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.)

[tewdles, RN]

There is "a defined foundation" - it's been around for hundreds of years - it's called medicine. We do it within a different scope of practice. That doesn't mean we need ridiculous ways of stating the obvious to do it.

PAs are considered medical professionals and don't have their own language - and they're not practicing within the scope of practice of a physician. So I seriously doubt we need a separate language that other medical professionals can't interpret.

I don't hear the cardiologist who comes up to my floor to consult on a bone marrow transplant patient speaking to our chief in a different language just because he's the cardio god and my chief is the oncology god. He talks about his concerns in the same language that the onc guy does - but his scope and focus are different.

I also doubt that an FNP, when prescribing antibiotics for a child's ear infection, is doing it with a nursing diagnosis in mind. Or the acute care NP who works in the ED is ordering a stat cardiac consult because the patient with an extensive cardiac hx who has come in with symptoms of heartburn and a tingling in his arm and nausea and the whole other bag of horrors is experiencing an "alteration in comfort".

That's medicine, folks!

To think otherwise is just preposterous.

Personally, I think Florence would be telling us to advance the profession - and I don't think some language that the rest of the medical world disregards (because they do - I've heard it) is the way to do that. I personally think that the sooner we drop this farce and start accepting that we're MEDICAL PROFESSIONALS (a title I'm rather proud of) - and therefore should tailor our scope within the preexisting one of MEDICINE, the better off we'll all be. It's the 21st century and if we want to identify ourselves as part of the modern-day medical team - and we are - then we should start acting like it.

I completely agree that when the FNP prescribes the antibiotic for the OM she is practicing medicine not nursing. When she determines that the parent needs education on diet or sun exposure during treatment she is operating within the nursing process...and that it decidely NOT medicine. I too am proud to be a medical professional...I am also extremely proud to be a nursing professional.

Florence would want us to remain faithful to the concept of NURSING the patient. The whole patient. I would suggest that if we allow ourselves to abandon our UNIQUE responsibilities in the health care of our patients, the patients will suffer.

I believe that modern day nurses are an important part of the health care team. It is not simply a medical team...it is a multidisciplinary team. In the home care and hospice settings, the game is entirely dependent upon the RNs managing the cases. Bad nursing care will often result in bad outcomes. Are the nurses practicing medicine in those settings? Heck no! Not any that I know anyways...we protect our nursing licenses.

But those nurses are immersed in the nursing process. They are visiting and assessing for alterations in mentation, B/B, comfort, skin integrity...etc. You get the picture. AND they must generate a nursing plan of care (they have to get paid). And they must communicate those findings to the other disciplines in an appropriate and timely fashion.

Nurses do not necessarily report their "nursing diagnosis" to the physician, they need to notify the physician of the problem that requires MEDICAL attention (we need an order). If my patient has an alteration in comfort I get orders for pain meds. Pretty simple. Honestly, I don't care if the MD wants to know the nrs dx...it is for nurses.

I completely agree that we need to reconsider the language used in this process. That's up to us...

But as a wise old grandmother I would suggest we not throw out the baby with the bath water.

[canoehead, BSN, RN]

Listing off problems and making nursing care plans is great to teach a step by step process that becomes second nature after a few years. It's like teaching grammatical rules, after a few years of speaking a language you don't even have to think about it anymore.

I think nursing is really a profession that coordinates care. We are the go-between for every department in the hospital, and the families. If it isn't done the buck stops with us, and we are great resources for knowing who to call about what. If you need to know how to squeeze into Dr Smith's clinic call his nurse. If you have a new diagnosis of diabetes or cancer and want to know what comes next talk to your nurse. If you need to run 3 different meds at the same time the Xray dept has an opening, and you only have one IV it's the nurse that figures it all out. Our job is essential, but it's also invisible, because if we do our jobs well it looks effortless.

[jjjoy, LPN]

Our job is essential, but it's also invisible, because if we do our jobs well it looks effortless.

so true!

[nursel56]

And yet pain and grief are valid nursing and medical diagnoses:

338.1 Pain, acute

338.2 Pain, chronic

309.0 Grief reaction

All billable. Medicare recognizes them. The medical profession recognizes them. But it's silly for nursing to do so?

The medical profession recognizes them and they are billable because doctors (and advanced practice nurses) specialize. If a patient is hospitalized for surgery and has pain, they are not billed for 338.1. If pain management is part of the nursing care plan, it isn't added to the medical diagnosis and charged to the patient's insurance.

If a doctor or nurse who gets into the area of medical diagnosis runs a Pain Management clinic, those codes are appropriate.

If a hospitalized patient finds out they only have 3 months to live, and they become distraught and start to cry, I don't believe that 309.0 is added to their medical diagnosis or they are charged for exhibiting grief. It would be a pretty crass world if that were acceptable. Although, I recently found out that internists can charge extra for telling the patient that smoking is bad for them, so it's getting harder and harder to know what is truly beyond the bounds of a profit-driven industry.

[HamsterRN, ADN, RN]

Patricia Benner recently put the final nail in the coffin of Nursing Diagnoses with her book "Educating Nurses; A Call for Radical Transformation".

While it is true that groups such as Medicare and the Joint Commission advocate the use of care plans, they do not advocate the use of official Nursing Diagnoses. In fact, The Joint Commission requires that Nursing care plans NOT include Nursing Diagnoses. The reason for this is that the current focus of the Joint Commission is to encourage better interdisciplinary communication, something that Nursing Diagnoses makes more difficult.

Nursing Diagnoses were the result of insecure, childish, petty, Nursing leadership who were far more focused on scoring PR points than caring for patients. Nursing prides itself on treating patients as individuals, yet nursing diagnoses paint patients in even broader strokes than medical diagnoses.

When I first started Nursing school, it never occurred to me that I would pick from a pre-written list of terms to describe a patient, so on my first assignment I made up my own that best described actual and potential problems of the patient. I got those answers wrong, although I've since realized I was probably right.

[tewdles, RN]

I think that considering where and what the patient's problems are before we communicate with other disciplines helps nurses to focus our communication...to be more focused on the patient's needs and nursing and not just on medicine.

I honestly do not see why it is undesirable for a nurse to examine a patient, determine that he has a sleep pattern disturbance, mild anxiety, and alterations in comfort, and then pursue nursing interventions to address those areas. I do not understand what is "bad" about this. This is the part of our care delivery that we (as nurses) have complete control over...but we want to throw it out??? We want ALL of our actions to be directed by other professionals???

If the beef is with the nomenclature, then by all means we should improve/change this....but the process? Why would nurses desire to eliminate the nursing process?

Professionals must choose from "lists" all the time...every discipline in all settings. I personally do not find the list too confining...and I do have the option to include a completely "custom" problem, intervention, or goal on my patient's plan of care. I must admit that I have never and probably never will use "energy field disturbance"...but I know nurses who would.

[Fribblet]

I honestly do not see why it is undesirable for a nurse to examine a patient, determine that he has a sleep pattern disturbance, mild anxiety, and alterations in comfort, and then pursue nursing interventions to address those areas. I do not understand what is "bad" about this. This is the part of our care delivery that we (as nurses) have complete control over...but we want to throw it out??? We want ALL of our actions to be directed by other professionals???

If I see my patient has a "sleep pattern disturbance," I ask the MD for medicine, or try to make environmental changes to facilitate better sleep. Then, I chart it.

i.e. - Pt states "I not sleeping well." blah blah blah, intervention, blah blah blah. In the morning, I ask if my interventions were useful and chart the patient's reaction, and pass along the information in report.

Where exactly does the nursing diagnosis come in? And where exactly does the nursing diagnosis prove itself useful? Where is the need for it?

There is no need for it. My patient has a problem. Yo, I solve it. Now check out the hook while my DJ revolves it....

dun dun dun dunduhdun dun.....

[nursel56]

QUOTE=tewdles;4396544]. . . . .If the beef is with the nomenclature, then by all means we should improve/change this....but the process? Why would nurses desire to eliminate the nursing process?

My complaints about nursing diagnoses are never about the nursing process, or the care planning process. Just out of curiousity I dusted off one of my original c.1973 textbooks to see what they had to say about care plans, as "nursing diagnosis" at that point hadn't been invented yet.

"The nursing care plan is the plan concerning the nursing approach for each patient. The entire nursing team plans the care in a team conference. The plan defines specific nursing problems and suggested approaches for solving these problems. An individual nursing care plan should be set up for each patient and should be kept up-to-date by the team leader and other members of the nursing team."

I think we can assume that the terminology would have been common medical terminology, and nursing interventions would have used words and phrases understood by a doctor, a social worker, etc. If a patient had trouble sleeping, both the doctor and the nurse would call it "insomnia". If the doc orders a sleeping pill, the nurse monitors for known side effects, charts effectiveness, etc. Nursing intervention might be to (remember this is the '70s, lol:)) offer the patient a backrub or reposition the pt for comfort.

I guess I'm not understanding what was wrong with the above process. BTW, student nurses would have loved the following also in the book,

"you should know that the nursing student is very much part of the nursing team and has a great deal to contribute to the nursing care plan". :nurse: Just as an aside, for the younger amongst us, all the references to the "team" represent an organizational approach with it's heyday back then, briefly supplanted by the primary, or total care nurse. Now it's the "whatever works best for the corporation to get maximum work from nurses with as little compensation as possible" approach.

[VTRN774]

Writing care plans in nursing school was a useful learning process, but once I learned to integrate this skill into my daily practice, nursing diagnoses became irrelevant. I thought then and still do now that nursing diagnoses are silly and a waste of time. There is enough jargon in nursing without adding nursing diagnoses. Also, I have never been disrespected by a physician, nor would that even be tolerated by the hospital I work in. I can't imagine why any institution continues to allow disrespectful behavior among colleagues.

[jzkfel]

If you want to be taken seriously as a professional, you have to work in a professional manner. That includes documenting and communicating patient information in a way that is succinct and understandable by all members of the health care team. It also includes prioritizing things you have to do and using good time management so you can care effectively for your patients. Sorry, but I don't see nursing diagnosis helping in any of those areas. Lets try communicating in plain English! It's faster and much more effective.

[lizlafoe]

I occasionally used nursing diagnoses for paperwork purposes in the ICU, never in the ER. Also, my hospital has new grads taking the PBDS, which I found much more challenging than the NCLEX. What I liked about the test, however, was that it accepted the medical diagnosis or medical differentials - no NANDA needed.

[island40]

I write annual care plans for my chronically mentally ill clients whom I provide home psychiatric nursing care for - they are a complete waste of time, nobody reads them and yet are requisite for reimbursement from Medicaid. Ugg. I have taught Nsg Dx to students and hear all the same gripes - I don't believe that nurses will ever been seen as a profession or as professionals until we delegate ADL care and yet that is when most of the phsycial assessment is done for our clients.

It has been a while but University of Arizona hospitals and clinics required SOAP notes as the method of nursing documentation. (S = subjective data, O= objective data, A= nursing diagnosis but I can't think of the word that is used; and P= planned interventions; also can have SOAPIE where the Plan and Interventions are separated out and then the Evaluation) Takes much more time than writing out a narative note but it helped new graduates to organize assessment and articulate specifics.