But it's silly for nursing to do so?

Physicians don't really "diagnose" pain, the patient either exhibits signs of pain (winces, moans, says 'it hurts') or doesn't. Whether or not the cause of the pain is discovered and treated, pain is a problem of its own that merits medical care. Medical care costs money and Medicare pays based on diagnoses. So to get paid for treating a patient's pain, it has to be submitted as a diagnosis to Medicare.

Grief was a bad example. Psychological diagnoses present their own controversies. I don't want to open that can of worms!

[jjjoy, LPN]

How do you develop interventions without diagnosing the problem first.

Diagnosing is determing what the problem is... if you know what the problem is, then you can go straight to addressing the problem. ADPIE works just fine without the D. Assess, plan, intervene, evaluate. If you bring a car in with the "Check engine" light on, the mechanic will do diagnostic tests on the engine. With a flat tire, there's no need for the diagnostic process. Assessment is still important... what caused the flat tire? was any damage done to the rim?... but to determine "flat tire" and develop the plan "change tire" does not require the diagnostic process.

Similarly, if a patient comes in complaining of chest pain, clinicians must first attempt to determine what is or isn't causing the pain using the diagnostic process. The diagnosis will determine what interventions to use. But if a patient comes in with blood gushing from a deep laceration, no diagnostic process is required to determine that stopping the blood loss and maybe even a transfusion will be potential interventions. Assessment is most definitely needed to determine what exact interventions are required and a thorough assessment may reveal other problems that do require the diagnostic process to figure out what plan of action to take.