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.
Specializes in Peds/outpatient FP,derm,allergy/private duty.
WHOA wait a minute. Let's not go down that path. Please.
Well. It was a baby-toe dip but . . .
Men can do everything right and will fix us and rescue us from our nursing diagnosis? Right.
If you read what I actually wrote broken down all I said was that when a group is a closed system (de facto or de jure) you tend to assume things to be true not out of malice or prejudice but the old saw "can't see the forest for the trees". It is not a value judgement at all.
The best teacher I had in college taught me that it is not the obvious stereotyping and assumptions we make about others that are dangerous but the unexamined assumptions that it would never occur to us to question. In fact it is that principle that is the underpinning of a lot of laws in our country and the basis for the diversity argument. It isn't black-white either-or man-woman or any other false polarization.
Anyway I took that paragraph out because I guess I underestimated the way it might be taken and I don't want to create a side-topic or offend my fellow women.
IWhat 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..)?
That makes sense to me. Things change over time... I don't see why ND (or however one labels the conclusions one draws based upon their assessment) can't change to be more clearly relevant and useful across the spectrum of nursing practice.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
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?
*** To me the problems of female dominated nursing and male dominated business are evidence that we need the skills and attributes of both sexes. Perferably in a something like an equal mix.
Yes I know. NANDA just tried to organize the information.
I hear no other remedy, just complaining.
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.
We don't need to come with anything to replace ND to do away with them. They aren't used in clinical practice, even if they had some useful purpose that would cause us to want to use them, the Joint Commission and my state Nursing Commission both discourage the use of ND because they impair patient safety.
In terms of education, my Nursing program did not use ND in their curriculum, although we did learn about them because we didn't know if they would be on the NCLEX or not (not a single student in my class had a ND question on the NCLEX). I don't agree that they serve any useful purpose in education and in fact are detrimental. It is true that it's much easier to re-label medical diagnoses as a generic, less complicated nursing diagnoses. ND are essentially a way of dumbing down what really needs to remain complex, even though it takes longer to understand, the easier way of doing something is not always the correct way to do something. In a way, ND do represent what Nursing is, since ND are essentially the ultimate work-around- why understand the intricacies of the medical condition affecting the patient when you can just dumb it down to the point of irrelevance but easier to understand. Students need to understand that nursing interventions, teaching, etc are going be different for a patient having an MI vs a patient with raynauds, even though they are both just 'impaired tissue perfusion' when using the ND view. The ND system seems to imply that the medical Dx isn't their responsibility, not only is involvement in the treatment of the medical Dx part of our responsibility, in my state I am legally required to be an active participant in the creating, implementing and evaluated the medical tx plan.
NIC and NOC doesn't depend on ND, and to be used effectively you need to plan your NIC/NOC on the medical diagnosis, not the ND. I realize it does make things easier for a nursing student, but it does so by teaching that a Nurse's thought process is nothing more than algorithm, just fill in the 'if____, then_____' blanks. In reality, Nurses have to move towards more abstract and intuitive thought process to be effective, which means they have to unlearn the bad habits established by a ND based system.
I don't agree that ND will help define Nursing or help prevent Nursing tasks from being taken over by unlicensed personal. Creating the false impression that Care planning is simply a matter of completing an algorithm implies that it's essentially a task that could be done by a computer, the cheapest of all unlicensed personnel.
Of course you can't base all of a Care plan on the patient's medical diagnose. For this we use patient specific problem statements, which then produce our NIC/NOC's, no ND needed. You mentioned post-sexual assault counseling and support. The ND approach is to rename this unnecessarily, there is a more practical way to describe the need for post-sexual assault counseling and support, it's called "post sexual assault counseling and support".
ND serve no purpose in reimbursement. We could never bill based on ND, although NIC/NOC has some potential. It would be extremely impractical since ND are so broad that they can include a huge range of interventions and actions, some may only require 5 minutes of teaching and some may require days of hospitalization for the same ND, billing the same amount for 5 minutes as you would for days of hospitalization makes no sense, which is why billing by the actual NIC's performed would make more sense, although I prefer hourly billing.
I can't even imagine how a ND would help an experienced nurse better understand a concept they are unfamiliar with, please give an example.
Benner has a new book out (Transforming Nursing Education; a call for radical transformation) that I would urge you to read if you are in Nursing Education, particularly if you're still a ND believer.
Joint Commission and my state Nursing Commission both discourage the use of ND because they impair patient safety.
Do you have their position statements on that?
I don't agree that they serve any useful purpose in education and in fact are detrimental.
Are you an educator?
NIC and NOC doesn't depend on ND, and to be used effectively you need to plan your NIC/NOC on the medical diagnosis
I'm confused because according to the ANA and (Kautz, Kuiper, Pesut, & Williams, 2006; Kelly, Weber, & Sprengel, 2005). The 3 together have become known as the Taxonomy of Nursing Practice (von Krogh, Dale, & Nåden, 2005).
Taxonomy of Nursing Practice. The combination of NANDA-I nursing diagnoses, NOC outcomes, and NIC interventions in a common unifying structure provides a comprehensive nursing language recognized by the American Nurses Association (ANA) and is coded in the Systematized Nomenclature of Medicine (SNOMED) in support of the electronic client record.
Benner has a new book out (Transforming Nursing Education; a call for radical transformation) that I would urge you to read if you are in Nursing Education, particularly if you're still a ND believer.
I have read most of Benner's work. I have read
Transforming
In fact my professor (and 1st reader for my thesis) was her co-worker and they wrote a book together. I was immersed in Benner for years.
As an educator I do use her work AND others. Benner is an expert in her theory and novice to expert, but she does not recommend disregarding NANDA diagnosis altogether as a teaching method. She only states that one should not "force nursing knowledge and curriculum into one theoretical theory" (p. 68)
My research in graduate school was on learning styles. In my time as educator, I realize that determining and presenting different types of techniques to all types of learning styles is one of the most helpful and productive things an educator can do for his or her students. If you have read my other posts, I do not believe the current NANDA system is right for every situation (especially in the hospital setting) but it is useful for some students to be able to organize their information. Trust me, I use a plethora of other techniques as well. But if you think ND is 'dumbing down the system' then again, I invite you to create your own method or suggestion.
We do need transformation because what I see coming out of nursing school these days is somewhat less of cause and effect plan of care. And for experienced nurses more fear of using what they know to do based on years of care planning and implementation of that plan of care. The cruel thing about plans of care are that they are to be individualized and changeable based on circumstances of the patient's course. Due to time constraints, limited staffing and increased patient load, care planning is minimized to treatments, therapy, medications, etc. There is not a noticeable action on changing the plan of care-its just computerized assessment sheets that are checked off at assigned time intervals. Tell if I am wrong. Back in the 70's and 80's there was a time when you reported, stated what worked and what didn't for each patient on your team and every nurse knew what was happening so that they could assist as needed. I don't know if that's done now or not based on the current forms of documentation.
*** To me the problems of female dominated nursing and male dominated business are evidence that we need the skills and attributes of both sexes. Perferably in a something like an equal mix.
A better way to put it, but I think that in general it is not the gender that matters, but the attributes of the people who are drawn to certain professions. Male nurses most likely have similar personality traits to female nurses and those who thrive in business definitely have similar attributes as I have seen in business school. I think that we need to move past the whole male/female stereotype thing. People are people and roles are pretty blurred these days.
Specializes in Infectious Disease, Neuro, Research.
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?
How very sexist. I'm not sure if that was directed towards Muno or me, but in any event, the point would be that we (regardless of gender) should be seeking the optimized performance models, regardless of the source.
The gist of my position is that there is no hard criteria/criterion of validity for NANDA; there is no pressure testing, we're left with, "it sorta works here, kinda works there, not really here...". The learning and operational models I've been working with have the advantage of being applied in contexts where fail-points are readily exposed- because they will be exploited.
My thinking was that it would be very applicable and universal to take Maslow on one axis, Erickson on the other, and have a "fundamental" grid, over which we could lay other assessments (ABCs, coping, education, wound healing, ADLs, rehab, etc..) It becomes readily apparent where the pt's needs are-they are either physical or psycho-social, or some combination. There is no need for sub-specialty language, "modified" language to fit a particular case...
Equally, in relation to billing/compensation, this would provide a validated basis for outcome measurements, little different than the docs, "levels of care".
Everyone has something to bring to the table. Males have much better negotiation skills and confront things in a more "to the point" way, less emotion in the arguments. Females are willing to take what is offered, not rock the boat and settle. I think the genders have alot to learn from each other. Since nursing has been a primarily feminine role, it will take years to incorporate a more neutral stance in decision making regarding the professional path. But, I have seen males castrated on the job, and I have seen females abused, so whenever we decide as humans to take the gender stereotypes out of the equation then we can make some solid decisions and learn to treat each other with respect and base our decisions on some middle ground and open our eyes and hearts to what works and brings the best outcomes to our patient populations.
I'm not sure if that was directed towards Muno or me, but in any event, the point would be that we (regardless of gender) should be seeking the optimized performance models, regardless of the source.
:smokin:
nursel56
7,122 Posts
Well. It was a baby-toe dip but . . .
If you read what I actually wrote broken down all I said was that when a group is a closed system (de facto or de jure) you tend to assume things to be true not out of malice or prejudice but the old saw "can't see the forest for the trees". It is not a value judgement at all.
The best teacher I had in college taught me that it is not the obvious stereotyping and assumptions we make about others that are dangerous but the unexamined assumptions that it would never occur to us to question. In fact it is that principle that is the underpinning of a lot of laws in our country and the basis for the diversity argument. It isn't black-white either-or man-woman or any other false polarization.
Anyway I took that paragraph out because I guess I underestimated the way it might be taken and I don't want to create a side-topic or offend my fellow women.