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.
"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?"
the difference between the derivation of a social worker's life care plan and a registered nurse's life care plans lies in the difference between licensures and the practice acts regulating them. as a registered nurse, i can do an assessment of human response to injury/illness based on my knowledge, experience, and education, and formulate a plan of care based on that. while a social worker can also say, for example, that this patient needs certain elements of a life care plan based on the checklist of common interventions per medical diagnosis, the legal challenge will be, "how are you able to diagnose the condition requiring that?" there is no legal basis for a social worker to diagnose. a physician needs to sign off on a non-rn's plan to validate this sort of finding and conclusion. this has been upheld in the courts repeatedly. and although there are physician life care planners, their plans are almost universally inadequate as they miss a lot of the non-medical-diagnosis components needed to address the whole person. sound familiar? i have colleagues whose challenges to md-derived plans have been successfully upheld by use of the nursing process, documenting deficiencies related to inadequate assessment. at least in the life care planning world, and increasingly in other areas, being a physician does not trump being a registered nurse :). (as an aside, courts are ruling that physicians are not able to testify on nursing standards of care and performance. duh.)
a registered nurse has the professional autonomy backed by the nurse practice act and nursing diagnosis do what we do independently, and nurse life care planning is nursing. and the reason for that is that nursing has a scientifically-validated body of knowledge and the taxonomy of nursing diagnoses with which to work.
Specializes in Spinal Cord injuries, Emergency+EMS.
the entire debate revolves around a few key factors
1. the 'need' to create a language of diagnosis that is entirely seperate from the language the rest of the professional team use .
2. the male bovine excrement surrounding people claiming that others are 'practicing medicine without a licence' if they dare to use the standard terminology for a condition without the 'permission' of the all mighty Doctor
3. the relevance and utility of the taxonomy proposed by 'Nursing diagnosis ' and whether it's actually relateable to the interventions performed without a huge journey up and down the garden path round the trees , and in and out of the teddy bears picnic ...
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
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.
A nursing diagnosis based curriculum is not a different "style" or "method" of learning, it's a Dogma. Saying ND's are a teaching style is like saying Creationism and Evolution are just different styles of teaching the origin of life. Group exercises and a powerpoint lesson are different styles of teaching; forbidding the use medical diagnoses in care planning makes what you are teaching different, not how you are teaching different. A ND based curriculum teaches that as Nurses, the Medical diagnosis is not of our concern, only the generalized response to the disease, implying that as Nurses we view patients having an MI, a hemorrhagic stroke, PAD, diabetic neuropathy, and Reynauds all the same since they are just "impaired tissue perfusion" patients. While in reality, to fulfill the needs of our patients, not to mention our legal responsibilities; how we assess, plan, intervene, and evaluate each of these patients must differ significantly based on the specific physiologic process affecting the patient (aka: medical diagnosis). In my experience, the ND based curriculum is not used as an optional learning modality but as sacrosanct, leaving many students to learn covertly the associations between the medical diagnosis and their care, as though they were trying to learn Buddhism at a Catholic school. If your students don't find the ND based curriculum useful are they free to base some of their interventions and outcomes in their careplans on the Medical diagnosis if they find that more intuitive?
We are not different than Medicine, we are a Medical Profession. Medicine is defined as the "science and art of healing", our use of the term "medicine" to refer to what is the sole domain of Physicians is unfortunate and seems to only further isolate ourselves. If you mean that a Nurse's role in Medicine is different than that of a Physician, then I'd agree with that, although I find it perplexing that we thought we could better define our differences from MD-medicine by copying the MD diagnosis model. What separates Nursing from MD-medicine is that Nursing views patients as a unique and complex web of various problems and circumstances and treats them without using some sort of cookie cutter generalization of patients. So for some reason, to help capture the fact that we don't use a cookie-cutter system when treating patients, we chose a cookie-cutter system that generalizes patients in to broad categories. Of all the things to copy in the MD system, I'm not sure why we decided it was an ICD type classification system that we needed. At least MD's put their process first, requiring ICD coding to adapt to their system, we for some reason adapted our process to an ICD type coding system, that doesn't seem just a little too eager to please the billing department at the expense of our practice?
While ND's might be useful for a filing system, they do not define what we do or provide an adequate learning basis. As Benner put it:"No wise psychiatrist or psychologist imagines that his or her work, or even the understanding of a patient is captured by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition." And regarding education: "Partial, trivializing classification systems are more of a problem for marginalized and traditionally invisible practices such as nursing. The risk is that classification schemes will be overgeneralized and taken as a basis for organizational priorities, accounting practices, and organizing curriculum and teaching."
Aside from being less functional, Nursing diagnoses are just embarrassing. When I first learned of ND's in school, I couldn't get the picture out of my head of my little brother with a metal colander on his head swinging a cardboard tube. Perhaps that deserves more explanation. I used to play baseball. My little brother would come the games and, to be more like his big brother, he would bring a metal colander and a cardboard tube and wear the colander as a batting helmet and swing the cardboard tube as a bat pretending he was playing in the game with the big boys. Since he was a little kid, it was cute, although if he was my age it would have just been sort of sad and pathetic. I can't help but think of Nursing diagnoses as our attempt to be more like the big brother we wish we were by trying (inadequately) to copy what they do, rather than forging our own path.
A nursing diagnosis based curriculum is not a different "style" or "method" of learning, it's a Dogma
Maybe I didn't make myself clear. I don't use an ND curriculum, I said I used ND to teach nurses how to think about patients above and beyond the medical diagnosis. For the other 40% of nurses who work outside the hospital setting (and some who do work in the hospital) we don't always have the medical diagnosis wrapped up in a nice package for us to use. In fact, the ones of us on the front lines usually don't have docs around at all. So when a patient comes into our free clinic site SOB, we can't medically diagnose, but we can sure use a ND to help us determine what to do.
A ND based curriculum teaches that as Nurses, the Medical diagnosis is not of our concern
I disagree with you on that statement, and again, it is how you teach.
There are many things in a nursing care plan that aren't in a medical plan of care. You can use ND as a teaching method intertwined with other techniques. If I hand out a care plan with a ND and use it as a case study, it is a technique. However, I am not going to argue about nursing education methods since that is off topic. You apparently do not like ND's and that is fine. You also don't seem to mind taking your lead from an MD, also fine. But the distain you show to the rest of us for wanting to communicate and try to improve certain methods is perplexing to me.
Since you only seem to quote Benner, she also said when discussing teaching methods, nursing diagnosis and the expert nurse:
“This is not to say that we are ready to recommend abandoning the movement to identify and classify the phenomena of concern to nurses. We believe this effort has served the discipline well in clarifying what phenomena are uniquely the concern of nurses.”
Benner is a sound author and instructor. I enjoyed the work she did at the hospital here in town where I teach (She trained the staff in reflectively reading nursing narratives), and I have a great deal of respect for her. However, she is only one voice in nursing and even she would tell you to do what works for you in your practice. That is what makes an expert nurse.
as Nurses, the Medical diagnosis is not of our concern, only the generalized response to the disease, implying that as Nurses we view patients having an MI, a hemorrhagic stroke, PAD, diabetic neuropathy, and Reynauds all the same since they are just "impaired tissue perfusion" patients. While in reality, to fulfill the needs of our patients, not to mention our legal responsibilities; how we assess, plan, intervene, and evaluate each of these patients must differ significantly based on the specific physiologic process affecting the patient (aka: medical diagnosis).
I think you make some good points here. A nurse is informed that pt has PAD, they draw upon their knowledge of pathophys and then "diagnose" impaired tissue perfusion? That's how we were taught ND. That is not a useful exercise in my book.
In my experience, the ND based curriculum is not used as an optional learning modality but as sacrosanct, leaving many students to learn covertly the associations between the medical diagnosis and their care, as though they were trying to learn Buddhism at a Catholic school. If your students don't find the ND based curriculum useful are they free to base some of their interventions and outcomes in their careplans on the Medical diagnosis if they find that more intuitive?
My experience in school was that ND of the NANDA variety wasn't taught as "just one way to conceptualize the issues which may or may not be helpful for you".
while a social worker can also say, for example, that this patient needs certain elements of a life care plan based on the checklist of common interventions per medical diagnosis, the legal challenge will be, "how are you able to diagnose the condition requiring that?" there is no legal basis for a social worker to diagnose.
hmm... knowledge deficit is a nursing diagnosis. by that logic, does it mean that only a nurse can formally address this issue? and it kind of sounds unnecessarily exclusionary as well. maybe that's how it is legally today, but maybe it shouldn't be. some physicians may argue that only physicians can legally diagnose a medical condition, but proponents of nurse practitioners would argue that nps have/should have that right as well.
at least in the life care planning world, and increasingly in other areas, being a physician does not trump being a registered nurse :).
that makes sense. similarly, should an rn developed care plan automatically trump a social worker's care plan? wouldn't it depend upon the specifics of the case in question and the specific expertise of the care planner in question?
What do you do when your patient does not have a medical diagnosis?
Many, many nurses work in settings where at least one known medical diagnosis is a primary reason for the patient's visit. Yet some instructors of ND would force linguistic contortions in attempts to avoid any direct reference to a documented medical condition because they feared a blurring of the lines between practicing nursing and medicine. One might argue that those instructors just didn't get ND, but if instructors get so easily confused about how to utilize NDs, doesn't that point to problem with the NDs themselves?
I see us a health care profession. I try and prevent disease instead of just healing someone after they have obtained one.
That's great. But nurses are not the only health care professionals tasked with prevention. Many health care professionals do not live up to that expectation, including nurses.
And even then, I'm not convinced that NDs are required. ADPIE works just find as APIE (no diagnosis) in many contexts. Assessment - pt unable to take care of ADLs, Plan - part-time in-home ADL assistance... why even bother with a diagnosis of "self care deficit"? Isn't it kinda like, well, "duh"? I can see that self care is a general category of nursing need to be assess and address. But I don't see that it's necessary step in identifying what the self care needs are or how to address them.
Specializes in Infectious Disease, Neuro, Research.
And regarding education: "Partial, trivializing classification systems are more of a problem for marginalized and traditionally invisible practices such as nursing. The risk is that classification schemes will be overgeneralized and taken as a basis for organizational priorities, accounting practices, and organizing curriculum and teaching."
Kinda where we find ourselves...
Aside from being less functional, Nursing diagnoses are just embarrassing.
...Since he was a little kid, it was cute, although if he was my age it would have just been sort of sad and pathetic. I can't help but think of Nursing diagnoses as our attempt to be more like the big brother we wish we were by trying (inadequately) to copy what they do, rather than forging our own path.
I think I just about had a herniation! Maybe more than one!
Many, many nurses work in settings where at least one known medical diagnosis is a primary reason for the patient's visit.
And many don't. If you don't want to use ND in your setting than find another way to document, communicate, and then make it a universal approach so when we all have online medical records, your information and work can be translated to any other nurse who cares for that patient.
"R/o PAD"... but perhaps I'm an under-reformed EMT.
Or just someone who does not work in the community health setting where no physicians are present. EMT are first responders who work with physicians, but they cannot R/O any medical diagnosis. That is a physician's job. Nurses in the community or at rural hospitals very often do not work with physicians or have a physician present for a number of hours. In the community, we try just as hard to prevent disease as we do to treat it. A medical diagnosis does not always exist or is irrelevant.
That's great. But nurses are not the only health care professionals tasked with prevention. Many health care professionals do not live up to that expectation, including nurses.
I never said we were the only ones in health care, but doctor's get medical degrees and we get nursing degrees so we are not in the medical field, we are in the health care field (my personal belief). Also, should we just all give up because some health care professionals don't do their job?
Also, what if the medical diagnosis is wrong and you are basing your entire care plan off of that dx?
My daughter almost died because 6 docs misdiagnosed her and the 7th reluctantly ordered test that finally led to her diagnosis. Very long story, but she was wasting away, and when the docs' tests did not produce any answers, they came up with 6 different medical dx and then said my daughter must have an eating disorder and that she was just being defiant. Their plan of care almost killed her, (increase in caloric intake). Turned out she had celiac disease.
If nurses only depend on medical diagnosis for care plan treatment, it can also be "detrimental" to a patient.
I am not trying to argue with anyone on this issue. I just see it from a different point of view - non-hospital nursing. Again, I think there needs to be a revision in the system because it is hard to use in certain situations. However, I also believe that nursing needs to define nursing as a separate practice from medicine; otherwise we become handmaidens to the docs.
Kinda where we find ourselves...
nurseprnRN, BSN, RN
1 Article; 5,116 Posts
"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?"
the difference between the derivation of a social worker's life care plan and a registered nurse's life care plans lies in the difference between licensures and the practice acts regulating them. as a registered nurse, i can do an assessment of human response to injury/illness based on my knowledge, experience, and education, and formulate a plan of care based on that. while a social worker can also say, for example, that this patient needs certain elements of a life care plan based on the checklist of common interventions per medical diagnosis, the legal challenge will be, "how are you able to diagnose the condition requiring that?" there is no legal basis for a social worker to diagnose. a physician needs to sign off on a non-rn's plan to validate this sort of finding and conclusion. this has been upheld in the courts repeatedly. and although there are physician life care planners, their plans are almost universally inadequate as they miss a lot of the non-medical-diagnosis components needed to address the whole person. sound familiar? i have colleagues whose challenges to md-derived plans have been successfully upheld by use of the nursing process, documenting deficiencies related to inadequate assessment. at least in the life care planning world, and increasingly in other areas, being a physician does not trump being a registered nurse :). (as an aside, courts are ruling that physicians are not able to testify on nursing standards of care and performance. duh.)
a registered nurse has the professional autonomy backed by the nurse practice act and nursing diagnosis do what we do independently, and nurse life care planning is nursing. and the reason for that is that nursing has a scientifically-validated body of knowledge and the taxonomy of nursing diagnoses with which to work.