i've been an adn for 16 years. recently, i finished my bsn and now am through my first year of a dnp program. like most students, i struggled with learning to understand a nursing diagnosis during my adn schooling. since that time the term has cropped up in various situations but usually as a passing comment. it has in no way benefitted my practice as a nurse. in fact, when i bring up the subject with colleagues i often get a smirk or an eye-roll!
the subject of nursing diagnoses happened to come up in one of my grad school classes the other day. i decided to take a stab at this sacred cow and suggest that maybe they are burdensome and irrelevant to a working nurse that they simply aren't utilized. my professor's response was a textbook explanation that i've only heard repeated on a college campus. "if you say your patient has pneumonia, you are using a medical diagnosis which is outside your scope of nursing practice. you must have a nursing diagnosis to be able to implement and evaluate your interventions." i may be wrong, but i'm pretty sure i've been able to implement and evaluate my nursing interventions without needing a nursing diagnosis.
personally, i believe the idea for a nursing diagnosis comes from the ongoing and hard-won independence from the thumb of the medical community. i am all for the continued growth of nursing science. however, on this point we overshot the mark. there is simply no justifiable rationale for calling pneumonia something like
"impaired gas exchange related to effects of alveolar-capillary membrane changes. or
ineffective airway clearance related to effects of infection, excessive tracheobronchial secretions, fatigue and decreased energy, chest discomfort and muscle weakness. "
why not just say the patient has pneumonia? because it a medical diagnosis and we don't practice medicine? baloney! its a pathologic condition. call it what it is. we dont need to reinvent the wheel.
why do we hang on to this? we need to eject it from nursing and maybe realize we don't use it like we thought we would. a lot of time and energy is wasted on this topic in nursing programs that could be better spent elsewhere.
If an MD diagnoses a medical condition, and the treatment is dietary, he will counsel the patient to change their diet.
Actually, it is the dietician that is counseling us and the nice part is we didn't have to get a referral for her. Most docs do not know how to properly consult a patient on dietary needs. Most of the ones out in practice today with some level of experience only had 1 or 2 classes on nutrition.
How would you simplify them? If you read through this thread you can't help but notice that well over 90% of working nurses find them a hindrance at best and the reasons are quite specific to their practice areas and administrative roles.
Where I teach, we have blended a care plan and a number of other techniques to help new students understand the process. Simplifying care plans is not that easy. Every state has different boards of nursing which can affect care significantly. Up to 40% of nurses work outside the hospital where there aren't necessarily doctors overseeing patient care. ND's have to be utilized to direct care.
Nurses have to teach patients about their care regardless of the setting. Some more than others. Continuity of care is also important. If you don't have some type of plan of care, how do you know the tasks are getting done AND what is the assessment and evaluation of that care?
Specializes in Peds/outpatient FP,derm,allergy/private duty.
Actually, it is the dietician that is counseling us and the nice part is we didn't have to get a referral for her. Most docs do not know how to properly consult a patient on dietary needs. Most of the ones out in practice today with some level of experience only had 1 or 2 classes on nutrition.
Where I teach, we have blended a care plan and a number of other techniques to help new students understand the process. Simplifying care plans is not that easy. Every state has different boards of nursing which can affect care significantly. Up to 40% of nurses work outside the hospital where there aren't necessarily doctors overseeing patient care. ND's have to be utilized to direct care.
Nurses have to teach patients about their care regardless of the setting. Some more than others. Continuity of care is also important. If you don't have some type of plan of care, how do you know the tasks are getting done AND what is the assessment and evaluation of that care?
Care plans were around long before NANDA. I have never said care plans are not of value. In fact, the way we used them back in the day they were quite helpful. Simplifying care plans without the extra layer of obfuscating NANDA diagnoses is not difficult. When they were co-opted by the nursing dx process they lost their former advantages. Again, back in this thread this point was brought up by others.
Patient teaching has been around long befoe NANDA. You don't need a NANDA diagnosis to teach a patient about their disease. Finding effective ways of teaching each individual patient according to his needs has been around long before NANDA.
Whatever advantages the few students who find them a great learning tool have, how can we say how well they would've done without that? If you identified what it was about the nursing dx that helped, are there not many other modalities that have the same characteristics? When the nursing diagnoses hoopla all started it was meant primarily as something to be used as much during a working day as a stethoscope for nurses. I remember reading about all of it in 1980-81 in my nursing journals.
Therefore, the question is what things are left after you remove those things that were not broken prior to NANDA that would justify the time and money expended on them, especially when the majority of nurses disagree with that proposition?
Yes I know. NANDA just tried to organize the information.
I hear no other remedy, just complaining.
Patient teaching has been around long befoe NANDA. You don't need a NANDA diagnosis to teach a patient about their disease. Finding effective ways of teaching each individual patient according to his needs has been around long before NANDA.
No you don't need NANDA, but you need a plan. Nurses aren't teachers by luck, it is a skill, a learned skill that not everyone possess. Most nurses are unfamiliar with things like health literacy so simply walking into a room and handing a patient a pre-printed sheet off the computer and taking 3 minutes to 'explain' the sheet is insane when more than 40% of people have a 6th grading reading level or below and D/C orders are written at a 10th grade level. It is no wonder patients return to the hospital so quickly, they truly do not understand what they should be doing at home.
Again, how do we quantify who we are and what we do I think is the question I have if you want to get rid of ND. I am sure there are other ways, but I haven't heard anything other than "let the medical field" dictate what we do. "Follow the medical diagnosis" when planning care. Bedside nurses complain that administration comes up with such "stupid stuff" and that bedside nurses are the ones who really know what is going on with the patient; then I invite the bedside nurse to come up with an idea to the problem.
But you have to have an idea. How do we quantify who we are? If we don't, we will have unlicensed personnel doing more of what we use to do because we have no true scope of practice. Maybe ND isn't the answer, but until we have another option, I will use it (among many other teaching strategies) to teach nursing students.
One of the clinicals I teach is at a free clinic in the inner city. We see a great number of sexually abused women. Gang rape, sex abuse, STD's. I would question how a medical diagnosis would properly address all of the patients needs without the training of a RAPE nurse. I emailed you our standard ND and care plan because it was too long post on the thread, but when teaching new nurses how to critically think and remain calm in this type of situation, the ND and CP addresses what the medical diagnosis and medical treatment does not.
Will historians say that in the last half of the 20th century the developing classifications revolutionized nursing practice? Perhaps so. Nursing diagnosis encouraged thinking to move from the notion of a work-task to a conceptualization of a patient's problem. It provided a language to communicate and a tool for critical thinking at a time when documentation was characterized by statements such as "appears to be bleeding" or "appears to be dead." The development of a language for interventions and outcomes revolutionized the "work-tasks" at a time when nurses thought of intervention as "provide emotional support" and outcomes as "slept well." The profession has come a long way in this past century. One wonders what the 21st century will bring.
Specializes in Peds/outpatient FP,derm,allergy/private duty.
Nursel56
One of the clinicals I teach is at a free clinic in the inner city. We see a great number of sexually abused women. Gang rape, sex abuse, STD's. I would question how a medical diagnosis would properly address all of the patients needs without the training of a RAPE nurse. I emailed you our standard ND and care plan because it was too long post on the thread, but when teaching new nurses how to critically think and remain calm in this type of situation, the ND and CP addresses what the medical diagnosis and medical treatment does not.
I've read them and sent you a PM. This is an instance where a lot of back and forth has helped me understand some things I didn't before. Thank you for taking the time to further explain things - some light bulbs went off. It certainly points up to the fact we have unique things to offer the medical model does not and we should never lose sight of that truth regardless of our personal differences. Thanks. :-)
I have been around long enough (and even been known to blown off ND here and there) to know that NANDA nurses don't usually work at the bedside. However, they are great teaching tools to use for a brand new spankin' student who has no context pertaining to nursing vs medicine or for a veteran nurse who encounters a new situation in his/her practice.
Although I can honestly say when I worked in cardiac ICU and a patient coded, the last thing I was thinking about was charting my ND intervention. In some cases, however, the ND works very well. Hopefully we can all start appreciating why we are different and develop those nursing skills, assessments, and evaluations to give our patients full holistic care.
Specializes in Infectious Disease, Neuro, Research.
How would you simplify them? If you read through this thread you can't help but notice that well over 90% of working nurses find them a hindrance at best and the reasons are quite specific to their practice areas and administrative roles. That can not last. Several people have mentioned "workarounds" - nobody wants to have to come up with workarounds that will skew the results of the QA process and add un-needed stress to their lives.
I tend to look at things in reductionist fashion, so...
I spend most of my time studying psych in relation to risk management and performance development. Many of my friends and people having similar interests work in high-risk professions, i.e., EMS, Fire, Mil/LE. What is readily apparent is that a primary framework (which at some stage NANDA was intended to be) is needed. These professions clarify one's thinking, because if the decisional tree is too involved, one gets dead or injured.
Because of the plethora of specilizations, NANDA has become a stilted, redundant, inadequate model, in much the same way "conflict de-escalation" has gone with some Mil/LE units.
What do we use, in virtually every assessment? Erickson and Maslow. Physical processes have symptoms in psych and vice versa. Rather than having, "risk for___" or, "ineffective coping r/____", and the whole smorgasborg of conditions and ailments, might it not be simpler to have a Maslow/Erickson matrix that would allow prioritization of individual physical and psycho-social needs in relation to any given sub-discipline(i.e., endo, GI, cardiac, psych, neuro, etc..)? Again, NANDA was trying to get there, but has become both overly specific and too generalized.
Rather than having the integral framework (Maslow/Erickson) from which assessement/decisional branches may be built, we have a mass of specialty-centric NANDA catchphrases, with their own self-sustaining and voluminous interventions/outcomes, rather than a minimalist (readily QA/QI assessed) core.
Stay tuned for the next wave from academia which makes more sense than the nursing diagnosis issues. It's outcome based or evidence based practice.
Outcome Based is well entrenched in Home Health. Nursing care plans are fading away into Best Practices. Much better. Much more user friendly. I agree that this is the way of the future, along with sharing of data which contributes to best practice development.
I will say before I condemn care plans that I really feel that they are a learning tool for students. It helps them to look at the whole patient and make sense of things in an
A + B + C = D sort of way. It helps them to think things through and put concepts to use. Not practical for many real work settings though.
Specializes in Peds/outpatient FP,derm,allergy/private duty.
I tend to look at things in reductionist fashion, so...
I spend most of my time studying psych in relation to risk management and performance development. Many of my friends and people having similar interests work in high-risk professions, i.e., EMS, Fire, Mil/LE. What is readily apparent is that a primary framework (which at some stage NANDA was intended to be) is needed. These professions clarify one's thinking, because if the decisional tree is too involved, one gets dead or injured.
Because of the plethora of specilizations, NANDA has become a stilted, redundant, inadequate model, in much the same way "conflict de-escalation" has gone with some Mil/LE units.
What do we use, in virtually every assessment? Erickson and Maslow. Physical processes have symptoms in psych and vice versa. Rather than having, "risk for___" or, "ineffective coping r/____", and the whole smorgasborg of conditions and ailments, might it not be simpler to have a Maslow/Erickson matrix that would allow prioritization of individual physical and psycho-social needs in relation to any given sub-discipline(i.e., endo, GI, cardiac, psych, neuro, etc..)? Again, NANDA was trying to get there, but has become both overly specific and too generalized.
Rather than having the integral framework (Maslow/Erickson) from which assessement/decisional branches may be built, we have a mass of specialty-centric NANDA catchphrases, with their own self-sustaining and voluminous interventions/outcomes, rather than a minimalist (readily QA/QI assessed) core.
some of that might possibly have sailed right over my head - if so I apologize . . .:-) having said that --
Maslow and Erickson have stood the test of time, clearly identify and prioritize subsets of information and have proven to be a useful framework to organize information from the simple to the complex. Just from an anecdotal perspective, my kids were first taught this in their high school "introduction to psych" sections of their required Health classes. But very little Freud. Thank God.
I tend to look at things by looking at the whole cultural cloth around them. Sometimes the true value of an idea at the center of an issue is completely obscured because of that. The nursing diagnoses as well as things like Jean Watson"s carative theory are reminiscent of the "gestalt" rage at the time, and for a while Fritz Perls was God - and you "got" information rather than "knew" information. Then people began to stealthily whisper "do you have any idea what they're talking about? me neither!!"
I'm not really trying to be flippant (well. . ) I think of the genesis of nursing diagnoses along with Rod McKuen poetry, shag carpet, Sister Corita, and "Love Means Never Having to Say You're Sorry". Like the Disturbed Energy Field, I spent years beating myself up trying to figure that out -- I thought you were supposed to say you're sorry? but yet I am still afraid to come right out and say that's a load of hooey!
But I don't think it is a load but a step along the path in need of refining and re-integrating with a more linear and easily understood expression.
I admit that "holistic" doesn't really lend itself well to specifics, but the concept does not lack merit all together. I made a joking reference to Freud because I think the passage of time may have made the florid and dense language of his day incomprehensible to us now, but it was spooned out dutifully for a long time before he lost his place center-stage. Now he is seen more as a very important part of a progression. Just as NANDA in it's original form will someday be.
msn10 sent me her care plan (including the nursing dx) that struck me as exactly right for the population and the problems of the clients she served in an urban clinic, but if you were to have a Maslow type framework it might be more universally applicable and branch out from there.
WHOA wait a minute. Let's not go down that path. Please. Men can do everything right and will fix us and rescue us from our nursing diagnosis? Right. That is why all the strictly male-run nations are in such great shape and why male dominated areas such as business have no problems. It is only nursing and this female-dominated profession that is screwed up?
but yet I am still afraid to come right out and say that's a load of hooey!
msn10
560 Posts
Actually, it is the dietician that is counseling us and the nice part is we didn't have to get a referral for her. Most docs do not know how to properly consult a patient on dietary needs. Most of the ones out in practice today with some level of experience only had 1 or 2 classes on nutrition.
Where I teach, we have blended a care plan and a number of other techniques to help new students understand the process. Simplifying care plans is not that easy. Every state has different boards of nursing which can affect care significantly. Up to 40% of nurses work outside the hospital where there aren't necessarily doctors overseeing patient care. ND's have to be utilized to direct care.
Nurses have to teach patients about their care regardless of the setting. Some more than others. Continuity of care is also important. If you don't have some type of plan of care, how do you know the tasks are getting done AND what is the assessment and evaluation of that care?