Nursing Diagnoses: Useless Statements secondary to Professional Insecurity

  1. 65
    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.)
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  3. 84 Comments so far...

  4. 11
    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.
    elkpark, NRSKarenRN, MissPiggy, and 8 others like this.
  5. 4
    Good luck taking on the federal government!!! I may be in the minority but I have always loved doing patient care plans. It allows to me sort out what my patient is dealing with so I can prioritize. Whereas care plans used to take me hours it now takes minutes. Not that big a deal in the grand scheme of things.
    NRSKarenRN, Tait, sharpeiluv, and 1 other like this.
  6. 11
    I don't think that they help physicians see us as colleagues (and I agree that as the older physicians retire, this is becoming less of an issue). I think they see it as defensive and a result of professional insecurity. Nursing diagnoses state the obvious.

    As a learning tool? An argument can be made for that, and, frankly, I think that's about the only valid argument for their continued existence. I do not think they should be called "diagnoses" though.

    However, when I was a nursing student, I saw them as more of an insult to my intelligence. I do not need to search though a compendium of "diagnoses" to come up with "Impaired gas exchange secondary to pneumonia." If you have a basic understanding of A & P and pathophysiology, the fact that gas exchange is impaired in an infected lung is, well, obvious. If a student is unable to understand that pneumonia impairs gas exchange, then their place in the nursing program needs to be re-evaluated.

    If we want to emphasize nursing as a discipline based in science and show that nurses have extensive medical knowledge, then nursing education should be based on science and pathophysiology and the medical basis for treatments should be taught. There's no need to dumb it down with nursing diagnoses.

    Perhaps care plans with scientific/medical justifications for specific nursing interventions would be more helpful to students? Personally, I think that would take a bit more thought and understanding, and would yield greater insight.

    Thanks for your response. I'm definitely interested in other's opinions on this subject, and it helps my flush out my own opinions.
  7. 4
    Quote from pielęgniarka
    Good luck taking on the federal government!!! I may be in the minority but I have always loved doing patient care plans. It allows to me sort out what my patient is dealing with so I can prioritize. Whereas care plans used to take me hours it now takes minutes. Not that big a deal in the grand scheme of things.
    Care plans are not dependent on nursing diagnoses. You can still use care plans without NANDA. Also, NANDA is not part of the federal government.
    CNL2B, Altra, mammac5, and 1 other like this.
  8. 3
    I know NANDA is not a part of the federal government. But the federal law interpreted by Medicare says care plans need to be in place. To formulate a care plan you need some sort of nursing diagnosis or wording of the symptoms to start out with. So NANDA provided us with that wording, so what?

    Quote from Fribblet
    Care plans are not dependent on nursing diagnoses. You can still use care plans without NANDA. Also, NANDA is not part of the federal government.
    elkpark, Tait, and Not_A_Hat_Person like this.
  9. 5
    The other reason they were invented was to provide documentation of nursing autonomy as a profession. It is supposed to reinforce the notion that we operate independently, but as real world nursing shows every student, we had BETTER be interdependent for our patient's sake. we had BETTER advocate between professions for the best treatments. Coming to an attending with a diagnosis of "risk for injury s/t seizures" is counterproductive. and hilarious.
    RN Dave, MissPiggy, MsBruiser, and 2 others like this.
  10. 11
    when I went to school back in the 90s I remember thinking it seemed like a neat gimmick at first...oh...nurses have their own diagnoses...???? until I spent any number of potentially productive minutes wasted on constructing a semi-worthless care plan that ever abundantly stated the obvious and distracted from the priority event----caring for the patient...!!!! man....if we could have spent the time we did working on care plans actually carrying out orders and caring for the patient meanwhile learning how to think proactively for the patient rather than learn about an entity that existed merely to fill up space in a fluff nursing course and sadly ---poorly attempt to legitimize nurses as autonomous...........in my experience, life proves that in order for something to prove itself.....overattempts to do so negate that outcome......if something has what it takes it needn't try THAT hard......it just does.......
  11. 4
    Quote from pielęgniarka
    I know NANDA is not a part of the federal government. But the federal law interpreted by Medicare says care plans need to be in place. To formulate a care plan you need some sort of nursing diagnosis or wording of the symptoms to start out with. So NANDA provided us with that wording, so what?
    I don't have problems with care plans. I have a problem with nursing diagnoses. I'm on the fence about having a specific nursing language (It seems, initially, to me that the healthcare team should all be speaking the same language....).

    How seriously are nursing diagnoses taken? Not very, nor should they be. They're silly.

    Seriously. How hard to you work to correct an aura displacement?

    By and large I believe nursing diagnoses make the nursing profession look silly. Shouldn't an organization that states, "Implementation of nursing diagnosis enhances every aspect of nursing practice..." actually enhance the nursing profession?
    DizzyLizzyNurse, Sisyphus, Faith213, and 1 other like this.
  12. 7
    Quote from hearticulture
    The other reason they were invented was to provide documentation of nursing autonomy as a profession. It is supposed to reinforce the notion that we operate independently, but as real world nursing shows every student, we had BETTER be interdependent for our patient's sake. we had BETTER advocate between professions for the best treatments. Coming to an attending with a diagnosis of "risk for injury s/t seizures" is counterproductive. and hilarious.
    I think that the idea of providing a way of documenting nursing autonomy isn't necessarily a bad thing, but NANDA does a poor job.

    And yes, coming to a doctor with a nursing diagnoses is hilarious, and I would imagine would result in a loud "DUH" from the physician.

    Frankly, if I'm a patient. I'd rather my nurse start working on getting seizure precautions in place rather than spending time scouring a NANDA list to make sure he or she documents the problem with the correct language according to NANDA. But, that's just me I suppose.


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