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.)

[nursel56]

I see a lot of people are thinking "no NANDA=no Care Plan". You don't need a nursing diagnosis to make a Care Plan. I know this because all of our hospitalized patients had them, and nursing diagnoses didn't hit the mainstream until the early 80s in my area

QUOTE=JulieCVICURN;4384457].....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).

I'll wager the docs have no idea what their patient's nursing diagnosis is, and I wouldn't leap to the conclusion that they all need to recognize that we are not their handmaiden. Thinking back, I can say I was never treated like a handmaiden. Some people are jerks (men and women), but they were jerks with their physician colleagues, too.

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'm really not trying to be negative, but how do you think we were taught to care for a patient like that before "altered tissue perfusion"? Answer= we were, and why add an extra layer of gobble-de-gook to a simple concept that is standard of care for every patient?

On to the points about the need for NANDA because "we can't use the same language the physician does"- why not? If the idea is to create respect for what nursing is about and promote a collegial atmosphere, doesn't it make more sense to use common nomenclature?

In the olden days, we had the care plan on a Kardex. It had a list of nursing interventions and projected goal times, when we charted, we picked one of the problems to highlight per shift, written on the same Progress Notes the doctors used, and written in the same format. That doesn't sound terribly archaic and sexist to me.

Recently I've been thinking about nursing theory in general, and another thread with an excellent discussion of the pros and cons. I've come to the conclusion it's a good thing, after uncoupling in my mind that it has to be immediately practical to have any value. Professions have academics and research and the marketplace of ideas. A trail and a record are a legacy for nurses of the future, even the wacky seeming opinions.

[jjjoy, LPN]

I see a lot of people are thinking "no NANDA=no Care Plan". You don't need a nursing diagnosis to make a Care Plan.

I second that thought!

[JulieCVICURN, BSN, RN]

I'm really not trying to be negative, but how do you think we were taught to care for a patient like that before "altered tissue perfusion"? Answer= we were, and why add an extra layer of gobble-de-gook to a simple concept that is standard of care for every patient

Which is precisely why I said, in the very same post, that it's a good teaching tool for student nurses. I don't know about your nursing school experience, but we had an awful lot of people in our class who would memorize what you needed to do for a particular case and not think about why they were doing it. It was one of my instructor's pet peeves, when she would ask a student why they were performing a particular task and they couldn't answer.

[jjjoy, LPN]

There are most certainly other ways for students to learn and demonstrate "why" without having to twist their assessments into nursing diagnoses as they are taught in many schools today. Other health care professionals manage to learn why without NANDA-like diagnoses, don't they?

[CBsMommy]

I agree, nursing care plans do not equal nursing diagnosis. I am currently in school and get my diagnosis handed back to me saying they do not fit exactly, but my plan of care is perfect! If someone wears glasses and they are having a hard time seeing, hand them their glasses! Do I really need to write a nursing diagnosis to map that goal/intervention? Geez!

Did Florence Nightingale need to write a confunded nursing diagnosis to figure out that her patients needed a bath or she needed to open a window?

I personally feel that nursing diagnosis put my ideas into a box and then I have to wind my ideas out of that box in order to personalize it towards the patients. It's so weird!!!

[tewdles, RN]

I agree, nursing care plans do not equal nursing diagnosis. I am currently in school and get my diagnosis handed back to me saying they do not fit exactly, but my plan of care is perfect! If someone wears glasses and they are having a hard time seeing, hand them their glasses! Do I really need to write a nursing diagnosis to map that goal/intervention? Geez!

Did Florence Nightingale need to write a confunded nursing diagnosis to figure out that her patients needed a bath or she needed to open a window?

I personally feel that nursing diagnosis put my ideas into a box and then I have to wind my ideas out of that box in order to personalize it towards the patients. It's so weird!!!

No, Flo probably didn't...but flo also wasn't consumed with the time consuming need to start IVs, deliver tube feedings, change the TPN, suction the trach, etc, etc, etc either. IMHO, the focus of nursing, particularly in the acute care setting, has evolved to become more and more medically focused and less and less nursing focused. There is a desire in professional nursing to remain an autonomous profession rather than simply a "helping" profession for the physicians. Maintaining control of and engagement with the nursing process is part of that autonomy, as is the nursing plan of care.

I will admit that the NANDA language is a bit ... uhm ... awkward and off putting. What is important to me, however, is that we continue to put the whole patient at the top of our priority list...not just medical orders...and that requires a nursing process.

What is true is that many nurses carry out good nursing plans of care without actually documenting their actions in terms of nursing diagnosis, goals, interventions... others...well, not so much. The downside of practicing the nursing process without a corresponding written nursing POC is that it is difficult to provide consistency from nurse to nurse and shift to shift. In the absence of a well communicated nursing plan of care, the next nurse may simply ignore those goals and interventions while focusing on the medical needs of the patient. Easy to do if you are running your butt off on a busy med-surg floor, or up to your bra straps in unstable admits to your ICU, etc.

Of course appropriate nurse/patient ratios and safe staffing are topics of a different thread...

[Tait, MSN, RN]

No, Flo probably didn't...but flo also wasn't consumed with the time consuming need to start IVs, deliver tube feedings, change the TPN, suction the trach, etc, etc, etc either. IMHO, the focus of nursing, particularly in the acute care setting, has evolved to become more and more medically focused and less and less nursing focused. There is a desire in professional nursing to remain an autonomous profession rather than simply a "helping" profession for the physicians. Maintaining control of and engagement with the nursing process is part of that autonomy, as is the nursing plan of care.

I will admit that the NANDA language is a bit ... uhm ... awkward and off putting. What is important to me, however, is that we continue to put the whole patient at the top of our priority list...not just medical orders...and that requires a nursing process.

What is true is that many nurses carry out good nursing plans of care without actually documenting their actions in terms of nursing diagnosis, goals, interventions... others...well, not so much. The downside of practicing the nursing process without a corresponding written nursing POC is that it is difficult to provide consistency from nurse to nurse and shift to shift. In the absence of a well communicated nursing plan of care, the next nurse may simply ignore those goals and interventions while focusing on the medical needs of the patient. Easy to do if you are running your butt off on a busy med-surg floor, or up to your bra straps in unstable admits to your ICU, etc.

Of course appropriate nurse/patient ratios and safe staffing are topics of a different thread...

That is pretty much what I was thinking but hadn't written.

Tait

[jjjoy, LPN]

I can see the value of certain NANDA-type categories for determining what nursing interventions apply to what conditions and symptoms and why (eg differentiating altered tissue perfusion from altered gas exchange or differentiating activity intolerance from impaired mobility). NANDA-type categories can provide a useful framework for conceptualizing nursing care, especially to demonstrate that there's more to good patient care than treating an acute medical condition. But to call it "diagnosing" just seems to further confuse things. And to demand that students always force the convoluted phraseology of NANDA into every day-to-day care plan doesn't seem a good use of limited teaching time.

[nursel56]

Which is precisely why I said, in the very same post, that it's a good teaching tool for student nurses. I don't know about your nursing school experience, but we had an awful lot of people in our class who would memorize what you needed to do for a particular case and not think about why they were doing it. It was one of my instructor's pet peeves, when she would ask a student why they were performing a particular task and they couldn't answer.

You're right, it can be a teaching tool. The question is "do nursing diagnoses add something to teaching and/or learning that would otherwise not be present?" If a student is memorizing what you need to do for a particular case without thinking about why they are doing it, why would you teach a nursing diagnosis as opposed to a thorough review of the critical thinking process? I can see that if a student isn't grasping the "why" of nursing actions, or the need to be thinking about "why" at all times, especially when unexpected events occur that don't fit the picture exactly as it was explained in the textbook, approaching it from a NANDA perspective may be the only thing that does the trick. That person's instructor would need to be keeping a really close eye on them, though, because there aren't enough or specific enough nursing diagnoses to apply to every situation, and it would take up a lot of time and energy to search for it.

I'm not trying to bash all of it as 'ehhh, it's crap--", get thee away NANDA, anyway. Apparently, some of the theory is intentionally provocative, and I like to mix it up if we can keep it respectful. The pioneers of this very young field of academia (compared to other professions) have put into words holistic concepts we've been vaguely aware of all along, and by necessity it will sound more like philosophy than cell biology, but I'm learning to see it as a stand-alone benefit and not ridicule the "ivory tower" too much, anyways.

[CarrieRNC]

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!

[clemmm78, 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.

[sharpeiluv]

No, Flo probably didn't...but flo also wasn't consumed with the time consuming need to start IVs, deliver tube feedings, change the TPN, suction the trach, etc, etc, etc either. IMHO, the focus of nursing, particularly in the acute care setting, has evolved to become more and more medically focused and less and less nursing focused. There is a desire in professional nursing to remain an autonomous profession rather than simply a "helping" profession for the physicians. Maintaining control of and engagement with the nursing process is part of that autonomy, as is the nursing plan of care.

I will admit that the NANDA language is a bit ... uhm ... awkward and off putting. What is important to me, however, is that we continue to put the whole patient at the top of our priority list...not just medical orders...and that requires a nursing process.

What is true is that many nurses carry out good nursing plans of care without actually documenting their actions in terms of nursing diagnosis, goals, interventions... others...well, not so much. The downside of practicing the nursing process without a corresponding written nursing POC is that it is difficult to provide consistency from nurse to nurse and shift to shift. In the absence of a well communicated nursing plan of care, the next nurse may simply ignore those goals and interventions while focusing on the medical needs of the patient. Easy to do if you are running your butt off on a busy med-surg floor, or up to your bra straps in unstable admits to your ICU, etc.

Of course appropriate nurse/patient ratios and safe staffing are topics of a different thread...

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!