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.)
When I was in school I dreaded care plans! Then into the real world and we barely saw them, and if we did we had "pre-made" ones that we would taylor to our patients. Now I am working in a large institution(still in L&D) and have just gone live with EHR! And WOW look whats back..... care plans! But now I have a new outlook on care plans. Maybe its because I have "grown up" or learned a thing or two as a nurse. It is the CARE PLAN that drives our assessments and interventions (those of you using KBC will understand that all to well)!!!! Yes, you still need critical thinking skills and realize that not every care plan is an ideal plan, you still need to individualize it! But, wow, I appreciate that it sets a standardized plan for our patients and supports best nursing practice that is recognized by JACHO and other organizations that support your specialty.
I honestly am insulted by having to use care plans. In no way do they list all the ways I intervene with my patients. And like you said, if someone has pneumonia it should be a no-brainer that they are going to have an impaired gas exchange...REALLY??? I NEVER THOUGHT OF THAT! ARGHHH!!!! And I honestly hate the documentation nazis who think I have nothing better to do with my time then to make sure they have the "appropriate" (according to them) care plan and that it is up to date. "I'm sorry Mr. Smith, you need to stop trying to die now because they would entail my having to open another care plan and try to get it adjusted to your needs. I just don't have the time to care for you due to all this useless paperwork!" I do SO MUCH MORE than what a care plan shows. And I truly hate the idea of care plans...I find them totally useless.
That being said, based upon your posts, I think this may be a passion of your's. Why not get involved to work on NANDA? See if you can support a move to change the whole idea from within. I'm sure with a bit of research you could find out what it might take to get on the committee. Go for it! Be the standard bearer for this change in ideas.
Listen, nursing is growing and changing as a profession. We are doing things today that in the past, doctors did for patients. Why are we tied to an archane system to try to establish what we do???? Ok ok, getting off my soapbox now.
Your rant.....for lack of a better word......is filled with contradictions. You acknowledge that we are "a distinct profession with unique duties and professional autonomy", yet you believe care plans serve no purpose except in education. Don't you understand that the diagnostic process is the framework for how you will treat your patients? You evaluate the patient, you make a diagnosis and prioritize, you prescribe and implement your interventions and you evaluate. I work on an interdisciplinary team and trust me every discipline does just that. Every one. Pharmacy, PT, all of them. Nursing is the only profession who resists this process. Why is that?
You say that it is just stating the obvious. Well let me tell you, if it was so obvious then why do patients still get post-op pneumonia? It should be obvious that they should be ambulated and encouraged to deep breathe and cough -both standard interventions on a nursing care plan- but they often don't get done because it is "too obvious" and too simplistic. That's just one example. There are many others I've seen in daily practice.
If you don't create a care plan, then how do you know what to do for them? You believe it's just obvious? If you're treating your patient without first assessing the problem and then creating a plan that you and everyone else can follow and evaluate, then you are exactly what you claim you are not: A handmaiden carrying out the tasks that somebody else has prescribed and you bring nothing to the table.
Remember highlandlass, a care plan is a guide, it is what drives best practice! and you don't have to get a new care plan every time your patient crashes, you individualize it. Something else to think about is the other ancillary depts that are involved in your patients care, this gives everyone a guide and helps to drive the education and outcomes that will only benefit your patient, after all isn't it about the patient!!
I just think that it is interesting that as soon as I entered grad school for my MSN, nursing diagnoses were never mentioned again. EVER. It was all medical diagnoses.
OMG, I am so going to print out this thread. :) I am a second career nursing student. I will say that I am not coming into this profession without being highly educated and maybe that is the reason that I was appalled at the sheer idea of NANDA's "version" of diagnosis and that I was expected to use them. The whole time I thought that if I was a doc and a nurse came to me with this crap, I'd kick her butt down the hall for wasting my time. It was then explained to me that it was intended for me to adjust the diagnosis to fit the situation. There were several times when there wasn't a NANDA diagnosis that fit the situation (I don't care how hard you twisted 'em). Then I was made aware that at least in some of my clinical instructors minds, these were to be used as a starting point and that the main thing I needed to focus on was the intervention, that helped me get through it. So I have basically stopped caring about the "diagnosis" and have become much more adept at the Assessing, Planning, Intervening and Evaluating. I do not plan on EVER discussing a nursing diagnosis once I graduate, I will continue to plan care and address my patients needs, I just don't have to give their condition a silly name in order to do it.
Specializes in PICU, NICU, L&D, Public Health, Hospice.
I work from a nursing care plan daily. I identify problems or potential problems and address them with goals and interventions. All of the disciplines review the nursing plan of care when we meet and when they see the patient
When I develop plans in the spectrum of well being or spiritual distress the social workers and pastoral care staff must follow that plan and document progress toward goals. When I identify mobility, safety, or functional issues in the patient's plan of care the nursing aides/assistants must follow the plan in their care of the patients.
In my line of work, it is the nursing assessment and plan of care which influences the physicians orders. The nursing plan of care is not the full sum of the plan but it is the foundation of the team's work. Each discipline adds their expertise to the goals and interventions.
I am responsible to see that the plan is current and relevant to the patient's needs. It is dynamic. Without the plan of care, it would be difficult for my colleagues to know what needs to be done for the patient. Continuity would suffer. Outcomes and patient/family satisfaction would suffer.
With the increase in technology and the use of nurses as the "doers" of essential and and sometimes complex medical tasks, the nursing process has suffered. The nursing profession has responded by creating nursing diagnosis to redirect our attention to include those functions that we must do...after all, if we don't who will? What other discipline is charged with considering the hospitalized patient as an entire human with physical, emotional, and spiritual needs? Typically, the medical team addresses the medical/physical needs of the patient. The therapies are involved only within the scope of their particular skill set and knowledge base. Pastoral care addresses the spiritual. Nursing addresses all of them.
As SharonH, RN said; post op patients get pneumonia too many times because of a failure of the nursing process. Patients get decubiti too often because of a failure in the nursing process.
This is our role...to see the whole patient, to advocate for them, to help them as they interact with the health care system or require health education/intervention (in every setting).
Nursing diagnoses are a great teaching tool. But that's where they should stay.
In the clinical setting, I find them embarrassing to our profession..they are either:
1) written by space cadets, like "disturbed energy field" :dzed:
2) the same as a real (medical) diagnosis, just exorbidantly verbose, such as: "disturbed sensory perception (visual) r/t altered sensory reception, transmission, integration, biochemical embalance aeb deficient sensory acuity, deficient change in usual response to stimuli, sensory distortions..." Aka..pt is blind! :nuke:
Do any of our docs get mad when we tell them pt X went into afib? NO, because we're speaking their language. If we had to communicate with them in NANDAnese, we'd be as understandable as if we were trying to talk past half a dozen tongue piercings at once, if they had the time to wait through it.
I agree. Can you imagine calling a doc at 2am to tell him that the patient is in afib, rate 150, hypotensive...and instead of just saying that you beat around the bush with NANDAs? "Dr., the patient began exhibiting a potential for altered level of consciousness and inadequate tissue perfusion along with activity intolerance possibly related to arrhythmia or disease process approximately 15 minutes ago. How would you like me to treat that?" The docs would probably bite your head off.
NANDA and having to write care plans are a complete waste of valuable time.
Nurses need to be taught to THINK about what they are doing and why they are doing procedures for patients.
I have wasted so much time using computer programs to get our diagnoses up to date, and having to write nursing notes on top of that as well.
One of the hospitals I work at has a brilliant way of coping with this. When patients are admitted, they are given a standard care plan for their condition/s and you just sign off what care you have given for that shift (you can add nursing diagnoses on in conjunction with the shift coordinator). The care plans are very good though, & have many relevant diagnoses on them. We as nurses are still required to write our nursing notes each shift, but we don't double-transcribe the nursing care plan. When you are busy having to sit and figure out NCP and diagnoses compromises patient care.
Specializes in LTC, assisted living, med-surg, psych.
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.)
Rambling? Hardly.........I think that was the most sensible, cogent, and well-articulated argument regarding NANDA I've ever read. I'd love to see what you come up with when you're firing on all eight cylinders!!
Seriously, I think you should submit this to a nursing journal for publication. I can see it now: "The Case Against Nursing Diagnosis" or some scholarly title, and nurses all over the country nodding their heads in agreement. YESSSSSS!!
CarrieRNC
41 Posts
When I was in school I dreaded care plans! Then into the real world and we barely saw them, and if we did we had "pre-made" ones that we would taylor to our patients. Now I am working in a large institution(still in L&D) and have just gone live with EHR! And WOW look whats back..... care plans! But now I have a new outlook on care plans. Maybe its because I have "grown up" or learned a thing or two as a nurse. It is the CARE PLAN that drives our assessments and interventions (those of you using KBC will understand that all to well)!!!! Yes, you still need critical thinking skills and realize that not every care plan is an ideal plan, you still need to individualize it! But, wow, I appreciate that it sets a standardized plan for our patients and supports best nursing practice that is recognized by JACHO and other organizations that support your specialty.