Time to call a duck a duck?

[eriksoln]

I remember having this debate with other students while I was in school. I have seen nothing during my time practicing nursing to change my mind about the issue. Now, with the recession bringing out the true colors of nurses and everyone around them, my opinion seems even more valid. I wonder what others think about it.

I remember sitting in nursing school as the instructor drummed on and on about how "Nursing is a profession." That exact theme butted it's head into almost every single class one way or another, regardless of the subject matter. I often found myself thinking "Who cares?" or "What's the point in that?". Then came the dreaded "Dimensions of Nursing" class. It was the class all RN's must go through at one point or another (IDK if LPNs do or not). There are other names for it "Political Aspects of Nursing" I've heard among a few others. It is the class in which you must discuss the political issues that involve nursing. You are encouraged to join this and that group, Nursing as a Profession is discussed over and over, and you must do a research paper. I never really said in that class how I really felt about the whole business of nursing being a profession in fear of drawing the ire of my superiors.

What is it I had to say that my fellow students got to hear during breaks that my instructors did not? Well: Nursing is not a profession, not even with a very generous stretch. It is a labor, a trade. We are judged solely by the amt. of patients we can handle and still keep the minimal quality expected by our administration up to par. Not very much unlike a McDonald's burger flipper. The faster you can cook those patties without screwing too many up, the better you are. That's all there is to it really. If you don't believe me, take a gander at where nursing expenses falls in the budget. We are not logged next to the admin./doctors/lawyers or any of the other professionals. We are grouped in with dietary/housekeeping/security. As far as budget makers are concerned (and, lets be honest, they make the rules), we are a debt, like a labor.

IT IS TIME FOR NURSING TO GIVE UP THIS IDENTITY CRISIS, THIS INFERIORITY COMPLEX IT HAS DISPLAYED SINCE ITS BIRTH AND MOVE ON, EMBRACE BEING A LABOR AND LOVE IT.

Ever see the movie "Man in the Iron Mask"? The King/spoiled twin tells his brother "Into the dungeon you will go, and you will wear this mask again, and you will wear it until you love it."

We are wearing the mask, but are for some reason we are unable to learn to love it. So we will forever stay in the dungeon denying what we are.

Lets face it. All the aspects of a "profession" are an illusion in nursing.

Definition of a profession:

A profession has a unique body of knowledge and values – and a perspective to go with it.

A profession has controlled entry to the group eg registration

A profession demonstrates a high degree of autonomous practice.

A profession has its own disciplinary system.

A profession enjoys the Recognition and Respect of the wider community.

1. Unique body of knowledge: We do need to go to school and must learn a lot, but I don't know about the unique part of it. Most CNA's pick up on how to do what we do after just a couple years, without the schooling. As far as values and perspective go, lets face it, we can't even agree in here on what that is. How many "Calling from God vs. Its a job" threads/rants have you seen on this site. I've lost count. We can't even agree amongst ourselves what degree we should have. I've also lost count of the "BSN vs. ADN vs. Masters" threads.

2. Controlled entry: Phfffft. It is controlled, but not by us. The hospital/medical field administration decides this. Whatever they decide they are willing to hire is what the rule is. If they decide tomorrow to never again hire ADNs.........that's that for them. We have no say in it. Seen any "Nurses eat their young" vents/threads lately. I know you have;), even if you were a blind, deaf mute with both hands tied behind your back you can't help but run into them on here. If we truly were in control of who came into the profession, such threads would be minimal. Can't be angry about who is allowed in when its your decision who gets in.

3. Demonstrates a high degree of autonomy: Again, I lead with PHfffffft. Our job description continues to be and will forever be everything and anything they can't pawn off on the other laborers. How many of us, since the recession hit, have been told to pick it up and help out in non-nursing job related ways? Empty the trash, stock the cabinets, hand out trays, collect and clean the trays..........its endless. We are unable to define for ourselves what we will and will not do. You don't see them sending the Legal dept. any emails about helping maintenance do you? Any rules/laws concerning scope of practice are simply to protect patients from us should we decide to play doctor. No laws exist to restrict what can be expected of us away from the bedside (no, that would actually be useful, help the pt., can't do anything silly like that).

4. Has its own disciplinary system: Do I need to insert Phffffft again? Oh, I just did. We only qualify here if badgering, cattiness and petty write ups are "disciplinary". Nuff said.

5. Respect of the community: I'll resist the urge to insert the obvious lead here. I'll just point out the complaining about surveys that's been the norm lately. Lets face it folks, professions who have respect are not surveyed like this. These surveys resemble grade school report cards "Nursey doesn't play well with others". If we were "respected", we'd be the ones filling out the surveys on how to improve the model of care given.

Think back to your highschool days. Remember that class clown who tried way too hard to be funny? The not so good looking girl who never stopped digging for compliments on her looks? The not so well liked guy always asking if you and he were buddies or not? That's what nursing has let itself become. Constantly running around worrying about impressing people and all the while completely losing its focus on the primary goal. A lost teenager suffering from an inferiority complex.

Maybe if we embrace the fact that we are............:eek:gasp..............a mere labor, we will be able to dedicate ourselves to our patients. Instead of worrying about proving nursing holds a "unique body of knowledge" and making up useless, pointless "theories" and such (tell me one instance you have found a use for nursing diagnosis), we will become more useful. Focus instead on better time management, better understanding of the things we actually use on the job (the equipment for instance) and a better understanding of the tasks expected of us (study IV insertion in school instead of writing papers about why nursing is a profession).

I know many of you will be upset with me and my views. They are what they are. I make no apologies for them. Not having a well liked opinion has never stopped me from saying what I feel needs said before.

So...............am I wrong? Why?

[ivanh3]

Well when a doctor walks in the room, they can figure out why a patient isn't breathing well, using medical diagnoses. And quite honestly, I don't determine if it's "ineffective breathing pattern vs. altered energy fields." I determine if it's, "CHF vs. asthma vs. pneumonia vs. just plain choking on something vs. cardiac ischemia."

I don't need a nursing diagnosis. I need the medical diagnosis. (emphasis by ivanh3) If I walk in a room, and someone has slurred speech and can't move one side of their body, I'm not going to call a doc and say they have "altered circulation" and we need to start the "altered circulation protocol." I'm going to call the doc and say, "They're having a stroke and we need to start the stroke protocol." Nobody cares about the nursing diagnosis except the people that desperately want this to be a "profession with their own language."

Then it is possible you have missed the point. Does it really matter initially if there is a medical DX or not? Patients can be in hospitals for hours to days without a medical DX. Does that mean they are not being treated? No. They most certainly are. Supportive care is initiated and much of that supportive care stems from (wait for it...) straight up nursing DXs! For example what if your "slurred speech" patient is a previous CVA with low blood sugar? CVA is a frequent misdiagnosis. So would we not be concerned about ABCs, effective breathing, clearance, risk for falls, safety, etc and initiate some type of care that would be common to both CVA and hypoglycemia?

People get so caught up in nursing DX and how they relate to the written care plan. Nursing DXs and their components are more than that. They are what we do.

More of my .02

Ivan

[NocturneRN]

Well when a doctor walks in the room, they can figure out why a patient isn't breathing well, using medical diagnoses. And quite honestly, I don't determine if it's "ineffective breathing pattern vs. altered energy fields." I determine if it's, "CHF vs. asthma vs. pneumonia vs. just plain choking on something vs. cardiac ischemia."

Yes, nursing diagnoses and care plans teach you to think through why you're doing what you do. And I would argue that nursing care plans, as much as I hated them, really were beneficial during nursing school in teaching me to think through what interventions to go through. But I also remember buying a little book, where I could look up the MEDICAL diagnosis and translate that into a nursing diagnosis. Because goodness gracious, it would be horrible of me to put the language of another profession on my NURSING care plan. But that extra step, translating it from a medical diagnosis to a nursing diagnosis IS STUPID and we only do it for the sake of calling ourselves a "profession" with our own "language" and our own "body of knowledge."

I don't need a nursing diagnosis. I need the medical diagnosis. If I walk in a room, and someone has slurred speech and can't move one side of their body, I'm not going to call a doc and say they have "altered circulation" and we need to start the "altered circulation protocol." I'm going to call the doc and say, "They're having a stroke and we need to start the stroke protocol." Nobody cares about the nursing diagnosis except the people that desperately want this to be a "profession with their own language."

If you want to deal only with medical diagnoses, then what you're saying is that you want to leave all assessment and planning up to the doctors. The fact is, saying "The patient is having a stroke" is technically an observation, not a diagnosis----because (1) nurses who aren't advanced practitioners aren't qualified to diagnose CVAs, and (2) the diagnosis of CVA requires more than just observing symptoms.

Even if you're dead certain that the patient is having a stroke, can you honestly say that you're not considering the problems or potential complications related to your findings? That, after all, is what nursing diagnoses are about, whether or not you choose to express them in the fancy sounding language that nursing textbook authors seem to favor.

[NocturneRN]

Then it is possible you have missed the point. Does it really matter initially if there is a medical DX or not? Patients can be in hospitals for hours to days without a medical DX. Does that mean they are not being treated? No. They most certainly are. Supportive care is initiated and much of that supportive care stems from (wait for it...) straight up nursing DXs! For example what if your "slurred speech" patient is a previous CVA with low blood sugar? CVA is a frequent misdiagnosis. So would we not be concerned about ABCs, effective breathing, clearance, risk for falls, safety, etc and initiate some type of care that would be common to both CVA and hypoglycemia?

People get so caught up in nursing DX and how they relate to the written care plan. Nursing DXs and their components are more than that. They are what we do.

More of my .02

Ivan

Thank you! That is exactly the point I was trying to make, but you stated it much more clearly than I did.

[SuesquatchRN, BSN, RN]

Right there is pretty much the jest of what I am trying to get at here. Eliminate all the walking in circles, creating labels for doing our job (nursing diagnosis, the nursing process, critical thinking........come on, trying way too hard to sound important is what I see it as) and focus on being better at our job. THEN, WE CAN TRULY HOLD OUR CHINS HIGH AS OUR FOCUS WILL ONCE AGAIN BE THE PATIENT.

I am not saying nursing is a useless trade to practice, nor am I saying we are less than anyone else. What I am saying is, the immature inferiority complex that often drives nursing theory is failing us. Refocus schools on teaching nurses to obtain the best outcome for their pt., not on passing some exam that, in theory separates the "concrete thinkers" from people able to "think critically" but in reality is nothing more than a hit and miss lottery. I'll say this much: If the NCLEX were any good, don't you think it would have eliminated someone like me who completely disposes of most "nursing theory" from the get go? I passed first time.

Stronly disagree that NCLEX is useless because it focuses on theory. I didn't get a single non-clinical question. Not a one.

[SuesquatchRN, BSN, RN]

I will borrow from one of my favorite philosophers, Satyr, here.

"We are defined by what we do, not the reasons for what we do."

Sartre, honey. A satyr is a woodland mythical creature. I'm not usually a correcter but I hadda.

I disagree that anyone can be a good nurse. I agree that most people can master the physical skills of being a nurse.

[pedicurn, LPN, RN]

Well when a doctor walks in the room, they can figure out why a patient isn't breathing well, using medical diagnoses. And quite honestly, I don't determine if it's "ineffective breathing pattern vs. altered energy fields." I determine if it's, "CHF vs. asthma vs. pneumonia vs. just plain choking on something vs. cardiac ischemia."

Yes, nursing diagnoses and care plans teach you to think through why you're doing what you do. And I would argue that nursing care plans, as much as I hated them, really were beneficial during nursing school in teaching me to think through what interventions to go through. But I also remember buying a little book, where I could look up the MEDICAL diagnosis and translate that into a nursing diagnosis. Because goodness gracious, it would be horrible of me to put the language of another profession on my NURSING care plan. But that extra step, translating it from a medical diagnosis to a nursing diagnosis IS STUPID and we only do it for the sake of calling ourselves a "profession" with our own "language" and our own "body of knowledge."

I don't need a nursing diagnosis. I need the medical diagnosis. If I walk in a room, and someone has slurred speech and can't move one side of their body, I'm not going to call a doc and say they have "altered circulation" and we need to start the "altered circulation protocol." I'm going to call the doc and say, "They're having a stroke and we need to start the stroke protocol." Nobody cares about the nursing diagnosis except the people that desperately want this to be a "profession with their own language."

Isn't that a fact ....sing it sister.

Doctors use the medical model and it works pretty well for them.

'If it aint broke....don't fix it'

[pedicurn, LPN, RN]

If you want to deal only with medical diagnoses, then what you're saying is that you want to leave all assessment and planning up to the doctors. The fact is, saying "The patient is having a stroke" is technically an observation, not a diagnosis----because (1) nurses who aren't advanced practitioners aren't qualified to diagnose CVAs, and (2) the diagnosis of CVA requires more than just observing symptoms.

Even if you're dead certain that the patient is having a stroke, can you honestly say that you're not considering the problems or potential complications related to your findings? That, after all, is what nursing diagnoses are about, whether or not you choose to express them in the fancy sounding language that nursing textbook authors seem to favor.

I don't think we need nursing diagnoses to guide us here ....after all doctors manage quite well to know the things we know using medical diagnoses.

A decent 'medical model' nurse should be able to identify potential issues relating to findings.

Do we really need to 'dress up' the obvious with nursing jargonese... we need to know what the blood sugar is....we know there is a falls risk...we know we need to have swallowing assessed etc

A good history and physical assessment plus a reasonable knowledge of differential diagnoses serve me pretty well when I initiate nursing care in the ED

[NocturneRN]

Do we really need to 'dress up' the obvious with nursing jargonese... we need to know what the blood sugar is....we know there is a falls risk...we know we need to have swallowing assessed etc

z----All of which are nursing diagnoses, even if you don't express them in "jargonese."

Every time you make an observation and start to plan how you're going to address it, you're making a nursing diagnosis. If you relied exclusively on the medical model, you wouldn't be doing anything on your own---you'd simply be following doctor's orders.

[pedicurn, LPN, RN]

Do we really need to 'dress up' the obvious with nursing jargonese... we need to know what the blood sugar is....we know there is a falls risk...we know we need to have swallowing assessed etc

z----All of which are nursing diagnoses, even if you don't express them in "jargonese."

Every time you make an observation and start to plan how you're going to address it, you're making a nursing diagnosis. If you relied exclusively on the medical model, you wouldn't be doing anything on your own---you'd simply be following doctor's orders.

Well no ...I initiate that stuff on my own before the doctor sees the p't. I have taken their bloods, assessed neurvasc and airway, done a blood sugar, done a venous gas, decided if they meet criteria for stroke pathway,initiated falls precautions, maybe even done a CXR. The only thing I haven't done is requested a head CT (because I am not able to as an RN) ...however I have prepared the p't for one.

[jjjoy, LPN]

Supportive care is initiated and much of that supportive care stems from (wait for it...) straight up nursing DXs! For example what if your "slurred speech" patient is a previous CVA with low blood sugar? CVA is a frequent misdiagnosis. So would we not be concerned about ABCs, effective breathing, clearance, risk for falls, safety, etc and initiate some type of care that would be common to both CVA and hypoglycemia?

I think what you're talking about is knowledge of signs and symptoms and pathophys and various known medical conditions... and knowledge of how nurses can address the situation when they make those assesssments. Nurses DO need that knowledge. They just don't need to craft "diagnoses" to competently and professionally apply that knowledge. Problem-solving (the nursing process) works just fine without "diagnose": assess/plan/implement/evaluate

Assessment: no milk in fridge --- Plan: go to store and buy more milk

Assessment: pain at surgical site --- Plan: position for comfort, pain meds Q4 as needed

Assessment: risk for falls --- Plan: ABC, XYZ, ...

------------------------------------

Below are some NANDA diagnoses that sound more like assessments (observed signs and symptoms) than diagnoses to me.

Fatigue

Constipation

Confusion

Hyperthermia

Pain

Ineffective airway clearance

Breating pattern, ineffective

Risk for fall/poisoning/trauma

Communication, impaired, verbal

Memory, impaired

Oral mucous membrane, altered

Swallowing, impaired

Physical mobility, impaired

[ivanh3]

I think what you're talking about is knowledge of signs and symptoms and pathophys and various known medical conditions... and knowledge of how nurses can address the situation when they make those assesssments. Nurses DO need that knowledge. They just don't need to craft "diagnoses" to competently and professionally apply that knowledge. Problem-solving (the nursing process) works just fine without "diagnose": assess/plan/implement/evaluate

From the NANDA website: A nursing diagnosis is a clinical judgment.

So yes, what I am talking about is using knowledge of signs and symptoms to make a clinical judgment. Nursing DXs are a tool that allows nurse educators to articulate that knowledge and also a means for nurses to organize that knowledge until it becomes second nature. Again, too many people are focused on the written nursing DX/care plan.

The nursing process is impossible without the diagnosis. I can assess all day, but if I don't come to any conclusions then I have done nothing. Following the NANDA definition then the process would be: assess and then use that information to form a clinical judgment (nursing diagnosis).

Now, and this relates to the OP, the "nursing" process is not unique to nursing. Just about any situation which involves problem solving uses those steps. Which is why I disagree with the "unique body of knowledge" component of the definition for "profession". It has been opined that development of NANDA terminology was another means of developing a "unique" body of nursing knowledge. I don't really care about what you call it. What it does is what counts. Nurses use nursing diagnoses all day long every day. Nurses might not articulate them, might not even be aware of it, but that doesn't mean the concept they represent does not exist.

[ivanh3]

Well no ...I initiate that stuff on my own before the doctor sees the p't. I have taken their bloods, assessed neurvasc and airway, done a blood sugar, done a venous gas, decided if they meet criteria for stroke pathway,initiated falls precautions, maybe even done a CXR. The only thing I haven't done is requested a head CT (because I am not able to as an RN) ...however I have prepared the p't for one.

Well yes, you have been using your "nursing" DX in the ER. I think your disconnect is that because you have experience two things are happening. Your "nursing" DX happens and is sometimes addressed almost simultaneously. Additionally, you're ER experience gives you a pretty good idea of the "medical" DX or as you mentioned, your medical differential DXs. That doesn't mean that at some point you didn't (almost subconsciously) raise your bed-rails because you recognized your CVA rule out patient is a fall risk. All of the other tasks you mention (labs, imaging, etc) are protocol/standard of care driven and used to make/confirm/rule out a medical DX. That is a different process than is used in the forming of a nursing DX. Nomenclature is often a matter of semantics, but the fact remains that there are nursing DXs and there are medical DXs and nurses use (if not make) both.