Nursing Diagnosis...the sacred cow that needs to go.

[Idaho4me]

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.

what say you?

[Boognish]

I cringe anytime a parent asks me 'What do you think my child has".....They think if you don't tell them that you dont know what you should know to do your job..

Yet they dont like to hear "It is not within my scope of practice to even offer a guess, as nurses cannot dx or offer medical opinions'

I tend to simply deflect..."well I am concerned that his pulse ox is not at his typical range and his heart rate is elevated with lots of secretions tonight. Lets see what the doctor has to say but in the meantime we can give him his ordered neb tx's"

I wonder am I the only one that is that cautious or would many nurses have simply said.."seems like he might be getting a respiratory infection but we'll see what the dr' says"

Could you imagine telling them or a Dr. that you have found 'ineffective airway clearance related to A B and C, as evidenced by D. Haha!!

GO PHILLIES!!!!!!!!!

That sounds a lot like how my school is teaching us to use nursing diagnoses. They've had us use them as written in the diagnosis manual for assignments, but they've been pretty frank about the fact that we're not going to use the manual in practice. They've essentially told us that it's a tool to teach us nursing process- but what you described sounds like exactly what my professors would want me to say to a family in that situation.

[msn10]

I wonder am I the only one that is that cautious or would many nurses have simply said.."seems like he might be getting a respiratory infection but we'll see what the dr' says"

Could you imagine telling them or a Dr. that you have found 'ineffective airway clearance related to A B and C, as evidenced by D. Haha!!

Well....you can't say he is getting a respiratory infection since you are correct in saying it is not our scope. We can't diagnose...period. Sure we have a pretty good idea, but I wouldn't want to be the nurse who says it is "diagnosis A" and then it turns out to be "diagnosis B." The family would trust you even less.

I think part of you answer is correct. You can definitely say "I am worried because your son isn't effectively clearing his airway and I know that because his pulse ox is not at his typical range and his heart rate is elevated with lots of secretions tonight." I am not sure I see the problem with that answer.

[Altra, BSN, RN]

I cringe anytime a parent asks me 'What do you think my child has".....They think if you don't tell them that you dont know what you should know to do your job..

Are you sure about this? Is there a possibility that the parent is simply (understandably) concerned and that the conversation is not about your abilities as a nurse?

Is there another way to conduct the conversation to avoid this?

[loveslife]

I think nursing diagnoses are pivotal for the student nursing for developing the skill of creating care plans and learning to think critically. Nursing diagnoses teach the student to identify the harmonies and disharmonies of the patient based on their assessments, prioritize the disharmonies, and most importantly, prioritize and develop a plan of care. Also, because nursing school is not designed in a way in which the clinical instructor follows the nursing student all day, the instructor needs a way to evaluate the student nurses ability to do the things mentioned above. Therefore, nursing diagnosis are most helpful to the student, but not practical in clinical practice because at this point the nurse has learn to assess and prioritize.

[Esme12, ASN, BSN, RN]

I think nursing diagnoses are pivotal for the student nursing for developing the skill of creating care plans and learning to think critically. Nursing diagnoses teach the student to identify the harmonies and disharmonies of the patient based on their assessments, prioritize the disharmonies, and most importantly, prioritize and develop a plan of care. Also, because nursing school is not designed in a way in which the clinical instructor follows the nursing student all day, the instructor needs a way to evaluate the student nurses ability to do the things mentioned above. Therefore, nursing diagnosis are most helpful to the student, but not practical in clinical practice because at this point the nurse has learn to assess and prioritize.

I agree 100%

So I can absolve myself of guilt for not helping the students who come here and plead "I NEED HELP WITH MY CARE PLAN!!!!!!!!!!!!!" that then get angry when I only give clues or links for them to follow? I feel much better!!!

[Rob72, ASN, RN]

I think nursing diagnoses are pivotal for the student nursing for developing the skill of creating care plans and learning to think critically. Nursing diagnoses teach the student to identify the harmonies and disharmonies of the patient based on their assessments, prioritize the disharmonies, and most importantly, prioritize and develop a plan of care. Also, because nursing school is not designed in a way in which the clinical instructor follows the nursing student all day, the instructor needs a way to evaluate the student nurses ability to do the things mentioned above. Therefore, nursing diagnosis are most helpful to the student, but not practical in clinical practice because at this point the nurse has learn to assess and prioritize.

I'm sorry, I would submit that the instructor is not able to evaluate anything other than that the student is able to marginally relate a pre-made decisional tree. Yet again, we are saying, "You'll learn it on the job...", and wondering why a majority do not stay in the field more than 5 years.

I do understand you point, but would again submit that we might find more "respect and definition" as a branch of medicine, rather than spending another 50-100 years trying to say we do the practical applications of medicine, but we, "can't think that way."

Let's be honest, much of the NPAs and SOPs are as much about political influence as safe and effective practice. For all the bruh-haha over AP nursing, the reality is that they are doing exactly as I suggest. For the most progressively minded, this AP model also plays some part in the BSN standard. Admirable. But, in practice, unless our scope is (justifiably) expanded, it does nothing more than enrich inadequate, overblown academic models, and create an artifical socio-economic barrier both to effective care and employment.

Frankly, there is no reason that a BSN (in a program without the excess fecal weight of current curricula) could not practice at the level of a 4th year resident. Obviously, the AMA might not be too appreciative of that concept, nor would many med schools.

[Deepsea_diver]

I have not seen or even heard of a nursing diagnosis or care plan since I graduated 13 years ago. Personally, I believe they are a total waste of time for nurses and nursing students. In my area of the country, nurses provide care following hospital policy and procedures based on physicians orders, not nursing diagnosis or care plans, I have worked in multiple magnet facilities none of which utilize care plans and all deliver the highest quality care. It's sad that nursing school is not evolving and changing as healthcare changes. Nurses want to be viewed as a valuable team member but our educators are still teaching concepts that have no value in the real world.

[nurseprnRN, BSN, RN]

Funny you should mention that, because I have just today spent all day reviewing a medical record of a patient who spent time in three different hospitals where they do use nursing diagnoses, and nursing plans of care are owned and operated by nursing, not as a subset of hospital policy and medicine. Had they worked only from physician orders, this patient would have been in the soup.

Physicians, bless them, know medicine, and we are legally obligated to implement some parts of their plans of care (other departments implement other parts). But by golly, they do not know nursing, and we do. Of course nursing is more than just implementing the medical plan of care.

I want to tell you that I can see exactly what nursing thought went into this patient's assessment, reassessment, and care, and how care got carried forward from one day to the next because it was planned, executed, and documented so well. I get to explain to the attorney that the nurses (at least) did a great job, because I can see how they did it.

[nurseprnRN, BSN, RN]

Why DOES it duplicate? Oh well.

[BrandonLPN, LPN]

I've been one of the more vocal advocates of the "nursing dx are a waste of time" theory. But since I've been assigned a caseload of monthly summaries at my LTC facility, I have come to appreciate them a little more.

They really help to organize and clarify what would otherwise be an unfocused, rambling mess. I format my summaries by addressing each "problem" (ie nursing dx) on the care plan and by stating the goal for said dx. I then evaluate if the goal has been met this month or not. This helps the RN case manager (as a LPN, I can't actually alter the care plan) decide if the current care plan is working, or if it needs to be changed.

All this would be much more difficult without everything neatly compartmentalized into nursing diagnoses.

And I've come to realize that many of my resident's biggest issues aren't really medical in nature at all. For many of them, there's no real medical reason for their "potential self care deficit". They just, well, don't take good care of themselves and have poor personal hygiene. It's still something that needs to be addressed with a plan of action. It's more of a "nursing" thing than a "medical" thing.

I still don't think nursing dx has much of a place in day to day care, but they're not worthless. If nothing else, they can help to organize thoughts and to form a nursing plan of care (which I can now better appreciate is separate from the medical plan of care).

[dudette10, MSN, RN]

I think nursing care plans are the only thing that makes life better for patients in an LTC setting. These are patients/residents that need day to day nursing care, NOT medical care. The staff know residents and can really think about what works, what doesn't, and make individualized plans to improve quality of life and prevent problems. Continuity of care is excellent in LTC settings with low turnover of staff. In acute care, things are a bit different, IMO, mainly due to LOS and inconsistent assignments of nurses. We do nursing interventions, of course, but they are more general and less directed by the care plan, per se, than by common sense. When doing the care plan review daily to meet Joint Commission requirements, we can hit a bunch of check boxes of nursing interventions that we've done. It's more of what we do driving the care plan than the care plan driving what we do. In fact there is very little "planning." We see what they need, we do it, then document it, with that care plan never being read again to "guide" care.

[canned_bread]

The nursing diagnosis should go. If my patient is febrile, I usually know why, and don't need to prattle on, I just ask what's needed and give. Ridiculous. I do not see the point in it.