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.
It is cultural expectations that make the difference. By repeating and propagating ideas such as this- the idea that there IS a difference, you are making it so. We are all the same and have the same capacity for compassion, caring, negotiation, corruption, whatever.
I agree we need a mix. In all fields. Just as we need a racial mix. Workplaces should reflect the general population. Only then can gender and cultural bias become a non-issue as it should be. It is cultural expectations that lead to women being less likely to enter certain jobs, and the same with men. It is not fair to either sex. No task should be gender specific. Just as I enjoy helping my son take out a windshield of a car, so should he feel free to enjoy baking a batch of pepperoni rolls which he does!
You're continuing to build a house around a doorknob if you are still talking about my comments. .I remember when Ms Magazine was still just a glimmer in Gloria Steinem's eye. My son makes the best pancakes I've ever had in my life. Normally they are the size of a Frisbee and kind of doughey in the middle with half a pound of syrup and powdered sugar on top. He is sensitive and tends to tear up at sad things. My daughter is driven, blunt, and task oriented. Yay! This is all a tangent.
If I wanted to delve into nature vs nurture and whether or not my thoughts amount to a dangerous prophecy capable of acting as a death-ray to girls who want to step out of traditional female roles I would do it more comprehensively than just a (to my mind) pretty innocuous comment about the Mars and Venus deal that was all the rage a while back.
So let's figure out how to fix nursing diagnosis together as nurses, not as men and women but as people.
sighhhh. . .
by the way . . . am I the only person who notices how often women are called catty. gossipy, backstabbing shrews on this forum and get kudos and handclap emoticons?
or how about the large number of posts joking about men as sex-crazed horn-dogs and that apparently is worth a right on! an attagirl and a fist pump?
We don't need to venture too far into the lofty stacks of history to stand up to these issues right here in our own "yard".
let me give you another perspective. we all had to learn a lot of things, nsg dx included, in school; the problem is that for that and so many other things it wasn't possible for students to fully understand the realities of being a professional. now, stand down. of course we're all professionals. the problem is that people do not understand that a nursing diagnosis and a medical diagnosis come from different standpoints. sure, i can say, "my patient's got pneumonia (a medical diagnosis)" and at the same time i'm thinking, "... and so i have to watch to see whether he gets short of breath when he moves around, and if he does, i'll think of some clever ways for him to do what he has to do without getting exhausted/desaturating." i have thus used nursing diagnoses, quite a few of them, without even needing to look them up, and really, not even needing to think twice about it: risk for activity intolerance, ineffective breathing pattern, self-care deficit, feeding self care deficit, toileting self-care deficit... and that's just a part of what you'd observe and act on related to this patient's physiological condition.
so, you say, if we already know all this, what's the point to writing it all down? well, let me give you some clues. one, you can bet your shirt that somebody is going to come along to take part in this guy's care who isn't going to think of as many things as you do; when you give report and make reference to all you've observed and concluded (diagnosed) when you make your plan of care, you have done something every bit as valuable for this patient's recovery as the physician who read the chest xray, prescribed rt and antibiotics, and generated a cpt code for the hospital to bill with. there is, actually, a move afoot to bill for nursing services as something more than just part of the room rent, like housekeeping and the clear-liqs trays. we prove our worth by observing, diagnosing, and treating as nurses every day. this is why we make a difference. can you prove it? this is how.
second, there is a difference between "insurance won't pay for it unless a physician orders it" and "i have the education and experience to know that something needs to happen for this patient's welfare." let me tell you about what i do. i am a certified nurse life care planner (go to http://www.aanlcp.org and learn more about that). i write plans of care for people with lifetime-impact conditions-- tbi, sci, multitrauma, kids with birth injuries, chronic pain, elders-- with goods, services, treatments, evaluations, avoiding complications, and all sorts of other things, with associated costs, and i have to justify what i put into them in deposition and trial because somebody has to pay for them, and i tell them what they need. for example, i will note that someone with a tbi has not had a neurospych eval by a qualified clinician with experience in his kind of injury/presentation, and so i will put that in my plan, because without that information many other things can't be planned for appropriately. invariably i get asked by some atty, "you can't prescribe anything, because you aren't a doctor, are you?" to which i reply sweetly that the nurse practice act which licenses me as a registered nurse allows me, and in some cases mandates me, to diagnose and treat human responses to illness and injury, and in my experience and opinion this evaluation would be critical to having a better handle on that. or i can say this sci patient hasn't had a driving safety eval, and put that in a plan, so we can know if he's cognitively and physically able to drive, and if so, with what kind of vehicle modifications. that, my friends, is the nursing process.... and i back it up with a scientifically tested, research-based taxonomy, the nursing diagnosis. and i win those points every single time.
so.. without the nurse practice act, nursing diagnosis, and nursing plans of care, i would be out of a job, my atty clients wouldn't have the benefit of my expertise to get money for their clients, and i wouldn't have the chance to explain to the court how a nurse, can, in fact, prescribe a plan of care. (yes, of course i collaborate with physicians and therapists and families. i include evaluations for pt, for example, but i don't prescribe how much or what kind of therapy, because that's not what i'm licensed to do. i get a physician to specify that, and put those treatments and costs in on a separate line. but i write a nursing assessment and life care plan incorporating all of it from a nursing perspective.)
nursing diagnosis is so much more than i see being discussed here. it is a real, research-based body of knowledge that forms the basis of nursing practice. we are so much more than "following doctor's orders," are we not? you use nursing diagnosis and plans of care every single day. honor that. know what you are doing; do it mindfully; teach it. our profession's future relies on you to give us the respect we deserve on its basis.
HAHAHAHA Just kidding. Trying to find some humor in this age old discussion on working toward perfection. Have some fun, value what you do, fill out the paper work and treat all with as much respect as you can. I won't back down either. 78 Grad and going strong.
Nursing diagnosis is so much more than I see being discussed here. It is a real, research-based body of knowledge that forms the basis of NURSING practice. We are so much more than "following doctor's orders," are we not? You use nursing diagnosis and plans of care every single day. Honor that. Know what you are doing; do it mindfully; teach it. Our profession's future relies on you to give us the respect we deserve on its basis.
The accreditation binder isn't online, but the section that addresses the need for universally understood language rather than using two different terms for the same thing is the section on "improving communication between caregivers". We recently revamped our care-planning system and brought in the Nursing Commission for input. Their focus came out of the John Nance "Why hospitals should fly" philosophy with a little "Checklist Manifesto" thrown in as well. The basic point of this philosophy is that even small communication barriers are deadly, making a system like ND which not only doesn't seek to facilitate communication between caregivers, it actually turns pre-existing terminology into a different language, probably the worst thing that could be done for patient safety.
"Are you an educator?"
I'm not an educator but I was a student. Not to imply this is what you were meaning, but I don't understand the belief that Nursing students are not fit to evaluate the effectiveness of a educational modality such as Nursing Diagnoses. If you're doing diabetes teaching and the patient tells you that the method you're using to teach doesn't work for them, would you tell them they wouldn't know what works and what doesn't since they aren't a nurse?
"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)."
The three have since been combined into the NNN system, although NIC/NOC were not designed to depend on ND and for many years (about 10) there was no system for correlating ND with NIC/NOC. We used NIC/NOC without basing them off of ND in school and had no problems with that structure.
"I have read most of Benner's work. I have read 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.
"
Benner's issue with ND in "Transforming..." is that Nursing education does not benefit from a simplifying nursing care into a taxonomic system; it's useful for filing things but not for teaching nursing. It does simplify some aspects of nursing, but simplification by fundamentally changing something is not always beneficial. It might be easier to successfully teach kidney failure if you limit the definition to "kidneys don't work", although that may be an insufficient amount of pathophysiology knowledge when trying to understand various interventions, causes, etc. A student is likely to report that just learning "Kidney's don't work" was an easier way to learn kidney failure, but was that really sufficient? Also, Nurses cannot separate their practice from the patient's medical diagnoses, since the patient's medical diagnosis often makes up a large part of what is affecting their health. Obviously her book isn't available online, but here are a couple articles where she enumerates her issues with ND (and NIC/NOC as well).
Benner's writing doesn't lend itself to a simple summary, but here's the closest I could find "My colleagues and I have tried to counter the flattening of nursing practice by the diagnostic or medical model of classification, inductively generating domains of nursing practice exemplified through narrative or observational accounts of actual practice."
I appreciate the example care plans, and they were helpful in understanding post-sexual assault care since that isn't my thing, but the ND's really added nothing to it. The Nursing Diagnoses listed are really just one phsyciatric diagnoses with a bunch of symptoms related to that psych dx. A better ND option besides "Post trauma syndrome", which is just PTSD renamed, would have been "Post-rape syndrome" which is actually a syndrome first described by a psychiatrist and a sociologist in the early 70's. Everything else listed for nursing diagnoses are really just symptoms of post-rape disorders, not diagnoses. Powerlessness for instance, is what most people call an adjective, not a diagnoses which a description of the root cause of a symptom or condition, social isolation is a symptom as is everything else listed.
I'm not an educator but I was a student. Not to imply this is what you were meaning, but I don't understand the belief that Nursing students are not fit to evaluate the effectiveness of a educational modality such as Nursing Diagnoses. If you're doing diabetes teaching and the patient tells you that the method you're using to teach doesn't work for them, would you tell them they wouldn't know what works and what doesn't since they aren't a nurse?
I am not saying you can't evaluate your own learning, but you said NANDA ND's are "detrimental" to nursing education. I find that to be an overstatement. To your point, and you may have missed mine in my post, I spent an entire year researching a writing about Learning styles. I am very aware that different people learn in different ways. That is why you wouldn't start a diabetic teaching session without first evaluating the patient's LS.
Your Benner articles are nice, and you can reference anything in her book for my review (I do have most of her work on my shelves) but she is not necessarily looking to do away with ND's altogether. If fact, in one of the articles you sent me she says that
Every classification system will necessarily render some things visible and some things invisible.... I do not look to any classification system to adequately capture a complex, undetermined practice such as nursing or medicine (including my own classification of situated knowledge).
Exactly what I am trying to say. You need more than one message to teach. We could go on about this for months, and I guess we just have to agree to disagree. I will continue to use some ND's when instructing students along with concept mapping, reflective journaling, modeling, lecture, webcams, role-playing, and about the other 50 techniques I have in my bag of tricks. I am a passionate educator and I think I have been teaching long enough to understand that there are pros and cons to every single teaching method out there. I am a linear thinker and the ND's helped me prioritize when I first started nursing school.
There is one aspect of nursing I will never give up on, however. We are different than medicine and we are our own worst enemy when trying to defend what we do. The ND is just an example of why we are different and how our work and profession maters. As nursing evolves, we will come up with other concepts, just as any profession should do.
for example, i will note that someone with a tbi has not had a neurospych eval by a qualified clinician with experience in his kind of injury/presentation, and so i will put that in my plan, because without that information many other things can't be planned for appropriately. invariably i get asked by some atty, "you can't prescribe anything, because you aren't a doctor, are you?" to which i reply sweetly that the nurse practice act which licenses me as a registered nurse allows me, and in some cases mandates me, to diagnose and treat human responses to illness and injury, and in my experience and opinion this evaluation would be critical to having a better handle on that. or i can say this sci patient hasn't had a driving safety eval, and put that in a plan, so we can know if he's cognitively and physically able to drive, and if so, with what kind of vehicle modifications. that, my friends, is the nursing process.... and i back it up with a scientifically tested, research-based taxonomy, the nursing diagnosis. and i win those points every single time.
a nurse, can, in fact, prescribe a plan of care. but i write a nursing assessment and life care plan incorporating all of it from a nursing perspective.
thank you for sharing your experience and perspective.
maybe you can clarify this for me... what you describe is indeed valuable and differentiated from medical diagnosis and treatment planning. however, if a nurse developing such a 'big-picture' care plan is "practicing nursing" then when a social worker develops a life care plan for someone with special needs, are they then practicing nursing without a license? or perhaps both nurses and social workers are qualified to practice "life care planning" in different scenarios - and when the nurse does it, it's nursing and when the social worker does it, it's social work? - i hope i don't come across as argumentative. i truly wonder about questions like this! if clinical nursing experience is required for certain life care plans, then that situation doesn't call for nursing care, it calls for life care planning from a reputable, credentialed person with relevant clinical nursing experience and with relevant life care planning experience as well. is that being too nitpicky with words?
to me, this gets back to the very basic question of "what is nursing?" (which is a very different question than what do licensed nurses do)? a very large percentage of practicing nurses rarely utilize the broader 'nursing' assessments and plans of care. in both outpatient and inpatient settings, a nurse's primary function is to do *physiologic* assessments and provide *medical* care. thus, taking into consideration and working with the psychsocial aspects of the situation, reassuring and providing understandable explanations, is not 'nursing' in my perspective. good nurses do it, definitely! so do good doctors, good accountants, good lawyers, etc. if the crux of nursing care is the psychsocial and long-term qol aspects (as opposed addressing immediate medical needs), i could go so far as to argue that many of today's nursing jobs involve relatively little nursing.
i just think that if we define "nursing" as anything that nurses (have been cross-trained or co-opted) to do or have done, it ends up being meaningless as it would encompass great swaths of psychotherapy, physical therapy, health education, public health, infection control, health informatics, and medicine itself, of course (nurse practitioners, anyone?)
definitely a fav subject of discussion for me... and it really does relate back to nursing diagnoses somehow, really, it does!
Sounds like another name for case manager to me. Ah "a rose by any other name"... I am glad that someone out there can use care plans to make a living. All is not lost.
I do remember a time when I found writing care plans to be rewarding in a way, a creative outlet. But the world has changed and the paperwork burden is so massive now that they just seem tedious. The worst part is knowing that no one looks at them anyway. We do them for the sake of policy. No one benefits, no one cares. They simply add to costs and the paperwork burden.
Specializes in Clinical Research, Outpt Women's Health.
"i'm willing to be i'm more girly that the whole lot of ya. i probably have more girl in my little pinky than you guys have.............................
<_>
>_>
ewwww, got my "inside" and "outside" voice mixed up there for a second. n/m. upon further review you weren't saying that anyway.
I"m sure many nurses do exactly what I do, but I'll give an example of how nursing care is different. I work in the OR and have very limited exposure to my patients. I do a pre-op assessment after reading the chart material and get a mental picture of the patient from lifestyle limitations, previous injuries/surgeries/medical conditions, to current problem. Then I meet the patient and put the two together. I discuss the procedure to be done, ask the patient and family member/friend/sig. other/ if they have any questions. I discuss the care with anesthesia and the surgeon if necessary-especially if there are any discrepancies or new issues that have arisen since the last visit with the doc. I also advocate for the patient and have the doctor re-visit with the patient if there are any issues/questions that the patient my have-I can tell you that this really does not make the doctor happy many times-and I make sure that the patient is calm and at ease to the best of my ability before we go to the OR suite. I stay with the patient while they go to sleep/or have sedation. I make sure all the universal protocol issues are addressed. Not to mention before the patient comes to the OR, there has been a whole coordination of equipment, room readiness and personnel available and ready. Once asleep I am responsible along with the doctor and anesthesia to safely position the patient and monitor that position throughout the procedure. I maintain cleanliness in the room to prevent staff injuries and monitor for all the dangers of fire and other environmental issues that could cause harm to my team/self. I am responsible for medications delivered to the sterile field, handling of specimen, retrieval of any unanticipated items and the documentation of all events in the OR. Once the procedure is over, I transport the patient to the post op area and report to the PACU nurse all the events, dressing care, drains/I&O, and other special information that may be useful to the PACU nurse in assisting in post op care. My job is to be knowledgeable about the procedure, help the patient/family and other nurses understand how the plan of care for this patient for this procedure and for this unique experience went. I also have to educate other nurses not familiar with expected outcomes of surgical procedures. When you think about all that is done is can be overwhelming, but this experience is called upon by ICU, L&D Radiology, Cardiology, when they are unfamiliar with OR type procedures in their areas. So we are mobile. We standardize the NCP in our documentation but must individualize to the patient and the procedures. There are basic implementations that we use for every patient, but we use standardized diagnosis to document the implementations. We comment when there are issues out of the norm.
Specializes in Infectious Disease, Neuro, Research.
I just think that if we define "nursing" as anything that nurses (have been cross-trained or co-opted) to do or have done, it ends up being meaningless as it would encompass great swaths of psychotherapy, physical therapy, health education, public health, infection control, health informatics, and medicine itself, of course (nurse practitioners, anyone?)
I would submit that that is exactly what we do. Medical General Practioners may not be Board certified in a specialty, but they can make assessments, diagnoses, and plans, and refer as necessary. I have always seen nurses as GPs who cannot prescribe(Type I IDDM since early childhood).
Granted, we all have different perspectives, but based on the structure and scope of our practice, we are (or should) be thinking along multidisciplinary lines.
Is a LSW practicing nursing w/o a license? If they are calling a doc for an order to draw an HBA1C on a suspected TypeII in the office, yeah. I can't think of too many (any) SW tasks that an RN is not qualified to perform, until you get to financial needs assessments and counselling.
Maybe I'm misunderstanding, but I don't see a problem with being "generalized". If I want to specialize, in two years I'll take the NeuroSciences exam. Someone else will be a Diabetes Educator, etc., etc., but we all share the multidiscliplinary core.
I believe I'm on the same page with GrnTea, I'm just looking for a less convoluted, "workaround" methodology.:)
:yeah:
:lol2:
I would submit that that is exactly what we do. Medical General Practioners may not be Board certified in a specialty, but they can make assessments, diagnoses, and plans, and refer as necessary. I have always seen nurses as GPs who cannot prescribe(Type I IDDM since early childhood).
nursel56
7,122 Posts
You're continuing to build a house around a doorknob if you are still talking about my comments. .I remember when Ms Magazine was still just a glimmer in Gloria Steinem's eye. My son makes the best pancakes I've ever had in my life. Normally they are the size of a Frisbee and kind of doughey in the middle with half a pound of syrup and powdered sugar on top. He is sensitive and tends to tear up at sad things. My daughter is driven, blunt, and task oriented. Yay! This is all a tangent.
If I wanted to delve into nature vs nurture and whether or not my thoughts amount to a dangerous prophecy capable of acting as a death-ray to girls who want to step out of traditional female roles I would do it more comprehensively than just a (to my mind) pretty innocuous comment about the Mars and Venus deal that was all the rage a while back.
sighhhh. . .
by the way . . . am I the only person who notices how often women are called catty. gossipy, backstabbing shrews on this forum and get kudos and handclap emoticons?
or how about the large number of posts joking about men as sex-crazed horn-dogs and that apparently is worth a right on! an attagirl and a fist pump?
We don't need to venture too far into the lofty stacks of history to stand up to these issues right here in our own "yard".