No more NANDA diagnoses? - page 2

One of the chief nurses on my med surge floor told us yesterday that they are doing away with the NANDA diagnoses. This is taking away from our profession, yet again. Correct? Why are they... Read More

  1. by   Tweety
    I agree traumaRUs, it's important to have a written plan, but does it have to include those dang ND's???
  2. by   traumaRUs
    Nope - I wanna get rid of them. The NANDA diagnoses are too nursing-specific and since RN's don't write orders they are useless as far as pt care goes.
  3. by   ZASHAGALKA
    Quote from Tweety
    I agree they aren't "referenced" on a routine basis.

    But the hallmark of RN practice is the ability to crtically think and care plan.

    When you arrive for the day you care plan and you carry out that plan of care whether you know it or not.

    ND is just a way to put it in writing and to teach it to students. We as experienced nurses do it naturally because this is what we've learned to do.

    Mind you, I'm not fan of care plans and ND's but students need to learn "what do I do with this patient with CHF?". You as a cardiac nurse with experience just walk into to work and start to do it. If you had to teach someone in a classroom who doesn't know what to do, how would you do it? There should be a standard. There should aslo be evidence that you know what you're doing........this for the lawyers and JACHO.
    I agree that NANDA can serve as a teaching tool, and I said as much.

    In reality, our care is planned and performed in real time and documented AFTER the fact. No 'plan of care' that tries to standardize that process IN ADVANCE can realistically take into account the 'critical thinking' and 'dynamic situations' that are an ongoing process. This makes the whole concept of nursing diagnoses a very unwieldy tool in real time nursing. As such, it's widely ignored for what it is: unworkable in the provision of real time care.

    In fact, the very attempt to standardize such processes in advance of care serves to disconnect such advance planning from an actual individualization of care, a key tenent of what it proposes to do! While claiming to be 'holistic', the actual results of such planning is to treat a collective group of symptoms of disease, not the patient.

    The time has long passed when our hospitals were full of stable patients, with stable issues the care of which could be planned well in advance. Most hospitals can accurately be described as fully critical care facilities - on most units. As such, the conditions of hospitalized patients are markedly dynamic, requiring changes to care 'on the fly'. Care plans just can't keep up, unless, we expect nursing to be much MORE about documentation than actual care.

    And so, while this might be a good teaching tool, it's just another form to fill out, print up, and file in day to day nursing. The original question was about the demise of NANDA. That isn't going to happen anytime soon. But my legitimate input is that it has no place outside of nursing schools. More to the point, the reality is that bedside nurses do NOT routinely use this tool. They don't use this tool because they cannot. They can't because as a tool, it bears little useful reference for a nurse juggling 10 priority care issues at once. No nurse is going to topple that juggling act by constantly taking the time to reference a plan of care that likely lost its relevancy hours ago. In fact, the mere attempt to do so could adequately be described as negative patient advocacy, placing documentation above actual and likely urgent needs of patients.

    In school, the production of care plans is unpaid, off site homework. In the real world, it is active, on-duty time away from patient care. THAT is a world of difference.

    ~faith,
    Timothy.
  4. by   VickyRN
    NANDA/ the nursing process is basically a way to introduce people off the streets (aka our beginning nursing students) into the language and culture of nursing. It is a systemic method of patient care that involves critical thinking and evaluation of outcomes. Most facilities don't use careplans anymore, but nurses instinctively use the nursing process. In fact, I use the nursing process with just about any decisions I need to make - totally non-nursing or non-medical-related.
  5. by   VickyRN
    One of my former nursing professors, Judy Carlson, is a strong advocate for NANDA - She calls this the "language of nursing." She is also a practicing NP and uses nursing diagnoses everyday in her practice. She writes eloquently and passionately on the subject:

    Nurse practitioners' use of nursing diagnoses Nursing Diagnosis - Find Articles

    Marketing nursing in a nurse practitioner practice Nursing Diagnosis - Find Articles
  6. by   Clarise
    Quote from ZASHAGALKA
    I agree that NANDA can serve as a teaching tool, and I said as much.

    In reality, our care is planned and performed in real time and documented AFTER the fact. No 'plan of care' that tries to standardize that process IN ADVANCE can realistically take into account the 'critical thinking' and 'dynamic situations' that are an ongoing process. This makes the whole concept of nursing diagnoses a very unwieldy tool in real time nursing. As such, it's widely ignored for what it is: unworkable in the provision of real time care.

    In fact, the very attempt to standardize such processes in advance of care serves to disconnect such advance planning from an actual individualization of care, a key tenent of what it proposes to do! While claiming to be 'holistic', the actual results of such planning is to treat a collective group of symptoms of disease, not the patient.

    The time has long passed when our hospitals were full of stable patients, with stable issues the care of which could be planned well in advance. Most hospitals can accurately be described as fully critical care facilities - on most units. As such, the conditions of hospitalized patients are markedly dynamic, requiring changes to care 'on the fly'. Care plans just can't keep up, unless, we expect nursing to be much MORE about documentation than actual care.

    And so, while this might be a good teaching tool, it's just another form to fill out, print up, and file in day to day nursing. The original question was about the demise of NANDA. That isn't going to happen anytime soon. But my legitimate input is that it has no place outside of nursing schools. More to the point, the reality is that bedside nurses do NOT routinely use this tool. They don't use this tool because they cannot. They can't because as a tool, it bears little useful reference for a nurse juggling 10 priority care issues at once. No nurse is going to topple that juggling act by constantly taking the time to reference a plan of care that likely lost its relevancy hours ago. In fact, the mere attempt to do so could adequately be described as negative patient advocacy, placing documentation above actual and likely urgent needs of patients.

    In school, the production of care plans is unpaid, off site homework. In the real world, it is active, on-duty time away from patient care. THAT is a world of difference.

    ~faith,
    Timothy.
    Yup, everything he has said!
  7. by   ZASHAGALKA
    I'd like to see some sort of EBP research that shows that this 'langauge' has a positive outcome in the actual provision of care. I'm not talking about components of care plans. We've discussed that many of the things those plans advocate are second nature to nurses. No, I'm talking about EBP research that shows using the plans THEMSELVES improves care.

    ~faith,
    Timothy.
    Last edit by ZASHAGALKA on Dec 8, '06
  8. by   Tweety
    Quote from ZASHAGALKA
    I'd like to see some sort of EBP research that shows that this 'langauge' has a positive outcome in the actual provision of care. I'm not talking about components of care plans. We've discussed that many of the things those plans advocate are second nature to nurses. No, I'm talking about EBP research that shows using the plans THEMSELVES improves care.

    ~faith,
    Timothy.

    There's a lot about your other post above (not the one in quotes above but above that #16) I could pick apart line by line and debate, but I'm not in the mood. Also, you make some good points too. :trout:

    I will say that I think the "language of ND's" is a bit irritating and useless.

    I still say that that teaching student/new grads to critically think "what is it as a nurse I can do, and what are the potential problems this patient can face" is a very important thing to be able to put into words. It's too bad that it has to be "a specific nursing diagnosis related to as evidenced by......" that is irritating to me to no end.

    I don't need any research to prove to me the language itself is useless. So perhaps we are on the same page for the most part.

    However, nurses making diagnosises specific to our professional practice and recognizing potential problems, recognizing what we have the power to teach, what outcomes we can affect...........priceless.
    Last edit by Tweety on Dec 8, '06
  9. by   Daytonite
    All I can add is that electronic record keeping of the charts is on the horizon. Uncle Sam says that every patient in a facility that takes Medicare payments must have a documented care plan. You will find that in Federal Law Title 42 Public Health Section 482.23 Conditions of Participation: Hospitals: Nursing services(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient. JCAHO accreditation give hospitals what is called "deemed" status with Medicare and allows them to be able to bill Medicare for service provided to Medicare beneficiaries. The current JCAHO standard that pertains to care planning is Standard PC(Patient Care)5.50 which says "Care, treatment, and services are provided in an interdisciplinary, collaborative manner." (2004 Comprehensive Accreditation Manual for Hospitals, JCAHO, page 278) Under this standard in its rationale JCAHO also explains, "While an interdisciplinary care plan may be one method of accomplishing this goal, it is not required." JCAHO further defines a care plan as "A written plan based on data gathered during assessment which identifies care needs, describes the strategy for providing services to meet those needs, documents treatment goals and objectives, outlines the criteria for terminating specified interventions, and documents the progress in meeting goals and objectives. The format of the plan in some organizations may be guided by patient-specific policies and procedures, protocols, practice guidelines, clinical paths, care maps, or a combination thereof. The care plan may include care, treatment, habilitation, and rehabilitation." (2004 Comprehensive Accreditation Manual for Hospitals, JCAHO, page 628-9)

    NANDA jumped on the bandwagon more than 20 years ago along with the College of Pathologists who saw the computer age coming and saw a feasible way to compress the data by using standard classification nomenclatures and language. Fight NANDAs use on written care plans if you want. Another method of expressing patient problems will replace it is all that will happen. Nursing educators see the use of NANDA guidelines in the writing of care plans as a practical way of reinforcing and teaching critical thinking in nursing. It is standardized and it is widely published, so easily accessible. How many of us can name the other nursing diagnosis organizations in existence? If the day comes when a mandate comes down that we will have to follow the NANDA rules, I, for one, will be glad to have had all this time to have worked with it and have an understanding of it. Those who don't or won't, I suspect, will not be employed for very long in facilities that are demanding this of them.

    I will admit, however, having worked for many years with care plans, that if you understand the nursing process, have been in nursing a while, then writing a care plan/care map/clinical pathway is a pretty routine and boring task. A task that most employers demand because it puts them in compliance with Title 42. Playing around with the words you use to put down on the paper is wordplay, a skill I would expect of any college graduate. For students, however, this is all brand-new and somewhat of a mystery to them. One way or another it has to be learned. As I say in so many of my posts to students, this is a skill like any other nursing skill. For this one, you need to use your cognitive abilities more than your physical ones.
  10. by   traumaRUs
    Daytonite - I really enjoy your well thought-out posts. I do know about the Medicare-funding and the plan of care. I currently work as an advanced practice nurse in chronic dialysis (read: Medicare patients). Yes, we do have care plans but they are actually care-maps that delineate what medical measures are going to be taken to correct problems. There are no NANDA diagnoses or really much of anything in the way of nursing judgement.

    As an APN, I would be laughed out of meetings and phone conversations if I was to spout NANDA to the docs and other mid-level providers. What I do is that I formulate my assessments based on medical diagnoses and medical care.

    I believe critical thinking is very important especially as a skill that must be developed by the novice nurse in order to progress to higher level thinking. However, believe that the NANDA stuff is just fluff that basically doesn't lead to better care.
  11. by   psychonaut
    This line of thinking is what finally brought me around to (grudgingly) acknowledging the utility of NANDA for us nursing students.
    I continually find myself digging deep into a case study, teasing out the pathophysiology, pharmacology, etc., only to be stumped by "So what are you going to do?"

    Sure, I find many of the NANDA dx silly or pedantic, but I try and view them as a necessary evil of the nursing program (one of many, in my eyes, but I digress).

    It is also clear to me that you skilled and experienced nurses have moved to a level of expertise where blatant steps of care (assess, monitor, intervene, teach, etc.) are second nature. That is, of course, the level of functioning towards which I am striving.

    The post re: speaking with other providers makes a great point, as well. I can't imagine replying to a "What's wrong with this patient?" from say a clinical pharmacist with "Oh, she has ineffective gas exchange secondary to pneumonia". I focus on learning medical terminology, and leave the NANDA stuff for school.

    Quote from Tweety
    I still say that that teaching student/new grads to critically think "what is it as a nurse I can do, and what are the potential problems this patient can face" is a very important thing to be able to put into words.
  12. by   ZASHAGALKA
    Yes, NANDA (btw, the other two prominent systems are NIC and NOC) is here to stay. It's written into our statutory guidelines BECAUSE those that pushed for it knew it was the only way to even give it lip service in the trenches. That was just yet another end run around clinicians. It IS wordplay. I just don't see how that advances actual care to waste my valuable active nursing time playing with words. Can I do it? Sure, I'm a college grad and long ago learned how to play the game.

    Just because I can acknowledge its inevitability does not mean I have to grant it any respect. Like most of nursing, true collaboration with end users (something the ANA strongly advocates) was ignored. Instead it's foisted upon us clinicians and as a result, treated all too often as necessary, if useless, paperwork.

    While I agree that students need a structure to their learning, this tool is simply grossly unwieldy. What it entrenches in nurses is the skill to hide our true contributions in pseudo-scientific language that can thusly be ignored by all power players. Even the head of NANDA, Judith Warren, in a report to HHS acknowledges that nursing's contributions are all too often all too invisible and there is no research to prove that NANDA improves things:

    Testimony of Judith J. Warren, NANDA

    "3. To what extent do you feel that your discipline and practice setting are well represented by the current system?

    Nursing is invisible in the current systems, yet significantly influences patient care and outcomes. The only way to capture this influence is through research which is very expensive to conduct. The National Institute of Nursing Research in NIH no longer funds this type of research, nor do they fund classification development research."


    In fact, I contend that NANDA and the like ENTRENCHES that invisibility by allowing our contributions to be ignored as 'another language'.

    ~faith,
    Timothy.
    Last edit by ZASHAGALKA on Dec 9, '06
  13. by   psychonaut
    You bring up a related point I have been struck with during my nursing education thus far: the seemingly thin skin posessed by the profession as a whole. Note I say "struck by" and not "confused by"; I fully realize that nursing is still working to move its perception from being assistants to physicians. However, I fail to see the need to try and make nursing some sort of parallel healthcare delivery system, instead of being part and parcel of medicine.

    As I noted above, I can see the utility of a language set that is focused upon what a nurse does. However, I fail to see the point in making it so difficult to say, "Pneumonia can lead to a, b, and c symptoms, which can be treated within the nursing scope of practice by x, y, and z interventions," instead of making the disease dx a minor footnote to the "true" nursing dx.

    Again, as a student, I am struck by how difficult it is to find a single list of medical diagnosis>>possible nursing diagnosis>>appropriate interventions. Sure, the info is out there, but seems to require a fair amount of rooting through textbooks, care plan books, etc. I own the NIC and NOC books, and though practice with them is increasing their usefulness, their Byzantine construction still frustrates me to no end.

    Considering the constant harping on "critical thinking" in nursing education, I find it amusing to watch my peers regurgitate the same cookbook care plans from their care plan books, without actually delving into the implications of the underlying pathophysiology. I find it much more educational to examine the symptomology and disease process, then try to address the resulting needs with appropriate interventions, even if I still miss some silly NANDA.

    As an aside, if it weren't for reading this site and knowing that there are nurses like some of those here, as well as some of my clinical instructors, I would be very despondent over my vocational choice. As it is, I simply tell myself to "suck it up" and remind myself that I'll be in the "real world" of nursing in eight months or so.

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