No more NANDA diagnoses?

Trauma Columnist · Dec 8, 2006

I would propose using the care maps that are becoming the rage now. The hospital where I used to work had care maps that were actually the orders for the patient. Say, you had a pt coming in for a CABG. The care map clearly delineates the education needed prior to surgery (and included the nursing rationale), as well as orders for labs, etc. It then proceded on to the care of the pt immediately post-op, things to look for, rationale for your charting, etc..

I do not believe NANDA is worth the paper it is written on and I'm kinda embarassed that nurses are still learning it. I'm sorry but writing only nursing related info is not helpful to the team approach of the care of the patient. Nurses and physicians must be on the same sheet of music. For this, I think the care map is a very functional document and useful. It is also used for billing purposes which brings us down to the bottom line in healthcare - getting people in and out of the hospital.

Tweety, BSN, RN · Dec 8, 2006

I agree traumaRUs, it's important to have a written plan, but does it have to include those dang ND's???

Trauma Columnist · Dec 8, 2006

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.

ZASHAGALKA, RN · Dec 8, 2006

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.

VickyRN, MSN, DNP, RN · Dec 8, 2006

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.

VickyRN, MSN, DNP, RN · Dec 8, 2006

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

Clarise · Dec 8, 2006

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!

ZASHAGALKA, RN · Dec 8, 2006

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.

Tweety, BSN, RN · Dec 8, 2006

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.

Daytonite, BSN, RN · Dec 8, 2006

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.

Trauma Columnist · Dec 9, 2006

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.

psychonaut · Dec 9, 2006

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.

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.